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Determination of who benefits most from prenatal class attendance Spoke, Mary Lily 1986

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DETERMINATION OF WHO BENEFITS MOST FROM PRENATAL CLASS ATTENDANCE By MARY L I L Y SPOKE B.ScN. The U n i v e r s i t y o f V i c t o r i a , 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n HEALTH SERVICES PLANNING AND ADMINISTRATION i n THE FACULTY OF GRADUATE STUDIES D e p a r t m e n t o f H e a l t h C a r e and E p i d e m i o l o g y We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1986 <^ > Mary L i l y Spoke, 1986 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of A/-^CX^L^J~ Ckj^. V The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date V J ABSTRACT A review of numerous studies that had been conducted on the subject of prenatal classes revealed two important themes: the inconclusiveness of prenatal class effectiveness and the apparent predominance of middle class women among prenatal class attenders. The main purpose of th i s study was to determine which expectant women appeared to derive the most benefit from attending prenatal classes and to determine what i t was that most affected health outcome - attendance at prenatal classes or the c h a r a c t e r i s t i c s of the mother attending classes. Two hundred and twenty-two B r i t i s h Columbian mothers who had recently delivered infants constituted the study sample. The study focuses on three v a r i a b l e areas: prenatal class atttendance factor, personal c h a r a c t e r i s t i c s of the mothers, and health-related outcomes i n terms of health knowledge, behaviour and status. A questionnaire was developed s p e c i f i c a l l y for t h i s study and was issued to the mothers i n the sample. The bulk of the data c o l l e c t e d derived from the questionnaire responses. Both a mailed and interview format were used. Other data came from o f f i c i a l B i r t h Notices. The study demonstrated that with regard to a few health-related outcomes, for example, use of labour breathing techniques and infant birthweight over 3000 grams, women who were multiparous, of minority group status and had average education appeared to gain the most from attending prenatal classes. It i s not known i f p a r i t y , e t h n i c i t y and education of mothers are c h a r a c t e r i s t i c s that might predict benefit i n terms of other outcomes. Within the va r i a b l e sets studied, prenatal class attendance was shown to be the strongest predictor of v i s i t s to the physician, infant complications and family planning. Other outcomes, for example, use of labour breathing techniques, d e l i v e r y mode and infant feeding p r a c t i c e , however, were better predicted by mother's personal c h a r a c t e r i s t i c s , i . e . , p a r i t y , language, education and age. In no s i t u a t i o n did any of the variables examined make appreciable e f f e c t s i n the outcomes measured. Despite the weak associations and lack of associations demonstrated between prenatal class attendance and outcomes, the sample mothers c i t e d what they thought were benefits a r i s i n g from p a r t i c i p a t i o n i n classes. Foremost among these was the social/emotional support mothers received from fellow class p a r t i c i p a n t s . As well, knowledge gained about pregnancy, and labour and del i v e r y were found to be categorized as useful by many. Recommendations r e s u l t i n g from this study centre around improving outreach e f f o r t s to women not attending classes. Also, the need to e l i c i t constant feedback from class p a r t i c i p a n t s about class content was stressed. TABLE OF CONTENTS Page Abstract i i L i s t of Tables v i L i s t of Figures ix Acknowledgement x Chapter I Introduction 1 Study Objectives and Hypothesis 13 End Notes 14 Chapter II Method 16 End Notes 39 Chapter I II Main Results 40 Objective I - Factors Related to Decision to Attend Prenatal Classes 45 Objective II - Relationship Between Prenatal Class Attendance and Outcomes 59 Objective III - Most Important Determinant of Outcome 69 End Notes 80 Chapter IV Selected Findings Relevant to Prenatal Educators 81 Chapter V Conclusions 95 Commentary on Main Results 95 Commentary on Other Findings 98 Implications for Prenatal Educators 101 Suggestions for Future Research 103 Bibliography 106 Appendix A Sample B i r t h Notice 109 Appendix B Study Questionnaire 110 Appendix C Permission from Assistant Deputy Minister, Preventive Services 133 Appendix D Code D e f i n i t i o n s of Some Study Variables 135 Appendix E Code Book 137 Appendix F Letter to Interviewees 152 Appendix G Mother's Consent to the Interview 154 iv TABLE OF CONTENTS, cont'd. Appendix H Letter to Mailed Subject 156 Appendix I Reminder Letter to Mailed Subject 158 Appendix J Response Bias Tables 160 Appendix K Objective I Tables 165 Appendix L Coding of Variables for Path Model: Figure 4 173 Appendix M Objective II Tables 175 Appendix N Objective I I I Figure and Table 186 v LIST OF TABLES Page 1. Percentage Live Births by B i r t h Mode, Study and Base Populations 22 2. Percentage Live Births by Legitimacy, Study and Base Populations 22 3. Percentage Live Births by Age of Mother, Study and Base Populations 23 4. Percentage Live Births by Infant Birthweight, Study and Base Populations 23 5. D i s t r i b u t i o n of Responders and Non-Responders by M a r i t a l Status 35 6. D i s t r i b u t i o n of Responders and Non-Responders by P a r i t y 35 7. D i s t r i b u t i o n of Responders and Non-Responders by Maternal Age 36 8. D i s t r i b u t i o n of Responders and Non-Responders by Delivery Mode 36 9. D i s t r i b u t i o n of Responders and Non-Responders by Birthweight 37 10. D i s t r i b u t i o n of Responders and Non-Responders by Infant B i r t h Complications 37 11. D i s t r i b u t i o n of Responders and Non-Responders by Maternal B i r t h Complications 37 12. Sociodemographic C h a r a c t e r i s t i c s of Sample 40 13. Sociodemographic C h a r a c t e r i s t i c s of Sample (continued) 41 14. Current Attendance by Main Sources of Information on Pregnancy 49 15. Current Attendance by Main Sources of Information on Labour and C h i l d b i r t h 49 16. Current Attendance by Main Sources of Information on Childcare 50 17. Ever Attendance by Main Sources of Information on Pregnancy 50 18. Ever Attendance by Main Sources of Information on Labour and C h i l d b i r t h 51 19. Ever Attendance by Main Sources of Information on Childcare 51 20. Results of C o r r e l a t i o n a l Analyses: Prenatal Class Attendance with Predictors 53 21. Path C o e f f i c i e n t s for Path Model Predict i n g Current Prenatal Class Attendance 56 22. Results of C o r r e l a t i o n a l Analyses: Determinants (Current Attendance Included) of Outcomes 71 23. Results of C o r r e l a t i o n a l Analyses: Determinants (Ever Attendance Included) of Outcomes 72 v i LIST OF TABLES, cont'd. Page. 24. Path C o e f f i c i e n t s for Path Model Predict i n g Infant Complications 77 25. Subjects Talked About During Pregnancy 82 26. Main Sources of Information i n Pregnancy by Current Attendance 84 27. Main Reasons for Prenatal Class Attendance 85 28. Main Reasons for Non-Attendance 86 29. Did You Learn Anything New About ? 89 30. What Attenders Liked Most About Classes 90 31. What Attenders Did Not Like About Classes 92 32. D i s t r i b u t i o n of Responders and Non-Responders by Delivery Mode 161 33. D i s t r i b u t i o n of Responders and Non-Responders by Birthweight 161 34. D i s t r i b u t i o n of Responders and Non-Responders by Gestational Age 162 35. D i s t r i b u t i o n of Responders and Non-Responders by F i r s t Apgar 163 36. D i s t r i b u t i o n of Responders and Non-Responders by Second Apgar 163 37. D i s t r i b u t i o n of Responders and Non-Responders by Mother's Place of Residence 164 38. Results of Cross-Tabulating Current Attendance with Independent Variables 166 39. Current Attendance by Mother's Education 166 40. Results of Cross-Tabulating Ever Attendance with Independent Variables 167 41. Ever Attendance by Mother's Education 167 42. Predictors of Current Prenatal Class Attendance 168 43. Predictors of Ever Prenatal Class Attendance 168 44. Current Attendance by Main Sources of Information on Pregnancy (Detailed) 169 45. Current Attendance by Main Sources of Information on Labour and C h i l d b i r t h (Detailed) 170 46. Current Attendance by Main Sources of Information on Childcare (Detailed) 171 47. Ever Attendance by Main Sources of Information on Pregnancy (Detailed) 171 48. Ever Attendance by Main Sources of Information on Labour and C h i l d b i r t h (Detailed) 172 49. Ever Attendance by Main Sources of Information on Childcare (Detailed) 172 50. Results of Cross-Tabulating Outcomes with Independent Variable, Current Attendance 176 v i i LIST OF TABLES, cont'd. Page 51. Results of Cross-Tabulating Outcomes with Independent Variable, Ever Attendance 176 52. Simple Correlations of Current Attendance with Dependent Variables 177 53. Simple Correlations of Ever Attendance with Dependent Variables 177 54. Labour Breathing Techniques by Current Attendance and Mother's Cultural Background 178 55. Labour Breathing Techniques by Current Attendance and Mother's Education in Years 178 56. Labour Breathing Techniques by Current Attendance and Parity 179 57. Labour Breathing Techniques by Number of Classes Attended 179 58. Infant Complications by Current Attendance and Mother's Cultural Background 180 59. Infant Complications by Current Attendance and Mother's Age in Years 180 60. Infant Complications by Current Attendance and Mother's Education in Years 181 61. Infant Complications by Current Attendance and Parity 181 62. Infant Complications by Number of Classes Attended 182 63. Infant Birthweight by Number of Classes Attended 182 64. Perceived Labour Discomfort by Number of Classes Attended 183 65. Mode of Delivery by Number of Classes Attended 183 66. Infant Birthweight by Ever Attendance and Mother's Cultural Background 184 67. Infant Birthweight by Ever Attendance and Mother's Age in Years 184 68. Infant Birthweight by Ever Attendance and Mother's Education in Years 185 69. Infant Birthweight by Ever Attendance and Parity 185 70. Path Coefficients for Path Model Predicting Use of Labour Breathing Techniques 188 v i i i LIST OF FIGURES Page 1. Study Factors 17 2. Geographic D i s t r i b u t i o n of Mothers i n Sample 19 3. Degree of Prenatal Class Attendance by Pa r t i c i p a n t s 43 4. Path Model Showing Predictors of Current Prenatal Class Attendance 55 5. S i g n i f i c a n t Paths to Current Attendance 58 6. Labour Breathing Techniques by Current Attendance and Culture 64 7. Labour Breathing Techniques by Current Attendance and Years of Education 64 8. Labour Breathing Techniques by Current Attendance and P a r i t y 64 9. Labour Breathing Techniques by Number of Classes Attended 64 10. Infant Complications by Current Attendance and Culture 65 11. Infant Complications by Current Attendance and Age 65 12. Infant Complications by Current Attendance and Education 65 13. Infant Complications by Current Attendance and P a r i t y 65 14. Infant Complications by Number of Classes Attended 66 15. Infant Birthweight by Number of Classes Attended 66 16. Labour Discomfort by Number of Classes Attended 66 17. Delivery Mode by Number of Classes Attended 66 18. Infant Birthweight by Ever Attendance and Culture 67 19. Infant Birthweight by Ever Attendance and Age 67 20. Infant Birthweight by Ever Attendance and Education 67 21. Infant Birthweight by Ever Attendance and P a r i t y 67 22. Path Model Showing Predictors of Infant Complications 76 23. Path Model Showing Predictors of Use of Labour Breathing Techniques 187 ix ACKNOWLEDGEMENT I wish to thank a number of people for the support they have leant me during this study project. Ms. Beulah Moricky, assistant Director of Public Health Nursing, I thank for helping me to define my subject of study. To my thesis committee, chairperson Dr. Nancy Waxier and committee members Dr. Annette Stark and Dr. Patricia Vertinsky is extended my sincere appreciation for their ongoing critique and encouragement. I thank Mr. Ronnie Sizto for his tremendous job in computing a l l ray st a t i s t i c a l analyses. Ms. Glenys Cameron and her staff are commended for putting everything together in a presentable form. Most of a l l , I need to acknowledge a l l the women who responded to my questionnaire and interview requests. Thank you. Mary Spoke 1 CHAPTER I  INTRODUCTION The issue underlying t h i s research project was the question of whether prenatal classes, as they are offered i n B.C., are useful for a l l expectant mothers and t h e i r partners, i n terms of influencing health knowledge, health behaviour and health status. Prenatal education through classes has t r a d i t i o n a l l y been a s i g n i f i c a n t part of the P e r i n a t a l Program of Public Health Nursing i n B r i t i s h Columbia (B.C. M i n i s t r y of Health). During the 1970s and the f i r s t years of the 1980s, these classes were heavily promoted among the general public, although usually the greatest thrust of promotion was aimed at f i r s t - t i m e mothers. This promotion, evidently, has had some success i n terms of o v e r a l l u t i l i z a t i o n rates, as i n 1980 i t was reported that during the next year, "a 34% increase i n the number of parent education classes offered was needed i n order to accommodate the number of parents e n r o l l i n g for series."1 U t i l i z a t i o n of t h i s program continues to increase. In addition to the o f f i c i a l agency (provincially-operated) classes, non-government prenatal c l a s s series are offered by a number of private organizations and i n d i v i d u a l s . The exact extent to which such classes are avai l a b l e i n B.C. and the attendance figures of same are unknown. Although attendance at such classes i s taken into consideration i n the analysis of thi s p a r t i c u l a r study, the overriding purpose of the study i s related to 2 discerning the usefulness of prenatal classes i n the province's P e r i n a t a l Program. It was said that u t i l i z a t i o n of the l a t t e r has been increasing. On the surface, t h i s increase might seem a p o s i t i v e accomplishment. There are issues r e l a t e d to the program, however, that warrant i n v e s t i g a t i o n . They are, that: (a) the effectiveness of prenatal classes i n terms of a t t a i n i n g stated desired outcomes i s inconclusive; (b) the majority of couples who attend classes seem to come from society's middle socio-economic s t r a t a and conversely, the majority of couples who do not attend classes come from society's lower socio-economic s t r a t a ; and (c) the program consumes a considerable amount of service time and i s , therefore, expensive. Issue (a): The Inconclusiveness of Prenatal Class Effectiveness No comprehensive i n v e s t i g a t i o n of the effectiveness of the p r o v i n c i a l prenatal c l a s s program has been undertaken since 1976 (Stark),^ and there i s l i t t l e consistent evidence to support claims of effectiveness. The effectiveness of classes needed to be determined using s p e c i f i c i n d i c a t o r s of benefit r e l a t e d to: ( i ) classes as a source of knowledge and support during pregnancy; ( i i ) the promotion of l i f e s t y l e patterns during the pregnancy and post-partum periods (e.g., smoking/diet h a b i t s ) ; and ( i i i ) health status of mother and infant (e.g., birthweight, pregnancy complications). It also needs to be ascertained whether c e r t a i n types of people benefit more from attending classes than others. 3 Various investigators have attempted to determine the effectiveness of prenatal classes. The reports reviewed present mixed but inconclusive evidence of the influence of classes i n terms of desired health-related outcomes, although most demonstrate at least one or more p o s i t i v e r e s u l t s from preparation.2-23 The r e s u l t s of an early non-comparative study by Thorns and Karlovsky (1947), reported by Cogan, suggested that primiparas who had attended classes had fewer depressed (low apgar) infants at b i r t h , shorter labours, fewer operative d e l i v e r i e s , less blood loss, smoother convalescence and became happier mothers.^ Davis and Morrone's 1962 comparative study,^ also of primiparous women, found attenders to be less anxious during pregnancy, to more often have concrete plans for t h e i r babies, to more often plan to breastfeed and to smoke l e s s , while Enkin et a l (1972), as reported by Cogan, demonstrated that "attendance at classes i s associated with less medication, less pain and a more p o s i t i v e experience i n giving b i r t h (p. 5).^ In a study by Ryan et a l (1981), primiparas were interviewed three days post-partum. S i g n i f i c a n t findings were that attenders experienced less pain during labour, used less analgesia during labour, smoked less often during pregnancy and more often chose breastfeeding for t h e i r i n f ants. A research project designed to evaluate the outcomes for Lamaze-prepared mothers (1978) found that these patients had fewer Caesarian sections, less f e t a l d i s t r e s s , less post-partum i n f e c t i o n , and fewer perineal lacerations as compared to non-prepared mothers. 0 4 Yarie (1977), too, was able to demonstrate some c o r r e l a t i o n s between attenders and p o s i t i v e outcomes i n terms of knowledge gained about pregnancy, c h i l d b i r t h and c h i l d c a r e . 7 Although the above studies did find some asso c i a t i o n between prenatal cl a s s attendance and p o s i t i v e health-related outcomes, most of the studies reported mixed and sometimes c o n f l i c t i n g r e s u l t s . These inconsistencies make i t d i f f i c u l t to make d e f i n i t i v e statements about the o v e r a l l effectiveness of prenatal classes. Davis and Morrone, who did report a number of p o s i t i v e findings, also found that for attenders, labour duration, use of forceps and use of anaesthesia were the same as for non-attenders.^ S i m i l a r l y , Huttel et a l (1971) discovered no s i g n i f i c a n t differences between primiparae prepared according to the Psycho-Prophylactic Method and a c o n t r o l group, with regard to frequency of o b s t e t r i c a l complications and infant apgar scores. The only s i g n i f i c a n t differences between the two groups was the experimental group's less frequent use of the drug, oxytocin, during labour.8 In Stark's 1976 i n v e s t i g a t i o n of a group of B.C. mothers, i t was judged that there were few s i g n i f i c a n t differences between prenatal class attenders and non-attenders concerning outcomes. She, i n f a c t , found that attenders had a longer duration of labour and a more negative perception of labour than non-attenders, but that these differences were not s i g n i f i c a n t . ^ Whether the former finding should be construed as a "negative" outcome i s not c l e a r . Ryan et a l , likewise, noted that for attenders (primiparas) labour was of longer duration, though the difference 5 was s i g n i f i c a n t . ^ On the whole, however, h i s findings supported the notion that classes are h e l p f u l for primiparas. Yarie, i n spite of some p o s i t i v e findings, as reported e a r l i e r , also discovered that there were no s i g n i f i c a n t differences between two groups of B.C. women i n r e l a t i o n to smoking and n u t r i t i o n a l habits during pregnancy.^ She found, as well, that more non-attenders were breastfeeding. In Walker and Erdman's (1984) survey, increased knowledge and confidence regarding labour were demonstrated to be s h o r t - l i v e d gains of class attendance.^ Following labour, knowledge and confidence returned to pre-class l e v e l s . Findings from Timm's (1979) evaluation of prenatal classes sponsored by a h o s p i t a l indicated that use of medication i n labour was lower for class p a r t i c i p a n t s but that birthweights were not s i g n i f i c a n t l y d i f f e r e n t regardless of age, race and p a r i t y . ^ Mogan, i n t e s t i n g for gains i n knowledge about i n f a n t — r e l a t e d n u t r i t i o n , discovered that there were important inconsistencies i n the information learned by class attenders.H One measure of the effectiveness of prenatal classes might be the perception of t h e i r usefulness by attenders by leading to p o s i t i v e health outcomes. Here, too, the evidence c u l l e d from f i v e studies i s neither p o s i t i v e nor consistent. Chamberlain and Chave (1977) showed that one-to-one contacts i n a c l i n i c a l s i t u a t i o n were the most rewarding for prenatal c l i e n t s although most attenders did say that classes were i n t e r e s t i n g and "something" was learned.12 Pridham and Shultz (1981), s i m i l a r l y reported that patients rated discussions with doctors as the most useful source of information on 6 labour and infant care, while prenatal classes were rated s i x t h i n usefulness out of a t o t a l of s i x sources named.^ In Kiss' (1983) study about health behaviour changes among prenatal cl a s s attenders, the major influences for changing health behaviour were determined to be the women's personal knowledge; the books, magazines and pamphlets read; and the contacts with physicians, family and f r i e n d s . ^ Adams i n 1982 i n England found that of a group of clas s attenders interviewed, only 21% said that the classes were a main source of information on p e r i n a t a l matters. However, although attenders had p o s i t i v e feelings about the classes i n terms of the rel a x a t i o n techniques learned and the other women met i n classes, a considerable number of them f e l t they were not prepared for labour and c h i l d b i r t h . ^ Classes were rated more highly as a source of information by the B.C. women of Stark's study. Seventy-one percent of the class attenders stated classes to be t h e i r p r i n c i p a l source of information on labour and child c a r e . D i f f e r e n t researchers have questioned whether the health outcomes measured i n studies might be more a function of mothers' s o c i a l backgrounds than class attendance. Cogan, as a r e s u l t of reviewing several studies surmised that "...any evident e f f e c t s of c h i l d b i r t h preparation were more l i k e l y to be rela t e d to differences i n the type of people who el e c t classes than to the e f f e c t s of the preparation per se" (p. 2).^ She thought, however, that studies which had co n t r o l l e d for socio-demographic factors such as those of Hughey (1977) and Enkin (1972), c l e a r l y and r e l i a b l y demonstrated some p o s i t i v e e f f e c t s of preparation. 7 Standley et a l i n 1978 ca r r i e d out a study of primiparas, however, that suggested that the women's background c h a r a c t e r i s t i c s of age and education were strongly associated with anxiety about c h i l d b i r t h and, subsequently, with the amount of medication used during labour.1° It has been mentioned that a mother's personal-social background might be a key determinant of health outcome. At issue, though, i s the necessity of determining whether class attendance might have a greater influence on some types of women than on others, or i n other words, that the benefit from attendance might be var i a b l e for d i f f e r e n t groups of women. Margaret Nelson (1982) explored the e f f e c t of formal prenatal education on women of d i f f e r e n t socio-economic classes and found that the "...impact of c h i l d b i r t h education was much greater among working class women" (p. 3 3 9 ) . ^ She began her work with the assumption that women of d i f f e r e n t s o c i a l backgrounds enter classes with knowledge l e v e l s and attitudes that are d i s s i m i l a r , and that this i s one of the reasons women benefit and learn d i f f e r e n t i a l l y . A study by Norr et a l (1977) has linked higher s o c i a l status, less t r a d i t i o n a l a ttitudes towards sex roles and great marital closeness with both better preparation for c h i l d b i r t h and, ultimately, with less pain and greater enjoyment during c h i l d b i r t h . ^ Measuring the impact of prenatal class programs has been d i f f i c u l t for researchers because there are so many p o t e n t i a l confounding v a r i a b l e s , such as s o c i a l class and p a r i t y , that need to be considered during analysis or con t r o l l e d for at the outset. Nancy Nelson (1981) states since c h i l d b i r t h i s now perceived as a more complicated process medically (more diagnostic and c l i n i c a l procedures), 8 there i s an increased need for prenatal education, but she r e a l i z e s there i s s t i l l controversy regarding the " r i g h t " content and s t y l e of education. She supports an " a t - r i s k " approach.^ She believes that classes need to be t a i l o r e d for and are p o t e n t i a l l y most e f f e c t i v e for s p e c i a l needs women, such as those who are alone, teenagers and women from language and/or ethnic minority groups. This review of various studies sheds some l i g h t on the issue of prenatal class effectiveness. None of the studies reviewed, however, demonstrated a causal r e l a t i o n s h i p between prenatal class attendance and po s i t i v e health-related outcomes. Issue (b): The Apparent Predominance of Middle Class Over Working Class Women Among Prenatal Class Attenders One problem perceived by prenatal class teachers and planners a l i k e i s the fact that those pregnant women thought to be most i n need of prenatal i n s t r u c t i o n appear to constitute the majority of those not a v a i l i n g themselves of i t . It i s suggested that these women are not necessa r i l y r e s t r i c t e d to the working class alone, but probably include, as well, the very young, the unmarried, the geographically-isolated and ethnic m i n o r i t i e s . It would be useful to determine i f there are some s e l e c t i o n factors that are of a kind that could be p o s i t i v e l y influenced through improved outreach strategy and program planning, should they be implemented. Various studies support the notion that more attenders are of middle class than of working class background. The studies of Davis and Morrone, Stark, Chamberlain and Chave, Yarie, Leonard, Cave and Norr et a l , for 9 e x a m p l e , a l l f o u n d a t t e n d e r s t o b e a s s o c i a t e d w i t h t h e h i g h e r s o c i o -e c o n o m i c c l a s s e s . ^ » 2 , 1 2 , 7 , 2 0 , 2 1 , 1 8 T h e s e same r e s e a r c h e r s , o t h e r t h a n C h a m b e r l a i n a n d C h a v e , a n d N o r r e t a l , a l s o , n o t e d t h a t m o s t a t t e n d e r s w e r e o l d e r t h a n n o n - a t t e n d e r s . 1 2 , 1 8 y a r i e a n d C a v e , a s w e l l , s p e c i f i e d t h a t f e w e r n o n - a t t e n d e r s w e r e o f e t h n i c m i n o r i t y background. 7 »21 H e a l t h b e h a v i o u r - s e l e c t i o n i n t o p r e n a t a l c l a s s e s b e i n g o n e e x a m p l e -h a s n o t b e e n e x a m i n e d o n l y i n t h e c o n t e x t o f p a r t i c i p a n t s ' s o c i o - e c o n o m i c c h a r a c t e r i s t i c s , p e r s e . R o s e n s t o c k , f o r i n s t a n c e , d e v e l o p e d a m o d e l o f h e a l t h b e h a v i o u r i n w h i c h i t w a s t h e o r i z e d t h a t a p e r s o n d e c i d e s t o t a k e " h e a l t h a c t i o n " , e . g . , a t t e n d c l a s s e s , d e p e n d i n g o n h o w s u s c e p t i b l e s h e p e r c e i v e s h e r s e l f t o b e f o r a p a r t i c u l a r h e a l t h p r o b l e m , o n h o w s e r i o u s s h e p e r c e i v e s t h e p r o b l e m t o b e , a n d h o w a v a i l a b l e a n d e f f e c t i v e s h e b e l i e v e s a p a r t i c u l a r c o u r s e o f a c t i o n t o b e , a n d o n w h e t h e r s h e s e e s a n y s e r i o u s b a r r i e r s t o t a k i n g a c t i o n . 2 2 T h i s h e a l t h b e h a v i o u r m o d e l f o r m e d t h e f r a m e w o r k f o r V e r t i n s k y e t a l ' s s t u d y i n t o c o m p l i a n c e f a c t o r s r e g a r d i n g a v o l u n t a r y s c r e e n i n g p r o g r a m . 2 3 T h e f a c t o r s e x a m i n e d i n s u c h p r o g r a m s may h a v e r e l e v a n c e i n t h e e x a m i n a t i o n o f s e l e c t i o n f a c t o r s r e l a t e d t o p r e n a t a l c l a s s p r o g r a m s . I t may a l s o b e t h a t t h e s e f a c t o r s c o r r e l a t e w i t h s o c i a l c l a s s , w i t h women o f o n e c l a s s p e r c e i v i n g a h e a l t h p r o b l e m a n d i t s r e q u i r e d a c t i o n d i f f e r e n t l y f r o m women f r o m a n o t h e r c l a s s . W h e t h e r p r e g n a n c y a n d c h i l d b i r t h i s a c t u a l l y p e r c e i v e d b y women a s a h e a l t h p r o b l e m , p o s s i b l y r e q u i r i n g p r e v e n t i v e o r t r e a t m e n t a c t i o n , i s n o t c l e a r . M a r g a r e t N e l s o n ' s u n d e r s t a n d i n g o f w h y p r e n a t a l c l a s s e s h a v e t r a d i t i o n a l l y e n j o y e d m o r e s u p p o r t f r o m m i d d l e c l a s s t h a n w o r k i n g c l a s s women i s b a s e d u p o n h e r b e l i e f t h a t p r e n a t a l c l a s s e s s u p p o r t : ( i ) t h e f e m i n i s t g o a l o f c h i l d b i r t h " a s a n i m p o r t a n t l i f e e x p e r i e n c e . . . i n w h i c h father) can a c t i v e l y p a r t i c i p a t e " , ( i i ) the "consumer movement's (encouragement of) c l i e n t s to be knowledgeable", and ( i i i ) the "back-to-nature romanticism" prevalent today (p. 3 3 9 ) I t i s assumed that i t i s to the women of middle class that these factors have most appeal and relevance. Issue (c): The Considerable Amount of Service Time the Prenatal Program Takes The Public Health Nursing D i v i s i o n of the B.C. Mi n i s t r y of Health i n t h i s time of f i s c a l conservatism i s having to be more accountable for i t s service outcomes. In l i n e with t h i s , a v a l i d concern could be that perhaps too much time i s spent i n prenatal classes teaching the already "converted". The question has been asked whether fewer classes would s u f f i c e for most of today's attenders, as i t i s assumed that the majority are from a higher s o c i a l s t r a t a than non-attenders and may, therefore, be motivated learners requiring less "teaching" than i s currently given. It i s supposed that such women usually f i n d ways of supplementing information already received and needed about pregnancy, c h i l d b i r t h and infant care. H a l l , i n a 1983 review of the antenatal care received by B r i t i s h women, concluded that "... resources are being dis s i p a t e d on blanket care applied u n c r i t i c a l l y to a l l pregnant women with l i t t l e c l i n i c a l benefit nor s a t i s f a c t i o n for women or the c l i n i c a l and mid-wifery s t a f f " (p. 103).^4 She suggested a need for r a t i o n a l i z a t i o n and a concentration of resources on h i g h - r i s k women. Although H a l l i s speaking of more than j u s t prenatal education by including prenatal medical care, and although her findings may not be pertinent to the B.C. s i t u a t i o n , her review has some possible 11 relevance for the subject of resource expenditure (time and money) on prenatal education. As resources become increasingly l i m i t e d , the time-consuming prenatal class program must be directed to those who, i t i s believed, would most benefit from i t . Public Health Nursing i n B.C. has begun to recognize the necessity of t h i s , as evidenced i n a 1982 memorandum on Public Health  Nursing P r i o r i t i e s , i n which nursing a c t i v i t i e s are divided up i n order of p r i o r i t y among three categories: e s s e n t i a l services, medium p r i o r i t y services and low p r i o r i t y services.25 Under " e s s e n t i a l services", a c t i v i t y number eight among 23 a c t i v i t i e s l i s t e d , i s "two early prenatal education sessions ( a l l prenatals) giving highest p r i o r i t y to " a t - r i s k " i n d i v i d u a l s . " The 23rd a c t i v i t y under " e s s e n t i a l s e r v i c e s " reads, "two l a t e r prenatal education sessions, a l l prenatals, but highest p r i o r i t y to " a t - r i s k " i n d i v i d u a l s . " A d d i t ional prenatal classes for sp e c i a l groups, e.g., "Caesarian b i r t h , teenage, adoptive parents, breastfeeding, e t c . " are c i t e d as medium p r i o r i t y a c t i v i t i e s . Some Differences Between This Study  and Those Reviewed This study proposed to d i f f e r from the studies just c i t e d i n some respects. The studies of Thorns/Karlovsky, Standley, et a l , Davis/Morrone, Ryan et a l , Huttel et a l , Leonard, Mogan and Yarie^>16,4,5,8,20,11,7 w e r e l i m i t e d to samples of primiparas while Kiss r e s t r i c t e d hers to prenatal class attenders alone. This study looked at both primiparas and multiparas, and at both cl a s s attenders and non-attenders. 12 An adequate response rate with limited response bias was being sought i n t h i s study. Three of the reviewed studies indicated the possible presence of s i g n i f i c a n t response bias. Bias was not tested for i n Pridham's 1981 study. He had a 39% non-response rate. S i m i l a r l y , response bias may have been present i n Chamberlain's and Nelson's studies, which had 40% and 32% a t t r i t i o n rates, r e s p e c t i v e l y . 1 7 A f a i l u r e to control for socio-economic factors while analyzing the r e l a t i o n s h i p between class attendance and outcome, also occurred with some studies. These were studies conducted by Thoms/Karlovsky, Walker/Erdman, Ryan et a l , Huttel et a l , Davis/Morrone, Timms, Yarie and K i s s . Nelson r e s t r i c t e d her control to one factor - working class.^»^>5>8,4,10,7,14,17 Whereas, t h i s study w i l l analyze associations between independent variables and dependent variables by moving from cross-tabulation analysis to simple c o r r e l a t i o n a l analyses to multiple c o r r e l a t i o n a l analysis, a number of the reviewed studies are r e s t r i c t e d to b i v a r i a t e analysis. In other instances, no s i g n i f i c a n c e testing was c a r r i e d out so that the "strength" of the associations described was not proven. By examining health-related benefits i n terms of health knowledge, behaviour and status, t h i s study attempted to be broad i n i t s scope and to keep i n mind what was assumed to be a l o g i c a l sequence of outcome. Some studies, for a reason, limited t h e i r outcome measures. Enkin and Hughey, for example, looked for labour-related benefits alone;3>6 Pridham, at perceived usefulness of c l a s s e s . ^ 13 STUDY OBJECTIVES AND HYPOTHESIS Objectives This study w i l l attempt: 1. To determine which factors are related to the decision to attend or not to attend prenatal classes. 2. To determine the differences between class attenders and non-attenders i n terms of c e r t a i n health-related outcomes. 3. By weighing the e f f e c t s of various factors and clas s attendance h i s t o r y on outcome, to determine what single factor (or what combination of factors) i s the most important determinant of outcome. Hypotheses 1. Prenatal class attendance w i l l a f f e c t and be affected by the l e v e l of knowledge, health behaviour and health status of mothers. 2. There are s e l e c t i o n factors which include health, education and s o c i a l c h a r a c t e r i s t i c s of women that can be used to predict which types of expectant women would most benefit from prenatal c l a s s attendance. 14 END NOTES •^Province of B r i t i s h Columbia, Mini s t r y of Health: Annual Report 1980 ( V i c t o r i a : Queens P r i n t e r of B.C., 1981). ^Annette Stark, "Styles of Health Care Offered to Pregnant Women and Mother-Child Outcomes" (Diss. University of North Carolina, 1976.) ^Rosemary Cogan, "E f f e c t s of C h i l d b i r t h Preparation," C l i n i c a l  Obstetrics and Gynecology 23 No. 1 (1980): 1 - 14. ^Clarence D. Davis and Frank A. Morrone, "An Objective Evaluation of a Prepared C h i l d b i r t h Program," American Journal of Obstetrics and Gynecology 84, No. 9 (1962): 1196 - 1201. -*Anne Ryan, Harry Murphy and Diarmuid O ' D r i s c o l l , "Influence of Antenatal Classes on Primigravid Pregnacy and Labour," I r i s h Medical  Journal 74, No. 3 (1981): 87 - 88. 6Michael J. Hughey, Thomas W. McElin, M.S. Facoq and Todd Young, "Maternal and F e t a l Outcome of Lamaze-Prepared Patients," Journal of the  American College of Obstetricians and Gynecologists 51, No. 6 (1978): 643 - 647. 7T.F. Yarie, "A Study of Factors Influencing U t i l i z a t i o n of Prenatal Educational Services" (Diss. UBC, 1977.) 8F.A. Huttel, I. M i t c h e l l , W.M. Fisher and A.E. Meyer, "A Quantitative Evaluation of Psychoprophylaxis i n C h i l d b i r t h , " Journal of Psychosomatic  Research 16 (1972): 81 - 92. ^Barbara Walker and Ann Erdman, " C h i l d b i r t h Education Programs: The Relationship Between Confidence and Knowledge," B i r t h 11, No. 2 (1984): 103 - 108. l^Margaret M. Timms, "Prenatal Educational Evaluation," Nursing  Research 28, No. 6 (1979): 338 - 342. 11Judith Mogan, " E f f e c t s of Antenatal Education on Expectant Parents' Knowledge and Attitudes Regarding Infant N u t r i t i o n , " Health Education  Journal 43, No. 4 (1984): 104 - 107. •^Geoffrey Chamberlain and Sidney Chave, "Antenatal Education," Community Health 9, No. 1 (1977): 12 - 16. l^Karen F. Pridham and Margaret E. Schutz, "Preparation of Parents for B i r t h i n g and Infant Care," Journal of Family Practice 13, No. 2 (1981): 181 - 188. 15 l^Linda Ann Kiss, "A Descriptive Survey of Health Behaviors of Prenatal Class Attenders" (Diss. UBC, 1983.) l^Lee Adams, "Consumers' View of Antenatal Education," Health  Education Journal 41, No. 1 (1982): 12 - 16. Standley, Bradley Soule and Stuart A. Copans, "Dimensions of Prenatal Anxiety and Their Influence on Pregnancy Outcome," American  Journal of Obstetrics and Gynecology 135, No. 1 (1979): 22 - 26. 1'Margaret K. Nel son, "The E f f e c t of C h i l d b i r t h Preparation on Women of Di f f e r e n t S o c i a l Classes," Journal of Health and S o c i a l Behavior 23 (1982): 338 - 352. ^ K a t h l e e n L. Norr, Carolyn R. Block, A l l e n Charles, Suzanne Meyering and E l l e n Meyers, "Explaining Pain and Enjoyment i n C h i l d b i r t h , " Journal of  Health and S o c i a l Behavior 18, No. 3 (1977): 260 - 273. •^Nancy M. Nelson, "A More Balanced Approach to Prenatal Education," Canadian Medical Association Journal 125 (1981): 331 - 332. 2 uRoger F. Leonard, "Evaluation of Selection Tendencies of Patients Preparing Prepared C h i l d b i r t h , " Obstetrics and Gynecology 42, No. 3 (1973): 371 - 377. Z i C a r o l y n Cave, " S o c i a l Characteri stxcs of Natural C h i l d b i r t h Users and Nonusers," American Journal of Public Health 68, No. 9 (1978): 898 -901. 22I.M. Rosenstock, "Why People Use Health Services," Milbank Memorial  Fund Quarterly 44, No. 3 (1966): 94 - 124. 2-*Patricia A. Vertinsky, Chung-fang Yang, Patrick J.M. MacLeod, and David F. Hardwick, "A Study of Compliance Factors i n Voluntary Health Behavior," International Journal of Health Education 19, No. 1 (1976): 3 -15. 2 4M. H a l l , "Are We Doing Too Much Antenatal Care?", Maternal and Child  Health: The Journal of Family Medicine 8, No. 3 (1983): 103, 106 - 109. 25 B.C. Mi n i s t r y of Health, "Public Health Nursing P r i o r i t i e s , " Action  Memorandum by Ron de Burger ( V i c t o r i a : 1982): No. 82: 139. 16 CHAPTER II METHOD Mothers who had recently delivered infants constituted the study sample. C h a r a c t e r i s t i c s d i f f e r e n t i a t i n g the selected mothers from one another were i d e n t i f i e d , thereby allowing the o r i g i n a l pool of mothers to be s p l i t into various categories for purposes of analysis. In p a r t i c u l a r , the sample was divided into those mothers who attended prenatal classes and those who did not. Other c h a r a c t e r i s t i c s d i f f e r e n t i a t i n g the mothers were educational background, prenatal health status, age and p a r i t y . It was intended that, by examining factors such as prenatal c l a s s attendance h i s t o r y and those related to s e l e c t i o n into classes, as well as the association of such factors with defined outcomes, a picture would appear that depicted who was attending classes. Such examination would d i s c l o s e those who might b e n f i t the most from cl a s s attendance and which of the " f r o n t l i n e " factors seemed to be most associated with the outcomes. Figure 1 i l l u s t r a t e s the perceived r e l a t i o n s h i p among factors being studied. FIGURE 1 STUDY FACTORS Age Health Education S o c i a l Status M a r i t a l Status P a r i t y M.D. V i s i t s E t h n i c i t y \ 1 / EXPECTANT MOTHERS Support Network Perceived Purpose of Classes Previous Attendance Health Behaviour Convenience of Class Location, etc. Awareness of Classes Locus of Control MOTHERS ATTENDING PRENATAL CLASSES MOTHERS NOT ATTENDING PRENATAL CLASSES Age Support Network Health Perceived Purpose of Education Classes So c i a l Status Previous Attendance M a r i t a l Status Health Behaviour Parity Convenience of Class M.D. V i s i t s Location, etc. Et h n i c i t y Awareness of Classes Lnr.us of Control INTERVENING/ MODIFYING VARIABLES - No. classes attended - Class content OUTCOMES 1. Knowledge - several variables 2. Behaviour - changes re smoking, alcohol intake, exercise, diet - infant feeding - infant immunization - contraception - M.D. v i s i t s - labour-related 3. Health - infant birthweight, apgar, b i r t h complications - maternal weight gain, b i r t h complications 4. Class Attenders' evaluation of classes Information gathered from health unit copies of B i r t h Notices (see Appendix A) and from mothers' responses to questionnaires (see Appendix B) was examined to i d e n t i f y the personal socio-deraographic, prenatal health and attendance h i s t o r y c h a r a c t e r i s t i c s of mothers and to determine presence of p a r t i c u l a r health-related outcomes of pregnancy. Permission was obtained from the Assistant Deputy Minister of Preventive Services i n the B.C. Mi n i s t r y of Health (see Appendix C) and from the Univ e r s i t y of B r i t i s h Columbia's C l i n i c a l Screening Committee for Research and Other Studies Involving Human Subjects. Verbal approval was also acquired from the relevant health unit Medical Health O f f i c e r s and Public Health Nurse Supervisors. Sampling Process Two hundred and twenty-two post-partum mothers were selected from the Central Fraser V a l l e y Health Unit and Coast G a r i b a l d i Health Unit catchment areas to become the study subjects. Although they originated from two d i f f e r e n t areas, the subjects were combined and treated, for convenience, as one sample for most of the analysis. Subjects were a l l mothers who had given b i r t h between January 15, 1983 to February 17, 1983. Names were taken from the B i r t h Notices f i l e d i n the two health u n i t s . Excluded were mothers who were not keeping t h e i r infants, mothers from the whistler o f f i c e (Coast G a r i b a l d i Health Unit) catchment area and s t i l l b i r t h s i t u a t i o n s . Figure 2 demonstrates the geographic d i s t r i b u t i o n of the mothers ( i n the study sample) between and within the two health u n i t s . 19 FIGURE 2 GEOGRAPHIC DISTRIBUTION OF MOTHERS IN SAMPLE Central Fraser Valley Health Unit ( 3 c a t c h m e n t a r e a s - M a p l e R i d g e - L a n g l e y - M i s s i o n ) Coast Garibaldi Health Unit ( 4 c a t c h m e n t a r e a s - G i b s o n s - P o w e l l R i v e r - S q u a m i s h - W h i s t l e r ) A l l c a t c h m e n t a r e a s M a p l e R i d g e 50 m o t h e r s 3 c a t c h m e n t a r e a s ( W h i s t l e r e x c l u d e d ) L a n g l e y 90 m o t h e r s M i s s i o n 23 m o t h e r s G i b s o n s P o w e l l R i v e r S q u a m i s h 2 0 m o t h e r s 24 m o t h e r s 15 m o t h e r s T o t a l S a m p l e 2 2 2 m o t h e r s 20 The mothers making up the study population constituted a cohort of mothers from two d i s t r i c t s who gave b i r t h during the period January 15, 1983 and February 17, 1983. In B.C., there are a t o t a l of 17 p r o v i n c i a l health units as well as the health units of the Greater Vancouver metropolitan area and the Capi t a l Regional D i s t r i c t . Because t h i s study t r i e d to l i m i t i t s e l f to making conclusions about post-partum mothers who l i v e within areas serviced by the 17 p r o v i n c i a l health u n i t s , i t was from these mothers the study sample was taken. The Central Fraser V a l l e y and Coast G a r i b a l d i Health Unit areas were not selected randomly from the t o t a l 17 health u n i t s . They were purposely chosen for t h e i r convenient geographic l o c a t i o n (Lower Mainland), and for the apparent mix i n rural/town l i v i n g and in economic conditions. Mothers serviced by the Whistler o f f i c e i n Coast G a r i b a l d i Health Unit were excluded from the sample. Because t h e i r numbers were few and the women were spread t h i n l y i n and between the Town of Whistler and Pemberton, prenatal classes were not a regular o f f e r i n g i n the area. Instead, the public health nurse i n i t i a t e d contact with pregnant women o f f e r i n g and providing them prenatal education/counselling, most t y p i c a l l y on a one-to-one basis. As " c l a s s " attendance and non-attendance were the primary independent variables of th i s study, i t was decided that mothers of the Whistler area would be unsuitable as study subjects because a consistent opportunity for them to p a r t i c i p a t e i n prenatal classes was not present. Mothers not keeping t h e i r infants and mothers with s t i l l b o r n infants were l e f t out of the study sample i n an attempt to l i m i t the sample to mothers experiencing r e l a t i v e l y normal post-partum periods, i n terms of in f a n t - r e l a t e d c r i t e r i a . A few words must be said about the comparability of the mothers i n the study sample and base population. Because s e l e c t i o n of mothers into the study was not c a r r i e d out i n random fashion, the p o s s i b i l i t y of sample bias existed. The extent to which the chosen sample was representative of the base population was, therefore, uncertain. Comparison between the sample and the B.C. base population was made by examining the d i s t r i b u t i o n of four v a r i a b l e s , as provided by the D i v i s i o n of V i t a l S t a t i s t i c s of B.C.1 See Tables 1, 2, 3 and 4. By focusing on the percentage d i s t r i b u t i o n s of the variables measured, the study sample appeared s u f f i c i e n t l y representative of mothers giving b i r t h i n a l l 17 p r o v i n c i a l health u n i t s . It i s recognized that sample bias may nevertheless have been present because a number of c h a r a c t e r i s t i c s of mothers that may have had p o t e n t i a l to influence study outcomes were not compared i n the base and sample populations. These are c h a r a c t e r i s t i c s such as p a r i t y , prenatal c l a s s attendance h i s t o r y , l i f e s t y l e f a c t o r s , o b s t e t r i c a l complications and socio-economic factors. Because true representativeness of the sample cannot be confirmed, the g e n e r a l i z a b i l i t y of any study conclusions i s to be considered l i m i t e d . 22 TABLE 1 PERCENTAGE LIVE BIRTHS BY  BIRTH MODE, STUDY AND BASE POPULATIONS BIRTH MODE STUDY HEALTH UNITS (Jan. 15 - Feb. 17/83) ALL 17 PROVINCIAL HEALTH UNITS (1st Quarter 1983) Spontaneous 69 68 Forceps 6 11 Caesarian 23 19 Other 2 2 100 (n = 222) 100 (n = 6878) TABLE 2 PERCENTAGE LIVE BIRTHS BY  LEGITIMACY, STUDY AND BASE POPULATIONS LEGITIMACY STUDY HEALTH UNITS ALL 17 PROVINCIAL HEALTH UNITS (Jan. 15 - Feb. 17/83) (1st Quarter 1983) Legitimate 87 82 I l l e g i t i m a t e 13 18 100 (n = 222) 100 (n = 6878) 23 TABLE 3 PERCENTAGE LIVE BIRTHS BY  AGE OF MOTHER, STUDY AND BASE POPULATIONS MOTHER'S AGE STUDY HEALTH UNITS ALL 17 PROVINCIAL HEALTH UNITS IN YEARS (Jan. 15 - Feb. 17/83) (1st Quarter 1983) <£. 20 8 8 20 - 29 63 69 30 - 39 27 22 739 1 1 Unknown 1 1 100 (n = 222) 100 (n = 6878) TABLE 4 PERCENTAGE LIVE BIRTHS BY  INFANT BIRTHWEIGHT, STUDY AND BASE POPULATIONS BIRTHWEIGHT STUDY HEALTH UNITS ALL 17 PROVINCIAL HEALTH UNITS IN GRAMS (Jan. 15 - Feb. 17/83) (1st Quarter 1983) <£. 2500 1 5 2500 - 2999 (2500 - 3000)* 14 13 3000 - 3499 (3001 - 3500) 37 36 ^3499 ( ?3500) 48 46 100 (n = 222) 100 (n = 6878) Birthweights for CFHVU and CGHU were grouped as indicated i n the brackets. The difference i n groupings i s not thought to be s i g n i f i c a n t . 24 Study Variables Three kinds of variables constituted the primary focus of this study. They were: the major independent variable the selection variables that modify or antecede the independent variable or are independent in themselves the dependent variables Prenatal class attendance/non-attendance was the major independent variable being examined. It was realized that differentiating mothers only in terms of current attendance and current non-attendance would be short-sighted as i t would ignore the probability that a number of current non-attenders had attended prenatal classes in the past. 2 It was important to be able to separate women not only with regard to their having attended or not attended classes during their most recent pregnancy but also with regard to their having ever attended classes. The influence of past attendance on selection/non-selection into current classes and on outcome was a probability that had to be anticipated. A further differentiation of the independent variable was made in terms of attendance at private classes versus health unit sponsored classes. It was surmised that women attending the typically longer and more expensive private classes may be different from women attending health unit classes. Any differences found between outcomes of private class attenders and health unit class attenders could possibly be explained as being a function of both selection and class content factors. Data collection was organized, therefore, to access information from the mothers in the study, not just on current attendance, "yes" or "no", 25 but also on previous attendance, and on the type of classes c u r r e n t l y attended. The choosing of the s e l e c t i o n variables to be included i n t h i s study was based, i n part, on the b e l i e f that c e r t a i n background c h a r a c t e r i s t i c s would probably have an influence on a woman's decision to p a r t i c i p a t e i n an educational program such as prenatal classes. Some of these same c h a r a c t e r i s t i c s would most probably also have a strong impact on outcomes. The variables examined included s o c i a l c l a s s , education, c u l t u r a l background ( e t h n i c i t y , r e l i g i o n ) , s o c i a l network, a c c e s s i b i l i t y to classes, p a r i t y , previous attendance, age, health and perception of classes' purpose. These variables were chosen as a r e s u l t of having reviewed a number of rela t e d studies, c i t e d i n Chapter I, that suggested t h e i r importance i n helping to predict attendance and health outcomes. A woman's sense of control over her own health was examined as we l l . The v a r i a b l e s that define the s o c i a l - c u l t u r a l aspect of a woman's l i f e are ones that are t r a d i t i o n a l l y included i n studies such as these, as are those v a r i a b l e s r e l a t e d to physical status. This i s done most often i n an attempt to control for b i a s . Here, however, there was an intention to go beyond " c o n t r o l l i n g " to demonstrating that, i n c e r t a i n cases, i t i s some of these c h a r a c t e r i s t i c s , not the prenatal c l a s s attendance factor, that play the more i n f l u e n t i a l r o l e i n bringing about health-related outcomes, while i n other cases, these c h a r a c t e r i s t i c s play a secondary r o l e to the prenatal class attendance factor. For d e f i n i t i o n of the key v a r i a b l e s , see Appendix D. Although i t was intended that the s e l e c t i o n variables be regarded as antecedent to the independent v a r i a b l e , c l a s s attendance/non-attendance, i t 26 was necessary to recognize that, sometimes, i n a retrospective study they might very well represent outcomes of attenders. Variables such as perceived purpose of classes, locus of c o n t r o l , information sources used, may f a l l into t h i s category. The outcome dependent v a r i a b l e s selected for scrutiny f a l l b a s i c a l l y into three d i f f e r e n t categories: knowledge behaviour health-related status Ideally, to test knowledge gain over a period of time, one would wish to conduct a pre- and post-test of knowledge, such as p r i o r to class attendance and a f t e r class attendance. This was not done i n the study. Instead, a number of forced-choice statements were included i n the questionnaire i n order to e l i c i t knowledge of c e r t a i n facts at one point i n time - post-partum. Information related to health care during pregnancy, to labour, and to infant n u t r i t i o n was e l i c i t e d . A more subjective picture of knowledge outcome was acquired by asking those mothers who attended classes whether they "learned something new" having attended c l a s s e s . Information received i n t h i s manner needs, of course, to be viewed with skepticism. However, there seemed to be some merit i n assessing the attenders' opinions about knowledge gain. Knowledge that does not carry through to p o s i t i v e behaviours might be considered i n e f f e c t i v e . A decision was made, therefore, to look at the behaviour of mothers i n the study, i n terms of smoking, d i e t , alcohol use and exercise, as well as, for example, v i s i t s to physicians, use of information sources, behaviour during labour, infant care, family planning p r a c t i c e s . The patterns of the f i r s t four behaviours were examined for the pre-pregnancy, pregnancy and post-parturn periods. It was the change or maintenance of these behaviours over the pre-pregnancy to post-partum time that was s c r u t i n i z e d rather than the absolute behaviour l e v e l s at one point i n time. Although the p o s i t i v e health status of mother and infant are c h i e f end goals of health education programs such as prenatal classes, these may be the most d i f f i c u l t to define, measure and e s t a b l i s h as "outcomes" of any program. In t h i s study the greater emphasis was placed on knowledge and behaviour measures. Health status outcomes that were investigated included those related to labour complications, infant gestational age, infant b i r t h weight and infant apgar scores. Outside the main independent, s e l e c t i o n and dependent v a r i a b l e s examined, factors related to number of classes attended by i n d i v i d u a l mothers and to c l a s s content were explored. It seemed important to e s t a b l i s h whether the number of classes attended by mothers made any diff e r e n c e i n the outcomes measured. Class content, per se, was not o b j e c t i v e l y measured although a review of the objectives for the prenatal class programs i n the Central Fraser V a l l e y and Coast G a r i b a l d i Health Units indicated that the topics covered are reasonably standard. The main topics dealt with i n health unit classes are generally divided as follows: 1. Early Bird Classes: (1st trimester of pregnancy) Changes during pregnancy Fe t a l development L i f e s t y l e during pregnancy 2. Later Classes: (3rd trimester of pregnancy) Understanding of and preparation for labour Infant care Adapting to parenthood 28 An important thrust of health unit classes i s expressed c l e a r l y i n the statement, "emphasis i s on classes i n early pregnancy where n u t r i t i o n a l and l i f e s t y l e modifications . . . are discussed". 4 The content of classes offered through private organizations was not examined. The unknown number of d i f f e r e n t series made th i s an impractical endeavour, but i t can be assumed that the private classes cover s i m i l a r topics addressed by health unit classes, perhaps i n more depth and possibly with a more intense bent towards non-intervention i n pregnancy and d e l i v e r y . Data Collection The measuring instruments used i n t h i s study included: 1. B i r t h Notices. The B i r t h Notice provided information on geographic l o c a t i o n of the mother, marital status of the mother, de l i v e r y mode, labour complications, infant's gestational age, infant's birthweight, infant's apgar scores and infant problems noted. The accuracy and completeness of the information found on the b i r t h notices was not v a l i d a t e d for t h i s study. The data recorded were assumed to be reasonably accurate i f not n e c e s s a r i l y comprehensive, and were abstracted and used to provide basic information on the mothers and i n f a n t s . 2. Prenatal Class Attendance Books. It was intended that the prenatal class attendance recordings i n the health unit o f f i c e s would constitute one set of information be used for determining who the attenders and non-attenders of health unit classes were i n the study population. In cross-checking some of these data with that provided 29 by the subjects i n t h e i r responses to questions about attendance, i t was found there was much discrepancy. E i t h e r the mothers were over-reporting attendance or the health unit attendance records r e f l e c t e d under-reporting. I t was decided that the information provided by the attendance records would be discarded, with attendance/non-attendance as defined by the mothers themselves c o n s t i t u t i n g the measure of attendance. An assumption was made that error was more l i k e l y to have occurred i n the gathering of attendance s t a t i s t i c s i n the health units than i n s e l f - r e p o r t i n g of attendance/non-attendance by mothers. 3. Questionnaire. The bulk of the data for t h i s study were c o l l e c t e d by a questionnaire for post-partum mothers developed s p e c i f i c a l l y for thi s study (see Appendix B). The questionnaire was tested i n a p i l o t study involving one to two months post-partum mothers. Twenty mothers were randomly selected (without replacement) from a l l the mothers who had given l i v e b i r t h during a one-month period i n the Maple Ridge area. The objectives of the p i l o t study were: a. To pr a c t i s e part of the main study sampling procedure, that i s , the random sampling procedure. b. To test the questionnaire's c l a r i t y to mothers i n order to make any necessary r e v i s i o n s with wording. c. To determine the extent of non-response that might be expected and to tr y out a "reminder" system. d. To check the adequacy of the codes chosen for the pre-coded questions i n order to make any necessary r e v i s i o n s . 30 e. To draw up possible coding categories for the open-ended questions based on the responses received. Revisions to the questionnaire were made as a r e s u l t of the p i l o t study. A code book was drawn up (see Appendix E). The "reminder" system was kept as o r i g i n a l l y designed. The questionnaire was designed to obtain information about a subject's personal background c h a r a c t e r i s t i c s , prenatal class attendance h i s t o r y and selected outcomes i n terms of health-related knowledge, s a t i s f a c t i o n with health services, health behaviour and health status. The ra t i o n a l e for seeking information on these v a r i a b l e s has been discussed e a r l i e r . R e l i a b i l i t y of the questionnaire was not established. The questionnaire was mailed to 182 subjects and was to be used as an interview guide with 40 subjects. The 40 interview subjects were randomly selected by taking a random sample from each of four health unit o f f i c e areas: 10 subjects from Maple Ridge, 15 subjects from Langley, 8 subjects from Gibsons and 7 subjects from Powell River. I n i t i a l contact was made with the subjects selected for interview by l e t t e r (see Appendix F), which was then followed up with a telephone c a l l . Verbal permission to interview was requested over the phone and l a t e r v e r i f i e d by the mother j u s t p r i o r to the actual interview session (see Appendix G). Interviews were conducted to check i f information gathered i n t h i s manner would be more d e t a i l e d or c l e a r e r than might r e s u l t from mailed questionnaires. A l l the interviews were conducted by the main in v e s t i g a t o r . Coding r e l i a b i l i t y was not s u f f i c i e n t l y tested. A minor attempt at tes t i n g r e l i a b i l i t y was made by taping two of the interviews and having two d i f f e r e n t people (the author and one other 31 person) code the interviews. On a couple of questions, discrepancy was noted but was of a minor nature. Coding for the actual study was carried out by one person (Mary Spoke). One hundred and eight-two letters (see Appendix H) were mailed to the remaining study population (222 - 40 = 182 mothers). A certain level of non-response to the mailed questionnaire was anticipated as a result of the pilot study undertaken. It was realized that the covering letter with its assurance of anonymity for the subject, and the stamped/addressed return envelope would not be sufficient to prompt every mother to respond. Anonymity was assured because questionnaires were identified only by number, after the i n i t i a l stage of e l i c i t i n g response. Even before then, only the principal investigator was able to tie numbers to names. Each sample participant was identified by number only for analysis purpose. Reminder letters were sent to those from whom complete questionnaires had not been received within two weeks (see Appendix I). A second reminder letter along with a second copy of the questionnaire, plus another stamped /addressed return envelope was sent to each mother who remained non-responsive. It was hoped that with this procedure a better than 80% response rate would be achieved. 4. Interview Technique Versus Mailed Questionnaire Two strategies for collecting data via the study questionnaire were used in this study. This was done mainly to determine i f one method was superior to the other in terms of being able to achieve more thoughtful and thorough answers to the questions posed. 32 The r e s u l t s suggested that on the whole, the mailed questionnaire fared well as a data gathering strategy. Response rate was s i m i l a r f or the two techniques. Also, perhaps because the study topic was one that seemed to p a r t i c u l a r l y i n t e r e s t new mothers, the answers given to the mailed questionnaire compared favorably r e l a t i v e to the interview responses; answers seemed often as candid and r i c h i n d e t a i l though admittedly more consi s t e n t l y so i n the interview s e t t i n g . The l a t t e r was most probably a r e s u l t of the i m p l i c i t encouragement to expand on responses that a personal face-to-face encounter affords. Having affirmed the mailed questionnaire's basic legitimacy, there i s one further observation regarding the interview techniques worth mentioning. The interview s e t t i n g allowed the interviewer the opportunity to c l a r i f y questions and response categories that were not c l e a r l y understood by the interviewees. Questions r e l a t i n g to exercise, d i e t , smoking and breathing during labour, for instance, caused confusion for a few mothers. It must be assumed from t h i s that the q u a l i t y of answers to some of the same questions i n the mailed questionnaire might have been adversely affected although the p i l o t study should have demonstrated t h i s . What has been learned from using the interview technique i n this study i s that extensive use of the interview strategy as part of the p i l o t study would have been most u s e f u l . The interview provides the best method for testing questionnaire c l a r i t y . Response Rate One hundred and forty-seven (80.8%) sample mothers responded to the 182 mailed questionnaires, and 30 (75%) sample mothers out of a t o t a l 40 33 approached agreed to be interviewed using the questionnaire. Overall response rate i n t h i s study i s , therefore, 79.7% (177/222). Although a better than 80% respone rate was desired by the researcher, the response rate achieved i s high enough to be thought s a t i s f a c t o r y . During computer data analysis, one case was l o s t so that for the greater part of t h i s study, findings were based on responses from 176 respondents, not 177. Response Bias The question of how the women who pa r t i c i p a t e d i n the study compared to those for whom no response was received was important to determine. Bias was checked for i n r e l a t i o n to the following ten v a r i a b l e s : mother's age, marital status, p a r i t y , gestational age, d e l i v e r y mode, infant birthweight, infant apgars, infant b i r t h complications, mother b i r t h complications and mother's areas of residence. Information on these variables was derived from b i r t h notices. The test was chosen to determine i f important differences existed between study p a r t i c i p a n t s and non-participants on some of the above factors. A n u l l hypothesis (no s i g n i f i c a n t differences) was to be accepted i f the si g n i f i c a n c e l e v e l associated with the was greater than 0.05. When the factors marital status, p a r i t y , mother's age, d e l i v e r y mode, birthweight, and infant and mother b i r t h complications were tested against the response factor, no systematic bias was found (see Tables 5 to 11). Younger mothers, for instance, did not respond s i g n i f i c a n t l y more than older mothers (Table 7) nor did mothers who experienced a spontaneous vaginal d e l i v e r y respond s i g n i f i c a n t l y more than those who experienced more complicated b i r t h procedures (Table 8). A tendency towards bias was noted i n terms of p a r i t y with response more c l o s e l y a l l i e d with fewer pregnancies. Appendix J contains further tables (32 to 37). The was not performed on these tables because of the small numbers i n some of the table c e l l s . By scanning the percentage d i s t r i b u t i o n s , however, comparability continues to be evident between responders and non-responders, but perhaps to a lesser extent. This might, i n part, be because factors such as birthweight and de l i v e r y mode are broken down into a larger number of categories. Perhaps from a p r a c t i c a l viewpoint these f i n e r sub-categories are not p o t e n t i a l l y useful for determining bias. Overall, response bias appeared to be n e g l i g i b l e . 35 TABLE 5 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY MARITAL STATUS Legally Married Other Responders 158 (100%) 19 (68%) Non-Responders 36 (19%) 9 (32%) 194 (100%) 28 (100%) n = 222 X 2 - 2.15 df = 1 P = J .10 TABLE 6 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY PARITY Primipara 1 2-3 Mult ipara 3 Responders 82 (85%) 84 (78%) 11 (65%) Non-Responders 15 (15%) 24 (22%) 6 (35%) 97 (100%) 108 (100%) 17 (100%) n = 222 X 2 = 5.44 df = = 2 P = y .05 (N.B. X 2 of 5.99 associated with P = • .05) 36 TABLE 7 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY MARITAL AGE 17-24 Years 25-29 Years 30-42 Years Responders 61 (85%) 70 (82%) 45 (73%) Non-Responders 11 (15%) 15 (18%) 17 (27%) 72 (100%) 85 (100%) 62 (100%) n = 219 X 2 = 3.88 df = 2 P = }> .10 TABLE 8 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY DELIVERY MODE Spontaneous Other Responders 123 (81%) 54 (77%) Non-Responders 29 (116%) 9 (23%) 52 (100%) 70 (100%) n = 222 X 2 = 0.54 df = 1 P = 7 .80 37 TABLE 9 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY BIRTHWEIGHT <l2999 Grams ? 3000 Grams Responders 153 (81%) 24 (71%) Non-Responders 35 (19%) 10 (29%) 188 (100%) 34 (100%) n = 222 X 2 = 1.92 df = 1 P = > .10 TABLE 10 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY INFANT BIRTH COMPLICATIONS None Minimum - Moderate Responders 137 (81%) 40 (77%) Non-Responders 33 (19%) 12 (23%) 170 (100%) 52 (100%) n = 222 X 2 = 0.31 df = 1 P = J .70 TABLE 11 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY MATERNAL BIRTH COMPLICATIONS None Min. - Mod. Serious Responders 119 (82%) 37 (77%) 21 (75%) Non-Re s p ond e r s 27 (18%) 11 (23%) 7 (25%) 146 (100%) 48 (100%) 28 (100%) n = 222 X 2 = 0.88 df = 2 P = 7 .50 S t a t i s t i c a l Treatment S t a t i s t i c a l analysis was conducted i n stages. Cross-tabulations and simple Pearson's c o r r e l a t i o n s were f i r s t u t i l i z e d to determine existence o b i v a r i a t e r e l a t i o n s h i p s between v a r i a b l e s . In most instances, e i t h e r the Chi-square Test or Fisher Exact P r o b a b i l i t y Test was used to e s t a b l i s h s t a t i s t i c a l significance.5 Multiple c o r r e l a t i o n a l analysis was used to test the impact of sets of independent variables on dependent variables.^> 7 39 E N D N O T E S ^The B.C. D i v i s i o n of V i t a l S t a t i s t i c s provided a number of 1982 and 1983 s t a t i s t i c s r e l a t e d to l i v e b i r t h s and th e i r a s s o c i a t i o n with mother and infant c h a r a c t e r i s t i c s . ^"Current attendance and current non-attendance" refers to p a r t i c i p a t i o n i n prenatal classes during the most recent pregnancy. ^Barbara S. Wallston, Kenneth A. Wallston, Gordon D. Kaplan and Shi r l e y A. Maides, "The Health Locus of Control Scale," Instruments for  Measuring Nursing Practice and Other Health Variables ed. Mary Jane Ward et a l (Washington, DC: US Government P r i n t i n g O f f i c e , 1979): 1, 154 -157. 4Coast G a r i b a l d i Health Unit, Coast G a r i b a l d i Health Unit Annual  Report (1982). ^Sidney Seigel, Nonparametric S t a t i s t i c s for Behavioral Sciences (New York: McGraw-Hill, 1956), pp. 42 - 47, 156 - 158, 96 104. 6 W i l l iam R. Klecka, Norman H. Nie, and C. Hadlai H u l l , S t a t i s t i c a l  Package for the S o c i a l Sciences Primer (New York: McGraw-Hill, 1975). ^Frank M. Andrews, Laura K l e i n , Terrance N. Davidson, P a t r i c k O'Malley, and Wil l a r d L. Rodgers, A Guide for Selecting S t a t i s t i c a l  Techniques for Analyzing S o c i a l Sciences Data 2 ed (Michigan: I n s t i t u t e for S o c i a l Research, The Univ e r s i t y of Michigan, 1981). 40 CHAPTER III MAIN RESULTS This chapter w i l l , i n more d e t a i l , describe the study mothers i n terms of t h e i r sociodemographic c h a r a c t e r i s t i c s and t h e i r prenatal class attendance pattern. I t w i l l then set forth the va r i a b l e s associated with the decision to attend classes. A f t e r that w i l l come a d e s c r i p t i o n of the apparent e f f e c t s of background and c l a s s attendance on health i t s e l f . These r e s u l t s w i l l l a r g e l y be presented i n r e l a t i o n to the three study objectives l i s t e d i n Chapter I. An expansion of the sample d e s c r i p t i o n follows. An i n i t i a l endeavour was given i n the previous chapter i n which the study sample was compared to the larger population of new mothers and infants i n the 17 p r o v i n c i a l health u n i t s . Tables 12 and 13 give a p r o f i l e of the study sample i n terms of some sociodemographic c h a r a c t e r i s t i c s . TABLE 12 SOCIODEMOGRAPHIC CHARACTERISTICS OF SAMPLE Characteristics X Range S.D. Maternal Age (years) Maternal Schooling (years) P a r i t y Household Size 26.6 12.5 1.8 2.2 17-42 7-19 1-7 1-9 4.8 2.0 1.0 0.9 TABLE 13 SOCIODEMOGRAPHIC CHARACTERISTICS OF SAMPLE (continued) C h a r a c t e r i s t i c Where Born (mother) - Canada, U.S., U.K., Europe - Other 163 12 92.6 6.8 n = 175 Cul t u r a l Group (mother) - Anglo-Saxon, European - Other 98 15 55.7 8.5 n = 113 Primary Language - English - L. of China - Japanese - L. of India - European - Other 167 2 0 4 2 1 94.9 1.1 0.0 2.3 1.1 0.6 Religion (mother) - Protestant - Catholic - Other - None 54 21 8 90 30.7 11.9 4.5 51.1 n = 173 Ma r i t a l Status - Single - Married - Widowed - Separated - Divorced - Other, e.g. Common-law 8 150 1 2 3 12 4.6 85.2 0.6 1.1 1.7 6.8 Occupation (mother) - Professional/Management - Technical - Service 17 89 17 9.7 50.6 9.7 n = 123 Major Wage Earner - Respondent - Husband/Partner - Mother/Father - Other 8 146 4 16 4.6 83.0 2.3 9.1 n = 174 Household Size - 2 persons - 3-4 persons - 5-9 persons 3 132 41 1.7 75.0 23.3 *n's do not always t o t a l 176 because of missing data. 42 The preceding tables indicate that there was not a great deal of v a r i a b i l i t y i n the marital status, employment status and e t h n i c - c u l t u r a l backgrounds of the sampled women. It i s known that at least 85.2% of the sample mothers were married, 92.6% were western born, 94.9% used English as th e i r primary language and 83% had partners who were the major wage earners. The group appeared somewhat more heterogeneous, however, i n terms of age, education, p a r i t y , r e l i g i o n , mother's occupation and household s i z e . There were, for instance, almost as many primiparous women (47%) as multiparous (53%). Likewise, v a r i a t i o n i s evident with regard to the educational l e v e l s of the women. T h i r t y - s i x percent had had better than 12 years of formal schooling and 12% less than 12 years. Analysis of prenatal class attendance h i s t o r y of the sample women presents some i n t e r e s t i n g findings. It was assumed at the beginning of thi s study that the study sample would not be a homogeneous group of mothers with regard to the prenatal cl a s s factor. This assumption was i n i t i a l l y supported when i t was found that 56% (99) of the women had attended classes during t h e i r most recent pregnancy (current class attenders) and 44% (75) had not (current non-attenders). Examining the attendance factor further, however, i t was apparent that 69% of the current non-attenders had attended classes during an e a r l i e r pregnancy. This meant that 86% (152) of the t o t a l sample had at one time or another attended prenatal classes (ever attenders) with only 14% (24) never having attended classes (never attenders). As there i s a differe n c e i n meaning between current and ever attendance, data analysis has been conducted keeping i n mind the separate connotations of current and ever attendance. 43 The degree of c l a s s attendance by each current attender was also assessed. It was thought that i n analyzing for possible associations of outcomes to c l a s s attendance that degree of attendance ( i . e . percentage of the t o t a l c l a s s s e r i e s attended) should be defined s p e c i f i c a l l y . Figure 3 shows the degree of prenatal c l a s s attendance for each type of c l a s s s e r i e s , i . e . s i n g l e s e r i e s and s p l i t series ("Early B i r d " s e r i e s plus Third Trimester s e r i e s ) . FIGURE 3 DEGREE OF PRENATAL CLASS ATTENDANCE BY PARTICIPANTS One Sanaa Claaiai E = 3 1 0 0 % A t t e n d a n c e 0JJJ 5 0 - 9 9 % A t t e n d a n c e < 5 0 % A t t e n d a n c e I I A t t e n d a n c e not r e p o r t e d n = 25 ^ ^ T l ^-^ Split Serial Claeeet "Early Bird: c i a » w Third Trlme»tor Claw? 12 44 Size of class series attended by th i s of sample mothers varied from three to eight classes. Series of three class lengths were refresher/review series for multiparous women who had attended before, whereas the longer series e n t a i l e d a f u l l program as described i n Chapter I. At least 38% of the women attended three or more classes. Looking at percentage of class attendance i t was found (see Figure 3) that a clear majority of women (72 to 85%) attended at least h a l f of the classes. F o r t y - f i v e to 62% attended a l l the classes. From this one might assume that most current attenders had a reasonable amount of exposure to prenatal class content through lecture and discussion as well as through receipt of resource materials such as the Baby's Best Chance and Pe r i n a t a l Fitness Manual publications.1 The l a t t e r publications are, as a rule, handed out to class p a r t i c i p a n t s during the f i r s t class so that even women who attend one or two classes only, have available to them the resource materials. As the number of those known to have attended fewer than three classes i s small - a t o t a l of eight women - analysis of the impact of degree of attendance on outcomes becomes s t a t i s t i c a l l y i mpractical. A larger sample size at the beginning might have eliminated t h i s problem of small numbers. More important than sample s i z e , however, would have been information on exposure to clas s content matched to s p e c i f i c classes attended. This was not ascertained i n the study. Current attendance for t h i s study remains defined as any attendance at prenatal classes during the most recent pregnancy regardless of number of classes attended. Chapter IV does describe i n an i n d i r e c t manner the classes which were attended by p a r t i c i p a n t s . What was a c t u a l l y asked of the mothers concerns 45 exposure to p a r t i c u l a r content areas. Mothers were asked i f they learned anything new about an array of pregnancy-related topics. One of the pre-determined responses to t h i s question allowed a mother to indicate that a p a r t i c u l a r topic "was not covered i n the classes I attended." From the responses, some insight i s gained regarding degree of attendance. How such degree of attendance associates with health outcomes was not analyzed, however. The responders to the question concerning attendance at private versus health unit classes indicated that a majority, 79%, attended health unit sponsored classes; 14% attended private classes; and 2% attended both types of classes. Five (5%) subjects provided no information on t h i s matter. Figure 3 seems to indicate that attendance at both types of classes was ac t u a l l y larger than 2%. Why t h i s was not supported by the above percentages derived from questionnaire responses i s not understood. It i s cl e a r that most attenders did go to health unit classes, t h i s probably because private classes were less a v a i l a b l e i n a l l study l o c a l e s . Objective I Findings w i l l f i r s t be described i n r e l a t i o n to Objective I of this study. That objective i s : TO DETERMINE WHICH FACTORS ARE RELATED TO THE DECISION TO ATTEND OR NOT TO ATTEND CLASSES What, i n essence, i s being sought i s information on who the prenatal class attenders were i n the study sample. What distinguished them with regard to t h e i r background c h a r a c t e r i s t i c s from the non-attenders? 46 Tables 38 to 49 i n Appendix K i l l u s t r a t e the var i a b l e s that have an associ a t i o n with attendance at classes. Tables 38 to 41 present data from collapsed cross-tabulations, whereas Tables 42 and 43 give the simple c o r r e l a t i o n values(rs) between attendance and various mother c h a r a c t e r i s t i c s . By examining the aforementioned r e s u l t s of b i v a r i a t e cross-tabulations and c o r r e l a t i o n s , i t i s evident that current attendance, for the mothers of this sample, was associated with: 1) f i r s t pregnancy (e.g., low p a r i t y , small household s i z e , no previous attendance) 2) existence of a support system (e.g., physician recommending classes, receiving encouragement from others to attend classes, t a l k i n g to various persons about pregnancy, having a v a i l a b l e and using various sources of information on c h i l d b i r t h ) 3) being western born and of an Anglo-Saxon or European background 4) having a regular v i s i t i n g pattern with a physician. Education and occupation has a less c l e a r association with current attendance than some of the above f a c t o r s . The data indicate that there i s a tendency for women with middle l e v e l occupations (e.g., tec h n i c a l , c l e r i c a l , sales) and with middle l e v e l education (11 to 12 years schooling) to attend classes more than those at the lower and upper extremes of these v a r i a b l e s ; that i s , a higher percentage of women with these c h a r a c t e r i s t i c s were attending classes. Making regular v i s i t s to the physician or having a number of persons to t a l k to about pregnancy may not necessarily, of course, be precursors of current attendance as I am suggesting i n points 2) and 4) above. They, i n part, may be rela t e d to attendance as an outcome rather than as a determinant. It should also be noted that to the questions on the mother's 47 c u l t u r a l h i s t o r y , only 113 out of 176 mothers responded. One cannot be c e r t a i n who ( i n terms of culture) were the non-responders. Factors that seem to have had l i t t l e bearing on the decision to attend classes during the l a s t pregnancy were mother's age; view of classes' purpose; awareness of classes ( v i a a d v e r t i s i n g ) ; general health status; pre-pregnancy d i e t , alcohol, smoking and exercise behaviour; r e l i g i o n ; knowing other c l a s s attenders; transportation time to classes and sense of control over own health. Concerning women who had ever attended classes, the data show that s e l e c t i o n into prenatal classes with at least one pregnancy followed a s i m i l a r pattern as s e l e c t i o n into classes with the l a s t pregnancy. Being married and having a partner as major wage earner are new factors that show association with ever-attendance. Educational status has a more l i n e a r r e l a t i o n s h i p with ever-attendance than i t did with current attendance. Years of schooling are p o s t i v e l y associated with the former. S p e c i f i c c h a r a c t e r i s t i c s of mothers found not to r e l a t e to ever-attendance are l i k e those mentioned concerning current attendance. As w e l l , p a r i t y ; occupational status; and receiving encouragement to attend classes from others and/or a physician no longer appear important i n pr e d i c t i n g attendance. In summary, then, s e l e c t i o n factors found to be r e l a t e d to current attendance are primiparity, existence of a support system, western c u l t u r a l background and regular v i s i t s to a physician. Except for p a r i t y and having classes recommended to one (defined as part of a support system), any attendance at classes i s , also, associated with the above fac t o r s . In addition, s e l e c t i o n appears affected by marital status, having one's partner as major wage earner and being more educated. Also examined were the information sources that women used during pregnancy. The purpose of th i s had been to gain a c l e a r e r picture of the type of women who are attending classes. Pregnant women have the p o t e n t i a l to receive information and gain knowledge about pregnancy, labour and c h i l d b i r t h , and childcare from many d i f f e r e n t sources. The study questionnaire gives examples of various sources of information. Summary Tables 14 to 19 explain which sources of information the study p a r t i c i p a n t s found most useful to them. They were each asked to name the two sources that were most h e l p f u l to them. Appendix K, Tables 44 to 49 provide the d e t a i l e d data from which Tables 14 to 16 are made. 49 TABLE 14 CURRENT ATTENDANCE BY MAIN SOURCES OF INFORMATION ON PREGNANCY Current Professional Other Attendance Sources* Sources Yes 91 (70.5%) 99 (48%) No 38 (29.5%) 108 (52%) 129 (100%) 207 (100%) 336* (168 Mothers) *336 = 168 mothers. Each mother c i t e d two main sources of information on pregnancy. X 2 = 18.46 p. 0.001 *Professional Sources - physician, physician's nurse, prenatal classes, public health nurse. TABLE 15 CURRENT ATTENDANCE BY MAIN SOURCES OF INFORMATION ON LABOUR AND CHILDBIRTH Current Professional Other Attendance Sources Sources Yes 92 (81%) 86 (40%) No 22 (19%) 128 (60%) 114 (100%) 214 (100%) 328 (164 Mothers) X 2 = 31.78 p. 0.001 50 TABLE 16 CURRENT ATTENDANCE BY MAIN SOURCES OF INFORMATION ON CHILDCARE Current Attendance Professional Sources Other Sources Yes 47 (64%) 139 (55%) No 26 (36%) 112 (45%) 73 (100%) 251 (100%) 324 (162 Mothers) X 2 = 1.8 p. not s i g n i f i c a n t Tables 14 and 15 indicate that the majority of respondents claiming professional sources of information on pregnancy and labour to be the most h e l p f u l sources are current class attenders. 2 Conversely, the respondents who claimed other than professional sources of information as the most useful tend to be those not currently attending classes.^ Table 16 presents no s i g n i f i c a n t differences i n terms of information sources on childcare p r e d i c t i n g current attendance. TABLE 17 EVER ATTENDANCE BY MAIN SOURCES OF INFORMATION ON PREGNANCY Ever Professional Other Attendance Sources Sources Yes 122 (95%) 168 (81%) No 7 (5%) 39 (19%) 129 (100%) 207 (100%) 336 (168 Mothers) X 2 = 12.8 p. Z. 0.001 51 TABLE 18 EVER ATTENDANCE BY MAIN SOURCES OF INFORMATION ON LABOUR AND CHILDBIRTH Ever Attendance Professional Sources Other Sources Yes 121 (94.5%) 161 (80.5%) No 7 (5.5%) 39 (19.5%) 128 (100%) 200 (100%) 328 (164 Mothers) X 2 = 12.2 p. ^ 0.001 TABLE 19 EVER ATTENDANCE BY MAIN SOURCES OF INFORMATION CHILDCARE Ever Attendance Professional Sources Other Sources Yes 66 (87%) 218 (88%) No 10 (13%) 30 (12%) 76 (100%) 248 (100%) 324 (162 Mothers) X 2 = 10.6 p. not s i g n i f i c a n t 52 Tables 17 and 18 show that the majority of respondents who claim professional sources of information on pregnancy and labour as the most useful sources are those who attended classes at some point i n time. The margin of difference i s much less here than with current attendance. It might be assumed that "other sources" of information had gained i n importance for ever-attenders because more have r e l i e d on increased experience (more multiparas) and on self-motivated study, e.g., reading (greater mass of older, more mature women). Again, as with current attenders, the women's main sources of information on childcare cannot be used to predict ever-attendance at prenatal classes (Table 19). That there was a r e l a t i o n s h i p between women who tended to seek and use professional resources for the most pregnancy-related information and women who decided to attend prenatal classes i s evident. In accordance with Objective I's p r i n c i p a l intent of finding the best predictors of prenatal cl a s s attendance, multiple c o r r e l a t i o n s were c a r r i e d out as a follow-up to the b i v a r i a t e findings just presented. Several variables were found to be rela t e d to attendance, e.g., p a r i t y , educational status, MD recommendation, culture, and i t i s known that some of these are related to each other, e.g., p a r i t y and MD recommendation. It was necessary to look at groups of var i a b l e s at once to see which i n d i v i d u a l ones have independent e f f e c t s and to see how strong an e f f e c t they have. Table 20 shows the r e s u l t s of some of these multiple c o r r e l a t i o n s . 53 TABLE 20 RESULTS OF MULTIPLE CORRELATIONAL ANALYSES: PRENATAL CLASS ATTENDANCE WITH PREDICTORS R Multiple R R2 Signifance F Current Attendance Low P a r i t y .521 .521 .271 .000 Physician Recommended .473 .565 .319 .000 Small Household Size .337 .566 .320 .000 Anglo-Saxon Culture .281 .586 .343 .000 Received Encouragement from Others .229 .596 .354 .000 Ever Attendance Frequency to Physician .422 .422 .178 .000 English Language .382 .517 .267 .000 Small Household Size .352 .570 .325 .000 Anglo-Saxon Culture .255 .573 .328 .000 Ever Attendance Frequency to Physician .276 .276 .076 .000 English Language .273 .355 .126 .000 Higher Education -.248 .400 .160 .000 Partner Major Wage Earner -.163 .442 .195 .000 Married .156 .446 .198 .000 More People Talked To -.141 .456 .08 .000 The j o i n t impact of the factors involved i n each of the above three analyses (Table 20) account for r e a l but modest proportions of the variance i n the attendance factor. A large proportion of the variance i s s t i l l l e f t unexplained. It i s evident from the second multiple c o r r e l a t i o n involving "Ever Attendance" that the addition of four variables d i f f e r e n t from the f i r s t set for "Ever Attendance", did nothing to further explain i t . The two independent factors most p r e d i c t i v e of current attendance i n the a v a i l a b l e analysis are p a r i t y (r = 0.52) and physician recommendation (r = 0.47). 54 The s e l e c t i o n factors of Table 20 are for the most part related to the socio-economic backgrounds of the respondents, e.g. frequency to physician, language, education. These cannot e a s i l y (or at a l l ) be manipulated by prenatal class planners and educators. Implications of t h i s w i l l be discussed i n the f i n a l chapter. A Predictive Model of Current Prenatal Class Attendance Up to this point, a number of variables have been examined for evidence of ass o c i a t i o n with current prenatal class attendance. This has been done in an attempt to f i n d predictors of class attendance. Low pa r i t y , for instance, i s linked with attendance as are physician recommendation, receiving encouragement from others to attend, small household s i z e , and Anglo-Saxon e t h n i c i t y . In order to see how variables such as these work together to predict current prenatal cl a s s attendance a path model has been constructed (Figure 4). The paths depicted i n Figure 4 derive from knowledge gained through the tabular and c o r r e l a t i o n a l analyses presented e a r l i e r . The path model i s constructed i n such a way that i t accounts for "time", i . e . , p a r i t y (pregnancy) comes p r i o r to MD recommendation, as w e l l , as obtaining d i r e c t and i n d i r e c t e f f e c t s of the chosen c h a r a c t e r i s t i c s on attendance. The f i v e c h a r a c t e r i s t i c s used for the path analysis r e f l e c t the strongest variables related to current attendance. They are assumed to influence, not necessar i l y cause, current attendance. 55 FIGURE 4 PATH MODEL SHOWING PREDICTORS OF CURRENT  PRENATAL CLASS ATTENDANCE. COEFFICIENTS (STANDARDIZED BETAS) REFER TO DIRECT EFFECTS ONLY 106 cases) 56 TABLE 21 PATH COEFFICIENTS FOR PATH MODEL PREDICTING CURRENT PRENATAL CLASS ATTENDANCE Total Causal Total Non-Covariance Direct Indirect A + B Causal Variable Pairs (A) (B) (C) (D) (E) Attendance, MD Recommendation .47 .28 - .28 .19 Attendance, Encouragement Others .23 -.13 - .13 .10 Attendance, Household Size .34 .04 .06 .10 .24 Attendance, P a r i t y .52 .37 .24 .61 -.08 Attendance, Culture .28 .16 .25 .41 -.13 MD Recommendation, Household Size .41 .16 - .16 .25 MD Recommendation, Pa r i t y .56 .48 .08 .56 .00 Encouragement Others, Household Size .34 .15 - .15 .19 Encouragement Others, P a r i t y .45 .37 .08 .45 .00 Household Size, P a r i t y .52 .50 - .50 .02 Household Size, Culture .20 .10 .10 .20 .00 P a r i t y , Culture .20 .20 - .20 .00 57 A path model, such as t h i s , r e l i e s on path analysis for i n t e r p r e t a t i o n of the l i n e a r r e l a t i o n s h i p s contained within i t . Path analysis has been described as "...superior to ordinary regression analysis since i t allows us to move beyond the estimation of d i r e c t e f f e c t s , which i s the basic output of regression " 4 It "...enables one to measure the d i r e c t and i n d i r e c t e f f e c t s that one v a r i a b l e has upon another."^ Appendix L indicates how the v a r i a b l e s , that are part of the Figure 4 path model, were coded. For the variables class attendance, MD recommendation, encouragement from others, and culture underlying continuous scales are presumed. Table 21 gives the data that form the basis of the path a n a l y s i s . The t o t a l variance that i s explained for current prenatal class attendance by the path model i s 34% (1 - .81 2). The path c o e f f i c i e n t s show that most of t h i s variance i s explained by p a r i t y ( t o t a l causal e f f e c t s = .61) and culture ( t o t a l causal e f f e c t s = .41). Household siz e ( t o t a l causal e f f e c t s = .10) and encouragement from others ( t o t a l causal e f f e c t s = .13) are not good explanations or predictors of attendance. P a r i t y has a strong d i r e c t e f f e c t on current attendance unmediated by other v a r i a b l e s , equalling .37. The l i n k between p a r i t y and attendance i s strengthened, however, through the variables MD recommendation ( d i r e c t e f f e c t s = .48) and encouragement from others ( d i r e c t e f f e c t s = .37) the former contributing the greater portion of the i n d i r e c t e f f e c t s ( t o t a l i n d i r e c t e f f e c t s = .24). These findings, thus, say that current attendance i s , i n part, predicted by MD recommendation, which, i n turn, i s influenced by p a r i t y . 58 Stepping back i n the path model to the mother's c u l t u r a l group i t i s noticed that i t , too, i s a predictor of attendance. Culture's e f f e c t on attendance i s enhanced when operating through intermediate v a r i a b l e s . Culture, i n f a c t , appears to gain most of i t s influence on attendance i n d i r e c t l y ( i n d i r e c t e f f e c t s - .25) rather than d i r e c t l y ( d i r e c t e f f e c t s = .16). P a r i t y i s the v a r i a b l e which most strengthens culture's ( d i r e c t e f f e c t s = .20) r e l a t i o n s h i p with current attendance. This model appears to say that majority group status (Anglo-Saxon) when linked to p r i m i p a r i t y influences a physician to recommend prenatal classes, which, i n turn, a f f e c t s a mother's decision to attend classes. Household size and receiving encouragement from others have a more limited a f f e c t on the d e c i s i o n to attend classes. Figure 5 i l l u s t r a t e s the manner i n which the s i g n i f i c a n t paths are linked together. It must be remembered too, that each v a r i a b l e , i n d i v i d u a l l y , e.g., p a r i t y , has i t s own singular d i r e c t e f f e c t on attendance. FIGURE 5 SIGNIFICANT PATHS TO CURRENT ATTENDANCE PRIMIPARITY MD RECOMMENDATIONS MAJORITY CULTURE CURRENT PRENATAL CLASS ATTENDANCE Household Size Encouragement "* From Others 59 Limitations of a path model, such as the one here, must be recognized. It i s important to r e c a l l that 66% of the v a r i a t i o n i n current attendance i s not explained by t h i s path model. S i m i l a r l y , each component v a r i a b l e i s affected mainly by factors situated outside the path model. By squaring the c o e f f i c i e n t of a l i e n a t i o n for the factor - encouragement from others (.892) - for instance, one sees that 79% of the v a r i a t i o n i n t h i s factor i s not explained by the s p e c i f i e d v a r i a b l e s of t h i s model. The model, therefore, i s constrained by the v a r i a b l e s chosen for i t s construction as well as by the manner i n which the chosen variables were measured and coded. One would not expect high variance explained for current attendance with an analysis i n which the i n d i v i d u a l woman i s the unit of study. One other point to mention i s that there are a large number of missing cases i n t h i s p a r t i c u l a r a n a l ysis. One hundred and six cases out of a t o t a l of 176 were used. In hindsight, i t i s evident that "place of b i r t h " would have been a better measure of e t h n i c i t y than " c u l t u r e " because more mothers responded to the question concerning place of b i r t h than did to the question concerning c u l t u r a l background. Despite some of the r e a l problems of the described path model, i t does a s s i s t i n c l a r i f y i n g some of the underlying processes of influence between var i a b l e s by measuring of i n d i r e c t and d i r e c t e f f e c t s . Objective II This objective proposes: TO DETERMINE THE DIFFERENCES BETWEEN ATTENDERS AND NON-ATTENDERS IN TERMS OF CERTAIN HEALTH-RELATED OUTCOMES 60 Evidence of associations between prenatal c l a s s attendance and health-related outcomes i s part of what i s being investigated with t h i s study objective. A sub-objective i s to examine v a r i a t i o n among attenders and non-attenders. In Appendix M are located b i v a r i a t e cross-tabulation tables and cor r e l a t i o n s (Tables 50 to 53) that i l l u s t r a t e r e l a t i o n s h i p s between attendance and outcomes with varying degrees of s t a t i s t i c a l s i g n i f i c a n c e . These data indicate that the following dependent v a r i a b l e s were associated with current prenatal c l a s s attendance: 1. Regular v i s i t s to physician. 2. Use of labour breathing techniques. 3. Infant complications. 4. Complicated d e l i v e r y mode. 5. Maternal complications. It was also found that there was a trend (p = 0.05) for current attendance to be rel a t e d to: 6. Perception of greater discomfort. 7. Less smoking post-partum. 8. Less breastfeeding. 9. Larger birthweight. Of i n t e r e s t i s that some of the above findings did not occur i n the desired (expected ?) d i r e c t i o n s . The current prenatal c l a s s attenders appeared to experience greater complications around the actual b i r t h process and they seemed to be less prone to p r a c t i s i n g breastfeeding than non-attenders. 61 The dependent variables found to associate with ever attendance at  prenatal classes (Appendix M) were: 1. Knowledge about d i e t and obesity i n pregnancy. 2. Use of labour breathing techniques. 3. No d e f i n i t e plans concerning family planning. 4. Regular v i s i t s to physician. 5. Complicated mode of de l i v e r y . Trends were evident i n terms of: 6. Knowledge about swimming during pregnancy. 7. Knowledge about breastfeeding. 8. More breastfeeding. Again, some associations i n the data occurred i n the opposite d i r e c t i o n than would be expected. Complicated b i r t h mode and lack of family planning during the post-pregnancy period, for instance, were linked to ever attendance. The above summary r e s u l t s of b i v a r i a t e analyses between prenatal class attendance and health-related outcomes are of limited meaning as they stand. To be meaningful, factors describing the attenders must be entered into the picture as shown i n Figure 1 of Chapter I. This i s s t i l l to be done. In the interim, what can be said of the differences between cla s s attenders and non-attenders i s that there are only a few s i g n i f i c a n t differences between the two groups of mothers and some of these outcome differences are not of the desired sort. Although there are some p o s i t i v e associations between health knowledge/behaviour and clas s attendance, o v e r a l l , knowledge and behaviour 62 were not s i g n i f i c a n t l y d i f f e r e n t for attenders and non-attenders. Nor did attenders indicate that they f e l t a greater sense of control over t h e i r health (locus of control) than did non-attenders. The one health status measure - infant birthweight - appearing to be linked i n a weak but p o s i t i v e way with attendance only did so with current attendance and under cross-tabular analysis (Appendix M, Table 50). Co r r e l a t i o n a l analysis erased evidence of any r e l a t i o n s h i p (r = 0.0560, p = 0.462). In the analyses conducted up to t h i s point, thus, no s i g n i f i c a n t p o s i t i v e health status differences are noted for c l a s s attenders. Part of Objective II (the sub-objective) aims to i d e n t i f y differences i n outcome within the attender group and within the non-attender group. From such findings, one might be able to determine i f c e r t a i n attenders/non-attenders have stronger l i n k s to p a r t i c u l a r outcomes than others. What i s r e a l l y sought i s a d e s c r i p t i o n of who appears to benefit the most from attendance. Although benefit implies that a causal r e l a t i o n s h i p i s at work, i t i s recognized that causation cannot be i n f e r r e d from the r e l a t i o n s h i p seen i n the cros s - s e c t i o n a l (and retrospective) data c i t e d next. Five health-related outcomes are examined for t h e i r r e l a t i o n s h i p s with prenatal c l a s s attendance while c o n t r o l l i n g for some respondent c h a r a c t e r i s t i c s . The referent c r o s s - s e c t i o n a l data are located i n Appendix M (Tables 54 to 69), show that the control v a r i a b l e s chosen, here, appeared to have some e f f e c t on c e r t a i n outcome measures. Figures 6 to 21 summarize the data from the tables and i l l u s t r a t e the key findings expressed i n percentages. Tests for s i g n i f i c a n c e of differences were not conducted. By looking at the percentages, however, i t i s possible to speculate upon which women clas s attendance appears to have the greatest e f f e c t i n terms of c e r t a i n outcomes. Current attendance, for instance, appeared to have the greatest impact, with regard to encouraging women to use s p e c i f i c labour breathing techniques, on multiparous women of non-Anglo-Saxon e t h n i c i t y who have an average education (Figures 5, 6 and 7 ) . Attendance at a minimum of three classes, also, seemed to make a differe n c e (Figure 8 ) . For t h i s study's sample of women and for t h i s p a r t i c u l a r outcome i t appears that prenatal cl a s s attendance may have been least e f f e c t i v e for primiparous Anglo-Saxon women of low or high educational backgrounds. Figure! 6 Labour Breathing Techniques by Current Attendance and Culture V?. Figure j 7 Labour Breathing Techniques by Current Attendance and Years of Education A n g l o Saxon Other Culture Current Attendance Current Non -A t tendance RsrcmlqgieftesparKters Figure 18 Labour Breathing Techniques by Current Attendance and Parity Fttnipara Multipara Figure /9 Labour Breathing Techniques by Number of Classes Attended 6 - 1 6 3 - 4 1 - 2 None Number of Classes Attended Used Labour Breathing Techniques Figure 10 Infant Complication* by Current Attendance and Culture Ang lo Other Saxon Culture Figure 11 Infant Complications by Current Attendance < 20 20 - 29 > 29 Years Years Years Current Attendance | | Current Non - Attendance Figure 12 Infant Complications by Years of Current Attendance and Education Figure 13 Infant Complications by Current Attendance and Parity 7 - 1 0 Years Prtmlpara Multipara N o In fant C o m p l i c a t i o n s F i g u r e 14 Infant Complication* by Number Classes Attended 5 - 1 5 3-4 1 - 2 N o n e N u m b e r of C l a s s e s A t t e n d e d N o infant C o m p l i c a t i o n s Cur ren t A t t e n d a n c e F igu re 16 Infant Birthweight by Number Classes Attended 5 - 1 5 3-4 1 - 2 N o n e N u m b e r of C l a s s e s A t t e n d e d Infant Bi r thweight > agog gram? Cur rent N o n - A t t e n d a n c e F igu re 16 Labour Discomfort by Number Classes Attended F igu re 17 Delivery Mode by Number Classes Attended 5 - 1 5 3-4 1 - 2 N o n e 5 - 1 5 3-4 1 - 2 N o n e N u m b e r o f C l a s s e s A t t e n d e d N u m b e r o f C l a s s e s A t t e n d e d Discomfort Spontaneous V a g i n a l Delivery Figure 18 Infant Birthweight by Ever - Attendance and Culture ^83 'A 100 Anglo Saxon Other Culture Ever-Attendance Figure 20 Infant Birthweight by Ever-Attendance and Years of Education Figure 19 Infant Birthweight by Ever-Attendance and Age 67 Never-Attendance Figure 21 Infant Birthweight by Ever-Attendance and Parity Frtmlpara Multipara In fant B i r thwe ight > 3 0 0 0 G r a m s 68 Concerning presence of infant complications, the apparent trend was for current c l a s s attendance to be p o s i t i v e l y associated with i t ; conversely, the fewer classes attended, the more l i k e l i h o o d of having no infant complications. With regard to t h i s outcome, the data predicted that those who might have the most to lose by attendance were non-Anglo-Saxon teenagers with minimal schooling (Figures 10, 11 and 12). Optimal infant health i s one of the key end goals of early prenatal education. Infant birthweight i s one measure of infant health. In speaking of birthweight, Figures 18, 19, 20 and 21 show that i t was the ever-attenders who were of minority group status, were under 20 years old or over 29 years old, were multiparous and had an averge education who seemed to gain more from t h e i r attendance than did other women. In looking at Figure 15 there appears to be no d i s c e r n i b l e pattern l i n k i n g degree of attendance to women's perception of labour discomfort. There i s some i n d i c a t i o n that those who attended many classes (5 to 15) or just a few (1 to 2) experienced more labour discomfort than those who did not attend any classes at a l l or those who attended a moderate number of three to four classes. The a s s o c i a t i o n of class attendance to mode of d e l i v e r y i s s i m i l a r to that of attendance to presence of infant complications. In general, the fewer classes attended the better, although some class attendance may be better than none (Figure 17). The findings j u s t presented give one some idea of the manner i n which prenatal c l a s s attenders d i f f e r e d from one another i n terms of s p e c i f i c outcome measures; dependent possibly on variables such as c u l t u r a l status, education, age, p a r i t y and degree of cl a s s attendance. Objective I I I This objective aims BY WEIGHING THE EFFECTS OF VARIOUS FACTORS AND CLASS ATTENDANCE HISTORY ON OUTCOME, TO DETERMINE WHAT (OR WHAT COMBINATION OF FACTORS) IS THE MOST IMPORTANT DETERMINANT OF OUTCOME The intention of this objective i s to i d e n t i f y the best predictors of outcome. Up to thi s point v a r i a b l es p r e d i c t i n g prenatal class attendance and non-attendance have been examined. As wel l , class attendance has been examined as a predictor of health-related outcome. It i s now, the intention, to put these two sets of independent variables together i n various sets to see what the r e l a t i v e e f f e c t s of each ( a l l ) of them are on health-related outcomes. Attendance, thus, i s being weighed against culture, p a r i t y , etc., as a predictor of outcome. The v a r i a b l e sets are made up of variables that showed s i g n i f i c a n t b i v a r i a t e r e l a t i o n s h i p s i n e a r l i e r analyses (Appendix K and M). Analyses for t h i s objective were performed f i r s t using "current attendance" as one of the independent variables i n four d i f f e r e n t v a r i a b l e packages, and then using "ever attendance" s i m i l a r i l y . Tables 22 and 23 show the r e s u l t s of these analyses. Of i n t e r e s t i s not only the cumulative e f f e c t of a p a r t i c u l a r set of vari a b l e s , but the determination of which variables within i t are most responsible for the variance i n the outcome. From Table 22 i t can be seen, for instance, that the v a r i a b l e set chosen to predict d e l i v e r y mode explains only 6% of the variance i n the l a t t e r ; p a r i t y accounting for the greatest amount of variance (.052), followed by current attendance (.006) and c u l t u r a l group status (.0005). The c o r r e l a t i o n a l analysis also shows 70 that d e l i v e r y mode associates negatively with a l l three contributing v a r i a b l e s , i . e . , spontaneous vaginal b i r t h i s shown associating with m u l t i p a r i t y , non-attendance and minority group status. The meaningfulness of the r e l a t i o n s h i p of current attendance and majority group status with complicated b i r t h mode, however, i s highly questionable when one remembers that the former two variables account for less than one percent of the variance i n d e l i v e r y mode. Examining another set of variables from Table 22, one sees that a lack of infant complications i s explained p a r t l y by current attendance (.025), by the presence of maternal health problems (0.27) and by m u l t i p a r i t y (.002). Together these variables contribute 5% of the variance of the outcome "no infant complications". 71 TABLE 22 RESULTS OF MULTIPLE REGRESSION ANALYSES:  DETERMINANTS (INCLUDING CURRENT PRENATAL CLASS  ATTENDANCE) OF OUTCOMES R Frequency to Physician Current Attendance .304 Cul t u r a l Group .258 Pari t y .083 Household Size .077 Maternal Health Problems -.033 Labour Breathing Techniques P a r i t y .251 Current Attendance .176 Cult u r a l Group .143 No. Sources Used on Labour and Delivery -.044 Delivery Mode P a r i t y -.227 Current Attendance -.177 Cu l t u r a l Group -.079 Infant Complications Current Attendance -.157 Maternal Health Problems -.143 Par i t y -.120 Multiple R R 2 P-Value .304 .092 .001 .354 .126 .001 .363 .132 .002 .364 .133 .004 .365 .133 .009 .251 .063 ? .259 .067 .023 .273 .074 .040 .273 .074 .080 .227 .052 ? .241 .058 .038 .242 .058 .038 .157 .025 .039 .227 .052 .011 .232 .054 .024 72 TABLE 23 RESULTS OF MULTIPLE REGRESSION ANALYSES;  DETERMINANTS (INCLUDING EVER PRENATAL CLASS  ATTENDANCE) OF OUTCOMES Multiple R R2 P-Value Frequency to Physician Ever Attendance .422 .422 .178 .000 Cu l t u r a l Group .258 .450 .202 .000 Ma r i t a l Status .115 .451 .204 .000 Language .215 .452 .204 .001 Household Size .077 .465 .216 .001 Labour Breathing Techniques Language .389 .389 .151 .000 Ever Attendance .307 .434 .189 .000 Cu l t u r a l Group .143 .434 .189 .000 No. Sources Used on Labour and Delivery -.044 .435 .189 .000 Family Planning Ever Attendance -.168 .168 .028 .080 Ma r i t a l Status .168 .263 .069 .022 Cul t u r a l Group .134 .336 .113 .006 Frequency to Physician -.082 .341 .117 .011 Education -.054 .355 .126 .015 Language .003 .355 .126 .029 Infant Feeding Education -.199 .199 .040 .008 Age -.187 .235 .055 .007 Ever Attendance .127 .253 .064 .010 Ma r i t a l Status .067 .253 .064 .023 73 In assessing how a combination of four p a r t i c u l a r variables predict the use of s p e c i f i c breathing techniques during labour (Table 22), i t i s evident that 7% of the variance i n the l a t t e r i s accounted for by the former. The current attendance factor i s responsible for only .004 of the variance when entered with the three other v a r i a b l e s , while p a r i t y contributes .063 of variance and i s the strongest predictor within t h i s group of v a r i a b l e s . The frequency of respondents' v i s i t s to physicians should possibly not be belaboured because i t i s a doubtful outcome measure. In an e a r l i e r part of t h i s study, i n f a c t , "frequency of v i s i t s to the physician" i s examined as a possible pr e d i c t o r of prenatal class attendance. It i s , here, being looked at as a possible outcome of attendance. Perhaps i t i s a question of which comes f i r s t , or of health behaviour t r a i t i n general, thus, not e a s i l y solved. At t h i s point, nevertheless, i t i s being treated as an outcome based on the assumption that class attenders are a c t i v e l y encouraged by t h e i r c l a s s teachers to seek regular medical attention during t h e i r pregnancies. Moving on to Table 23, where "ever attendance" i s examined as part of four v a r i a b l e sets, one can see that class attendance, here, just as in Table 22, i s as might be expected, i s more strongly associated with physician v i s i t s than with any of the other variables with which the l a t t e r i s combined. Turning elsewhere i n Table 23, a respondent's primary language appears somewhat more i n f l u e n t i a l i n p r e d i c t i n g use of labour breathing techniques (15% of the variance) than does ever-attendance which explains a further 74 49% of the v a r i a t i o n . The other two variables of the set accounted for a n e g l i g i b l e amount of the variance. Thirteen percent of the variance i n family planning decision-making i s credited to the f i v e factors described i n Table 23. Never attendance i s the best predictor (.028) with m a r i t a l status (.041) and majority group status (.044) being second best predictors. A respondent's decision to breastfeed her c h i l d r e n was best predicted by her l e v e l of education (.04 of the variance), then, by her age (.025 of the variance) and next, by her prenatal class attendance h i s t o r y (.009). M a r i t a l status appeared to be of l i t t l e consequence i n the decision to breastfeed. The more educated respondents of older age who had attended classes at some point i n time, however, had a greater tendency to breastfeed than did the other respondents. Class attendance i s of importance i n p r e d i c t i n g v i s i t s to the physician, infant complications and family planning, but other outcome measures are, evidently, better predicted by other variables such as p a r i t y , language and education. In no s i t u a t i o n studied do any of the variables make large e f f e c t s on the outcome v a r i a b l e s . A P r e d i c t i v e Model of Health Outcome Through multiple c o r r e l a t i o n analysis c e r t a i n health-related outcomes were shown to be predicted by p a r t i c u l a r sets of variables including prenatal class attendance. To r e i t e r a t e the findings r e l a t e d to the health outcome measure -absence of infant complications - i t i s seen that presence of maternal 75 health problems, m u l t i p a r i t y and non-attendance at prenatal classes are minimally associated with absence of infant complications (Table 22). A path model (Figure 22) was constructed 1) to include variables which p r i m a r i l y l i n k the attendance factor to outcome and 2) to include pathways l i n k i n g a d d i t i o n a l background variables to attendance as per the insights gained from the f i r s t path model constructed (Figure 4). This second path model may help i n the understanding of the i n d i r e c t and d i r e c t causal paths from background to outcome. The expectation i s , therefore, that the way i n which a l l these variables function together to e f f e c t the outcome may be c l a r i f i e d . The manner i n which the variables are coded for t h i s path model i s deta i l e d i n Appendix L. The decomposition of the path c o e f f i c i e n t s , as written i n Table 24, are important to the i n t e r p r e t a t i o n of the linkages seen between the variables of the path model. The t o t a l variance that i s explained by the path model with regard to the absence of infant complications i s 6% (1 - .972). Infant complications are, thus only barely predicted by the factors which were measured. 76 FIGURE 2 2 PATH MODEL SHOWING PREDICTORS OF INFANT  COMPLICATIONS (STANDARDIZED BETAS  REFER TO DIRECT EFFECTS ONLY) ( n = 111 c a s e s ) 77 TABLE 24 PATH COEFFICIENTS FOR PATH MODEL PREDICTING INFANT COMPLICATIONS Total Causal Total Non-Covariance Direct Indirect A + B Causal Variable Pairs (A) (B) (C) (D) (E) Infant Complications, Current Attendance -.09 -.10 .02 -.08 .01 Infant Complications Maternal Health Status -.12 -.15 - -.15 .03 Infant Complications, MD Recommendation -.04 .20 .03 .23 .21 Infant Complications, P a r i t y -.11 -.16 .09 -.07 .04 Infant Complications, Culture -.04 -.05 - -.05 .01 Current Attendance, MD Recommendation .49 .42 - .42 .07 Maternal Health Status, Current Attendance -.15 - -.12 - .12 .03 Maternal Health Status, P a r i t y -.03 .04 - - .04 .01 Maternal Health Status Culture .11 -.08 -.05 -.13 .02 MD Recommendation, Pa r i t y .58 .56 - .56 .02 MD Recommendation, Culture .23 .12 .10 .22 .01 P a r i t y Culture .17 .17 - .17 78 The path c o e f f i c i e n t s i n Table 24 indicate that most of the v a r i a t i o n i n the outcome measure i s explained by physician recommendation to attend prenatal classes ( t o t a l causal e f f e c t s = -.23) and presence of maternal health problems ( t o t a l causal e f f e c t s = -.15). The manner i n which these two variables operate to predict 3% of the absence of infant complications i s not explained by the path model. How the presence of maternal health problems and a physician's recommendation to attend classes might correlate with absence of infant complications i s not c l e a r . Any possible explanation confirmed by the evidence that attendance at classes i n turn, negatively influences absence of infant complications. Class attendance i s seen to a f f e c t "presence" of infant complications i n a minor way. O v e r a l l , both current attendance and c u l t u r a l background were not strong predictors of t h i s outcome. M u l t i p a r i t y as a v a r i a b l e , unmediated by other v a r i a b l e s , appears to have a f a i r l y strong connection with the absence of infant complications ( d i r e c t e f f e c t s = -.16) but when modified by the other s p e c i f i e d v a r i a b l e s , e.g. class attendance and maternal health status ( i n d i r e c t e f f e c t s = .09) i t s e f f e c t on the outcome i s considerably weakened ( t o t a l causal e f f e c t s = -.07). C l e a r l y there are important variables missing i n the causal chain outlined by t h i s path model. Not only did the variables included i n the model explain only a small proportion of the v a r i a t i o n i n the "infant li complications outcome measure, but the s p e c i f i e d p r e d i c t i v e v a r i a b l e s themselves were only minimally explained by the other variables i n the model, as shown i n Figure 22. A more i n c l u s i v e model which would involve a d d i t i o n a l intermediate factors, such as, socio-economic status, n u t r i t i o n a l status, age, frequency of contact with physician, length of gestation and use of drugs during pregnancy might be more meaningful i n i t s p r e d i c t i o n of infant complications. Such a model might c l a r i f y how i t i s that the absence of infant complications i s influenced by various f a c t o r s . It might explain the discrepancies i n linkages between variables as were seen i n the model as i t stands now. How class attendance might r e l a t e to presence of infant complications whereas physician recommendation to attend classes are not explained by the path model, for instance. Within the l i m i t s of v a r i a b l e s used, however, i t i s c l e a r that prenatal class attendance had no appreciable e f f e c t on the outcome "infant complications". A t h i r d path model i s located i n Appendix N. This model u t i l i z e s "use of labour breathing techniques "as the dependent v a r i a b l e " and "Ever attendance" as one of the set of predictors. 80 END NOTES 1Baby's Best Chance (1979) and P e r i n a t a l Fitness Manual (1980) are two B.C. M i n i s t r y of Health publications a v a i l a b l e free of charge to a l l pregnant women i n B.C. through l o c a l health u n i t s . ^"Professional Sources" i s defined, for purposes of Tables 14 to 19, to include physicians, nurses, prenatal class teachers, and public health nurses. 3"0ther Sources" i s defined, for purposes of Tables 14 to 19, to include readings, media presentations, r e l a t i v e s and friends and personal experience. ^Herbert B. Ahser, "Causal Modeling," Quantitative Applications i n  So c i a l Sciences 3 (1976): 34, 32. 81 CHAPTER IV SELECTED FINDINGS RELEVANT TO PRENATAL EDUCATORS The questionnaire used i n th i s study was devised not only to survey responses relevant to the stated study objectives but, also to gain broader insight into the effectiveness of prenatal classes and other sources of "learning" for pregnant women. It i s assumed that those involved i n prenatal education, whether public health nurses or others, would be interested i n knowing, for instance: Which subject areas are most discussed by (of i n t e r e s t to?) women during pregnancy? What do they report as t h e i r reasons for attending or not attending prenatal classes? What did they like/not l i k e about going to classes? - Did they f i n d sources of information, other than prenatal classes, helpful? How did these information sources compare with prenatal classes? On the following pages are the summarized findings to the above questions. 82 Subjects Women Talked About During Their Pregnancy Study p a r t i c i p a n t s were asked to describe what they talked about with t h e i r r e l a t i v e s , friends, physicians, etc., during t h e i r pregnancy. One hundred and sixty-three women responded to the question. The women's topics of discussion were categorized into f i v e subject areas. Each i s l i s t e d i n Table 25 along with the percentage of respondents admitting to having shared discussion, concerns and feelings within that general subject area. TABLE 25 SUBJECTS TALKED ABOUT DURING PREGNANCY Subject Area % Respondents Prenatal Care 65% Mental State 42% Personal, Family Adjustments 33% Labour, Delivery 30% Infant Care 28% n = 163 Prenatal care discussion focussed on p r a c t i c a l issues, such as, dealing with pregnancy-related discomforts, e.g. morning sickness; sex during pregnancy; d i e t , exercise and alcohol intake i n pregnancy. A number of women (42%) talked about t h e i r anxieties, apparently, but there were few s p e c i f i c examples given of these. Some did mention having r e a l fears about the p o s s i b i l i t y of deformity i n t h e i r developing infants. It i s i n t e r e s t i n g to note that much fewer than 50% of the respondents appeared to dwell on the personal/family adjustments to be made with the arrival of a new child (33%) and on the actual care of the baby (28%). By and large i t seems that subjects related to the pregnancy period, i t s e l f , are what captured the interest of most of the respondents rather than events related to the postpartum period of time. Sources of Information Most Important To Study Participants Tables 44 to 49 in Appendix K describe in cross-tabular form the importance of various sources of information to responders. Table 26 provides a summary of this data in terms of current prenatal class attenders and non-attenders. It is interesting to note that only 22% of attenders considered prenatal classes as a main source of information on pregnancy. They, as a group, rated both individual professionals and reading/media sources more highly as providers of useful information. Even fewer attenders (11%) considered classes to be a good source of childcare information. For learning about labour and delivery, attenders rated prenatal classes highest in usefulness among the various sources named. 84 TABLE 26 MAIN SOURCES OF INFORMATION IN PREGNANCY BY CURRENT ATTENDANCE Pregnancy Labour/Childbirth Childcare Information Information Information Attendance Attendance Attendance Information (%) (%) (Z) Sources Yes No Yes No Yes No Prenatal Classes 22 6 34.3 0 11 0 Individual Professionals 26 21 17.4 14 14 9 Readings/Media 29 28 20.2 22 27 22 Partner/Relatives/Friends 15 20 16.3 19 29 20 Personal Experience 7 24 8.4 33 15 33 Other 1 2 3.4 12 4 6 100% 100% 100% 100% 100% 100% (n = 169) (n - 165) (n = 165) Usefulness of the media or of reading materials did not appear to vary by the class attendance factor. They rated highest as source s of information about pregnancy. Personal experience as a major source of information for non-attenders of classes i s assumed to be so, because the majority of non-attenders are multiparas with experience of previous pregnancies. Friends and r e l a t i v e s appear to be the favourite source of childcare information for cla s s attenders. Reasons for Attending Prenatal Classes Current prenatal class attenders were asked to l i s t up to four reasons for attending classes and then to i d e n t i f y the main reason. From a t o t a l of 99 women attending classes, 89 presented one reason for attendance, 70 presented two reasons, 35 presented three and seven presented four reasons. The majority of attenders acknowledged one or two motives, only, for p a r t i c i p a t i o n i n classes. The main reasons for attendance at classes are shown i n Table 27. TABLE 27 MAIN REASONS FOR PRENATAL CLASS ATTENDANCE % of Responding Reasons Attenders Labour/Delivery Preparation 48 Overall Knowledge Gain 21 Healthy Pregnancy/Infant 14 Newborn Care and Information 0 Involvement of Husband/Partner 10 Sharing With/Support of Other Attenders 0 Other 7 100% n = 89 From examining Table 27 i t appears that p r a c t i c a l information and knowledge gain were the primary motives for class attendance. Review of a l l the reasons c i t e d for attendance revealed that 57% of class p a r t i c i p a n t s went to classes for information and knowledge gain alone, 2% went for personal-social reasons, alone, and 41% went for a combination of reasons, i . e . , knowledge and personal-social. 86 Main Reasons for not Attending Prenatal Classes The reasons given why prenatal classes were not attended are summarized i n Table 28. TABLE 28 MAIN REASONS FOR NON-ATTENDANCE % of Reasons Non-At tenders P o s i t i v e Previous Class Experience 39 P r a c t i c a l Problems 20 Negative Previous Class Experience 5 Pregnancy and B i r t h a Natural Process 5 Reading Provided Information 1 Other 30 100% n = 77 By and large, i t seems that a good proportion of current non-attenders (39%) f e l t that they had had a previous good experience with prenatal classes and that what was learned, then, would stand them i n good stead with this l a t e s t pregnancy. A good number (20%), also, stated p r a c t i c a l problems to be the main deterrent to attendance. Examples of responses were: "working long hours - own business" " l i v e out of c i t y " "I a c t i v e l y t r i e d to get a refresher going but health nurse and others couldn't f i n d a convenient time" "too far away from home" "babysitting arrangements" Negative reaction to experience with previous class attendance were few. Example responses were: "the movie turned me away" "attended once previously. Can't simulate labour pains r e a l i s t i c a l l y i n classes. Emphasized labour wasn't bad as a l l that and i t was!" A v a r i e t y of the reasons given for not attending classes were not e a s i l y categorized into the arranged codes. These were termed "other". They are of in t e r e s t as they r e f l e c t a high portion of the t o t a l main reasons given by respondents. Some are l i s t e d below: " f e l t I didn't need to go" "previous experience with pregnancy and labour" "my husband wouldn't attend along with me" "had an easy labour f i r s t time" "expected to have a caesarian section" "was i n touch with doctor, maternity and public health nurses through my work" "practised at home on my own. Informed myself p r i v a t e l y " Month of Pregnancy That Classes Were Begun Pregnant women are encouraged by health units to begin prenatal class attendance during t h e i r f i r s t trimester of pregnancy; p a r t i c u l a r l y primiparous women. Women wanting only to p a r t i c i p a t e i n refresher courses which concentrate on labour preparation do usually r e g i s t e r somewhat l a t e r i n pregnancy. The data show, however, that the bulk of class attenders (at least 82%) were s t a r t i n g attendance beyond the f i r s t trimester even though 67% of attenders were primiparas only 18% of the attenders began t h e i r attendance during the f i r s t three months of pregnancy. What Attenders Thought They Learned i n Class Table 29 d e t a i l s an array of subject areas that were t y p i c a l l y discussed i n a f u l l series of prenatal classes. The abbreviated refresher classes, i t must be noted, do not usually handle a l i s t of subjects as comprehensive as t h i s one. Class attending mothers were asked i f they learned anything about the topics l i s t e d i n Table 29. Their were responses are given i n the table. One can see that more than h a l f of the attenders claimed to have learned something new concerning exercise, labour (breathing techniques, process, h o s p i t a l procedures), and managing the discomforts of pregnancy. Seventy-three percent, also, f e l t they had learned something from having had t h e i r s p e c i f i c questions answered. The l a t t e r i s one f a i r measure of l e v e l of s a t i s f a c t i o n with the classes. 89 TABLE 29 DID YOU LEARN ANYTHING NEW ABOUT ? Topics Learned Something New Didn't Learn Something New Not Covered i n Classes I Attended No Response Diet Exercise Labour Breathing Techniques Managing Pregnancy Discomforts Adjustment to Changes in Marriage Because of Pregnancy Sexual Adjustment Because of Pregnancy Adjustment for Fathers Changes i n L i f e After Pregnancy Labour Process Hospital Procedures - Labour Caesarian Section Family Planning Infant Feeding Other Infant Care Answers to One's Questions 36 57 84 52 28 24 45 42 71 73 62 20 44 43 72 47 33 8 29 33 41 25 34 19 14 18 46 38 31 8 8 3 11 26 25 18 14 1 6 10 26 9 16 6 n = 99 12 9 11 9 8 7 9 7 8 19 13 The subject of d i e t or n u t r i t i o n rates high i n importance to the prenatal c l a s s teacher. This study finds, however, that far less than h a l f 90 of the attenders (36%) thought they had learned anything new about n u t r i t i o n . What Attenders Liked About Classes Class attenders of th i s study were given an opportunity to explain what i t was they l i k e d most about classes or about going to classes. Table 30 explains the findings. TABLE 30 WHAT ATTENDERS LIKED MOST ABOUT CLASSES Areas of Interest Meeting Others Labour Preparation Overall Knowledge Partner Involvment Info on L i f e s t y l e , Pregnancy Infant Development Info on Newborn Care Other No Mothers Mentioning Interest 44 36 12 12 6 1 39 n = 99 (15 non-responses) Meeting other attenders was not given as one of the main reasons for class attendance but one sees here that a good number of women benefited from the s o c i a l aspect of class attendance. Preparation for labour was not s u r p r i s i n g l y one of the better l i k e d aspects of the classes. However, having 36% of the attenders say they l i k e d t h i s part of classes may not be so reassuring when we remember that 91 48% c i t e d labour preparation to be t h e i r main reason for attending classes (Table 27). Evidently the codes chosen for the responses to th i s question of "what was l i k e d " were not adequate for the responses given. A great many responses had to be c l a s s i f i e d "other", therefore. Examples from this category are as follows: "the nurse ws very f r i e n d l y and easy to ta l k to" "discussing problems" "able to ask questions and f e e l able to obtain knowledgeable answers" "my husband and I r e a l l y enjoyed the f i l m s . . . . " "reading materials supplied" "I l i k e d everything about the classes e s p e c i a l l y the good movies and pamphlets" "teacher gave ••• a balanced view" "I enjoyed i t when a month old baby came for a v i s i t at the c l a s s " "the relaxed atmosphere and the in s t r u c t o r ' s a b i l i t y to make i t seem as i f we were the only people having a baby. She generated excitement about the baby expected" A great many of the responses i n the "other" category r e f e r r e d to the teacher's behaviour i n the prenatal classes. What Attenders Did Not Like About Classes Almost h a l f of the attenders stated there were some aspects of prenatal classes that were not appreciated. Features of class content were the greatest source of c r i t i c i s m , with class s t y l e the second most. 92 Following are some examples of complaints about class content: "too much time spent on exercises none of which were of any use to me during labour" "we had twins and there was no information to help us with our questions" "too much time on labour and breathing" "needed more time on care of newborn" "didn't pick up much new information" "films ok but got too emotional" "the films went into a l o t of d e t a i l . Caesarian section r e a l l y upset me I I TABLE 31 WHAT ATTENDERS DID NOT LIKE ABOUT CLASSES Things Not Liked No. Mothers Responding Class Content Class Style Inconvenience Content and Style Content and Inconvenience Content, Style and Inconvenience 20 13 3 7 1 _1 45 (n = 99) (54 non-respondents) 93 Concern about classroom s t y l e included: "public health nurse came on very strong sometimes regarding d i e t , e t c . " "there was one lady that had a C-section (and several miscarriages) before and she continued to talk about them through the whole class which was quite discouraging" "less questions and answers and more structured discussion" "too large - 26 couples" "teacher's s t y l e . There because she had to be there?" Inconvenience about classes' scheduling, distance, etc., was not apparently a problem to most class attenders. Three examples of perceived inconvenience are: "inconvenience of the time. Too l a t e , too long" "I would l i k e to see a babysitter for the older c h i l d r e n ••• for mothers to come the second time" "held too lat e at night" Although the findings described i n t h i s chapter do not d i r e c t l y pertain to the three study objectives, they should nonetheless be an in t e r e s t to prenatal educators. There was, for instance, for many of t h i s study's class attenders the seemingly unexpected p o s i t i v e experience of meeting other expectant couples through class attendance. Communication with others sharing a s i m i l a r experience appeared, i n fact to be the aspect of class attendance most appreciated. Prenatal classes, however, were clearly not the sole nor necessari most important source of information during pregnancy. Classes were pronounced very useful as a means of learning about labour and delivery but competed unfavourably with individual health professional support and reading/media information sources for others learning about the pregnancy and postpartum experience. 95 CHAPTER V  CONCLUSIONS Commentary on Main Results The meeting of Objectives I, II and III helps one to comment on and to make conclusions about the study hypotheses. The hypotheses state: 1 . PRENATAL CLASS ATTENDANCE WILL AFFECT AND BE AFFECTED BY THE LEVEL OF KNOWLEDGE, HEALTH BEHAVIOUR, AND HEALTH STATUS OF MOTHERS. 2. THERE ARE SELECTION FACTORS WHICH INCLUDE HEALTH, EDUCATIONAL AND SOCIAL CHARACTERISTICS OF WOMEN THAT CAN BE USED TO PREDICT WHICH TYPE OF EXPECTANT WOMAN WOULD MOST BENEFIT FROM PRENATAL CLASS ATTENDANCE. The f i r s t hypothesis states that attendance w i l l be predicted/affected by the health knowledge, behaviour and health status of mothers. This is not generally supported by the study results. Attendance was more associated with the socio-cultural characteristics of mothers than by the above. Parity and maternal health status were the exceptions. Primiparity and presence of maternal health problems were somewhat predictive of prenatal class attendance. The strongest predictor of prenatal class attendance was the active presence of the physician in a woman's support system. Both frequent physician v i s i t s and a physician's recommendation to attend classes correlated strongly with class attendance. 96 Did class attendance predict or a f f e c t c e r t a i n health outcomes? Of the associations seen between attendance and outcomes, a number showed to be negative. Attendance, e.g., was associated with complicated b i r t h mode, infant complications and maternal complications. Objective II findings, however, showed some rel a t i o n s h i p s between class attendance and p o s i t i v e outcomes. Attendance was seen to weakly l i n k to knowledge of d i e t i n pregnancy, knowledge about pregnancy, knowledge about breastfeeding, regular v i s i t s to the physician, use of labour breathing techniques, less smoking postpartum and larger birthweights. No differences were noted between cla s s attenders and non-attenders i n terms of o v e r a l l health-related knowledge and behaviour, however. Neither were there patterns, d i s c e r n i b l e , connecting le v e l s of knowledge with s p e c i f i c a l l y related behaviours. With regard to health behaviours, themselves, changes over a time period, i . e . , from pre-pregnancy to post-pregnancy were not seen. There was no c o r r e l a t i o n a l support to indicate that l e v e l s of pre-pregnancy behaviour, e.g., mother's d i e t , had changed during pregnancy and post-pregnancy as a r e s u l t of prenatal c l a s s attendance. A mother's sense of control over her own health was assumed to be p r e d i c t i v e of a health behaviour, such as prenatal class attendance; the mother with a strong locus of control being one to take actions, such as, attending classes, reading books, etc. Locus of control, as measured by the study questionnaire, however, was found to be no d i f f e r e n t for cl a s s attenders than for non-attenders. Limited support for the second hypothesis comes from the data analysis conducted i n r e l a t i o n s h i p to Objectives II and I I I . It was seen, for 97 instance, that current attenders who were primiparous, were of a minority ethnic background and had a higher education seemed more associated with use of s p e c i f i c learned breathing techniques during labour. It was the women who were multiparous, of minority ethnic background and had an average education, however, who appeared to most benefit from attendance i n terms of use of labour breathing techniques (Figures 6 to' 9). Infant birthweight over 3000 grams i s another possible measure of benefit. There was a trend for those women who were multiparous, of minority group status, under 20 years or over 29 years old, and who had an average education to gain the most from class attendance (Figures 17 to 20). With regard to these just described outcomes - use of labour breathing techniques and infant birthweight - one gains a picture of a few of the sel e c t i o n factors that might predict who benefits from classes. It i s not known i f p a r i t y , e t h n i c i t y , age and education of mothers are c h a r a c t e r i s t i c s that could predict benefit i n terms of other outcomes. Data i n Tables 22 and 23 provide some of the support for the hypothesis that there are some s e l e c t i o n factors determinant of benefit from prenatal classes. In terms of breastfeeding, e.g., i t i s shown that respondents who were older, married, highly educated, and had ever attended classes were associated with breastfeeding t h e i r infants. Some benefit seems to drive from attendance at classes. The factors, education and age i n t h i s instance, however, are more strongly associated with breastfeeding pr a c t i s e than i s prenatal class attendance. Over a l l , the hypotheses have not been well-supported by the study findings, p a r t i c u l a r l y with concern to i d e n t i f y i n g the type of expectant 98 women who might gain broad benefit from attending prenatal classes. In examining a wide spectrum of outcome measures related to health knowledge, health behaviour and health status, the majority lacked any s i g n i f i c a n t a ssociation with c l a s s attendance or with s e l e c t i o n factors. Commentary on Other Findings Chapter IV includes study r e s u l t s which are found to be outside the realm of the three study objectives. Although not a program (prenatal class) evaluation study, some of Chapter I V s findings constitute evaluative comment by class attenders. The l a t t e r were given the opportunity to provide opinion on how they valued prenatal classes. This was discussed i n terms of t h e i r main reasons for attending classes, what i t was they thought they had learned i n classes, what they most l i k e d about going to classes and what other sources of pregnancy-related learning they u t i l i z e d . There i s some i n d i c a t i o n of consistency between the reasons given for prenatal class attendance and the actual subjects learned about i n classes. Labour/Delivery preparation, for instance, was the most frequently mentioned main reason for class attendance (Table 27) with labour-related class content (labour proess, breathing techniques, h o s p i t a l procedures, caeserian section) c o n s t i t u t i n g the subject learned about by more women than any other subject (Table 29). It should be remembered that any claims of learning by class attenders were not borne out by the forced-choice knowledge questions of the questionnaire. The l a t t e r , however, were not s u f f i c i e n t l y d e t a i l e d or s p e c i f i c to be regarded as a test s i t u a t i o n for evaluating whether actual learning had taken place i n r e l a t i o n to the topics l i s t e d i n Table 29. Interestingly, as a reason for attending prenatal classes, the sharing with and receiving support from other class attenders, rated low compared to other reasons given. As discussed e a r l i e r , when one examines what i t was that was l i k e d most about going to classes one sees that more attenders c i t e d the meeting of other class attenders as the aspect most l i k e d about classes (Table 30). This i l l u s t r a t e s that there are perhaps unforeseen or unplanned benefits derived from class attendance. Labour preparation ran a close second to the meeting of other attenders, as an aspect l i k e d about classes. This was fortunate as labour preparation was the main reason given for attending classes for most of this study's attenders. Learning about the newborn and his/her care appeared to be the least appreciated part of c l a s s attendance. Across the board, from reasons for attendance, to what i t was women thought they had learned, to what i t was they l i k e d the most about classes, the "newborn" as a subject did not rate highly with the majority of attenders. Noticeable i n the responses given regarding subject matter talked about during pregnancy, i s the fact that a moderate number discussed t h e i r emotional state and the adjustments to pregnancy and l i f e a f t e r pregnancy faced by themselves and t h e i r families (Table 25) one finds, though that for the majority of attenders, classes did not provide a p o s i t i v e mileau for learning about making adjustments as a r e s u l t of pregnancy (Table 29). Table 26 provides some s i g n i f i c a n t insights into how classes are rated alongside other sources of information, i n terms of usefulness. I t i s only 100 with regard to l a b o u r / c h i l d b i r t h information that classes were rated more highly, o v e r a l l , than other sources of information. Individual professionals, e.g., physicians and nurses, and books, pamphlets and the media were more valued as providers of pregnancy information. For childcare information, prenatal classes rated p a r t i c u l a r l y low as a source of information. Given that none of the attenders claimed learning about childcare to be a main reason for attendance, perhaps this finding i s not as s i g n i f i c a n t as the previous two just mentioned. For prenatal educators i t w i l l be g r a t i f y i n g to see that the non-attending study respondents said that having had a p o s i t i v e previous class experience was what made a repeat attendance seem unnecessary to them (Table 28). Very few stated a previous negative experience with classes to be a reason for current non-attendance. P r a c t i c a l problems, a category of reasons for non-attendance, stood prominant among a f a i r portion (20%) of the non-attenders as a cause for not attending classes. Examples of what was not l i k e d about classes are also given i n Chapter IV. As in t e r e s t i n g as some of the responses given by attenders are, i t i s just as noteworthy to r e a l i z e that over 50% of the attenders did not explain t h e i r d i f f i c u l t i e s with the classes (Table 31). The data i n Table 29 shows that most attenders had learned nothing new abut many of the pregnancy-related subjects l i s t e d . The response by attenders to the question of what was not l i k e d about classes, thus, was probably not as complete as i t could have been. 101 Implications of Results for  Prenatal Educators Findings from the study cannot l e g i t i m a t e l y be generalized to beyond the study population. Having tested for sample bias, however, and finding i t to be minimal i n terms of a number of mother/infant c h a r a c t e r i s t i c s (Tables 1 to 4), implications of the study r e s u l t s are probably safely generalized to mothers i n B.C. The information obtained i n th i s study can hopefully be used to help i n the planning, teaching and outreach e f f o r t s associated with prenatal classes. The factors found to correlate with a decision to attend prenatal classes give educators an i n d i c a t i o n of who i s not attending classes. Although findings do not e s t a b l i s h causal l i n k s they lend some basis for greater outreach e f f o r t s that might be focussed upon women who are multiparous, have weak s o c i a l support systems, are of ethnic minority group status, are unmarried and have had fewer years of schooling. Physicians appear to have some influence i n promoting prenatal class attendance p a r t i c u l a r l y with western born primiparas. Attendance might become more broad-based, to include multiparas and ethnic minority groups, i f physicians can be encouraged to foster class p a r t i c i p a t i o n by these women. Educators, themselves, need to recognize that often the classes they advertise do not spark the inte r e s t of the t y p i c a l non-attenders. Although the socio-economic and health c h a r a c t e r i s t i c s of these women are not for educators to modify, these women may see prenatal classes as relevant to thei r needs i f they f e l t confident that the classes were not "white and middle c l a s s " i n or i e n t a t i o n . Seeing advertisements i n th e i r ethnic 102 newspapers and knowing that t r a n s l a t i o n s of readings are a v a i l a b l e , for example, may assure some women that e f f o r t s to include them are serious. Actions along these l i n e s are already being made i n the urban areas of the province and deserve to be t r i e d i n less populated areas, such as, i s often being c a r r i e d out with teenaged pregnant g i r l s , already. With a clear majority of the study's class attenders not s t a r t i n g attendance u n t i l a f t e r t h e i r f i r s t trimester of pregnancy, educators and physicians need to stress the importance of early attendance i n t h e i r promotional e f f o r t s , i f t h i s i s indeed a worthy goal. Both attenders and non-attenders admitted to some p r a c t i c a l problems associated with class attendance. Educators need to be aware of the p r a c t i c a l impediments to attendance for mothers i n t h e i r communities and need to be f l e x i b l e i n dealing with them. Attention may need to be paid to finding alternate times for classes, e.g., not just i n the evenings. Distance r u r a l women/couples may f i n d i t possible only to attend a cl a s s on an afternoon for instance. Despite the fact that t h i s study provides no proof of the effectiveness of classes i n terms of causing changes i n health knowledge, behaviour and status some associations between attendance and benefit were i d e n t i f i e d as described in Chapter III and the early part of t h i s chapter. In a number of s i t u a t i o n s the attendance factor seemed to play a secondary role to personal s o c i o - c u l t u r a l c h a r a t e r i s t i c s but nonetheless appeared to be somewhat p r e d i c t i v e , i t s e l f , of benef i t . In general, however, i t must be emphasized that c l i e n t attendance played only a minor part i n health-rel a t e d outcomes. i 103 Prenatal teachers would do well, though to r e c a l l some of the negative r e l a t i o n s h i p s found to e x i s t between class attendance and labour/birth-related complications. A c a r e f u l review of what i s a c t u a l l y taught about labour and de l i v e r y , and how i t i s discussed with class p a r t i c i p a n t s seems advisable. The findings imply the p o s s i b l i t y of increased anxiety about labour among class p a r t i c i p a n t s . That attenders did speak about concerns with both class content (Tables 26, 29, 31) and s t y l e of teaching (Table 31) makes i t c l e a r that teachers must e l i c i t constant feedbak from t h e i r class members about these areas. Suggestions for Future Research Although t h i s study has i t s strength c h i e f l y as a de s c r i p t i v e survey of possible predictors of health outcome benefits, i t has a number of f a u l t s . The study's shortcoming are that i t : 1. was retrospective rather than prospective 2. r e l i e d mainly on s e l f - r e p o r t i n g by study p a r t i c i p a n t s . Accuracy of par t i c i p a n t s r e c a l l and o b j e c t i v i t y of responses were not confirmed 3. u t i l i z e d a non-experimental design 4. had hypotheses which were too broad 5. t r i e d to examine too many outcomes 6. did not control adequately, for a l l the variables p o t e n t i a l l y e f f e c t i n g outcomes 7. did not adequately v a l i d a t e the questionnaire As well, the theory underlying "causal processes" between class attendance, s e l e c t i o n factors and varoius health-related outcomes were not c l a r i f i e d . The study's basic aim has been to find out who would most benefit from prenatal classes i n terms of c e r t a i n health outcomes. This a c t u a l l y translates into an attempt to find the best "causes" of health outcome. The study as i t was conducted was unable to achieve t h i s . One reason for t h i s may be that very possibly the wrong outcome measures were used, e.g., birthweight. It i s probably very dubious that class attendance would have any e f f e c t on birthweight, for instance. Some suggestions for future research projects are: 1. to conduct a quasi-experimental prospective study of pregnant women taking some baseline measures of t h e i r health knowledge, behaviour and status before a decision to attend or not to attend classes i s made. Socio-economic c h a r a c t e r i s t i c s would be measured at the s t a r t as w e l l . A true experimental study i s impractical. 2. to develop c l e a r e r , more r e l i a b l e measures of independent and dependent v a r i a b l e s , i . e . , less r e l i a n c e on s e l f - r e p o r t i n g . Study par t i c i p a n t s could be tested for knowledge of various stages, e.g., pre-attendance, during attendance and post-partum. Maternal health status, e.g., could be measured p a r t l y as reported by the p a r t i c i p a n t and p a r t l y as reported by her physician. Class attendance, i t s e l f , could be defined more p r e c i s e l y during analysis, i n terms of s p e c i f i c content covered i n the classes attended. Actual number of classes attended i s probably meaningless as a v a r i a b l e without knowing the type of content addressed i n the classes attended. to narrow the hypothesis focus to one or two ben e f i t s . One could l i m i t the outcome focus for instance, to health knowledge and health behaviour as i t re l a t e s to e.g., breastfeeding. An assessment of health knowledge and behaviour change would be a p r a c t i c a l focus as these are areas more amenable to cla s s i n s t r u c t i o n , to conduct a more extensive p i l o t study for the purpose of better testing the r e l i a b i l i t y of the questionnaire as a t o o l , as well as, i t s s e n s i t i v i t y , and a c c e p t a b i l i t y to a study sample, to attempt to root out the causal process between independent variables and the dependent va r i a b l e by more extensively using the path analysis technique. To elucidate more c a r e f u l l y the possible factors associated with the dependent v a r i a b l e through more extensive and concentrated l i t e r a t u r e review. 1 0 6 BIBLIOGRAPHY Adams, Lee. "Consumers' Views of Antenatal Education." Health Education  Journal 41 (1982): 12 - 16. Andrews, Frank M.; Klem, L.; Davidson, T.N.; O'Malley, P.M.; and Rodgers, W.L. 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Diss., UBC, 1977. 1 0 9 APPENDIX A SAMPLE BIRTH NOTICE D o n o t u s e Province of British Columbia MINISTRY O F H E A L T H -DIVISION O F V I T A L STATISTICS P H Y S I C I A N ' S N O T I C E O F A L I V E B I R T H O R S T I L L B I R T H Do not use NAME OF FATHER ( S u r n a m e ) ( G i v e n n a m e s ) If parents legally married to each other, is father non Indian Q or registered Indian Q NAME OF MOTHER ( M a i d e n s u r n a m e ) ( G i v e n n a m e s ) AGE If parents not legally married to each other, is mother non Indian Q or registered Indian Q PERMANENT ADDRESS OF MOTHER ( H o u s e N o . ) ( S t r e e t ) ( C i t y o r M u n i c i p a l i t y ) Postal Code Was child born alive? • Yes DNO PLACE OF BIRTH ( N a m e o f I n s t i t u t i o n ) ( L o c a t i o n ) Office Use Only DATE OF BIRTH D a y M o n t h a . m . p . m . 19 Male Female • • A p g a r S c o r e a t * 1 m i n . 5 m i n . Single Twin Triplets • • • BIRTH WEIGHT Gestation period Total pregnancies Total live births Total stillbirths Total abortions (Spont. & induced) What special measures (if any) were taken to promote respiration? If stillborn, did death occur before labour during labour • • Mode of delivery: Spontaneous Forceps vertex vertex Breech • - • • Caesarean 1st 2 n d + • • Other operative procedure (specify): Abnormality (major or minor) or pathology of infant: No • If yes, describe: If yes. No describe:. • Complications of pregnancy, labour or delivery: P h y s i c i a n ' s s i g n a t u r e P h y s i c i a n ' s a d d r e s s D a t e : PLEASE REMO VE CARBON BEFORE MAILING FORM V . S . 3 APPENDIX B STUDY QUESTIONNAIRE I l l APPENDIX B(a) QUESTIONNAIRE: EXPLANATION & INSTRUCTIONS 1. Unless i t i s stated otherwise, the questions r e f e r to your experiences with your l a s t pregnancy. 2. Answer each question from your own experience. There are no r i g h t or wrong answers. 3. Where there are blanks ( ) written next to possible answers, please use a check(s) for your answer(s). 4. Please take note that i n the middle of the questionnaire there i s a separate set of questions for women who have attended any kind of prenatal classes (14 to 31), and another set of questions for women who have not attended prenatal classes 32 to 39). APPENDIX B(b) NOTICE FOR SUBJECTS RECEIVING  MAILED QUESTIONNAIRE THIS IS AN IMPORTANT PIECE  OF INFORMATION. IF THE PERSON TO WHOM THIS IS ADDRESSED DOES NOT READ ENGLISH, PLEASE FIND SOMEONE WHO DOES READ ENGLISH TO HELP HER COMPLETE THE ANSWERS TO THE QUESTIONS APPENDIX B(b)  NOTICE FOR SUBJECTS BEING INTERVIEWED THIS IS AN IMPORTANT PIECE  OF INFORMATION. IF THE PERSON TO WHOM THIS IS ADDRESSED DOES NOT READ OR SPEAK ENGLISH, PLEASE PHONE ME (OR LEAVE A MESSAGE) at 228-6765 BETWEEN 8:30 A.M. AND 4:30 P.M. THANK YOU. MARY SPOKE 114 No: APPENDIX B(d) QUESTIONNAIRE Questions 1 to 55 w i l l mainly be about the time during your pregnancy 1. On what date was your baby born? Day Month Year 2. Including t h i s past pregnancy, how many pregnancies altogether, have you completed? 3. Who did you talk with (share your f e e l i n g s and concerns with) the most during your pregnancy? Give r e l a t i o n s h i p to you (for example, husband, mother, physician, f r i e n d , public health nurse, neighbour), not name(s). 4. What did you talk about with the person(s) l i s t e d i n question 3? 5. Women get information on how to care for themselves during pregnancy from many sources. Which of the following sources of information did you use during your pregnancy? (Check a l l you used.) Husband Relative (other than husband) Friend/neighbour Doctor Doctor's o f f i c e nurse Prenatal classes Public Health Nurse Reading material from doctor and/or health unit Other reading material (e.g., books, magazines) T.V. and radio Previous peronal experience Other (specify) Please go back and c i r c l e the two sources of information that were most h e l p f u l to you. 1 Women get information on labour and c h i l d b i r t h (regular and Caesarean section) from many sources. Which of the following sources of information did you use during your pregnancy? (Check a l l you used.) Husband Relative (other than husband) Friend/neighbour Doctor Doctor's o f f i c e nurse Prenatal classes Public Health Nurse Reading material from doctor and/or health unit Other reading material (e.g., books, magazines) T.V. and radio Hospital tour Previous peronal experience Other (specify) Please go back and c i r c l e the two sources of information that were most h e l p f u l to you. Women get information on c h i l d care from many sources. Which of the following sources of information did you use during your pregnancy? (Check a l l you used.) Husband Relative (other than husband) Friend/neighbour Doctor Doctor's o f f i c e nurse Prenatal classes Public Health Nurse Reading material from doctor and/or health unit Other reading material (e.g., books, magazines) T.V. and radio Previous peronal experience Other (specify) Please go back and c i r c l e the two sources of information that were most h e l p f u l to you. 116 8. Did you see a doctor about your pregnancy any time before your delivery? Yes No 9. In which month of your pregnancy did you f i r s t see a doctor about your pregnancy? 10. How often did you v i s i t a doctor during your pregnancy? 11. During your pregnancy were you being treated for any health problem (for example, diabetes, high blood pressure, depression)? No Yes Specify 12. Did your doctor say anything about prenatal classes? He did not mention classes He recommended that I attend classes He recommended that I not attend classes Other (specify) 13. Did you attend any prenatal classes during t h i s past pregnancy? No Yes I f "yes", continue to question 14. If "no", skip to question 32 14. Which classes did you attend? classes given by a p r o v i n c i a l Public Health Unit other classes (specify) 15. How did you hear about the classes you attended? 117 16. Did any person(s), other than a doctor, a c t u a l l y encourage you to attend classes? No Yes I f "yes", answer to question 17. 17. Who or what encouraged you ( r e l a t i o n s h i p to you, not name)? C i r c l e the person or thing that was most important i n getting you to attend classes. 18. Have you ever attended prenatal classes before? No Yes If yes, when (year)? I f "no", answer to question 19. 19. Did you personally know anyone who attended classes before you decided to attend classes? No Yes Specify: 20. People have d i f f e r e n t reasons for attending prenatal classes. Would you t e l l me your s p e c i f i c reasons for attending classes? L i s t up to four reasons. Check ( ) the main reason i f there i s more than one reason. 21. In what month (e.g., t h i r d month) of pregnancy did you begin to attend prenatal classes? 118 22. Some classes are s p l i t into two series (for example, an E a r l y B i r d or Head Start series i n early pregnancy, followed by a Labour Preparation series i n l a t e r pregnancy). Other classes are offered as one series of classes. Please check the type of series you attended and indicate the number of classes you a c t u a l l y attended. One series c l a s s e s : I attended out of classes Two series c l a s s e s : 1st s e r i e s : I attended out of classes 2nd s e r i e s : I attended out of classes If you did not attend a l l of the classes i n your s e r i e s , please answer question 23. 23. What were your reasons for missing some classes? 24. 25. Did your husband/partner attend any classes with you? No Yes Did someone close to you other than a husband/partner ( f o r example, mother, g i r l f r i e n d ) attend classes with you? No Yes 26. Did you learn anything new about the following things from the lectures and discussion i n classes? Please place checks i n the appropriate columns. Did not Learned learn something anything new new Was not covered i n the classes I attended Eating a balanced d i e t during pregnancy Exercise during pregnancy Breathing/relaxation techniques for labour Managing common discomforts of pregnancy 119 Did not Learned learn something anything new new Adjusting to changes i n marriage because of pregnancy Adjusting one's sexual l i f e to pregnancy Preparing other chidren for new baby Helping father of baby to get ready for parenthood Preparing for changes i n one's l i f e a f t e r baby comes What labour i s a l l about Hospital procedures during labour Preparing for p o s s i b i l i t y of a Caesarean section Family planning a f t e r pregnancy Feeding the baby Caring for the baby, e.g. bathing, immunizations Whatever questions one had 27. What did you l i k e most about the classes pr about going to the classes? Describe: Was not covered i n the classes I attended 28. As a r e s u l t of going to classes did you, outside of cla s s time, make contact with (phone, v i s i t ) anyone who attended your classes? No Yes 120 29. Was there anything you did not l i k e about the classes or going to the classes? No Yes Describe: 30. How long ( i n minutes) did i t take you to get to the classes from home? (Approximately) 31. How did you get (transport) yourself to the classes (e.g., walk, car, bus)? Be s p e c i f i c ? Skip to question 42. Questions 32 to 41 are for women who have not attended prenatal classes during t h i s past pregnancy. 32. During t h i s past pregnancy, did you know whether prenatal classes were being offered by - the Public Health Unit? No Yes - Others? No Yes 33. I f you know about prenatal classes being offered through the Public Health Unit, how did you hear about them? 121 34. Have you ever attended prenatal classes before? No Yes I f yes, when (year)? I f "no", answer question 33. 35. Did you personally know anyone who attended classes? No Yes Specify: 36. Did any person(s) a c t i v e l y encourage you to attend prenatal classes? No Yes Specify: 37. Did any persons(s) a c t i v e l y discourage you from attending prenatal classes? No Yes Specify: 38. During the time of your pregnancy what did you see as the purpose of prenatal classes? 39. People have d i f f e r e n t reasons for not attending prenatal classes. Would you t e l l me what your main reason(s) was(were) for not attending classes? L i s t up to four reasons. Check ( ) the main reason i f there i s more than one reason. 122 40. How long ( i n minutes) would i t l i k e l y take you to get to your nearest Public Health Unit? 41. What, i f any, transportation i s ava i l a b l e to you - in the daytime? - i n the evenings? Continue on with a l l the questions. 42. Before t h i s past pregnancy, did you smoke? No Yes I f yes, average number of cigarettes per day 43. Did you smoke during the pregnancy? No Yes If yes, average number of cigarettes per day 44. What would best describe the amount of exercise you had immediately before t h i s past pregnancy (for example, sports, b r i s k walking, runnning, exercise class)? None Less than once a week Once or twice a week Three or more times a week Describe s p e c i f i c a l l y 45. During t h i s past pregnancy how much exercise did you have ( f o r example, sports, b r i s k walking, runnning, exercise class)? None Less than once a week Once or twice a week Three or more times a week Describe s p e c i f i c a l l y 46. Before t h i s past pregnancy how much alcohol did you drink? None Some Average number of drinks per week (1 drink = 1 b o t t l e beer or 1 glass wine or 1 shot of s p i r i t s ) 123 4 7 . During t h i s past pregnancy how much alcohol did you drink? None Some Average number of drinks per week (1 drink = 1 b o t t l e beer or 1 glass wine or 1 shot of s p i r i t s ) 4 8 . How much weight did you gain during t h i s past pregnancy? 4 9 . How would you rate your d i e t (the food you ate) before and during pregnancy? Please check ( ) one answer under each column: Before pregnancy During pregnancy - not too good - not too good - adequate - adequate - excellent - excellent 50. How many servings of milk or equivalent (e.g., 1 cup yogurt, lh oz. cheese, 1 t i n sardines) did you drink/eat on average per day, during pregnancy? 51. Did you use s p e c i a l breathing techniques during your labour and delivery? No Yes ( I f yes, please answer question 52) Describe: 52. Where did you learn the breathing techniques that you used during labour and delivery? 53. Ove r a l l , how would you describe the l e v e l of discomfort you f e l t during labour and delivery? minimal ) Explain i f you wish: moderate ) severe ) 124 54. Besides the breathing and r e l a x a t i o n techniques that you may have used during labour and de l i v e r y , what else did you use to prevent or reduce discomfort and pain? nothing medication by mouth or by i n j e c t i o n anaesthetic ( f o r example, spinal (epidural) anaesthetic, general anaesthetic, anaesthetic given by yourself through a mask). other Explain: Questions 55 to 69 are about the time since your d e l i v e r y . 55. Are you smoking now? No Yes If yes, average number of cigarettes per day _ 56. How much alcohol do you drink now? None Some Average number of drinks per week (1 drink = 1 b o t t l e beer or 1 glass wine or 1 shot of s p i r i t s ) 57. How would you rate your d i e t (the food you eat)? Please check ( ) one answer. not too good adequate excellent 58. What would best describe the amount of exercise you get now ( f o r example, sports, b r i s k walking, running, exercise class)? None Less than opte a week Once or twice a week Three or more times a week Describe 125 59. How are you feeding your baby? Bot t l e feeding Breastfeeding Both b o t t l e feeding and breast feeding Other Explain: 60. If you are breastfeeding, for how long do you plan to breastfeed (approximate number of months) ? Are there any reasons that might cause you to stop e a r l i e r than you plan? No Yes Explain: 61. How often w i l l you take your baby for check-ups (e.g., doctor's o f f i c e , Public Health Unit)? Only i f sick Other Explain: 62. W i l l you have your baby immunized? No Explain why: Yes Explain why: 63. At what age do you plan to have your baby f i r s t immunized? 64. Has a public health nurse v i s i t e d you i n your home since the b i r t h of your baby? No Yes 65. Have you any plans concerning family planning/birth control? No Yes Please explain: 126 66. Which person(s) do you t a l k to the most about caring for your baby (for example, husband, mother, fr i e n d , public health nurse, doctor)? 67. Based on the kinds of experience you had during your pregnancy and at the time of your labour and delivery, were there any kinds of information that you .did not have but that you now think might have been useful (helpful) to you? 68. Thinking 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 useful (helpful) to you in caring for your c h i l d (information that you did not have when your baby was born or that you do not have now)? Statements 69 to 80 are a few comments concerning pregnancy, labour, baby care and s e l f care. I am i n t e r e s t i n g i n knowing how you f e e l about the comments. Please check the answer that most nearly agrees with how you f e e l , check only one answer for each statement. 127 69. Eating f r i e d foods i s a l r i g h t during pregnancy. I strongly agree I disagree I agree I strongly disagree 70. The weight of the baby i s not affected by c i g a r e t t e smoking during pregnancy. ' I strongly agree I disagree I agree I strongly disagree 71. Eating vegetables every day during pregnancy i s necessary. I strongly agree I disagree I agree I strongly disagree 72. Swimming or fast walking during pregnancy i s not a good idea. I strongly agree I disagree I agree I strongly disagree 73. F i l t e r s make cigarettes safe. I strongly agree I disagree I agree I strongly disagree 74. There i s r e a l l y l i t t l e a woman can do to help h e r s e l f during labour and d e l i v e r y . I strongly agree I disagree I agree I strongly disagree 75. One should not give a baby 2% milk before at least eight months of age. I strongly agree I disagree I agree I strongly disagree 76. Swelling of hands and feet i n pregnancy i s normal and to be expected. I strongly agree I disagree I agree I strongly disagree 128 77. I f one i s overweight when one becomes pregnant i t i s p a r t i c u l a r l y important to t r y to gain less than 25 pounds during pregnancy. I strongly agree I disagree I agree I strongly disagree 78. Eating beef, chicken, f i s h or dried beans of some sort, every day during pregnancy i s important. I strongly agree I disagree I agree I strongly disagree 79. Breastfeeding i s one way to prevent further pregnancies from occurring. I strongly agree I disagree I agree I strongly disagree 80. It i s advisable not to take any medicine i f one i s breastfeeding. I strongly agree I disagree I agree I strongly disagree Statements 81 to 88 are some comments about health and i l l n e s s , i n general. I am interested i n knowing how you f e e l about these statements. Please check the answer that most nearly agrees with how you f e e l . Check only one answer for each statement. 81. Good health i s l a r g e l y a matter of good fortune. I strongly agree I disagree I agree I strongly disagree 82. If I take care of myself I can avoid i l l n e s s . I strongly agree I disagree I agree I strongly disagree 83. Whenever I get sick i t i s because of something I've done or not done. I strongly agree I disagree I agree I strongly disagree 129 84. No matter what I do, i f I am going to get sick I w i l l get sick. I strongly agree I disagree I agree I strongly disagree 85. I can only do what my doctor t e l l s me to do. I strongly agree I disagree I agree I strongly disagree 86. When I f e e l s i c k I know i t i s because I have not been getting the proper exercise or eating r i g h t . I strongly agree I disagree I agree I strongly disagree 87. There are so many strange diseases around that you can never know how or when you might pick one up. I strongly agree I disagree I agree I strongly disagree 88. People who never get sick are ju s t p l a i n lucky. I strongly agree I disagree I agree I strongly disagree Questions 89 to the end w i l l be about yourself and your family/household. 89. In what year were your born? 90. What i s your marital status? Single Divorced Married Separated Widowed Other (specify) 91. Where were you born (country)? 130 92. As well as perhaps being a Canadian, do you belong to any of these broad c u l t u r a l groups? B r i t i s h (Anglo/Saxon) Native Indian Chinese French Japanese European (other than French) East Indian Other (specify) 93. Which language i s pri m a r i l y spoken i n your home? English French Language of China Language of Europe (other than French East Indian Other (specify) 94. How well do you understand English? Spoken English: No Somewhat Yes Written English: No Somewhat Yes 95. Do you belong to a r e l i g i o u s ( f a i t h ) group? No Yes Describe: 96. How many years of schooling have you had ( s t a r t i n g with Grade 1)? 97. Who i s the major wage-earner i n your household ( r e l a t i o n s h i p , not name ) ? 98. I f you normally work for a wage or salary, what i s your usual occupation? Be s p e c i f i c about what you do on your job? 99. I f you normally work for a wage or salary, when did you l a s t work? (Month, year) 131 100. If your husband/partner normally works for a wage or salary, what i s h i s usual occupation? Be s p e c i f i c about what he does on h i s job. 101. If your husband/partner normally works, i s he employed r i g h t now? No Yes 102. L i s t a l l the people who l i v e i n your household, including c h i l d r e n . L i s t these persons by r e l a t i o n s h i p (e.g., husband, daughter, mother, f r i e n d ) , not by t h e i r names: Thank you for your assistance i n t h i s study. I f you have any other information or thoughts that you wish to add, please write on the following page. 132 APPENDIX C PERMISSION FROM ASSISTANT DEPUTY MINISTER PREVENTIVE SERVICES APPENDIX D CODE DEFINITIONS OF SOME STUDY VARIABLES 136 Code Definitions of Some Variables in Questionnaire  that are not Self-Explanatory 10. FREQUENCY TO DOCTOR - Regularly: minimum every month - Less Regularly: when symptomatic only, once i n a while, interrupted pattern, less than every month 11. HEALTH PROBLEMS (requiring treatment) - S l i g h t : minor complaints, e.g., morning sickness less than four months, varicose veins, transient "blues" requiring no medication therapy - Moderate: persistent d i f f i c u l t i e s or accumulation of minor symptoms connected with pregnancy, e.g., morning sickness more than four months, high blood pressure/pre-eclampsia requiring no medication or h o s p i t a l therapy, p s y c h i a t r i c symptoms but no psychosis - Serious: menace to pregnancy, e.g., suspected miscarriage, extrauterine pregnancy, eclampsia. Anything requiring h o s p i t a l i z a t i o n . (Huttel et a l . , 1971, Adaptation.) 98. RESPONDENT'S USUAL OCCUPATION ( i f normally work for a wage or salary) - Professionals, managers, o f f i c i a l s , e.g., doctor, lawyer, engineer, nurse with degree or at management l e v e l , manager/owner of a large or professional business, teacher of Grade 1 and above - Technical, Sales, C l e r i c a l , Draftsmen, Foremen, Operatives, e.g., draftsman, secretary, teacher of kindergarten or preschool, mechanic, nurse without degree/management p o s i t i o n , manager/owner of a small or technical business, policeman, salesperson - Service workers, Labourers, Farmers, e.g., waitress, security, guard, cashier, j a n i t o r , farmhand. (Cave, 1978, adaptation.) 100. As above.' APPENDIX E CODE BOOK 133 COOKBOOK - F I L E ONE (PARTIAL SAMPLE: RESPONDERS) Participant # Card # • 1 • • 2 3 • * BIRTH NOTICE DATA Town Area: Maple Ridge Langley Mission Gestational Age (weeks): Infant Birth Weight (grams); Apgar (1st & 2nd): Maternal Complications: Infant Complications: 1 2 3 <37 37-42 >42 Gibsons Powell River Squamish 3 2 1 Delivery Mode: Marital Status: 4 3 2 1 4 5 6 <2500 2500-3000 = 3001-3500 =• >3500 0-4 - 3 5-7 = 2 8-10 = 1 None 1 Min.-mod. 2 Serious 3 None 1 Min.-mod. 2 Serious 3 Spontaneous Forceps Spont.-ass't/extracted breech C/S Legally married Other • 1 2 3 4 1 2 o • n L> 139 QUESTIONNAIRE DATA 1. 2. 3. Date born: day, month # Pregnancies Talked with: • • • • 14 15 16 17 Husband/Partner Other Relative(s)/Friend(s)/Neighbour(s) Professional(s) 1 & 2 1 & 3 2 & 3 1 & 2 & 3 # People talked to: 4. Talked about: Prenatal Care Mental State Infant Labour, De1ivery Personal, Family Adjustments 5. Information on Pregnancy: Yes, circled Yes No 1 2 3 Husband L_l26 PHN Relative 1 127 Readings - Prof. Friend/Neighbour 1 128 Readings - Lay Doctor 1 |29 TV, Radio Dr.'s Nurse 1 ! 3 0 Experience Prenatal Classes L J 3 1 Other # Sources Named Main Sources/Combinations Doctor/Dr.'s Nurse/PHN 1 Readings, Media 2 Husband/Relative/Friend 3 Prenatal Classes 4 Personal Experience 5 Other 6 1 & 2 7 1 & 3 8 1 & 4 9 1 & 5 10 1 & 6 11 2 & 3 12 2 2 2 3 3 3 4 4 5 4 5 6 4 5 6 5 6 6 don't know no response inapplicable 13 14 15 16 17 18 19 20 21 88 99 0 1 2 4 | |l9 5 6 7 n • 2 2 *^J23 24 H25 20 21 I 132 • 3 3 ! 134 135 136 J37 tZ]381 [39 I [40 [ZJ41 140 Information on Labour & Childbirth: Yes, circled 1 Yes 2 No 3 Husband Relative Friend/Neighbour Doctor Dr.'s Nurse Prenatal Classes PHN # Sources Named Main Sources/Combinations: 142 • 43 I 144 • 45 1 146 47 48 # Sources Named Main Sources/Combinations: Doctor/Dr.'s Nurse/PHN 1 Readings, Media 2 Husband/Relative/Friend 3 Prenatal Classes 4 Personal Experience 5 Other 6 Readings - Prof. Readings - Lay TV, Radio Hospital Tour Experience Other Doctor/Dr.'s Nurse/PHN 1 2 & 4 13 Readings, Media 2 2 & 5 14 Husband/Relative/Friend 3 2 & 6 15 Prenatal Classes 4 3 & 4 16 Personal Experience 5 3 & 5 17 Other 6 3 & 6 18 1 & 2 7 4 & 5 19 1 & 3 8 4 & 6 20 1 & 4 9 5 & 6 21 1 & 5 10 don't know 88 1 & 6 11 no response 99 2 & 3 12 inapplicable 0 Information on Childcare: Yes, circled 1 Yes 2 No 3 Husband 59 PHN Relative L _ 60 Readings - Prof. Friend/Neighbour 1 61 Readings - Lay Doctor 162 TV, Radio Dr.'s Nurse 63 Experience Prenatal Classes 164 Other 4 5 6 4 5 6 13 14 15 16 17 18 • 49 50 51 52 53 54 • 5 5 Q L>D • 65 • 66 • 67 O 6 8 69 70 [711 1 72 I73CI74 141 8. 9. 10. 1 & 2 1 & 3 1 & 4 1 & 5 1 & 6 2 & 3 Doctor in Pregnancy Month to Doctor Frequency to Doctor: 11. Health Problems: 12. Dr.-Prenatal Classes: 7 8 9 10 11 12 4 & 5 19 4 & 6 20 5 & 6 21 don't know 88 no response 99 inapplicable 0 Regularly Less Regularly Never No complaints Slight Moderate Serious Recommended No Mention Other Not Recommended 1 2 3 1 2 3 4 1 2 3 4 o D8 D» 13. Attended Classes • 80 Participant # Card # 14. Type - Classes: 15. How Hear Classes: 16. Encouragement 17. Who/What Encouraged # Persons Mentioned Most N.B.: Provincial Other Both Professionals/Class Leaders Advertising Relatives/Friends/Neighbours 1 & 2 1 & 3 2 & 3 1 & 2 & 3 4 2 D 3 2 3 4 5 Husband Other Relatives/Friends/Neighbours PHN(s) D 142 Doctor/Dr.'s Office Posters, Advertising Other 18. Previous Classes # Years Ago 19. Knew Other Attenders 20. Reasons - Attendance: (1st column =• main reason)! \l3 Overall knowledge gain Healthy Pregnancy/Infant Labour/Deliver Preparation Newborn Care & Information Involve Husband/Partner Share with/Support other attenders Other Information/Knowledge of Pregnancy, Birth, Infant Reasons Personal/Family/Social Reasons Both 21. Started Classes 4 5 6 _ 0 Q*DO< 2 3 22. Classes Attended One Series Classes: <50% attendance 50-99% attendance 100% attendance Two Series Classes 1st series <50Z attendance 50-99% attendance 100% attendance 2nd series <50Z attendance 50-99% attendance 100% attendance Total # Classes Attended 23. Reasons for Missing Classes: Nothing to be Learned Didn't like classes attended Practical problems 1 & 2 1 & 3 2 & 3 1 & 2 & 3 1 2 3 • 19 Q . : Q 3 1 2 3 4 5 6 7 24 143 24. Husband/Partner Attendance 25. Other Attendance 26. Learned Something New: Diet I 127 Breathing Techs. 1 |28 Managing Discomforts) |29 Changes in Marriage | (30 Sexual Adjustment 01 Preparation Children! J32 Father Adjustment ] B3 t Things Learned 27. 25 >6 Learned Not Learned Not Covered Labour Hospital C/S Family Planning Feeding Baby Other Care Baby Questions Information/Knowledge of Preg., Labour, Infant Personal/Family/Social 1 2 Both Liked About Classes: Overall Knowledge Gain l Information on Lifestyle, Pregnancy, Infant Development Labour/Delivery Preparation 3 Information on Newborn Care 4 Partner Involvement Meeting, Sharing with Others Other 1 144J I45J UZW 5 6 Information/Knowledge of Preg., Labour, Infant 1 Personal/Family/Social 2 Both 3 28. Contact with others after 29. Didn't Like About Classes: Content 1 Style 2 Inconvenience 3 1 & 2 4 1 & 3 5 2 & 3 6 1 & 2 & 3 7 • • 48 49 50 Content: Too much Too l i t t l e Inaccurate 1 2 3 144 Overall Information Lifestyle, Pregnancy, Labour/De1ivery Newborn Care 30. Time to Classes: 31. Transportation: 32. Knew About Classes: 33. How Hear - Classes: Infant Development <15 minutes 1 15-30 minutes 2 31-60 minutes 3 >60 minutes 4 Walk 1 Bus 2 Car 3 1 & 2 4 1 & 3 5 2 & 3 6 1 & 2 & 3 7 Other 8 Provincial 1 Other 2 Both 3 Professionals/Class Ldrs. 1 Advertising 2 Relatives/Friend3/Nbrs. 3 1 & 2 4 1 & 3 5 2 & 3 6 1 & 2 & 3 7 I 151 ZI152 • 5 3 L _ l 5 4 • 56 34. Prior Attendance # years ago 35. Knew Other Attenders 36. Enc ouragemen t Who Encouraged: Husband 1 Other Rels./Friends/Nbrs. 2 PHN(s) 3 Doctor/Dr.'s Office 4 Other 5 59 160 61 63 37. Who Discouraged: Husband 1 Other Rels./Friends/Nbrs. 2 PHN(s) 3 Doctor/Dr.'s Office 4 Other 5 64 145 38. 39. Purpose - Classes: Overall knowledge Healthy Lifestyle, Pregnancy, Infant Labour/Delivery Preparation Newborn Care & Information Involve Husband/Partner Share with/Support others Other (1st column =» main reason) | |&5^  |>6j js71 |>8 1 2 3 4 5 6 7 Reasons - Non-Attendance: (1st column=main reason)69( frp| |7l[ \l Positive Previous Class Experience 1 Negative Previous Class Experience 2 Natural Process 3 Dr. Provides Information 4 Family/Friends Provide Information 5 Reading Provides Information 6 Practical Problems 7 Other 8 40. Time to Classes: <15 minutes 15-30 minutes 31-60 minutes >60 minutes 1 2 3 4 41. Transportation: (pms=lst column; daytime=2nd column) Walk Bus Car 1 & 1 & 2 & 1 & & 3 42. Smoking Before: Other No 43. Smoking During: Yes - no # indicated <1 package 1 package >1 package (<than 2) 2+ packages No Yes - no # indicated <1 package 1 package >1 package (<than 2) 2+ packages 1 2 3 4 5 6 7 8 1 2 3 4 5 6 1 2 3 4 5 6 '4 75 44. Exercise Before: 45. Exercise During: 46. Alcohol Before: Participant # Card # 47. Alcohol During: 48. Weight Gain (pounds): 49. Diet Before: Diet During: 50. Milk Servings 51. Breathing Techniques: 52. Where Learned: Current Classes Alone Classes Combined With None 4 <l/week 3 1-2/week 2 3+/week 1 None 4 <l/week 3 1-2/week 2 3+/week 1 None 1 1-4/week 2 5-9/week 3 >9/week 4 None 1-4/week 2 5-9/week 3 >9/week 4 Not too good 3 Adequate 2 Excellent 1 Not too good 3 Adequate 2 Excellent 1 Specific Pattern as learned 1 Other 2 None in Particular 3 1 & 2 4 Past Experience Current Prenatal Classes Hospital Staff/Dr. Other 1 Something Else 2 1 4 b • 5 D o 1 5 * 6 1 4 7 53. Labour Discomfort: Minimum 1 Moderate 2 Severe 3 54. Pain Reduction: Medication 1 Anaesthesia 2 Other 3 1 & 2 4 1 & 3 5 2 & 3 6 1 & 2 & 3 7 55. Smoking Now: No 1 Yes - no # indicated 2 <1 package 3 1 package 4 >1 package (<than 2) 5 2+ packages 6 56. Alcohol Now: No 1 1-4/week 2 5-9/week 3 >9/week 4 57. Diet Now: Not too good 3 Adequate 2 Exc e l l e n t 1 58. Exercise Now: None 4 <l/week 3 1-2/week 2 3+/week 1 59. Feeding Baby: B o t t l e 3 Both 2 Breast 1 Other 4 17 18 19 20 21 22 23 60. Breastfeeding: # months Stop E a r l y Reasons: Low Milk Supply T i r e d Work Other 1 2 3 4 24 27 J25 ""26 > 61. Baby Check-ups Regular Sick only Other 148 62. Immunization Why Not: Conscientious Objector Other 1 & 2 63. Age Immunization (months) 64. PHN Visit 65. Family Planning: Definite Plans Thinking about Undecided/no plans Definitely not 66. Talk With About Baby: Husband/Partner Other Relatives/Friends/Neighbours Professional(s) 1 & 2 1 & 3 2 & 3 1 & 2 & 3 # People Talked To 67. Information - Pregnancy & Labour/Deliver: No General exercise Nutrition, alcohol, smoking Labour information/preparation C/Section Dangers of toxemia, other complications Hospital routine Other 68. Information - Caring For Child No Nutrition Protection, care (infections, etc.) Colic Skin Siblings Scheduling (e.g., sleep, bathing, eating) Other 1 2 3 1 2 3 4 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 L> bi • 32 33 34 •3 7 40 4l| |»2 69. Fried Foods: 70. Smoking: 4 4 3 3 2 2 43 44 149 71. Vegetables 1 2 3 4 72. Swimming 4 3 2 1 73. F i l t e r s 4 3 2 1 74. Labour/Delivery 4 3 2 1 75. 2Z Milk 1 2 3 4 76. Swelling 4 3 2 1 77. Overweight 4 3 2 1 78. Pr o t e i n 1 2 3 4 79. Breastfeeding 4 3 2 1 80. Medicine - breastfeeding 1 2 3 4 81- $8 Locus of Control Score (81 =» 4 3 2 1 82 - 1 2 3 4 83 = 1 2 3 4 84 =• 4 3 2 1 85 =• 4 3 2 1 86 =• 1 2 3 4 87 - 4 3 2 1 88 - 4 3 2 1) 89. Year Born. (Age) 90. M a r i t a l Status: Single 1 Divorced 4 Married 2 Separated 5 Widowed 3 Other 6 91. Where Born: Canada U.S. U.K. Europe Asi a Other 1 2 3 4 5 6 92. C u l t u r a l Group: B r i t i s h (Anglo-Saxon) Chinese Japanese East Indian 1 Native Indian 5 2 French 6 3 European (not Fr.) 7 4 Other 8 47 48 49 50 • L> •» 5€> j 57) 58 60 61 62 150 93. Language: English 1 L. of China 2 Japanese 3 94. Understand English: Poor Somewhat Yes 95. 96. 97. 98. 99. Religion: Protestant Catholic Other None Years of Schooling Major Wage Earner: Respondent Husband/Partner Mother/Father Other L. of India French European (not Fr.) Other 3 2 1 1 2 3 4 4 5 6 7 Spoken Written 63 64 67 68 1 2 3 4 69 70 Respondent's Usual Occupation: Professional, managers, officials Technical, sales, clerical , craftsmen, foremen, operatives Service workers, labourers, farm workers Last worked: # years ago 2 3 100. Husband's/Partner1s Occupation Professional, managers, officials Technical, sales, clerical , craftsmen, foremen, operatives Service workers, labourers, farm workers 101. Employed 102. Household members # people t children # adults # generations 72 |73 I 176 177 i 7 8 COOKBOOK - FILE TWO (TOTAL SAMPLE: RESPONDERS & NON-RESPONDERS) Pa r t i c i p a n t # Card # Response BIRTH NOTICE DATA Town Area: Maple Ridge 1 Langley 2 Mission 3 Gibsons 4 Powell River 5 Squamish 6 Gestational Age (weeks): <37 =» 3 37-42 = 2 >42 = 1 Infant B i r t h Weight (grams): <2500 = 4 2500-3000 = 3 3001-3500 = 2 >3500 - 1 Apgar (1st & 2nd): 0-4 = 3 5-7 = 2 8-10 - 1 Maternal Complications: None 1 Min.-mod. 2 Serious 3 Infant Complications: None 1 Min.-mod. 2 Serious 3 Delivery Mode: Spontaneous Forceps Spont.-ass't/extracted breech C/S Ma r i t a l Status: L e g a l l y married Other APPENDIX F LETTER TO INTERVIEWEES T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Faculty of Medicine 153 Department of Health Care and Epidemiology Mather Building 5804 Fairview Avenue Vancouver, B .C . V6T 1W5 Dear As a graduate student i n the Health Services Planning Program at U.B.C, I am interested i n conducting a study involving mothers who have recently given b i r t h . The purpose of this study i s to find out what the experiences of these women have been during pregnancy, labour and the period of time immediately a f t e r giving b i r t h ; i n terms of health, t h e i r health pr a c t i c e and the types of care (services) and support they received. For the study you are one of the mothers chosen to be a representative of a l l mothers who have given b i r t h during the period January 15 to February 16, 1983, and who l i v e i n the area covered by the Coast-Garibaldi and Central Fraser Valley Health Units. I wish to interview you within the next month or two. The information you would be able to give i s important to the study. In about a week, I w i l l phone you at which time you w i l l be able to t e l l me whether you are w i l l i n g to help i n the study. Any questions you have about the study can be discussed at th i s time, too. The interview would take about one to one and one-half hours of your time. Your p a r t i c i p a t i o n i n this study i s voluntary. Refusal to p a r t i c i p a t e or a decision to withdraw from the study, at any time, w i l l not jeopardize further health care for you. A l l the information you provide would be kept c o n f i d e n t i a l . Only myself and one t y p i s t w i l l know the names of the women p a r t i c i p a t i n g i n the study. Your name would not be recorded i n any way i n the study r e s u l t s . The actual answers that are given w i l l only be seen by me and my faculty advisor, Dr. Nancy Waxier at U.B.C. Your cooperation i n th i s matter w i l l be appreciated. Yours sincerely, Mary L . Spoke, R.N., B.S.N. (Student i n Health Services Planning Program, U.B.C.) APPENDIX G MOTHER'S CONSENT TO THE INTERVIEW THE UNIVERSITY OF BRITISH COLUMBIA Faculty of Medicine 155 Department of Health Care and Epidemiology Mather Building 5804 Fairview Avenue Vancouver, B . C . V 6 T 1W5 I understand that the purpose of th i s study concerns new mothers and t h e i r experiences during the pregnancy, c h i l d b i r t h and p o s t - c h i l d b i r t h periods. This has been explained to me to my s a t i s f a c t i o n . I also understand that c o n f i d e n t i a l i t y i s assured; that i s , that only the interviewer and her facul t y advisor w i l l know me by name as a p a r t i c i p a n t i n th i s study; that my name w i l l not be i d e n t i f i e d i n any way i n the study r e s u l t s ; and that no quotations or case h i s t o r i e s w i l l be used which can be i d e n t i f i e d . It has been explained to me that my decision to p a r t i c i p a t e i n the study i s voluntary and that should I decide to withdraw from the study, at any time, I w i l l not be jeopardizing further care for myself. I give the interviewer permission to interview me. Date 19 (Interviewer-Witnes s) Mary L. Spoke Date 19 APPENDIX H LETTER TO MAILED SUBJECT a u s e T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Faculty of Medicine - _._ 157 Department of Health Care and Epidemiology Mather Building 5804 Fairview Avenue Vancouver, B .C. V6T 1W5 Dear As a graduate student i n the Health Services Planning Program at U.B.C, I am interested i n conducting a study involving mothers who have recently given b i r t h . The purpose of th i s study i s to find out what the experiences of these women have been during pregnancy, labour and the period of time immediately a f t e r giving b i r t h ; i n terms of health, t h e i r health pr a c t i c e and the types of care (services) and support they received. For the study you are one of the mothers chosen to be a representative of a l l mothers who have given b i r t h during the period January 15 to February 16, 1983, and who l i v e i n the area covered by the Coast-Garibaldi and Central Fraser Valley Health Units. Enclosed i s a questionnaire which I hope you w i l l agree to complete. This should take approximately one-half to one hour of your time. Your p a r t i c i p a t i o n i n th i s study i s voluntary. Refusal to p a r t i c i p a t e , or a decision to withdraw from the study, at any time, w i l l not jeopardize further health care for you. A l l the information that i s provided w i l l be kept s t r i c t l y c o n f i d e n t i a l . Only myself and one t y p i s t w i l l know the names of the women p a r t i c i p a t i n g i n the study. Your name w i l l not be recorded i n any way i n the study r e s u l t s . The actual answers that are given w i l l only be seen by me and my facul t y advisor, Dr. Nancy Waxier at U.B.C. Your cooperation i n th i s matter w i l l be appreciated. Should you have any questions, please do not hesitate to c a l l me, or leave a message at between 8:30 a.m. and 4:30 p.m. I f c a l l i n g long distance, please phone c o l l e c t , , between 7:00 and 8:00 a.m. Yours sincerely, Mary L. Spoke, R.N., B.S.N. (Student i n Health Services Planning Program, U.B.C.) Enclosed: Questionnaire Stamped/addressed return envelope APPENDIX I REMINDER LETTER TO MAILED SUBJECT T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Faculty of Medicine Department of Health Care and Epidemiology Mather Building 5804 Fairvicw Avenue Vancouver, B .C. V6T 1W5 159 Dear On March 25, 1983, I sent to you a questionnaire designed to find out about your experiences during pregnancy, labour and the period of time immediately a f t e r giving b i r t h . The questions concerned your health, health practices and the types of care (services) and support you received during that period. If you have already completed the questionnaire and mailed i t to me, please ignore t h i s l e t t e r . If you have received t h i s questionnaire but have not yet completed i t and mailed i t back to me, I would appreciate you doing so as soon as possible. It i s important to the study that I get your information and views. Yours sincerely, Mary L. Spoke, R.N., B.S.N. (Student i n Health Services Planning Program, U.B.C.) APPENDIX J RESPONSE BIAS TABLES TABLE 32 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BT DELIVERY MODE Spontaneous Assisted/ Extracted Caesarian Spontaneous Forceps Breech Section Responders 123 (81%) 13 (93%) 4 (80%) 37 (73%) Non-Responders 29 (19%) 1 (4%) 1 (20%) 14 (27%) 152 (100%) 14 (100%) 5 (100%) 51 (100%) n = 222 TABLE 33 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY BIRTHWEIGHT 3001 - 3500 2500 - 3000 />3500 Grams Grams Grams <C 2500 Grams Responders 85 (80%) 68 (83%) 21 (68%) 3 (100%) Non-Responders 21 (20%) 14 (17%) 10 (32%) 0 (0) 106 (100%) 82 (100%) 31 (100%) 3 (100%) n = 222 TABLE 3 4 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY GESTATIONAL AGE 37 Weeks 37-42 Weeks ^>42 Weeks Responders 2 (100%) 165 (79%) 6 (86%) Non-Responders 0 (0) 43 (21%) 1 (14%) 2 (100%) 208 (100%) 7 (100%) n = 217 TABLE 35 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY FIRST APGAR Responders 0-4 (75%) 5-7 24 (69%) 8-10 148 (82%) Non-Responders (25%) 11 (31%) 32 (18%) 4 (100%) 35 (100%) 180 (100%) n = 217 TABLE 36 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS BY SECOND APGAR Responders 5-7 (75%) 8-10 165 (80%) Non-Responders (25%) 41 (20%) 8 (100%) 20% (100%) n = 214 TABLE 37 DISTRIBUTION OF RESPONDERS AND NON-RESPONDERS  BY MOTHER'S PLACE OF RESIDENCE Maple Ridge Langley Mission Gibsons Responders 41 (82%) 76 (94%) 14 (61%) 14 (70%) Non-Responders 9 (18%) 14 (16%) 9 (39%) 6 (30%) 50 (100%) 90 (100%) 23 (200%) 20 (100%) Powell River Squamish Responders 20 (83%) 12 (80%) Non-Responders 4 (17%) 3 (20%) 24 (100%) 15 (100%) n = 222 165 TABLE 38 RESULTS OF CROSS-TABULATING CURRENT ATTENDANCE WITH INDEPENDENT VARIABLES Total Factors Related to Current Attendance Current Yes Class Attendance No "n" Used Significance Primiparous Multiparous 81.5% 34% (66) (32) 18.5% 66% (15) (61) 174 0.000 Doctor Recommended Classes 76% (76) 24% (24) 174 0.000 Received Encouragement from Others to Attend Classes 72% (55) 28% (21) 169 0.001 Previously Attended Classes 31% (24) 69% (53) 171 0.000 Regularly V i s i t e d Doctor 60% (99) 40% (66) 175 0.002 Anglo-Saxon Culture 71% (40) 29% (16) 113 0.006 Born i n N. America or U.K. 60% (94) 40% (62) 175 0.010 Used More Sources of Information on C h i l d b i r t h (4 to 10 compared to 1 to 3) 62% (77) 38% (48) 174 0.038 TABLE 39 CURRENT ATTENDANCE BY MOTHER'S EDUCATION Current Attendance 7-10 Education (Years) 11-12 13--19 Yes 7 (32%) 56 (61 .5%) 36 (57%) No 15 (68%) 35 (38 .5%) 27 (43%) Total 22 (100%) 91 (100%) 63 (100%) n = 176 X 2 = 6.391 p. 0.0409 1 6 6 TABLE 40 RESULTS OF CROSS-TABULATING EVER ATTENDANCE WITH INDEPENDENT VARIABLES Factors Related Attendance to Ever Attendance Yes No N Significance English Language 89% (148) 11% (19) 175 0.001 Born i n N. America or U.K. 89% (139) 11% (17) 175 0.006 Anglo-Saxon Culture 89% (87) 11% (11) 113 0.012 Talked to a Number of People About Pregnancy Talked to One Person About Pregnancy 90% 76% (113) (38) 10% 24% (12) (12) 175 0.024 Used More Sources of Information on C h i l d b i r t h (4 to 10 Compared to 1 to 3) 90% (113) 10% (12) 174 0.045 TABLE 41 EVER ATTENDANCE BY MOTHER' S EDUCATION Ever Attendance 7-10 Education (Years) 11-12 13--19 Yes 13 (59%) 81 (89%) 58 (92%) No 9 (41%) 10 (1 1%) 5 (8%) Total 22 (100%) 91 (100%) 63 (100%) n = 176 X 2 = 16.174 0.0003 167 TABLE 42 PREDICTORS OF CURRENT-PRENATAL CLASS ATTENDANCE Pearson Co r r e l a t i o n Variables C o e f f i c i e n t s P-values P a r i t y 0.4734 0.000 Physician Recommendation 0.4484 0.000 Household Size 0.3338 0.000 Received Encouragement 0.3151 0.000 V i s i t s to Physician 0.2810 0.000 Culture 0.2789 0.003 Place of B i r t h 0.2184 0.004 Occupation -0.1918 0.034 No. Persons Talked to About Pregnancy 0.1788 0.022 TABLE 43 PREDICTORS OF EVER-PRENATAL  CLASS ATTENDANCE Pearson Co r r e l a t i o n Variables C o e f f i c i e n t s P-values Language 0.3104 0.000 Place of B i r t h 0.2862 0.000 Culture 0.2731 0.003 V i s i t s to Physician 0.2686 0.000 Education 0.2425 0.001 Household Size 0.2147 0.004 No. Sources of Information on C h i l d b i r t h 0.1706 0.024 No. Persons Talked to About Pregnancy 0.1644 0.030 Ma r i t a l Status 0.1612 0.033 Chief Wage Earner - Partner 0.1574 0.038 APPENDIX K OBJECTIVE I TABLES TABLE 44 CURRENT ATTENDING BY MAIN SOURCES OF INFORMATION ON PREGNANCY (DETAILED) Main Sources of Information Current Attenders Prenatal Classes Pro-fessionals Readings/ Media Partner/ Relatives, Friends Personal Experience Other Yes 41 (84%) 50 (62.5%) 55 (57%) 28 (49%) 14 (29%) 2 (40%) No 8* (16%) 30 (37.5%) 41 (43%) 29 (51%) 35 (71%) 3 (60%) Total 49 (100%) 80 (100%) 96 (100%) 57 (100%) 49 (100%) 5 (100%) 336** (168 mothers) :a few current non-attenders ci t e d classes as a main sources of information. These were women who had presumably attended classes previously. **336 - 168 mother respondents. Each cited two main sources of information. TABLE 45 CURRENT ATTENDANCE BY MAIN SOURCES OF  INFORMATION ON LABOUR AND CHILDBIRTH (DETAILED) Main Sources of Information Current Attenders Prenatal Classes fes Pro-ssionals Readings/ Media Partner/ Relatives, Friends Personal Experience Other Yes 61 (100%) 31 (58.5%) 36 (52%) 29 (51%) 15 (23%) 6 (25%) No 0 (0%) 22 (41.5%) 33 (48%) 28 (49%) 49 (77%) 18 (75%) Total 61 (100%) 53 (100%) 69 (100%) 57 (100%) 64 (100%) 24 (100%) 328 (164 mothers) o TABLE 46 CURRENT ATTENDING BY MAIN SOURCES OF INFORMATION ON CHILDCARE (DETAILED) Main Sources of Information Current Attenders Prenatal Classes Pro-fessionals Readings/ Media Partner/ Relatives, Friends Personal Experience Other Yes 21 (100%) 26 (50%) 51 (62%) 54 (67%) 27 (37%) 7 (47%) No 0 (0%) 26 (50%) 31 (38%) 27 (33%) 46 (63%) 8 (53%) Total 21 (100%) 52 (100%) 82 (100%) 81 (100%) 73 (100%) 15 (100%) 324 (162 mothers) TABLE 47 EVER-ATTENDANCE BY MAIN SOURCES OF  INFORMATION ON PREGNANCY (DETAILED) Main Sources of Information Current Attenders Prenatal Classes Pro-fessionals Readings/ Media Partner/ Relatives, Friends Personal Experience Other Yes 49 (100%) 73 (91%) 81 (84%) 42 (74%) 41 (84%) 4 (80%) No 0 (0%) 7 (9%) 15 (16%) 15 (26%) 8 (16%) 1 (20%) Total 49 (100%) 80 (100%) 96 (100%) 57 (100%) 49 (100%) 5 100%) 336 (168 mothers) H -TABLE 48 EVER-ATTENDANCE BY MAIN SOURCES OF  INFORMATION ON LABOUR AND CHILDBIRTH (DETAILED) Main Sources of Information Current Attenders Prenatal Classes Pro-fessionals Readings/ Media Partner/ Relatives, Friends Personal Experience Other Yes 75 (100%) 46 (88%) 54 (78%) 44 (77%) 54 (84%) 9 (90%) No 0 (0%) 7 (12%) 15 (22%) 13 (23%) 10 (16%) 1 (10%) Total 75 (100%) 53 (100%) 69 (100%) 57 (100%) 64 (100%) 10 (100%) 328 (164 mothers) TABLE 49 EVER-ATTENDANCE BY MAIN SOURCES OF  INFORMATION ON CHILDCARE (DETAILED) Main Sources of Information Current Attenders Prenatal Classes Pro-fessionals Readings/ Media Partner/ Relatives, Friends Personal Experience Other Yes 24 (100%) 42 (81%) 67 (92%) 78 (87%) 64 (88%) 9 (75%) No 0 (0%) 10 (19%) 6 (8%) 12 (13%) 9 (12%) 3 (25%) Total 24 (100%) 52 (100%) 73 (100%) 90 (100%) 73 (100%) 12 (100%) 324 (162 mothers) APPENDIX L CODING OF VARIABLES FOR PATH MODEL: FIGURES 4 AND 22 Specific forms in which control variables of the path model in Figures 4 to 2 2 are coded and analyzed Variable  Current prenatal class attendance MD recommended prenatal class attendance Other people encouraged prenatal class attendance, e.g., friends, relatives Household size Parity Culture, ethnic group membership of mother Infant Complications Maternal Health Status Form of Measurement 1. Yes (one or more classes) 2. No 1. Recommended 2. No mention 3. Other 4. Not recommended 1. Yes 2. No Number of household members including new infant Number of pregnancies 1. British (Anglo-Saxon) 2. Other 1. None 2. Minimum - Moderate 3. Serious 1. No complaints 2. Slight problems 3. Moderate problems 4. Serious problems APPENDIX M OBJECTIVE I I TABLES 176 T A B L E 5 0 R E S U L T S O F C R O S S T A B U L A T I N G O U T C O M E S W I T H  I N D E P E N D E N T V A R I A B L E , C U R R E N T A T T E N D A N C E Total Outcomes Current Yes Attendance No V Used Significance No Infant Complications 72% (71) 86% (66) 176 0.04 Minimum Labour Discomfort Perceived 15% (14) 28% (20) 168 0.06 Spontaneous Vaginal Delivery 64% (63) 78% (60) 176 0.06 Birthweight 3000 Grams 91% (89) T A B L E 80.5% 5 1 (62) 175 0.08 R E S U L T S O F C R O S S T A B U L A T I N G O U T C O M E S W I T H I N D E P E N D E N T V A R I A B L E , E V E R A T T E N D A N C E Outcomes Ever Attendance Yes No Total "n" Used Significance Used Labour Breathing Techniques 83% (126) 58% (14) 175 0.009 Family Planning Used 76% (113) 96% (22) 172 0.03 Knowledge About Swimming i n Pregnancy 95% (144) 83% (20) 176 0.06 Spontaneous Vaginal Delivery 67% (102) 87.5% (21) 176 0.05 Breastfeeding Knowledge 93% (141) 79% (19) 175 0.02 Knowledge About Diet and Obesity 62% (94) 33% (8) 175 0.01 177 TABLE 52 SIMPLE CORRELATIONS OF CURRENT ATTENDANCE WITH DEPENDENT VARIABLES Variables V i s i t s to Physician Use of Labour Breathing Techniques Infant Complications Maternal Complications Delivery Mode Smoking Behaviour Post-Partum Feeding of Baby Pearson C o r r e l a t i o n Coe f f i c ients P-values 0.2810 0.2248 -0.1672 -0.1594 -0.1545 0.1290 -0.1260 0.000 0.003 0.027 0.035 0.041 0.089 0.096 TABLE 53 SIMPLE CORRELATIONS OF EVER ATTENDANCE WITH DEPENDENT VARIABLES Variables V i s i t s to Physician Use of Labour Breathing Techniques Family Planning Decision Delivery Mode Alcohol Behaviour During Pregnancy Knowledge of Breastfeeding Feeding of Baby Pearson Correlation C o e f f i c i e n t s P-values 0.02686 0.2159 -0.1641 -0.1526 0.1347 0.1341 0.1271 0.000 0.004 0.031 0.043 0.075 0.078 0.093 TABLE 54 LABOUR BREATHING TECHNIQUES BY  CURRENT ATTENDANCE AND MOTHER'S CULTURAL BACKGROUND Used Labour Yes Current Attendance No Breathing Techniques Anglo-Saxon Other Culture Anglo-Saxon Other Culture Yes 35 (87.5%) 23 (92%) 14 (93%) 22 (69) No 5 (12.5%) 2 (8%) 1 (7%) 10 (31%) Total 40 (100%) 25 (100%) TABLE 55 15 (100%) 32 (100%) 112 LABOUR BREATHING TECHNIQUES BY CURRENT ATTENDANCE AND MOTHER'S EDUCATION IN YEARS Used Labour Yes Current Attendance No Breathing Techniques 9-10 Years 11-12 Years 13-19 Years 7-10 Years 11-12 Years 13-19 Years Yes 5 (71%) 49 (87.5%) 33 (92%) 10 (67%) 21 (62%) 22 (81.5%) No 2 (29%) 7 (12. 5%) 3 (8%) 5 (33%) 13 (38%) 5 (18.5%) Total 7 (100%) 56 (100%) 36 (100%) 15 (100%) 34 (100%) 27 (100%) 75 179 TABLE 56 LABOUR BREATHING TECHNIQUES BY CURRENT ATTENDANCE AND PARITY Used Labour Breathing Yes Current Attendance No Techniques Primipara Multipara Primipara Multipara Yes 59 (89%) 27 (84%) 12 (80%) 41 (68%) No 7 (11%) 5 (16%) 3 (20%) 19 (32%) Total 66 (100%) 32 (100%) 15 (100%) 60 (100%) 173 TABLE 57 LABOUR BREATHING TECHNIQUES BY NUMBER OF CLASSES ATTENDED Used Labour Breathing Techniques 5-15 Number of CI; 3-4 asses Attended 1-2 • 0 Yes 63 (91%) 13 (100%) 5 (62.5%) 53 (70%) No 6 (9%) - 3 (37.5%) 23 (30%) Total 69 (100%) 13 (100%) 8 (100%) 76 (100%) 166 TABLE 58 INFANT COMPLICATIONS BY CURRENT ATTENDANCE AND MOTHER'S CULTURAL BACKGROUND Current Attendance Yes No Infant Anglo- Other Anglo- Other Complications Saxon Culture Saxon Culture No 31 (77.5%) 18 (72%) 12 (75%) 28 (87.5%) Yes 9 (22.5%) 7 (28%) 4 (25%) 4 (12.5%) Total 40 (100%) 25 (100%) 15 (100%) 32 (100%) 114 TABLE 59 INFANT COMPLICATIONS BY CURRENT ATTENDANCE AND MOTHER'S AGE IN YEARS Current Attendance Yes No Infant ^ 20 20-29 29 20 20-29 > 29 Complications Years Years Years Years Years Years Yes 47 (70%) 21 (72%) 3 (100%) 43 (86%) 20 (83%) 3 (100%) No 20 (30%) 8 (28%) - 7 (14%) 4 (17%) Total 67 (100%) 29 (100%) 3 (100%) 50 (100%) 24 (100%) 3 (100%) 176 TABLE 60 INFANT COMPLICATIONS BY CURRENT ATTENDANCE AND MOTHER'S EDUCATION IN YEARS Current Attendance Yes No Infant 7-10 11-12 13-19 7-10 11-12 13-19 Complications Years Years Years Years Years Years Yes 3 (43%) 41 (75%) 27 (75%) 13 (87%) 33 (94%) 20 (74%) No 4 (57%) 15 (27%) 9 (25%) 2 (13%) 2 (6%) 7 (26%) Total 7 (100%) 56 (100%) 36 (100%) 15 (100%) 35 (100%) 27 (100%) 176 TABLE 61 INFANT COMPLICATIONS BY CURRENT ATTENDANCE AND PARITY Current Attendance Infant Yes No Complications Primipara Multipara Primipara Multipara Yes 47 (71%) 24 (75%) 12 (80%) 53 (87%) No 19 (29%) 8 (25%) 3 (20%) 8 (13%) Total 66 (100%) 32 (100%) 15 (100%) 61 (100%) 174 182 TABLE 62 INFANT COMPLICATIONS BY NUMBER OF  CLASSES ATTENDED Infant Number of Classes Attended Complications 5-15 3-4 1-2 0 Yes 47 (68%) 11 (85%) 6 (75%) 66 (86%) No 22 (32%) 2 (15%) 2 (25%) 11 (14%) Total 69 (100%) 13 (100%) TABLE 63 8 (100%) 77 (100%) 167 INFANT COMPLICATIONS BY NUMBER OF CLASSES ATTENDED Infant Birthweight 5-15 Number of Classes 3-4 Attended 1-2 0 Yes (<3000 grams) 61 (88%) 13 (100%) 7 (87.5%) 62 (80.5%) No (7 3001 grams) 8 (29%) - 1 (12.5%) 15 (19.5%) Total 69 (100%) 13 (100%) 8 (100%) 77 (100%) 167 183 TABLE 64 PERCEIVED LABOUR DISCOMFORT BY NUMBER OF CLASSES ATTENDED Perceived Labour Number of Classes Attended Discomfort 5-15 3-4 1-2 0 Yes 7 (10%) 5 (38.5%) - 20 (28%) No 61 (90%) 8 (61.5%) 8 (100%) 52 (72%) Total 68 (100%) 13 (100%) 8 TABLE 65 (100%) 72 (100%) 161 MODE OF DELIVERY BY NUMBER OF CLASSES ATTENDED Mode of Delivery 5-15 Number of Classes 3-4 Attended 1-2 0 Yes (Spontaneous Vaginal) 42 (61%) 11 (85%) 7 (87.5%) 60 (78%) No (Other) 27 (39%) 2 (15%) 1 (12.5%) 17 (22%) Total 69 (100%) 13 (100%) 8 (100%) 77 (100%) 167 TABLE 66 INFANT BIRTHWEIGHT BY EVER-ATTENDANCE AND MOTHER'S CULTURAL BACKGROUND Current Attendance Yes No Infant Anglo- Other Anglo- Other Complications Saxon Culture Saxon Culture 3000 grams 44 (83%) 41 (98%) 3 (100%) 10 (71%) 3001 grams 9 (17%) 1 (2%) - 4 (29%) Total 53 (100%) 42 (100%) 3 (100%) 14 (100%) 112 TABLE 67 INFANT BIRTHWEIGHT BY EVER-ATTENDANCE AND MOTHER'S AGE IN YEARS Current Attendance Yes No Infant < 20 20-29 29 20 20-29 ? 29 Complications Years Years Years Years Years Years 3000 grams 88 (89%) 42 (89%) 4 (80%) 12 (71%) 5 (83%) 3001 grams 11 (11%) 5 (11%) 1 (20%) " 5 (29%) 1 (17%) 1 (100%) Total 99 (100%) 47 (100%) 5 (100%) 17 (100%) 6 (100%) 1 (100%) 175 TABLE 68 INFANT BIRTHWEIGHT BT EVER-ATTENDANCE AND MOTHER'S EDUCATION IN YEARS Current Attendance Yes No Infant Birthweight 7-10 Years 11-12 Years 13-19 Years 7-10 Years 11-12 Years 13-19 Years < 3000 Grams 12 (92%) 71 (88%) 51 (89.5%) 7 (78%) 6 (60%) 4 (80%) p> 3001 Grams 11 (8%) 10 (12%) 6 (10.5%) 2 (22%) 4 (40%) 1 (20%) Total 13 (100%) 81 (100%) 57 (100%) 9 (100%) 10 (100%) 5 (100%) 175 TABLE 69 INFANT BIRTHWEIGHT BY EVER-ATTENDANCE AND PARITY Ever-Attendance Infant Yes No Birthweight Primipara Multipara Primipara Multipara <3000 Grams 59 (85.5%) 74 (92.5%) 9 (75%) 8 (67%) p> 3001 Grams 10 (14.5%) 6 (7.5%) 3 (25%) 4 (33%) Total 60 (100%) 80 (100%) 12 (100%) 12 (100%) 173 APPENDIX N OBJECTIVE I I I FIGURE AND TABLE FIGURE 23 PATH MODEL SHOWING PREDICTORS OF USE OF  LABOUR BREATHING TECHNIQUES (STANDARDIZED  BETAS REFER TO DIRECT EFFECTS ONLY) oo 188 TABLE 70 PATH COEFFICIENTS FOR PATH MODEL PREDICTING  USE OF LABOUR BREATHING TECHNIQUES Non-Total Causal Total Causal Covariance Direct Indirect A + B A - D Variable Pairs (A) (B) (C) (D) (E) Labour Breathing Techniques, Ever Attendance .33 .23 - .23 .10 Labour Breathing Techniques, Number of Sources of Info on Labour and Delivery -.04 .04 -.03 .01 -.03 Labour Breathing Techniques, Frequency to Physician .11 - .07 .07 .04 Labour Breathing Techniques, Language .39 .31 .05 .36 .03 Labour Breathing Techniques, Culture .15 .02 -.16 -.14 .02 Ever Attendance, Number of Sources of Info on Labour and Delivery -.21 -.12 - -.12 .09 Ever Attendance, Frequency to Physician .37 .29 - .29 .08 Ever Attendance, Household Size .38 .27 - .27 .11 Ever Attendance, Language .33 .19 .05 .24 .09 Ever Attendance, Culture .24 .03 .10 .13 .11 Number of Sources of Info on Labour and Delivery and Ever Attendance -.21 -.16 - -.16 -.05 Number of Sources of Info on Labour and Delivery, Frequency to Physician -.20 -.10 .22 .12 .08 Number of Sources of Info on Labour and Delivery, Household Size -.04 .08 .04 .12 .08 189 TABLE 70, cont'd. PATH COEFFICIENTS FOR PATH MODEL PREDICTING  USE OF LABOUR BREATHING TECHNIQUES Non-Total Causal Total Causal Covariance Direct Indirect A + B A - D Variable Pairs (A) (B) (C) (D) (E) Number of Sources of Info on Labour and Delivery, Language -.08 .01 -.04 -.03 -.05 Number of Sources of Info on Labour and Delivery and Culture -.24 -.20 -.03 -.23 -.01 Frequency to Physician, Household Size .08 -.02 - -.02 -.06 Frequency to Physician, Language .22 .16 - .16 .06 Frequency to Physician, Culture .26 .22 .04 .26 Household Size, Culture .21 .21 - .21 Language, Culture .22 .27 - .27 

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