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A study of factors influencing utilization of pre-natal educational services Yarie, Sarah Fulton 1978

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A STUDY OF FACTORS INFLUENCING UTILIZATION OF PRE-NATAL EDUCATIONAL SERVICES by Sarah Fulton Yarie B.A., West V i r g i n i a U n i v e r s i t y , 1975 A Thesis Submitted i n P a r t i a l F u l f i l l m e n t of The Requirements For the Degree of Master of Science in The Faculty of Medicine Department of Health Care and Epidemiology We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA December.,. 1977 (c)Sarah Fulton Yarie, 1977 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and stu d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department of Health Care and Epidemiology The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 an advanced degree at the U n i v e r s i t y o f B r i t i s h C olumbia, I agree t h a t i i ABSTRACT A comparative study of two groups of primiparas was conducted i n Vancouver, British Columbia (Canada), during the summer of 1976. The f i r s t group was comprised of those women who attended 50 per cent or more of a series of prenatal classes (the attenders), and was compared to a group of non-attenders, those who had not attended prenatal classes during their pregnancy. The objective of the study was to examine those factors which are expected to influence u t i l i z a t i o n of prenatal educational programs. The long-term objective was to generate data which could be used to improve these programs; and, consequently, also to improve the health of the mother and child. From a total sample of 154 primiparas drawn from the mothers having given birth to a liv e baby in April, May or June 1976, 127 were inter-viewed: 54 non-attenders and 73 attenders. The comparison of the groups of attenders and non-attenders showed the following results: 1) There were differences between the two groups in regard to basic socio-economic and demographic characteristics. In general, the non-attenders tended to be younger, less educated, poorer, new immigrants, and less fluent in English than the attenders. 2) When tested on a set of knowledge questions, the two groups showed differences in the areas of pregnancy, childbirth and child care knowledge. In general, the attenders responded correctly to more of the questions than did the non-attenders. However, / i i i on some questions, the differences were not very large and i t would be i n t e r e s t i n g to re-examine these differences when con-founding factors are co n t r o l l e d (e.g., Eng l i s h fluency). The comparison of behavioural health practices revealed the following: The non-attenders were les s l i k e l y to smoke during pregnancy than were the attenders. - The two groups were f a i r l y comparable i n terms of a p o s i t i v e change i n t h e i r n u t r i t i o n habits during pregnancy. - As expected, more attenders than non-attenders used c o n t r o l l e d breathing techniques during the d e l i v e r y . Seventy-six per cent of the non-attenders ei t h e r p a r t i a l l y or t o t a l l y breastfed t h e i r babies compared with 55 per cent of the attenders. When asked about t h e i r reasons f o r not attending prenatal classes, the non-attenders most frequently mentioned a lack of awareness of the existence of the classes and a general f e e l i n g that i t was unnecessary to attend. D i f f i c u l t y i n speaking and understanding Engl i s h was also a factor i n n o n - u t i l i z a t i o n of classes. In regard to wife-husband r e l a t i o n s h i p s , husbands were given as a source of support by more attenders than non-attenders, although the d i f f e r e n c e was not s t a t i s t i c a l l y s i g n i f i c a n t . It could be worthwhile to investigate t h i s area more thoroughly to determine whether the presence of support from a husband/partner i s a reason iv f o r attendance or occurs as a r e s u l t of the attendance. The data on knowledge and behavioural health p r a c t i c e s could r a i s e questions concerning the effectiveness of the prenatal programs. However, t h i s study has not been designed to evaluate these programs. Most of the factors studied regarding knowledge and health p r a c t i c e s are known to be associated with socio-economic and c u l t u r a l f a c t o r s . An analysis of the true e f f e c t of the program should take these factors into consideration. In conclusion, t h i s study has shown ways of increasing u t i l i z a t i o n of prenatal educational programs. Emphasis should be placed on the following: The target population - More e f f o r t and resources should be de-voted to reach lower socio-economic groups, new immigrants, and those l e s s f l u e n t i n the English language. The method - New communication and information dissemination techniques, as well as d i v e r s i f i e d teaching methods, should be developed (e.g., more courses should be taught i n a language other than English). The content - Given the differences i n knowledge l e v e l s and health p r a c t i c e s , the content should be geared more to meet the needs of s p e c i f i c sub-groups i n the population. P u b l i c i t y - The study demonstrates the need f o r making better known the existence of the program as well as i t s present objectives. 1) 2) 3) 4) V This study has raised a number of questions regarding both u t i l i z a t i o n of prenatal care and outcome measures r e l a t i n g to t h i s care. Therefore, a larger and well designed study to investigate these questions more extensively i s recommended. v i TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i i LIST OF FIGURES x i i ACKNOWLEDGEMENTS x i i i INTRODUCTION 1 CHAPTER I BACKGROUND OF THE STUDY 6 Previous Investigations 6 Physical and Socio-demographic Setting of the Study 11 Description of Prenatal Programs . . . 13 CHAPTER II RATIONALE AND OBJECTIVES OF STUDY . . . 15 Rationale for Study 15 Research Objectives 16 Significance of Study 20 CHAPTER III METHODOLOGY 22 Sampling Methods 22 Interview Schedule and Administration . 24 Measurement of Socio-economic Status . 28 Assessment of Language, Knowledge and Health Practices 29 Stati s t i c a l Treatment 30 v i i Page CHAPTER IV RESULTS , . , 32 Sample D e s c r i p t i o n . . . . . . 32 Pe r c e p t i o n of Purpose of P r e n a t a l Classes: Hypothesis I A l Measurement of Socio-economic Status: Hypothesis I I 42 The Respondents' System of S o c i a l Networks: Hypothesis I I I . . . . 44 Summary 47 CHAPTER V SUMMARY OF OTHER FINDINGS 50 Reasons f o r Non-Attendance . . . . 50 Other Factors I n f l u e n c i n g P r e n a t a l Care 52 Knowledge Questions 59 Health P r a c t i c e s of Respondents . . 68 Summary 71 CHAPTER VI DISCUSSION AND IMPLICATIONS OF RESULTS . 75 Di s c u s s i o n of Major Findings . . . 75 Di s c u s s i o n of Other Findings . . . 77 Suggestions f o r A d d i t i o n a l Research . 83 I m p l i c a t i o n s 85 CONCLUSION^ .. 8 6 a BIBLIOGRAPHY 87 APPENDIX A Interview Schedule 91 APPENDIX B L e t t e r to Respondent 112 APPENDIX C Planning/Programming Information . . . 114 v i i i LIST OF TABLES Page TABLE I Number and Percentage D i s t r i b u t i o n of Sampling Frame, Projected Sample and Actual Sample by Geographic Location of Respondent, Number of Parents i n Family and Month of Delivery . . . . 33 I I Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Age . . 35 I I I Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by M a r i t a l Status 36 IV Respondents' Place of O r i g i n by Geographic Area of Residence 37 V Number and Percentage D i s t r i b u t i o n of Respondents by P r i n c i p a l Language Spoken 38 VI Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Level of Education 39 VII Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Family Income 39 VIII Number and Percentage D i s t r i b u t i o n of Actual Sample and General Population of Primiparas by Age, 1974 41 IX Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Perceived Purpose of Prenatal Classes 41 X Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Socio-economic Rankings 43 ix X TABLE Page XXII Number and Percentage Distribution of Non-Attenders and Attenders by Recommendation of Doctor to Attend Prenatal Classes • 57 XXIII Number and Percentage Distribution of Non-Attenders and Attenders by Recommendation of Doctor Not to Attend Prenatal Classes 58 XXIV Number and Percentage Distribution of Medical Specialty by Recommendation of Doctor Not to Attend Prenatal Classes 58 XXV Number and Percentage Distribution of Medical Specialty by Recommendation of Doctor to Attend Prenatal Classes . . 59 XXVI Number and Percentage Distribution of Non-Attenders and Attenders by Responses to Knowledge Questions on Nutrition • . 63 XXVII Number and Percentage Distribution of Non-Attenders and Attenders by Responses to Knowledge Questions on Infant Feeding . 64 XXVIII Number and Percentage Distribution of Non-Attenders and Attenders by Responses to Knowledge Questions on Labour and Delivery 66 XXIX Number and Percentage Distribution of Non-Attenders and Attenders by Primary Source of Knowledge 68 XXX Number and Percentage Distribution of Non-Attenders and Attenders by Feeding Pattern 69 XXXI Number and Percentage Distribution of Non-Attenders and Attenders by Smoking during Pregnancy 70 XXXII Number and Percentage Distribution of Non-Attenders and Attenders by Use of -Breathing Techniques during Labour and Delivery 70 x i TABLE XXXIII XXXIV XXXV XXXVI Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Change i n N u t r i t i o n Habits during Pregnancy Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Type of Health Service Preferred f o r Baby Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Information Desired Regarding Pregnancy and Delivery Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Information Desired Regarding Ch i l d Care Page 71 118 118 119 x i i LIST OF FIGURES FIGURE Page I Flow Chart of the Interview Process 27 x i i i ACKNOWLEDGEMENTS I am indebted to many people who contributed to the completion of t h i s t h e s i s . A s p e c i a l acknowledgement, however, i s due to my husband, John, whose patience, encouragement, and humour helped make i t p o s s i b l e for me to complete graduate school. I would also l i k e to express my appreciation to Dr. Michel Vernier, my thesis committee chairman, for h i s guidance and support, e s p e c i a l l y during the reading of the t h e s i s . In addition, g r a t e f u l thanks are due to the other members of my thesis committee, Dr. K a r l Smith, Dr. Annette Stark, and Dr. Andrew S e l i g , f or t h e i r assistance and constructive c r i t i c i s m s . Thanks i s also due to Don Earner who, through his r o l e as consultant, answered my numerous questions and provided p o s i t i v e comment. The constant support of Diane Layton throughout t h i s project and e s p e c i a l l y i n the early stages of my w r i t i n g i s g r a t e f u l l y acknowledged, as i s the assistance of B i l l Falk i n the proofreading of the t h e s i s . Also to Cora van Ginkel many thanks for her t i r e l e s s e f f o r t s during the f i n a l typing. Thanks are also due to the s t a f f of the Metropolitan Health Services for allowing me access to the physicians' c e r t i f i c a t e s of l i v e b i r t h s . In p a r t i c u l a r , I am indebted to Ms. Lara Thordarson for her invaluable help during the i n i t i a l phases of the project. Many thanks are also due to the United Way of Greater Vancouver, as well as National Health and Welfare, f o r t h e i r f i n a n c i a l assistance throughout the project. F i n a l l y , I would l i k e to thank the many women who, by t h e i r p a r t i c i p a t i o n i n answering my innumerable questions, made t h i s study poss i b l e . 1 INTRODUCTION It i s generally acknowledged in developed countries that, since the primary health care needs of the majority of the population are being met and knowledge of the factors which promote and maintain health i s increasing, there i s concern among both health care providers and lay persons that a l l individuals have access to additional services which are specifically designed to promote health and to provide individuals with the opportunity to enhance the quality of their lives. (Stark, 1976). Pregnancy and the addition of a family member i s one type of event which could benefit from the provision of these additional services. There i s evidence, at least i n the presence of significant stress, that those with l i t t l e general support experience more complications of labour and delivery. (Nuckolls, 1972) Prenatal education courses, also known as "preparation for parenthood" classes, have provided expectant parents with a method of enhancing the experience of pregnancy and de-livery as well as promoting child and family health. Prenatal classes in British Columbia, for example, have as their focus "the promotion of confidence in the a b i l i t y of parents themselves to develop their own i n -dividual family pattern as well as the opportunity to gain specific i n -formation about pregnancy and childbirth and to develop attitudes that w i l l promote positive mental health and to help parents to have emotion-a l l y healthy children." (British Columbia Health Branch, 1966.) These services are considered to be beneficial for both the parents 2 and the child. For example, in a study conducted by the Metropolitan Health Services in British Columbia (Thordarson and Costanzo, 1976) i t was found that women who attended prenatal classes were satisfied with the content of the classes. In a detailed study conducted by Primrose and Higgins (1971) on dietary planning for pregnant women, those women receiving counselling experienced a great decrease in prematurity and an increase in birth weights of the infants. There were also fewer perinatal deaths, the incidence of toxemia was reduced and an increased incidence of sponta-neous deliveries was reported. In effect, the positive outcome of the pregnancy was related to the length of time the mother had been receiv-ing the dietary help. Earlier studies reporting the beneficial effects of prenatal edu-cation and prenatal care indicate a number of other positive outcomes at delivery. For example, a shorter labour time for prepared women i s reported by Van Auken (1953); less use of analgesia and anaesthetic i s reported by Laird and Hogan (1956); less use of forceps i s reported by several investigators (Tupper, 1956; Van Auken, 1953; Laird and Hogan, 1956); less need for resuscitation of babies is reported by Van Auken (1953) and also by Thorns (1954); and f i n a l l y , less postpartum blood loss was reported by Thorns (1954). However, some of the more recent investigators studying prenatal education programs have not found the same degree of beneficial effects as did earlier studies. In the earlier studies, i t was expected that pre-pared mothers would cope more adequately with the labour experience and 3 thereby shorten their labours. It became apparent that, once any con-t r o l variables were introduced into the analysis (other than parity), this finding of shorter labour was not supported. (Stark, 1976; Scott, 1976; Enkin, 1972, and Zax, 1975.) Shapiro's (1973) finding of shorter f i r s t stage of labour in prepared women stands alone in recent investi-gations. However, he has defined the onset of labour more precisely than have other investigators. Consistent with earlier findings, Enkin and Scott both reported less use of analgesia in the f i r s t stage of labour by prepared mothers, and fewer operative deliveries. Stark found no differences between attenders and non-attenders of prenatal classes in the use of anaesthesia but noted that more than 70 per cent of a l l women studied received only local anaesthetics or none at a l l . Thordarson and Costanzo (1976), in studying 1,021 women, found no sig-nificant differences between attenders and non-attenders in mothers' reports of hours of labour at home or in minutes between contractions at admission to hospital. There were also no differences in mothers' reports concerning the analgesia and anaesthetics. Comparative lengths of labour were not studied. A major weakness of this study is the lack of control for age, social class and other non-attender/attender charac-te r i s t i c s in the analysis. Although the authors discuss the use of multivariate analysis, these i n i t i a l findings are based primarily on the use of non-parametric st a t i s t i c s . , Although these more recent study findings are somewhat inconsis-tent with earlier studies, much of the d i f f i c u l t y seems to occur in se-lecting meaningful outcome measures and then attempting to match these outcomes with the prenatal program content. There is also the problem 4 of randomly selecting comparable populations of attenders and non-attenders. It i s l i k e l y that some differences i n outcomes may be attributed to these varying populations. It seems reasonable to assume that the attendance rate for these prenatal programs would not be so high i f the consumer (i.e. expectant parents) were not receiving some positive benefits from the programs. However, specification of these ex-act benefits remains somewhat d i f f i c u l t . Suchman (1967), in discussing the necessity for evaluation of public service programs, states that, i n general, a balance w i l l be struck between faith and fact, reflecting the degree of man's respect for authority and tradition within the particular system versus his scepticism and desire for tangible "proofs of work." Assuming beneficial effects of prenatal education services, i t is accepted as desirable to deliver these services in a manner which allows them to be available and accessible to a l l . However, in the study con-ducted by Thordarson and Costanzo, i t was found that,bf the 1,021 primi-paras sampled in Vancouver, British Columbia, only 62 per cent attended the prenatal education program offered in the area. The 38 per cent of the primiparas who were non-attenders were considered to be of import-ance, as they tended to have a greater percentage (i.e. nine per cent of the non-attenders compared with five per cent of the attenders) of im-mature babies and a slightly higher incidence of toxemia than the mothers who attended prenatal classes. Those attending gained more weight dur-ing their pregnancies than the non-attenders, and, consequently, had heavier babies. (Thordarson and Costanzo, 1976.) 5 It i s considered important, then, to motivate non-attenders into seeking prenatal education services. The f i r s t step i n t h i s motivation process should be an examination of those factors which either f a c i l i t a t e or i n h i b i t the u t i l i z a t i o n of prenatal education services. Generally, once t h i s information i s obtained, incentives can be devised which may a s s i s t i n a t t r a c t i n g a greater proportion of the target population ( i . e . , parents expecting t h e i r f i r s t c h i l d ) . Consequently, t h i s study has been designed and c a r r i e d out to de-termine those f a c t o r s which influence u t i l i z a t i o n of prenatal educational programs by a group of primiparas i n Vancouver, B r i t i s h Columbia. Em-phasis i s placed on predisposing factors r e l a t e d to socio-economic status, age, e t h n i c i t y , and perception of the purpose of these programs. The study also focuses on the r e l a t i o n s h i p between attendance and non-attendance at these classes, as evidenced by the l e v e l of knowledge of these groups concerning pregnancy, c h i l d b i r t h and c h i l d care. The measurement of t h i s knowledge l e v e l i s one means of examining outcomes of these classes. 6 CHAPTER I BACKGROUND OF THE STUDY Previous Investigations A review of the literature regarding factors affecting the use of health services indicates that, in general, greater vise i s made of health services by better educated mothers (Merrill, 1958); Donabedian, 1961; Collver, 1967; Schonfeld, 1962; Mindlin and Densen, 1971; and Smiley, 1972), as well as by families of higher income and occupational status. (Kegeles, 1963; Donabedian, 1961; and Mindlin and Densen, 1971.) Some authors suggest that this i s as much a function of peer group orientation and previous experience and behaviour as i t is of available funds. (Glasser, 1958; Mechanic, 1962; Me r r i l l ; Kegeles; Nolan, 1967.) Hoff (1966) discusses the groups of people who f a i l to respond to organized health services, namely the lower socio-economic groups, and offers as some of the reasons health agencies f a i l to reach these people: lack of understanding (by providers) of the basic health and welfare needs of the population, negative attitudes on the part of health pro-fessionals, poor or insufficient communication on the part of these pro-fessionals with some segments of the community, and the r i g i d i t y of health programming in terms of the services and f a c i l i t i e s an agency offers. Hochbaum (1960), in describing why certain groups are hard to reach, concluded that they are d i f f i c u l t primarily because we appeal to values which are ours, and because we like to strive for things which are simply not important or perhaps not understandable to them. 7 Yerby, in a paper presented at the White House Conference on Health in 1965, stated that in comparison with higher income people, the poor are much less l i k e l y to obtain maternal health services such as prenatal and postnatal care, and family planning assistance. Given this basic premise, Collver (1967) interviewed 774 women in a follow-up of mater-nity patients in the Detroit area, in an attempt to measure the impor-tance of a number of variables in influencing their probability of attending c l i n i c s for maternal health services. This study demonstrated that the rates of attendance at prenatal, postpartum and family planning cl i n i c s are associated with a variety of patients' characteristics such as age, number of livin g children, and level of education. Specifically, the use of prenatal and postpartum care was higher among those of low parity, but women with large families were more lik e l y to seek family planning services. The use of prenatal and postpartum services tended to increase with age, but older women tended to have low rates of family planning c l i n i c attendance. Other variables had consistent associations with a l l three services. For example, married women were consistently more li k e l y to attend c l i n i c s than other women while formal education tended to increase the likelihood of attendance at a l l three services. In addition, accessibility or distance of clin i c s from patients' homes clearly had an effect on c l i n i c attendance. However, once these ob-jective characteristics were taken into account, the expressed attitudes or intentions of the patients themselves contributed nothing to the prediction of attendance rates. Another study, conducted by the University of Wisconsin Department of Nursing and the Milwaukee Health Department (Regan, Millington and 8 Waver, 1969) attempted to examine ways of obtaining and maintaining attendance at prenatal classes for expectant mothers living in low socio-economic areas and to identify factors affecting their attend-ance. This study demonstrated that mothers who liv e in lower socio-economic urban areas w i l l attend classes (58 per cent of the women in the study were attenders at prenatal classes). However, repeated per-sonal contacts, as well as a contact shortly before the class began, were needed to secure and maintain class attendance. Transportation and babysitting were two factors identified as problems prohibiting attend-ance. Responses from the interviews with both attenders and non-attenders revealed that health practices (e.g. as defined by the nutri-tional habits of the respondents) of expectant mothers who attended classes were better than those of the non-attenders. A series of studies i n California between 1952-1956 a l l found that a considerable proportion of women of lower income groups were either not receiving any prenatal care at a l l or were not receiving care as early i n the pregnancy as the medical profession deems necessary. (Monahan and Spencer, 1962.) In a study carried out in San Jose by the University of California (Broker, 1959), the major deterrents to seeking prenatal care involved a combination of external obstacles (e.g. finan-c i a l and babysitting problems), an inadequate perception of what prenatal care involves, and dissatisfaction with the c l i n i c ' s procedures. In the Los Angeles City Health Department study (Swayne, 1960), the fact that a woman was married and li v i n g with her husband seemed to be a significant motivating factor for seeking prenatal care, since mothers who were not with their husbands had on the whole received less prenatal attention. 9 Established Los Angeles residence, l e v e l of education and mothers' a t t i t u d e s were also i d e n t i f i e d as factors i n f l u e n c i n g prenatal care. In a t h i r d study conducted i n C a l i f o r n i a i n 1954 at the Los Angeles County General H o s p i t a l i t was found that mothers who d i d not receive prenatal care consisted l a r g e l y of the less educated, the older woman, the users of p u b l i c transportation and women who had not received pre-nata l care i n a previous pregnancy. In a recent study conducted i n London, Ontario, by Brown (1976), an attempt was made to determine the reasons for u t i l i z a t i o n or non-u t i l i z a t i o n of prenatal classes by parents who l i v e i n the London area and who were expecting t h e i r f i r s t c h i l d during a four-month period i n 1975 (N = 547). The r e s u l t s of the survey i n d i c a t e that n o n - u t i l i z e r s of prenatal care tend to be younger, l e s s well-educated and have a lower income than do the women who use classes. The reason given most often for non-attendance at these classes was s u f f i c i e n t knowledge of infant care and labour and del i v e r y , followed c l o s e l y by r e g i s t r a t i o n problems, inadequate information regarding c l a s s e s , pregnancy and health f a c t o r s , and personal and environmental factors (e.g. transportation or language problems or too busy). F i n a l l y , i n a yearly report prepared by the C i t y of Montreal Depart-ment of S o c i a l A f f a i r s , information i s provided about a number of mothers who had delivered within a s p e c i f i e d area and a s p e c i f i e d time period, and who had not attended prenatal classes. The women were asked t h e i r reasons for not attending and the main findings were: 1) They did not speak either English or French; 10 2) They did not think such classes were necessary; 3) Greek women were especially interested but the language problem served as a real barrier. (Paquin, 1976) The studies cited above have certain obvious limitations. The ma-jorit y of the studies were conducted in the United States and, conse-quently, on different populations and in different circumstances (e.g. payment for health services is more of an obstacle in the United States than in Canada). Also, with the exception of the Collver and Brown studies, these studies were mainly descriptive in nature and therefore were reported without the benefit of s t a t i s t i c a l tests of significance of the differences found. The San Jose study conducted by Broker did not report on how the sample was selected and a sample of only 30 mothers was interviewed. The study conducted by Swayne for the Los Angeles City Health Department had no control group, per se, and the interviews with the mothers were conducted by the Public Health Nurse who worked for the department, increasing the risk of bias during the interviewing phase. The Los Angeles County Hospital study was also purely descriptive , as well as the study conducted in Wisconsin by Regan, Millington and Waver (1969). Although the results of the study conducted by Thordarson and Constanzo are directly applicable to the Vancouver community, they did not attempt to examine in any depth the reasons for attendance or non-attendance at prenatal classes, nor did they specifically test hypotheses in order to isolate factors which influence u t i l i z a t i o n . However, these studies have identified some factors which inhibit or f a c i l i t a t e seeking prenatal education services as well as other maternal health services, 11 and have provided a basis for the present study. Physical and Socio-Demographic Setting of Study The City of Vancouver is situated in the extreme southwest corner of the Mainland of Canada in the province of British Columbia. Vancouver and i t s surrounding areas are commonly referred to as the Lower Mainland, although this term prescribes no s t r i c t geographic boundaries. In general, i t refers to the populated portion of the Lower Fraser Valley which fa c i l i t a t e s access to the eastern part of the province. "The view of the mountains and the sea, as well as the many parks and recreational areas, i t s strategic position and the mild oceanic climate, are a l l physical characteristics of the Vancouver area." (Lioy, 1975.) According to the Census st a t i s t i c s , the population of Vancouver City was 426,298 in 1971 and was 396,563 in 1976. Overall, Vancouver contributed 14.9 per cent to the growth of the Greater-Vancouver Region-al District between 1961 and 1971, exceeded only by the contribution of the municipality of Surrey with a percentage growth of 21.6 per cent. (Lioy, 1975.) During the past three decades, there have been changes in migration and in birth rates.''" One significant trend occurring i s the increasing proportion of young adults aged 20-34 now living in the Greater Vancouver Region; this increase i s due partially to the baby boom of the late 40s and early 50s. Also, many young adults are immigrating to the area, 1. Number of l i v e births per 1,000 population during a one year period. 12 resulting in an accelerated rate of household formation. The fact that in 1971 only 46.1 per cent of the people l i v i n g in the region were born in British Columbia, and 26.5 per cent were born outside of Canada, gives an indication of the importance of immigration. (Lioy, 1975.) The high crude birth rate (which peaked for the region around 1956) only became obvious in 1961, resulting in a large number of children aged 0-9 (15 per cent of the population). With a birth rate of 15.7 per cent in 1964 for Vancouver City, the effects of declining birth rates began to appear in 1966, but was even more apparent in 1971. By 1975, in Vancouver, the birth rate had dropped to 11.3. The movement in the 2 general f e r t i l i t y rate is another indicator of the decline in births. The general f e r t i l i t y rate for British Columbia dropped from 101.56 in 1964 to 57.42 in 1974. A similar decline has occurred in the Vancouver area. In spite of declining birth rates, there was s t i l l a total of 3 8,685 births in 1974 in the Metropolitan Vancouver area. With the i n -creasing emphasis on preventive health care and enhanced quality of l i f e , prenatal classes provide women with the preparation and support needed for childbirth. The present study was conducted in collaboration with the Metropol-itan Health Service of Greater Vancouver, the body responsible for the provision of public health services to the municipalities of Vancouver, Richmond, Burnaby, and the North Shore ( a l l municipalities in the Lower Mainland of British Columbia). Each of these municipalities has i t s own 2. The number of live births per 1,000 women in the 15-49 age group during a one-year period. 3. The birth rate in 1974 for Metropolitan Vancouver was 11.1. 13 autonomous health department which provides direct service to a munici-pality. The Vancouver City Health Department is divided into five health units: North, South, East, West, and Burrard. The health unit for the University Endowment Lands is a f f i l i a t e d with the Family Practice Unit of the University of British Columbia, also located in Vancouver. Description of Prenatal Programs Prenatal education programs are both available and accessible to expectant parents in the Lower Mainland, and especially to those l i v i n g in Vancouver. The Vancouver Health Department held i t s f i r s t prenatal class in November 1956, and gradually expanded these classes throughout the Metropolitan Health Service area. At present, the public health de-partment offers 42 courses in the space of every two months and enrolment 4 increased from 1652 women in 1956 to 4,720 women and 3,024 men in 1976. The overall objective of the expectant parent classes sponsored by Metropolitan Health Services are: 1) to present to expectant parents adequate knowledge on which to build strong, happy, healthy babies and families; 2) to prepare the pregnant woman for the process of labour through a method of conscious, controlled breathing and relaxation tech-niques, and to demonstrate and practise exercises relevant to childbirth; 3) to relate the story of the baby's prenatal development and birth, and of the powerful influence of the home atmosphere and the 4. The number of men enrolled at that time is unknown. 14 relationship within a family on the whole process of child rearing. (Thordarson and Costanzo, 1974) A series of prenatal classes consists of seven two-hour sessions at weekly intervals. One hour of the session is devoted to group dis-cussion, followed by an hour of demonstration and practice of appro-priate exercises, breathing and relaxation techniques. In addition to the classes held by the Vancouver Health Department, there are seven private organizations sponsoring childbirth classes in Vancouver. One of them, the Vancouver Childbirth Association, is fre-quently used by expectant parents, and offers an intensive nine-week course in natural childbirth. In the study conducted by Thordarson and Costanzo (1976), i t was shown that, of those women interviewed, 49 per cent attended publicly sponsored health classes, while 15 per cent attended those sponsored by the private sector, and 36 per cent of the expectant women did not attend private or public classes. 15 CHAPTER II RATIONALE AND OBJECTIVES OF STUDY Rationale for Study The f i r s t rationale for the study relates to the concern expressed by the staff of the Vancouver City Health Department to know the reasons why expectant women do not attend the prenatal programs during their pregnancy. Findings from a study conducted by that department in 1974 indicated that non-attenders were women who generally had a lower level of education and thus, one would expect, could profit considerably from prenatal education. D i f f i c u l t i e s had been encountered i n attracting ex-pectant women from the lower socio-economic strata, and this study w i l l attempt to ascertain the reasons why attendance i s lower among these groups and what type of incentives (e.g. knowledge, styles of presenta-tion and content) might f a c i l i t a t e further attendance. As well as in-centives, this study w i l l attempt to further the knowledge of those fac-tors which act as deterrents to prenatal care i n a manner which i s generalizable to a l l types of prenatal programs. A limited amount of information i s available in the literature on this area, and i t needs to be further explored. The second rationale for undertaking the study i s to provide a measure of the influence that individuals who constitute the social net-work of the primiparas have on the level of knowledge and, consequently, the behaviour of the woman during her pregnancy. The study w i l l also 16 attempt to measure the accuracy of the information when disseminated by a variety of sources, such as friends, relatives, prenatal classes and health professionals. Research Objectives The objectives of the present research are as follows: 1) to document the reasons why some expectant women do not attend prenatal education classes^ within the City of Vancouver; 2) to relate these reasons for non-attendance to the women's per-ception of these classes; 3) to provide comparative data on the primiparas who did participate in the prenatal programs; 4) to delineate various socio-economic and demographic characteristics of these two groups of expectant women; 5) to determine the level of knowledge regarding the areas of child-birth, prenatal care and postnatal care of the non-attenders and attenders; 6) The sixth objective i s to test the following three hypotheses: 5. Prenatal classes are those designed for expectant parents which offer information on anatomy and physiology of reproduction, hygiene of pregnancy, nutrition, relaxation and breathing tech-niques, the birth process, care of the mother and child after birth, feeding the infant, and adjustment of the new baby into the family. (Adapted from Regan, Millington and Waver, 1969.) 17 Hypothesis #1: Non-attendance at Prenatal Classes i s Directly Related to Misperceptions of the Course. Hypothesis #2; Non-attendance at Prenatal Classes i s Inversely Related to Social Class. Hypothesis #3: The System of Social Networks Determines whether or not a Woman Attends Prenatal Classes. In addition, the study w i l l provide documentation on the following areas, although they are not hypotheses, per se: 1) The routine use of a language other than English contributes to non-attendance at prenatal courses. 2) Obstetricians and physicians whose practices relate more to ob-stetrics make fewer referrals to prenatal classes than do other physicians. 3) Attenders w i l l have more knowledge on (1) controlled breathing and relaxation techniques; (2) contractions during labour and delivery; (3) nutritional requirements during pregnancy; (4) dieting during pregnancy; (5) weight gain; (6) restriction of salt intake during pregnancy; (7) breast-feeding and bottle-feeding; and (8) smoking during pregnancy, than w i l l non-attenders. 4) The attenders' level of health practices in the areas of (1) infant feeding; (2) smoking during pregnancy; (3) use of controlled breathing techniques during labour and delivery; and (4) nutri-tional habits, w i l l d i f f e r significantly from that of the non-attenders. 18 The f i r s t hypothesis w i l l be to determine whether a r e l a t i o n s h i p e x i s t s between u t i l i z a t i o n of prenatal programs and the perceptions of these programs by the women interviewed. More s p e c i f i c a l l y , i t i s hypo-thesized that i f a woman has an incor r e c t perception of the purpose of prenatal classes, the l i k e l i h o o d of her attending would be lessened. On the other hand, i f a woman has a correct perception of the purpose, she w i l l be more l i k e l y to attend. The analysis w i l l focus on the r e l a -tionship between "awareness of correct purpose" (purpose was defined by each respondent) and prenatal u t i l i z a t i o n , which w i l l be measured by whether or not a woman attended prenatal education classes during her pregnancy. As there i s considerable evidence i n the l i t e r a t u r e to support the assumption that lower income groups are much l e s s l i k e l y to seek and obtain maternal health services such as prenatal and postnatal care, i t i s recognized that the second hypothesis has been previously tested on other populations. However, i t was considered important to test Hypothesis 2 on a Vancouver population and to test Green's scale f o r measuring economic status^ i n a Canadian c i t y . For purposes of t h i s study, socio-economic status i s defined as the r e l a t i v e p o s i t i o n of a person, or family, i n a hierarchy and i s used as a t o o l to predict the outcome of preventive health behaviour. SES i s not regarded as an a t t r i b u t e i n and of i t s e l f , but rather a 6. The purposes given by the respondents were considered, by the i n -vestigator, to be 'correct' i f they coincided with the objectives of both p r i v a t e and public c h i l d b i r t h classes. 7. This scale w i l l be discussed i n Chapter I I I on Research Design. 19 composite of characteristics, such as income, education, and occupation. Operationally, SES has been divided into three groupings: lower, middle and upper class. These groups are defined as follows: Lower Class: A respondent whose family income i s between $0 and $8,999 or who has an education level of less than Grade 12. Middle Class: A respondent whose family income is between $9,000 and $14,999 or who has completed High School or has attended University or College. Upper Class: A respondent whose family income is $15,000 and over or who has completed an undergraduate degree or postgraduate training. The focus of Hypothesis #2 is the influence of social class on the primiparas' u t i l i z a t i o n of prenatal programs. The analysis w i l l focus on the association between the independent variables of .family income and educational level of the respondent (i.e. the SES composite score) and the dependent variable of prenatal u t i l i z a t i o n . The third hypothesis concerns u t i l i z a t i o n of prenatal classes and the support available to a woman during the time of her pregnancy. More specifically, the hypothesis states that the presence of the immediate family reduces the likelihood of attendance at prenatal classes. Con-versely, the absence of a system of support increases the likelihood of attendance. That i s , i f a woman has close support from individuals in her family on an ongoing basis, she may not feel that i t is necessary to attend prenatal classes. Social network i s defined here as the im-mediate family ( i . e . husband or common law husband, father and mother). 20 In order to test t h i s hypothesis, i t w i l l be necessary to examine two aspects. F i r s t , the percentage of women who a c t u a l l y have someone from whom t h i s support can be received. Secondly, given that there are d i f f e r -ences i n the two groups, then, what i s the e f f e c t of t h i s support on the u t i l i z a t i o n of prenatal classes by the respondent. Sign i f i c a n c e of Study This study i s expected to provide benefits to three major groups: (1) women of childbearing age, who become pregnant; (2) health p r o f e s s i o -nals who plan and provide prenatal services, e s p e c i a l l y those i n the Vancouver C i t y Health Department; and (3) educators who provide t r a i n i n g for students i n the health professions. (1) I t i s expected that one outcome of t h i s study w i l l be the pro v i s i o n of more comprehensive information than already e x i s t s , on the expectations and needs of women who are pregnant. (2) This study w i l l benefit health professionals who plan and provide prenatal services, i n three p r i n c i p a l ways. The f i r s t i s that, given the d e s i r a b i l i t y of prenatal education, a study such as t h i s one would aid considerably i n gaining an understanding of the health knowledge, p r a c t i -ces and behaviour of the users and non-users of prenatal health education services. The second p r i n c i p a l c ontribution would be to provide a system-a t i c basis f o r making changes i n order to meet the educational/social/ psychological needs of the p o t e n t i a l p a r t i c i p a n t s i n these courses. The t h i r d major be n e f i t to the health professionals w i l l be the assistance t h i s study w i l l provide i n formulating an information d e l i v e r y system 21 geared to a t t r a c t i n g a greater proportion of the target population ( i . e . of s p e c i a l importance are those women who, i n the past, have not been s u f f i c i e n t l y motivated by the programs to attend). (3) I t i s expected that information derived from t h i s study w i l l give those who are providing t r a i n i n g f o r students i n the health professions a broader base from which to conduct t h i s t r a i n i n g and to promote r o l e d e f i n i t i o n . I t may make them also more aware of the increasing import-ance of the i n t e r d i s c i p l i n a r y team approach i n the f i e l d of maternal and c h i l d health. 22 CHAPTER III METHODOLOGY A group each of attenders and non-attenders and their reasons for attending and non-attending were examined in an attempt to identify the differences between the two groups. Specifically, two samples of mothers delivering first-born infants were selected from the total group of primiparas in the City of Vancouver, who delivered in April, May, or June 1976. A standardized interview schedule was devised, pretested and admin-istered by trained interviewers to these two groups of women in their homes during July and August 1976. Generally speaking, the interview addressed those topics which have been identified by individuals working in the health f i e l d as influencing attendance or non-attendance at pre-natal classes. Although the problems associated with selective recall are recognized, i t was only feasible to interview these women between one and four months after delivery. Sampling Methods The participants in this investigation included two groups of primi-paras, one of which attended and one which did not attend a prenatal education program during pregnancy. Since a given precision of + 15 per cent of true proportion with a r e l i a b i l i t y of 95 per cent was desirable, a sample size of 70 attenders and 70 non-attenders was deemed necessary to conduct the analysis. 23 The total sample was str a t i f i e d based on (1) the geographic location of the respondent, and (2) attendance or non-attendance at prenatal education programs, in accordance with the following procedure: A l l certificates of li v e births among, primiparas for Apr i l , May and June 1976 were photocopied and kept on f i l e by the Vancouver Health De-partment. At the end of the three-month period the certificates of liv e births were strati f i e d according to the five health units i n the city to which they related (e.g. North, East, South, West, and Burrard). The investigator then contacted these five separate health units, and through the use of their prenatal appointment books, attempted to further stratify the population of women by separating those who did attend the prenatal education courses in those particular months from those who did not attend. The names were then matched with the mothers' names on the physicians' certificates of liv e births, enabling the investigator to separate the attenders from the non-attenders. The random sample of 70 attenders and 70 non-attenders was then selected, using these validated physicians' certificates of liv e births. Attenders were only counted as such i f they had attended 50 per cent or more of the classes. Those women who had attended less than 50 per cent were counted as dropouts and were treated as a separate group. However, this latter group was considered to be a small portion of the total group and was not included in the f i n a l analysis. A practical consideration was the exclusion of multiple births from the sample. These were excluded primarily because of the complexities involved in recording and analyzing responses involving more than one 24 baby (e.g. questions regarding c h i l d care i s s u e s ) . In addition, i t was f e l t that the number of women having multiple b i r t h s would be small enough not_.to s i g n i f i c a n t l y a f f e c t the r e s u l t s . In f a c t , only one woman was excluded from the sample because she had a mult i p l e b i r t h . Limitations of the study include the r e c a l l problems inherent i n interviewing women about circumstances revolving around the pregnancy and d e l i v e r y between one to four months a f t e r the de l i v e r y , as well as the s e l e c t i n g of women who delivered only during three months of the year ( i . e . A p r i l , May and June). As expectant women t y p i c a l l y begin prenatal programs four to f i v e months p r i o r to t h e i r d e l i v e r y , many of the p o t e n t i a l users of these programs would have begun around December or January. The influence of bad weather, vacations and holidays could have a f f e c t e d attendance or non-attendance at these classes. Although these l i m i t a t i o n s are recognized, i t was only p o s s i b l e to study a cer-t a i n proportion of the t o t a l group of primiparas for the year. Interview Schedule and Administration An interview schedule (See Appendix A) was chosen as the p r i n c i p a l means of data c o l l e c t i o n f or two reasons: (1) since a considerable por-t i o n of the information to be c o l l e c t e d required the p a r t i c i p a n t s to be able to r e c a l l experiences and events which occurred p r i o r to the d e l i -very, considerable probing was necessary; and (2) since the emphasis was on non-attenders and t h e i r reasons f o r n o n - u t i l i z a t i o n of prenatal classes, i t was f e l t that a personal interview would e l i c i t a greater rate of p a r t i c i p a t i o n than the use of a questionnaire administered by mail. 25 The data c o l l e c t i o n instrument, then, consisted of a personal i n -terview using a standardized interview schedule. A form of p i l o t study was undertaken among s i x women i n the Vancouver area i n an attempt to detect the more serious flaws i n the instrument. A pretest was also conducted among a group of ten primiparas who delivered during the same period ( A p r i l , May and June) but who l i v e d i n the municipality of Rich-mond. This pretest was conducted over a one week period. Of the ten primiparas i n the pretest, s i x were attenders at a prenatal educational program and four were non-attenders. Two female students from the U n i v e r s i t y of B r i t i s h Columbia were hir e d to conduct the interviews. Both of these students were i n t h e i r early twenties and one had received her undergraduate t r a i n i n g i n Nu-t r i t i o n / D i e t e t i c s while the second had received t r a i n i n g i n the f i e l d of Sociology. The Sociology student had some previous experience i n interviewing and the N u t r i t i o n / D i e t e t i c s student had p a r t i c i p a t e d i n courses offered i n her department on interviewing techniques. In addi-t i o n , these two students were given a two-day t r a i n i n g session i n the techniques of interviewing. In essence, the t r a i n i n g included two main areas: (1) a general discussion r e l a t i n g to the strategies and t a c t i c s of interviewing, and (2) a s p e c i f i c discussion regarding the instrument i t s e l f and a check on the degree of r e l i a b i l i t y between the two i n t e r -viewers. This r e l i a b i l i t y check, combined with the pretest, indicated a f a i r l y high degree of r e l i a b i l i t y between the two interviewers. The main differ e n c e between these interviewers was i n the s t y l e of i n t e r -viewing and was recognized and con t r o l l e d f o r as much as possible. During the t r a i n i n g , the interviewers were also made aware of the general 26 purpose and objectives of the study. Before the f i e l d work began, a letter was sent to each potential participant explaining the project, requesting her participation and co-operation and assuring anonymity and the confidentiality of her res-ponses. (A copy of the letter sent to each woman can be found in Appendix B.) This letter was followed by a telephone c a l l from the i n -terviewer to schedule an appointment and to answer any questions the woman might have concerning the research. At this point, the inter-viewers were not aware of who constituted an "attender" or "non-attender" but they were each given a l i s t of potential participants and were instructed to attempt to contact each of the individuals on the l i s t either by telephone, or in person i f no telephone number was list e d , at least four times before removing her name from the primary sample. Obviously, during the interview (at a mid-point on the inter-view schedule) the interviewers found out who was an attender or non-attender. Although i t would have been preferential to contact and i n -terview the non-attenders f i r s t , the i n i t i a l interviews were conducted with a mix of attenders and non-attenders. Interviews were conducted in the home of each participant during a seven-week period from July 7th to August 31st, 1976. During this seven-week period, a total of 154 contacts were made (See Figure I). Interviewing was conducted mainly during the hours of 9 a.m. to 4 p.m. and occasionally during the evening or on the weekend. Since a tele-phone c a l l was f i r s t made to the potential participant to schedule the 8. Additional names were drawn from the "non-attending" frame to compen-sate for the small number of non-attenders who were being interviewed. FIGURE I F l ow C h a r t of I n t e r v i e w P r o c e s s I n t e r v i e w P r e n a t a l C a r e s t u d y ; one i n t e r v i e w was e x c l u d e d b e c a u s e of i n t e r p r e t a t i o n d i f f i c u l t i e s and the s e c o n d i n t e r v i e w was m i s t a k e n l y c o n d u c t e d w i t h a m u l t i p a r a . 28 interview, a number of interviews, especially among the attenders, were carried out f a i r l y readily. However, of the i n i t i a l l i s t (i.e. the primary sample) of attenders and non-attenders, 32 out of 140 (or 23%) did not have phone numbers which we could locate. Of the total 154 women contacted, only two refused to participate. We were unable to locate four of the women and 14 women had moved from the Vancouver area. Measurement of Socio-economic Status (SES) The scale chosen for measuring SES in this study was developed by Lawrence Green of Johns Hopkins University, principally for research into health behaviour. The index was developed from a stepwise regres-sion analysis on data from a statewide sample (N = 1,592) of California families with at least one child under five years of age. (Green, 1968; Mellinger, 1967.) The criterion or dependent variable in the regression analysis was a composite index of nine types of preventive health be-haviour. (Green, 1968.) Green contends that the SES indices are intended to optimize the prediction of family health actions from socio-economic information. He also emphasizes that these indices are not intended to be applied to institutionalized, adolescent or aged populations. Further tests of validation of the scale are recommended for populations which di f f e r from the Californian sample. This study i s an attempt to use this scale in a Canadian city. 29 A few b r i e f comments may be made regarding the use of a composite index f o r measuring socio-economic status as contrasted with examining independent v a r i a b l e s such as family income and education. The compo-s i t e allows one to look at a si n g l e score and make inferences about that score without the benefit of noting s p e c i f i c differences r e l a t i n g to the independent v a r i a b l e s . The use of a composite score, however, does provide for an easier analysis. Assessment of Language, Knowledge and Health Practices Given the large numbers of immigrants i n Vancouver, i t seemed im-portant to inve s t i g a t e the r e l a t i o n s h i p between the routine use of a language other than English and u t i l i z a t i o n of prenatal classes. Each respondent was asked what was the p r i n c i p a l language she spoke, and the interviewer provided an assessment of"the respondent's a b i l i t y to speak and understand spoken Engl i s h based on the interview process. R e l i a b i l -i t y checks between the two interviewers were made during the pretest and i n the t r a i n i n g sessions, u n t i l the inv e s t i g a t o r was s a t i s f i e d with the degree of r e l i a b i l i t y . An itemized r a t i n g scale was used by the i n t e r -viewers to make the assessment. It consisted of r a t i n g each of the res-pondents i n one of three categories: speaks English w e l l , f a i r l y , or poorly. Although the s i m i l a r i t i e s between " w e l l " and " f a i r l y " were recognized, a c e n t r a l point i s necessary for t h i s type of scale. ( S e l l t i z , 1959.) As the attenders had p a r t i c i p a t e d i n prenatal classes and conse-quently received a considerable amount of information on pregnancy, c h i l d b i r t h and c h i l d care, one would expect them to have more accurate 30 knowledge on these areas than would non-attenders. Both groups were read a series of statements and asked to indicate whether they agreed or disagreed with the statements. A third category of "don't know" was not offered to the respondents as a choice, but was recorded by the i n -terviewers when this was the reply, or the interviewee indicated that she lacked the information either to agree or disagree. Probing con-sisted of repeating the original statement and the interviewers were cautioned not to rephrase or reword any of the statements. It follows, then, that i f the attenders are using the knowledge they have, their level of health practices would also dif f e r considerably from the non-attenders. This study attempted to examine differences between the two groups in the following four areas: (1) infant feeding; (2) smoking during pregnancy; (3) use of breathing techniques during labour and delivery; and (4) nutritional habits. Each respondent was asked an open-ended question which related to each of the above areas. S t a t i s t i c a l Treatment The Fisher's Exact Probability Test (Siegel, 1956, pp. 96-104) was used in assessing the s t a t i s t i c a l significance of the differences be-tween the two groups in relation to Hypothesis 1 on perceived purpose of prenatal classes. This test was especially useful because of i t s poten-t i a l for analyzing discrete data with small samples. The Mann-Whitney U test, a non-parametric form of the t test, (Siegel, pp. 116-126) was chosen as the means of testing the degree of association between the independent variables of family income and edu-31 cational level of the respondent (i.e. the SES composite score) and the dependent variable of prenatal u t i l i z a t i o n . Pearson's chi-square test for homogeneity (Siegel, pp. 104-111) was used in testing Hypothesis 3 which was concerned with participation in prenatal classes and the support available to a woman during the time of her pregnancy. The chirsquare test was also used to test for differences between the two groups and their level of knowledge and health practices. 32 CHAPTER IV RESULTS Sample Description To reiterate, the interviewers contacted women who had either attended or not attended prenatal classes during their pregnancy. In this section, I would like to address three principal questions: 1) How representative of the sampling frame are the groups interviewed? 2) What are the characteristics of the total and the sub-groups interviewed? 3) How does the group interviewed differ from the general population of expectant women? The groups interviewed w i l l be compared with the sampling frame on three separate variables: (1) geographic location of respondent; (2) number of parents in family; and (3) month the baby was delivered. As can be seen in Table I below, the projected sample (i.e. those who were randomly selected for the study but whom we could not locate, refused to participate, etc.) and the actual sample (i.e. those interviewed) are slightly under-represented in the South Health Unit area. The percent-age of children from one-parent families is also somewhat under-repre-sented in the projected sample and especially in the actual sample. The months during which the children were born seem generally representative of the total sampling frame. TABLE I Number and P e r c e n t a g e D i s t r i b u t i o n of Sampling fF.r tame, P r o j e c t e d Sample and A c t u a l Sample by G e o g r a p h i c L o c a t i o n of Respondent, Number of P a r e n t s i n F a m i l y and Month of D e l i v e r y G e o g r a p h i c L o c a t i o n o f Respondent N o r t h E a s t South U n i v e r s i t y West Bu r r a r d No. % No. % No. Q, "o No. % No. % No. o, ~o S a m p l i n g Frame 57 18.3 48 15 . 4 46 14. 7 75 -2 4..0 81 26. 0 5 1.6 P r o j e c t e d Sample (P e o p l e S e l e c t e d ) 3> 20.11' 21 13. 6, 15 9.7; 41 26. 6 M 2 28' .6? 2 1.3 A c t u a l Sample 22 16.7> 19 14.,^. 12 9..B- 38' 28.8) 39 29.53 2 1.5 (P e o p l e I n t e r v i e w e d ) Number of P a r e n t s i n F a m i l y ( P e o p l e S e l e c t e d ) A c t u a l Sample ( P e o p l e I n t e r v i e w e d ) Two-Parent No. % One No. - P a r e n t % S a m p l i n g Frame 265 84.9 47 15.1 P r o j e c t e d Sample ( P e o p l e S e l e c t e d ) 142 90. 4 15 9.6 A c t u a l Sample ( P e o p l e I n t e r v i e w e d ) 124 Month o f 9 2.5 D e l i v e r y • 10 7.5 A p r i 1 No. % May No. % June No. %_ S a m p l i n g Frame 113 36.2 6 6 21. 1 133 42.6 P r o j e c t e d Sample 56 35.7 37 23. 6 64 40.8 53 39.5 33 24.6 48 35 . 8 34 The most significant factor in terms of implications of results i s the under-representativeness of the South Unit area and the number of one-parent families. In general, the South Unit has a growing number of immigrant families who could probably benefit from prenatal education programs. Additional information on expectant women in this area could help considerably in planning more effective programs. It can be expec-ted that the under-representation of one-parent families occurs because of the d i f f i c u l t y encountered in locating some of the women in the study sample. The overall implications of this w i l l be discussed more thorough-ly in Chapter Six. The total group interviewed w i l l be described by the following characteristics: u t i l i z a t i o n of prenatal classes, age, marital status, country of origin, level of education, family income, and outcome of attendance/non-attendance as indicated by neonatal deaths. The f i r s t variable to be discussed is the distribution of women in the sample according to their u t i l i z a t i o n of prenatal education. The sample was divided into three primary groups: attenders, non-attenders and dropouts. 55.3 per cent of the actual sample was comprised of attenders, 40.9 per cent were non-attenders and 3.8 per cent were c l a s s i -fied as dropouts from classes. The age range for women in the respondent population was 16 years to 39 years. Within this age range, 97 per cent of the women were in the main family formation age group of 15 to 35 years. Overall, the mean age in the sample was 24.6 years and the median age 26.0 years. In examining the data in Table II, the largest group of attenders and non-35 attenders f e l l into the 20-29 age grouping. Specifically, 74 per cent of the non-attenders and 73 per cent of the attenders were in this grou-ping. However, within this age group i t was found that 63 per cent of the non-attenders were under 24 years: .of age compared to only 41 per cent of the attenders. TABLE II Number and Percentage Distribution of Age * Non--Attender Attender Total No. % No. % No. % 19 years and under 9 16.7 6 8.2 15 11.8 20 - 24 years 25 46.3 24 32.9 49 38.6 25 -29 years 15 27.8 29 39.7 44 34.7 30 - 39 years _ 5 9.3 14 19.2 19 15.0 54 ** 100.0 73 100.0 127 100.0 * The age intervals are uneven in this table principally because of the small numbers within each grouping. ** In any of the tables to follow, totals may not add to exactly 100% due to rounding. Table III below presents the data on marital status. As was to be expected, the large majority of women in the study sample (110 women or 86.6%) were married at the time of the interview. This included 85.2 per cent of the non-attenders and 87.7 per cent of the attenders. The number of "single-never been married" women was f a i r l y comparable, with seven in the non-attending group (13.0 per cent of the total) and eight in the attending group (10.9 per cent of the total). 36 TABLE III Number and Percentage Distribution of  Non-Attenders and Attenders, by Marital  Status Marital Status Non-Attenders Attenders Total No. _% No. % No. % Single 7 13.0 8 10.9 15 11.8 Married 46 85.2 64 87.7 110 86.6 Widowed - - - - - -Divorced - - - - - -Separated 1 1.8 1 1.4 2 1.6 Other - - - - - -54 100.0 73 100.0 127 100.0 A significant proportion (74 cases or 56%) of the women interviewed was born outside Canada, and most of these (33 cases or 25%) were from Asian countries. The largest sub-group was East Indian, and the majori-ty of these women were ^ contacted in South Vancouver (See Table IV). Of those respondents not born in Canada, non-English speaking immigrants in the actual sample accounted for approximately 35 per cent (See Table V). The predominant non-English languages spoken were Chinese/Japanese (13.4 per cent) and a language of India (9.4 per cent). Differences between non-attenders and attenders and use of a principal language w i l l be compared in Chapter V. PLACE OF ORIGIN TABLE IV R e s p o n d e n t s ' P l a c e of O r i g i n by; G e o g r a p h i c 'Area of -Residence. AREA 1, N o r t h AREA 2 E a s t AREA 3, South AREA a. West AREA 5. B u r r ard' OTHER TOTAL Canada A s i a E u r o p e U.K. O t h e r No, 8 5 3 1 5 22 No. 100: 4 2 2 1 19 No. 2 6 1 0 3 12 No, 19 9 0 3 7 38 No. 15 8 3 2 7 35 No. 4 1 0 1 0 6 No. 58 33 9 9 2 3 113 2 * * T h i s t o t a l i n c l u d e s f i v e "drop o u t s " f r o m p r e n a t a l c l a s s e s . 38 TABLE V Number and Percentage Distribution of  Respondents by Principal Language  Spoken Principal Language No. %_ English 82 64.6 Chinese/Japanese 17 13.4 A language of India 12 9.4 European (non-English) 8 6.3 Other 8 6.3 127 100.0 * European languages include Greek, French, Italian, German, Spanish, Portuguese and Slavic. Sixteen per cent of the mothers interviewed had less than Grade IX education (elementary), 49 per cent had some secondary education (Grade X - XIII), and nearly 35 per cent had at least some college or univer-sity. A comparison of summary levels of education between the non-attenders and the attenders shows that the. largest percentage (29.6%) of the non-attenders f e l l into the "elementary" grouping, while the attenders were evenly divided in terms of their education with 34 cases or 46.6 per cent f a l l i n g into the "secondary education" category and the same number' in the college or university category (See Table VI). 39 TABLE VI Number and Percentage Distribution of  Non-Attenders and Attenders by  Level of Education Non-Attenders Attenders Total v , No. % No. % No. % Education — — — Elementary (Less than Grade IX) 16 29.6 5 6.9 21 16.5 Secondary (Grades X -XIII) 28 51.9 34 46.6 62 48.8 Some College or University and Graduates 10 18.5 34 46.6 44 34.6 54 100.0 73 100.0 127 100.0 Total family income is also considered to be highly correlated with the u t i l i z a t i o n of prenatal care. (Green,, 1970.) As shown in Table VII, the mothers interviewed over-represented the higher income groups in the respondent population. It can be seen that 57.4 per cent (or 31 cases) of the non-attenders are from families which earn $12,000 and over per annum. This compares with 65.8 per cent (or 48 cases) of the attenders who earn $12,000 and over. TABLE VII Number and Percentage Distribution of  Non-Attenders and Attenders by  Family Income Income Less than $11,999 $12,000 and over Non-Attenders Attenders Total No. % No. % No. % ;23 42.6 25 34.2 48 37.8 31 57.4 48 65.8 79 62.2 54 100.0 73 100.0 127 100.0 40 Finally, the sub-groups within the total sampling frame were exam-ined to see whether differences existed with regard to the number of neo-natal deaths. There was only one neonatal death in the total sampling frame of 309 births. As this one case was not in the groups interviewed, the attendance or non-attendance of the mother is unknown. The group interviex^ed can be compared with the general population of expectant women in 1974. Of the total 35,450 l i v e births i n Br i t i s h Columbia in 1974, 8,685 or 24.5 per cent were born in the Metropolitan Health Services Area (i.e., this includes the municipalities of Vancouver, Richmond, Burnaby and the North Shore). In Vancouver City there were 4,501 l i v e births of which 2,414 or 53.6 per cent were primiparas. This present study sample i s comprised of approximately 20 per cent of the primiparas delivering i n Vancouver during the months of April, May and June, 1974. The primiparas in the actual sample can also be compared with those in the general population of expectant women in terms of age (See Table VIII). Although these data are only available for the province of British Columbia, there is a f a i r degree of comparability between the two groups. That i s , 73.2 per cent of the primiparas in the study sample f e l l into the 20-29 age grouping, as compared with 68.3 per cent in the general primipara population. (Vital Statistics, 1974.) 41 TABLE VIII Number and Percentage Distribution of Actual  Sample and General Population of Primiparas  by Age, 1974 Age Actual Sample General Population No. 1 No. I 19 years and under 15 11.8 3,662 23.2 20 - 24 years 49 38.6 6,427 40.6 25 - 29 years 44 34.6 4,383 27.7 30 years and over 19 15.0 1,340 8.5 127 100.0 15,812 100.0 Source: Department of Health, V i t a l Statistics of the Province of British Columbia, One Hundred and Third Report, 1974. Perception of Purpose of Prenatal Classes: Hypothesis I Table IX below presents the data on perceived purpose by ut i l i z a t i o n of prenatal classes. TABLE IX Number and Percentage Distribution of Non- Attenders and Attenders by Perceived Pur- pose of Prenatal Classes Perceived Purpose Non-Attenders Attenders Total No. 1 No. 1 No. % Preparation for Labour and Delivery 29 53.7 47 64.4 76 59.8 Education regarding Pregnancy 6 11.1 6 8.2 12 9.4 Education regarding Child-birth and/or Child Care 5 9.3 12 16.4 17 13.4 Other* 5 9.3 6 8.2 11 8.7 Did not know Purpose 9 16.7 1 1.4 10 7.9 No Response 0 - 1 1.4 1 .8 54 100.0 73 100.0 127 100.0 * "Other" category was collapsed to include Education regarding nutrition, Psychological Preparation (i.e. Reassurance and Relaxation), and a l l other responses. 42 It is important to note here that each respondent had the opportu-nity to respond to the question, "During the time of your pregnancy, what did you see as the purpose of prenatal classes?" with any answer she liked (i.e., the question provided no fixed choice, but, rather, was open-ended). By examining the data in Table IX, one can see that a l -though the respondents could have given incorrect answers (i.e., those which incorrectly identified purposes for the course), no one actually did respond incorrectly, and that both non-attenders and attenders res-ponded in a similar fashion. Not only were the cited purposes similar between the two groups, but a ranking of the most to least frequently indicated responses was much the same for both groups. For example, both groups ranked "Preparation for labour and delivery" f i r s t , and d i -verged only slightly with the second and third set of responses. In total, 74.1 per cent of the non-attenders and 89.0 per cent of the attenders ranked the same three items as principal purposes for the course. The only point where there was a substantial difference between the two groups occurred within the category of "Did not Know Purpose." That i s , 16.7 per cent (9 cases) of the non-attenders as compared to 1.4 per cent (1 case) of the attenders stated they did not know the purpose of the program. The difference i s s t a t i s t i c a l l y significant (p = 0.00197). Measurement of Socio-economic Status: Hypothesis II This analysis examined, the association between the independent variables of family income and educational level of the respondent (i.e., the SES composite score) and the dependent variable of prenatal u t i l i z a -43 tion. The data presented in Table X shows a larger percentage of the attenders (54.8%) than the non-attenders (27.8%) to be in the "upper-class" category. A larger proportion of the non-attenders (14.8%) com-pared with the attenders (6.8%) were in the "lower class". In applying the Mann-Whitney U Test, a significant difference was observed between the two groups in relation to the independent variable. The raw data and the z-values are given in Table X. TABLE X Number and Percentage Distribution of  Non-Attenders and Attenders by  Socio-economic Rankings Non- Attenders Attenders Total No. % No. 1 No. % Upper"'" 15 27.8 40 54.8 55 43.3 Middle 2 31 57.4 28 38.4 59 46.4 Lower^ _8 14.8 _5 6.8 13 10.2 54 100.0 73 100.0 127 100.0 z = -2.58 Significance Level = 1.812 p .05 Number of Missing Observations = 0 1. Upper Class is defined as a respondent whose family income was $15,000 and over or who had completed an undergraduate degree or postgraduate training. 2. Middle Class i s defined as a respondent whose family income was be-tween $9,000 and $14,999 c-r who had completed high school or had attended university or college. 3. Lower Class is defined as a respondent whose family income was between $0 and $8,999 or who had an educational level of less than Grade 12.. 44 The Respondents' System of Social Networks: Hypothesis III The table below presents the data on the number of women'who have a major source of social support,by non-attender and attender. TABLE XI Number and Percentage Distribution of  Non-Attenders and Attenders by  Presence of Husband Non-Attenders Attenders Total No. % No. % No. 1 With Husband 46 86.8 64 88.9 110 88.0 Without Husband 7 13.2 8 11.1 15 12.0 53 100.0 72 100.0 125 100.0 Number of Missing Observations = 2 X 2 = .0061 df = 1 p ^ s - .05 As can be seen from Table XI, then, a comparable percentage from both the attending and non-attending groups have these systems of support within their environment. In fact, both groups have a very high percen-tage of respondents who do have husbands (i.e. 88.9% of the attenders and 86.8% of the non-attenders). A Chi-Square test was used to test for 2 association, and the computed value of X i s less than the 3.84 value needed to reject the n u l l hypothesis (p^^.05). We must therefore con-clude that we have been unable to demonstrate any association between the presence of social networks and attendance vs. non-attendance at prenatal classes from the sample drawn. The respondents were asked several additional questions which rela-ted to other social contacts and peripheral support and information 45 systems. Fi r s t , the respondent was asked whether or not there was some member of her family whom she considered as having the responsibility of taking care of her (e.g., taking her to the doctor, hospital, etc.) and i f so, the relationship of this person to the respondent. Tables XII and XIII below summarize the results of this part of the questioning. TABLE XII Number and Percentage Distribution of Non-Attenders and Attenders by Respons- i b i l i t y of Family Member for Health  Problems of Respondent Non-Attenders Attenders Total No. % No. % No. % Yes , someone was responsible 50 92.6 66 90.4 116 91.3 No, no one was responsible 4 7.4 7 9.6 11 8.7 54 100.0 73 100.0 127 100.0 No. x 2 of Missing Observations = = 0.9100 df = 1 p > 0 -.05 In both of these groups, then, at least 90 per cent of the respondents answered in the affirmative when asked i f there was some family member responsible for their care. Again, using Chi-Square to test for association, we found no demonstrable association between having some family member responsible for the respondent's health and attendance or non-attendance at prenatal classes. Table XIII describes specifically those individuals who were considered responsible for the woman's care. 46 TABLE XIII Number and Percentage Distribution of  Non-Attenders and Attenders by Person  Responsible for Health of Respondent Non- •Attenders Attenders Total No. % No. J t No. % Husband 27 54.0 47 71. 2 74 63.8 Mother 19 38.0 18 27. 3 37 31.9 Father 4 8.0 1 1. 5 5 4.3 Other 0 0.0 0 0. 0 0 0.0 * Total 50 100.0 66 100. 0 116 100.0 X 2 = 2.94 df = 1 p > .05 * Eleven respondents (i.e. seven attenders and four non-attenders) stated that, other than themselves, no one was responsible for taking care of them. Again, the importance of the husband to the respondent can be ob-served. Given, then, that 91.3 per cent of the respondents lis t e d either their husband, mother or father as being responsible for their care, we asked one f i n a l question of the respondent. Specifically, each respondent was asked to rank those relatives with whom she spent the most time dis-cussing her pregnancy. As can be seen from Table XIV below, the i n d i v i -duals ranked as f i r s t and second sources, respectively, are husband and mother. However, once again the husband constitutes the most frequent source of contact and support during the pregnancy for 77.7 per cent of 2 the non-attenders and 89.0 per cent of the attenders. Using X to test for association, there was no significant difference between the two groups in regard to the data in Table XIV. 47 TABLE XIV Number and Percentage Distribution of  Non-Attenders and Attenders by Family  Member with Whom Expectant Mother Dis- cussed Pregnancy Most Often Non-Attenders Attenders Total No. 1 No. % No. % Husband 42 77.8 65 89.0 107 84,2 Mother 5 9.2 3 4.1 8 6.3 Father 0 0.0 1 1.4 1 .8 Other 7 13.0 4 5.5 11 8.7 54 100.0 73 100.0 127 100.0 X 2 = 2.179 df = 1 p >.05 It can be concluded, then, that there is no difference between the two groups with regard to the availability of support during the period of pregnancy. Consequently, we may conclude that this a v a i l a b i l i t y of support does not bear on the question of prenatal class u t i l i z a t i o n . Summary The sample and the actual respondent population were compared with the sampling frame and were considered to be somewhat under-representa-tive in terms of geographic location and number of one-parent families. The South Vancouver area was slightly under-represented in the sample and this area i s considered important because of the growing number :Q'f immigrant families there. Of those women actually interviewed, 56 per cent were born outside Canada and one-half of them were from Asian countries. Non-English speaking immigrants in the actual sample account-48 e.d: for 35 per cent. This resulted i n the necessity f o r v e r b a l i n t e r -p retation i n order to conduct 20 of the interviews. Almost one-half of the women interviewed had some secondary edu-cation, and i n general the attenders had a higher l e v e l of education than the non-attenders. The women interviewed over-represented the higher income groups i n the study population, with a higher percentage of attenders than non-attenders earning $12,000 and over. Differences between the groups of non-attenders and attenders were tested i n regard to three v a r i a b l e s : perceptions of the purpose of pre-natal classes, socio-economic rankings, and the existence of a system of s o c i a l networks. No d i f f e r e n c e s existed between the two groups i n terms of the "cor r e c t " or " i n c o r r e c t " perceptions of the purpose of prenatal classes. In f a c t , both groups were f a i r l y comparable i n the perceived purpose they gave f o r the course (e.g., a large percentage of both groups ranked "Preparation f o r Labour and Delivery" as the primary purpose of these c l a s s e s ) . However, more non-attenders than attenders stated they did not know the purpose of the course. I t was hypothesized that socio-economic standing influenced u t i l i -zation of these courses. The Mann-Whitney U Test was used to tes t the si g n i f i c a n c e between the socio-economic v a r i a b l e s and u t i l i z a t i o n . The test supported the hypothesis that the two samples d i f f e r e d s i g n i f i c a n t l y , on the v a r i a b l e of socio-economic status, and that the non-attenders do come from a population ranked lower i n s o c i a l c l a s s than the attenders. 49 F i n a l l y , i t was hypothesized that the presence of a system of s o c i a l networks ( i . e . , husband, mother or father) reduced the l i k e l i h o o d of attendance at prenatal classes. A Chi-Square test was used to test f o r ass o c i a t i o n , and i t was concluded that no demonstrable ass o c i a t i o n e x i s t s between the presence of s o c i a l networks and attendance or non-attendance at prenatal classes. I t can be cautiously concluded that t h i s support has no bearing on prenatal u t i l i z a t i o n . 50 CHAPTER V . SUMMARY OF OTHER FINDINGS This chapter w i l l present data on some of the other factors rela-ting to the use of prenatal care, which were not subjected to s t a t i s t i -cal testing. This chapter w i l l also discuss the reasons expectant . women do not attend prenatal education courses within Vancouver City, and examine the differences in level of knowledge and behavioural prac-tices between the non-attenders and the attenders. Reasons for Non-Attendance In testing the hypotheses in Chapter V, i t was possible to examine some of the relationships between non-attendance and the factors identi-fied as influencing prenatal care u t i l i z a t i o n (e.g., social class, system of social networks). On a more subjective level, each non-attending respondent was asked two questions relating to why she did not attend classes. First , she was asked to state the one main reason for not attending. She was also asked to state any other reason which may have further influenced her decision not to attend. Table XV shows the re-sults. As can be seen (Table XV), 18.5 per cent of the non-attenders did not feel i t was necessary for them to attend prenatal classes, while 16.7 per cent said they had no knowledge that the classes were being offered. Being too tired or sick to attend (14.8%) and not being i n -formed about classes by a doctor (9.3%) were also reasons given by women 51 for not attending. It seems that 35 per cent of the non-attenders were potential recruits for the prenatal classes with l i t t l e additional effort. TABLE XV Number and Percentage Distribution of  Primiparas by Principal Reason for Non-Attendance at Prenatal Classes Reasons Did not think i t necessary to attend No knowledge of classes Too tired or sick to attend Doctor did not inform woman of classes Classes were f u l l Employment prevented attendance Attending other classes (e.g., English) Di f f i c u l t y getting to classes (e.g., transport problems) Other (e.g., d i f f i c u l t y understanding or speaking English, waited too late i n pregnancy to attend) Number 10 9 8 5 4 3 3 9 54 Percentage 18.5 16.7 14.8 9.3 7.4 5.5 5.5 5.5 16.7 100.0 In an attempt to identify secondary reasons affecting prenatal class attendance, the interviewers probed for additional responses. The re-sults are shown in Table XVI. Twenty-five per cent (or 7 cases) of the 27 non-attenders who gave additional reasons stated they had d i f f i c u l t y understanding or speaking English. This is understandable in the light of the large percentage (56%) of immigrant women in the study group. An additional 11.1 per 52 cent (or 3 cases) said they had received a l l necessary information from relatives and friends, while 3 other cases (11.1%) said they were too busy to attend. TABLE XVI Number and Percentage Distribution of  Primiparas by Secondary Reasons for  Non-Attendance at Prenatal Classes Reasons Number Percentage Dif f i c u l t y understanding spoken English 7 25.9 Received a l l necessary information from friends and relatives 3 11.1 Too busy to attend 3 11.1 Did not know about course 2 7.4 Did not have transportation 2 7.4 Other (e.g., employment prevented from attending, husband/partner discour-aged from attending) 10 37.0 27''"' 100.0 Twenty-seven non-attenders did not give additional reasons. Other Factors Influencing Prenatal Care A. Principal Language of Respondents Given the large number of immigrants in Vancouver, i t seemed import-ant to investigate the relationship between the routine use of a lan-guage other than English and u t i l i z a t i o n of prenatal classes. Tables XVII through XX present the data on language and u t i l i z a t i o n . The majority of the attenders (58 cases or 79.4%) had English as 53 their principal language, while less than one-half (_24 cases or 44.4%) of the non-attenders had English as their principal language (i.e., on a percentage basis, 2 1/2 times as many non-attenders as attenders did not have English as their principal language). More specifically, nearly seven times as many non-attenders as attenders had one of the East Indian languages as their principal language. However, there was a high degree of comparability between the two groups in the use of Chinese or Japanese as a principal language. This could be partially accounted for by the fact that prenatal classes are offered in Chinese in Vancouver. TABLE XVII Number and Percentage Distribution of  Non-Attenders and Attenders by Principal Language Non-Attenders Attenders Total No. % No. % No. % English 24 44.4 58 79.4 82 64.6 Chinese/Japanese 7 13.0 10 13.7 17 13.4 Language of India 10 18.5 2 2.7 12 9.4 Europe (non-English) 7 13.0 1 1.4 8 6.3 Other 6 11.1 2 2.7 8 6.3 54 100.0 73 100.0 127 100.0 * European languages include Greek, Portuguese and Slavic. French, Italian, German, Spanish, The most significant differenc es between the two groups became apparent in examining the interviewers' assessments of the respondents' ab i l i t y to speak and understand English. Ninety-three per cent (68 cases) of the attenders were assessed as speaking English "well" or " f a i r l y " as 54 compared to only 65 per cent (35 cases) of the non-attenders. Overall, then, the a b i l i t y of attenders to speak English was considerably greater than that of the non-attenders. TABLE XVIII Number and Percentage Distribution of  Non-Attenders and Attenders by  Abil i t y to Speak English Ability to Speak English Non-Attenders Attenders Total No. 1 No. % No. % Well 25 46.3 61 83.6 86 67.7 Fairly 10 18.5 7 9.6 17 13.4 Poorly 19 35.2 _5 6.8 24 18.9 54 100.0 73 100.0 127 100.0 Table XIX demonstrates the attenders' a b i l i t y to understand spoken English as greater than the non-attenders' a b i l i t y . More specifically, 94.5 per cent (69 cases) of the attenders were assessed as understanding spoken English "well" or " f a i r l y " , as compared to 66.6 per cent (36 cases) of the non-attenders. TABLE XIX Number and Percentage Distribution of  Non-Attenders and Attenders by Abi l i t y Ability to Understand Non- -Attenders Attenders Total No. % No. % No. % Well 24 44.4 60 82.2 84 66.1 Fairly 12 22.2 9 12.3 21 16.5 Poorly 18 33.3 _4 5.5 22 17.3 54 100.0 73 100.0 127 100.0 55 On the basis of the above data, the number of women for whom verbal interpretation was required, is documented in Table XX. Of the 54 non-attenders interviewed for the study, 16 (29.6%) required verbal interpre-tation as contrasted with only four (5.5%) of the attenders. TABLE XX Number and Percentage Distribution of  Non-Attenders and Attenders by Inter- pretation Required for Interview Interpretation Required Non-Attenders Attenders Total No. 1 No. % No. % Yes 16 29.6 4 5.5 20 15.7 No 38 70.4 69 94.5 107 84.3 54 100.0 73 100.0 127 100.0 As expected, there was an association between use of English as a principal language and ut i l i z a t i o n of prenatal programs. However, as the study was not specifically designed to test this association in depth, additional supportive evidence i s required. B. Use of Medical Care The second set of factors to be examined relates to the use of medi-cal care by these expectant women. It was expected that the type of medical specialty would influence whether or not a referral;.to prenatal classes was made. That i s , i t was anticipated that obstetricians and physicians whose practices relate more to obstetrics, make fewer refer-rals to prenatal classes than do other physicians. 56 Each respondent was asked a series of questions regarding her con-tact with a doctor, the doctor's medical specialty, and whether or not the doctor recommended prenatal classes. It was found that a l l (127) of the women interviewed had contact with a physician prior to delivery. Of these 127 women, 70 per cent had made i n i t i a l contact in the f i r s t two months of pregnancy. The length of time between this i n i t i a l contact and the gestation has not been analyzed. In examining the data on medical specialty and the u t i l i z a t i o n of prenatal classes, 75.9 per cent (41 cases) of the non-attending group went to general practitioners for medical care, while 24.1 per cent (13 cases) attended an obstetrician/gynecologist during pregnancy. Of the attenders, 65.8 per cent (48 cases) sought care from a general practi-tioner and 34.2 per cent (25 cases) attended an obstetrician/gynecologist (See Table XXI). We found no significant difference between u t i l i z a t i o n of prenatal classes and medical specialty. TABLE XXI Number and Percentage Distribution of Specialty of Physician Medical Specialty Non-No. -Attenders % Attenders No. % No. Total % General Practitioner 41 75.9 48 65.8 89 70.1 Obstetrician/Gynecologist 13 24.1 25 34.2 38 29.9 Unknown — — — _ 54 100.0 73 100.0 127 100.0 X 2 = 1.11 df = 1 p ^ > .05 57 The next set of questions related to the recommendation of the physician to attend classes and the utilization of these classes. As can be seen in Table XXII, 40.7 per cent (22 cases) of the non-attende received a recommendation to attend from the physician. This compares with 76.7 per cent (56 cases) of the attenders. TABLE XXII Number and Percentage Distribution of  Non-Attenders and Attenders by Recom- mendation of Doctor to Attend Prenatal Classes Non-No. Attenders % Attenders No. % No. Total % Yes, did recommend 22 40.7 56 76.7 78 61.4 No, did not recommend 31 57.4 17 23.3 48 37.8 No response 1 1.9 - - 1 .8 54 100.0 73 100.0 127 100.0 Each respondent was also asked whether or not her doctor had actually recommended that she not attend these classes. Only three women (2 non-attenders and one attender) responded that their physicians specifically advised them not to attend. Of these recommendations not to attend, two were made by general practitioners and one was made by an obstetrician/ gynecologist. Tables XXIII and XXIV show these data. 58 TABLE XXIII Number and Percentage Distribution of  Non-Attenders and Attenders by Recom- mendation of Doctor Not to Attend Pre- natal Classes Recommendation Not to Attend Non-Attenders Attenders Total Did recommend not attend Did not recommend not attend Other No. % No. % No. I 2 6.5 1 5.9 3 6.3 29 93.5 16 94.1 45 93.7 .31 100.0 17 100.0 48 100.0 TABLE XXIV Number and Percentage Distribution of  Medical Specialty by Recommendation  of Doctor Not to Attend Prenatal Classes General Obstetrician/ Recommendation Not to Attend Practitioner Gynecologist Total No. % No^ % No^ % Did recommend not attend 2 5.7 1 7.1 3 6.3 Did not recommend not attend 32 94.3 13 92.9 45 93.7 34 100.0 14 100.0 48 100.0 Finally, an examination was made of the medical specialty of each physician by whether or not the physician recommended attendance at these classes (See Table XXV). Of those physicians engaged in a general practice, 62.0 per cent did recommend prenatal classes to their patients. This compares with 63.2 per cent of the obstetricians/ gynecologists who recommended classes. 59 TABLE XXV Number and Percentage Distribution of  Medical Specialty by Recommendation  of Doctor to Attend Prenatal Classes General Recommendation Practi- Obstetrician/ to Attend tioner Gynecologist Other Total No. % No. % No. % No. % Yes, did recommend 57 62.0 24 63.2 1 100.0 82 62.6 No, did not recommend 34 38.0 14 36.8 - 48 37.4 91 100.0 38 100.0 1 100.0 130 100.0 Although i t was expected that obstetricians and physicians whose practices related more to obstetrics make fewer referrals to prenatal classes than other physicians, i t must be concluded that there appears to be no real difference between referral to prenatal classes and type of medical specialty. The data indicate a similar referral pattern between obstetricians/gynecologists and general practitioners. 9 Knowledge Questions Overall, the attenders responded accurately to more of the knowledge statements than did the non-attenders (i.e., of the 17 statements read to both groups of respondents, the attenders scored higher on 14 of the 17 statements or 82.3 per cent). In the three general categories of nutrition, infant feeding and labour and delivery, the following break-down occurred: the attenders scored higher than the non-attenders on a l l four of the questions relating to nutrition (attenders responded correctly on 80.1 per cent of the total compared with 68.1 per cent for 9. These questions were designed with the assistance of Lara Thordarson, Assistant Director of Community Health Nursing, Vancouver City Health Department. 60 the non-attenders); the attenders scored higher on 7 of the 9 questions asked on infant feeding (attenders responded correctly on 77.9 per cent of the total compared with 67.7 per cent for the non-attenders); and the attenders also responded more accurately to 3 of the 4 questions asked on labour and delivery (attenders responded correctly on 76.4 per cent of the total compared with 73.6 per cent for the non-attenders). Sta-t i s t i c a l testing on the total responses showed a significant difference between the attenders and non-attenders on a l l three areas. Tables XXVI through XXVIII show the results of these responses. In examining the three sections on nutrition, infant feeding and labour and delivery, a significant difference was observed between the attenders and non-attenders in regard to specific questions. In the section on nutrition, 98.6 per cent of the attenders (72) and 85.2 per cent of the non-attenders (46) responded correctly that a pregnant woman should drink at least four glasses of milk or the equivalent per day (Question I). In this same section, 94.5 per cent of the attenders (69) and 79.6 per cent of the non-attenders (43) responded correctly in knowing that an overall weight gain of approximately 24 pounds during the course of one!-s.pregnancy should be expected (Question III). A significant d i f f e r -ence between the two groups was found on these two questions. In the section on infant feeding, a significant difference was found on 3 of the 9 questions. In the attenders group, 72.6 per cent (53 cases) compared with 34.0 per cent (18 cases) in the non-attenders group knew that i t was not necessary for an infant to wait at least 24 hours after delivery be-fore nursing (Question II). Again, in the attenders group, 89.0 per cent (65 cases) and 69.8 per cent (37 cases) of the non-attenders were correct 61 in responding that the early milk in the breast contains substances which help the baby fight disease or illness (Question III). The third question in this section could be answered correctly by disagreeing with the state-ment "The weight of the baby is not affected by smoking during pregnancy'.1 (Question I). Seventy-eight per cent (57) of the attenders and 46.3 per cent (25) of the non-attenders responded correctly. In the third section on labour and delivery, a significant d i f f e r -ence was found on two of the four questions. In the non-attenders group 81.1 per cent (43) compared with 52.1 per cent (38) of the attenders knew that the contractions which signal the onset of labour occur at regular intervals (Question I). Finally, 86.3 per cent of the attenders (63) and 67.9 per cent of the non-attenders (36) knew that the breathing methods used during labour should provide needed oxygen to the womb and the baby (Question II). Equally important, however, is the number of "don't know" responses in both the attending and non-attending groups. When asked whether or not restriction of salt intake i s recommended for women having a normal pregnancy (the correct answer is that restriction is not recommended) 15.1 per cent of the attenders (11) and 9.3 per cent of the non-attenders (5) responded "don't know" to the question,(Question IV). Some of the questions on infant feeding also had a f a i r l y high "don't know" response rate. On two questions concerning breastfeeding and nursing time, 20.8 per cent (11) and 22.6 per cent (12), respectively, of the non-attenders did not know the correct responses (Questions I and II). Over one fourth (28.3% or 15 cases) of the non-attenders also did 62 not know that the early milk in the breast contains substances which help the baby fight disease or illness (Question III)• Both the non-attenders and the attenders lacked the knowledge of the effects of ciga-rette smoking on the baby. Although the number of cigarettes the mother smokes during pregnancy influences both the quantity and quality of the milk, 57.5 per cent of the attenders (42) and 50.0 per cent of the non-attenders (27) did not know the correct response to the question (Ques-tion VIII). Similarly, 13.7 per cent of the attenders (10) and 31.5 per cent of the non-attenders (17) did not know that the weight of the baby i s affected by smoking during pregnancy (Question IX). Finally, 22.6 per cent of the non-attenders (12) and 6.8 per cent of the attenders (5) did not know that controlled breathing techniques used during labour and delivery should provide needed oxygen to the womb and the baby (Question II). It may be concluded, then, that the attenders' level of knowledge regarding pregnancy, childbirth and child care, was higher than that of the non-attenders. 63 TABLE XXVI Number and Percentage Distribution of  Non-Attenders and Attenders by Respon- ses to Knowledge Questions on Nutri-tion Knowledge re: Nutrition Non-Attenders Attenders Significance Question I (Re: Milk Intake during pregnancy) No. I No. . 1 ** Correct 46 85.2 72 98.6 Sign. Incorrect 6 11.1 1 1.4 x 2 = 8.65 Didn't know 2 3.7 0 0.0 df = 2 Total 54 100.0 73 100.0 Question II (Re: Results of dieting during pregnancy) Correct 43 79.6 66 90.4 N.S. Incorrect 6 11.1 3 4.1 x 2 = 3.19 Didn't know 5 9.3 4 5.5 df = 2 Total 54 100.0 73 100.0 Question III (Re: Expected weight gain during pregnan-cy) Correct 43 79.6 69 94.5 Sign. ** Incorrect 7 13.0 4 5.5 x 2 = 8.19 Didn't know 4 7.4 0 0.0 df = 2 Total 54 100.0 73 100.0 Question IV (Re: Restriction of normal salt intake) Correct 15 27.8 27 37.0 N.S. Incorrect 34 63.0 35 47.9 ? X" = 2.91 Didn't know 5 9.3 11 15.1 df = 2 Total 54 100.0 73 100.0 Total: Correct Responses 147 68.1 234 80.1 Sign. ** Incorrect Responses 53 24.5 43 14.7 x 2 = 9.78 Didn't know 16 7.4 15 5.1 df = 2 Total 216 100.0 292 100.0 * P-=£.05 ** p-^.01 N.S. = not : significant p~ ==. .05 64 TABLE XXVII Number and Percentage D i s t r i b u t i o n of  Non-Attenders and Attenders by Respon- ses to Knowledge Questions on Infant  Feeding Knowledge re: Infant Feeding Non-Attenders Question I (Re: Breast fee-ding time) No. 1 No. % Correct 36 67.9 51 69.9 N.S. Incorrect 6 11.3 16 21.9 x 2 = 5.56 Didn't know 11 20.8 6 8.2 df = 2 T o t a l 5 3 1 100.0 73 100.0 Question II (Re: Nursing time a f t e r d e l i v e r y ) ** Correct 18 34.0 53 72.6 Sign. Incorrect 23 43.4 11 15.1 x 2 = 19.22 Didn't know 12 22.6 9 12.3 df = 2 T o t a l 5 3 1 100.0 73 100.0 Question I I I (Re: Disease r e -sistance during breast feeding) Correct 37 69.8 65 89.0 Sign. * Incorrect 1 1.9 1 1.4 x 2 = 7.61 Didn't know 15 28.3 7 9.6 df = 2 T o t a l 5 3 1 100.0 73 100.0 Question IV (Re: Mother's l i q u i d intake during breast feeding) Correct 48 90.6 72 98.6 N.S. Incorrect 1 1.9 0 0.0 x 2 = 4.53 Didn't know 4 7.5 1 1.4 df = 2 T o t a l 5 3 1 100.0 73 100.0 Question V (Re: Sanitary con-d i t i o n s re bo t t l e s ) Correct 52 96.3 67 91.8 N.S. Incorrect 2 3.7 4 5.5 x 2 = 1.75 Didn't know 0 0.0 2 2.7 df = 2 T o t a l 54 100.0 73 100.0 65 Knowledge re: Infant Feeding (Continued) Non-Attenders Attenders S i g n i f i c a n c e No. % No. % Question VI (Re: Use of medi-cation while breast feeding) Correct 49 92.4 73 100.0 N.S. Incorrect 1 1.9 0 0.0 x 2 = 5.69 Didn't Know 3 5.7 0 0.0 df = 2 T o t a l 5 3 1 100.0 73 100.0 Question VII (Re: Sore nipples i n early stages of breast feeding) Correct 36 67.9 51 69.9 N.S. Incorrect 6 11.3 11 15.1 x 2 = 0.904 Didn't Know 11 20.8 11 15.1 df = 2 T o t a l 5 3 1 100.0 73 100.0 Question VIII (Re: Influence of cig a r e t t e smoking on q u a l i t y and quantity of milk) Correct 24 44.4 23 31.5 N.S. Incorrect 3 5.6 8 11.0 x 2 = 2.77 Didn't Know 27 50.0 42 57.5 df = 2 T o t a l 54 100.0 73 100.0 Question IX (Re: Influence of ci g a r e t t e smoking on weight of baby) Correct 25 46.3 57 78.1 Sign. ** Incorrect 12 22.2 6 8.2 x 2 = 13.76 Didn't Know 17 31.5 10 13.7 df = 2 Total 54 100.0 73 100.0 T o t a l : Correct Responses 325 67.7 512 77.9 Sign. * Incorrect Responses 55 11.5 57 8.7 x 2 = 15.39 Didn't Know 100 20.8 88 13.4 df = 2 T o t a l 480 100.0 657 100.0 1: One immigrant woman i n the non-attending group refused to respond to these statements for r e l i g i o u s and c u l t u r a l reasons. * p .05 ** p -<~ .01 N.S. = not s i g n i f i c a n t pr=> .05 66 TABLE XXVIII Number and Percentage Distribution of  Non-Attenders and Attenders by Respon- ses to Knowledge Questions on Labour  and Delivery Knowledge re: Labour and Non-. Attenders Attenders Significance Delivery No. % No. 1 Question I (Re: Frequency of labour contractions) Correct 43 81.1 38 52.1 ** Sign. Incorrect 6 11.3 31 42.5 X 2 = 14.38 Didn't know 4 7.5 4 5.5 df = 2 Total 53 1 100.0 73 100.0 Question II (Re: Controlled breathing techniques during labour, and oxygen to womb) Correct 36 67.9 63 86.3 * Sign. " Incorrect 5 9.4 5 6.8 X 2 = 7.25 Didn't know 12 22.6 5 6.8 df = 2 Total 53 1 100.0 73 100.0 Question III (Re: Controlled breathing techniques and amount of pain experienced during labour) Correct 30 56.6 51 69.9 N.S. Incorrect 14 26.4 18 24.6 X 2 = 4.81 Didn't know 9 17.0 4 5.5 df = 2 Total 53 1 100.0 73 100.0 Question IV (Re: Symptoms indi-cating onset of labour) Correct 47 88.7 71 97.3 N.S. Incorrect 3 5.7 2 2.7 X 2 = 5.03 Didn't know 3 5.7 0 0.0 df = 2 Total 53 1 100.0 73 100.0 67 Knowledge re: Labour and Delivery (cont'd) Non-Attenders No. % No. % Correct Responses 156 73.6 223 . 76.4 Incorrect Responses 28 13.2 56 19.1 Didn't know 28 13.2 13 4.5 Total 212 100.0 292 100.0 A Sign. X 2 = 14.32 One immigrant woman in the non-attending group refused to respond to these statements for religious and cultural reasons. * p .05 ** p-<C .01 N.S. = not significant p > .05 In an attempt to determine the source of knowledge, we asked each respondent the one source from which she obtained most of her knowledge of the above subject areas. Table XXIX presents the results of this question. The majority of the attenders cited either prenatal classes (65.8% or 48 cases) or books (19.2% or 14 cases) as the primary sources of knowledge. The non-attenders cited books (31.5% or 17 cases), relatives (including mother) cited by 27.8 per cent (15 cases), and previous education or experience"^ cited by 13.0 per cent (or 7 cases). As can be seen from the table, the non-attenders had considerably more diversified sources of information than the attenders who obtained most of their information from prenatal classes. This information provides additional support for the supposition stated in Chapter IV that non-attenders rely on outside sources for their information during and after their pregnancy. 10. Previous experience includes responses such as nursing experience and experience through caring for younger siblings. 68 TABLE XXIX Number and Percentage Distribution of  Non-Attenders and Attenders by Primary Source of Knowledge Non- -Attenders Attenders Total No. % No. % No. % Prenatal Classes 0 0.0 48 65.8 48 37.8 Books 17 31.5 14 19.2 31 24.4 Previous Experience or Education 7 13.0 2 2.7 9 7.1 Public Health Nurse or Clinic 2 3.7 3 4.1 5 3.9 Doctor 3 5.5 2 2.7 5 3.9 Mother 5 9.3 1 1.4 6 4.7 Other Relative 10 18.5 0 0.0 10 7.9 Friend/Neighbour 4 7.4 2 2.7 6 4.7 Other 5 9.3 1 1.4 6 4.7 No Response 1 1.9 0 0.0 1 .8 54 100.0 73 100.0 127 100.0 Health Practices of Respondents  Feeding Patterns In the area of infant feeding, the two groups were asked whether they breastfed or bottlefed their baby or both. Almost one half of the non-attending group (25 cases or 46.3%) breastfed their babies; 29.6 per cent (or 16 cases) both breastfed arid bottlefed; arid 24.1 per cent (or 13 cases) bottlefed their babies. In the attending group, the inverse was true. The largest proportion of the attenders bottlefed their babies (33 cases or 45.2%); 34.2 per cent or 25 cases both breastfed and bottle-69 fed; and 20.5 per cent or 15 cases breastfed their babies (Table XXX). A significant difference at the .05 level was found between the atten-ders and non-attenders and the dependent variable of breastfeeding. TABLE XXX Number and Percentage Distribution of  Non-Attenders and Attenders by Feeding  Pattern Type of Feeding Non-Attenders Attenders Total No. 1 No. % No. 1 Bottlefed 13 24.1 33 45.2 46 36.2 Breastfed 25 46.3 15 20.5 40 31.5 Both 16 29.6 25 34.2 41 32.3 54 100.0 73 99.9 127 100.0 X 2 = 5.12 p <=X .05 df = 1 Smoking Habits When asked whether or not they smoked during their pregnancy, a large proportion (45 cases or 83.3%) of the non-attenders stated they had not smoked during their pregnancy. This compares with 74.0 per cent (54 cases) of the attending population. As the percentage di f ferences were f a i r l y small, a test for s t a t i s t i c a l significance was performed (Table XXXI). We were unable to demonstrate any significant differences between the two groups in terms of smoking during pregnancy. 70 TABLE XXXI Number and Percentage Distribution of  Non-Attenders and Attenders by Smoking  during Pregnancy Smoking during Pregnancy Non- •Attenders Attenders Total No. % No. % No. % Yes 9 16.7 19 26.0 28 22.0 No 45 83.3 54 74.0 99 :078.0 54 100.0 73 100.0 127 100.0 X 2 = 1.08 p > .05 df = 1 Breathing Techniques One could speculate that more of the attenders would have used con-trolled breathing during the labour and delivery than the non-attenders. Examining the data in Table XXXII, i t can be seen that this did occur, with 63 cases (86.3%) of the attenders using breathing techniques. This compares with the 64.8 per cent (35 cases) of the non-attenders who used these techniques during the labour. A significant difference at the .05 level was found between the two groups. TABLE XXXII Number and Percentage Distribution of  Non-Attenders and Attenders by Use of  Breathing Techniques during Labour and Breathing Techniques Delivery Utilized Non-•Attenders Attenders Total No. % No. % No. % Yes 35 64.8 63 86.3 98 77.2 No 18 33.3 9 12.3 27 21.2 No Response 1 1.9 _1 1.4 2 1.6 54 .100.0 73 100.0 127 100.0 X 2 = 7.08 p .05 df = 1 71 The fourth, area was concerned with whether or not a positive change in nutrition habits had occurred during the woman's pregnancy. The two groups were f a i r l y comparable in their responses to this question. That i s , 78.1 per cent (57 cases) of the attenders and 74.1 per cent (40 cases) of the non-attenders responded in the affirmative to this question, i.e. they responded that their nutrition habits had changed, in a positive direction, during their pregnancy (Table XXXIII). We were unable to de-monstrate any significant difference between the two groups in terms of nutritional habits. TABLE XXXIII Number and Percentage Distribution of  Non-Attenders and Attenders by Change  in Nutrition Habits during Pregnancy Change in Nutrition Habits Non- Attenders Attenders Total No. % No. % No. % Yes 40 74.1 57 78.1 97 76.4 No 14 25.9 16 21.9 30 23.6 No Response _0 0.0 0 0.0 0 0.0 X 2 = .1 p > .05 df = 1 54 100.0 73 100.0 127 100.0 Summary This chapter focused on three primary subject areas: 1) the reasons given for non-utilization of prenatal classes by the non-attenders; 2) a discussion of additional factors which may have affected u t i l i z a t i o n of prenatal classes; and 3) the effects of ut i l i z a t i o n or non-utilization based on level of knowledge and behavioural health practices. 72 There were two primary reasons given for non-attendance at these classes. F i r s t , a number of women (18.5% of non-attenders) f e l t that i t was unnecessary for them to attend. Secondly, somecof the women (16.7% of non-attenders) stated they had no knowledge of the existence of these classes during the period of their pregnancy. A secondary reason given by some of the women (25.9%) was the d i f f i c u l t y they experienced in understanding and speaking English. This secondary reason relates to the data on language as a barrier to prenatal care u t i l i z a t i o n . That i s , almost twice as many attenders as non-attenders had English as their principal language, and overall the attenders' a b i l i t y to speak and un-derstand spoken English was much greater than the non-attenders. In addition, there were five times as many nori-attenders as attenders who required a verbal interpretation for the interview. A second factor examined was whether or not a physician whose prac-tice was obstetrics :or related more to obstetrics, made fewer referrals to prenatal classes than did other physicians. An analysis of the data indicated that there existed a similar referral pattern between obste-trician/gynecologists and general practitioners. From these data i t may then be asserted that medical specialty has no real bearing on u t i l i z a -tion as a function of the referral pattern. It was expected that, given the exposure to a prenatal program, attenders would have more accurate information on pregnancy, childbirth and child care than the non-attenders. The attenders did respond with greater accuracy to 14 of the 17 statements (82.3%) read to them than did the non-attenders. S t a t i s t i c a l testing on the three areas of nutri-t i o n , infant feeding, and labour and d e l i v e r y found a s i g n i f i c a n t d i f f e r e n c e between the attenders and the non-attenders. There were, however, several questions r e l a t i n g to infant feeding ( e s p e c i a l l y with regard to c i g a r e t t e smoking) and c o n t r o l l e d breathing techniques on which both groups indicated that they did not know the correct answers. It was also expected that the attenders would engage i n more p o s i -t i v e behavioural health p r a c t i c e s than would the non-attenders. Ques-tions were asked regarding four separate health p r a c t i c e s with the following r e s u l t s : (1) a s i g n i f i c a n t difference was found between the two groups i n terms of c o n t r o l l e d breathing techniques used during labour and i n regard to infant feeding ( i . e . , more non-attenders than attenders breastfed t h e i r babies); (2) we were unable to demonstrate s i g n i f i c a n t d i f f e r e n c e s between the two groups with regard to smoking during pregnancy and n u t r i t i o n a l habits. I t may be concluded, then, that personal motivation and d i f f i c u l -t i e s i n speaking and comprehending Engl i s h were prime f a c t o r s i n non-u t i l i z a t i o n of prenatal classes, while medical s p e c i a l t y of care provider seemed to have no d i r e c t bearing on r e f e r r a l to these classes and, consequently, on u t i l i z a t i o n . Outcome measures generally supported the assumption that attenders would have more accurate knowledge on areas r e l a t i n g to pregnancy, c h i l d b i r t h and c h i l d care than would non-attenders. In terms of more p o s i t i v e behavioural health p r a c t i c e s , the non-attenders were more l i k e l y to breastfeed t h e i r babies and not to smoke during pregnancy, while more attenders stated they used c o n t r o l l e d breathing techniques during the d e l i v e r y . Both groups were f a i r l y com-74 parable i n terms of a p o s i t i v e change i n t h e i r n u t r i t i o n habits during pregnancy. 75 - CHAPTER VI DISCUSSION AND IMPLICATIONS OF RESULTS Discussion of Major Findings One of the hypotheses proposed f o r study was the r e l a t i o n s h i p be-tween u t i l i z a t i o n of prenatal educational classes and the respondents' perceptions of the classes. No d i f f e r e n c e was found between the two groups i n t h e i r perceptions and, i n f a c t , the rankings of purpose were s i m i l a r . O v e r a l l i t could be said that the respondents i n both groups were aware of the correct purposes of the classes and that lack of know-ledge of correct purpose was not a primary f a c t o r i n non-attendance. I t i s doubtful, then, from a planning/programming viewpoint whether i t would be a worthwhile use of resources to provide a d d i t i o n a l information to possible r e c i p i e n t s of these services on the purpose of prenatal education programs. The f a c t that there were nine non-attenders and one attender who did not know the purpose of the classes i s a somewhat more important f i n d i n g . Some of the women i n t h i s group also stated that they did not even know of the existence of these classes. The p o s s i b i l i t y of p r o v i -ding information on the existence of classes to physicians, s o c i a l groups, immigrant groups, community centres and churches should be ex-plored. The second hypothesis r e l a t e d to the a s s o c i a t i o n between s o c i a l class and attendance or non-attendance at prenatal classes. It was 76 found that the two groups (attenders and non-attenders) were s i g n i f i c -antly d i f f e r e n t on the v a r i a b l e of socio-economic status and that the non-attenders do come from a population ranked lower i n s o c i a l class than the attenders. Given the a v a i l a b i l i t y of l i t e r a t u r e that supports the assumption that s o c i a l c l a s s i s r e l a t e d to u t i l i z a t i o n of health services and more s p e c i f i c a l l y to prenatal and postnatal care, the r e -s u l t s are quite understandable. I t was expected however, that there would be a greater d i f f e r e n t i a t i o n between the non-attenders and the attenders i n the middle class grouping. That i s , one might expect more attenders than non-attenders to f a l l i nto the middle class group. F i n a l l y , i t was hypothesized that the presence of a s o c i a l network system would reduce the l i k e l i h o o d of attendance at prenatal classes and conversely, that the absence of a system of s o c i a l networks would increase the l i k e l i h o o d of attendance. Examination of the data shows no d i f f e r e n c e between the two groups with regard to the a v a i l a b i l i t y of support during the duration of the pregnancy, and we may therefore cautiously conclude that the a v a i l a b i l i t y of support does not bear on the question of prenatal u t i l i z a t i o n . That i s , there were no demon-strab l e s i g n i f i c a n t differences between the attenders and non-attenders i n terms of the presence of a husband or another close r e l a t i v e such as a mother or father. From a planning/programming viewpoint, i t would seem unnecessary to concentrate on t h i s as a f a c t o r which influences the u t i l i z a t i o n of these services. Although t h i s study d i d not exten-s i v e l y document i t s existence, women obtained a d d i t i o n a l support from f r i e n d s , co-workers, or other r e l a t i v e s , implying that a sort of peer group influence does e x i s t . Since there i s l i t t l e d i f f e r e n c e between 77 the attenders and non-attenders i n regard to t h e i r family structures and the a v a i l a b i l i t y of support during the pregnancy, i t may be specu-lated that expectant women do not see prenatal classes as a source of primary support during the pregnancy. However, these data may be under-representative of the unmarried mothers who chose not to keep t h e i r babies. Also, i t i s not known whether a cause-effect r e l a t i o n -ship e x i s t s with regard to t h i s information on a v a i l a b i l i t y of support. Although i t was hypothesized that i f a woman had immediate support systems i n her environment ( i . e . , husband, mother, father) she would be l e s s l i k e l y to attend, the r e s u l t s of t h i s hypothesis-testing lends some support to the inverse of t h i s . I t also leads one to inquire as to whether the a v a i l a b i l i t y of support served as a substitute f o r the classes or whether i t a c t u a l l y helped to f a c i l i t a t e attendance at these cla s s e s . A d d i t i o n a l research i n these areas i s warranted. Discussion of Other Findings One of the primary objectives of t h i s research was to determine the reasons expectant women were not u t i l i z i n g prenatal education services, i n sp i t e of the fa c t that prenatal services were a v a i l a b l e from both public and private sources to the women i n the Vancouver area for a minimal fee. Given t h i s a v a i l a b i l i t y , the task then was to de-termine the deterrents to the u t i l i z a t i o n of these educational services. In examining the data on the reasons given for non-attendance by each respondent i n the study, there appears to be a group of p o t e n t i a l p a r t i c i p a n t s of these classes who do not attend because they either are not convinced of the benefits of t h i s service or because they f e e l 78 alternative sources of information are available to them. As some of them cited previous education and/or previous experience (e.g. baby-sitting) as sources from which they obtained much of their information, i t may be concluded that they f e l t they already had sufficient knowledge regarding the subject areas taught at prenatal classes. Brown (1976) also found that the non-attenders in her study group f e l t more experien-ced in some aspects of infant care such as bathing, diapering and feed-ing- but they were not motivated to attend classes to increase their knowledge of pregnancy, infant care or parenthood. In this present study, there existed a second group of women who stated they did not attend because of a lack of knowledge of the existence of the classes. A third group of women stated they were too tired or sick to attend. This third group could be comprised of women who were expecting compli-cations with either their pregnancy or delivery and who probably needed additional information and support. From a planning/programming viewpoint i t would seem most logical and worthwhile to concentrate on the second group - those unaware of the existence of the classes. Since some of the women in this group are immigrant women, a concentration on disseminating information, in a num-ber of languages, and offering classes in languages other than English could assist these women. Although prenatal classes are offered in Chinese, they may be too few to meet the needs of the growing Chinese/ Japanese community. Given the large proportion of Asians and other immigrants i n the total Vancouver population, i t i s f a i r l y easy to understand the propor-t i o n of women i n the study sample who were born outside of Canada and who had a language other than English as t h e i r p r i n c i p a l one. On a percentage basis, over 2 1/2 times as many non-attenders as attenders did not have English as t h e i r p r i n c i p a l language, and the differences i n the East Indian groups were even more pronounced. This high propor-t i o n of non-English speaking women could help account for a proportion of the non-attenders. In addition, a c u l t u r a l b a r r i e r may e x i s t . The culture and r e l i g i o n of many East Indian women may f o r b i d them to d i s -cuss topics of a private nature, such as breastfeeding and experiences during c h i l d b i r t h , e s p e c i a l l y i n large and unfamiliar groups. Many of these women are not allowed to leave t h e i r homes without the escort of t h e i r husband, another male member of the household, mother, or mother-in-law. In addition, discussions with public health nurses indicated that many immigrant groups, e s p e c i a l l y those from countries ruled by d i c t a t o r s h i p , held a basic d i s t r u s t f o r public services and, consequent-l y , d i d not u t i l i z e these services. These explanations should help account for the East Indians who were non-attenders. There were only two attenders at prenatal classes who were East Indian, and i t i s known that one of them had an i n t e r p r e t e r ( i . e . , her sister-in-law) who accom-panied her to the classes. One of the greatest discrepancies between the attenders and non-attenders appeared i n t h e i r a b i l i t i e s to speak English and understand  spoken English. The attenders' a b i l i t y was ranked higher on both catego-r i e s than the non-attenders'. There i s the p o s s i b i l i t y of interviewer bias here, although steps vere taken to co n t r o l f or t h i s as much as • possible. I t appears that i t would be useful to concentrate on immi-80 grant women of childbearing age, using a d i f f e r e n t s e rvice d e l i v e r y approach, such as public health nurses o f f e r i n g informal sessions i n apartment buildings or community centres, and having an i n t e r p r e t e r present. O v e r a l l , i t was found that a higher percentage of attenders than non-attenders had accurate knowledge on questions of pregnancy, c h i l d -b i r t h and c h i l d care than non-attenders. The questions asked both groups rel a t e d to general information on these subject areas, which could be obtained from prenatal classes, books, physicians, etc. The s u r p r i s i n g differences between the two groups occurred on the questions of infant feeding and the number of "don't know" responses. As the questions p r i m a r i l y r e l a t e d to infant feeding and c i g a r e t t e smoking, i t i s conceivable that prenatal classes do not elaborate extensively on t h i s issue. The data on sources of knowledge were examined f o r both groups and i t was found that the non-attenders had considerably more d i v e r s i f i e d sources of information than the attenders who obtained most of t h e i r information from prenatal classes. I t i s obvious that non-attenders r e l y on outside sources for t h e i r information; however, i t should be noted that they r e l y heavily on previous education and experience, and other r e l a t i v e s . This can be more e a s i l y understood i n view of the f a c t that most of them have r e l a t i v e s with whom they made frequent con-tacts during t h e i r pregnancy. This fa c t also helps to re-emphasize the f i n d i n g that many of them f e l t they d i d not need to attend prenatal classes as they already had the experience and/or education necessary to deal with the pregnancy and d e l i v e r y . 81 We were unable to demonstrate any s i g n i f i c a n t d ifferences between the two groups i n terms of t h e i r smoking habits during pregnancy and the changes i n t h e i r n u t r i t i o n a l habits. The s i m i l a r i t i e s i n smoking habits might be explained by the lack of knowledge of the consequences of smoking displayed by both groups. The number of women from eastern countries, e s p e c i a l l y i n the non-attending group, could account for at l e a s t some of the non-smokers. In terms of the smokers, i t seems appa-rent that the e f f e c t s of smoking are not strongly emphasized at prenatal classes, or more r e a l i s t i c a l l y , that i t i s quite d i f f i c u l t to stop smoking even though you may have information d e t a i l i n g the negative e f f e c t s . A greater v a r i a t i o n i n n u t r i t i o n a l habits between the two groups was also expected, as one of the primary topics of prenatal classes i s to emphasize the benefits or p o s i t i v e e f f e c t s of good n u t r i t i o n during pregnancy. One also expects i n d i v i d u a l s from the middle and upper classes to have better n u t r i t i o n . However, l i t t l e d i f f e r e n c e was ob-served between the two groups. Non-attenders stated they derived i n -formation from sources such as books, r e l a t i v e s , and previous education/ experience. I t could be surmised that the information ( i . e . , knowledge) they obtained from these sources led to a change i n n u t r i t i o n a l prac-t i c e s , much as the knowledge obtained from prenatal classes would lead to a change i n behaviour f o r the attenders. Differences between the two groups were observed i n regard to infant feeding and whether or not c o n t r o l l e d breathing techniques were used during the labour and d e l i v e r y . As benefits of breastfeeding are 82 explained and discussed at prenatal classes, one would expect more attenders to breastfeed than non-attenders, yet the reverse i s true. This could possibly be explained by the fa c t that bottlefeeding tends to be more acceptable to middle and upper class women than does breast-feeding. This p r a c t i c e does seem to be changing, however slowly. P r i o r a t t i t u d e s about breastfeeding would also seem to contribute to th i s inverse r e l a t i o n s h i p . As the use of con t r o l l e d breathing techniques i s one of the main purposes of prenatal classes, one would expect more attenders than non-attenders to use these techniques. This, i n f a c t , did occur, yet a s u r p r i s i n g l y high percentage of the non-attenders stated they also used these techniques during the labour and de l i v e r y . I t i s f e a s i b l e , e s p e c i a l l y with the non-English speaking women, that the terminology "breathing techniques" was misunderstood or misinterpreted. A more accurate means of assessing t h i s would have been to ask the women to demonstrate the way they breathed during the d e l i v e r y and to have trained the interviewers to assess these techniques. In addition, a question could have been asked on whether or not an anaesthetic was used during the labour - both of these might have l i m i t e d any p o s s i b i l i t y f or m i s i n t e r p r e t a t i o n or misunderstanding of the terms. P a r t i c u l a r l y relevant to the discussion of immigrant women i s the under-representativeness of respondents from the South Health Unit area and the number of one-parent f a m i l i e s . As the South Unit area has a growing number of immigrant f a m i l i e s , i t might be expected that the findings on language and u t i l i z a t i o n would have been even more pronounced 83 had there been a larger representation from t h i s area. The under-representiveness of one-parent f a m i l i e s has implications i n terms of the a v a i l a b i l i t y of the system of s o c i a l supports. That i s , had a larger percentage of t h i s group been included i n the study, then a greater d i f f e r e n c e between attenders.and non-attenders and t h e i r systems of support ( i . e . , s o c i a l networks) may have emerged. One might even expect more pronounced di f f e r e n c e s i n terms of s o c i a l c l a s s and u t i l i z a -t i o n of physician services. Although none of t h i s i s conclusive, i t i s important to note i t i n terms of the o v e r a l l implications of the r e s u l t s . F i n a l l y , i t i s important to note that differences between these two groups may have occurred because of basic c h a r a c t e r i s t i c s of the two populations. Hence, the importance of c o n t r o l l i n g f o r a number of f a c -tors such as education, e t h n i c i t y , age, income, ma r i t a l status and other socio-demographic c h a r a c t e r i s t i c s and using these v a r i a b l e s to match attenders and non-attenders i s recognized. Suggestions f o r A d d i t i o n a l Research One of the primary areas warranting further i n v e s t i g a t i o n i s that of l e v e l of knowledge. Because of the p r a c t i c a l d i f f i c u l t i e s i n l o c a t i n g non-attenders p r i o r to the ac t u a l d e l i v e r y , i t was impossible to conduct a pre - post test on the two groups. This method of t e s t i n g would allow for a more accurate measurement of the di f f e r e n c e s i n knowledge between the two groups. A d d i t i o n a l research into the s p e c i f i c r e l a t i o n s h i p s between knowledge and behavioural p r a c t i c e s should also be explored. It was beyond the scope of t h i s study to examine, i n any depth, these r e l a t i o n s h i p s , yet t h i s area i s considered to be an important one and 84 c e r t a i n l y has implications for the future planning of pre- and postnatal education programs. The area of the actual experiences during the labour and d e l i v e r y of the two groups i s another area for further i n v e s t i g a t i o n . S p e c i f i -c a l l y , research into the amount of pain experienced (e.g., women of d i f f e r e n t ethnic backgrounds view pain i n a d i f f e r e n t and more favour-able l i g h t than North American women), the perception of the experience and the support they received during the experience. This l a t t e r area indicates the need f o r a " c l i e n t s a t i s f a c t i o n " study d e t a i l i n g the treatment of the woman i n h o s p i t a l , the w i l l i n g n e s s of the medical prac-t i t i o n e r to adhere to the desires of the woman and her general percep-t i o n of the h o s p i t a l experience. (For example, did the woman receive any information, while i n h o s p i t a l , which would a s s i s t her i n the post-partum period either i n adjusting or i n caring for the child? Was she allowed "rooming-in" p r i v i l e g e s ? Were h o s p i t a l methods and procedures adequately explained to her? Did the h o s p i t a l s t a f f know and support the woman's class-acquired information? Was t h i s information h e l p f u l i n "coping" with the h o s p i t a l experience?) A t h i r d area involves the ro l e and p a r t i c i p a t i o n of the husband/ partner during the labour and de l i v e r y . A su b s t a n t i a l number of women stated that t h e i r husbands attended prenatal classes with them, yet the s p e c i f i c r o l e of the husband/partner during c h i l d b i r t h or h i s perception of the b i r t h could not be explored within the scope of t h i s study, but may warrant further i n v e s t i g a t i o n . A f i n a l area may warrant further exploration: t h i s i s the r e l a t i o n -85 ship between the expectant woman's attendance at prenatal education classes and her sj'stem of s o c i a l supports. In the author's view, t h i s r e l a t i o n s h i p could have been pursued and examined more exhaustively, since i t s implications for immigrant and transient women, i . e . , those who l i k e l y have few contacts i n the community, are se l f - e v i d e n t . Implications This study was expected to provide information which would be n e f i t three primary groups: (1) those women of childbearing age who become pregnant; (2) the health professionals who are planning for and providing these prenatal services; and (3) u n i v e r s i t y professors who provide t r a i n i n g f o r students i n the health d i s c i p l i n e s . One outcome of t h i s study has been the pr o v i s i o n of information on the expectations and perceived needs of expectant women during the time of t h e i r pregnancy and d e l i v e r y and i n caring for the c h i l d a f t e r b i r t h . In general, women wanted more d e t a i l e d information on preparation for labour and d e l i v e r y and on caring for the c h i l d a f t e r b i r t h (e.g., i n f a n t feeding, general health of baby). The lack of knowledge of one or both groups i n c e r t a i n areas also provides information for planning of these programs. The need f o r a concentration on immigrant women has also been indicated and i s a s p e c i f i c sub-group which could benefit considerably from dissemination of information and a l t e r n a t i v e modes of service d e l i v e r y . For example, u t i l i z a t i o n of indigenous, "non-p r o f e s s i o n a l " health aides i n r e c r u i t i n g these women f o r classes, or the promotion of these classes v i a physicians ( p a r t i c u l a r l y i n those areas where immigrant women are predominant) could be h e l p f u l i n serving 86 the needs of t h i s sub-group. In addition, information i n a v a r i e t y of languages could be mailed to a l l expectant mothers, based on p r a c t i -tioners' b i l l i n g f o r prenatal v i s i t s . In terms of d e l i v e r y of health services, a number of women stated that although they attended a pr i v a t e doctor for the care of t h e i r baby, many of the working mothers expressed the need for Well Baby C l i n i c s to be scheduled e i t h e r i n the evenings or on weekends, as t h e i r jobs prevented them from u t i l i z i n g t h i s service (See Appendix C). In addition, the need f o r a postnatal component was emphasized by many women."'""'" These suggestions have implications f or a reorganization and expansion of the present p u b l i c health system. I t i s also expected that the information derived from t h i s study w i l l give those who are providing t r a i n i n g f o r students i n the health professions (e.g., medical, nursing, and s o c i a l work students) a broader base from which to conduct health manpower planning and to promote r o l e d e f i n i t i o n . The value of t h i s study to the Faculty of Nursing and Faculty of Medicine i s e s p e c i a l l y important, as i t i s p r i n c i p a l l y nurses who are responsible for planning, administering and conducting these programs. In addition, i t should a i d i n re-emphasizing the importance of physician r e f e r r a l to prenatal classes and a recog-n i t i o n of the information and service needs of these women. 11. Some of the Public Health Units are now o f f e r i n g these postnatal classes. However, the demand at present i s greater than the supply. 86a CONCLUSION Although the primary focus of t h i s study was on those factors which influenced u t i l i z a t i o n of prenatal educational services by a group of primiparas i n Vancouver C i t y , the most i n t e r e s t i n g and s i g n i f i c a n t findings occurred i n terms of p r i n c i p a l language u t i l i z e d and the outcome measures. A s i g n i f i c a n t l y higher percentage of attenders had English as t h e i r p r i n c i p a l language and were assessed as speaking and understanding Engl i s h w e l l or f a i r l y w e l l , as compared with the non-attenders. This data indicates the need for a greater emphasis on more d i v e r s i f i e d i n -formation dissemination and service d e l i v e r y systems dire c t e d toward new immigrants and non-English speaking women. The data regarding knowledge indicated that attenders had more accurate knowledge than did the non-attenders i n the areas of pregnancy, c h i l d b i r t h and c h i l d care. If a commitment e x i s t s to concentrate on outcome measures i n the f i e l d of public health, then t h i s knowledge area needs to be more f u l l y explored using c o n t r o l l i n g f a c tors such as age, e t h n i c i t y and socio-economic status. In the area of behavioural health p r a c t i c e s , i t was found that non-attenders smoked l e s s during pregnancy than did attenders, and also more non-attenders breastfed t h e i r babies. This suggests the necessity f or re-examination of the content areas and teaching methods used during prenatal classes, as w e l l as the impact of these methods on the l i f e s t y l e behaviour of the mother and, consequently, on the health of the c h i l d . 87 BIBLIOGRAPHY Blishen, B.R. "A Socio-Economic Index for Occupations i n Canada." 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"The Disadvantaged and Health Care." American Journal of  Public Health, Volume 56, No. 1 (1966), pp. 5-9. Young, M.A. Review of Research and Studies Related to Health Education P r a c t i c e (1961-1966): What People Know, Believe and Do About Health. Health Education Monograph No. 23. New York: Society of Public Health Educators, 1967. 91 APPENDIX A PRENATAL INTERVIEW SCHEDULE 92 PRE-NATAL INTERVIEW SCHEDULE ADDRESS OF RESPONDENT: RESPONDENT IDENTIFICATION NO. DATE OF INTERVIEW: TIME INTERVIEW STARTED: TIME INTERVIEW COMPLETED: LENGTH OF INTERVIEW: DATE CHECKED: CHECKED BY: NAME OF INTERVIEWER: 93 YOU DON'T HAVE TO ANSWER THESE QUESTIONS IF YOU DON'T WANT TO. OR IF THERE IS ONE PARTICULAR QUESTION YOU DON'T WANT TO ANSWER, PLEASE TELL ME, O.K.? MAY I ASK YOU THESE QUESTIONS? PRE-NATAL EDUCATION: ITS USE AND NON-USE INTERVIEW: Card # | | 1 P a r t i c i p a n t ID # \ | | | | | 2 3 4 Interviewer # ' 5 THE MAIN PURPOSE OF THIS INTERVIEW IS TO ASK YOU ABOUT THE CARE AND SUPPORT YOU RECEIVED DURING YOUR PREGNANCY. FIRST, I'D LIKE TO ASK YOU SOME GENERAL QUESTIONS ABOUT YOU AND YOUR FAMILY. PERSONAL DATA 1. Date of Delivery Day Month • • • • 6 7 8 9 2. Could you please t e l l me your age? Age of Respondent. 3. Could you also t e l l me your date of b i r t h ? Date of B i r t h • • 10 11 • • • • • • 12 13 14 15 16 17 94 4. What i s your m a r i t a l status? (ASK AS OPEN QUESTION.) SINGLE MARRIED WIDOWED DIVORCED SEPARATED 18 1 2 3 4 5 OTHER (Specify) 6 5a. What i s your country of o r i g i n ? 69 5b. What i s the language you f e e l most comfortable with? (ASK AS OPEN QUESTION.). ENGLISH 1 GREEK 5 CHINESE 2 FRENCH 6 JAPANESE 3 GERMAN 7 LANGUAGE OF INDIA 4 ITALIAN 8 • 19 OTHER (Specify) 9 I NOW WANT TO ASK YOU SOME QUESTIONS ABOUT YOUR RELATIVES AND YOUR CONTACT WITH THEM DURING YOUR PREGNANCY. ASK ALL RESPONDENTS: 6. I f you had a health problem, i s there one s p e c i f i c member of your family, other than y o u r s e l f , who i s responsible f o r taking care of you? (e.g. taking you to the doctor, h o s p i t a l , etc.) Yes 1 No 2 • 20 IF YES, ASK: IF NO, PROCEED TO QUESTION 8. 7. Who i s t h i s person? (Relationship to Respondent) • 21 95 ASK ALL RESPONDENTS: 8. With which r e l a t i v e s d i d you spend the most time discussing your pregnancy? (INTERVIEWER: ASK RESPONDENT TO RANK EACH OF THESE INDIVIDUALS IN ORDER FROM MOST TO LEAST IN TERMS OF TIME SPENT DISCUSSING HER PREGNANCY.) (USE N/A OR DECEASED FOR THOSE THAT DON'T APPLY) Husband • 22 Mother • 23 Father CXI. 4 Mother-in-law • 25 Father-in-law • 26 Aunts • 27 Uncles • 28 Grandmother(s) • 29 Grandfather(s) • 30 Cousins • 31 Brothers or S i s t e r s • 32 Others (Specify) • 33 9. Other than r e l a t i v e s , with which other i n d i v i d u a l s d i d you spend the most time d i s c u s s i n g your pregnancy? (RELATIONSHIP, NOT NAMES.) • • • • ' f 34 35 36 96 WE'RE ALSO INTERESTED IN THE SOURCE OF YOUR INFORMATION ON CHILDBIRTH AND CHILD CARE. WOULD YOU PLEASE TELL ME: 10. From what source d i d you receive most of your information on c h i l d b i r t h ? (INTERVIEWER: ASK AS OPEN QUESTION.) • No Reply Relative (including husband) Friend/Neighbour 37 0 1 2 Doctor O f f i c e Nurse Pre-Natal Classes 3 4 5 Community Health Nurse Books and Magazines TV & Radio 6 7 8 Other (Specify) 9 11. From what source did you receive most of your information on c h i l d care? (INTERVIEWER: ASK AS OPEN QUESTION.) • No Reply Relative (including husband) Friend/Neighbour 38 0 1 2 Doctor O f f i c e Nurse Pre-Natal Classes 3 4 5 Community Health Nurse Books and Magazines TV & Radio 6 7 8 Other (Specify) 9 IF RESPONSE TO EITHER 10 OR 11 IS 'RELATIVE', ASK QUESTION 12. IF RESPONSE IS OTHER THAN 'RELATIVE', PROCEED TO QUESTION 13. 97 12. During your pregnancy, d i d you ever obtain information from any of these r e l a t i v e s with regard to the following areas: Yes No • 39 1. Exercise and re s t during pregnancy 1 2 Yes No d 40 2. Eating habits during pregnancy 1 2 Yes No • 41 3. Weight gain during pregnancy 1 2 Yes No • 42 4. How you would f e e l during c h i l d b i r t h 1 2 Yes No • 43 5. Breast feeding 1 2 ASK ALL RESPONDENTS: NOW, I'D LIKE TO ASK SOME QUESTIONS ABOUT YOUR CONTACTS WITH A DOCTOR. 13. Did you see a doctor about your pregnancy anytime p r i o r to your d e l i v e r y ? No Reply Yes No 0 1 2 9 IF YES, ASK QUESTIONS 14 THROUGH 18. IF NO, PROCEED TO QUESTION 19. 14. Was there one doctor t h a t you saw more than others throughout your pregnancy? No Reply Yes No 0 1 2 J J 45 15. In which month of your pregnancy d i d you f i r s t see t h i s p a r t i c u l a r doctor? (PROBE AND RECORD AS REPORTED.) Month 46_. 47. 98 16. Was t h i s doctor a General P r a c t i t i o n e r , Obstetrician/Gynaecologist or what? • 48 No Reply = 0 General P r a c t i t i o n e r = 1 Obstetrician/Gynaecologist = 2 (PROBE: SPECIALIST) Other = 3 Don't Know = 4 17. Did your doctor recommend that you attend p r e - n a t a l classes? No Reply Yes No Q 0 1 2 49 IF RESPONSE IS NO, ASK: 18. Did your doctor recommend that you not attend pre-natal classes? No Reply Did recommend Did not recommend £ j not attend not attend 50 0 1 2 Other (Specify) 3 OPINION QUESTIONS: WE ARE INTERESTED IN YOUR OPINIONS ABOUT SOME ISSUES RELATING TO CHILDBIRTH AND CHILD CARE. THERE ARE NO RIGHT  OR WRONG ANSWERS FOR THE FOLLOWING STATEMENTS: I WOULD JUST LIKE YOU TO LISTEN CAREFULLY TO EACH OF THE STATEMENTS AND TELL ME WHETHER YOU AGREE OR DISAGREE WITH IT. NUTRITION 19. A pregnant woman should drink a t l e a s t four glasses of milk or the equivalent per day. ^—^ Agree Disagree Don't Know 51 1 2 3 99 20. D i e t i n g during pregnancy can r e s u l t i n changes i n intake of important n u t r i e n t s with unpredictable e f f e c t s on your and the baby's well-bein Agree Disagree Don't Know Q 1 2 3 52 21. An o v e r a l l weight gain of approximately 24 l b s . during the course of your pregnancy should be expected. Agree Disagree Don't Know | [ 1 2 3 53 22. R e s t r i c t i o n of the normal s a l t intake i s gene r a l l y recommended f o r e -women having a normal pregnancy. Agree Disagree Don't Know | | 1 2 3 54 FEEDING THE INFANT 23. Generally, the feeding time on each breast begins with 2 minutes on the f i r s t day, progresses to 5 on the second day, and then upwards oh each successive day. Agree Disagree Don't Know 1 2 3 55 24. Generally, i n f a n t s must wait at l e a s t 24 hours a f t e r d e l i v e r y before they can nurse. Agree Disagree Don't Know \_^ \ 1 . 2 3 56 25. The e a r l y milk i n the breast contains substances which help the baby f i g h t disease or i l l n e s s . Agree Disagree Don't Know \_^} 1 2 3 57 100 26. The mother's l i q u i d intake, p a r t i c u l a r l y milk, should be increased during breast feeding. Agree Disagree Don't Know \_^ \ 1 2 3 58 27. Before b o t t l e feeding an i n f a n t , the b o t t l e should be washed with soap and b o i l e d with water. Agree Disagree Don't Know Q 1 2 3 59 28. I t i s advisable not to take any medicine while your baby i s breastfeeding, unless advised by a doctor. Agree Disagree Don't Know ]_^\ 1 2 3 60 29. In the e a r l y stages of breastfeeding, sore nipples can us u a l l y be prevented by not allowing the baby to nurse f or more than ten minutes. Agree Disagree Don 11 Know [Q] 1 2 3 61 30. The amount of c i g a r e t t e s the mother smokes during pregnancy inf l u e n c e s the q u a l i t y or quantity of the milk. Agree Disagree Don't Know Q 1 2 3 62 31. The weight of the baby i s not af f e c t e d by smoking during pregnancy. Agree - Disagree - Don't Know not a f f e c t e d i s a f f e c t e d _^~] 1 2 3 63 LABOUR AND DELIVERY 32. The contractions which s i g n a l the onset of labour occur at regular i n t e r v a l s . Agree Disagree Don't Know \_^} 1 2 3 64 101 33. The breathing methods used during labour should provide needed oxygen to the womb and the baby. Agree Disagree Don't Know 1 2 3 65 34. The amount of pain f e l t during a contraction i s not i n f l u e n c e d by breathing techniques. Agree Disagree Don't Know [^) 1 2 3 66 35. When nearing the end of your pregnancy, a show of blood or water usu a l l y means that labour i s beginning. Agree Disagree Don't Know J^ j 1 2 3 67 36. What i s the one source from which you think you obtained most of your knowledge about these areas? _ • - - • - - - - - 68 HEALTH PRACTICES: NOW, I WANT TO ASK YOU A FEW MORE QUESTIONS CONCERNING THE THINGS WE'VE JUST BEEN DISCUSSING. 37. Did you breastfeed or b o t t l e f e e d your baby or both? No Reply Breast Feed Bottle Feed 0 . . 1 . . . _2 Both Other (Specify) 3 4 38. Did you smoke during your pregnancy? • 69 No Reply Yes No 0 1 2 70 39. Did you use breathing techniques during your labour and d e l i v e r y ? No Reply Yes No Q 0 1 2 71 102 40. Do you f e e l you had b e t t e r n u t r i t i o n during pregnancy than before? No Reply 0 Yes 1 No 2 • 72 WE WOULD NOW LIKE TO ASK YOU A FEW QUESTIONS ON PRE-NATAL CLASSES. PRE-NATAL CLASS ATTENDANCE:' (INTERVIEWER: IF WOMAN INDICATED EARLIER THAT SHE ATTENDED PRE-NATAL CLASSES, THEN QUESTION 41 SHOULD BE USED ONLY TO VERIFY THAT INFORMATION. E.G. YOU MENTIONED PRE-NATAL CLASSES EARLIER - YOU DID ATTEND?) 41. Did you attend pre-natal classes during your pregnancy^ Yes 1 No 2 • 1 IF YES, ASK THE FOLLOWING QUESTIONS THROUGH QUESTION 56. IF RESPONSE IS' NO, PROCEED TO QUESTION 57. 42. How many classes were there i n the se r i e s ' • 2 43. How many classes d i d you attend? • 3 44. Did your husband/partner attend these classes with you? Yes 1 No 2 • 4 IF RESPONSE IS YES, ASK QUESTIONS 45 AND 46. IF RESPONSE IS NO, PROCEED TO QUESTION 47. 45. Would you please t e l l me why he attended? • • • 5 6 7 103 46. How many classes d i d he attend? 47. Would you please t e l l me why he didn't attend? ASK ALL ATTENDERS: 48. How d i d you hear about these classes? 49. Did any i n d i v i d u a l ( s ) a c t i v e l y encourage you to attend pre-natal classes? I f yes, who? • • • • 9 10 11 • • 12 13 • • • 14 15 16 50. Who was most i n f l u e n t i a l i n g e t t i n g you to attend these classes? j^j 17 51. When you were considering pre-natal care, what did you see as the purpose of pre-natal classes? • 18 • • 19 20 104 D i f f e r e n t people have d i f f e r e n t reasons f o r attending pre-natal classes Could you t e l l me: 52. What was the one main reason f o r your attending these classes? • : 2 1 INTERVIEWER: ASK QUESTION 53 IF RESPONDENT STATES MOST COMFORTABLE LANGUAGE IS NOT ENGLISH. 53. What was the language used i n the pre - n a t a l classes you attended? ENGLISH CHINESE JAPANESE A LANGUAGE OF INDIA Q 1 2 3 4 22 GREEK FRENCH GERMAN" ITALIAN 5 6 7 8 : OTHER (Specify) " 9 ASK ALL ATTENDERS.: 54. Did you attend pre-natal c l a s s e s at a Metropolitan Health Unit or p r i v a t e c h i l d b i r t h classes or where? ^ Metropolitan Health P r i v a t e C h i l d b i r t h Classes 23 1 2 Other (Specify) 3 105 55. I'm sure a l o t has happened since your pregnancy and the b i r t h of your baby, but I wonder i f you would mind t h i n k i n g about those times and t e l l me: j—-j j—j r—-j j — j Based on the kinds of experiences you had during your pregnancy 24 25 26 27 and at the time of d e l i v e r y , what kinds of information would have been h e l p f u l to you but was not provided by the pre-natal classes? PLEASE SPECIFY. 56. Thinking f o r a minute about your experiences since the b i r t h of your c h i l d , what kinds of information would be h e l p f u l to you i n carin g f o r your c h i l d , but was not provided by the pre-natal classes? PLEASE SPECIFY. j — j j — | |—| j — j 28 29 30 31 IF ATTENDER, PROCEED TO QUESTION 65. IF NON-ATTENDER, ASK QUESTIONS 57 THROUGH 64. WE KNOW IT IS OFTEN DIFFICULT TO PARTICIPATE IN CLASSES OR OTHER EVENTS BECAUSE OF FAMILY OF JOB RESPONSIBILITIES, LACK OF TRANSPORTATION, ETC. WE WOULD NOW LIKE YOU TO STOP AND THINK FOR A FEW MINUTES ABOUT THE TIME DURING YOUR PREGNANCY WHEN YOU MIGHT HAVE BEEN CONSIDERING PRE-NATAL CLASSES. 106 57. Did you know then whether or not pre-natal c l a s s e s were being o f f e r e d i n Vancouver? • Yes No 32 1 2 58. During the time of your pregnancy, what d i d you see as the purpose of pre - n a t a l classes? • • • 33 34 35 59. Now, i f you don't mind, could you t e l l me the one main reason you didn't attend pre-natal classes? • 3b 60. Could you t e l l me which other f a c t o r s may have f u r t h e r influenced your not attending the classes? (INTERVIEWER: ASK AS OPEN QUESTION.) Did not know about the course = l Did not think anything important could be learned = 2 Received a l l necessary information from f r i e n d s and r e l a t i v e s . 3_ F e l t uncomfortable with group s i t u a t i o n = 4 Did not have t r a n s p o r t a t i o n to get to classes = 5 Husband/partner discouraged me from attending = 6 Family p h y s i c i a n f e l t I d i d not need to attend = 7 Heard about c l a s s e s too l a t e = 8 Had i l l n e s s i n the family = 9 Employment prevented me from attending = 10 Did not f e e l w e l l enough to attend = n Too busy to attend = 12 D i f f i c u l t y understanding or speaking E n g l i s h = 13 Other (Specify) = 14 • • • • 37 38 39 40 107 NOW, WE'RE INTERESTED IN KNOWING IF ANYONE MIGHT HAVE EITHER ENCOURAGED OR DISCOURAGED YOU FROM ATTENDING PRE-NATAL CLASSES: 61. F i r s t of a l l , d i d anyone a c t i v e l y encourage you to attend pre-natal classes? I f yes, who? __ _ 41 42 62. Was there anyone who discouraged you from attending pre-natal classes? I f yes, who? • • 43 44 I'M SURE A LOT HAS HAPPENED SINCE YOUR PREGNANCY AND THE BIRTH OF YOUR BABY, BUT I WONDER IF YOU WOULD MIND THINKING ABOUT THOSE TIMES AND TELL ME: 63. Based on the kinds of experiences you had during your pregnancy or at the time of d e l i v e r y , what kinds of information do you think would have been h e l p f u l to you? • • • • 45 46 47 48 108 64. Thinking f o r a minute about your experiences since the b i r t h of your c h i l d , what kinds of information do you think would be h e l p f u l to you i n caring f o r your c h i l d ? • • • • 49 50 51 52 ASK ALL RESPONDENTS: NOW, I'D LIKE TO ASK YOU JUST A FEW MORE QUESTIONS WHICH MIGHT HELP PEOPLE WHO ARE PLANNING SERVICES FOR EXPECTANT PARENTS. 65. Which health service do you mainly plan to use f o r your baby? Pr i v a t e doctor = 1 j^J 53 Outpatient C l i n i c i n H o s p i t a l = 2 Well Baby C l i n i c s (Public Health C l i n i c s ) = 3 Other (Specify) = 4 SOME RESEARCH HAS SHOWN THAT USE OF HEALTH SERVICES RELATES TO FACTORS SUCH AS INCOME, OCCUPATION OR EDUCATION. FOR THIS REASON.ONLY I WOULD LIKE TO ASK YOU THESE FEW QUESTIONS: = = . 54 55 66. What i s the highest grade or year of school which you attended? R S Post graduate t r a i n i n g = 1 Q I IUndergraduate t r a i n i n g from U n i v e r s i t y or'College (4 yrs.) = 2 P a r t i a l U n i v e r s i t y t r a i n i n g o r Community College (1 yr . +) = 3 High School graduate = 4 P a r t i a l High School (Grades 10, 11) = 5 Junior High School (Grades 7, 8 or 9) = 6 Less than 7 grades of school = 7 (Education score = ) 109 67. Who i s the major wage earner i n your household? Respondent = 1 56 Spouse/Partner = 2 Father = 3 Mother = 4 Other = 5 (Specify) 68. What i s your usual occupation when you are working f o r a wage or salary? (INTERVIEWER: STRESS USUAL.) • 57 69. What i s the usual occupation of your husband/partner? (INTERVIEWER: STRESS USUAL.) • 58 70. Please look at t h i s card and choose the number of the grouping which i s c l o s e s t to your combined family income. (Family income i s the combined wages, s a l a r i e s , government plans (welfare, pensions, e t c . ) , i n t e r e s t and investments of a l l members of your family who l i v e with you.) • Card: 59 Up to $5,999 $6,000 - $8,999 $9,000 - $11,999 7 6 5 $12,000 - $14,999 $15,000 - $17,999 $18,000 - $20,999 4 3 2 $21,000 and over 1 THANK RESPONDENT PROFUSELY FOR HER CO-OPERATION! I ! ! I '. 110 NOTE TO INTERVIEWER. PLEASE RESPOND TO THE FOLLOWING QUESTIONS BASED ON YOUR OBSERVATIONS OF THE RESPONDENT DURING THE INTERVIEW. PLEASE TRY TO BE AS OBJECTIVE AS POSSIBLE. 71. How well do you think the respondent speaks English? • Well F a i r Poor 60 1 2 3 72. How well do you think the respondent understands spoken English? • Well F a i r Poor 61 1 2 3 PLEASE CHECK TO SEE THAT ALL QUESTIONS ARE ANSWERED AND RECORD THE RESPONSES TO QUESTION 8. INTERVIEWER'S IMPRESSIONS 1. Was respondent interviewed by h e r s e l f or were others present? • Alone Others Present 62 • • 2. Was general atmosphere f r i e n d l y , n e utral or h o s t i l e ? • F r i e n d l y Neutral H o s t i l e 63 • • : • 3. Do you think the respondent was minimally t r u t h f u l , mainly t r u t h f u l or wholly t r u t h f u l ? • Minimally Mainly Wholly 64 • • • I l l 4. L i s t (by number) any questions you think made the respondent uncomfortable. d • • • 65 66 67 68 5. Any other comments: PLEASE GO BACK AND COMPLETE THE COVER PAGE I 112 APPENDIX B LETTER TO RESPONDENT 114 APPENDIX C PLANNING/PROGRAMMING INFORMATION 115 PLANNING/PROGRAMMING INFORMATION At the request of individuals working i n the f i e l d of public health, several questions were asked which would assist them in planning programs for expectant parents. The f i r s t question related to postnatal care for the baby and consisted of asking each respondent which type of health service she preferred for her baby. The results indicate that both groups prefer private doctors (See Table XXXIV). Specifically, 81.5 per cent (or 44 cases) of the non-attenders and 75.3 per cent (or 55 cases) of the attenders prefer the private sector. Well baby cl i n i c s were preferred by 14.8 per cent (or 8 cases) of the non-attenders and 20.5 per cent (or 15 cases) of the attenders. Therefore, both groups were f a i r l y comparable in their choice of preferred health services. However, several of the mothers stated a preference for well baby c l i n i c s but did not use them because they were available only during the day. The second set of questions had two dimensions. Both groups of respondents were asked to state the kinds of information that would have been helpful to them both during the pregnancy and delivery and in caring for the child after the birth (i.e., information they did not receive from anyone or information on which they required elaboration). The results are presented in Tables XXXV and XXXVI. In examining the data in Table XXXV, i t can be seen that informa-tion on preparation for labour and delivery was ranked f i r s t by both the non-attenders and the attenders. That i s , 35.2 per cent (or 19 116 cases) o f the non-attenders and 21.9 per cent (or 16 cases) of the attenders f e l t t h i s information was important to them. The second category of information concerning 'al t e r n a t i v e methods of d e l i v e r y and complications o f c h i l d b i r t h ' d i d not have the same amount of importance f o r both groups. A f a i r l y large portion of the attenders, 20.6 per cent (or 15 cases), ranked t h i s as t h e i r f i r s t p r i o r i t y f o r information as compared with 3.7 per cent (or 2 cases) of the non-attenders. This divergence i s also true f o r the category 'Hospital Methods and Procedures', i n which 9.6 per cent (or 7 cases) of the attenders f e l t t h i s was important a d d i t i o n a l information. However, none of the non-attenders f e l t t h i s was important. E s p e c i a l l y interesting, however, i s the number of women who f e l t that no a d d i t i o n a l information was necessary. This included 38.9 per cent (21 cases) of the non-attenders and 37.0 per cent (27 cases) of the attenders. The second set of information we asked the respondents about was information regarding the care of the c h i l d . Table XXXVI shows that 'feeding the infan t ' ranked f i r s t among both the non-attenders (33.3 per cent or 17 cases) and the attenders (23.9 per cent or 17 cases). A comparable percentage of both groups f e l t that 'crying and screaming of baby' was also an important information need (13.7 per cent of the non-attenders and 11.3 per cent of the attenders ranked i t f i r s t ) . Both groups also f e l t that 'care of baby' (e.g., bathing, holding and/or diapering baby) and 'general health of baby' (e.g., rashes, constipation, appointments with doctor) were important and ranked them f i r s t . Post-partum care of mothers was considered important by a few of the attenders (7.0 per cent or 5 cases) but 117 only 1 non-attender (2.0 per cent). Again, some of the primiparas f e l t no a d d i t i o n a l information was necessary. This included 19.6 per cent (or 10 cases) of the non-attenders and 18.3 per cent (or 13 cases) of the attenders. In summary, i t seems apparent from t h i s data that there are s p e c i f i c information needs which are not being met through e i t h e r formal or informal structures. Better preparation f o r labor and d e l i v e r y as well as i n f a n t feeding were high information needs f o r both groups of mothers. However, i s i t recognized that information on c h i l d care gains i n importance once the baby a r r i v e s and the d i f f i c u l t y i n providing t h i s information p r i o r to the d e l i v e r y i s also acknowledged. 118 APPENDIX C TABLE XXXIV Number and Percentage D i s t r i b u t i o n of  Non-Attenders and Attenders by Type of Health Service Preferred f o r Baby Type of Health Service Non- Attenders Attenders To t a l No. % No. Q. *o No. % Private Doctor 44 81.5 55 75.3 99 78.0 Well Baby C l i n i c s 8 14.8 15 20.5 23 18.1 Other or Combination of Above 2 3.7 3 4.1 5 3.9 54 100.0 73 99.9 127 100.0 TABLE XXXV Number and Percentage D i s t r i b u t i o n of Non-Attenders and Attenders by Infor- mation Desired Regarding Pregnancy and Delivery Information Non-Attenders No. % Attenders T o t a l No. % No. Better Preparation f o r Labour and Delivery A l t e r n a t i v e Methods of Delivery and Complications of C h i l d b i r t h Hospital Methods and Procedures Health of Mother and C h i l d during Pregnancy Other No A d d i t i o n a l Information Necessary No Response 19 4 4 21 4 35.2 3.7 7.4 7.4 38.9 7.4 16 21.9 35 27.6 15 20.6 17 13.4 27 2 9.6 8.2 10 5.5 3.1 7.9 37.0 48 37.8 2.7 6 4.7 54 100.0 73 100.0 127 100.0 119 APPENDIX C TABLE XXXVI Number and Percentage D i s t r i b u t i o n of  Non-Attenders and Attenders by Infor- mation Desired Regarding C h i l d Care Information Non-Attenders Attenders T o t a l No. % No. %_ No. %_ Feeding the Infant 17 33.3 17 23.9 34 27.9 Crying and Screaming of Baby 7 13.7 8 11.3 15 12.3 Sleeping Habits o f Baby 0 0.0 1 1.4 1 0/8 Care of Baby* 7 13.7 15 21.2 22 18.0 General Health of Baby** 9 17.6 12 16.9 21 17.2 Post-partum Care of Mother 1 2.0 5 7.0 6 4.9 C h i l d Development 0 0.0 0 0.0 0 6.0 Other 0 0.0 0 0.0 0 0.0 No A d d i t i o n a l Information Necessary 10 19.6 13 18.3 23 18.9 51 100.0 71 100.0 122 100.0 * For example, bathing, holding and/or diapering baby. ** For example, rashes, constipation, appointments with doctors. 

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