Supporting Childbirth Knowledge Acquisition and Decision-making
through Digital Communication Technology: The Research Design of
an Ongoing Study following a Mixed-Method Approach
Carla V. Leite
1,2 a
and Ana Margarida Almeida
1b
1
Department of Communication and Art, Digital Media and Interaction Research Centre (Digimedia),
University of Aveiro, Aveiro, Portugal
2
Department of Education and Psychology, University of Aveiro, Aveiro, Portugal
Keywords: e-Health, Health Literacy, Childbirth Education, Perinatal, Decision-making, Methodology, Mixed Methods.
Abstract: This paper describes the research design of an ongoing study that overlaps three main fields: technology,
health, and social science. This transdisciplinarity approach naturally brings challenges to the methodological
plan, which this paper presents, and aims to guide the creation, validation and evaluation of a digital decision
aid, and its comparison to a paper-based solution. Through the data collection from different natures, it is
expected to be possible to understand the different sources, channels and formats of content that can contribute
for childbirth knowledge acquisition; if communication can be facilitated between expectant parents, health
care professionals, and childbirth educators; and ultimately, if the tool could provide a mean to create a
document regarding birth preferences.
1 INTRODUCTION
Maternal Care is being highlighted in the political
agenda for the past decades (United Nations, 2015a,
2015b); however, researchers report general gaps in
antenatal care, a lack of communication and
educational activities, and underline its importance
and impact in mental health during postnatal, not just
for the women who were pregnant, but for both
expectant parents (Suto, Takehara, Yamane, & Ota,
2016). There are several Childbirth Educational
Programs implemented in most western countries
(Barimani, Frykedal, Rosander & Berlin, 2017)
aspiring to add an educational component to care,
which can be individual or in group, clinical-, home-
, internet-, telephone-, or pamphlet-based, or even the
combination of several approaches (Suto et al., 2016).
Its goals vary nationally and internationally, but a
common goal is to strengthen, support and help
expectant parents for childbirth and parenting, in
order to deal with this imminent major life transition,
that can be confusing and overwhelming (Barimani,
Vikstrom, Rosander, Frykedal, & Berlin, 2017).
a
https://orcid.org/0000-0001-5803-2775
b
https://orcid.org/0000-0002-7349-457X
Expectant parents have been also using digital
technologies for information and support (Huberty,
Dinkel, Beets, & Coleman, 2013), giving
differentiated uses according to successive digital
technology eras. They searched for information in
pregnancy related websites and blogs, and interacted
through discussion forums (Doty & Dworkin, 2014),
and with the advent of diverse new digital media,
social web and mobile ubiquitous computing devices
they expanded their use, culminating in the access to
a wide range of products and services by mobile
devices (Thomas & Lupton, 2015).
It is known that expectant parents seek
information from a variety of sources and formats
(Wallwiener et al., 2016), but there is some
controversy, or possibly a tendency of change of
behaviour over time, about the ideal option.
According to Grimes, Forster, and Newton (2014)
study, expectant mothers prefer electronic
information over printed materials, with the last ones
being regarded as unhelpful since women do not take
the time to properly review their content. On the other
hand, Hawley, Janamian, Jackson, and Wilkinson
Leite, C. and Almeida, A.
Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of an Ongoing Study following a Mixed-Method
Approach.
DOI: 10.5220/0010350307010707
In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 701-707
ISBN: 978-989-758-490-9
Copyright
c
2021 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
701
(2014) research reports that most pregnant women
preferred to have paper-based health information to
easily access and show to relatives, not only with
educational proposes, but also to engage their
relatives in the pregnancy experience.
Since there is no unique solution, in order to embrace
different preferences (paper, oral and digital) and
different needs (search, share, carry with them, etc.)
in addition to show healthcare related dummies and
accessories and to offer printed materials to expectant
parents, healthcare professionals and childbirth
educators could recommend online courses and
digital materials aiming: a) autonomous learning,
since it is considered a significant skill in current
times (Freitas, Leite, de Souza, & Costa, 2019); b) to
explore new scenarios of interactive, digital mediated
and distance education; c) to promote informed-
decision making among expectant parents.
Under the scope of the above-described scenario,
and taking in consideration the Portuguese current
context: antenatal classes are being tutored all over
the country, however only few hospitals advocate
birth plan’s usage, since its regulation is still under
discussion (GPPS, 2018); this ongoing study intends
to explore an innovative educational approach, to
understand the benefits and disadvantages of using
digital technology in knowledge acquisition and in
the informed decision-making process regarding
childbirth preferences, in comparison to printed
materials, since it seems to exist a gap in the literature.
Carefully thinking the research design is of utmost
importance since this study overlaps social, health
and technology research fields, which naturally deal
with different theories, techniques, approaches,
settings and data types, what could be a limitation of
the study and affect dramatically the results.
However, it also opens the possibility to explore
borders and blinders (Fetters & Freshwater, 2015).
2 MIXED METHODS APPROACH
After carefully analysing the problem, this research
was framed in the Socio-critical paradigm (Anguera
Argilaga, 1985; Habermas, 1974), as it will follow the
tendency of Mixed Methods (Creswell & Plano
Clark, 2018; Latorre, Rincon, & Arnal, 1996;
Solomon, 1991).
This Mixed Method approach can be better
understood when analysing the different phases that
will be conducted (Figure 1). The research is a
transversal study in what concerns the temporal
scope, planned to start as exploratory during Phase 1,
followed by activities of Research and Development
as Phase 2 (Gajbhiye & Prasad, 2013), and then
followed by a quasi-experimental approach as Phase
3 (Bisquerra Alzina, 1989), see Figure 1.
Figure 1: Research plan design, by Phase.
Phase 1 started with the literature review in order
to: understand the current approaches to health
education; explore the extent of maternal education in
Portugal; comprehend the social acceptance of
informed decisions for birth; understand what
influences the preferences of pregnant women. This
initial study helped to identify the current gap and
formulate the research question:
How can a digital tool support the informed
decision-making of pregnant women regarding birth
preferences?
In addition, a Content Analysis was planned,
starting by the identification of online tools for birth
plans creation, so categories of data would emerge
(Bardin, 2008; Ghiglione & Matalon, 1997). The
results would contribute for the establishment of the
information architecture of the digital resource.
Partnerships are of utmost importance allowing to
frame the research in a network, which, besides
amplifying its magnitude, can also provide extremely
important resources, namely expedite access to
participants for the study, so during Phase 1 relevant
institutions were identified and contacts were
established.
Besides searching for an answer to the research
question that guided this mixed methods approach
(Tashakkori & Creswell, 2007), and to discover and
understand the reality, one of the main goals of this
study is having an explicitly practical outcome by
contributing to understand the relevance of digital
media in the maternal health education, which can
represent a turning point for healthcare promotion and
outreach.
HEALTHINF 2021 - 14th International Conference on Health Informatics
702
Therefore, the study includes Research and
Development tasks during Phase 2, in order to
conceptualize and create a proof of concept of a
digital tool, which intends to, simultaneously, provide
evidence-based information, and enable the creation
of a birth plan according to each pregnant person
preferences. Those tasks include the definition of the
extent of the proposal considering feasibility,
usability and accessibility factors; the specification of
functional requirements; the content creation based
on WHO guidelines (WHO, 2016; 2018) and expert’s
validation; defining the approach to integrate the
content with the decision aids tool; establishing the
design concept, in order to design interfaces and
interactions; and finally, implement the digital tool
using final technologies.
In Phase 3, aiming to evaluate the digital tool
proposal, an experiment will be conducted, and to
prepare it, the main tasks defined are: the creation,
adaptation and experts’ validation of instruments for
data collection; the preparation of a controlled setting,
and selecting and contacting participants.
A convenience sample will be used and
participants will be split up into two groups: Control
Group A will explore only printed materials, and the
Experimental Group will explore the digital
resources; both using the same created contents but
adapted to the different formats. The distribution
criteria between the two groups to guarantee the
maximum possible homogeneity will be gestational
weeks, and score on the digital literacy questions.
The contact of the participants will be gathered
through a partner of this study, a Portuguese Public
Health Centre. As inclusion criteria to participate in
the study, it was established: expectant mothers, with
pregnancies ranging from 20 to 37 weeks, that
enrolled as a participant on the antenatal classes
provided by the health centre as already stated, a
partner of this study. They will be contacted by the
phone, and requested to answer a short questionnaire
with recruitment and selection purposes (QR), so it is
related to the exclusion criteria: a) under 18 years old;
b) non-European Portuguese native speaker; c) to
carry a high risk pregnancy; d) to have or have had
health issues or complications for herself during
pregnancy or for the foetus; e) gestation under 20 or
over 37 weeks; f) previous gestation above 12 weeks;
g) psychiatric patient before or during pregnancy; h)
to have clinical issues regarding memory and
cognition; i) under 12th grade of qualification; j) have
participated in any formal course, online or in person,
regarding childbirth; k) low digital literacy. A total of
15 questions following auto-report approach, with 3
of them particularly aiming to calculate a score
regarding their digital literacy, based on DIGCOMP
scale (Vuorikari, Punie, Carretero Gomez & Van den
Brande, 2016), but using a set of proposed questions.
Targeting Level 2 or above (out of 8) aims to exclude
the participants who necessarily need guidance to use
digital technology, specifically when using
Computers and Mobile devices, and Internet.
Only the ones eligible will be invited to participate
in the experiment that will be scheduled individually,
in person. It is believed that no relevant selection bias
will occur, nevertheless the non-randomization factor
will be taken in consideration while analysing the
results.
The target number of participants for the next
phase is around 30. There is a 7 weeks’ window to
conduct the test: the pregnant person can apply to join
the antenatal classes until they reach 21 weeks of
gestation, and the course will start when they around
28 weeks. The recruitment phase will be repeated
until the target number is reached.
That second contact with the participants will be
in person, and it will start by requesting them to
answer a first questionnaire (Q1), in digital format
and by self-completion, and Likert scales will play a
major role for self-assessment questions. It includes
six groups of questions regarding: socio-
demographic, regarding the pregnant person and the
partner; clinical factors; birth information that were
already exposed, orally, on paper and digital formats;
expectations of a tool for learning and to list
preferences regarding birth.
Then the study follows a Pretest-Posttest Design:
before and after testing the digital tool, or paper based
for the Control Group A, the participants will be
requested to answer the same questionnaire (QPPF,
standing for Pre, Post and Follow-up), and they can
not check nor change their previous answers. This
study design (Figure 2) is widely used to compare
different groups and measure behavioural changes
regarding the experimental intervention (Dimitrov &
Rumrill, 2003). It is also used in Educational models
to assess students’ outcome, even in self-learning
students, being the instruction period the intervention
(Sumner & Capano, 2010). In this study, this design
will allow to analyse the changes on their birth
preferences after exposed to the content and the
individual learning outcomes. This questionnaire is
focused on collecting data regarding: knowledge,
influential factors, autonomy and self-relevance
regarding pregnancy and birth; perception of
credibility of different sources of information.
The test will be conducted by asking two groups
to perform guided-tasks in a controlled environment.
Kaikkonen et al. (2008) study shows that important
Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of
an Ongoing Study following a Mixed-Method Approach
703
results can be achieved through laboratory tests, even
in settings when the cognitive load from using digital
devices could be an issue. The preparation of the
environment to simulate a real situation is highly
recommended, and the complexity of real usage
needs to be foreseen and reflected on the tasks guide.
A printed guide will be handle to each participant,
which lists a set of numbered tasks to be performed,
and clarifies that they should be autonomous, despite
the fact that a thinking-aloud protocol is being
followed (Boren & Ramey, 2000) and they under
observation - direct and structured by using a
behaviour schedule and keeping it as discrete as
possible to avoid Hawthorne effect (McLeod, 2015).
After the conclusion of the test, and after
answering one more time the QPPF questionnaire, the
participants will be asked to fill in a questionnaire
(Q2) related to their perceptions and experience
during the test, to measure adequacy and quality of
the content, aiming to check if the information
provided meet their needs. For the version Q2a, some
questions regarding the digital tool usage will be
included, in order to understand if the tool was well
designed and developed, and how important was the
interactivity and dynamism provided by digital
media. On the other hand, the participants from the
Control Group A will answer Q2b which includes
questions related to paper-based experience. This will
allow a comparison between the two formats, and the
main data collection ends after Q2 completion.
For reliability and validity purposes, the
participants will be contacted once more for a follow-
up questionnaire (QPPF), after they attend the
antenatal classes. This collection aims to understand:
what are the impacts of being exposed to content, by
testing a digital or a paper-based tool; if
acknowledging the possibility of listing their birth
preferences triggers behavioural changes and the
communication with health professionals, namely
searching for information in different sources; how
obtaining more knowledge helps creating a labour
and birth preferences list.
Control Group B will be needed for this part of the
study. It will be composed by participants who
attended the antenatal classes, but did not participate
in the previous part of the study. They will be asked
to fill in a questionnaire (Q3) for feedback regarding
the classes, plus the QPPF questionnaire for
comparison purposes with the other groups.
Figure 2: Data collection plan, by Group.
The literature, namely results from recent
systematic reviews (Suto et al, 2016; Brixval, 2016;
Kilfoyle, Vitko, O’Conor & Bailey, 2016; Say,
Robson & Thomson, 2011; Vlemmix et al, 2013),
shows that research on Comprehensive Sexual
Education, Childbirth Literacy and Self-care for
Health can still be conducted for different
contributions, since several topics are unexplored yet.
The most common topics found are related to:
Satisfaction of women with antenatal education and
with the birth outcome; Impact of informed-decision
making and decision aids in maternity care; Maternal
depression; Maternal and Infant mortality and
morbidity rates; Reproductive and sexual behaviours
of the women; Impacts on decisions regarding
nutrition during pregnancy and for the child; Impact
on child development and health outcomes. The less
common, but also present, are evidences collected in
other studies (Sanders & Crozier, 2018; Wallwiener
et al, 2016) regarding: Preventive health care;
Influences for pregnant person’s decisions regarding
birth (Barimani, Frykedal, et al., 2017; Frykedal et al.,
2015; Lima-Pereira, Bermudez-Tamayo, &
Jasienska, 2012); Paternal depression; Partners’ fears
and anxiety regarding birth; Partner attendance and
satisfaction with childbirth; Satisfaction with the
postnatal couple relationship; Parenting behaviours
and distress; and Parent-infant interaction.
While the usage of media and e-health technology
is a rising topic (Khanum, de Souza, Sayyed & Naz,
2017; Moore, Drey & Ayers, 2017), some literature
gaps form the social sciences perspective could be
identified: partners participation taking in
consideration LGBT+ and different patchwork
families (Entsieh & Hallstrom, 2016; Vikstrom &
Barimani, 2016); decision tendencies considering
different cultural backgrounds, needs, abilities and
resources (Frykedal, Rosander, Berlin, & Barimani,
2015); sources of information to their reach
(Barimani, Frykedal, et al., 2017).
In what concerns the specific, yet transdiciplinary,
field that is Perinatal Digital Education, studies are
still scarce. Keeping that in mind, an analysis model
was created for this research, and part of it can be seen
HEALTHINF 2021 - 14th International Conference on Health Informatics
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on Table 1, related to the Concept of Informed
Decision-making regarding birth options, listing the
Dimensions and highlighting the Indicators, being
this part of the major innovations of this research.
Table 1: Part of the Analysis’ Model.
Dimensions Indicators
Knowledge Access to perinatal formal courses;
Searching behaviour for general
information, for health, for pregnancy
and for labour and birth topics;
Access to birth data by format, people
and commercial bias;
Perception of accuracy when obtained
from different sources, channels and
formats;
Motivation to know more when
obtained from different sources,
channels and formats;
Opinion on the relevance of being
informed through scientific evidence.
Values,
Attitudes
and
Behaviours
Tendency on the decisions according to
religion, prejudice, fear, life style,
believes, empower.
Influence Influence on the decisions when
information comes from different
sources, channels and formats.
Pregnant
person
Expectations of amount of labour and
birth information;
Expectations for autonomy on labour
and decisions;
Opinion on current printed and digital
materials distributed by Portuguese
National Health System;
Sensitivity to explicit content.
Notes:
“Different sources” refers to people, institutions and
companies; “Different channels” refers to oral, paper and
digital; “Different formats” refers to text, visuals and
audio.
3 EXPECTED CONTRIBUTIONS
The innovation of the study resides in filling an
existent gap in the literature, since: no studies
comparing the outcomes of Print vs. Digital-based
Decision aids for Childbirth Education purposes were
found; no studies were found on providing
information side by side with the decision options for
the birth plan creation; the online tools available for
birth plan creation are scarce and do not cover a wide
range of topics and suffer from limitations of
interactivity - details regarding this literature review
and benchmarking analysis will be published in the
near future; and ultimately, this provides an example
how mixed methods can contribute to establish the
bridges, not only between two, but three different
fields of study.
The research design as planned can contribute to
better understand if exposing pregnant women to the
created content and to the concept of informed
decision-making leverages their knowledge and
contributes for the decision-making process for their
own birth, and if it triggers rich discussions between
them and Childbirth Educators. Besides, the initial
data collection is intended to make possible to
understand: which are the other agents involved on
the Maternal Education; what type of information
they provide; how they reach the pregnant person;
and the accuracy perceived of that information.
By including a Control Group B, it will also be
possible to measure the outcome from antenatal
classes of the partner Health Centre, which will be the
only source of feedback they have until the moment.
Analysing the gathered data may clarify if different
learning paths have difference learning outcomes, and
if it would be tool to use within the classes.
Nevertheless, an online learning and decision aid tool
could engage expectant parents who might not
available to enroll the classes, due to health, time,
transportation and other constrains.
As concluded by Zisman-Ilani, Gordbenko, Shern
and Ewlyn (2017) on a study also comparing Digital
vs. Paper-base Decision Aids but on a different
context (Psychiatric field), it is relevant to develop a
specific digital tool so the respondents can address
advantages and disadvantages of a particular material.
Besides the paper-based materials, an interactive,
accessible and digital tool, with simple language and
multimedia contents illustrating scientific concept
following WHO (2016; 2018) guidelines, it is
expected to meet the audience needs, who is not
supposed to be expert in health. The proposal is
intended to provide safe and reliable source of
information, and become a reference for other studies
and projects, and which can be used by Childbirth
Educators - in Portuguese speaking contexts due to
language constrains. Details regarding the creation
Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of
an Ongoing Study following a Mixed-Method Approach
705
and validation of the content created will be published
in the near future.
It is relevant to recall that this study is a step
forward for Portuguese context and can establish
ground for public health policies to recognize women
empowerment regarding birth, by providing a
proposal which is missing on the Pregnancy
Monitoring and Parenting Preparation Program from
Directorate-General for Health (DGS, 2015), as a
dematerialised option that could be adopted
nationally, a topic currently under the political radar
(GPPS, 2018).
Due to Coronavirus disease 2019 (COVID-19),
the proposed research design may suffer some
adjustments in order to comply with the countrys
most up to date Restrictions Regulations.
ACKNOWLEDGEMENTS
The authors would like to thank: Rita Leal, RN/CNM
for her support on the design settings of the
experimental phase; the three anonymous reviewers
for the most helpful comments; and the HEALTHINF
2021 organisation committee for the registration
grant provided, and the Secretariat for their diligent
work; and, the University of Aveiro and António
Moreira in particular, for all the support provided.
CVL would like to acknowledge the fund support
through the Doctoral Programme in Technology
Enhanced Learning and Societal Challenges
(PD/00173/2013) by FCT, through their research
grants PD/BI/135241/2017, followed by doctoral
grants PD/BD/143077/2018.
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