The development and process evaluation of an information-based intervention for pregnant women aimed at addressing rates of caesarean section
Dr R. Walker, Department of Public Health, University of Adelaide, South Australia 5005, Australia.
Objective Few strategies aimed at addressing rising rates of caesarean section have explicitly involved information-based approaches for pregnant women. This study describes the development and evaluation of such an intervention for pregnant women, encompassing pamphlets and a peer support network (PSN).
Design Process evaluation.
Setting The study was undertaken at a metropolitan teaching hospital in Adelaide, South Australia.
Population A consecutive sample of pregnant women attending the ultrasound clinic over a two-month period, recruited at 18 weeks of gestation.
Methods Participants received two pamphlets at 18 weeks of gestation and information on a PSN at around 28 weeks of gestation. A questionnaire was sent to women at seven weeks postnatal, asking them to evaluate the intervention.
Main outcome measures The extent to which the intervention resources were used and participants were satisfied with the resources they received.
Results Ninety-two women returned questionnaires (response rate of 62%). Women generally resisted engaging with the informational resources, citing irrelevance to their situation, for example, 53% (49/92) read all of the pamphlets. None of the women used the PSN. Women who had experienced childbirth previously and those of higher education were significantly more likely to read the pamphlets. While generally satisfied with pamphlet content, one in five women reported feeling distressed by some of the information.
Conclusions This exploratory study casts doubt on the notion of information provision for pregnant women as a panacea for addressing rising rates of caesarean section.
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Steadily increasing global rates of caesarean section have evolved into one of the most widely debated topics relating to maternity care. As a result, numerous publications in the medical literature have featured debates over how, or whether, rates should be reduced.1–4 Central to much of this debate has been the notion of women's role, in terms of preference for caesarean section5–7 or involvement in the decision making for this mode of delivery.8,9 Consequently, calls for provision of information upon which pregnant women can make informed decisions, thereby avoiding unnecessary procedures, have been heard.10–12 At the same time, reports from the United Kingdom,13 Australia14 and New Zealand15 have reinforced the call for information provision.
The primary reasons on which these calls are based are twofold. Firstly, provision of information could act to counteract or minimise the risk of psychological distress for women who have caesarean section,16,17 particularly in an emergency situation.18,19 For example, a review of empirical research carried out in North America, Canada and Europe developed a profile of women at relatively high risk of adverse psychosocial outcome following caesarean section.20 It found that those women who had little or no knowledge about caesarean section and its physical and/or psychosocial implications and those who had little or no control over the birthing experience or participation in the decision making were frequently cited in the literature as experiencing negative psychosocial outcomes. Secondly, provision of information on the indications, risks, benefits and alternatives to caesarean section could lessen the trivialisation of the surgical aspect of this procedure,20 potentially influencing medically unnecessary caesarean sections.
Despite such a rationale for an information-based approach for women as a means of addressing caesarean section rates, examination of the literature over the last 20 years finds few studies focussed on the distribution of specific caesarean section information for pregnant women.21–24 These series of related studies were carried out in the United States in the 1980s and early 1990s to determine, firstly, the needs of caesarean-birth parents and, secondly, to test a specially designed information intervention. These studies found inconclusive evidence for the benefit of detailed caesarean section information on adaptation to unplanned caesarean section. While they found a real need for information among those experiencing unplanned caesarean section,21 no difference in physical or psychological outcomes was found between those who received detailed information incorporated into antenatal classes and those who received traditional childbirth preparation classes.24
Although there is widespread agreement that lowering caesarean section rates requires novel approaches, there is a lack of recent empirical research focussing on the development and evaluation of information-based strategies for pregnant women. The North American studies carried out by Fawcett et al. over a decade ago offer only limited insight into how such a strategy might function within the current obstetric climate. It remains unknown the types of information women need or want, or how such information might be received. Prior to determining whether information-based approaches could realistically influence caesarean section rates, the aim of this study was to investigate how such an approach could be developed and to evaluate women's reactions to the approach in the first instance. The aims of the study were therefore to describe women's response to a purpose-designed intervention, in particular to explore whether
- •participants actively used the intervention resources (uptake); and
- •participants were satisfied with the resources they received (satisfaction).
This study was designed as a process evaluation.25 This design is recommended for evaluating novel interventions for feasibility and potential effectiveness, prior to embarking on a large and costly randomised controlled trial.26
The current study was conducted at the Women's and Children's Hospital (WCH) in Adelaide, the capital city of the State of South Australia. Approximately 18,000 births occur annually in South Australia, predominantly in metropolitan teaching and private hospitals (78%) with the remainder in country hospitals (22%).27 Of approximately 8600 births at the teaching hospitals per year, approximately 4000 occur at the WCH.27 The WCH is the largest obstetric service of five Adelaide metropolitan public teaching hospitals and is a Level III teaching hospital with a high risk pregnancy service and neonatal intensive care unit. Most women delivering at this hospital are of European descent (86%), with the remainder of Asian (8%), Aboriginal (3%) or ‘other’ (3%) descent (including from the Middle East or Africa).27
Study participants included a consecutive sample of pregnant women recruited at 18 weeks of gestation. Consent to participate was obtained when women attended the WCH ultrasound clinic during a two-month period. Hospital ethics committee approval was obtained before recruitment. A questionnaire was sent to women seven weeks after delivery to ascertain extent to which women engaged with the intervention resources and their satisfaction with the resources. Women were eligible to participate in the study if they had had no more than one previous caesarean section, were able to complete a questionnaire in English, were having a singleton pregnancy, were publicly insured patients and were over 18 years of age.
Two pamphlets and a specially developed peer support network (PSN) formed the information resources distributed to women who consented to join the study. Participants received the two pamphlets at recruitment (around 18 weeks) followed by PSN information at their standard 28-week visit. This two-pronged approach was based on the premise that the basic acquisition of knowledge (i.e. information received through a pamphlet or brochure) is argued to be necessary but not sufficient in promoting behaviour change.28
The written materials consisted of firstly, a ‘motivational’ pamphlet: ‘Making informed decisions about caesarean section: information for all pregnant women, their partners and family’; and secondly, a more information-based pamphlet—‘Caesarean section—What are your options? Information for women who are considering caesarean section for the birth of their baby’. The motivational pamphlet was developed by one of the research team (RW). A nurse-midwife, as part of her postgraduate research, developed the informational pamphlet and permission was obtained for this pamphlet to be distributed and evaluated for the purposes of this study. This paper describes only the methodology relating to the development of the motivational pamphlet.
The motivational pamphlet incorporated both affective and motivational components. Past experimental research has pointed to the fact that women's motivations, and underlying attitudes in particular, are critical components of their decision to have a caesarean section.29 Therefore, by developing a pamphlet that encompassed both affective and motivational components, the aim was to ensure that the pamphlet differed from, while at the same time complemented, the more evidence-based informational pamphlet.
A number of stakeholders were invited to appraise the motivational pamphlet, including WCH clinicians (one obstetrician and two midwives), networks in the local community (three consumers from CARES SA, Caesarean Awareness, Recovery, Education and Support group) and a random sample of 10 pregnant women recruited from the WCH antenatal clinic. For clinicians and networks in the community, this appraisal took the form of semi-structured one to one interviews. Pregnant women were asked to complete a short questionnaire.
Once the pamphlet had been evaluated and revised, readability was measured using the SMOG Formula.30 This formula is recommended for health promotion material25 and enabled an assessment of the approximate reading grade needed to read and understand the pamphlet. The pamphlet was found to have a reading grade of 11, which translates, approximately, to that required to comprehend a popular Australian magazine.
The PSN was aimed toward providing an informal, one-to-one, home-based avenue for pregnant women to telephone another woman (a ‘peer supporter’). The peer supporters were non-professionally trained women in the community who had had a caesarean section but who had also experienced either a vaginal birth after caesarean (VBAC), or an external cephalic version (ECV) or who had had a vaginal breech delivery (VBD). Therefore, it was assumed that these peer supporters had had experience in making decisions about whether to have a caesarean section and the associated experiences implicit in exploring these options. It was thought that such a network could offer an alternative information source, particularly for those women who might feel that there were questions they did not wish to ask staff at the hospital regarding caesarean section, VBAC or VBD. Peer supporters were discouraged, however, from giving medical advice. The network was therefore developed with the aim that women could telephone their peer supporter and discuss issues on their own terms, from their own home.
A postal questionnaire was developed for the purposes of this study and was distributed to participants at approximately seven weeks postnatal, after assessment for adverse outcomes. This questionnaire was reviewed by a panel of five researchers and consumers who offered critical feedback regarding level of comprehension and ease of understanding, prior to the development of the final draft. The four-part questionnaire included three sections relating to use of and satisfaction with intervention resources and one section including questions relating to socio-demographic background, mode of delivery and cultural attitudes toward caesarean section. The findings regarding cultural attitudes toward caesarean section are described in an earlier paper.31
Questionnaire data were analysed using the Statistical Package for the Social Sciences (SPSS, Chicago, Illinois, USA) for Windows, version 10.0.32 One-way frequency distributions were used to determine magnitude of response to questions such as use of resources and attitudes toward caesarean section as well as socio-demographic details.
A second aim of data analysis was to determine whether socio-demographic and obstetric variables predicted women's uptake of the intervention resources (i.e. the extent to which they read the pamphlets, etc.). Tests for association were analysed using χ2 or Fisher's exact test as appropriate. P values were used to yield the degree of association between variables, at the 5% level of significance. Confidence intervals were calculated using the Confidence Interval Analysis software package.33
Following univariate χ2 analyses, logistic regression was used to identify significant independent predictors of programme uptake. For univariate analysis, P values less than 0.20 were included, as advised by a consultant statistician (P Ryan, personal communication). For multivariate analysis, any variables with P values less than 0.05 were deemed to be significant independent predictors of uptake.
Of approximately 450 women booked to attend the ultrasound clinic during the recruitment period, 216 were potentially eligible to participate (i.e. in their second trimester and aged over 18 years). Further analysis of eligibility was carried out when checking potential participants' case notes. Some women were deemed not eligible if, at further scrutiny, they had more than two previous caesarean sections or had a serious medical or psychological condition. Of these 216 potentially eligible women, 50 were deemed ineligible at either case note review or on attendance at the clinic. Twenty women were seen by sonographers prior to the researcher (RW) being able to discuss study participation, and four women missed their appointment. Of the 166 eligible women remaining, 15 declined participation (8 did not want to be part of a study, and 5 did not feel the need for caesarean section information), leading to a consent rate of 91% (151/166).
Questionnaires were sent to 148 participants at seven weeks after delivery (they were not sent to two women who had adverse outcomes and one woman who moved interstate during the study). Of these, 92 were returned (62% response rate). Socio-demographic and obstetric characteristics are given in Table 1. The sample was representative of the national birthing population in terms of maternal parity, age and mode of delivery.34 Non-respondents were similar to respondents in terms of age and parity. Mode of delivery differed slightly between the groups, with more non-respondents having an instrumental delivery. Rates for VBAC also differed in that no non-respondents had a VBAC.
Table 1. Socio-demographic and obstetric characteristics of respondents and non-respondents. Values are presented as n (%), unless otherwise indicated.
|Primiparous||43 (46.7)||29 (51.7)|
|Multiparous||49 (53.2)||27 (48.2)|
|1||32 (34.7)||17 (30.3)|
|2||26 (28.2)||19 (33.9)|
|3||23 (25.0)||11 (19.6)|
|4||11 (11.9)||9 (16.0)|
|Mode of delivery|
|Vaginal delivery||60 (65.2)||39 (69.6)|
|Emergency CS||11 (11.9)||6 (10.7)|
|Instrumental delivery||8 (8.6)||10 (17.8)|
|Elective CS||5 (5.4)||1 (1.7)|
|CS planned but performed as emergency||3 (3.2)||–|
|Tertiary||40 (43.4)|| |
|Some secondary schooling||32 (34.7)|| |
|Higher degree (including bachelor, master or doctorate level)||20 (21.7)|| |
|Main language spoken at home|
|English||71 (77.1)|| |
|Italian||4 (4.3)|| |
|Greek||4 (4.3)|| |
|Russian||2 (2.1)|| |
|Spanish||2 (2.1)|| |
|Hindi||2 (2.1)|| |
|Czech||2 (2.1)|| |
|Other||5 (5.4)|| |
|Rural||10 (10.8)|| |
|Urban||79 (85.8)|| |
|Other||3 (3.2)|| |
|Shared care||33 (35.8)|| |
|Standard antenatal clinic||22 (23.9)|| |
|Midwives clinic||18 (19.5)|| |
|Birthing centre||13 (14.1)|| |
|Other||6 (6.5)|| |
As presented in Table 2, just over half of women reported that they read all of the pamphlets. The number of women who did not read the pamphlets at all was relatively small, n= 16 (17%) for the motivational pamphlet and n= 20 (22%) for the informational pamphlet. Reasons given for not reading the pamphlets varied; however, most women stated that they thought the information was irrelevant to their situation or stated ‘other’ reasons for not reading. When asked to specify these other reasons in an open-ended question, women responded with such comments as: ‘I knew I didn't need a caesarean’ (19-year-old primipara), or ‘Giving birth naturally, I didn't need to read it’ (35-year-old multipara). Although reasons for not reading the motivational pamphlet tended to vary, half of respondents did not read the informational pamphlet citing they thought it was irrelevant to their situation.
Table 2. Women's uptake of pamphlets (n= 92). Values are presented as n (%), unless otherwise indicated.
|Did you get around to reading?||Yes, all of it||49 (53.3)||48 (52.2)|
|Yes, part||23 (25.0)||18 (19.6)|
|No||16 (17.4)||20 (21.7)|
|I can't remember||4 (4.3)||6 (6.5)|
|If no, was there a reason you didn't get around to reading?|| ||(n= 16)||(n= 20)|
|I thought it was irrelevant to my situation||5 (31.3)||10 (50.0)|
|Other||5 (31.3)||2 (10.0)|
|I didn't have time||3 (18.8)||4 (20.0)|
|It didn't interest me||2 (12.5)||3 (15.0)|
|I lost it||1 (6.3)||1 (5.0)|
|Describe what you did with the pamphlet after reading it|| ||(n= 71)||(n= 69)|
|I kept it but didn't look at it again||32 (45.1)||33 (47.8)|
|I kept it and discussed it with my partner/family||17 (23.9)||17 (24.6)|
|I kept it and referred to it a few times||14 (19.7)||10 (14.5)|
|I threw it away||8 (11.3)||9 (13.0)|
|I kept it and discussed it with my care provider||–||–|
Nearly half of participants said they kept the pamphlets but did not look at them again. Around 25% reported discussing the information with their partner or family and around 17% of women did actively use the information, referring to the pamphlets again after reading. None of the women reported keeping the pamphlets and discussing them with their care provider.
Tables 3 and 4 present women's satisfaction with the pamphlets. While women were generally satisfied that both pamphlets were useful and interesting in terms of the information they provided, it is important to note that one in five women were distressed by the pamphlet information.
Table 3. Level of satisfaction with motivational pamphlet. Values are presented as n (%).
|1. Pamphlet told me things I hadn't considered.||3 (4.2)||43 (60.5)||10 (14.0)||11 (15.4)||2 (2.8)||2 (2.8)|
|2. Pamphlet didn't provide enough information for me.||–||6 (8.4)||14 (19.7)||43 (60.5)||7 (9.8)||2 (2.8)|
|3. I think this pamphlet should be given to all pregnant women.||24 (33.8)||34 (47.8)||9 (12.6)||3 (4.2)||–||1 (1.4)|
|4. Some of the quotes in the pamphlet distressed me.||–||7 (9.8)||8 (11.2)||38 (53.5)||16 (22.5)||2 (2.8)|
|5. The information in the pamphlet made me anxious.||–||6 (8.4)||10 (14.0)||37 (52.1)||16 (22.5)||2 (2.8)|
|6. Pamphlet prompted me (or partner) to ask questions during pregnancy wouldn't have ordinarily thought of.||4 (5.6)||26 (36.6)||11 (15.4)||22 (30.9)||6 (8.9)||2 (2.8)|
|7. Pamphlet prompted me (or partner) to ask questions during labour wouldn't have ordinarily thought of.||3 (4.2)||20 (28.1)||9 (12.6)||29 (40.8)||7 (9.8)||3 (4.2)|
|8. There were too many ideas presented in the pamphlet.||1 (1.4)||1 (1.4)||15 (21.1)||43 (60.5)||10 (14.0)||1 (1.4)|
Table 4. Level of satisfaction with informational pamphlet. Values are presented as n (%).
|1. I learnt new things about CS from this pamphlet.||13 (18.8)||34 (49.2)||8 (11.5)||13 (18.8)||1 (1.4)||–|
|2. I would recommend this pamphlet to friends.||16 (23.1)||40 (57.9)||8 (11.5)||4 (5.7)||–||1 (1.4)|
|3. I think vaginal birth is safer than CS.||15 (21.7)||19 (27.5)||22 (31.8)||10 (14.4)||2 (2.8)||1 (1.4)|
|4. I didn't know about the alternatives to CS.||2 (2.8)||23 (33.3)||15 (21.7)||22 (31.8)||6 (8.6)||1 (1.4)|
|5. I think fear of labour is the reason a lot of women have a CS.||14 (20.2)||25 (36.2)||19 (27.5)||7 (10.1)||3 (4.3)||1 (1.4)|
|6. The information in the pamphlet made me scared about birth in general.||2 (2.8)||7 (10.1)||9 (13.0)||39 (56.5)||12 (17.3)||–|
|7. The information in the pamphlet made me scared about vaginal delivery.||1 (1.4)||1 (1.4)||6 (8.6)||41 (59.4)||19 (27.5)||1 (1.4)|
|8. The information in the pamphlet made me scared about CS.||2 (2.8)||11 (15.9)||10 (14.9)||33 (47.8)||12 (17.3)||1 (1.4)|
Of 58 women who reported receiving information on the PSN, only one woman attempted contact with her peer supporter (her peer supporter was not home and she did not try to contact her again) (Table 5). This participant was a 34-year-old multipara (her third pregnancy) who responded that her reason for attempting contact with her peer supporter was as follows:
Table 5. Women's use of PSN.
|Did you receive the information on the peer support network?|| ||n= 92|
|I can't remember||21 (22.8)|
|If did not, specify reason|| ||n= 13|
|Went to GP for 28-week visit||4 (30.7)|
|The researcher was not there||4 (30.7)|
|I am not sure||4 (30.7)|
|Did not attend 28-week visit||1 (7.2)|
|If you received the information, how were you allocated to your peer supporter?|| ||n= 53 (5 cases missing)|
|I didn't really know so the researcher helped me choose||20 (37.7)|
|I can't remember||10 (18.8)|
|Interest in her particular experience||8 (15.0)|
|Her experience was relevant to mine||4 (7.5)|
|Did you get around to contacting your peer supporter?|| ||n= 58|
|If you didn't contact your peer supporter, specify reason|| ||n= 57|
|I didn't need to||28 (49.1)|
|I didn't feel comfortable telephoning a stranger||10 (17.5)|
|I felt it was irrelevant to my situation||10 (17.5)|
|I didn't have time||1 (1.7)|
|How much do you agree with the statement: ‘Even though I didn't contact my peer supporter, it reassured me to know she was there if I needed or wanted to talk to her’.|| ||n= 57|
|Strongly agree||14 (24.5)|
|Not sure||9 (15.7)|
|Strongly disagree||2 (3.5)|
My baby was breech and they wanted to turn it, I was booked in the next day to have it turned. I tried to get hold of her late that night (but she was not there) to see if she could help me make up my mind whether to have a caesarean or let them turn it. But I decided it was safer to try and turn it and have natural birth—all worked out well.
Reasons given by women for not contacting peer supporters varied (Table 5). Nearly half stated that they did not make contact because they did not feel the need. Feeling that the network was irrelevant to their situation or being uncomfortable telephoning a stranger was also identified as reasons. When asked to explain why they felt the network was irrelevant to their situation, most women reported that they had never experienced caesarean section and did not expect to for the current pregnancy. For example, a number of women cited relying on friends and family for support and information so not needing the support offered by the network:
I have a wide circle of friends with small children … fantastic family support from sisters and in-laws etc, I have talked about birthing with lots of women over the past couple of years, some of which have had c-sections (31-year-old multipara).
When asked if, despite not contacting their peer supporter, women felt reassured to know support was available if needed, 72% (41/57) agreed, including 25% who strongly agreed (14/57). Women who disagreed with this statement mostly felt uncomfortable with the idea of sharing their experience with a stranger, or felt generally uncomfortable:
I think I didn't contact her because you never are really sure what outcome your pregnancy is going to be. The reason is I never tempt fate as I've had two previous miscarriages before (33-year-old multipara).
I would not have contacted her because I felt uncomfortable about talking to someone I didn't know (33-year-old multipara).
I am not sure if her support was really valuable. This is more of a family affair or a personal thing (41-year-old multipara).
As programme participants did not use the PSN, analyses of predictors of programme uptake were restricted to use of the pamphlets.
As shown in Table 6, both univariate and multivariate statistical analyses were carried out to determine whether socio-demographic and obstetric characteristics were associated with use of the intervention resources. Two separate outcomes were analysed, firstly, likelihood of reading the pamphlets and, secondly, likelihood of actively using the pamphlet (e.g. not only reading the pamphlets but also discussing the information with partner or family, or referring to the information subsequent to initial reading).
Table 6. Odds ratios for association between socio-demographic and obstetric characteristics of respondents and use of pamphlets.
|Read pamphlet (n= 92)|
| Some secondary||1.0|| || || || ||1.0|| || || || |
| Higher degree||3.4||(1.0–11.2)||3.6||(1.1–12.0)||0.04*||4.3||(1.3–15.1)||5.5||(1.4–22.0)||0.02*|
| Primiparous||1.0|| || || || ||1.0|| || || || |
| 19–23|| || || || || ||1.0|| || || || |
| 24–28|| || || || || ||0.7||(0.2–3.0)||0.5||(0.1–2.3)||0.38|
| 29–33|| || || || || ||2.0||(0.5–7.9)||1.2||(0.3–5.2)||0.79|
| 34–41|| || || || || ||3.0||(0.7–12.9)||1.3||(0.3–6.5)||0.75|
|Actively used the pamphlet (n= 92)|
| Multiparous|| || || || || ||2.7||(1.0–7.4)||1.9||(0.7–5.9)||0.23|
| Primiparous|| || || || || ||1.0|| || || || |
| 19–24|| || || || || ||1.0|| || || || |
| 24–28|| || || || || ||2.6||(0.3–25.3)||2.7||(0.3–26.4)||0.40|
| 29–33|| || || || || ||3.7||(0.4–33.0)||3.1||(0.3–28.9)||0.39|
| 34–41|| || || || || ||9.2||(1.0–83.8)||6.9||(0.7–66.0)||0.09|
Socio-demographic and obstetric characteristics found to be significantly associated with pamphlet use following univariate analysis (at or below the 0.20 level) were considered together in a logistic regression model, enabling identification of independent predictors of pamphlet use. P values up to the 5% level were considered statistically significant in the logistic regression modelling.
When focussing on whether women read the motivational pamphlet, education level and parity were significantly associated with reading at univariate analysis. However, at multivariate analysis, only education level remained as a significant independent predictor of reading this pamphlet. For the informational pamphlet, at univariate analysis education level, parity and age group were significantly associated with reading. At multivariate analysis, both education level and parity remained as significant independent predictors. Therefore, those women with a higher degree were more likely to read the pamphlets. For the informational pamphlet only, multiparous women were nearly three times more likely to read this pamphlet.
When focussing on whether women actively used the motivational pamphlet, there were no significant predictors of active use at univariate analysis. For the informational pamphlet, parity and age group were significantly associated with active use at univariate analysis. At multivariate analysis, neither remained as significant independent predictors.
This process evaluation has highlighted women's response to an information-based intervention for pregnant women aimed toward addressing rising rates of caesarean section. There has been a lack of research evaluating the distribution of information on which pregnant women can make informed decisions regarding caesarean section, despite such approaches being advocated for addressing rising rates of this procedure.10–12,14,35,36
While response rates were relatively low at 62%, they were in keeping with similar population-based surveys carried out in Australia with new mothers.37 The sample size however meant that some of the data presented in this study represents a small number of respondents. Non-respondents were similar to respondents in terms of socio-demographic and obstetric characteristics. Notwithstanding the limitations of this study, we found women frequently did not use extra information when provided in written and other formats.
Rates of reading the pamphlets were consistent with studies in similar settings38,39 in that a relatively small proportion of women did not read the pamphlets at all. However, what became clear from this study is that while women may have initially read the pamphlets, they did not actively engage with the information subsequently (i.e. discussing with partner/family, or health care provider).
The fact that socio-demographic factors such as age and educational attainment were associated with use of the information resources reflects similar studies. Glazier et al.40 found that certain subgroups of women did not benefit from an educational pamphlet on triple-marker screening distributed during pregnancy. Younger women and those not speaking English at home were least likely to benefit from the pamphlet. In addition, several observational studies have found having higher educational attainment to be associated with higher involvement in health promotion activities.41–43
A discourse analytic study carried out in South Australia44 found a relationship between social class and narratives of control regarding pregnancy and childbirth. ‘Middle class’ women, who could be expected to be of higher education, tended to adopt an ‘activist’ orientation in managing their birth. This involved reading and relying on abstract knowledge to inform their decision making in the antenatal period. ‘Working class’ women, on the other hand, were more likely to be fatalistic about their birth and to rely on their care provider's knowledge. Therefore, it could be expected that in the current study, women of higher educational attainment were also of less social disadvantage, hence may be more likely to see value in utilising the intervention resources.
The fact that parity was an independent predictor of whether or not women read the informational pamphlet could be explained by the perceived relevance of such a pamphlet. That is, women having their second or third child may have found the information more salient given previous experience of childbirth. These women may have been more accepting of the notion of being prepared for caesarean section, particularly if they had had one previously, and may be more interested in engaging with the pamphlet information. Informal discussions with programme participants in the current study found that while multiparous women tended to assume their birth would be similar to their previous experiences, they were more likely to see the relevance in receiving the programme resources as part of general knowledge gathering around childbirth. Primiparous women may instead have higher expectations of the ‘perfect delivery’ and thus be unlikely to accept that a caesarean section could eventuate. The following quote from a primiparous programme participant illustrates this notion:
As I was intending to have a natural birth and there were no obvious reasons why this would not be possible, I felt that there was little relevance to my situation (28-year-old primipara).
Some women could however see the potential advantages of having such information, as the following quote demonstrates:
It is a great idea that students present these pamphlets to pregnant ladies as most do not pick up pamphlets on things like c-section, ventouse or forceps if they are planning a natural birth. It is considered as something that ‘will not happen to them’. It is also good to have someone explain it and to ask questions early in the pregnancy so it is something you consider could happen and when it does happen, if you have had the information, it does not seem so overwhelming and scary (24-year-old primipara).
While women were generally satisfied with the intervention, it was evident that the pamphlets disturbed around one in five women. These women responded that the pamphlets had caused them to feel distressed or had made them anxious about birth in general or about caesarean section. The notion that providing information can have the opposite, and in fact detrimental, effect on recipients has been found in a randomised controlled trial focussing on over 1000 women who received debriefing following operative birth.45 This trial found that midwife-led debriefing did not result in improved postnatal maternal morbidity and in fact could have contributed to negative emotional health problems for some women. Similarly, an observational study carried out by Fawcett46 revealed that a small number of women and their partners who participated in a caesarean birth information programme had negative reactions to the information, regardless of subsequent mode of delivery.
It has been suggested that the effectiveness of information provision may vary depending on who is providing the information.47 For example, analyses have found that likelihood of behavioural change can vary according to the particular doctor delivering brief anti-smoking advice.47 Such findings could have implications for the current programme in that the researcher (RW), rather than health care professionals, distributed the pamphlets. Use of resources may have been substantially greater if obstetricians or midwives were responsible for pamphlet distribution.
Given that most (77%, 71/92) programme participants spoke English at home, and eligibility to join the programme included the ability to complete the questionnaire in English, it could be assumed that difficulties in English comprehension were not the cause of low levels of programme uptake. Further, univariate analyses provided no evidence to suggest women who spoke English as a second language were less likely to read the pamphlets.
The PSN, in particular, does not appear to have been a useful component of this programme. Effective peer support programmes in areas relating to maternity care have tended to have the peer supporter initiate contact and are targeted at women sharing a health condition or behaviour, thereby ensuring significance to participants.48–50 The current network differed from standard programmes in these two key approaches. Firstly, participants and peer supporters did not share a health condition per se. The network was aimed at providing an alternative information source should women wish to obtain information about caesarean section or alternatives, if this became relevant to them during their pregnancy. Secondly, because the support offered may not have been relevant to all women, participants themselves were to initiate the contact with their peer supporter on a needs basis, which is generally not the approach taken by studies that have demonstrated peer support to be effective. These differences between our programme and other programmes make it difficult to compare rates of uptake with other studies.
It was identified that women generally felt they did not need peer support and information regarding caesarean section, or they felt the PSN was irrelevant to their situation. Again, women may not actively seek to prevent an event that they do not perceive as being likely to happen to them. Further, when women were asked to elaborate on reasons for not using the network, they responded that they would prefer to speak to family and friends about childbirth experiences, on a casual level, rather than contact an unfamiliar person.
It has been argued that a primary difficulty when measuring such forms of social support relates to the issue of how to best define such a concept.51 Lin52 defines social support as ‘perceived or actual instrumental and/or expressive provisions supplied by the community, social networks, and confiding partners’ (p. 18). This issue has implications for the current study in the fact the programme evaluation measured women's uptake of the PSN at the instrumental level rather than the perceived level. The majority of women (72%, 41/57) indicated that they felt reassured to have the phone number of their peer supporter, even though they did not contact her. Therefore, it could be argued that the PSN had an indirect influence on women's sense of empowerment, in the form of perceived social support. This notion has been recognised in the psychological literature as the subjectively assessed support of friends, family and significant others.51 In relation to uptake of the PSN, it cannot be discounted that women may have indirectly benefited from perceiving the availability of support offered by the network, even if they did not physically make use of it.
The notion of providing information on which pregnant women can make informed decisions has been advocated in recent times, particularly as a means of addressing rising caesarean section rates.11,36 In exploring the systematic distribution of resources aimed toward such information provision, the present study calls into question the efficacy of this notion. Although the sample in this exploratory study was relatively small (n= 92), it involved a cross section of women of differing ages and educational and obstetric backgrounds. What became apparent from this study was that these women did not actively engage with either the pamphlets or the PSN and in fact the pamphlets caused negative reactions in one in five of these women. The fact that women did not utilise the resources could be due to the fact that pregnant women do not actively seek to prevent an event that may or may not happen to them, expecting to have a normal delivery and preferring instead to take the opinion of ‘if it happens, it happens’. Anecdotal reports from women in this study certainly confirm this idea. These findings do not suggest information provision is unjustified, but we must realise that information provision alone is not a panacea for addressing the steady rise in rates of caesarean section.