Original Investigation

Awareness of Pregnant Women About Routine Applied Screening Tests and Supportive Treatments in a University Hospital

10.4274/imj.galenos.2019.20280

  • Ruhuşen Kutlu
  • Latife Uzun
  • Nazan Karaoğlu
  • Hüseyin Görkemli

Received Date: 24.07.2019 Accepted Date: 13.12.2019 IMJ 2020;21(1):71-77

Introduction:

In this study, we aimed to evaluate the awareness of pregnant women about routine applied screening tests and supportive treatments in a university hospital and the factors affecting this.

Methods:

This observational, descriptive study was carried out between 15th April and 30th November 2018. Four hundred and ninety-three volunteer pregnant women who applied to the Necmettin Erbakan University Meram Faculty of Medicine outpatient clinic for the first time or were being followed up formed the study cohort. In order to determine sociodemographic characteristics, awareness of screening tests, and supportive therapies, and the factors affecting this, a questionnaire consisting of 36 multiple-choice, open-ended questions was applied through face-to-face interviews.

Results:

The median age of the participants was 27. More than half (57.4%) were graduated from primary school or did not receive education, and 89.0% were unemployed. The majority of the participants stated that they knew screening tests (92.1%) and supportive treatments (93.9%). Forty-eight point one percent and 44.0% of screening tests and supportive treatments were learned from obstetricians, respectively. The reason stated by 57.6% of the participants who did not want to have screening tests was, “I find it unnecessary because I do not want to end my pregnancy”. Participants who were 27 years old or older (p=0.021), who were at least high school graduates (p=0.016), who were employed (p=0.041), and who had given birth before (p<0.001) knew the screening tests more significantly.

Conclusion:

The study results showed that the awareness of pregnant women about screening tests and supportive treatments increased with increasing maternal age, education level, employment status, and the number of births. Although the percentage of getting information from healthcare workers about screening tests and supportive treatments was higher, it was still not at the desired level. Therefore, we believe that healthcare workers should be more sensitive to informing and counseling during prenatal care, especially for young and loweducated mothers living in rural areas.

Keywords: Prenatal care, screening tests, supportive treatments, pregnancy

Introduction

Complications in pregnancy, birth, and puerperium in developing countries are the leading causes of morbidity and mortality among women of reproductive age. According to the “National Maternal Mortality Study” data of the Ministry of Health in our country, 25.5% of maternal deaths during this period were due to not receiving any prenatal care (PNC), and 23.6% were due to receiving low-quality PNC (1). With the implementation of sufficient and qualified PNC services, the maternal mortality rate dropped to 14.7 in 2016 from 64 in 2002 per hundred thousand live births, and the infant mortality rate dropped to 7.3 in 2016 from 31.5 in 2002 per thousand (2).

PNC is the follow-up of the fetus and mother by trained health personnel at regular intervals during pregnancy by making necessary examinations and making recommendations in order to ensure that mothers have a healthy pregnancy and deliver their babies in a healthy way (3). In the PNC management guide created by the Ministry of Health, examinations, measurements, tests, and consultancy services that need to be performed during at least four follow-ups are defined, including one within the first 14 weeks, at 18-24th weeks, 30-32nd weeks and 36-38th weeks (2).

Periodic checks and screening tests during pregnancy allow early detection of high-risk pregnancies (4). In addition to the dual screening test on the 11th-14th week of pregnancy, ultrasonography (US) examination performed on the same day measures the nuchal thickness of the fetus and the presence of nasal bone. The triple screening tests are performed during the 16th-18th week of pregnancy (5,6). The detailed US is evaluated by experienced physicians at 18-23rd weeks (7). Gestational diabetes screening is held between 24-28th weeks. However, these tests should be performed in the first trimester in pregnant women with a history of gestational diabetes, macrosomic baby (>4.500 gr at birth), polyhydramnios, anomaly, unexplained fetal or newborn death, diabetes in close relatives, and pregnant women with a body mass index of ≥30 kg/m2 (8,9).

Within the framework of the “neonatal tetanus elimination program”, the first dose of the tetanus vaccine is applied at the 4th month of pregnancy or in the first encounter, and the second dose at least four weeks after the second dose (2,7). During pregnancy, which is an anabolic process, energy, vitamin, and mineral needs increase. For this reason, folic acid, iron, and vitamin D supplements are recommended to each pregnant woman by the Ministry of Health (10).

In our country, the level of knowledge about the pregnancies of expectant mothers and the sources from which they obtained this information are quite limited. However, it is thought that wrong or incomplete information negatively affects the view of pregnant women to screening tests and supportive treatments. For this reason, primary healthcare professionals have essential duties.

In this study, we aimed to evaluate the awareness of pregnant women about routine screening tests and supportive treatments in a university hospital and the factors affecting this.


Methods

All pregnant women who applied to Necmettin Erbakan University Meram Faculty of Medicine outpatient clinics for the first time between 15 April 2018 and 30 November 2018 or who were still in the follow-up and who agreed to participate in the study were included in this observational and descriptive study.

Since it was not known how many pregnant women would come and agree to participate in the study with the random sampling method since it was a cross-sectional study, it was assumed that the number of individuals in the universe was unknown, so it was planned to reach at least 377 pregnant women with 5% margin of error and 95% confidence interval (CI), and it was planned to include at least 414 people in the study by adding 10% to this number due to the possibility of not filling the survey questions. In keeping with the planned date range, 493 voluntary pregnant women were included. Also, the prevalence of the event was unknown since the subject being studied was not a clinical condition. According to the size of the sample determined by random sampling in this way, a pregnant applying to the outpatient clinic was a part of the universe.

The questionnaire form prepared by the researchers was applied to ten pregnant women, and the questionnaire form was finalized after the necessary corrections were made to the questions. A 36-item questionnaire was filled with face-to-face interviews, including questions aimed at obtaining socio-demographic information such as age, profession, education level, age of spouse, education status of spouse, kinship status, smoking, previous pregnancy and questions about birth process if they had given birth, knowledge about the screening tests given in options, source of this information, questions about their current pregnancy, and the recommended screening and supportive treatments (folic acid, multivitamin, vitamin D, and iron supplement) and the attitudes of pregnant women to these. One of these questions is open-ended, and it is about the reason for not wanting a screening test. Answers to this question are categorized, as “I find it unnecessary because I do not want to end my pregnancy”, “I think it will harm the baby”, “I do not want to have a triple test because the double test is normal”, “It could not be done because the time to be done has passed” and “I do not find it reliable”.

The ethical permission of the study was taken before the study, with the number of 2018/1259, dated 16.03.2018, from the Ethics Committee of Necmettin Erbakan University Meram Faculty of Medicine, Pharmaceuticals and Non-medical Researches Ethics Committee. The participants were informed about the study, and their written and verbal consents were obtained according to the Helsinki Declaration principles.


Statistical Analysis

While evaluating the findings obtained in the study, SPSS for Windows 21.0 was used for statistical analysis. Frequency, mean, standard deviation, median, minimum, and maximum values ​​were calculated. In the comparison of categorical data, a chi-square test was used. Results were evaluated at a 95% CI and significance level at p<0.05.


Results

The mean age of 493 pregnant women aged 16-47 years who participated in the study was 27.6±5.8 years (median age: 27). Two hundred and eighty-three (57.4%) had primary education or less, 89.0% (n=439) were unemployed and 11.4% (n=56) were relatives with her spouse. While 7.1% (n=35) of women stopped smoking when they learned about pregnancy, 3.3% (n=16) continued to smoke. Various socio-demographic data of the participants are shown in Table 1.

Regarding first control, 46.5% of pregnant women (n=229) applied to a state hospital, 19.7% (n=97) to a private clinic/private hospital, 17% (n=84) to a university hospital, and 14.8% (n=73) to a family health center. The mean gestational age was 22.8±10.2 weeks (median: 22 weeks). The vast majority of pregnant women (n=474, 96.1%) conceived naturally and 36.1% (n=178) were nulliparous. Four hundred and sixty-two (93.7%) women included in the study stated that they applied to the family physician they were affiliated with. When the health problems arose during pregnancy were examined, seven had hypertension, 18 had diabetes, 12 had thyroid disease, 27 had anemia, and 18 had a clotting disorder.

The majority of participants (n=454, 92.1%) stated that they knew the screening tests. When the source of information was asked to women who knew about screening tests, 52% (n=236) stated that they learned from gynecology and obstetrician, 14.5% (n=66) from a family physician, and 32.4% (n=147) from experience from a previous pregnancy. Table 2 shows the state of knowing screening tests and supportive treatments.

The most common test (n=445, 90.3%) that the pregnant women participating in the study had or asked to have was the detailed US. Table 3 shows the status of having/not having screening tests done. When women that did not want to have screening tests were asked for the reason, 57.6% (n=208) of the participants answered as “I find it unnecessary because I do not want to end my pregnancy”, 19.4% (n=70) as “I think it will harm the baby”, 10% (n=36) as “I do not want to have a triple test because the double test is normal”, 7.8% (n=28) as “It could not be done because the time to be done has passed”, and 1.9% (n=7) as “I do not find it reliable”.

The relationship between the knowledge of the screening tests and educational level, age, working status, education level of the spouse, number of pregnancies, and birth status were statistically examined. Awareness of screening tests was found to be statistically significantly higher in patients aged 27 years or older (p=0.021), with high school or more education (p=0.016), employed (p=0.041), and those who had given birth before (p<0.001) (Table 4).

The majority of the participants (n=463, 93.9%) stated that they knew supportive treatments. Information sources for screening tests and supportive treatments are shown in Table 5. Among the supportive treatments, the highest awareness was found in vaccines during pregnancy. Four hundred and seventy-one women (95.5%) participating in the study stated that they had the vaccines during pregnancy or wanted to have them. Table 6 shows other recommended therapies and the usage status of them. Three hundred and forty-two (69.4%) women answered the question, “Should the family physician play an effective role at the community level in promoting supportive treatment during pregnancy?” as “I totally agree”.


Discussion

Mothers having a healthy pregnancy and the birth of healthy babies are the cornerstones of public health. For this reason, screening tests and supportive treatments, which are among the components of PNC, are critical. In our study, we examined the factors that affect the compliance of screening tests and supportive treatments applied to the expectant mothers who applied to the pregnancy clinic of our hospital and the factors that affect their compliance, if any.

While the highest fertility rate in our country was in the 20-24 years age group in previous studies, it was observed in the 25-29 years age group in Turkey Demographic and Health Survey (TDHS)-2013. This result indicates that pregnancies are delayed to the advanced ages in Turkey (11). Similarly, the median age of mothers was found to be 27 years in our study. According to the TDHS-2013 report, 81% of women were living in urban areas, 44% of women in the 25-29 years age group and 18% of women in the 45-49 years age group were at least high school graduates, and 31% of women were employed during the study (11). Similarly, in our study, 73.8% of the participants lived in the city center of Konya, and 49.9% of them had high school and above education. Unlike the TDHS report, in our study, 89% of pregnant women were housewives, and only 11% were employed.

According to the 2016 Turkish Statistical Institute data, rates of consanguineous marriage in our country is 23.2% (12). In our study, the rate of consanguineous marriage was found to be 11.4%. Although this result is evaluated as a positive development for our country, it is necessary to know that the study sample and the place where the study was conducted may also be effective in this difference.

Smoking during pregnancy increases risks such as miscarriage, premature birth, low birth weight, and sudden infant death, causing severe harm. In our study, 87.6% of the participants stated that they did not smoke at all, 2% stated that they quitted before pregnancy, 7.1% stated that they quitted when they learned their pregnancy, and 3.3% stated that they were still smoking. In studies conducted in England and Scotland, it was reported that one in four women smoked before or during pregnancy, and one in eight women continued smoking during their pregnancy. In a study conducted in Romania, it was reported that 30% of the interviewed mothers were smoking before pregnancy and that 43.3% of them continued smoking during pregnancy (13,14). In a study conducted with 513 pregnant women in Italy, 22.3% of the participants continued to smoke during their pregnancy and claimed that they continued smoking during their pregnancy because they received very little information about this subject during their examination (15). Pirdal et al. (16) reported that 79.4% of pregnant women never smoked in their lives, 18.1% stopped smoking during pregnancy, and only 2.5% continued smoking during pregnancy. These examples in the literature highlight the importance of providing more information about the risks of smoking in pregnancy during PNC, as women planning pregnancy and currently pregnant women are a high priority target group for smoking cessation interventions.

In our study, 93.7% of the pregnant women stated that they admitted to the family physician they were affiliated with, and 46.5% stated that they admitted to the state hospital for the first examination. In the study of Kurnaz et al. (17), 94.0% of the participants stated that they had a pregnancy record in the family physician, and 43.4% stated that they went to the family health center for the first control. In the study conducted by Durusoy et al. (18) in İzmir, the rate of pregnant women who were followed up by the family physician was 85%, and the place for first control was state hospital with a rate of 33.2%. We think that this may be due to the idea that pregnant women apply to hospitals in order to learn the baby’s gender or that they believe they should be examined by an obstetrician, even if the pregnancy is not risky at all.

In our study, the participants stated that they had or they wanted to have a double test (57%), triple test (46%), glucose challenge test (53.5%), and detailed US (90.3%) performed. In the study of Potur et al. (19), it was reported that 70.3% of the pregnant women had a glucose challenge test, 59.5% had a double test, and 48.6% had a triple test. In the study conducted by Desdicioğlu et al. (20), 72.25% of the pregnant women stated that they had or wanted to have all screening tests. In the study of Bilgin et al. (21), out of 300 pregnant women, 192 answered yes to only triple, 20 only to double, and 41 to both to the question whether they had any screening test during pregnancy.

In our study, the source of information was obstetricians in 52% of pregnant women, family physicians in 14.5%, internet/social media in 7.5%, and experience from previous pregnancy in 32.4%. In the study of Ruhat Karakuş, the answers given to the question of “where did you learn the double or triple screening test?” were “my physician recommended” (86.5%), “I learned from the internet” (8.1%), “my friends recommended” (2.7%), “I learned from TV or newspaper” (2.7%) (22).

In our study, the awareness of pregnant women about screening tests was found to be significantly higher in those who were 27 years of age and older, who had high school and above education, who were employed and who gave birth before. Unlike our study, the mean age of pregnant women who knew the double and triple tests was found to be lower in the study of Desdicioğlu et al. (20). In the study of Pirdal et al. (16), two independent factors affecting the knowledge level of pregnant women were found to be the education level and age. In the study of Bilgin et al. (21), the rate of obtaining information about screening tests and the level of the evaluation were increasing as the level of education increased; however, the increase in the parity seemed to decrease these. Increased awareness with age was considered to be related to the increasing number of births and information learned from previous pregnancies. Increasing awareness with education level may be the result of education facilitating learning and understanding in general.

When women that did not want to have screening tests were asked for the reason, 57.6% (n=208) of the participants answered as “I find it unnecessary because I do not want to end my pregnancy”, 19.4% (n=70) as “I think it will harm the baby”, 10% (n=36) as “I do not want to have a triple test because the double test is normal”, 7.8% (n=28) as “It could not be done because the time to be done has passed”, and 1.9% (n=7) as “I do not find it reliable”. When the participants were asked about the reasons for not wanting prenatal tests in the study by Lewis et al. ​​(23), they stated that the participants responded as “ending pregnancy is not an option” and “invasive tests increase the risk of miscarriage”, which are mostly based on opinions and moral values. Desdicioğlu et al. (20) stated that 75% of the pregnant women telling that they would not have/did not have the diabetes screening test stated that they heard from the media that the test was harmful. In the same study, the most common reasons for not having double and/or triple tests were “finding the tests unnecessary” (54.7%) and “missing the time of the test” (35.7%). Although the majority of the participants stated that they knew the screening tests, the rate of pregnant women who stated that they did not have the tests due to any missing or wrong information, avoiding the risk of harm to the baby, and moral values ​​was found to be high.

According to the Turkey Nutrition and Health Survey 2010 data, the most widely used nutritional supplement during pregnancy is iron (43.5%), followed by multivitamin/mineral (27.1%), folic acid (15.1%), and vitamin D (5.7%) (24). In our study, the participants stated using folic acid (83.4%), vitamin D (74.5%), iron (67.2%), and multivitamin (58%).

In our study, 95.5% of the pregnant women stated that the tetanus vaccine was/would be administered. In the study of Kurnaz et al. (17), 73.6% of the participants had a tetanus vaccine, and the remaining participants stated that they did not get a tetanus vaccine because they were fully vaccinated. Tetanus vaccine was administered to 71.2% of the pregnant women in the study of Çatak et al. (25) and 77.6% of the pregnant women in the study of Ergün et al. (4).

The results of the use of supportive treatments in the presented study were found to be compatible with the literature. In other studies, it was found that the pregnant women received more adequate and qualified PNC as the age of the mothers, the level of education, the number of births, and the rate of living in the urban area increased (26,27). It is known that as the awareness of healthcare professionals and information and consultancy services provided to pregnant women increase, their compliance with screening tests and supportive treatments increases (28).


Conclusion

In this study, it was found that awareness about screening tests and supportive treatments increased with increased maternal age, education level, number of births, and the employment status of the mother. Although we have found high rates of learning screening tests and supportive treatments from healthcare professionals, it is a pity that all pregnant women are not contacted, and PNC is not at the desired level. We can say that this result refers primarily to the family physicians, who are the first point of contact with pregnant women, and to the healthcare professionals in the services and information of PNC. We think that younger mothers with lower education levels in rural areas should be prioritized for information about counseling during the PNC services.

The most important limitation of the study was that the study was conducted in a tertiary healthcare institution. Therefore, there is a possibility that some of the participants were pregnant women who were referred to due to more problematic pregnancy processes. However, we can say that the absence of a referral chain in our country is a situation that eliminates this bias. Nevertheless, extensive studies in primary care are needed to cover the general population. Although the results of the study cannot reflect the general public, we believe that it is a study that can contribute to the literature and contribute to the future studies with the awareness of pregnant women about routine screening tests and supportive treatments and the possible role of family physicians in this regard.


Ethics Committee Approval: The ethical permission of the study was taken before the study, with the number of 2018/1259, dated 16.03.2018, from the Ethics Committee of Necmettin Erbakan University Meram Faculty of Medicine, Pharmaceuticals and Non-medical Researches Ethics Committee.

Informed Consent: The participants were informed about the study, and their written and verbal consents were obtained according to the Helsinki Declaration principles.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - R.K.; Design - R.K., L.U., N.K., H.G.; Data Collection and/or Processing - L.U., H.G.; Analysis and/or Interpretation - R.K., L.U., N.K.; Literature Search - N.K., L.U.; Writing Manuscript - R.K, L.U.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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