Supporting Childbirth Knowledge Acquisition and Decision-making

through Digital Communication Technology: The Research Design of

an Ongoing Study following a Mixed-Method Approach

Carla V. Leite

1,2 a

and Ana Margarida Almeida

Department of Communication and Art, Digital Media and Interaction Research Centre (Digimedia),

University of Aveiro, Aveiro, Portugal

Department of Education and Psychology, University of Aveiro, Aveiro, Portugal

Keywords: e-Health, Health Literacy, Childbirth Education, Perinatal, Decision-making, Methodology, Mixed Methods.

Abstract: This paper describes the research design of an ongoing study that overlaps three main fields: technology,

health, and social science. This transdisciplinarity approach naturally brings challenges to the methodological

plan, which this paper presents, and aims to guide the creation, validation and evaluation of a digital decision

aid, and its comparison to a paper-based solution. Through the data collection from different natures, it is

expected to be possible to understand the different sources, channels and formats of content that can contribute

for childbirth knowledge acquisition; if communication can be facilitated between expectant parents, health

care professionals, and childbirth educators; and ultimately, if the tool could provide a mean to create a

document regarding birth preferences.

1 INTRODUCTION

Maternal Care is being highlighted in the political

agenda for the past decades (United Nations, 2015a,

2015b); however, researchers report general gaps in

antenatal care, a lack of communication and

educational activities, and underline its importance

and impact in mental health during postnatal, not just

for the women who were pregnant, but for both

expectant parents (Suto, Takehara, Yamane, & Ota,

2016). There are several Childbirth Educational

Programs implemented in most western countries

(Barimani, Frykedal, Rosander & Berlin, 2017)

aspiring to add an educational component to care,

which can be individual or in group, clinical-, home-

, internet-, telephone-, or pamphlet-based, or even the

combination of several approaches (Suto et al., 2016).

Its goals vary nationally and internationally, but a

common goal is to strengthen, support and help

expectant parents for childbirth and parenting, in

order to deal with this imminent major life transition,

that can be confusing and overwhelming (Barimani,

Vikstrom, Rosander, Frykedal, & Berlin, 2017).

https://orcid.org/0000-0001-5803-2775

https://orcid.org/0000-0002-7349-457X

Expectant parents have been also using digital

technologies for information and support (Huberty,

Dinkel, Beets, & Coleman, 2013), giving

differentiated uses according to successive digital

technology eras. They searched for information in

pregnancy related websites and blogs, and interacted

through discussion forums (Doty & Dworkin, 2014),

and with the advent of diverse new digital media,

social web and mobile ubiquitous computing devices

they expanded their use, culminating in the access to

a wide range of products and services by mobile

devices (Thomas & Lupton, 2015).

It is known that expectant parents seek

information from a variety of sources and formats

(Wallwiener et al., 2016), but there is some

controversy, or possibly a tendency of change of

behaviour over time, about the ideal option.

According to Grimes, Forster, and Newton (2014)

study, expectant mothers prefer electronic

information over printed materials, with the last ones

being regarded as unhelpful since women do not take

the time to properly review their content. On the other

hand, Hawley, Janamian, Jackson, and Wilkinson

Leite, C. and Almeida, A.

Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of an Ongoing Study following a Mixed-Method

Approach.

DOI: 10.5220/0010350307010707

In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 701-707

ISBN: 978-989-758-490-9

701

(2014) research reports that most pregnant women

preferred to have paper-based health information to

easily access and show to relatives, not only with

educational proposes, but also to engage their

relatives in the pregnancy experience.

Since there is no unique solution, in order to embrace

different preferences (paper, oral and digital) and

different needs (search, share, carry with them, etc.)

in addition to show healthcare related dummies and

accessories and to offer printed materials to expectant

parents, healthcare professionals and childbirth

educators could recommend online courses and

digital materials aiming: a) autonomous learning,

since it is considered a significant skill in current

times (Freitas, Leite, de Souza, & Costa, 2019); b) to

explore new scenarios of interactive, digital mediated

and distance education; c) to promote informed-

decision making among expectant parents.

Under the scope of the above-described scenario,

and taking in consideration the Portuguese current

context: antenatal classes are being tutored all over

the country, however only few hospitals advocate

birth plan’s usage, since its regulation is still under

discussion (GPPS, 2018); this ongoing study intends

to explore an innovative educational approach, to

understand the benefits and disadvantages of using

digital technology in knowledge acquisition and in

the informed decision-making process regarding

childbirth preferences, in comparison to printed

materials, since it seems to exist a gap in the literature.

Carefully thinking the research design is of utmost

importance since this study overlaps social, health

and technology research fields, which naturally deal

with different theories, techniques, approaches,

settings and data types, what could be a limitation of

the study and affect dramatically the results.

However, it also opens the possibility to explore

borders and blinders (Fetters & Freshwater, 2015).

2 MIXED METHODS APPROACH

After carefully analysing the problem, this research

was framed in the Socio-critical paradigm (Anguera

Argilaga, 1985; Habermas, 1974), as it will follow the

tendency of Mixed Methods (Creswell & Plano

Clark, 2018; Latorre, Rincon, & Arnal, 1996;

Solomon, 1991).

This Mixed Method approach can be better

understood when analysing the different phases that

will be conducted (Figure 1). The research is a

transversal study in what concerns the temporal

scope, planned to start as exploratory during Phase 1,

followed by activities of Research and Development

as Phase 2 (Gajbhiye & Prasad, 2013), and then

followed by a quasi-experimental approach as Phase

3 (Bisquerra Alzina, 1989), see Figure 1.

Figure 1: Research plan design, by Phase.

Phase 1 started with the literature review in order

to: understand the current approaches to health

education; explore the extent of maternal education in

Portugal; comprehend the social acceptance of

informed decisions for birth; understand what

influences the preferences of pregnant women. This

initial study helped to identify the current gap and

formulate the research question:

How can a digital tool support the informed

decision-making of pregnant women regarding birth

preferences?

In addition, a Content Analysis was planned,

starting by the identification of online tools for birth

plans creation, so categories of data would emerge

(Bardin, 2008; Ghiglione & Matalon, 1997). The

results would contribute for the establishment of the

information architecture of the digital resource.

Partnerships are of utmost importance allowing to

frame the research in a network, which, besides

amplifying its magnitude, can also provide extremely

important resources, namely expedite access to

participants for the study, so during Phase 1 relevant

institutions were identified and contacts were

established.

Besides searching for an answer to the research

question that guided this mixed methods approach

(Tashakkori & Creswell, 2007), and to discover and

understand the reality, one of the main goals of this

study is having an explicitly practical outcome by

contributing to understand the relevance of digital

media in the maternal health education, which can

represent a turning point for healthcare promotion and

outreach.

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Therefore, the study includes Research and

Development tasks during Phase 2, in order to

conceptualize and create a proof of concept of a

digital tool, which intends to, simultaneously, provide

evidence-based information, and enable the creation

of a birth plan according to each pregnant person

preferences. Those tasks include the definition of the

extent of the proposal considering feasibility,

usability and accessibility factors; the specification of

functional requirements; the content creation based

on WHO guidelines (WHO, 2016; 2018) and expert’s

validation; defining the approach to integrate the

content with the decision aids tool; establishing the

design concept, in order to design interfaces and

interactions; and finally, implement the digital tool

using final technologies.

In Phase 3, aiming to evaluate the digital tool

proposal, an experiment will be conducted, and to

prepare it, the main tasks defined are: the creation,

adaptation and experts’ validation of instruments for

data collection; the preparation of a controlled setting,

and selecting and contacting participants.

A convenience sample will be used and

participants will be split up into two groups: Control

Group A will explore only printed materials, and the

Experimental Group will explore the digital

resources; both using the same created contents but

adapted to the different formats. The distribution

criteria between the two groups to guarantee the

maximum possible homogeneity will be gestational

weeks, and score on the digital literacy questions.

The contact of the participants will be gathered

through a partner of this study, a Portuguese Public

Health Centre. As inclusion criteria to participate in

the study, it was established: expectant mothers, with

pregnancies ranging from 20 to 37 weeks, that

enrolled as a participant on the antenatal classes

provided by the health centre as already stated, a

partner of this study. They will be contacted by the

phone, and requested to answer a short questionnaire

with recruitment and selection purposes (QR), so it is

related to the exclusion criteria: a) under 18 years old;

b) non-European Portuguese native speaker; c) to

carry a high risk pregnancy; d) to have or have had

health issues or complications for herself during

pregnancy or for the foetus; e) gestation under 20 or

over 37 weeks; f) previous gestation above 12 weeks;

g) psychiatric patient before or during pregnancy; h)

to have clinical issues regarding memory and

cognition; i) under 12th grade of qualification; j) have

participated in any formal course, online or in person,

regarding childbirth; k) low digital literacy. A total of

15 questions following auto-report approach, with 3

of them particularly aiming to calculate a score

regarding their digital literacy, based on DIGCOMP

scale (Vuorikari, Punie, Carretero Gomez & Van den

Brande, 2016), but using a set of proposed questions.

Targeting Level 2 or above (out of 8) aims to exclude

the participants who necessarily need guidance to use

digital technology, specifically when using

Computers and Mobile devices, and Internet.

Only the ones eligible will be invited to participate

in the experiment that will be scheduled individually,

in person. It is believed that no relevant selection bias

will occur, nevertheless the non-randomization factor

will be taken in consideration while analysing the

results.

The target number of participants for the next

phase is around 30. There is a 7 weeks’ window to

conduct the test: the pregnant person can apply to join

the antenatal classes until they reach 21 weeks of

gestation, and the course will start when they around

28 weeks. The recruitment phase will be repeated

until the target number is reached.

That second contact with the participants will be

in person, and it will start by requesting them to

answer a first questionnaire (Q1), in digital format

and by self-completion, and Likert scales will play a

major role for self-assessment questions. It includes

six groups of questions regarding: socio-

demographic, regarding the pregnant person and the

partner; clinical factors; birth information that were

already exposed, orally, on paper and digital formats;

expectations of a tool for learning and to list

preferences regarding birth.

Then the study follows a Pretest-Posttest Design:

before and after testing the digital tool, or paper based

for the Control Group A, the participants will be

requested to answer the same questionnaire (QPPF,

standing for Pre, Post and Follow-up), and they can

not check nor change their previous answers. This

study design (Figure 2) is widely used to compare

different groups and measure behavioural changes

regarding the experimental intervention (Dimitrov &

Rumrill, 2003). It is also used in Educational models

to assess students’ outcome, even in self-learning

students, being the instruction period the intervention

(Sumner & Capano, 2010). In this study, this design

will allow to analyse the changes on their birth

preferences after exposed to the content and the

individual learning outcomes. This questionnaire is

focused on collecting data regarding: knowledge,

influential factors, autonomy and self-relevance

regarding pregnancy and birth; perception of

credibility of different sources of information.

The test will be conducted by asking two groups

to perform guided-tasks in a controlled environment.

Kaikkonen et al. (2008) study shows that important

Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of

an Ongoing Study following a Mixed-Method Approach

703

results can be achieved through laboratory tests, even

in settings when the cognitive load from using digital

devices could be an issue. The preparation of the

environment to simulate a real situation is highly

recommended, and the complexity of real usage

needs to be foreseen and reflected on the tasks guide.

A printed guide will be handle to each participant,

which lists a set of numbered tasks to be performed,

and clarifies that they should be autonomous, despite

the fact that a thinking-aloud protocol is being

followed (Boren & Ramey, 2000) and they under

observation - direct and structured by using a

behaviour schedule and keeping it as discrete as

possible to avoid Hawthorne effect (McLeod, 2015).

After the conclusion of the test, and after

answering one more time the QPPF questionnaire, the

participants will be asked to fill in a questionnaire

(Q2) related to their perceptions and experience

during the test, to measure adequacy and quality of

the content, aiming to check if the information

provided meet their needs. For the version Q2a, some

questions regarding the digital tool usage will be

included, in order to understand if the tool was well

designed and developed, and how important was the

interactivity and dynamism provided by digital

media. On the other hand, the participants from the

Control Group A will answer Q2b which includes

questions related to paper-based experience. This will

allow a comparison between the two formats, and the

main data collection ends after Q2 completion.

For reliability and validity purposes, the

participants will be contacted once more for a follow-

up questionnaire (QPPF), after they attend the

antenatal classes. This collection aims to understand:

what are the impacts of being exposed to content, by

testing a digital or a paper-based tool; if

acknowledging the possibility of listing their birth

preferences triggers behavioural changes and the

communication with health professionals, namely

searching for information in different sources; how

obtaining more knowledge helps creating a labour

and birth preferences list.

Control Group B will be needed for this part of the

study. It will be composed by participants who

attended the antenatal classes, but did not participate

in the previous part of the study. They will be asked

to fill in a questionnaire (Q3) for feedback regarding

the classes, plus the QPPF questionnaire for

comparison purposes with the other groups.

Figure 2: Data collection plan, by Group.

The literature, namely results from recent

systematic reviews (Suto et al, 2016; Brixval, 2016;

Kilfoyle, Vitko, O’Conor & Bailey, 2016; Say,

Robson & Thomson, 2011; Vlemmix et al, 2013),

shows that research on Comprehensive Sexual

Education, Childbirth Literacy and Self-care for

Health can still be conducted for different

contributions, since several topics are unexplored yet.

The most common topics found are related to:

Satisfaction of women with antenatal education and

with the birth outcome; Impact of informed-decision

making and decision aids in maternity care; Maternal

depression; Maternal and Infant mortality and

morbidity rates; Reproductive and sexual behaviours

of the women; Impacts on decisions regarding

nutrition during pregnancy and for the child; Impact

on child development and health outcomes. The less

common, but also present, are evidences collected in

other studies (Sanders & Crozier, 2018; Wallwiener

et al, 2016) regarding: Preventive health care;

Influences for pregnant person’s decisions regarding

birth (Barimani, Frykedal, et al., 2017; Frykedal et al.,

2015; Lima-Pereira, Bermudez-Tamayo, &

Jasienska, 2012); Paternal depression; Partners’ fears

and anxiety regarding birth; Partner attendance and

satisfaction with childbirth; Satisfaction with the

postnatal couple relationship; Parenting behaviours

and distress; and Parent-infant interaction.

While the usage of media and e-health technology

is a rising topic (Khanum, de Souza, Sayyed & Naz,

2017; Moore, Drey & Ayers, 2017), some literature

gaps form the social sciences perspective could be

identified: partners participation taking in

consideration LGBT+ and different patchwork

families (Entsieh & Hallstrom, 2016; Vikstrom &

Barimani, 2016); decision tendencies considering

different cultural backgrounds, needs, abilities and

resources (Frykedal, Rosander, Berlin, & Barimani,

2015); sources of information to their reach

(Barimani, Frykedal, et al., 2017).

In what concerns the specific, yet transdiciplinary,

field that is Perinatal Digital Education, studies are

still scarce. Keeping that in mind, an analysis model

was created for this research, and part of it can be seen

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on Table 1, related to the Concept of Informed

Decision-making regarding birth options, listing the

Dimensions and highlighting the Indicators, being

this part of the major innovations of this research.

Table 1: Part of the Analysis’ Model.

Dimensions Indicators

Knowledge Access to perinatal formal courses;

Searching behaviour for general

information, for health, for pregnancy

and for labour and birth topics;

Access to birth data by format, people

and commercial bias;

Perception of accuracy when obtained

from different sources, channels and

formats;

Motivation to know more when

obtained from different sources,

channels and formats;

Opinion on the relevance of being

informed through scientific evidence.

Values,

Attitudes

and

Behaviours

Tendency on the decisions according to

religion, prejudice, fear, life style,

believes, empower.

Influence Influence on the decisions when

information comes from different

sources, channels and formats.

Pregnant

person

Expectations of amount of labour and

birth information;

Expectations for autonomy on labour

and decisions;

Opinion on current printed and digital

materials distributed by Portuguese

National Health System;

Sensitivity to explicit content.

Notes:

“Different sources” refers to people, institutions and

companies; “Different channels” refers to oral, paper and

digital; “Different formats” refers to text, visuals and

audio.

3 EXPECTED CONTRIBUTIONS

The innovation of the study resides in filling an

existent gap in the literature, since: no studies

comparing the outcomes of Print vs. Digital-based

Decision aids for Childbirth Education purposes were

found; no studies were found on providing

information side by side with the decision options for

the birth plan creation; the online tools available for

birth plan creation are scarce and do not cover a wide

range of topics and suffer from limitations of

interactivity - details regarding this literature review

and benchmarking analysis will be published in the

near future; and ultimately, this provides an example

how mixed methods can contribute to establish the

bridges, not only between two, but three different

fields of study.

The research design as planned can contribute to

better understand if exposing pregnant women to the

created content and to the concept of informed

decision-making leverages their knowledge and

contributes for the decision-making process for their

own birth, and if it triggers rich discussions between

them and Childbirth Educators. Besides, the initial

data collection is intended to make possible to

understand: which are the other agents involved on

the Maternal Education; what type of information

they provide; how they reach the pregnant person;

and the accuracy perceived of that information.

By including a Control Group B, it will also be

possible to measure the outcome from antenatal

classes of the partner Health Centre, which will be the

only source of feedback they have until the moment.

Analysing the gathered data may clarify if different

learning paths have difference learning outcomes, and

if it would be tool to use within the classes.

Nevertheless, an online learning and decision aid tool

could engage expectant parents who might not

available to enroll the classes, due to health, time,

transportation and other constrains.

As concluded by Zisman-Ilani, Gordbenko, Shern

and Ewlyn (2017) on a study also comparing Digital

vs. Paper-base Decision Aids but on a different

context (Psychiatric field), it is relevant to develop a

specific digital tool so the respondents can address

advantages and disadvantages of a particular material.

Besides the paper-based materials, an interactive,

accessible and digital tool, with simple language and

multimedia contents illustrating scientific concept

following WHO (2016; 2018) guidelines, it is

expected to meet the audience needs, who is not

supposed to be expert in health. The proposal is

intended to provide safe and reliable source of

information, and become a reference for other studies

and projects, and which can be used by Childbirth

Educators - in Portuguese speaking contexts due to

language constrains. Details regarding the creation

Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of

an Ongoing Study following a Mixed-Method Approach

705

and validation of the content created will be published

in the near future.

It is relevant to recall that this study is a step

forward for Portuguese context and can establish

ground for public health policies to recognize women

empowerment regarding birth, by providing a

proposal which is missing on the Pregnancy

Monitoring and Parenting Preparation Program from

Directorate-General for Health (DGS, 2015), as a

dematerialised option that could be adopted

nationally, a topic currently under the political radar

(GPPS, 2018).

Due to Coronavirus disease 2019 (COVID-19),

the proposed research design may suffer some

adjustments in order to comply with the country’s

most up to date Restrictions Regulations.

ACKNOWLEDGEMENTS

The authors would like to thank: Rita Leal, RN/CNM

for her support on the design settings of the

experimental phase; the three anonymous reviewers

for the most helpful comments; and the HEALTHINF

2021 organisation committee for the registration

grant provided, and the Secretariat for their diligent

work; and, the University of Aveiro and António

Moreira in particular, for all the support provided.

CVL would like to acknowledge the fund support

through the Doctoral Programme in Technology

Enhanced Learning and Societal Challenges

(PD/00173/2013) by FCT, through their research

grants PD/BI/135241/2017, followed by doctoral

grants PD/BD/143077/2018.

REFERENCES

Anguera Argilaga, M. T. 2008. Posibilidades de la

metodologia cualitativa vs cuantitativa. Revista de

Investigación Educativa, 3(6), 127–144.

Bardin, L. 2008. Análise de conteúdo (L’analyses de

contenu). Lisbon, Portugal: Edições 70. (Original

document in French published by Presses

Universitaires de France).

Barimani, M., Frykedal, K. F., Rosander, M., & Berlin, A.

2017. Childbirth and parenting preparation in antenatal

classes. Midwifery. doi: 10.1016/j.midw.2017.10.021.

Barimani, M., Vikstrom, A., Rosander, M., Frykedal, K. F.,

& Berlin, A. 2017. Facilitating and inhibiting factors in

transition to parenthood - ways in which health

professionals can support parents. Scandinavian

Journal of Caring Science, 31, 537–546.

Berlin, A., Tornkvist, L., & Barimani, M. 2016. Content

and presentation of content in parental education groups

in sweden. Journal of Perinatal Education, 25, 87–96.

Bisquerra Alzina, R. 1989. Métodos de investigacion

educativa: Guia practica. Barcelona, Catalonia:

Ediciones CEAC.

Boren, T., & Ramey, J. 2000. Thinking aloud: reconciling

theory and practice. In Ieee transactions on professional

communication (43rd ed., pp. 261–278).

Brixval, C. S. 2016. Antenatal education – a systematic

review and a randomised trial. (Doctoral thesis).

National Institute of Public Health, Faculty of Health

Sciences, University of Southern Denmark.

Creswell, J. W., & Plano Clark, V. L. 2018. Designing and

conducting mixed methods research (3rd ed.).

Thousand Oaks, CA: Sage.

DGS. 2015. Programa Nacional para a Vigilância da

Gravidez de Baixo Risco.

Dimitrov, D. & Rumrill, P. 2003. Pretest-Posttest Designs

and Measurement of Change. Work (Reading, Mass.).

20. 159--65.

Doty, J. L., & Dworkin, J. 2014. Online social support for

parents: A critical review. Marriage and Family

Review, 50, 174–198. doi:

10.1080/01494929.2013.834027.

Entsieh, A. A., & Hallstrom, I. K. 2016. First-time parents’

prenatal needs for early parenthood preparation-a

systematic review and meta-synthesis of qualitative

literature. Midwifery, 39, 1–11.

Fetters, M. D., & Freshwater, D. 2015. The 1 + 1 = 3

integration challenge. Journal of Mixed Methods

Research, 9(2), 115-117.

doi:10.1177/1558689815581222

Freitas, F., Leite, C. V., de Souza, F. N., & Costa, A. P.

2019. How the "help" feature can boost the self-

learning process of caqdas: The webqda case study

(Vol. 1068; L. R. A. Costa & A. Moreira, Eds.).

Springer, Cham. doi: 10.1007/978-3-030-31787-4_14

Frykedal, K. F., Rosander, M., Berlin, A., & Barimani, M.

2015. With or without the group: Swedish midwives’

and child healthcare nurses’ experiences in leading

parent education groups. Health Promotion

International, 31, 899–907.

Gajbhiye, B. N., & Prasad, V. K. 2013. Model for defence

R&D scientific and engineering software development.

Lecture Notes on Software Engineering, 1(3).

Ghiglione, R., & Matalon, B. 1997. O inquérito: Teoria e

prática. Oeiras, Portugal: Celta Editora.

GPPS. 2018. Projeto de Lei n.o 872/XIII/3.a - Regime de

proteção na pré conceção, na procriação medicamente

assistida, na gravidez, no parto, no nascimento e no

puerpério.

Grimes, H. A., Forster, D. A., & Newton, M. S. 2014.

Sources of information used by women during

pregnancy to meet their information needs. Midwifery,

30. doi: 10.1016/j.midw.2013.10.007

Habermas, J. 1974. Theory and practice. London, United

Kingdom: Heineman.

Hawley, G., Janamian, T., Jackson, C., & Wilkinson, S. A.

2014. In a maternity shared-care environment, what do

HEALTHINF 2021 - 14th International Conference on Health Informatics

706

we know about the paper hand-held and electronic

record: a systematic literature review. BMC Pregnancy

and Childbirth, 14, 52-64. doi: 10.1186/1471-2393-14-

Huberty, J., Dinkel, D., Beets, M. W., & Coleman, J.

(2013). Describing the use of the internet for health,

physical activity, and nutrition information in pregnant

women. Matern Child Health. Journal, 17, 1363–1372.

doi: 10.1007/s10995-012-1160-2

Kaikkonen, A., Kekäläinen, A., Cankar, M., Kallio, T., &

Kankainen, A. 2008. Will laboratory test results be

valid in mobile contexts? In J. Lumsden (Ed.),

Handbook of research on user interface design and

evaluation for mobile technology (Vol. 3, pp. 897–909).

Hersey, EUA: Information Science Reference.

Khanum, S., de Souza, M., Sayyed, A., & Naz, N. 2017.

Designing a Pregnancy Care Network for Pregnant

Women. Technologies, 5(4), 80. doi:

10.3390/technologies5040080

Kilfoyle, K.A. Vitko, M., O’Conor, R. & Bailey, S.C. 2016.

Health Literacy and Women’s Reproductive Health: A

Systematic Review. Journal of Women’s Health, 25

(12), 1237—1255. Mary Ann Liebert, Inc. DOI:

10.1089/jwh.2016.5810

Latorre, A., Rincon, D. D., & Arnal, J. 1996. Bases

metodológicas de la investigación educativa.

Barcelona, Catalonia: Hurtado Ediciones.

McLeod, S. A. 2015. Observation methods. Retrieved from:

https://www.simplypsychology.org/observation.html

Moore, D., Drey, N., & Ayers, S. 2017. Use of Online

Forums for Perinatal Mental Illness, Stigma, and

Disclosure: An Exploratory Model. JMIR Mental

Health. 4(1):e6). doi:10.2196/mental.5926

Sanders, R. A. & Crozier, K. 2018. How do informal

information sources influence women’s decision-

making for birth? A meta-synthesis of qualitative

studies. BMC Pregnancy and Childbirth. DOI

10.1186/s12884-017-1648-2

Say, R., Robson, S., & Thomson, R. 2011. Helping

pregnant women make better decisions: a systematic

review of the benefits of patient decision aids in

obstetrics. BMJ open, 1(2), e000261. doi:

10.1136/bmjopen-2011-000261

Solomon, G. 1991. Transcending the qualitative-

quantitative debate: The analytic and systematic

approaches to educational research (Vol. 20).

Sumner, E. S. & Capano, C. D. 2010. Pre and post

evaluations for assessment of student learning

outcomes; A simple approach. In Proceedings of the

46th Associated Schools of Construction Annual

Conference.

Suto, M., Takehara, K., Yamane, Y., & Ota, E. 2016.

Effects of prenatal childbirth education for partners of

pregnant women on paternal postnatal mental health: a

systematic review and meta-analysis protocol.

Systematic reviews, 5, 21. doi: 10.1186/s13643-016-

0199-3

Tashakkori, A., & Creswell, J. W. 2007. Exploring the

nature of research questions in mixed methods research.

Journal of Mixed Methods Research, 1(3), 207-211.

doi:10.1177/1558689807302814

Thomas, G. M., & Lupton, D. 2015. Threats and thrills:

pregnancy apps, risk and consumption. Health, Risk

and Society. doi: 10.1080/13698575.2015.1127333

United Nations. 2015a. The Millennium Development

Goals Report. United Nations, 72. doi: 978-92-1-

101320-7

United Nations. 2015b. Transforming our world: the 2030

Agenda for Sustainable Development. General

Assembley 70 session, 16301(October), 1–35. doi:

10.1007/s13398-014-0173-7.2

Vikstrom, A., & Barimani, M. 2016. Partners’ perspective

on care-system support before, during and after

childbirth in relation to parenting roles. Sexual and

Reproductive Healthcare, 8, 1–5.

Vlemmix, F., Warendorf, J., Rosman, A., Kok, M., Mol, B.,

Morris, J., & Nassar, N. 2013. Decision aids to improve

informed decision-making in pregnancy care: a

systematic review. BJOG, 120, 257–266.

Vuorikari, R., Punie, Y., Carretero Gomez S. & Van den

Brande, G. 2016. DigComp 2.0: The Digital

Competence Framework for Citizens. Update Phase 1:

The Conceptual Reference Model. Luxembourg

Publication Office of the European Union. EUR 27948

EN. doi:10.2791/11517

Wallwiener, S., Müller, M., Doster, A., Laserer, W., Reck,

C., Pauluschke-Fröhlich, J., . . . Wallwiener, M. 2016.

Pregnancy eHealth and mHealth: user proportions and

characteristics of pregnant women using Web-based

information sources—a cross-sectional study. Archives

of Gynecology and Obstetrics, 294(5), 937–944. doi:

10.1007/s00404-016-4093-y

World Health Organization. 2016. Recommendation on

antenatal care for positive pregnancy experience. World

Health Organization Press.

World Health Organization. 2018. Who recommendations

intrapartum care for a positive childbirth experience.

World Health Organization Press.

Zisman-Ilani, Y., Gorbenko, K., Shern, D., & Elwyn, G.

2017. Comparing Digital vs Paper Decision Aids about

the Use of Antipsychotic Medication. International

Journal of Person Centered Medicine, 7, 21–30.

Supporting Childbirth Knowledge Acquisition and Decision-making through Digital Communication Technology: The Research Design of

an Ongoing Study following a Mixed-Method Approach

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