Midwifery 30 (2014) e26–e33

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Sources of information used by women during pregnancy to meet their information needs Heather A. Grimes, RM, BHSc, GradDipClinEd, MMid (Lecturer in Midwifery)a,n, Della A. Forster, Dip App Sci (Nurs), BHealthSci (Nurs), MMid, PhD (Professor of Midwifery and Maternity Services Research)b,c, Michelle S. Newton, Dip App Sci (Nursing), PG Dip App Sci (Health Education), MMid (Lecturer in Midwifery, Course Co-ordinator BNBM)d a

Faculty of Health Science, La Trobe University, PO Box 199, Bendigo, Victoria 3550, Australia Mother and Child Health Research and School of Nursing and Midwifery, La Trobe University, Parkville, 215 Franklin St, Melbourne 3000, Australia c The Royal Women's Hospital, Parkville, 215 Franklin St, Melbourne 3000, Australia d School of Nursing and Midwifery, Faculty of Health Science, La Trobe University, Bundoora 3086, Australia b

art ic l e i nf o

a b s t r a c t

Article history: Received 14 June 2013 Received in revised form 10 October 2013 Accepted 13 October 2013

Aim of the study: to explore the information sources used by women during pregnancy to meet their information needs regarding pregnancy, birth and the postpartum period. Design: a cross-sectional postal survey of all eligible women who birthed at the Royal Women's Hospital, Melbourne, Australia between November 2010 and January 2011. Surveys were sent at four months post partum. Findings: forty-seven per cent (350/752) of eligible women returned the surveys, of whom 62% were primiparous. ‘Discussion with a midwife’ was the source of information used by the greatest number of women during pregnancy (246/350, 70%). Less than half of the women used the internet to access information (154/350, 44%), and group information sessions were the least preferred information format (8/330, 2.4%). Women from non-English speaking backgrounds (NESB) were less likely to use written and online resources. One-third of the women had unmet learning needs, particularly in relation to breast feeding and postnatal recovery. Overall, women rated books as the most useful source of information (57/332, 17.2%). The model of pregnancy care influenced the source women rated as most useful. Women who received most of their pregnancy care from a midwife described discussion with a midwife as their most useful source of information (42/150, 28%). In contrast, of the group who received most of their care from a doctor in antenatal clinic, the largest proportion reported that the internet was their most useful source of information (10/57, 28%). Conclusion and recommendations: discussion with midwives is an important source of information for women. The internet did not play a significant role in information seeking for more than half of the women in the study. Existing sources of information may not meet the needs of women from NESB, either because women do not access the multilingual resources currently available or because resources may only be provided in English or a few other common languages. & 2013 Elsevier Ltd. All rights reserved.

Keywords: Information Pregnancy Internet Information seeking

Introduction Having a baby is a major life event, and for many women, particularly those having a first baby, it is a time when they seek information to help them during the transition to parenthood (Shieh et al., 2010). Many important learning needs may arise as prospective parents prepare for and adjust to their new role. Currently, women n

Corresponding author. E-mail addresses: [email protected] (H.A. Grimes), [email protected] (D.A. Forster), [email protected] (M.S. Newton). 0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.10.007

may have access to significant volumes of information about pregnancy, birth and parenting from a number of sources, including the internet, family and friends, popular media such as newspapers and television, and written material from professional and commercial entities, childbirth education classes and discussions with health professionals. The ability of a woman to have her information needs met is impacted by the access she has to different sources of information, and her ability to comprehend that information. Access to large volumes of information does not necessarily equate with understanding and comprehension (Carolan, 2007), and regardless of literacy skills, most people need help understanding health care

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information (Gazmararian et al., 2005). A woman's level of health literacy influences her information seeking strategies and subsequent health knowledge and behaviour (Shieh et al., 2009). Women are encouraged to be active participants in decisionmaking during pregnancy and early parenting (Department of Health Victoria, 2009). To support this goal and to meet their individual needs for information, women need access to quality health information that reflects current evidence. Leaflets and brochures are frequently given to women as part of a pack of information during pregnancy and the postnatal period; however, there is little evidence to guide their use as a resource for women. It has been reported that when leaflets are distributed amongst other written information without discussion or checking for understanding, women are less likely to read them (Stapleton et al., 2002). This suggests their use is primarily to support discussion with a health professional, rather than as a ‘stand alone’ resource. A review of consumer information given to new mothers in public hospitals providing postnatal care in Victoria, Australia, found that the quality of documents varied considerably (Savage, 2008). The study examined more than 900 consumer information documents that were provided to women by public and private hospitals in Victoria and reported that women could potentially receive up to 58 pages of consumer information during the postnatal period alone. Quality issues were identified, including brochures being undated or out of date, references inadequately cited, or no references provided, and poor quality formatting and printing (Savage, 2008). Although the twentieth century saw an increase in the availability of written health information, over the past two decades the internet has emerged as an increasingly important information source (Weaver et al., 2010). The extent to which the use of the internet has influenced women's health seeking behaviour is unclear. The literature related to the use of the internet by women to retrieve pregnancy and childbirth information is not extensive (Larsson, 2005; Lowe et al., 2009; Lagan et al., 2010; Lagan, 2011). The methods used have been mainly descriptive surveys (Larsson, 2005; Lagan et al., 2010), and comparisons are limited due to differences in methodology and the variables studied. The concept of a ‘digital divide’ between those who have access to the internet and those who do not (based on sociodemographic factors) has been described (Dickerson, 2006; Miller and West, 2009); however, the concept has not been universally supported, with reports of no apparent social bias influencing the use of online parenting websites according to socio-economic demographics (Sarkadi and Bremberg, 2005). Whilst there has been some research on the use of traditional information sources by pregnant women (Singh et al., 2002; Risica and Phipps, 2006; Shieh et al., 2009), there has been limited exploration of women's current information-seeking behaviour (Larsson, 2005; Lowe et al., 2009; Lagan et al., 2010; Lagan, 2011). There is a lack of comprehensive information available about the sources of information women use in pregnancy, and about the relative merits of various information sources. Although many ‘traditional’ sources appear to be used extensively, there is little information on the uptake of internet-based information. We aimed to explore the sources of information used by women to meet their information needs in relation to pregnancy, birth and the postpartum period, and to identify: which sources were used most frequently; which were considered most useful; what other information women wanted; and which format was preferred.

Methods Study design A cross-sectional, descriptive design was used to capture a current understanding of women's information-seeking behaviour.

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This study used data collected as a component of a larger postal survey titled ‘Exploring the care we provide to new mothers’ (ECPNM). The ECPNM study was designed to explore the views, experiences and health outcomes of women who gave birth at the Royal Women's Hospital (the Women's) before and after the implementation of changes to postnatal care. Data for this article were collected only at baseline as no changes were made to the provision of information for women as part of the changes. Ethics approval was obtained from the Royal Women's Hospital Human Research Ethics Committee (Project 10/48) and from the La Trobe University Faculty of Health Sciences Ethics Committee (Reference FHEC10/250). Participants The Women's is a public tertiary women's hospital in Melbourne, Australia, which has approximately 7000 births per year (The Royal Women's Hospital, 2011), and we aimed to survey all eligible women who birthed at the Women's from 1st December 2010 until our sample size was reached (details below). Women who had a stillbirth or known neonatal death were excluded. There were no exclusions for language; however, the questionnaire was sent only in English. Surveys were sent when infants of the women in the study were four months of age to look at the medium term effects of changes to postnatal care that were implemented as part of the ECPNM study. In the Australian maternity care context, approximately two-thirds of women have care in the public maternity system, with the other third accessing private obstetric care, and a very small percentage choosing private midwifery care (Consultative Council on Obstetric and Paediatric Mortality and Morbidity, 2012). In the public system, maternity services may provide various models of maternity care, e.g. midwifery continuity of care models, midwife-led care, obstetricled care and various constructions of these (National Health and Medical Research Council, Department of Health and Aging, 2010). The Women's offer hospital-based care, community shared care, community clinics and specialist clinics such as young women's clinics. Hospital-based care is provided primarily by midwives at the Women's. Women in this model also have three visits with a doctor in antenatal clinic: at their first pregnancy clinic appointment, at 36 weeks and at 41 weeks (The Royal Women's Hospital, 2013).

Data collection A self-administered postal survey was designed for the ECPNM study. The survey questions were based on the current literature and included a number of questions that had been used in previous studies of maternity care in Victoria (Forster et al., 2003; McLachlan et al., 2008; Forster et al., 2011). The questionnaire included closed, categorical and open-ended questions, divided into seven sections: ‘Your baby’, ‘Feeding your baby’, ‘Your pregnancy and birth’, ‘Your care in hospital after the birth’, ‘Your care at home after the birth’, ‘Your health since being at home after the birth’, ‘Your feelings and emotions’ and ‘Questions about you’. The questions described in this paper came from the sections ‘Your pregnancy and birth’ and ‘Questions about you’. The section ‘Your pregnancy and birth’ consisted of 15 questions. Six questions addressed the provision of antenatal care, and another six sought to identify the sources of information women used during their pregnancy regarding pregnancy, birth or the postnatal period. Women were asked from which sources they received information to help them get ready for caring for their new baby and themselves, and which of these was the source they found most useful or used most often. A list of the sources of information considered most relevant by the research team was provided. Women could tick more than one response to the

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question ‘During your pregnancy, from which of the following sources did you receive information to help you get ready for caring for your new baby and yourself’. Options provided were midwifediscussion/education; midwife-written information; maternal and child health nurse; family member; friends; family doctor (General Practitioner); ‘Having your Baby at the Women's’ book; obstetrician; childbirth education classes; internet (list three sites used most); the Women's website; the Women's Health Information Centre (WHIC); Books (list three books used most); Other (please describe). The following questions asked them to choose one of these options as their most useful and the source they used most often. They were also asked about their preferred format for receiving information, and whether there was other information they would have liked to have received during pregnancy. Comments were sought about the sources of information women's partners used and found useful, but analysis of these questions is not included in this paper. Midwives who were currently engaged in clinical practice and research participated in the initial piloting of the survey. Changes were made, and the subsequent version re-piloted with the same group of participants. This process was repeated twice. Five women who had given birth in the previous 12-month period and who would not be eligible to participate in the current study took part in the next stage of piloting; minor amendments were made, then another group of five participated in the final pilot. No further issues were identified. Eligible women were identified from the computerised obstetric database at the Women's. Name and address labels were printed for all eligible women and a letter was sent inviting women to participate and providing information on the study. The invitation included a questionnaire and a reply-paid envelope in which to return the questionnaire. Two weeks after the first mail-out of the questionnaire a follow up reminder letter was sent, then two weeks after this, a second and final reminder was sent. The final reminder included another copy of the questionnaire, as well as a letter thanking women if they had already completed and returned the questionnaire. As there were no identifiers on the questionnaire it was necessary to send all reminders to each woman, as it was not known who had/had not returned the questionnaire. Written consent was not sought for the evaluation as return of the questionnaire was taken as implied consent. Sample size The sample size for this study was determined by that used in the ECPNM study. Power calculations were based on detecting a 10% difference in the rate of any breast feeding at eight weeks post partum, the primary outcome measure. The breast feeding rate at the time of the study was estimated to be approximately 70% at eight weeks post partum (Department of Education and Early Childhood, 2010) and the sample size determined to ensure a change to a rate as low as 60% or an increase to 80% was detected. It was calculated that 376 women would be required to detect the 10% difference. Allowing for a response rate of 50%, a sample size of 752 women was required. The estimated response rate of 50% was based on that achieved in other recent studies conducted in Victoria (Brown et al., 2001; Forster et al., 2011). A decision was made later to adjust the survey timing to four months post partum, and the original sample size was considered to be still appropriate. Data analysis Data entry was completed by an external provider, then returned to the research team, downloaded to an Access database for cleaning and then analysed. Quantitative data were analysed

using Stata (StataCorp, 2009). Frequencies, percentages and means were used to describe the data. Where appropriate, two-way chi-square tests (χ2) were used to determine whether the relationship between two variables was statistically significant (Pierson, 2010). Responses to open-ended questions were analysed using content analysis (O'Cathain and Thomas, 2004).

Findings Response rate Questionnaires were sent to all eligible women who had given birth to a live baby at the Women's from 1st December 2010 to 16th January 2011, when their infants were four months of age. The mail-out of questionnaires commenced in March 2011. Of those sent a questionnaire, 350/752 completed and returned it to the Women's. A further fourteen were returned unopened with no known forwarding address. The response rate was therefore calculated as 47.4% (350/738). Demographic characteristics of respondents The characteristics of women who responded are shown in Table 1. The mean age of respondents was 32.4 years (SD 4.9) and the mean age of their infants at the time of responding to the survey was 20.3 weeks (SD 3.5). Nearly half of the respondents to this survey received their care from a midwife/midwives in the hospital antenatal clinic (157/349, 45.0%). Almost 18% received care from doctor/doctors in the antenatal clinic (62/349, 17.8%) or their family doctor (62/349, 17.8%). Hospital midwives in community clinics provided care to 6.3% of the sample, whilst the remaining women received their care from private obstetricians (14/349, 4.0%) or ‘someone else/outside the Women's’ (10/349, 2.9%). Sources of information used by women during pregnancy Women were asked to indicate the sources from which they received information during pregnancy using a list provided in the questionnaire. There was also an option of answering ‘Other (please describe)’. The most frequent source of information (used by 70% of women) was ‘Discussion with a midwife’ (Table 2). Written information provided by midwives was used by 39% (136/350) of women. The booklet, ‘Having Your Baby at The Women's’ (The Royal Women's Hospital, 2010), which is provided to women at their first antenatal visit, was used by 61% of women. The booklet provides women with information on services, supports and pregnancy care options available at the Women's, as well as information on self-care during pregnancy, preparation for women's hospital stay and the postnatal period, and some discussion on labour and birth. The Women's Health Information Centre was a source of information for 6% of participants. WHIC is a free information centre located at the Women's (but open to the general public) that provides support and advice, and offers a library of resources related to women's health issues. The relationships between internet use and demographic variables are presented in Table 3. The use of the internet as a source of information was significantly higher amongst women who had tertiary education than those without a degree (127/257, 49% versus 26/89, 29%, p¼0.001). There was no difference between the use of the internet by women in different age or income groups. A higher proportion of women who spoke English as their first language used the internet (105/225, 68%) compared to women whose first language was not English (49/122, 32%, p¼0.24), but this difference was not statistically significant.

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Table 1 Characteristics of respondents. Characteristic

n

Infants' age in weeks at time of survey (n¼342, mean¼ 20.3 weeks, SD ¼ 3.5) First baby (n¼ 349)

20.3 (range 10–41) (3.5) 218

Mother's age in years (n¼ 346, mean ¼32.4, SD 4.9)

%

62.4

32.4 (range 18–44) (4.9)

18–25 years 26–34 years Z 35 years

27 202 117

7.8 58.3 33.8

Marital status (n¼ 348) Married Living with your partner Have a partner but do not live together Separated or divorced Widowed Single

254 75 6 3 1 9

72.9 21.5 1.7 0.8 0.2 2.5

Education (n¼ 346) Completed a Degree or higher Completed secondary school to Year 12 (or equivalent) Did not complete secondary school

257 68 21

74.3 19.6 6.0

Employment (n¼ 347) Employed full-time Employed part-time Maternity leave Home duties Pensioner/government benefits Student Other

24 20 147 108 10 18 20

6.9 5.8 42.3 31.0 3.0 5.0 6.0

Household income before tax at time survey completed ($AUD) (n¼ 348) Less than $350 per week (less than $18,200 per year) $350–$649 per week ($18,200–$33,799 per year) $650–$999 per week ($33,800–$51,999 per year) $1000–$1399 per week ($52,000–$72,999 per year) $14,000–$1999 per week ($72,800–$103,999 per year) More than $2000 per week ($104,000 or more per year)

17 39 63 60 77 72

5.1 11.8 19.2 18.2 23.4 21.9

Pension or government benefit the main family income (n¼ 341) Yes

47

13.7

Born in Australia (n¼ 350) Yes

169

48.2

English first language (n¼ 347) Yes

225

64.8

Women who used the internet were asked to list the three internet sites they used most often, and 132 women provided responses. A total of 210 online resources where listed, which included 47 different websites. Five were non-commercial, and the remaining 42 were commercial sites or search engines (e.g. www.google.com). Not-for-profit sites provided by organisations or government departments were identified by the inclusion of ‘. gov’ or ‘.org’ in the universal resource locator (URL), and commercial sites by the inclusion of ‘.com’ at the end of the URL. The two most frequently cited commercial sites were www. babycentre.com (55/132, 47%) and www.huggies.com (28/132, 21%). These were accessed by more than half of the women who identified internet sites. Websites presented in languages other than English were accessed by a small number of women (4/132, 3%). Three women reported using pregnancy-related phone applications in their response to this question. There was no question specific to phone applications, so this was not asked of all women. Women were asked to list up to three books they had used to gain information. One hundred and forty-eight women responded to this question and provided the names of 233 books or written items such as magazines. From these responses, 66 individual books were identified. More than one-third of the women used either of the two most frequently cited books. These were What to

Expect when you're Expecting by Mazel and Murkoff (2009) and Up the Duff by Kaz Cook (2009). Women were asked to indicate which sources of information were most useful, and which sources they used most often. A similar number of women indicated that books (57/332, 17%), discussion with a midwife (52/332, 16%) and the internet (50/332, 15%) were their most useful sources of information. Of those women who spoke English as their first language, books were identified as the most useful source of information for the largest proportion of women (45/214, 21%), whereas of the women from a non-English speaking background (NESB), the largest proportion rated discussion with a midwife as their most useful source of information (23/115, 20%). The internet was used by equal percentages of women who were from English and non-English speaking backgrounds. In terms of what information source was used most often (as opposed to being most useful), books were cited most often (90/330, 27%), but this was less likely to be the case for women from a NESB (18/113, 15.9%) compared with women whose first language was English, (72/217, 33.2%) (p ¼0.15). The source of information used most often by women from a NESB was the internet (24/71, 34%) (Table 4). We explored what sources of information were most useful and used most often by women of different age groups. Of those

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Table 2 Sources of information used by women during pregnancy. Information source

%n

n (n¼ 350)

Midwife-discussion/education ‘Having Your Baby at The Women's’ booklet Family Friends Internet Childbirth education classes Books Midwife-written information General Practitioner Maternal and Child Health nurse The Women's website Obstetrician Women's Health and Information Centre Other

246 214 183 182 154 149 148 136 117 61 54 44 21 36

70.3 61.1 52.3 52.0 44.0 42.6 42.2 38.9 33.4 17.4 15.4 12.6 6.0 10.3

n Percentages add to more than 100 because women were able to identify more than one information source.

to the source of information used most often by women of different age groups, the largest proportion of younger women (r 25 years) used the internet most frequently (6/26, 23%); however, the numbers in this category were small. In the 26–34 year age group, 18% of women found books to be both the most useful (34/191) and most frequently used source of information (56/190, 29%). Older mothers reported the internet as the source they found most useful (23/111, 21%) and both the internet (30/113, 27%) and books (30/113, 27%) as the source used most often. There was also a difference between the sources of information women found most useful and used most often depending on who provided their pregnancy care. In the group of women who received most of their care from a midwife, 21% (31/150) found that discussion with a midwife was their most useful source of information, and books were the source they used most frequently (42/150, 28%). In contrast, in the group who received most of their care from a doctor in an antenatal clinic, 18% (10/57) reported that the internet was both their most useful source of information and the source used most often (16/57, 28%). Topics women wanted further information about during pregnancy

Table 3 Used the internet as a source of information, by demographic variables. nn

%

p value

12/27 84/202 58/117

44.4 41.6 49.6

0.38

Level of education (n¼346) Degree or higher No degree

127/257 26/89

49.4 29.2

0.001

Income (n¼ 328) Less than $1000/week More than $1000/week

50/119 100/209

42.0 47.8

0.31

English first language (n¼ 347) Yes No

105/225 49/122

46.7 40.2

0.24

Demographic factor Age (n¼ 346) 25 years or less 26–34 years 35 years or more

n

The number in each category who used the internet as an information source.

Table 4 Sources of information found most useful, and used most often by women during pregnancy. Information source

Books Midwife-discussion/education Internet ‘Having Your Baby at The Women's’ booklet Family Friends Childbirth education classes Maternal and Child Health nurse General practitioner Obstetrician Midwife-written information The Women's website Women's Health and Information Centre Other answer

Most useful source (n¼332)

Source used most often (n¼ 333)

n

n

%

90 35 71 43 34 16 5 9 5 3 6 3 0 13

27.0 10.5 21.3 12.9 10.2 4.8 1.5 2.7 1.5 o 1.0 1.8 o 1.0 0.0 3.9

57 52 50 40 35 23 22 12 11 10 4 1 2 12

% 17.2 15.7 15.1 12.0 10.5 6.9 6.6 3.6 3.3 3.0 1.2 o1.0 o1.0 3.6

women aged 25 years or less, the most useful source of information was discussion with a midwife (7/26, 27%), followed by 15% reporting books, the internet and family as most useful. In relation

Although 67% (225/334) of women indicated that they felt they received adequate information during pregnancy, 33% (109/334) would have liked to receive more information about caring for their infant or themselves. These women were asked to describe what other information they required. The most common topic requested was breast feeding information (32/109), followed by information regarding women's own recovery and postnatal health (23/109) (Table 5). Preferred format of information Women were also asked to indicate their preferred format for receiving information. Younger women ( r25 years) showed a preference for having a variety of options (9/26, 38%), followed by one-to-one information (6/26, 25%) and written information (5/26, 21%); however, the numbers in this subgroup were small. Older women (Z35 years) preferred a variety of options (58/111, 50%) and written information (25/111, 22%). The majority of women who spoke English as their first language preferred a variety of options with regard to the information format (101/214, 47%), but 42% of women from NESB identified a preference for written information (48/114, 42%).

Discussion The findings from this study support the assertion that women access information from a variety of sources. We found that discussion with a midwife was the most frequently cited source of information for women responding to this survey (of whom just over half had midwife-led care). Previous studies have reported that women prefer receiving information from a health care professional (Risica and Phipps, 2006). The provision of health information to women is an important part of the role of the midwife (Australian Nursing and Midwifery Council, 2006). Amongst the women surveyed, the most commonly used source of information was discussion with a midwife, and for those women who received midwiferyled pregnancy care, the largest proportion rated discussion with a midwife as the source they found most useful. This was in contrast to the 19% of women who received most of their pregnancy care from a doctor (or doctors) in an antenatal clinic, who rated the internet as both their most useful source of information and the source they used most often. It is unclear whether this group had more complex pregnancies and higher information needs than the

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Table 5 Topics women wanted further information about during pregnancy. Topic

%n

n (n¼ 109)

Breast feeding Mother's postnatal recovery Organisation of care Infant care Infant settling and sleeping Labour and birth Psychosocial changes Infant feeding (exclusive of breast feeding) Pregnancy care and complications Home routine and expectations Neonatal complications Community resources

32 23 16 15 11 10 8 7 6 6 5 4

29.3 21.1 14.7 13.8 10.1 9.2 7.3 6.4 5.5 5.5 4.6 3.7

n Percentages do not equal 100, as each woman may have provided multiple topics.

predominantly low-risk women who received care from midwives, which may have influenced this finding. It may also relate to how information needs are addressed by different providers. It is possible that women having midwife-led care are given more opportunity to talk about their concerns and have their questions answered during appointments with midwives, and this may relate to different time constraints, different practices or women's own perceptions of the role of different providers. It has been suggested that when women say they want more information, what they really want is to voice their concerns and to have their questions answered by supportive carers (Singh et al., 2002). Previous research has reported that women turn to the internet in response to inadequate information provision by health professionals or reduced opportunities for discussion with health professionals as a result of decreased antenatal visits (Lagan, 2011). In addition, studies have suggested that organisational factors such as time pressures and decreased antenatal contacts may undermine the capacity for midwives to provide adequate support and counselling to women and their partners (Dykes, 2005; McCourt, 2006). These factors are likely to impact many clinicians providing in-hospital maternity care. The growth in internet access over the past decade has provided many women with access to a broad range of pregnancy, birth and parenting information. The reasons why women may prefer the internet to other sources of information relate to privacy, accessibility and scope of information available (Eriksson-Backa, 2003; Lowe et al., 2009; Lagan et al., 2010). It has also been found that women use the internet to enhance their understanding of information provided by their pregnancy care provider, or to determine if they should seek further advice (Lowe et al., 2009). The concept of a digital divide based on sociodemographic factors between those who have access to the internet and those who do not was not fully supported by this study. In previous studies, women and individuals who have a higher level of education have been found to be the group most likely to seek online health information (Eriksson-Backa, 2003; Sarkadi and Bremberg, 2005; Miller and West, 2009). This association was supported by this study, with internet use higher amongst women who had a tertiary level of education than those who did not. Women who spoke English as their first language were also more likely to use the internet than those from a NESB; however, this relationship was not statistically significant (the study was underpowered for this analysis). Other sociodemographic variables such as income or age were not associated with an increased likelihood of citing the internet as a source of information during pregnancy. In our study, women using the internet for online information were more likely to access commercial sites in preference to

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not-for-profit sites. Questions arise about the quality of some information that may be accessed and also the commercial agenda of these sites. Women may not have the necessary skills to evaluate information they access online (Lagan et al., 2010), and maternity care providers may also be missing an opportunity to provide women with quality information. Providing written information leaflets and brochures to women during antenatal visits, either as information packs or in response to requests for specific information, may be a valid means of increasing women's understanding and knowledge (Cooper and Warland, 2010). However, in Victoria, Australia, a large proportion of the material provided to women by maternity providers has been found to be of poor quality (Savage, 2008). Additionally, the provision of information, even if it is of high quality, will not necessarily make it accessible to women or influence their decision-making (O'Cathain et al., 2002; Stapleton et al., 2002). This was evident in our study, where 39% of women used written information provided by a midwife, but very few of them rated it as their most useful information source, or as the source they used most often. Nearly half of the women who responded to this survey used books as a source of information. Twenty-seven per cent of these women said books were the source of information they used most often, and 17% said they were the source they found most useful, suggesting books are both accessible and useful. The type of books used varied from pregnancy, birth and parenting information books to humorous texts, which, while entertaining, may or may not present accurate and relevant information to address women's information needs. The value of books as a source of information for women is an important area for health providers to take into account when developing or recommending resources for women. In 2010, The Women's cared for women from 175 countries, who spoke more than 60 different languages (The Royal Women's Hospital, 2011). Previous studies have reported that women from NESBs are less likely to use written sources of information (Singh et al., 2002); however, in this study, when asked to indicate their preferred format, women from NESB indicated a preference for written material (42%). Previous research has suggested that government-funded pregnancy booklets that are provided free of charge are considered useful by women (Singh et al., 2002). The Women's provides women with a booklet titled ‘Having Your Baby at the Women's’ during the first antenatal appointment. This was used by almost two-thirds of the women surveyed, but less often used by women from NESBs. It is currently only available in English, which is the most likely factor explaining its reduced use as a resource in this group of women. Consideration should be given to making resources such as this available in languages other than English, as women from NESBs responding to this survey indicated a preference for written information, yet did not use the existing written resources. The extent to which information resources can be translated into several languages is limited by resource availability. The Women's publishes 150 online fact sheets in 29 languages including Arabic, Chinese, Greek, Italian, Somali, Turkish, Vietnamese and Spanish and these are also downloadable from the Women's website (The Royal Women's Hospital, 2011). The degree to which women from NESB are using these fact sheets requires further exploration. Less than half of the women from NESB stated that they used the internet during pregnancy (49/122, 32%), and very few women overall accessed the Women's website (54/350, 15%). This indicates that women from NESB are not actively seeking these resources, but it is unclear whether they are receiving the fact sheets in a ‘package’ of material during discussion with a midwife. In addition to the level of health literacy of the NESB respondents, which is dependent on more general levels of literacy (World Health Organization, 1998), consideration needs to be

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given to the impact levels of English proficiency have on the accessibility of information resources. Women may reach the postpartum period with an accumulation of learning needs that have been unmet during pregnancy. Two-thirds of the women who participated in this study reported that they had received adequate information. Of the women who felt that they had unmet learning needs, the most frequent topics requested were related to postnatal care of the mother and breast feeding. However, postnatal learning needs and priorities have been found to change with time (Ruchala, 2000), and it may be reasonable to assume that women surveyed in the postnatal period may answer this question differently than if they had been surveyed during their pregnancy.

Strengths and limitations The study was undertaken at the Royal Women's Hospital, a large tertiary referral centre in a metropolitan area in Victoria, Australia. The respondents to this study were more likely to be older and have high incomes compared with the general population of women who birth at the Women's (The Royal Women's Hospital, 2007). The findings may not fully reflect the experiences of women in regional or rural centres who may not have access to all the sources of information offered at the Women's, nor may they apply to all women in other countries. Although a large proportion of respondents were from NESB, the availability of the survey in English would have limited participation by women with low levels of English literacy. The quantitative nature of this research limited our capacity to explore the subjective experience of individual women. The inclusion of qualitative research in this area may have provided a more complete understanding about the way in which individuals seek information and the impact of not having their information needs met. However the study does provide data on the information needs and preferences of quite a diverse group of women, who were born in a number of countries, came from a variety of NESBs and included women from a range of ages and incomes. This adds to the literature on what is currently known about this topic, but should be interpreted with caution, particularly the sub-group analyses presented here, as the study was not adequately powered for these.

Implications for practice This study highlights the need for maternity service providers to sustain, or be able to recommend, multiple sources of information for use by women and their partners. The use of new technologies such as the internet and mobile phone applications will most likely increase; however, the level of use at present does not suggest that they are superceding more traditional sources of information such as books. It appears that women benefit from access to a midwife in the antenatal period in terms of having their information needs met. Discussion with a midwife is an important source of information for the majority of women, and women who received midwife-led antenatal care regarded discussion with a midwife as their most useful source of information. It may be beneficial if women who require medical care throughout their pregnancy are also able to access a midwife for discussion of their information needs during pregnancy. Women from non-English speaking backgrounds represent a group that may be somewhat under-served in terms of information provision and access. The ‘Having Your Baby at the Women's’ booklet that is provided free of charge was widely used amongst

women who spoke English as their first language and rated as their second most useful source of information. However, women whose first language was not English did not use the booklet as commonly and were less likely to rate it as their most useful source, despite this group preferring a written format for their information. The lack of availability of this resource in languages other than English may account for this finding and may be important for the hospital to consider in view of the fact that women from non-English speaking backgrounds were less likely to access the multilingual resources that were available from WHIC or the Women's website. This study has highlighted issues regarding the accessibility of information sources for women from NESB and the disparity between their preferences and use. Further promotion of, and ready access to, these sources for women from NESB may provide them with an additional source of information. The effective provision of high quality information to pregnant women may be hindered by a lack of understanding about which sources women have access to and which sources they find useful. This study builds on the small amount of literature on this topic, and may provide some direction to organisations seeking to support and establish sustainable information resources for women.

Conclusion The key findings of this study build on what is known about information provision to pregnant women. Women indicated that they use a number of different sources of information and when given the option, the majority preferred a variety of formats. The use of the internet was less than expected given the growth in access to services over the past decade, whereas books were a useful and frequently used information source for almost half of the women. The study has also highlighted issues regarding the accessibility of information sources for women from NESBs and the disparity between their preferences and use. Although many sources of information are available to women, one-third of the women surveyed felt that some of their information needs during pregnancy were unmet. Breast feeding information and advice on the mother's postnatal recovery were the most common topics mothers felt uninformed about. It is unclear how unmet learning needs during pregnancy may add to a woman's stress and anxiety during pregnancy and post partum. Further research is required in relation to the most effective ways for health professionals to provide information to women and how women can be better supported in relation to their information needs.

Funding This study received funding from a small grant from the Faculty of Health Sciences, La Trobe University.

Acknowledgements We would like to express gratitude to the women who took time to respond to the survey at a busy time of their lives. We would also like to thank the Royal Women's Hospital, Melbourne, and La Trobe University, Melbourne, for supporting this study. References Australian Nursing and Midwifery Council, 2006. National Competency Standards for the Midwife. Australian Nursing and Midwifery Council, Canberra. Brown, S., Darcy, M., Bruinsma, F., Lumley, J., 2001. Victorian Survey of Recent Mothers 2000. Women's Views and Experiences of Different Models of

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