Impact of no publicly accessible prenatal education programming on patients and their care providers: a descriptive qualitative study in Nova Scotia, Canada

Abstract

Objective

Patients in Nova Scotia do not have access to public prenatal education programming. This study aimed to explore whether care providers find patients are uninformed or misinformed, and the impact of that on patients and their care providers with a focus on clinical outcomes, time, resources and informed decision-making.

Methods

Semistructured interviews were conducted with 13 care providers around Halifax and Cape Breton. An interview guide (supplemental) of open-ended questions was used for consistency. A descriptive qualitative approach was employed to describe the contents of the interviews. Each interview was audio-taped and transcribed verbatim by an interdependent transcriber. Transcripts were analysed using established techniques in qualitative descriptive research including coding, grouping, detailing and comparing the data using NVivo V.12 software. A co-coder (SS) independently coded two interviews for inter-rater reliability.

Results

The study revealed six themes: (1) concern for a significant population of Nova Scotians experiencing pregnancy, birth and postpartum uninformed and misinformed, (2) consequences for patients who are uninformed and misinformed, (3) more time and resources spent on care for patients who are uninformed or misinformed, (4) patients and their care providers need a publicly available education programme, particularly vulnerable populations, (5) emphasis on programme quality and disappointment with the programme previously been in place and (6) recommendations for an effective prenatal education programme for Nova Scotians.

Conclusions

This study shows care providers believe a public prenatal education programme could improve health literacy in Nova Scotia. Patients are seeking health education, but it is not accessible to all and being uninformed or misinformed negatively impacts patients’ experiences and outcomes. This study revealed excess time and resources are being spent on individualised prenatal education by care providers with high individual and system-wide cost and explored the complicated process of providing patient-centred care for people who are uninformed or misinformed.

Correspondence to Dr Megan Rae Strachan-Whaley; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Diverse perspectives from a range of care providers are a strength of this study.

• Participation was voluntary, and the authors acknowledge that those who offer to participate are also those most likely to have an interest in the topic, which is a limitation of this study.

• The lack of patient perspective is a limitation, though this is an important area for future research.

• This study did not explore why there is no longer a prenatal education programme in Nova Scotia, a possible area for future research.

Introduction

Background

The goals of the WHO prenatal care model are focused on providing pregnant individuals with respectful, individualised, patient-centred care at every contact, including the provision of relevant and timely information and psychosocial and emotional support.¹ Some of the primary goals of Canadian prenatal care include identifying those at risk for complications and providing appropriate education.² The patient and family-centred approach is highly valued in Canadian and Nova Scotian healthcare, and significant emphasis is placed on prioritising the patient experience.³ At the foundation of patient-centred care is autonomy and informed decision-making which requires that the patient understands the diagnosis, the relevant options for treatment (including no treatment), and any respective risks and benefits.⁴ While informing patients is crucial from both legal and ethical perspectives, it is time-consuming and resource-consuming, therefore, situations in which patients have poor health literacy the process of informing patients may be significantly more difficult, requiring individualised time and resources.⁴

Given the emotional and physical challenges associated with pregnancy and birth, routine and uncomplicated experiences could result in poor patient experience and perceived loss of autonomy, even in the absence of overtly abusive practice or care if the patient is uninformed or unprepared for those challenges. It has been shown that events in which patients experience feelings of loss of dignity, fear, helplessness and loss of control can all contribute to postpartum post-traumatic stress disorder (PTSD).⁵ An Italian study found that participation in prenatal classes reduced analgesic use and increased successful practice of recommended coping methods during birth, emphasising the positive impact of being informed.⁶ Primiparous patients (those experiencing their first pregnancy/birth) who reported feeling informed about labour and delivery after attending prenatal classes demonstrated greater knowledge of childbirth and reported less painful childbirth than those who did not.⁷ Indeed, those who reported the greatest level of fear prior to prenatal education also reported lower levels of anxiety during labour if they attended prenatal classes.⁷ One study found that patients who participated in prenatal education experienced greater quality of life and had few complaints during pregnancy,⁸ and a German study found that patients who received prenatal education demonstrated improved mental, physical and sexual health scores during pregnancy and post partum.⁹

Publicly accessible prenatal education programming is available to patients in the other Atlantic Canadian provinces. New Brunswick offers in-person or online courses covering child development from prenatal to adolescence¹⁰ and hospital-specific resources.¹¹ Similarly, Newfoundland offers synchronous courses through Zoom and asynchronous online prenatal classes.¹² Prince Edward Island offers a range of resources including prenatal classes and breast feeding support.¹³ In contrast, there is a distinct lack of available prenatal education in Nova Scotia. There is no provincial prenatal education programming, and the content of private programming are undetermined.

Rationale

The objective of this study was to explore whether care providers find patients are uninformed or misinformed, and the impact of that on patients and their care providers with a focus on clinical outcomes, time, resources and informed decision-making. The specific aims were to (1) explore the impact of the lack of accessible prenatal education on patients; (2) explore the impact of not having publicly accessible prenatal education on care providers who care for Nova Scotians through pregnancy, birth and post partum; (3) explore provider opinions on the current approach to prenatal education in Nova Scotia vs a publicly available population-based approach and (4) explore the knowledge gaps in the patient population and recommendations for prenatal education programming to optimally support improved health literacy for Nova Scotians approaching pregnancy, birth and post partum.

Provision of publicly accessible and targeted prenatal education programming would represent a population-based approach to care. Population-based medicine has many advantages including the efficient allocation of limited resources, responsiveness to specific community needs and enhanced healthcare equity.¹⁴ Health equity is of particular concern in this context where high-risk communities in Canada, such as Indigenous populations, were identified to report negative pregnancy and birth experiences with recommendations to improve patient-centred care practices.^{15 16}

Materials and methods

Study design

This study employed a qualitative descriptive design,¹⁷ which is concerned with summarising and describing the informational contents of the interviews. There is minimal interpretation and data are presented on their own terms.

Participant recruitment

Participants were care providers involved in patient prenatal, birth and postpartum care. Included were three doulas, three family physicians who provide obstetrical care, three midwives, three obstetricians and one nurse focused on obstetrical care. Participants were recruited via department leads through email communication across Nova Scotia including rural communities. Participants were also asked to identify individuals within their programmes/organisations who have an interest in prenatal education (ie, snowball sampling, a purposeful non-probability sampling technique).

Interviews

Data collection occurred from 5 August 2022 to 6 November 2023. Participants were invited to take part in a single semistructured virtual interview using Zoom for Healthcare. The interview questions were created based on the study objectives. The interview guide including open-ended questions is available as online supplemental file. In addition to basic demographic questions, open-ended questions sought to understand participants’ experiences around health literacy and access to prenatal education among Nova Scotians through preconception, pregnancy, birth and post partum. The interviewer was the primary investigator, trained in qualitative methods and supervised by an experienced qualitative researcher. The length of interview ranged from 25 to 60 min. Each interview was audio-taped and transcribed verbatim. No interviews were completed with participants with whom the PI had any personal or professional relationship. No hypotheses were presented to the participants prior to the interview.

Analysis

A number was allocated to each participant and identifying information was removed prior to analysis to protect anonymity. Transcripts were analysed using established techniques in qualitative descriptive research,¹⁷ including coding, grouping, detailing and comparing the data. One investigator (MRS-W) coded all transcripts, with the support of another investigator (SS) who independently coded two transcripts for confirmation of inter-rater reliability. NVivo V.12 was used to manage the coding process. Emergent codes and resulting themes were identified, discussed and refined by the research team through multiple discussions as the analyses ensued.

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination of this work.

Results

Participants were care providers supporting people during pregnancy, birth and post partum in Nova Scotia. A total of 13 interviews were conducted with 3 doulas, 3 midwives, 3 family physicians, 3 obstetricians and 1 nurse. Care providers from multiple communities participated, 3/13 care providers described their patient population as urban, 4/13 described working with a mixed patient population that was mainly urban, 1/13 described working with a mixed patient population that was mainly rural, 5/13 participants described serving a mixed rural and urban patient population. The analysis resulted in six themes explored within the four study aims below and summarised in table 1.

Table 1

Summary of themes and subthemes

	Theme	Doulas	Midwives	Family doctorss	Nurse	Obsetricians	Total	Participants
1	Concern over a population of Nova Scotians proceeding through pregnancy, birth and postpartum uninformed and misinformed	3	3	3	1	3	100	13.00
1.1	Not all patients, but a significant population have very poor health literacy around pregnancy, birth and postpartum	3	3	3	1	3	100	13
1.2	The knowledge gaps and questions asked by patients are most often basic and foundational topics	3	3	2	1	3	92.3	12
1.3	Patients are seeking education around pregnancy, birth, and postpartum	2	3	3	1	3	92.3	12
1.4	Education is not available to everyone seeking it	3	3	3	1	2	76.9	10
1.5	Google, Social media, and blogs are a common source of harmful misinformation	3	3	2	1	3	100	13
2	Consequences for patients who are uninformed and misinformed	3	3	3	1	3	100	13
2.1	Negative birth experience	2	3	2	1	3	84.6	11
2.2	Unnecessary fear/anxiety	3	2	2	0	2	69.2	9
2.3	Unrealistic expectations	2	3	1	1	3	76.9	10
2.4	Increased risk of poor post-partum mental health	1	3	1	1	1	53.8	7
2.5	Trauma	2	3	0	1	1	53.8	7
2.6	Impacts on interventions and clinical outcomes	1	3	1	0	3	61.5	8
3	More time spent on more complicated care for patients who are uninformed or misinformed	3	3	3	1	3	100	13
3.1	Time is a significant barrier	1	3	3	1	3	84.6	11
3.2	More difficult to ensure informed choice	3	2	3	1	1	76.9	10
3.3	More complicated to provide patient-centred care	3	0	3	1	3	76.9	10
3.4	Challenging or even impossible to inform patients while in labour	1	2	2	0	2	53.8	7
4	Patients and their care providers need a publicly available education programme, particularly vulnerable populations	3	3	3	1	3	100	13
4.1	Indigenous populations	2	2	2	1	2	69.2	9
4.2	High-risk pregnancy	1	1	1	0	3	46.1	6
4.3	Newcomers/English as an additional language	0	0	2	1	3	46.1	6
4.4	Those needing mental health support	1	0	1	0	0	15.4	2
4.5	LGTBQ2S populations	2	0	1	1	1	38.4	5
4.6	African Nova Scotians	1	0	3	1	1	46.1	6
4.7	People living with disabilities	1	0	1	0	0	15.4	2
4.7	Teen/younger parents	1	1	0	0	2	30.7	4
4.9	Single parents, IVF pregnancies, people living in larger bodies, people living with addictions	2	0	1	0	2	38.4	5
4.10	Emphasised need for an individualised patient-specific approach as needed	3	2	2	1	3	84.6	11
5	Emphasis on quality and overall disappointment with the programme that had previously been in place	2	2	1	1	3	69.2	9
6	Recommendations for an effective prenatal education programme for Nova Scotians	3	3	3	1	3	100	13
6.1	Normal pregnancy	1	3	2	1	2	69.2	9
6.2	Stages of labour, birth, length of time at each stage, coping/comfort measures, pharmacological and non-pharmacological pain relief	3	3	3	1	3	100	13
6.3	Postpartum as a major gap for patients; feeding, safe sleep, bathing, care and recovery expectations	3	3	2	1	1	76.9	10
6.4	Explanation for screens and tests	0	2	2	0	1	38.4	5
6.5	Vaccine information, intercourse	0	1	1	0	0	15.4	2
6.6	Maternal health, diet, exercise	0	1	2	0	3	46.1	6
6.7	Smoking and cannabis use	0	0	2	0	0	15.4	2
6.8	Role clarity and interprofessional collaboration	2	0	0	1	1	53.8	7

IVF, In-Vitro Fertilization; LGTBQ2A, Lesbian, Gay, Trans, Bisexual, Queer, 2-Spirit, Asexual.

Impact of the lack of accessible prenatal education on patients

Theme 1: Concern over a large population of Nova Scotians proceeding through pregnancy, birth and postpartum uninformed and misinformed.

All 13 participants expressed concern that a large population of patients are uninformed and/or misinformed in Nova Scotia. While care providers explained that not all patients are uninformed or misinformed, they perceive a significant population of patients who have very poor health literacy around pregnancy, birth and postpartum.

Oh, uninformed. Well, both, uninformed and misinformed. Participant #3

Yes. Yes, for sure. Definitely uninformed, and to a certain degree, misinformed as well. …when I arrived in Nova Scotia to start my residency, I was like shocked, to be honest, that there was nothing here. And so, you know, I really think it’s a huge gap in our healthcare system. Participant #6

I’d probably hear some false information at least once a shift, say. I mean not every single patient, but not uncommon. Participant #2

Within this context of a notable patient population found to be uninformed and misinformed, 12/13 participants stated that patients are seeking education and resources, and they are asking a lot of questions. The knowledge gaps described were vast, but the common questions routinely asked by patients were most often described as basic and foundational topics.

I think some of the questions and concerns that you get highlight the lack of overall knowledge of pregnancy and what’s normal in pregnancy. Like a lot of these questions are kind of normal…what we call normal or common pregnancy complaints… there just seems to be this lack of awareness of what to expect in pregnancy, I would say, overall… Participant #7

People sometimes have extremely unrealistic expectations, and very limited understanding of what it is like to have a baby. Participant #13

Accessibility was a common subtheme acknowledged by 10/13 participants, along with concern that prenatal education is not accessible to all patients who are seeking it. Participants also commented on the poor accessibility of resources, midwives and private doula support in rural communities.

I mean realistically, most people that hire doulas are people who have higher socioeconomic status participant #12

It’s all the vulnerable patients who don't have the means who really would benefit from community-driven prenatal classes or hospital-driven prenatal classes that we are lacking. Participant #10

The midwives cited their model of care including prenatal education embedded in their appointments as a common reason for patients to seek their services. One midwife explained that despite high demand, they only have the resources to accept care for half the people requesting their services and deny approximately 50% the requests received. Doulas are a significant source of the private education available to Nova Scotians. All three doulas described spending time volunteering to support people without the means to access their services but also emphasised their inability to independently provide education for the province. Two of the three doulas, along with two other participants acknowledged that the population of patients accessing doula services are more likely to have greater socioeconomic status and education.

…in rural Nova Scotia, I'm not sure how much they learn about resources for prenatal education. And also, I don't know how much resources are available, especially for those clients who don't have the resources to pay a doula or pay for private education. Participant #11

It means that only those who have, you know, the means are able to access quality prenatal education. Participant #4

Theme 2: Significant consequences for patients identified by care providers of being uninformed and misinformed.

When asked how patients are informing themselves within the existing system, all 13 participants identified internet sources including Google searches, blogs and social media as common resources. Furthermore, all participants acknowledged internet and social media as a source of misinformation and/or fear-mongering. The consequences of seeking education independently online were serious and included unnecessary fear, impacts on intervention and unrealistic expectations.

I'm still kind of shocked by the amount of misinformation that’s out there, and how ill-prepared people are for that. Participant #7

There was particular concern for the impact of social media on patient confidence in medical care. Some care providers described situations in which patients were dangerously misinformed and refused to consider provider education. Fear and suspicion fueled by social media was described driving patients’ refusal to consider evidence based medicine.

People might actually be pushed from safer things to have less safe things. The best example there that I can think of would be people coming to you without an indication for a C-section, with absolutely none, wanting it. And not really understanding that a C-section is the highest risk way to have a baby for both you and the baby, and that we only should be doing it for medical indications. But because on (social media), they hear about somebody who had a horrendous tear or who had a stillbirth, which are real but rare complications, they take that…people take that as the gospel truth, and don't really understand the statistics, and aren't really able to understand that, okay, yeah, that can happen, but your risk is like 1 in 1,000, vs your risk of complication of surgery being 8%. So, people are definitely making harmful choices based on what people say online. At the end of the day, that isn't really an accurate assessment of true risk or true benefit. Participant #9

Negative consequences of being uninformed or misinformed for patients were identified by all 13 participants. Among the consequences listed, 11 participants included a negative impact on birth experience, with 10 participants listing unrealistic expectations, 9 participants listing unnecessary fear and anxiety, and 7 participants listing an increased risk of poor postpartum mental health (table 1).

So, uninformed or misinformed definitely can lead to outcomes that are unexpected simply from just simply being blindsided. Somebody can have a completely normal pregnancy and labour and birth, but without having had that prenatal education to expect what does labor feel like, what does it look like, how long does it go on for, what might come up for you during that process? Just that. And then not having… Going into that blindly. Participant #3

I have had moms actually say to me postpartum, “I feel like this is not my child because this child did not come out my vagina.” I feel like, again, there are some negative social media influences that contribute to patients feeling less worthy as mothers if they do not have a vaginal delivery without analgesia. Participant 13

As a consequence of being uninformed or misinformed, and a poor or unexpected pregnancy and/or birth experience, seven participants included birth and postpartum trauma as a potential outcome.

I think from a patient perspective, when they're coming in with less education or less awareness of what’s happening, their risk of trauma is increased. And that’s been shown by studies. Like we see that. We see people that have less awareness of what’s going on, and feel less power in their decisions, they will feel more traumatized by an experience, whether the outcome is positive or not. Participant #8

In addition to negative impacts on patient experience, eight participants described potential impacts on interventions and clinical outcomes.

A lot of (people) have very little expectation or understanding of the second stage of labour. So, like actually pushing and like delivering their baby, which can have a lot of effect on like their pelvic floor health later in life, and those types of things. So, you know, I know that they can access, if they have funds, pelvic floor physiotherapy and stuff like that. We do talk about that a little bit in our prenatal visits. But again, you have to have the resources available to you in order to afford pelvic floor physiotherapy to discuss pelvic floor health and to discuss pushing techniques or positions in labour. So, it’s a lot of onus on the patients themselves. Participant #6

Impact of not having publicly accessible prenatal education on care providers who care for Nova Scotians through pregnancy, birth and post partum

Theme 3: Caring for patients who are uninformed or misinformed requires more time and makes it more complicated for care providers to ensure informed decision-making and patient-centred care.

Limited time is a significant subtheme and identified barrier discussed by 11 study participants. The first evidence of this was during the recruitment stage of this study. Multiple obstetricians voiced an interest in the study but could not make time to commit to an interview. Once recruited, four participants provided interviews from their cell phones while working and one provided their interview in a closet. A participant interviewed while on a half hour lunch between clinics, another interviewed while a patient was in early labour and did not yet need them and was interrupted by regular updates. The time constraints for primary care providers were staggering. Multiple care providers interviewed in the evenings from home, and several had to reschedule because of extra call shifts or unexpected delays. All six physicians noted time as a factor that limited their capacity to provide prenatal education with the current individualised approach. This was often described in the context of needing to prioritise primary care within the limited appointment time.

All the time, there’s more things that we have to do. And I'm finding in prenatal care, that’s one of the things, too. We're, you know, sending people for iron transfusions when we never used to before. And there’s… It’s just there’s more and more and more and more. And so it’s one of those things that isn't urgent medical care and so we don't get to it. I don't get to it. Participant #5

The set-up for caring for prenatal patients, the way it’s set up. It’s set up so that there’s five-to-ten-minute visits. And you can't accomplish what you need to accomplish in that time. So, it needs to be supplemented with either group prenatal or prenatal education. Participant #3

Both individual and systemic impacts of not having publicly available prenatal education on care providers of Nova Scotians were identified. When discussing individual approaches to prenatal education for patients, care providers described widely variable approaches and time spent assessing, organising and providing relevant resources. The midwives use a patient binder of resources and checklists for each patient to ensure an organised and consistent approach. Despite access to this resource and the allowance of 30–45 min appointments, the midwifery participants still expressed concern over limited time to adequately provide prenatal education in addition to primary care. Two of the three midwives described efforts and discussion around the need to implement publicly accessible prenatal education for Nova Scotians as a serious healthcare gap. The six physician participants all had variable and independent approaches to prenatal education including the use of out-of-province resources, and even integrating the services of a doula into their practice. Of the six physician participants, three expressed frustrations about situations when they did not have time to provide education or discuss prenatal topics with their patients to their satisfaction.

You do the best that you can within the limitations of a system that is strained to the max. But again, when it’s strained to the max, unfortunately at the end of the day, what takes priority is going to be the medical stuff—talking about their blood pressure medications, their insulin, or whatever. And you just aren't left with adequate time to give them more information about the more general things. And the other piece of that, too, is information overload for patients. So, if you've just had a really… You know, you've just told someone like,” Oh, your blood pressure is getting worse. We have labs. You might have preeclampsia. We might need to induce you early,” they're not going to be thinking of the question that they came in with about like what are my options for pain control? Who can be in the room? Because you've just made it like it’s very serious now, and they're focused on that. So that’s another element of it, too, I think. That there is too much information in one visit. Participant #9

When considering the process of patient-centred care and informed consent, 11 participants felt this was a more difficult and time-consuming process for patients who are uninformed or misinformed. Without publicly available prenatal education, significant time is spent determining what people know and what they need to know at the moment to fill in knowledge gaps. The importance of informed decision-making and the complicated nature of informing patients who are uninformed or misinformed was identified by 10 of the participants.

From a provider perspective that (supporting uninformed or misinformed patients to make informed choices) requires a lot more time and a lot more care in explaining everything, you know…And sometimes those moments, there’s not a lot of time or space to be doing that. So, I think that that puts the provider in an awkward position where they might need to make decisions quickly, but also, they need to get an informed choice from the patient. Participant #8

it’s probably not very informed consent because people are in pain, people are angry…or not angry, people are anxious, they're worried. And so, it will have an impact. You know, I think we like to fool ourselves that even though we're giving all the information, it’s being accepted. But it’s likely not. Yeah. Participant #5

One subtheme that was emphasised by seven participants was the difficulty and sometimes impossibility to adequately inform patients while they are in labour. Participants described an altered mental state during labour, limited time in emergencies to adequately explain the situation and all options, and the difficulty of determining whether the labouring person really understands the information being communicated. Some participants felt that patients cannot be informed adequately during labour, and that this process needs to happen beforehand.

if you have to pull somebody out of their labour, you know, emotionally and cognitively, to say, I know you're in the middle of this but we need to actually ask you this question, that’s a challenging thing to do… And then if you have somebody that’s completely uninformed, that makes it even more tricky because you're dealing with a time sensitive situation, right? … And then you might have two min in between contractions to try to have informed decisions. So, this is a conversation that amongst providers we've had for years—Can you truly get informed decision-making during the course of labour? I would say no. That’s why you have to make sure you do it prenatally. Participant #3

In the heat of the moment, in an emergency on labour and delivery, is not an optimum time for full consent in a variety of sort of topics. Participant #13

One physician described frustrations about situations when there is not enough time to inform a patient adequately, and their concern that this could impact interventions and clinical outcomes. Time and resource shortages as a strain on our current healthcare system were also identified, including the ongoing physician shortage, and an interest in relieving the individual burden on family physicians.

I just don't have that opportunity, and I don't have the time. And I'm not the person that should be doing it, is the other thing, right? Like, you know, there’s a certain amount of patient education that physicians should do. But we really need to, with a physician shortage… I mean whether it’s a physician… I don't think it’s a physician shortage, I think it’s a lack of appropriately allocating resources where they're best used. Me talking to people about prenatal education is not the best use of my time, and it’s not the best way to get that information to the patients. Participant #5

In addition, unintentional misuse of the system as a consequence of patients being uninformed or misinformed was identified as a systemic burden that could be relieved with publicly available prenatal education.

I also think it impacts like visits to our healthcare system. Like it’s not uncommon for me to see someone in the early labour assessment unit who’s come to be checked out because it’s their due date, and they're wondering when they're going to go into labour. So that’s an entire like emergency department visit, essentially, that could be completely avoided. Participant #6

Provider opinions on the current approach to prenatal education in Nova Scotia versus a publicly available population-based approach

Theme 4: Nova Scotians and their care providers would benefit from a publicly available prenatal education programme, particularly for certain at-risk populations without means or access to private education.

All participants believed Nova Scotians need a publicly available and accessible prenatal education programme. The reasons for this need included reduced burden on the healthcare system, clarification of province and hospital-specific policies and protocols for patients and improved individualised education for specific populations who they felt would be most at risk of negative consequences of being misinformed or uninformed. Participants also emphasised the need for an individualised patient-specific approach for these populations.

I mean most definitely having a population-based approach is going to reach more people. And I think it would act to me if as a launching off point for discussion in individual cases where they may deviate from the population, the norm, and that sort of thing. So, some sort of baseline to give parents some more comfort and self-assuredness going into the process. But if there are things that they read that they want to know more about or talk more about, or ask clarity around, it allows them to bring those questions to their care provider. Participant #10

While all 13 participants felt a publicly available population-based approach to prenatal education would benefit Nova Scotians, 12 participants wanted both population-based and individualised programmes and included the caveat that a population-based programme would greatly enhance but could not replace individualised education. Indeed, the same populations they identified as at risk of experiencing the negative consequences of being uninformed or misinformed were felt to need greater accessibility and individualised education and support. Of the populations identified, nine participants felt a culturally competent/decolonised approach was needed for Indigenous populations, six identified patients with high risk or complicated pregnancies requiring more individualised education, five mentioned inclusive education for non-traditional families including Lesbian, Gay, Trans, Bisexual, Queer, 2-Spirit, Asexual (LGTBQ2A) populations, six identified the need for health literacy support among newcomers to Canada and/or people who speak English as a second language, six included cultural competency for African Nova Scotians, four identified teen/young parents and two participants mentioned two or more of single parents in-vitro fertilization (IVF) pregnancies, people living with disabilities, people living in larger bodies and people needing mental health and/or addictions support.

Well, I mean I think, like to nobody’s surprise, if they’re BIPOC patients, if they're low SES patients, if they’re patients who are on disability, are patients who have housing instability and addictions, you know, if they’re patients who… You know, it’s all of our English second language patients who are coming from all over the world for a better life in Canada who need access to resources in their own language. Participant #5

Colonialism skews a lot of everything we do day-to-day, whether we see it or not. And just be mindful that some of these recommendations often are very paternalistic, and often not very culturally safe or aware. So, I think being mindful that we probably need a different or an integrated cultural safety approach. And trans care is another big one. So being mindful of language. Participant #1

What knowledge gaps exist in the patient population and recommendations for prenatal education programming to optimally support improved health literacy for Nova Scotians approaching pregnancy, birth and post partum.

Theme 5: Disappointment with the programme that had previously been in place and emphasis on the importance of quality and the usefulness of the content if a programme were to be developed.

Six of the participants were knowledgeable about and had experience with the previous public prenatal education programme and expressed overall disappointment with its usefulness and relevance to patients. These six participants described the prior programme as very provider-centric, with a focus on hospital protocols and procedures rather than preparing patients for pregnancy, labour and post partum.

A lot was excluded. Like what a physiological birth actually can look like. And I get it. They don't have… You know, everyone’s strapped for time and resources. So, you know, no shame or blame. But, yeah, it’s super basic. “Here’s the room. Here’s the drugs. This is how you're going to get checked in, and where you're going to deliver your baby.” Participant #8

They emphasised the need to include information about the patient experience of pregnancy, birth and post partum. They felt the public education that was previously available to Nova Scotians failed to prepare patients or provide helpful information. Indeed, one participant had attended the previously available classes and commented that there was pressure to breastfeed without any information about how to do it or what to expect with infant feeding.

There was no description of how to breastfeed. Which seems insane to me in a breastfeeding class. That that’s great if you want to try and convince everybody why it’s important. However, it’s incredibly difficult at the same time. And there was zero discussion of that. Participant #12

Infant feeding was addressed by nine participants, and the pressure to breast feed as a source of misinformation, unrealistic expectations and postpartum difficulty was discussed by six participants. They described observing patients’ feelings of failure, exhaustion and poor mental health when faced with the reality of breastfeeding unprepared.

We have so much focus on breastfeeding, which I’m a hundred percent of a believer in. But there also needs to be more understanding around the…not implications of formula feeding, but, you know, how to support people that are formula feeding as well, or hybrid feeding. Because there’s a little bit too much guilt out there. And I think women and moms deal with enough guilt that we don't need that. Participant #3

It leads to a lot of feelings like of worthlessness as a parent, it impacts bonding when you don't know that this is normal, and don't have the tools to manage it. Participant #10

Theme 6: Recommendations for an effective prenatal education programme for Nova Scotians.

The need to explain normal pregnancy was emphasised by 9 participants, along with a discussion about the need to support health literacy and optimal outcomes around pregnancy, birth and post partum by all 13 participants. This subtheme emerged in discussions around common knowledge gaps and in discussions around recommendations for an effective prenatal education programme. Similarly, all 13 participants felt a need to provide a realistic explanation of labour and birth experience with an emphasis on topics including the physiology, stages of labour, length of time at each stage, coping/comfort measures, pharmacological and non-pharmacological pain relief, interventions and their purpose/risks/benefits. Post partum was a significant gap in care that 10 participants expressed concern about. The lack of support and resources for postpartum care by physicians was a source of frustration and disappointment across professions.

It’s the time I think when the internal struggle takes place. It’s not talked about. Postpartum mental psychosis only really makes the news when it’s major. Somebody, you know, dies. And so much of it is preventable. Participant #3

The potential consequences of failing to provide education and care around postpartum included unrealistic expectations, difficulty with infant feeding, parental guilt and poor postpartum mental health. This was emphasised among recommendations by 10 participants, particularly around topics like feeding, safe sleep, bathing, care, recovery and realistic expectations.

Just honesty around that this is also work, and this is not the pictures you see in books …You are not the only one who has this pain, and you need to figure out breastfeeding, and you are over-tired and you are overwhelmed. This is normal. Everybody experiences it. So, I think that’s the other thing I always highlight to my clients. To say, “No, no, no, you don't hear about it, but this is the reality for everybody. Participant #11

Smoking and consequences of cannabis use were recommended topics by two participants who had safety concerns about misinformation around these topics. Healthy lifestyle topics such as nutrition, exercise and foods/substances to avoid were recommended by six participants. The importance of explaining various screens and tests including their purpose, the meaning of possible results and what are the next steps was included in recommendations by five participants. Other topics recommended by participants included clarifying misinformation and myths around things such as episiotomies, vaccines and intercourse to reduce unnecessary fears and anxieties, and an emphasis on role clarity and scope of practice for different care providers.

You know, a birth plan is a great thing to have. It means you've been thinking about what you want in your labour. But a lot of the things that they're requesting are things that we would always do or always offer. And so, it’s sad to me that they think, you know, that they would be concerned that we wouldn't offer those things. Like explaining everything as we go, or offering pain medications, or like, you know, like routine stuff that I would hope everyone does. And patients are obviously coming in worried that they're not going to get that care. So that’s another interesting component of the lack of prenatal education Participant #6

I mean sometimes patients treat me as though as I'm a rampaging maniac wandering around with a scalpel who wants to cut babies out of people for fun. Nothing could be further from the truth, especially at 3am when I want to be in bed. But people don't understand these ideas of safety and risk. Participant #13

One subtheme that was identified by seven participants was a need for improved role clarity for patients and interprofessional collaboration. This was often emphasised in discussions around creating an effective and relevant programme targeted to Nove Scotians.

Just making sure that all of the stakeholders, as many as possible, can be involved. So even including, if it’s appropriate to your study, I don't know, but even involving the patients, and making sure that you draw out some of those who are not your typical husband and wife. Participant #2

So that the same information is being shared. So it isn't necessarily, you know, oh, well, the midwives say this, but the family medicine say this, and the OB say this. Participant #3

Discussion

The purpose of this study was to explore the impact of not having a publicly available prenatal education on Nova Scotians and their care providers. The first aim was to explore whether and the extent to which Nova Scotians approaching pregnancy, birth and post partum are informed, and the consequences of being uninformed or misinformed. Participants of this study expressed concern for a significant population of Nova Scotians they perceived to be proceeding through pregnancy, birth and postpartum uninformed or misinformed. Furthermore, participants identified serious consequences for patients including negative birth experiences, unnecessary fear and anxiety, unrealistic expectations, increased risk of poor postpartum mental health, trauma and potential impacts on clinical outcomes. These results are consistent with other studies that have shown a positive correlation between being informed and positive pregnancy, birth and postpartum experiences and outcomes.

Factors known to facilitate a positive birth experience from the literature include having a sense of control during birth, opportunity for active involvement in care, and support and responsive care from others.¹⁸ Maternal Perinatal Self-Efficacy (MPSE) is a pregnant individuals believe in their capability to cope with and manage birth, with higher MPSE considered protective and lower MPSE associated with fear and negative outcomes.¹⁹ The goal of prenatal education is to increase knowledge and empower patients, and prenatal education has been shown to improve MPSE during childbirth.¹⁹ One study found that for patients with pregnancy complications resulting in preterm birth hospitalisation, an education programme provided a foundation of knowledge that supported informed choices.²⁰ A Chinese study showed that attendance at a prenatal education course significantly reduced the rate of caesarean section on maternal request, suggesting that being informed could reduce caesarean section rates in that population.²¹ A longitudinal quasi-experimental study in urban Japan showed that prenatal education programme decreased postpartum depression and increased maternal confidence.²²

The most devastating potential consequence of being uninformed or misinformed identified by participants was birth trauma and postpartum PTSD which has been well established, though poorly explored in the literature.²³ It has been estimated that approximately one-third of individuals will experience birth trauma, and one-third will continue to experience symptoms from their trauma 4–6 weeks after their birth.^{24 25} Feelings of powerlessness, loss of choice and withholding of explanations are all key correlates with traumatic birth experiences, with studies emphasising the importance of being informed and autonomous informed decision-making to protect patients from traumatic birth experiences.^{23 26–28}

Since participants described a significant population of Nova Scotians with poor health literacy around pregnancy, birth and post partum, this study explored how patients were accessing information without public education programmes available to them. When discussing where and how patients access information, participants overwhelmingly felt the internet was the most common source. Furthermore, participants expressed significant concern that the internet was a major source of misinformation and fear-mongering in the form of ‘mommy-blogs’ describing horror stories, and misinformation from other provinces or countries.

These observations are consistent with a Canadian study that found pregnant individuals placed little importance on their mothers’ or grandmothers’ birth experiences but were influenced strongly by ‘horror stories’ provided by friends or the media.²⁹ Indeed, people’s decisions were often heavily influenced by media sources including the portrayal of pregnancy and birth on television, with individuals often explaining how misleading and incorrect this information was, leaving them feeling unprepared.³⁰ Those with access to midwifery care received most of their prenatal education from midwives prior to their birth while those cared for by physicians were more likely to attend prenatal classes.³⁰ One study asked people to report levels of helpfulness for various resources and found that information and advice provided by health professionals were rated more helpful than books and leaflets, which were still rated more helpful than information accessed on the internet, personal experience or information provided by friends and family.²⁹

The second aim of this study was to explore whether specific populations might be at greater risk of experiencing the consequences of poor health literacy around pregnancy, birth and post partum. Participants identified particularly vulnerable patients in Nova Scotia as those most at risk of experiencing the consequences of being uninformed or misinformed, including Indigenous populations, African Nova Scotians, high-risk pregnancies, newcomers and those speaking English as a second language, those needing mental health support, LGTBQ2S populations, people living with disabilities, teen/younger parents, single parents, IVF pregnancies, people living in larger bodies and people living with addictions.

The disparities in health and healthcare between Indigenous and non-Indigenous Canadians are increasingly identified in the literature, and the systemic racism that leads to worse health outcomes, premature death and limited economic opportunities is identified in the Truth and Reconciliation Commission 94 Calls to Action.³¹ Indigenous people in Canada have twice the risk of maternal mortality in comparison to non-Indigenous Canadians.^32–34 Additionally, Indigenous patients experience greater rates of adverse outcomes including stillbirth, perinatal death, low birthweight infants, prematurity and infant death.^32–34 A recent study has also demonstrated a significant disparity in prenatal healthcare between Canadian’s with disabilities and those without, including higher rates of inadequate or no care for Canadians living with disability.³⁵

Our third aim was to explore the impact of having no publicly accessible prenatal education programme on care providers who care for Nova Scotians through pregnancy, birth and post partum, with a focus on time, resources and informed decision-making. Participants shared their experiences that lack of access to prenatal education requires excess time and resources that participants felt could be better spent on primary care and more individualised care if a population-based programme were available. While participants emphasised the need for patients to have access to individualised education according to their specific needs, they felt a prenatal education programme could provide a foundation from which care providers could work to support more individualised care.

Participants felt that informed decision-making was more complex for patients who are uninformed or misinformed and felt this could negatively impact patient-centred care. Participants across professions emphasised the difficulty, and sometimes even the impossibility of adequately informing patients while in labour, and the importance of facilitating informed decision-making prenatally. These observations are also supported by the literature. A Norwegian study that included interviewing primiparous parents after uncomplicated, vaginal non-instrumental births to healthy babies found that the timing of information was crucial.³⁶ People who were informed prior to birth were more likely to make informed decisions while many people described being unable to attend or care about information given during their birth to support decision-making.³⁶

This study provided a unique opportunity to explore expert recommendations to support health literacy around pregnancy, birth and post partum for Nova Scotians. Our fourth aim was to identify care providers’ recommendations for prenatal education programming to optimally support improved health literacy for Nova Scotians approaching pregnancy, birth and post partum. All participants felt the basic fundamentals of normal pregnancy, birth and/or post partum are important topics for an effective prenatal education programme. In addition, when discussing the types of questions and concerns that patients commonly brought to them, participants found people most often had questions about normal and expected pregnancy and birth-related outcomes. This highlights not only as massive knowledge gap in the Nova Scotian population but further demonstrates the potential impact of a very basic prenatal education programme. Another important topic recommended by participants included hospital and province-specific information because patients are accessing the internet to become informed and are often accessing resources from other provinces or countries, sometimes leading to unrealistic expectations. A Canadian study identified the impacts of unrealistic patient expectations including patient understanding that they would have different options when it came to position, pain management, monitoring and the presence of different attendants at their births but complained of being denied many of those choices at the time of birth.³⁰ Participants were particularly distressed about hospital-based generic prenatal education, which often included information for people at different hospitals in completely different provinces and thereby misinformed them about the options that would be available once they arrived.³⁰ The level of feeling informed and prepared after prenatal education depended on how relevant the information was to their birth experience.³⁰

A related theme discussed by participants was an overall disappointment with the discontinued publicly available education programme that had previously been available. Many participants felt the previously available programme was provider-centric and failed to inform patients about key topics around basic pregnancy, birth and post partum. While prenatal education is important, there is documented concern for the quality of prenatal education.^{37 38} One group found that hospital-specific prenatal education programmes focused more on preparing patients for compliance with hospital preferences and obedience than on education about pregnancy, birth or post partum.³⁷ Alternatively, the importance of targeted and quality prenatal education for families at elevated risk of negative pregnancy or birth outcomes was demonstrated by a study that showed psychoeducational programmes reduced the incidence of birth complications in people at elevated risk.³⁹ The authors correlated enhanced birth outcomes with reductions in public and personal healthcare costs.³⁹

Diverse perspectives from a range of care providers is an important strength of this study, but there are some limitations. Participation was voluntary, and the authors acknowledge that those who offer to participate are also those most likely to have an interest in the topic. The lack of patient perspective is a limitation, though this is an important area for future research. Other future directions for this work include assessing the current baseline health literacy in the population and implementing a programme to determine whether a prenatal education programme improves health literacy in Nova Scotia. It would also be useful to correlate improved health literacy to outcomes like birth experience, postpartum and clinical outcomes.

Conclusions

The results of this study suggest that failure to provide public prenatal education is a potential contributing factor for a significant population of Nova Scotians proceeding through pregnancy, birth and postpartum uninformed or misinformed. Participants of this study noted the lack of prenatal education could be a contributing factor to their observation that patients are accessing misinformation via social media and internet blogs. The most vulnerable patient populations were identified as most at risk of experiencing the consequences of being uninformed or misinformed including Indigenous people, LGTBQ2S, African Nova Scotians and people living with disabilities. Furthermore, participants expressed concern regarding the serious potential consequences of being uninformed or misinformed including poor birth experience, poor postpartum mental health, trauma and altered clinical outcomes. The task of ensuring informed decision-making for patients who are uninformed or misinformed was described as much more complicated, and potentially even impossible if patients are labouring when care providers are trying to provide information. Participants further acknowledged that the extra responsibility to provide prenatal education is a time and resource burden to an already strained healthcare system.

Topics recommended by participants to include in a prenatal education programme were primarily focused on the fundamentals of pregnancy, birth and post partum. Participants described a need for basic education that is accessible and relevant for everyone so that care providers could then use a foundation for individualised care. Recommendations also included targeted hospital and province-specific information and improved role clarity for patients to avoid confusion and reduce unnecessary fear and anxiety. The importance of patient-centric education and the need for exploration of all options to facilitate informed decision-making was emphasised, with an overall disappointment with the discontinued programme that was previously available.

Data availability statement

Data are available on reasonable request. The datasets generated and/or analysed during the current study are not publicly available given the qualitative nature of these data but are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Research ethics board approval was granted by the Nova Scotia Health Research Ethics Board (REB file #1028264). All methods were carried out in accordance with institutional guidelines as well as the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. Informed consent was obtained from all subjects involved in the study via consent discussion and signed consent forms.

Footnote

Contributors MRS-W and RU conceptualised the study. MRS-W and CJB managed patient recruitment. MRS-W managed consent and data collection. MRS-W and SS completed the formal analysis. MRS-W is the guarantor author who prepared the original manuscript draft. All authors read and approved the final manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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