Bayrampour Hamideh

ADVANCED MATERNAL AGE & RISK PERCEPTION
Advanced Maternal Age and Risk Perception
by
Hamideh Bayrampour
A Dissertation submitted to the Faculty of Graduate Studies of

The University of Manitoba
in partial fulfilment of the requirements of the degree of
DOCTOR OF PHILOSOPHY
Department of Applied Health Sciences

University of Manitoba
Winnipeg
Copyright 2011 by Hamideh Bayrampour
Abstract
Advanced maternal age (AMA) is linked to several adverse pregnancy outcomes, hence
these pregnancies are considered to be "high risk." Risk perception impacts pregnant
womens health care use, health behaviors, and adherence to medical recommendations.
Yet, a gap remains in the understanding of perception of pregnancy risk and its
contributing factors. This mixed methods research study was developed to address this
gap, using a conceptual framework based on a literature review and the Psychometric
Model of risk perception. The specific objectives of this study were to compare risk
perception in nulliparous women of AMA with younger women, determine the factors
influencing perception of pregnancy risk, and gain an understanding of womens
perspectives of risks associated with AMA.
Between December 2009 and January 2011, a sample of 159 participants (105 women
aged 20-29 years and 54 women aged 35 years or older) was recruited from a variety of
settings in Winnipeg, Manitoba. Several questionnaires were completed by participants.
Descriptive statistics, chi square, t tests, Pearson's r correlations, and stepwise
multivariate linear regressions were used to analyze data. Fifteen women of AMA were
chosen purposefully to participate in individual and semi-structured interviews.
Interviews were audio-taped and transcribed verbatim, and content analysis was used to
identify themes.
Results revealed that pregnancy-related anxiety, maternal age, medical risk, perceived
control (internal), and gestational age were significant predictors of perception of
pregnancy risk accounting for 47-49% of the variance in risk perception. Maternal age
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interacted in a synergistic manner with pregnancy-related anxiety to increase perception

of pregnancy risk levels. In the qualitative component, four main themes emerged from
the data: definition of pregnancy risk, factors influencing risk perception, risk alleviation
strategies, and risk communication with health professionals.
Women of AMA perceived higher pregnancy risk for both themselves and their fetuses
than younger women. However, they were not a homogenous group in their pregnancy
risk appraisal. This study contributed to the field by proposing pregnancy-related anxiety
as a pregnancy dread factor in risk perception theories. Risk communication is an
important element of developing care plans for women of AMA and should be integrated
into prenatal care visits.
Keywords: advanced maternal age, perception of pregnancy risk, mixed methods
research, high risk pregnancy, anxiety, risk communication.
iii
Acknowledgements
I would like to express my utmost appreciation and gratitude to my advisor, Dr.
Maureen Heaman for her guidance, inspiration, and mentorship throughout my PhD
studies. Without her guidance and support this dissertation would not have been possible.
I would like to thank my committee members, Dr. Karen Duncan and Dr. Suzanne
Tough for their valuable input throughout the process. Their direction and encouragement
kept me motivated throughout this research project.
I would like to gratefully acknowledge the scholarship/fellowship support and
recognition I received from the Canadian Institutes of Health Research Strategic Training
Program in Maternal-Fetal-Newborn Health, the CIHR-Graduate Student Trainee Award
from Dr. Maureen Heaman, the CIHR- Manitoba Health Research Council Regional
Partnership Program, and the University of Manitoba Graduate Fellowship (UMGF).
Funding for this study was received from the Manitoba Institute of Child Health (MICH)
small grant.
I am grateful to the staff members in the Manitoba Centre for Nursing and Health
Research (MCNHR), especially Diane Cepanec who helped me all the way through my
PhD studies. I would also like to thank Mary Cheang for her assistance with statistical
analysis during this study.
I would like to thank all of the participants who generously devoted their time to
increase knowledge on this topic. Thank you to the nurses and staff members of the St.
Boniface Hospital, Health Sciences Centre, and all other settings that assisted with
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identifying and recruiting potential participants for this study. I would like to send a
special thank you to Mary Driedger, Clinical Nurse Specialist at the Health Sciences
Centre who assisted me in the completion of data collection.
Completing this project is an accomplishment that I am pleased to be able to share
with those who supported and encouraged me in this endeavor: friends and my family
members. I am very fortunate to have been raised by parents who value higher education.
I can honestly say that I have come as far as I have because of your influence,
encouragement, support, and optimism. Finally, my everlasting gratitude to Kurosh
Zareinia and to my lovely son, Ario, who is true sunshine in my life.
Dedication
To my son, and my parents
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Table of Contents
Abstract ............................................................................................................................... i
Acknowledgements .......................................................................................................... iii
Dedication .......................................................................................................................... v
Dissertation Organization ............................................................................................. xiii
Chapter One: Introduction .............................................................................................. 1
Purpose of the Study ............................................................................................. 4
Significance of the Study ...................................................................................... 4
Chapter Two: Literature Review .................................................................................... 5
The Trend of Delayed Childbearing and Contributing Factors ............................ 5
Risks Associated with Pregnancy at AMA ........................................................... 7
Mortality. ..................................................................................................... 7
Morbidity. .................................................................................................... 8
Definition and Theoretical Underpinnings of Risk Perception .......................... 11
Risk perception theories. ........................................................................... 12
Factors influencing risk perception. .......................................................... 13
Risk Perception during Pregnancy...................................................................... 15
Factors influencing perception of pregnancy risk. .................................... 17
Risk Perception at AMA ..................................................................................... 18
Chapter Three: Conceptual Framework ...................................................................... 21
Research Questions ............................................................................................. 26
Research questions for the quantitative component. ................................. 26
Research questions for the qualitative component. ................................... 27
Chapter Four: Design and Methods .............................................................................. 28
Mixed Methods Research ................................................................................... 28
Paradigm (world view). ............................................................................. 29
Study Design ....................................................................................................... 30
Sampling ............................................................................................................. 30
Quantitative Component ..................................................................................... 31
Design........................................................................................................ 31
vii
Study setting. ............................................................................................. 32

Population and sample. ............................................................................. 32
Instruments. ............................................................................................... 33
Data collection procedures. ....................................................................... 37
Sample size. ............................................................................................... 39
Data analysis. ............................................................................................ 39
Qualitative Component ....................................................................................... 41
Design........................................................................................................ 41
Sample. ...................................................................................................... 42
Data collection procedures. ....................................................................... 42
Data analysis. ............................................................................................ 43
Rigor. ......................................................................................................... 43
Ethical Considerations ........................................................................................ 44
Chapter Five: Manuscript One...................................................................................... 46
Introduction to Findings ..................................................................................... 46
Manuscript 1: Comparison of Perception of Pregnancy Risk of Nulliparous
Women of Advanced Maternal Age and Younger Age...................................... 48
Abstract ............................................................................................................... 48
Introduction......................................................................................................... 49
Methods .............................................................................................................. 52
Instruments. ............................................................................................... 53
Data analysis. ............................................................................................ 55
Results................................................................................................................. 56
Pregnancy characteristics. ......................................................................... 56
Perception of pregnancy risk. .................................................................... 57
Pregnancy-related anxiety. ........................................................................ 58
Risk knowledge. ........................................................................................ 58
Health status. ............................................................................................. 59
Perceived control. ...................................................................................... 59
Medical risk. .............................................................................................. 59
Discussion ........................................................................................................... 60
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Conclusion .......................................................................................................... 64
References........................................................................................................... 66
Chapter Six: Manuscript Two ....................................................................................... 81
Introduction to Chapter Six ................................................................................ 81
Manuscript 2: Predictors of Perception of Pregnancy Risk among Nulliparous
Women ................................................................................................................ 82
Abstract ............................................................................................................... 82
Introduction......................................................................................................... 83
Conceptual Framework ....................................................................................... 85
Psychometric Model of risk perception. ................................................... 85
Summary of the literature review. ............................................................. 86
Methods .............................................................................................................. 89
Instruments. ............................................................................................... 91
Data analysis. ............................................................................................ 94
Results................................................................................................................. 96
Model 1 ..................................................................................................... 98
Model 2 ..................................................................................................... 98
Discussion ........................................................................................................... 99
Implications for Practice ................................................................................... 105
Conclusion ........................................................................................................ 107
References......................................................................................................... 109
Chapter Seven: Manuscript Three .............................................................................. 126
Introduction to Chapter Seven .......................................................................... 126
Manuscript 3: Advanced Maternal Age and Risk Perception: A Qualitative
Study ................................................................................................................. 127
Abstract ............................................................................................................. 127
Introduction....................................................................................................... 128
Methods ............................................................................................................ 130
Results............................................................................................................... 134
Definition of pregnancy risk. .................................................................. 135
Factors influencing risk perception. ........................................................ 136
ix
Risk alleviation strategies........................................................................ 145

Communication with health professionals. ............................................. 148
Discussion ......................................................................................................... 149
Implications ...................................................................................................... 157
Conclusion ........................................................................................................ 158
References......................................................................................................... 160
Chapter Eight: Discussion ............................................................................................ 172
Integration of Findings ..................................................................................... 172
Integrations of findings at the data analysis level. .................................. 173
Integrations of findings at data interpretation level. ............................... 174
Conceptual Framework ..................................................................................... 175
Quantitative results. ................................................................................. 175
Qualitative results. ................................................................................... 175
Discrepancies between the two components. .......................................... 176
New factors emerging from Qualitative Data. ........................................ 176
Product of Compared or Integrated Findings ................................................... 177
Contribution to the Field ................................................................................... 180
Future Research ................................................................................................ 182
Strengths and Limitations of the Study ............................................................ 184
Implications for Practice ................................................................................... 185
Conclusion ........................................................................................................ 188
References......................................................................................................... 189
Appendix A: Questionnaire ......................................................................................... 208
Appendix B: Prenatal Scoring Form........................................................................... 224
Appendix C: Permission to use the Perception of Pregnancy Risk Questionnaire. 225
Appendix D: Permission to use the Pregnancy-related Anxiety Scale ..................... 226
Appendix E: Permission to use the Knowledge of Maternal Age-related Risks of
Childbearing Questionnaire ......................................................................................... 227
Appendix F: Script for Approaching Potential Participants .................................... 228
Appendix G: In-Person Contact with Potential Participants ................................... 229
Appendix H : Research Subject Information and Consent Form (For Quantitative

Component) ................................................................................................................... 230
Appendix I : Invitation Letter ..................................................................................... 235
Appendix J: Research Subject Information and Consent Form (For Qualitative
Component) ................................................................................................................... 240
Appendix K: Interview Guide...................................................................................... 245
Appendix L: Contact Summary Sheet for Interviews ............................................... 247
Appendix M: Education/Nursing Research Ethics Board Approval Certificate .... 248
Appendix N: Education/Nursing Research Ethics Board Renewal Approval
Certificate ...................................................................................................................... 249
Appendix O: Health Sciences Center Research Access Approval Certificate ........ 250
Appendix P: St. Boniface Hospital Research Access Approval Certificate ............. 251
Appendix Q: Winnipeg Regional Health Authority Research Access Approval
Certificate ...................................................................................................................... 252
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List of Tables
Chapter 5
Table 1.Comparison of Characteristics of Younger (Aged 20-29 years) and Older (Age
>35 years) Nulliparous Women Using Independent t-test .................................... 73
Table 2. Comparison of Characteristics of Younger (Aged 20-29 years) and Older (Age
>35 years) Nulliparous Women Using Fishers Exact Test (Two-sided) ............. 74
Table 3. Comparison of Scores on Study Variables of Younger (Aged 20-29 years) and
Older (Age >35 years) Nulliparous Women Using Independent t-test ................. 76
Table 4. Comparison of Scores on Each Item in the Perception of Pregnancy Risk
Questionnaire of Younger (Aged 20-29 years) and Older (Age >35 years)
Nulliparous Women Using Independent t-test ...................................................... 78
Table 5. Pearson Correlation Coefficients between Perception of Pregnancy Risk Score
and Major Study Variables.................................................................................... 79
Chapter 6
Table 1. Descriptive Statistics for Major Study Variables ............................................. 120
Table 2. Pearson Correlation Coefficients between Perception of Risk Score and Major
Study Variables and Partial Correlation Coefficients (Controlling for Maternal
Age) ..................................................................................................................... 121
Table 3. Multiple Regression Analysis (without Interactions)- Perception of Pregnancy
Risk as the Dependent Variable .......................................................................... 122
Table 4. Multiple Regression Analysis (With Interactions)- Perception of Pregnancy Risk
as the Dependent Variable .................................................................................. 123
Chapter 7
Table 1. Classifications of the PPRQ, Pregnancy-related Anxiety, and Perceived Control
(internal) Scores in Tertiles Using Data for Women of AMA from the Advanced
Maternal Age and Risk Perception Study (n=54) ............................................... 168
Table 2. Frequency of Participants in each Tertile (N=15) ............................................ 169
Table 3. Demographic Characteristics of Participants (N=15) ....................................... 170
Table 4. Obstetrics Characteristics of Participants (N=15) ............................................ 171
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List of Figures
Chapter 2
Figure 1. Conceptual framework of the study .................................................................. 25
Chapter 6
Figure 1. Conceptual framework of the study ................................................................ 124
Figure 2. The effect of maternal age on the perception of pregnancy risk-anxiety scores
......................................................................................................................................... 125
Chapter 8
Figure 2. Modified conceptual framework ..................................................................... 178
xiii
Dissertation Organization
This dissertation is organized following the manuscript format, in which three distinct,
but inter-related manuscripts constitute the body of the dissertation. Chapter 1 presents an
introduction to the topic. Chapter 2 includes a review of pertinent literature that provides
a context to situate the current study. Chapter 3 outlines the conceptual framework
underlying this study. Chapter 4 describes the design and methods used to conduct the
study. Chapters 5, 6, and 7 are stand-alone manuscripts reporting the results and
conclusions of this study. Chapter 5 compares perception of pregnancy risk in the two
groups of nulliparous women. Chapter 6 determines factors influencing the perception of
pregnancy risk and finally, Chapter 7 reports the findings of the qualitative component of
the study. This chapter presents participants' perspectives on pregnancy risk and
examines their risk appraisals. A brief section prior to each manuscript is included to
outline the logic in linking these chapters and to explain how the results of the previous
manuscript have informed the subsequent manuscript. Chapter 8 is a discussion section
that explains the process of integration of the findings of the two components and
provides a general discussion of the overall findings. This chapter also considers
limitations and strengths of the study, and proposes recommendations for future research.
Tables and figures are found at the end of each chapter and presented in the order they
appeared in the text.
Because each manuscript is constructed as a self-contained and standalone research
paper, some redundancy between Chapters 2, 3 and 4 and the introduction and methods
sections of the manuscripts exist, which is the results of including this information in
each manuscript.
xiv
Chapter One: Introduction

Modern social life has had considerable effects on womens reproductive life in
the past three decades. Today, it has become more commonplace for women to delay
childbearing into their mid thirties and early forties for educational, social, and economic
reasons (Benzies et al., 2006; Tough, Benzies, Fraser-Lee, & Newburn-Cook, 2007). The
maternal age of 35 years or older at the time of delivery has been defined as advanced
maternal age (AMA). According to the National Vital Statistics Report, the birth rate for
women aged 35 to 39 years in the United States increased to 47.5 births per 1,000 women
in 2007, the highest rate since 1964, and the birth rate for women 40 to 44 years
increased to 9.5 births per 1,000 women in 2007, the highest rate since 1968 (Hamilton,
Martin, & Ventura, 2009). In Canada, the live birth rate among women of AMA has
increased substantially. Between 1995 and 2004, the live birth rate for women aged 35 to
39 years increased by 32.5% (from 28.0 to 37.1 per 1,000 females). Correspondingly the
live birth rate for women aged 40 to 44 years increased by 42.9% (from 4.2 to 6.0 per
1,000 females) and the live birth rate for women aged 45 to 49 years increased by 58.8%
(from 0.17 to 0.27 per 1,000 females) (Public Health Agency of Canada, 2008).
AMA is associated with adverse pregnancy outcomes and increasing costs in
relation to child birth (Zasloff, Schytt, & Waldenstrom, 2007). Several studies have
demonstrated an association between AMA and preterm birth, low birth weight, still
birth, chromosomal abnormalities, gestational diabetes, and multiple births (ClearyGoldman et al., 2005; Huang, Sauve, Birkett, Fergusson, & Walraven, 2008; Jacobsson,
Ladfors, & Milsom, 2004; Joseph et al., 2005; Newburn-Cook & Onyskiw, 2005). The
recent report of the Canadian Institute for Health Information (CIHI) on births from
20062007 through 20082009, demonstrated that the risks of gestational diabetes,
cesarean section, placenta previa, labour complications and interventions, preterm birth,
small for gestational age, and chromosomal defects were higher among Canadian women
of AMA than younger women. Also based on this report, both maternal and neonatal
hospital costs were higher for the women of AMA and their infants (Canadian Institute
for Health Information, 2011). Due to the increased risk at AMA, pregnancy at age 35
years or older is considered to be a "high risk" pregnancy. Nevertheless, it is not clear
how women of AMA perceive and evaluate their pregnancy risk compared to younger
women.
Risk perception is about capturing the myriad meanings and weights that an
individual assigns to the experience of being at increased risk (Pilarski, 2009) and is
something quite different from risk (Sjoberg, 2000). This concept was introduced in 1960
by Bauer as a two dimensional structure, which included uncertainty and adverse
consequences. Risk perception has been defined as "ones expectancy about the
probability of an event" (Weinstein et al., 2007, p.147) or "beliefs about potential harm"
(Brewer et al., 2007, p.136). Risk perception is incorporated as a key concept in
constructing several theories of health behavior such as the Health Belief Model (Janz &
Becker, 1984), Protection Motivation Theory (Maddux & Rogers, 1983), and Prospect
Theory (Kahneman & Tversky, 1979). Most of these theories assume that individuals
decisions regarding health-related behaviors are based on rational analyses of risks and
benefits.
Pregnancy risk perception is important because it affects pregnant womens health

care utilization, motivations to seek prenatal care, decisions about place of birth or choice
about intensive medical interventions, adherence to medical procedures and
recommendations, and healthy behaviors (Atkinson & Farias, 1995; Carolan & Nelson,
2007; Kolker & Burke, 1993; Kowalewski, Jahn, & Kimatta, 2000; Spielberger &
Gorsuch, 1983). Unlike health care providers understandings of risk that are the result of
their knowledge, training, experiences, and values, pregnant womens understandings of
risk are more contextual and individualized (Handwerker, 1994), reflecting their values,
education, and social class (Searle, 1996; Saxell, 2000). Current knowledge indicates that
pregnancy risk perception is highly individualized and that it is not exclusively based on
medical diagnoses (Heaman, Gupton, & Gregory, 2004). For instance, results of a study
by Gray in 2006 demonstrated an incongruity in risk assessment by pregnant woman and
their care providers in which women tended to underestimate their pregnancy risk
compared to their providers. Another study demonstrated that several factors other than
medical risk may contribute to perception of pregnancy risk in which the majority of
these factors are not identified yet (Gupton, Heaman, & Cheung, 2001). Knowledge of
womens attitudes toward pregnancy risk may facilitate risk communication between
health care providers and pregnant women (Jordan & Murphy, 2009). Current risk
communication approaches that are mainly based on epidemiological risk factors, without
attention to womens perceptions, might not entirely meet the needs of high risk women
(Kowalewski et al., 2000). In spite of the importance of understanding the risk perception
concept in providing high quality prenatal care, a gap remains in the understanding of
perception of pregnancy risk and its contributing factors.
Purpose of the Study

The purpose of this research was to explore risk perception of nulliparous women
of AMA from an in-depth perspective and to compare their risk perception to that of
younger women (age 20 to 29 years). To achieve this goal, a mixed methods research
study was employed. The main research question for this study was "How do nulliparous
women of AMA perceive the risk of their pregnancies?" This mixed methods research
study was composed of a quantitative component and a qualitative component. Each
component included several specific research objectives, developed based on the
literature review presented in Chapter 2. To facilitate reading of the dissertation, these
objectives will be introduced in Chapter 3.
Significance of the Study
Pregnancy at age 35 years or older is considered to be a medically high risk
situation. However, little is known about womens perception of pregnancy risk at AMA.
Current knowledge indicates that pregnancy risk perception is an important factor in
pregnant womens health care use and decision making during pregnancy. In spite of the
significance of risk perception, current pregnancy risk assessment systems do not include
womens beliefs and concerns. This work is an essential precursor in developing an
understanding of women's pregnancy risk appraisal. The results will provide concrete,
useful knowledge for designing effective approaches to caring for pregnant women,
particularly women of advanced maternal age. Understanding how women perceive
pregnancy risk can also assist policy makers in developing better policy and more
effective programs in areas involving risk management.
Chapter Two: Literature Review

This literature review provides an overview of advanced maternal age (AMA) and
perception of pregnancy risk. This review was undertaken to establish a context to
examine the perception of pregnancy risk at AMA. The following five themes were
addressed in this review: 1. A review of the trend of delayed childbearing and
contributing factors; 2. A summary of risks associated with pregnancy at AMA; 3. An
overview of the definitions and theoretical underpinnings of risk perception and factors
influencing risk perception; 4. A summary of current knowledge in perception of
pregnancy risk; and 5. A review of perception of pregnancy risk at AMA.
The Trend of Delayed Childbearing and Contributing Factors
In the past three decades, maternal age has increased worldwide. The fertility rate
for women of AMA is growing fast in developed countries. For example, in Australia
since 2003, the fertility rate for women aged 35 to 39 years has exceeded that of women
aged 20 to 24 years (Australian Bureau of Statistics, 2010). Between 1991 and 2001 in
the United States, the number of first births per 1000 women aged 35 to 39 years
increased by 36% and the rate for women aged 40 to 44 years increased by 70% (Heffner,
2004). In Canada, between 1995 and 2004, the live birth rate for women aged 35 to 39
years, 40 to 44 years, and 45 to 49 years has increased by 32.5%, 42.9%, and 58.8%,
respectively (Public Health Agency of Canada, 2008).
The trend of delayed childbearing has been contemporaneous with recent social
changes that provided greater employment opportunities for women, and increased
female labour force participation (Tudiver, 2005). In current Canadian society, more
women are in the labour force than ever before. In 2008, women accounted for more than
47% of the labour force in Canada (Statistcs Canada, 2009). Several other factors may
also influence decisions about the timing of childbearing, including acceptance of
delayed commencing of childbearing, decreasing family size, late marriage, advances in
equality in the workplace, and increasing educational opportunities for women (Benzies
et al., 2006; Carolan, 2003; Freeman-wang & Beski, 2002; Windridge & Berryman,
1999; Usta & Nassar, 2008). Advances in health care have also provided broader
reproductive rights for women and contributed to increasing rates of delayed
childbearing. Longer life expectancy, more effective contraceptive techniques, modern
infertility treatments, and developments in obstetric care are some examples in this regard
(Carolan, 2003; Delpisheh, Brabin, Attia, & Brabin, 2008; Tudiver, 2005; Windridge &
Berryman, 1999).
Tough, Benzies, Fraser-Lee, and Newburn-Cook (2007), a group of researchers
from Alberta, conducted a study on the timing of childbearing among Canadian men and
women. One of the objectives of their study was to determine the factors influencing the
timing of childbearing for non-parenting men and women. The survey was completed by
500 men and 1,006 women from two cities in Alberta (Calgary and Edmonton).
Researchers reported that there were four factors that respondents consider in timing their
childbearing including: financial security, their partners suitability to parent, their own
interest in or desire for having children, and their partners interest in or desire for having
children. They concluded that delayed pregnancy may be a consequence of not finding
the right partner, financial instability, and lack of awareness about the risks associated
with AMA. In this regard, Benzies et al. (2006) conducted a qualitative study of 45
Canadian women aged 20 to 48 years to examine the factors that influence Canadian
womens decisions about the timing of motherhood. The results of this qualitative study
suggested that decisions about the timing of childbearing were complex and influenced
by several individual, familial, and societal factors. The investigators reported that older
participants were more likely to value independence, having a stable relationship, and
readiness to start a family than younger women.
Risks Associated with Pregnancy at AMA
Even though women of AMA are more likely than younger women to be well
educated, have more knowledge about pregnancy and its complications, and be engaged
in healthy behaviors (Bayrampour & Heaman, 2011), there are increased risks for adverse
pregnancy outcomes at AMA. Although some researchers have argued that the absolute
rate of adverse outcomes associated with AMA is low and most women of AMA will
have the desired pregnancy outcomes (Joseph et al., 2007), literature supports the premise
that AMA is an independent risk factor for poor pregnancy outcomes. In the following
section, maternal and fetal mortality and morbidity associated with pregnancy at AMA
are outlined and reasons for increased adverse pregnancy outcomes at AMA are
discussed.
Mortality. There is a dramatic increase in the overall maternal mortality rate with
increasing maternal age in developed countries (Hansen, 1986; Temmerman, Verstraelen,
Martens, & Bekaert, 2004). Temmerman (2004) reported women aged 35 to 39 years in
Belgium had a sevenfold increased risk for pregnancy-related death in comparison to
women giving birth in their 20s (22.1 vs. 2.9 per 100,000 live births). Based on the
Confidential Enquiries into Maternal Mortality Report in the United Kingdom,
thrombosis and hypertension were the leading causes of maternal death in 1994-1996
among all ages. Death as a result of hypertension was reported to be related to increasing
maternal age and was five times more likely in women aged 40 years or older than in
women aged 25 years (De, 2000). In Canada (excluding Quebec) between 1997-2000,
women aged 35 to 39 years had a fivefold increased risk for maternal mortality ratio
(MMR) per 100,000 live births, compared to women aged 20 to 24 years (Health Canada,
2004).
It should be noted that despite the increased maternal mortality with advancing
maternal age, because maternal mortality occurs rarely in developed countries, the use of
maternal mortality as an indicator of maternal health has been challenged, and maternal
morbidity has been suggested as an appropriate alternative measure (Carolan, 2003;
Temmerman et al., 2004; Waterstone, Bewley, & Wolfe, 2001).
Morbidity. Pregnancy at AMA is associated with pregnancy complications and
adverse outcomes such as preterm birth, low birth weight, still birth, chromosomal
abnormalities, preeclampsia or eclampsia, and gestational diabetes. (Cleary-Goldman et
al., 2005; Huang et al., 2008; Jacobsson et al., 2004; Joseph et al., 2005; Newburn-Cook
& Onyskiw, 2005). Moreover, women of advanced maternal age are more likely to
experience assisted conception, cesarean section, assisted vaginal delivery, and multiple
births. Also, their newborns are more likely to be macrosomic or need intensive care
(Delbaere et al., 2007; Delpisheh et al., 2008). Joseph et al. (2005) conducted a
population-based study of all women in Nova Scotia, who delivered a singleton fetus
between 1988 and 2002. The purpose of the research was to determine if the rates of
pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and
serious neonatal morbidity were higher among women of AMA compared to women
aged 20 to 24 years. They found that women of AMA were more likely to have
hypertension, diabetes mellitus, placental abruption, or placenta previa, preterm birth, and
small for gestational age. In another Canadian study, older maternal age was determined
as a significant risk factor for hysterectomy due to atonic postpartum haemorrhage
(Joseph et al., 2007). The recent analysis of the Canadian Institute for Health Information
(CIHI) of births from 20062007 through 20082009 demonstrated that pregnancies at
AMA is associated with several adverse maternal and neonatal outcomes (Canadian
Institute for Health Information, 2011). Current knowledge suggests that the effect of
increasing maternal age is a continuum rather than a threshold effect (Montan, 2007).
Explanations for the increased adverse pregnancy outcomes at AMA. Although
the exact mechanisms underlying this issue are not fully explained yet, the following
reasons may be noted: First, an aging reproductive system might contribute to increased
adverse pregnancy outcomes (Cleary-Goldman et al., 2005; Jolly, Sebire, Harris,
Robinson, & Regan, 2000; O'Leary et al., 2007; Treacy, Robson, & O'Herlihy, 2006;
Yuan et al., 2000). An inefficiency of the aging myometrium is associated with
myometrium incompetency and decrease in the number of oxytocin receptors resulting in
increased risk of dysfunctional labour patterns and induction of labor (Bianco et al.,
1996; Bobrowski & Bottoms, 1995; Usta & Nassar, 2008). Decreased pelvic compliance
10
and reduced maternal voluntary effort during labor are also documented (Bell et al.,
2001; Treacy et al., 2006).
Another explanation is increasing prevalence of preexisting disease at AMA. The
contribution of aging of other systems and rising incidence of medical conditions and
chronic disease such as cardiovascular disease, arthritis, and diabetes might increase the
risk of adverse perinatal outcomes (Cleary-Goldman et al., 2005; Cnattingius,
Cnattingius, & Notzon, 1998; Delbaere et al., 2007; Usta & Nassar, 2008).
Another possible explanation is that advancing mothers age is associated with
declining fecundity. Therefore, older women are more likely to require infertility
treatment to become pregnant than younger women. Evidence indicates that pregnancy
outcomes are worse among pregnancies with assisted reproductive technology (ART)
than non ART pregnancies (Salihu, Wilson, Alio, & Kirby, 2008; Usta & Nassar, 2008).
A study by Buckett et al. (2007) demonstrated that ART pregnancies are more likely to
be associated with an increased risk of multiple pregnancy, cesarean delivery, and
congenital abnormality. Findings of a recent review suggested that spontaneous
pregnancies in untreated infertile women may be at higher risk for obstetrical
complications and perinatal mortality than spontaneous pregnancies in fertile women
(Allen, Wilson, & Cheung, 2006).
Obesity, which has become a common issue in the western world, might be
another reason for increased adverse pregnancy outcomes at AMA. In Canada, the
proportion of obese pregnant women increased from 3.2% in 1988 to 10.2% in 2002.
Maternal obesity has a documented association with adverse maternal and fetal outcomes,
11
particularly among women of AMA, who are at increased risk for several pregnancy
complications (Rowlands, Graves, de, McIntyre, & Callaway, 2010). Even moderately
obese women had an increased risk of pregnancy-induced hypertension, antepartum
venous thromboembolism, labour induction, caesarean section, and wound infection
(Montan, 2007).
Definition and Theoretical Underpinnings of Risk Perception
Risk has been defined as an "uncertainty about and severity of the consequences
(or outcomes) of an activity with respect to something that humans value" (Aven & Renn,
2009, p. 6). Risk perception can be different from actual risk (Sjoberg, 2000) and
includes meanings that each individual assigns to being at increased risk (Pilarski, 2009).
In 1960, risk perception was introduced by Bauer as a two dimensional structure
including uncertainty and adverse consequences. Risk perception has been defined as
"ones expectancy about the probability of an event" (Weinstein et al., 2007, p.147) or
"beliefs about potential harm" (Brewer et al., 2007, p.136). Nevertheless, risk perception
is a complex concept that is not completely understood in the literature (Pilarski, 2009).
Risk perception is integrated as a key concept in constructing several theories of health
behavior such as the Health Belief Model (Janz & Becker, 1984), Protection Motivation
Theory (Maddux & Rogers, 1983), and Prospect Theory (Kahneman & Tversky, 1979).
Most of these theories assume that an individuals decisions about health behaviors are
based on the rational analyses of potential risks and possible benefits.
12
Risk perception theories. There are numerous theories which attempt to explain
risk perception. The most well-known theories are the Cultural Theory and the
Psychometric Model.
Cultural Theory. This theory was developed by Douglas and Wildavsky (1982)
and assumes that risk perception is socially and culturally framed. Based on this theory,
peoples values, attitudes, and worldviews are characterised within their social structure
and context, and these values and worldviews shape the individuals perception and
evaluation of risks. Cultural Theory groups people into four categories based on their
concerns about different types of risk: some people are more concerned with risks
associated with technology and the environment (egalitarian), while others focus on war
and other threats to the markets (individualistic), law and order (hierarchic), or none of
the above (fatalistic) (Sjoberg, 2000). According to this theory, the most important
predictors for selecting what people fear or do not fear are socially shared worldviews.
These worldviews are called cultural biases, which determine individuals perceptions,
not their cognitive processes and feelings (as stated in the Psychometric Model) (Dake,
1992; Wildavsky & Dake, 1990).
Psychometric Model. The Psychometric Model focuses mainly on cognitive
factors that influence individuals' risk perception. Two key cognitive factors in this model
are the dread risk factor and the unknown risk factor (Slovic, Fischoff, & Lichtenstein,
1980; Slovic, 1987). This theory approaches risk as a subjective issue; "risk does not
exist out there, independent of our minds and cultures, waiting to be measured" (Slovic,
1992, p.119).
13
The Psychometric Model was introduced in 1978 by Fischhoff et al. They

evaluated the importance of people's judgments about risk by studying nine
characteristics of risk: voluntariness of risk, newness, immediacy of effect, public
knowledge about risk, scientists' knowledge (the extent that risks are known in literature),
control over risk, its potential for catastrophic (multiple-fatality) consequences, the
severity of consequences, and common dread. They found that these nine characteristics
of risk influenced judgments of perceived and acceptable risk and were highly intercorrelated. Therefore, they reduced these characteristics to two dimensions; the degree to
which a risk is unknown and the degree to which a risk elicits dread (Fischoff, Slovic,
Lichtenstein, Read, & Combs, 1978; Gerend, Aiken, & West, 2004).
Factors influencing risk perception. Based on the literature, risk perception is a
multifactorial concept, which is the result of an individuals cognitions and motivations
and is influenced by the social, political, and cultural environment (Slovic, 1992). Unlike
experts risk estimation, mostly based on statistical and probabilistic information
(Boholm, 1998), peoples risk assessments may be influenced by several factors. The
following sections introduce some of these factors: social and cultural contexts;
familiarity with, availability, and representativeness of risk; perceived control over risk;
gender; age; and trust in the source of information.
Social and cultural contexts. Social and cultural contexts are essential to how
people understand and perceive risk (Weyman & Kelly, 1999). As stated in Cultural
Theory, a social structure forms individuals values and manners. Therefore, the values
14
and worldviews of certain social or cultural contexts outline different risk perceptions
(Douglas & Wildavsky, 1982).
Familiarity. Familiarity with risk refers to the extent that an individual has
knowledge of, or is familiar with, a risk. The degree of familiarity with risk is part of the
wider concept of "unknown risk", which is considered one of two important concepts in
the Psychometric Model of risk perception (Fischoff et al., 1978; Williamson &
Weyman, 2005). Familiarity is related to personal experience of risk, risk knowledge, and
the perceived control over risk (Williamson & Weyman, 2005).
Availability. Risk availability influences risk perception. Individual or non
individual experience (e.g., through the media or a friends illness) with a risk may
increases its perceived availability, and as a result, its perceived possibility (Gerend,
Aiken, West, & Erchull, 2004).
Representativeness. Risk representativeness (similarity) is also considered an
important factor in judging the probability of an event. According to Kahneman and
Tversky (1973), "people predict the outcome that appears most representative of the
essential features of the evidence" (p. 237). In other words, the probability of an event is
evaluated by its similarity to events with comparable characteristics (Gerend et al., 2004).
Perceived control. There is growing interest in understanding the role of
perceived control in risk perception. Research indicates that people with higher perceived
control perceive themselves as less vulnerable to negative health outcomes. Alternatively,
15
people with lower perceived control over their own health may feel at a higher risk for
adverse health outcomes (Gerend et al., 2004).
Gender. Gender may influence perceived risk. In general, men have a tendency to
rate the risks associated with hazards lower than do women (Hawkes & Rowe, 2008;
Boholm, 1998).
Trust. Because not all people experience an actual risk, their perceptions of risk
are mostly through information that is received from different sources. Therefore, the
degree of trust that people have in risk information sources is important in risk perception
(Williamson & Weyman, 2005).
Age. Age also might play a role in risk perception. Although older age usually is
considered as a risk factor for developing several diseases, Gerend et al. (2004) reported
that in their study on perceived risk of osteoporosis, breast cancer, and heart disease,
older women had a lower perceived risk in comparison to younger women.
Risk Perception during Pregnancy
The concept of pregnancy risk has grown in recent years, partly due to advances
in pregnancy risk knowledge and technologies and also increasing community knowledge
(Carolan, 2003). A "high risk pregnancy" has been defined as a pregnancy in which there
is a probability of adverse outcomes for the mother or baby, which is greater than for the
general pregnant population (James & Stirrat, 1988). Similar to risk perception in other
fields, pregnancy risk perception is highly individualized and several factors may
influence the perception of pregnancy risk (Heaman et al., 2004). The term risk may be
16
interpreted differently by health care providers and women. While health care providers
understandings of risk are the result of their knowledge, training, experiences, and values,
womens understandings of risk are more contextual and individualized (Handwerker,
1994) and reflect their values, education, and social class (Saxell, 2000; Searle, 1996).
Johanson, Newburn, and Macfarlane (2002) believe that for developing clinically
effective services, womens wishes and fears should be addressed. There is evidence
indicating that pregnancy risk perception affects pregnant womens health care use and
motivations to seek prenatal care. For instance, Blankson et al. (1994) found that the
discrepancy between high risk pregnant womens risk perception and care providers' risk
perception may be responsible for missed prenatal appointments. In another study,
Atkinson et al. (1995) conducted 51 qualitative interviews to explore the relationship
between perceptions of pregnancy risk and pregnant women's motivations for using
health services in Brazil. Researchers reported that from the women's perspective, the
most important risks related to pregnancy were cesarean section, abortion (induced and
spontaneous), high blood pressure, and anaemia. They found that womens risk
perception may not be always related to the medical diagnosis, and risk may be explained
in different language and concepts than the biomedical model. Atkinson et al. (1995) also
reported that there were many factors affecting risk perception such as health services
characteristics and structures and the context within which women live. They suggested
that approaches to understanding perceptions of health risks should be comprehensive
and broad.
Kolker and Burke (1993) determined a relationship between risk perception and
the decision making process about prenatal diagnosis. Suplee et al. (2007) stated that risk
17
perception may influence womens decisions during pregnancy about place of birth or
about their choices in having intensive medical interventions. Kowalewski et al. (2000)
conducted a study to identify barriers to use of referral level care by high risk pregnant
women. These researchers found that the problem of access to care goes far beyond
distance and costs. They concluded that the current risk approach that is mainly based on
epidemiological risk factors is not helpful to high risk mothers.
Factors influencing perception of pregnancy risk. According to the literature,
there are several factors affecting perception of pregnancy risk. In 2004, a qualitative
study by Heaman, Gupton, and Gregory was conducted to identify factors that pregnant
women considered in making personal risk assessments. They found that their
participants' assessment of risk was a multidimensional process and influenced by several
factors such as self image of their own general health, health and family history, the
healthcare system, and the odds of the unforeseen and unknown complications. Based on
findings of Heaman et al., women who perceived themselves as healthy perceived lower
risk for their pregnancy than women who had less positive views of themselves or their
pregnancies. They also found that womens health history, current health status, previous
reproductive experiences, and family histories played an important role in risk appraisal.
Patterson (1993) reported that their pregnant participants defined pregnancy risk based on
their experiences of problematic change and on the assessment of their care providers.
Atkinson et al. (1995) reported that pregnant womens perceived risks can be influenced
by health services structure and practices and also women's socio-economic status.
18
From a quantitative perspective, Gupton, Heaman, and Cheung (2001) explored

the relationship between biomedical, psychosocial, and demographic risk factors with
perception of pregnancy risk. Results of their study revealed that biomedical risk and
state anxiety were predictors of perception of pregnancy risk. They also reported that
women with complicated pregnancies perceived their risk as significantly higher than
those with uncomplicated pregnancies. In another study, the degree of confidence that
pregnant women had about the health care they received was found to be related to their
perceived risk (Heaman et al., 2004). Feedback from peers may also contribute to
perception of pregnancy risk. Patterson (1993) reported that black pregnant women in
defining pregnancy risk not only were considering their own experiences and the health
care provider's assessment, but also were relying upon the feedback they received from
the counsel of other black women.
Risk Perception at AMA
As discussed in an earlier section, pregnancy at AMA is associated with a variety
of adverse pregnancy outcomes (Cleary-Goldman et al., 2005; Hung, 2008; Jacobsson et
al., 2004; Joseph et al., 2005; Joseph et al., 2007). Carolan and Nelson (2007) suggested
that concept of risk at AMA may be composed of two parts: the physiological challenges
associated with AMA and medical risks, and the social discourse of risk associated with
pregnancy at AMA and timing of childbearing. Recently, a few studies were conducted
that have provided some insights into women's knowledge of risks associated with AMA.
For example, Tough et al. (2006) conducted a study to determine women's knowledge
about maternal age-related reproductive risks, such as pregnancy complications
19
associated with low birth weight (LBW), preterm delivery, and multiple birth. Computerassisted telephone interviews were conducted with 1,044 randomly selected women who
delivered their first live-born infant in Calgary or Edmonton, Alberta. Their findings
demonstrated that although most women were aware of conception difficulties associated
with AMA, the majority of them were not informed about adverse pregnancy outcomes
related to increased maternal age including multiple birth, caesarean section, preterm
delivery, and LBW. The results of another study conducted by these researchers indicated
that most non-parenting Canadians were not informed about risks associated with delayed
childbearing (Tough et al., 2007).
A few studies have focused on perception of pregnancy risk at AMA as a primary
interest. The perception of risk was mainly discussed as a part of pregnancy experiences
at AMA. Windridge (1999), in a study on womens experiences of giving birth after age
35 years, reported that women of AMA were more informed about risks associated with
pregnancy and were more likely to admit that their babys life might have been at risk
during labor compared to women aged 20-29 years. Therefore, these women may believe
that their age makes their infants particularly vulnerable. Another important study on this
topic is an Australian work. In 2005, Carolan conducted a qualitative study of 22
primigravid women aged 35 years or older with uncomplicated pregnancies. The initial
purpose of this qualitative study was to understand the experiences of first mothering for
women over age 35 years. Later, Carolan and Nelson (2007) undertook a secondary
analysis of the original data and examined the transcripts to find statements and terms
that were related to risk. They reported four themes central to perception of pregnancy
risk of these women, including "realizing I was at risk," "hoping for reassurance,"
20
"dealing with uncertainty," and "getting through it/negotiating risk." They found that the
notions of risk had impacted negatively on older mothers in terms of concern and
additional surveillance. Their participants had experienced a high level of concern and
anxiety in spite of having healthy and full-term pregnancies. The notable limitation of
this study is that it is a secondary analysis and no specific questions about perception of
risk were asked.
A study by Saxell (2003) had a primary focus on perception of pregnancy risk at
AMA. Saxell (2003) designed a qualitative study to explore women's understanding and
beliefs about the risks associated with nulliparous pregnancy over age 35 years. This
Canadian qualitative study was composed of ten participants, and the results showed that
the pregnant women experienced challenges in regards to risk labeling. These women
attempted to cope with these concerns by rejecting the label of high risk and creating a
safe environment free from stress and conflict. Saxell stated the need for developing a
new model of care according to these womens needs. A significant limitation of this
study was that data were collected retrospectively (36 months after delivery). In addition,
its unique population (participants who chose midwifery care) should be considered in
the interpretation of the results.
The review of the literature on risk perception at AMA highlights that little
research has been conducted in this area. The purpose of this study was to gain further
understanding and knowledge about risk perception and its contributing factors at AMA.
In the next chapter, this review will be incorporated in the conceptual framework of the
study.
21
Chapter Three: Conceptual Framework

In this chapter, the conceptual framework underlying this study will be
introduced. Risk perception is an area with many unsolved and poorly understood issues
(Hawkes & Rowe, 2008). Experts in the field of risk perception believe that current
theories applied in risk perception are not comprehensive and can explain only a small
fraction of the whole phenomenon (Slovic, Monahan, & MacGregor, 2000). Although
there is no widely accepted model of risk perception that explains what factors and in
what ways are related to risk perception (Hawkes & Rowe, 2008), the Psychometric
Model is currently considered as the best theory in this area (Slovic et al., 2000).
Therefore, for the purpose of this study, the Psychometric Model of risk perception is
employed as the core component of the conceptual framework. However, due to the
complex and multidimensional nature of risk perception, especially among women of
AMA who are faced with the conceptualization of multiple risks, several other concepts
were added to the Psychometric Model to achieve a better understanding of risk
perception at AMA.
As mentioned earlier, the Psychometric Model consists of two core concepts: the
unknown risk and the amount of a dread feeling evoked by risk. In this study, risk
knowledge and pregnancy-related anxiety were selected to represent the "unknown" and
"dread factor" respectively. In addition to these two concepts, four concepts were
identified by the literature review to be important in constructing perception of pregnancy
risk: medical risk, health status, cognitive heuristics (availability and similarity), and
22
perceived control. The following is a description of how these concepts were applied in
the current study.
Risk knowledge. The degree of familiarity with risk or risk knowledge is part of
the wider concept of "unknown risk", which is the first concept in the Psychometric
Model of risk perception (Boholm, 1998; Fischoff et al., 1978; Williamson & Weyman,
2005).
Dread factor. In applying the second concept, it was assumed that a greater
feeling of dread might be observed in women who have more anxious feelings about
having a healthy pregnancy with desirable outcomes. This placement is supported by the
findings of a previous study, which illustrated that state anxiety predicted perception of
pregnancy risk (Gupton et al., 2001).
Medical risk. Previous research supports the role of objective medical risk in
constructing perception of pregnancy risk. For example, Atkinson et al. (1995) reported
that although their participants' risk perception was sometimes different than modern
medical perspectives, there was not always conflict between womens lay perceptions
and medical explanations. Findings of two other studies also supported the inclusion of
medical history and personal and family health history as important in the determination
of perception of pregnancy risk (Gerend et al., 2004; Heaman et al., 2004).
Health status. A womans current health status might be important in her
interpretation of the amount of dread. The findings of Heaman et al. (2004) suggested
that women considered their own general health in their pregnancy risk appraisal.
23
Cognitive heuristics. Cognitive heuristics, mental guidelines that are used to

process whether risk knowledge is available or represented (Boholm, 1998), is another
significant concept arising from the literature review. The availability heuristic refers to
"a cognitive shortcut used for judging the probability of an event by the ease with which
examples of the event come to mind" (Gerend et al., 2004, p.248). In other words, the
availability heuristic is a cognitive plan for processing and understanding information and
it refers to what people remember, not to what actually has happened (Boholm, 1998).
The similarity or representativeness heuristic reflects "a cognitive shortcut used for
judging the probability of an event by its similarity to events with comparable features"
(Gerend et al., 2004, p.248).
Perceived control. There is growing evidence regarding the significance of a
persons self-image (Heaman et al., 2004) and perceived control (Kolker et al., 1993) in
risk perception. If people have some measure of control over a potential risk, they may
consider that as less risky. In fact, from this perspective, a controllable risk that poses a
high degree of risk is perceived safer than others which are less risky but uncontrollable
(Nordgren, Van Der Pligt, & Van Harreveld, 2007). Results of a study by Kolker and
Burke in 1993 that was conducted to describe the relationship between risk perception
and decision making about prenatal diagnosis, demonstrated that perceived control, the
severity or impact of the outcome (dread factor), and the psychological availability of the
risk can influence risk perception (Kolker & Burke, 1993).
Because the main interest of this study was to understand the perception of
pregnancy risk at AMA, maternal age was also included in the conceptual framework. In
24
the review of the literature, perception of pregnancy risk appears to be influenced by

perceived control, cognitive heuristics (availability and similarity), health status, and
medical risk. Because the Psychometric Model does not include some of these concepts,
a new conceptual framework to study perception of pregnancy risk was developed based
on the literature review and guided by the Psychometric Model of risk perception. Figure
1 illustrates the conceptual framework of the study. In addition to anxiety and risk
knowledge, five new factors identified through the literature review were also included in
the framework. Later, through in-depth interviews of women for the qualitative
component of this mixed methods study, gestational age was identified as another
important factor in perception of pregnancy risk and was included in the framework as
the eighth variable.
Medical Risk
Operationalized by
Prenatal Scoring
Form(Morrison & Olsen,
1979)
Risk Knowledge
Operationalized by
Knowledge of Maternal
Age-Related Risks of
Childbearing (Tough et
al., 2006)
Dread Factor:
Pregnancy-related
Anxiety Operationalized
by Pregnancy-related
Anxiety (Rini, DunkelSchetter, Wadhwa, &
Sandman, 1999)
Health Status
Operationalized by the
SF-12v2 Health Status
Survey (Ware, Jr.,
Kosinski, & Keller, 1996)
Risk Perception
Operationalized
by PPRQ
(Heaman &
Gupton, 2009)
Perceived Control
Operationalized by
MHLC (Wallston,
Wallston, & DeVellis,
1978)
Maternal Age
Age 20-29 versus age 35
or older
Gestational Age
(emerged through
qualitative findings)
Figure 1. Conceptual framework of the study
Cognitive Heuristics
Operationalized by a
questionnaire adapted
from Gerend et al.
(Gerend, Aiken, West, &
Erchull, 2004)
25
26
Research Questions
As noted in Chapter One, the purpose of this research was to advance an
understanding of perception of pregnancy risk at AMA. A mixed methods research study
with both qualitative and quantitative components was employed to address this question.
In each component of the mixed methods research different aspects of the phenomenon
were studied.
Research questions for the quantitative component. The objectives of the
quantitative component were to compare perception of pregnancy risk in women of AMA
(age 35 years or older) to younger women (age 20 to 29 years) and to determine the
association of pregnancy-related anxiety, risk knowledge, perceived control, health
status, medical risk, gestational age, cognitive heuristics, and maternal age with
perception of pregnancy risk. The following were the research questions for this
component:
1. Is perception of pregnancy risk in nulliparous women of AMA different from
nulliparous women aged 20 to 29 years?
2. What are the associations of pregnancy-related anxiety, risk knowledge, perceived
control, health status, medical risk, gestational age, cognitive heuristics, and maternal
age with perception of pregnancy risk among nulliparous women?
3. How does maternal age interact with pregnancy-related anxiety, risk knowledge,
perceived control, health status, medical risk, gestational age, and cognitive heuristics
in relation to perception of pregnancy risk in nulliparous women?
27
Research questions for the qualitative component. The objectives of the

qualitative component of the study were to explore how nulliparous women of AMA
evaluate and define pregnancy risk and to arrive at a detailed understanding of their risk
perception. The following were the research questions for the qualitative component:
1. How do nulliparous women of AMA define pregnancy risk?
2. What factors, including risk perception, affect decision making about timing of
childbearing in women of AMA?
3. Why do women of AMA feel that their pregnancy is/is not at risk? Which factors
influence perception of pregnancy risk for women of AMA?
4. What were the experiences of women of AMA with risk communication from health
care providers during this pregnancy? How do women feel their perceptions of risk
differed from that of their health care providers, if at all?
5. What impact, if any, does being labeled high risk have on the womens life and health
behaviors?
28
Chapter Four: Design and Methods

In this chapter the overall plan for addressing the research questions will be
described. This study employed mixed methods research with both qualitative and
quantitative components. In the beginning of the chapter, the mixed methods approach is
explained, followed by a detailed description of the research design, setting, sampling
methods, data collection procedures, selection of measurement methods (instruments),
and methods of data analysis for both quantitative and qualitative components. Finally,
the ethical considerations are outlined.
Mixed Methods Research
Traditionally, research has been conducted from either a quantitative or a
qualitative paradigm. In 2004, Johnson and Onwuegbuzie proposed mixed methods
research as the third major research paradigm, along with qualitative research and
quantitative research, to recognize that both quantitative and qualitative research are
important and to encourage the advocators of the two former paradigms to move beyond
their classic arguments (Johnson & Onwuegbuzie, 2004; Johnson, Onwuegbuzie, &
Turner, 2007). Mixed methods research has been defined as "research in which the
investigator collects and analyzes data, integrates the findings, and draws inferences
using both qualitative and quantitative methods in a single study or a program of inquiry"
(Tashakkori & Creswell, 2007, p.4). According to Creswell (2008), mixed methods
research helps answer questions to which qualitative or quantitative approaches alone
would not provide a satisfactory answer. Mixed methods research is unique because it
gives the researcher an ability to apply all possible methods and use both numbers and
29
words and combine inductive and deductive thinking to address the research problem
(Creswell & Plano Clark, 2007). Mixed methods research employs more than one
research method; for example, a mixed methods research study may include two
quantitative methods or two qualitative methods or one qualitative and one quantitative
method (Peter & Gallivan, 2004). The current mixed methods study included both
qualitative and quantitative components and each component will address different
aspects of risk perception at AMA.
Paradigm (world view). Paradigms have been defined as "worldviews or allencompassing ways of experiencing and thinking about the world, including beliefs about
morals, values, and aesthetics" (Morgan, 2007, p. 50). While data collection and analysis
techniques are not linked to paradigms, the researchers' attitudes toward and treatment of
data is completely influenced by the researchers world view. Hence, the resulting mix
and how the researcher will treat the results analytically are determined by the
researcher's paradigm (Sandelowski, 2000a). This mixed methods study is based on the
pragmatism paradigm. Pragmatism has been defined as "a deconstructive paradigm that
debunks concepts such as 'truth' and 'reality' and focuses instead on 'what works' as the
truth regarding the research questions under investigation" (Teddlie & Tashakkori, 2003,
p.713). It has been argued that this paradigm is the overarching paradigm for mixed
methods research because it supports the position that qualitative and quantitative
research methods can be used in a single study; the research question is of primary
importance rather the method or the philosophical worldviews; and finally, it provides a
practical and applied research philosophy to direct methodological choices rather than a
30
forced dichotomous choice between postpositivism and constructivism (Creswell &

Plano Clark, 2007; Tashakkori & Teddlie, 2003).
Study Design
Based on the timing of the quantitative and qualitative methods, a mixed methods
research design can be classified as either sequential or concurrent (Giddings & Grant,
2006). In the sequential design, one component is completed first. Then, based on the
results, the second or third components are designed. In the concurrent design, both
methods are employed at the same time and data are collected concurrently. Typically,
the main intention of concurrent design is to verify, cross-validate, explain or confirm
findings from one method with those from another (Creswell & Plano Clark, 2007;
Giddings & Grant, 2006). In both designs, either method could have equal significance to
answering the research question or one set of findings can be used as a secondary method
to complement the other (Giddings & Grant, 2006; Wilkins & Woodgate, 2008). In the
current study, both qualitative and quantitative methods were employed concurrently, and
an equal weight was assigned to each component; therefore, a concurrent design was
employed to address the research questions.
Sampling
In mixed methods research, a combination of quantitative and qualitative
sampling techniques may be used. According to Teddlie and Yu (2007), there are four
sampling techniques for mixed methods research: basic mixed methods sampling,
31
sequential mixed methods sampling, concurrent mixed methods sampling, multilevel

mixed methods sampling, and a combination of mixed methods sampling strategies.
Sampling for the purpose of the present study was based on a concurrent mixed
methods sampling. There are two concurrent mixed methods sampling techniques: In the
first method, sampling procedures for each component take place independently. In other
words, quantitative sampling techniques are used to collect data for the quantitative
component and purposive sampling techniques are used to generate data for the
qualitative component. In the second method, both quantitative and qualitative sampling
techniques are utilized to create a single sample (Teddlie & Yu, 2007). Sampling for the
current study included a combination of both convenience sampling (quantitative) and
purposive sampling (qualitative).
In a concurrent study, it is recommended that researchers use the same individuals
for both quantitative and qualitative data collections, because selecting different
individuals, who have different demographic characteristics, may influence comparability
of the results (Creswell & Plano Clark, 2007; Creswell & Tashakkori, 2007). In this
study, a sub-set of women participating in the quantitative component was invited to
participate in the qualitative interviews.
Quantitative Component
Design. The objectives of this component were to compare risk perception in
women of AMA with younger women and to determine the role of pregnancy-related
anxiety, risk knowledge, medical risk, health status, cognitive heuristics, perceived
32
control, maternal age, and gestational age in constructing risk perception during
pregnancy. To achieve these goals, a comparative descriptive design, with a correlational
component to examine factors associated with perception of pregnancy risk, was
employed. Because this design is used to examine and describe differences in the
variables of the two groups that occur naturally in a setting, it can appropriately address
the objectives of this study (Burns & Grove, 2005).
There were one dependent and eight independent variables in the current study.
Perception of pregnancy risk was the dependent variable and the independent variables
included pregnancy-related anxiety, risk knowledge, medical risk, health status, cognitive
heuristics, perceived control, maternal age, and gestational age. In addition, several
interaction terms were later defined between maternal age and those independent
variables that had a significant bivariate relationship with perception of pregnancy risk.
Study setting. Participants were recruited from selected physician's offices and
prenatal classes, and from the outpatient departments and antepartum units of two tertiary
hospitals, St. Boniface General Hospital and the Health Sciences Centre in Winnipeg,
Manitoba.
Population and sample. Data were collected between December 2009 and
January 2011. All nulliparous women (defined as a woman who has never completed a
pregnancy beyond 20 gestational weeks) attending selected physician's offices, prenatal
classes, and the outpatient departments and antepartum units of St. Boniface General
Hospital and the Health Sciences Centre comprised the population of the study. The
sample was confined to nulliparous women to minimize the effect of previous pregnancy
33
experiences on risk perception. The sample consisted of two groups of women. Group
one included nulliparous women aged 35 years or older and group two included
nulliparous women between the ages of 20 to 29 years. The maternal age of 20 to 29
years has been used as a comparison group in several previous studies (Bayrampour &
Heaman, 2011; Jacobsson et al., 2004; Windridge & Berryman, 1999; Ziadeh & Yahaya,
2001). All nulliparous women attending the study settings were considered as potential
participants and were evaluated based on eligibility criteria. Therefore, a convenience
sampling method was employed to recruit participants in this study.
Inclusion criteria. The following criteria were used in recruiting participants:
1. Nulliparous women,
2. Age between 20 to 29 years for younger women and age 35 years or older for women
of AMA,
3. Singleton pregnancy,
4. Ability to speak, read, and write in English, and
5. Gestational age of 28 weeks or more (because women in the third trimester of their
pregnancy might be more adapted to their pregnancy situation and be more
informed).
Exclusion criteria. Any known and severe psychological disorder was considered
as an exclusion criterion.
Instruments. All participants completed the Perception of Pregnancy Risk
Questionnaire (PPRQ), the Pregnancy-related Anxiety scale, the Knowledge of Maternal
Age-related Risks of Childbearing Questionnaire, the SF-12v2 Health Status Survey, the
34
Multidimensional Health Locus of Control (MHLC) Questionnaire, the Prenatal Scoring

Form, and a demographic and childbirth data collection form. To measure the cognitive
heuristics of availability and similarity, two questions were adapted from questions used
by Gerend et al. (2004). To examine the availability heuristic, women were asked to
report the number of female friends they knew with a complicated pregnancy. To
examine the representativeness (similarity) heuristic, women were asked to rate their
perceived similarity to the typical pregnant woman of the same age who developed
pregnancy complications. The questionnaire is available in Appendix A. The Prenatal
Scoring Form can be found in Appendix B.
The PPRQ consists of a nine-item scale including a five-item "Risk for Baby"
subscale and a four-item "Risk for Self" subscale. This questionnaire uses a series of nine
visual analog scales (VAS) to measure the perception of pregnancy risk. Respondents are
asked to place a vertical mark through the line to indicate their assessment of risk for
each item, yielding a score ranging from 0 to 100. Scores for the nine items are added
together and then divided by nine to yield an overall risk perception score out of 100.
Higher scores indicate higher levels of perceived risk. This scale has good internal
consistency reliability, with a Cronbachs coefficient alpha of 0.87 for the total scale, an
alpha of 0.84 for the "Risk for Baby" subscale, and an alpha of 0.81 for the "Risk for
Self" subscale (Heaman & Gupton, 2009). Validity of the scale was assessed using a
sample of 199 women in the third trimester of pregnancy. The concurrent validity of the
scale was confirmed by its correlation with the Spielberger State Anxiety Inventory
(Spielberger & Gorsuch, 1983) (r=.46, p<.001). In addition, construct validity was
35
demonstrated using the known-groups technique and through convergent validity

(Heaman & Gupton, 2009).
The Pregnancy-related Anxiety scale was used to assess a womans fears and
worries about her babys health, her own health, and labor and delivery (Rini, DunkelSchetter, Wadhwa, & Sandman, 1999). The scale consists of ten items rated on a 4-point
Likert scale ranging from one (1 = never or not at all) to four (4 = a lot of the time or
very much). The internal consistency reliability of the scale is acceptable (alpha = 0.78).
An exploratory factor analysis by Rini et al. (1999) revealed that the items were best
represented by a single score. The total score is computed by reversing scores where
applicable and calculating the mean of responses to all items, yielding a score ranging
from one to four. Higher scores indicate higher levels of pregnancy-related anxiety (Rini
et al., 1999; Wadhwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993).
The Knowledge of Maternal Age-related Risks of Childbearing scale developed
by Tough et al. (2006) was utilized to measure risk knowledge. This scale consists of ten
questions about various risks associated with advancing maternal age, answered as true,
false, or don't know. Nine of these questions were used in this study. The number of
correct responses was tabulated, yielding a score from zero to nine. According to Tough
et al. (2006), the face and content validity of the scale was ensured through focus group
testing, pilot interviews, and consultation with medical experts.
The SF-12v2 Health Status Survey is a shorter version of the SF-36v2 Health
Survey (Ware, Jr., Kosinski, & Keller, 1996). The SF-12v2 measures functional health
and well-being from the patients point of view. The SF-12v2 is useful in measuring two
36
components including physical health (PCS) and mental health (MCS) functioning and
covers the same eight health domains as the SF-36v2 with one or two questions per
domain. These domains include: physical functioning, role limitations due to physical
health problems, bodily pain, general health perceptions, vitality, social functioning, role
limitations due to emotional problems, and mental health. The reliability and validity
tests of the SF-12v2 have been proven to be satisfactory. Its Cronbachs coefficient alpha
is 0.88 for the physical component summary (PCS) and 0.82 for the mental component
summary (MCS) (Cheak-Zamora, Wyrwich, & McBride, 2009).
The MHLC was used to measure womens perceived control (Wallston, Wallston,
& DeVellis, 1978). The MHLC has been applied successfully as a measure of perceived
control in a wide variety of populations, including pregnant women (Baldwin, 2006).
This instrument is composed of 18 items about perceived control over health outcomes
measured on a six-point Likert scale ranging from one (1 = strongly disagree) to six (6 =
strongly agree). The instrument includes three subscales that measure health-specific
perceived control in the following areas: internal, chance, and powerful others. Based on
Wallston et al. (1978), there is no such thing as a "total" MHLC score. Higher scores in
each subscale indicate greater belief in that subscale domain of control over health.
According to Wallston et al. (1978), correlations in the predicted direction of the MHLC
scales with health status confirmed some evidence of predictive validity of the scale.
Cronbach's coefficient alpha for the MHLC subscales (six-item forms) ranges from 0.67
to 0.77.
37
The Prenatal Scoring Form developed by the College of Physicians and Surgeons
of Manitoba was used to collect data related to medical risk (Coopland et al., 1977). This
instrument consists of 26 possible factors related to the womans reproductive history,
her present medical condition, and complications of the present pregnancy. Each factor is
scored with a numerical value ranging from zero to three according to its presence or
absence. The total score is calculated by adding each factors score and may range from
zero to 49. Women with risk scores of 0-2 are considered at low risk, those with scores of
3-6 at high risk, and those with scores of 7 or more at extreme risk. In this scale, two
points are assigned for maternal age > 35 years. In the current study, to avoid a linear
effect of maternal age distribution on this score, the two points assigned for maternal age
> 35 years were deleted.
The MHLC and the Prenatal Scoring Form are in the public domain. Permissions
were obtained from the respective authors to administer the PPRQ (Appendix C), the
Pregnancy-related Anxiety scale (Appendix D), and the Knowledge of Maternal Agerelated Risks of Childbearing (Appendix E) scale in this study. A license was purchased
to administer the SF-12v2 Health Status Survey. A demographic and childbirth data
collection form was developed to collect descriptive information on the sample. These
variables included maternal age, marital status, family income, education, race/ethnicity,
childbirth education, and information about the pregnancy not captured with the other
instruments.
Data collection procedures. In the quantitative component, two approaches were
used for participant recruitment. In the first approach, the student met with nursing
38
personnel of the hospital settings and private physician's offices to explain the study and
answer questions. The charge nurse or her/his designate identified potential participants
and obtained permission for the student to speak to these participants. A script was
developed for the charge nurse or his/her designate to use when approaching potential
participants to determine their willingness to receive an explanation of the study
(Appendix F). If potential participants agreed to speak with the student, the student
approached them and introduced herself and invited them to participate (see script in
Appendix G for this in-person contact with potential participants). The student explained
the study verbally and in written form and all potential participants had the opportunity to
ask questions about their participation. All participants in this approach signed a consent
form (Appendix H). A mutually convenient time and place was arranged to complete the
survey. After consent had been obtained, the woman completed the questionnaires and
then was interviewed by the student to complete the Prenatal Scoring Form.
Questionnaires were offered to women in a specified order. The PPRQ was offered first,
followed by the cognitive heuristics questions, the Multidimensional Health Locus of
Control (MHLC) scale, the SF-12v2 Health Survey, the Pregnancy-related Anxiety scale,
the Knowledge of Maternal Age-Related Risks of Childbearing scale, and the
demographic childbirth data collection form, respectively. Finally, the student
interviewed women to complete the Prenatal Scoring Form.
In the second approach, the staff members in various settings were asked to screen
for women who met the inclusion criteria, and to determine their willingness to consider
participating in this study. If potential participants agreed to learn more about the study, a
package of questionnaires with a cover letter (Appendix I) was handed to them to be
39
completed and returned in the stamped addressed envelope to the researcher. The
completion and return of the questionnaire signified implied consent.
Sample size. Although there is no clear agreement on the optimum sample size
for regression analysis, an absolute minimum of 10 participants per predictor variable has
been recommended for regression equations when using six or more predictors (Harris,
2001). In the current study, variables that were correlated with the dependent variable
were entered in the first step of the analysis (11 variables); therefore, a minimum sample
of 110 participants was required.
It was originally planned to recruit 200 participants, 100 per group. After starting
data collection, it was realized that the participant recruitment process was not
proceeding as quickly as was expected, specifically for the AMA group. Although the
number of women who delay their first pregnancy until AMA is increasing, the
proportion of pregnant women in this cohort is still relatively small, therefore resulting in
fewer eligible women for the AMA group. For example, results of a recent national
survey that used a large, randomly selected sample of Canadian women having a
singleton birth illustrated that the number of respondents who were both nulliparous
(prior to the birth of their baby) and AMA was quite small (4.7% of the whole sample)
(Bayrampour & Heaman, 2011). After recruiting participants for 14 months, the final
sample consisted of 105 women aged 20-29 years and 54 women aged 35 years or older.
Data analysis. Descriptive statistics were used to summarize the demographic
data from the participants and to compare the two groups of women by each variable.
Independent t-tests were performed to examine the differences between mean levels of
40
perception of pregnancy risk, pregnancy-related anxiety, medical risk, health status, and
perceived control in younger and older women. Chi-square analyses were conducted to
examine the differences in proportions between categorical variables in the two groups.
Where the chi-square test could not be performed (i.e., the frequency of one or more
categories in studied variables was less than five), the Fishers exact test was reported.
All descriptive and inferential statistics were conducted using PASW (Predictive
Analytics Software) Statistics for Windows version 18.0.2. An alpha level of 0.05 was
used for all statistical tests.
For the total sample and each group, separate Pearson's r correlation matrices
were constructed to explore linear associations between the medical risk score,
pregnancy-related anxiety score, the subscales of the perceived control score (i.e.,
internal, chance, and powerful others), subscales of health status (i.e., PCS, MCS,
physical functioning, role limitations due to physical health problems, bodily pain,
general health perceptions, vitality, social functioning, role limitations due to emotional
problems, and mental health), and selected demographic and childbirth variables (i.e.,
maternal age, gestational age, and education) with the perception of pregnancy risk score.
Both backward and forward stepwise multivariate linear regression analyses were
conducted to investigate relationships between risk perception and various predictors, and
to determine the strength of significant predictors in the sample. The perception of
pregnancy risk score was the dependent variable in the regression models. Only those
factors that had a significant bivariate relationship with the criterion were entered in the
equations (Abu-Bader, 2006). In the stepwise regression model, variables were
41
sequentially removed from or included in the model. The deletion or addition was based
on the variable's association with the outcome after adjusting for any other variables in
the model (Katz, 2006). In the first model, perceived control (internal), pregnancy-related
anxiety, cognitive heuristics (availability), five subscales of the health status variable
(i.e., physical functioning, role limitations due to physical health problems, general health
perceptions, vitality, and mental health), medical risk, gestational age, and maternal age
(as a continuous variable) were entered. Prior to developing the second model, several
interaction terms were defined between maternal age and the independent variables
entered in the first model. The second model was tested to determine whether the effects
of these factors on perception of pregnancy risk score were modified by maternal age. In
addition, a multiple-line plot was created to investigate the interaction pattern between
maternal age and anxiety score with the perception of risk score. A multiple-line plot is a
scatter plot with lines and colors that are used "to present and compare data between
measurements by overlaying them in a single graph" (Lolov & Edrev, 2007, p.127).
Maternal age was entered in the regression models as a continuous variable.
However it was entered as a dichotomous variable in the plot to demonstrate the
interaction effects across younger and older groups.
Qualitative Component
Design. A qualitative descriptive study was undertaken to obtain a rich and
detailed source of explanatory data regarding risk perception from women of AMA. As
described by Sandelowski (2000b), a qualitative descriptive study provides "a
comprehensive summary of an event in the everyday terms of those events" (p.336). The
42
qualitative descriptive method is a distinctive and valuable technique that offers a direct
description of phenomena which is still interpretive (Sandelowski, 2010). In other words,
as Sandelowski (2000b) stated, this kind of research can address both descriptive and
interpretive validity to account for participants' observations and their understandings of
these events.
Sample. Potential participants for this component were chosen purposefully from
among the quantitative participants. In purposeful sampling, the sample is intentionally
selected according to the needs of the study (Coyne, 1997). In qualitative inquiry, sample
size relies on the concept of "saturation," which is the point at which no new information
or themes are observed in the data. In qualitative research, there is always the potential
for new data to emerge, therefore saturation is determined when new data are
contributing very little to the themes or categories (Guest, Bunce, & Johnson, 2006). In
this study, saturation was reached after interviewing 15 participants. Participants were
selected to ensure diversity in characteristics, most notably gestational age, and
pregnancy complications. In addition, participants were recruited to reflect a range of
scores using the Perception of Pregnancy Risk Questionnaire (Heaman & Gupton, 2009)
used in the quantitative component, to ensure including participants with different levels
of perceived risk.
Data collection procedures. The student asked selected women who had
participated in the quantitative component of the study if they were willing to participate
in the qualitative component. A mutually convenient time and place were arranged to
conduct the interview. Potential participants were provided with a written and verbal
43
explanation of the qualitative component of the study. Each participant signed a consent
form (Appendix J). In-depth, semi-structured, face to face interviews, using an interview
guide (Appendix K), were conducted by the researcher. All interviews were audiorecorded and transcribed verbatim. To provide a description of the context of the
interview, the student also completed a contact summary sheet that summarized the field
experience (Appendix L). As Miles and Huberman (1994) stated, these summaries can be
used to suggest new themes, and capture thoughtful impressions and reflections.
Data analysis. Data analysis was carried out concurrently with data collection.
Descriptive statistics were used to summarize the demographic data from the participants
and transcripts were analyzed using a content analysis technique. Content analysis is
defined as any technique for making inferences by objectively and systematically
identifying specified characteristics of messages (Holsti, 1969). In other words, content
analysis is a systematic and replicable method used for condensing many words of text
into fewer content categories based on explicit rules of coding (Stemler, 2001). In this
technique, first the transcripts were read in full. Then, analysis continued using standard
qualitative analysis techniques of open coding by inputting and sorting codes, using
NVivo version 9. Next, the definition of each code was created and codes were clustered
into categories. Finally the categories were grouped to create themes.
Rigor. According to Davies and Dodd (2002), rigor refers to the reliability and
validity of qualitative research; however, it does not necessitate the sense of replicability
of the research in different situations, which is common in quantitative research. In fact,
visibility of research practices and accountability of the data analysis are the essence of
44
rigor in qualitative inquiry. In the current study, a validation process for the qualitative
component was performed during and after conducting the research using two strategies.
In the first method, member checking was used in which the results were verified with
participants by asking them to confirm the researcher's interpretations during interviews
and after obtaining interpretations. Second, the results were confirmed with peer review
and debriefing through regular meeting with the dissertation advisor to achieve a jointly
developed interpretation of the data. Dependability was obtained through use of an audit
trail. In this strategy, contextual information, and participants reflections were
documented. The ways to address confirmability in this study were using direct quotes
and confirming the findings with participants during interviews.
Ethical Considerations
The research ethics board approval and agency access approvals were obtained
prior to commencing data collection. This project was reviewed and approved by the
University of Manitoba Education/Nursing Research Ethics Board (Appendix M & N),
Health Sciences Centre Research Impact Committee (Appendix O), St. Boniface Hospital
Research Review Committee (Appendix P), and Winnipeg Regional Health Authority
Research Review Committee (Appendix Q).
Potential participants were provided with a written and verbal explanation about
the study, and participants signed a consent form, where applicable. The following
considerations were addressed: participation was voluntary; refusal to participate did not
affect services received; study participants were fully informed of the nature of the study
as well as of their rights and obligations as research participants, including the right to
45
withdraw at any time without negative consequences. To ensure confidentiality,

participants were informed that their inputs were kept strictly confidential and the
interviews contained no names. Instead, participants were assigned a research code
number. In addition, participants were not identifiable from any quotes or descriptive data
used in conjunction with quotations. A list linking the participant study number and name
was kept in a secure place separate from the participant file containing the questionnaire
forms. All information was stored in a locked filing cabinet in a locked research office in
the Faculty of Nursing at the University of Manitoba with access denied to anyone except
the student and her advisor. All data including completed questionnaires, transcripts,
compact discs, and electronic storage devices have been stored in a locked cabinet and
will be destroyed seven years after the completion of study.
There were no ethical dilemmas during this project. There were no immediate or
direct benefits associated with this research to the participants. There were no potential
risks associated with this type of research. However, there was a possibility that
discussing the topic of pregnancy risk, particularly with those women of AMA, might
trigger some anxiety or concern. Therefore during interviews, the student did not directly
state that pregnancies at AMA are high risk and instead focused on obtaining the
womans perception of her risk status. It was also planned that if a participant became
anxious or upset by the presented information or questions, the student would offer to
make a referral to a social worker. There was no need to make any referral during the
course of the study.
46
Chapter Five: Manuscript One

Introduction to Findings
The results of this study are presented as a series of three papers, found in
Chapters 5 to 7. Each chapter is composed of an introductory section which provides
background information to each specific research objective, and a results section in which
research findings are presented in the form of a publishable manuscript.
In the quantitative component of this study, nulliparous women aged 35 years or
older were compared to nulliparous women aged 20 to 29 years. Although the maternal
age of 20 to 29 years has been used as a comparison group in several previous studies
(Bayrampour & Heaman, 2011; Jacobsson et al., 2004; Windridge & Berryman, 1999;
Ziadeh & Yahaya, 2001), to ensure that the maternal age of 20 to 29 years was an
appropriate age range to address the objectives of this study, the younger group was
divided into two sub-categories: nulliparous women aged 20 to 24 and nulliparous
women aged 25 to 29 years. It was noted that even though there were significant
differences between the two groups in demographic characteristics (i.e., education,
income level, ethnicity, and marital status), there were no significant differences between
the two groups in major study variables including perception of pregnancy risk,
pregnancy-related anxiety, perceived control subscales, health status subscales, medical
risk, and risk knowledge (data not shown). Therefore, nulliparous women aged 20 to 29
years were retained as a comparison group in data analyses.
One of the objectives of this mixed methods research study was to determine
whether perception of pregnancy risk of women of AMA is different from that of women
47
aged 20-29. The first manuscript, Comparison of Perception of Pregnancy Risk of

Nulliparous Women of Advanced Maternal Age and Younger Age, addresses the first
research question of the quantitative component of this study. Also, in this manuscript,
risk knowledge, pregnancy-related anxiety, perceived control, prenatal risk score, and
health status were compared between the two groups and the relationships between these
variables and the perception of pregnancy risk were examined in each group.
The article has been submitted to the Journal of Midwifery & Women's Health for
consideration for publication. The journal is a peer-reviewed journal and mainly
publishes manuscripts that address midwifery, women's health, education, evidencebased practice, public health, and policy. The student wrote this article, while the
students advisor and her committee members provided constructive suggestions on the
manuscript.
48
Manuscript 1: Comparison of Perception of Pregnancy Risk of Nulliparous Women

of Advanced Maternal Age and Younger Age
Abstract
Objectives: Over the last three decades, the proportion of women who have delayed
childbearing into their mid thirties and early forties has been increasing. Because
advanced maternal age (AMA) is associated with several adverse maternal, fetal, and
neonatal outcomes, these pregnancies are considered to be "high risk". Research
indicates that pregnancy risk perception is an important factor in pregnant womens
health care utilization and decision making during pregnancy. The objectives of this
study were to compare risk perception in pregnant women of AMA (aged 35 years or
older) with younger women (aged 20-29 years) and to explore the relationship between
perception of pregnancy risk and selected variables.
Methods: A sample of 159 nulliparous pregnant women (105 in the younger group and 54
in the older group) were recruited from a variety of settings in Winnipeg, Manitoba,
Canada. Women were asked to complete questionnaires to assess perception of
pregnancy risk, risk knowledge, pregnancy-related anxiety, perceived control, health
status, and medical risk.
Results: Women of AMA had higher education levels, were more likely to work during
pregnancy, and had higher medical risk scores than younger women. Women of AMA
perceived higher pregnancy risk for both themselves and their fetuses than younger
women. They rated their risks of cesarean section, dying during pregnancy, preterm birth,
having a baby with a birth defect or one needing admission to NICU higher than those of
49
younger women. There were no significant differences between the groups on pregnancyrelated anxiety, knowledge of risk, perceived control, and health status.
Conclusions: Women of AMA have a higher perception of pregnancy risk than younger
women. Current evidence suggests that incorporating discussions of pregnancy risk into
prenatal care visits may assist pregnant women of AMA to make more informed choices
and avoid unnecessary interventions.
Keywords: advanced maternal age, perception of pregnancy risk, anxiety, high
risk pregnancy.
Introduction
Advanced maternal age (AMA) has been defined as a maternal age of 35 years or
older at the time of delivery. Over the last three decades, the proportion of women who
have delayed childbearing into their mid thirties and early forties has increased. In the
United States, the birth rate for women aged 3539 years increased to 47.5 births per
1,000 women in 2007, the highest rate since 1964, and the birth rate for women 4044
years increased to 9.5 births per 1,000 women in 2007, the highest rate since 1968
(Hamilton, Martin, & Ventura, 2009). In Canada, the proportion of live births to women
aged 35-39 and 40-49 years as a proportion of all births increased from 9.8% and 1.4%
respectively, in 1995, to 12.9% and 2.6% in 2004 (Public Health Agency of Canada,
2008).
Pregnancy at AMA may be the result of infertility, planned postponement of
motherhood, or previous fetal losses (Delpisheh, Brabin, Attia, & Brabin, 2008). Delayed
50
pregnancy may also be a consequence of not finding the right partner, financial
instability, and lack of awareness about the risk associated with AMA (Tough, Benzies,
Fraser-Lee, & Newburn-Cook, 2007). Several factors contribute to increasing rates of
delayed childbearing such as longer life expectancy, more effective contraceptive
techniques, modern infertility treatments, and developments in obstetric care (Carolan,
2003; Delpisheh et al., 2008; Tudiver, 2005; Windridge & Berryman, 1999). In addition,
changes in societal values may influence the decision about the timing of childbearing
including acceptance of delayed commencing of childbearing, decreasing family size, late
marriage, advances in equality in the workplace, and increasing labour force participation
and educational and employment opportunities for women (Benzies et al., 2006; Carolan,
2003; Freeman-wang & Beski, 2002; Usta & Nassar, 2008; Windridge & Berryman,
1999).
Generally, nulliparous women are more likely to be employed and to have higher
socioeconomic status than multiparous women. These women may be more likely to
consider postponing their first pregnancy to accommodate their career and social lifestyle
demands (Delpisheh et al., 2008). Women of AMA typically have a higher
socioeconomic status than their younger counterparts and differ from them in several
demographic and obstetric characteristics, health behaviors and knowledge (Bayrampour
& Heaman, 2011; Delbaere et al., 2007; Delpisheh et al., 2008; Hammarberg & Clarke,
2005; Joseph et al., 2009; Windridge & Berryman, 1999). However, a link between AMA
and several adverse pregnancy outcomes has been documented in previous research
including preterm birth, low birth weight, still birth, chromosomal abnormalities, and
multiple births (Cleary-Goldman et al., 2005; Huang, Sauve, Birkett, Fergusson, &
51
Walraven, 2008; Jacobsson, Ladfors, & Milsom, 2004; Joseph et al., 2005). Increased
perinatal risks associated with AMA have resulted in categorizing these pregnancies as
"high risk". Nevertheless, it is not clear how these women perceive and evaluate their
pregnancy risks compared to younger women.
Risk perception is something different from risk, and reflects "ones expectancy
about the probability of an event" (Weinstein et al., 2007, p.147). Previously, a few
qualitative studies have been conducted to explore risk perception among women of
AMA. Their results suggest that most women in this group were concerned about risks
associated with their pregnancies (Carolan & Nelson, 2007; Saxell, 2003). One limitation
of these studies is that risk perception was not clearly defined and was often used
interchangeably with the concept of "worry". Pregnancy risk perception is important,
because it affects pregnant womens health care utilization, motivations to seek prenatal
care, decisions about place of birth, choices about intensive medical interventions,
adherence to medical procedures and recommendations, and health behaviours (Atkinson
& Farias, 1995; Kowalewski, Jahn, & Kimatta, 2000; Suplee, Dawley, & Bloch, 2007).
Therefore, a careful examination of perception of pregnancy risk is warranted.
A review of the empirical literature revealed no quantitative studies on this topic
to determine whether risk perception among women of AMA is different than that of
younger pregnant women. The objective of this study was to compare perception of
pregnancy risk in nulliparous women of AMA with nulliparous women aged 20-29 years.
In addition, risk knowledge, pregnancy-related anxiety, perceived control, prenatal risk
52
score, and health status were compared between the two groups. Finally, the relationships
between these variables and perception of pregnancy risk were explored in each group.
Methods
A comparative descriptive design was employed to examine and describe
differences in the variables of the two groups, which occur naturally in a setting (Burns &
Grove, 2005). A convenience sample of pregnant women in their third trimester (> 28
weeks) with singleton pregnancy who could speak, read, and write in English were
recruited. Data were collected between December 2009 and January 2011 from selected
physician's offices, prenatal classes, and outpatient departments and antepartum units of
two tertiary hospitals in Winnipeg, Manitoba. The sample consisted of two groups of
women: nulliparous women aged 20-29 years and nulliparous women aged 35 years or
older. The maternal age of 20-29 has been used as a comparison group in previous studies
(Bayrampour & Heaman, 2011; Jacobsson et al., 2004; Windridge & Berryman, 1999;
Ziadeh & Yahaya, 2001).
Two approaches were used for participant recruitment. In the first approach, the
researcher provided written and verbal explanations about the study to potential
participants in the hospital settings and private physician's offices, and those who were
willing to participate signed a consent form and completed the questionnaires. In the
second approach, the staff members in other settings were asked to screen for women
who met the inclusion criteria and to determine their willingness to consider participating
in this study. If potential participants agreed to learn more about the study, a package of
questionnaires with a cover letter was handed to them to be completed and returned in the
53
stamped addressed envelope to the researcher. The completion and return of the
questionnaire signified implied consent. This project was approved by the University of
Manitoba Education/Nursing Research Ethics Board, Health Sciences Centre Research
Impact Committee, St. Boniface Hospital Research Review Committee, and Winnipeg
Regional Health Authority Research Review Committee.
Questionnaire (PPRQ), the Pregnancy-related Anxiety scale, Knowledge of Maternal
Age-related Risks of Childbearing Questionnaire, the SF-12v2 Health Status Survey, the
Multidimensional Health Locus of Control (MHLC) Questionnaire, the Prenatal Scoring
Form, and a demographic and childbirth data collection form.
each item, yielding a score ranging from zero to 100. Scores for the nine items are added
consistency reliability, with a Cronbachs alpha of 0.87 for the total scale, 0.84 for the
"Risk for Baby" subscale, and 0.81 for the "Risk for Self" subscale (Heaman & Gupton,
2009). Validity of the scale was assessed using a sample of 199 women in the third
trimester of pregnancy. The concurrent validity of the scale was confirmed by its
54
correlation with state anxiety. In addition, construct validity was demonstrated using the
known-groups technique and through convergent validity (Heaman & Gupton, 2009).
worries about her babys health, her own health, and labor and delivery (Rini, DunkelSchetter, Wadhwa, & Sandman, 1999). The scale consists of 10 items rated on a scale
from one (1 = never or not at all) to four (4 = a lot of the time or very much). Higher
scores indicate higher levels of pregnancy-related anxiety. The internal consistency
reliability of the scale is acceptable (alpha = 0.78) (Rini et al., 1999; Wadhwa, Sandman,
Porto, Dunkel-Schetter, & Garite, 1993).
by Tough et al. (2006) was utilized to measure risk knowledge. This scale consists of 10
correct responses was tabulated, yielding a score from zero to nine. The face and content
validity of the scale was ensured through focus group testing, pilot interviews, and
consultation with medical experts.
The SF-12v2 Health Status Survey is a shorter version of the SF-36v2 (Ware,
Jr., Kosinski, & Keller, 1996) and measures functional health and well-being from the
patients perspective. The SF-12v2 is useful in measuring two components including
physical health (PCS) and mental health (MCS) functioning and covers the same eight
health domains as the SF-36v2. The reliability and validity tests of the SF-12v2 have
been proven to be satisfactory. Its Cronbachs coefficient alpha is 0.88 for the physical
55
component summary (PCS) and 0.82 for the mental component summary (MCS) (CheakZamora, Wyrwich, & McBride, 2009).
This instrument is composed of 18 items and includes three subscales that measure
health-specific perceived control in the following areas: internal, chance, and powerful
others. Cronbach's coefficient alpha for the MHLC subscales (six-item forms) ranges
from 0.67 to 0.77 (Wallston et al., 1978).
her present medical condition, and complications of the present pregnancy. Women with
risk scores of 0 to 2 are considered at low risk, those with scores of 3 to 6 at high risk,
and those with scores of 7 or more at extreme risk. In this scale, two points are assigned
for maternal age > 35 years. In the current study, to avoid a linear effect of maternal age
distribution on this score, the two points assigned for maternal age > 35 years were
deleted.
Data analysis. Descriptive statistics were calculated to compare the two groups of
women by each variable. Independent t-tests were performed to examine the differences
between means of level of perception of pregnancy risk, pregnancy-related anxiety,
medical risk, health status, and perceived control in younger and older women. Chi-
56
square analyses or the Fishers exact test were conducted to examine the differences in
proportions between categorical variables in the two groups. All descriptive and
inferential statistics were conducted using PASW (Predictive Analytics Software)
Statistics for Windows version 18.0.2. An alpha level of .05 was used for all statistical
tests.
For each group, separate Pearson's r correlation matrices were constructed to
explore linear associations between the medical risk score, pregnancy-related anxiety
score, the subscales of the perceived control, subscales of health status, and selected
demographic and childbirth variables with the perception of pregnancy risk score.
Results
The sample consisted of 159 nulliparous women: 105 women (66%) aged 20-29
years and 54 women (34%) aged 35 years or older. The majority of women were
recruited from outpatient clinics or prenatal classes (n=135). Twenty four participants
were recruited from antepartum inpatient units or antepartum home care program (12
participants in each group). The mean age for the younger group of women at the time of
participation was 25.67 years (SD=3.10) and for older group was 37.39 years (SD=2.00).
The mean gestational age for the younger group was 34.95 weeks (SD = 3.63) and for the
older group was 33.01 weeks (SD = 3.94). Sample characteristics are summarized in
Table 1 and Table 2.
Pregnancy characteristics. There was a significant difference between the two
groups in timing of the current pregnancy. A higher percentage of women of AMA
57
reported wanting to become pregnant sooner than those in the younger group (64.8% vs.
25.7%), and younger women were more likely to report wanting to become pregnant later
(34.3% vs. 3.7%) (p <.001). There was no significant difference between the two groups
in the proportion attending prenatal classes.
A slightly higher proportion of women of AMA reported having pregnancy
complications than younger women, (41.5% vs. 37.1%) however the difference was not
statistically significant. Anemia was the most common problem among both groups:
21.9% of younger women and 18.5% of older women reported having low blood iron.
While 17.0% of women of AMA reported use of fertility medications to become
pregnant, only 2.9% of younger women did, and this difference was significant (p =.003).
In addition, 9.4% of women of AMA and 1.0% of younger women reported use of
fertility procedures (i.e., IVF, ICSI, or IUI) to become pregnant (p =.017).
Perception of pregnancy risk. The independent t-test was used to test for
differences in perception of pregnancy risk between the younger and older age groups.
Women aged 35 years or older had significantly higher mean perception of pregnancy
risk scores than younger women. Similarly, women of AMA reported significantly higher
levels of perception of "risk for self" and "risk for baby" than women aged 20-29 years
(Table 3). We also examined the differences in each item comprising the PPRQ. As
shown in Table 4, pregnant women of AMA reported significantly higher levels of
perception of risk of having cesarean section, dying during pregnancy, having a baby
being born prematurely, having a baby with a birth defect or one admitted to the neonatal
intensive care unit (NICU) than women aged 20-29 years. There were no significant
58
differences between the two groups regarding perception of risk of hemorrhaging, risk for
self during pregnancy, and risk of baby dying. There was a negative correlation between
gestational age in weeks and risk perception in the older group of women (r = -0.30, p
=.031), but not in the younger group.
Pregnancy-related anxiety. There were no significant differences between the
two groups in pregnancy-related anxiety (Table 3). However, there were strong positive
correlations between pregnancy-related anxiety and perception of pregnancy risk in both
groups (p < .001) (Table 5).
Risk knowledge. There were no significant differences between the two groups in
total score for knowledge of maternal age-related risks of childbearing (Table 3). The
majority of women in both groups (91.4% of younger group and 83.3% of older group)
were aware that women aged 35 years or older experience more fertility problems than
younger women. An interesting finding was that fewer women of AMA than younger
women were aware that pregnancy at AMA is more likely to be associated with higher
rates of medical problems (63.0% vs. 80.8%), cesarean birth (25.9% vs. 41.0%), preterm
birth (22.2% vs. 30.5%), and low birth weight (13.0% vs. 19.0%). Women of AMA had
better knowledge about AMA related pregnancy risks including a higher risk of having a
multiple birth (50.0% vs. 21.0%), being eligible for amniocentesis (77.8% vs. 51.4%),
and having a baby with Down Syndrome (88.9% vs. 78.1%) or a congenital anomaly
(58.8% vs. 46.7%). A positive correlation between risk knowledge and perception of
pregnancy risk was found only in the older group (r = 0.30, p = .028) (Table 5).
59
Health status. There were no significant differences between the groups in

physical functioning, role limitations due to physical health problems, bodily pain,
general health perceptions, vitality, social functioning, role limitations due to emotional
problems, mental health, PCS, and MCS (Table 3). As shown in Table 5, different
patterns of correlations with perception of pregnancy risk were found. In the older group,
vitality and physical functioning had significant negative correlations with perception of
pregnancy risk. In the younger group, role limitations due to physical health problems
were significantly correlated with perception of risk. Mental health had a significant
negative correlation with perception of pregnancy risk in both groups, although this
correlation was stronger in the AMA group than the younger group (r = -0.50 vs. r = 0.21). The mental component summary score was significantly correlated with the
perception of pregnancy risk in women of AMA (r = -0.38).
Perceived control. Health-specific perceived control was compared using the
following three subscales: internal, chance, and powerful others. The differences
between the two groups were not significant (Table 3). A significant negative correlation
was found between internal perceived control and perception of pregnancy risk in the
younger group (r = -0.32, p =.001) but not in the older group (Table 5).
Medical risk. Women of AMA had significantly higher medical risk scores than
younger women even after removing the age factor points (p =.009) (Table 3).
Interestingly, there was no significant correlation between medical risk score and
perception of pregnancy risk in older group. A moderately strong positive correlation was
60
found between these variables in the younger group of women (r = 0.41, p <.001) (Table
5).
Discussion
This study compared two groups of nulliparous women to determine differences
in perception of pregnancy risk, selected psychological measures, health status and
medical risk. Consistent with current literature, women of AMA had a higher
socioeconomic status than younger women (Delbaere et al., 2007; Delpisheh et al., 2008;
Hammarberg & Clarke, 2005; Joseph et al., 2009). Our findings revealed that women of
AMA had a higher perception of pregnancy risk than younger women, which is
consistent with the increased risk of medical complications in this age group. These
results suggest that a medically known risk factor, such as age, may influence perception
of pregnancy risk. To our knowledge, there is no previous quantitative research
attempting to measure and compare perception of pregnancy risk between younger and
older pregnant women. However, findings of a qualitative study by Carolan and Nelson
(2007) stated that most women of AMA learned that they were regarded as being "at risk"
because of their age through interaction with the health system. Similarly, a study in the
United Kingdom in 1999, which explored womens experiences of giving birth after age
35, reported that these women were more informed about risks associated with pregnancy
and were more likely to acknowledge that their babys life might have been at risk during
labor (Windridge & Berryman, 1999).
The results of a U.S. study in 2008 illustrated that women of AMA perceived their
risk of having a baby with Down syndrome to be higher than did younger women
61
(Caughey, Washington, & Kuppermann, 2008). In the current study, differences between
the two groups in perception of pregnancy risk subscales were more evident in the
perceived risks for the fetus (i.e., prematurity, birth defect, NICU admission) than for the
mother. As Windridge et al. (1999) stated, women of AMA may believe that their age
makes their infants particularly vulnerable. There is evidence suggesting that pregnant
women's intention to prevent harm to the fetus might drive most of their pregnancy and
labor decisions (Romero, Coulson, & Galvin, 2011).
Our findings demonstrate that women of AMA perceived their risk of having a
cesarean section to be significantly higher than did younger women. Consideration of the
fact that women of AMA have higher rates of cesarean section than younger women
(Bayrampour & Heaman, 2010) may raise the question of whether perceived risk of
cesarean section influences the mode of delivery, particularly resulting from maternal
request for a cesarean delivery (Bayrampour & Heaman, 2011). Although contributing
factors to higher cesarean rates, such as infertility and poor reproductive history, are more
common among women of AMA (Dulitzki et al., 1998; Horey, Weaver, & Russell, 2004;
O'Leary et al., 2007; Treacy, Robson, & O'Herlihy, 2006), research suggests that along
with medical indications, psychological factors may contribute to higher rates of cesarean
section. Wagner (2000) declares that fear and lack of confidence are the main reasons
that women choose cesarean birth. Findings of a recent study demonstrated that being
somewhat to very worried about the delivery and its safety for the fetus correlated with
preference for mode of delivery, and that a womans desire for choosing cesarean section
increases substantially as worries increase (Romero et al., 2011). A previous Canadian
study illustrated that in comparison to younger women, women of AMA were more likely
62
to request a cesarean birth from their health care providers at any point during their
pregnancy, or to have a cesarean birth recommended by their health care provider before
labor (Bayrampour & Heaman, 2011).
Pregnancy-related anxiety was strongly correlated with perception of pregnancy
risk in both groups. However, there was not a significant difference between the two
groups in levels of pregnancy-related anxiety. Compared to a U.S. study that examined
pregnancy-related anxiety among White and Hispanic women with various parities (Rini
et al., 1999), our participants in both groups had a relatively higher mean level of anxiety.
One possible explanation is that nulliparous women might have a higher anxiety level
than multiparous women. There are some statements in the literature claiming that AMA
might be associated with higher anxiety due to awareness of several risks associated with
older age such as fertility issues, coexisting obstetric complications, and also competing
social roles and responsibilities (Neumann & Graf, 2003; Suplee et al., 2007). The results
of our study do not support these statements. In the current study, although women of
AMA reported a higher prevalence of infertility problems, their mean anxiety level was
not different than younger women. This could be a sign of coping effectively with being a
potentially high risk pregnancy. Similar levels of anxiety for both groups also suggest
that there are factors other than risk perception that may influence maternal anxiety.
The scores on the perceived control subscales in our study were similar to those of
nulliparous women in a U.S. study (Lowe, 2000). Although we expected women of AMA
to have higher levels of perceived control, because of having higher education and
socioeconomic status, there was no significant difference between the two groups in
63
mean level of perceived control subscales. This lack of significance might be explained
by the fact that the MHLC scale measures a person's perceived control over his/her
health, which might be different than a person's perceived control over his/her life.
There were no significant differences in the health status subscales between the
two groups, suggesting that pregnant women of AMA perceived their bodies to be as
healthy as younger women. In both groups, mean scores on almost all the SF12 health
survey subscales were higher than those for non-pregnant women at the same ages (Ware,
Kosinski, Turner-Bowker, & Gandek, 2009). An interesting finding was that in the
younger group, role limitations due to physical health problems was correlated with
perception of pregnancy risk, while in women of AMA, vitality and physical functioning
showed a correlation with perception of risk. These results suggest that pregnant women
at various ages consider different aspects of health to assess risk. While health problems,
and the limitations imposed by them, are more significant from the younger womens
perspective, women of AMA may focus on body performance and energy level in their
appraisal of risk.
Although it was expected that women of AMA would be more informed about
risks associated with delayed childbearing (Wagner, 2000), we found no significant
difference in mean scores of knowledge of maternal age-related risks of childbearing
between the younger group (M=4.59) and the older group (M=4.81). Similarly, Tough et
al. (2006) reported that many women in various age groups were unaware of the potential
consequences of delayed childbearing. As they suggested, these results indicate that the
64
majority of women, including women of AMA, are making family-planning decisions

without having sufficient information.
Limitations of the study that need consideration when interpreting the results
include the use of convenience sampling for collecting data. Due to a non-random
method of sample selection, those who volunteered to participate might have been
different than those who did not, resulting in selection bias. We encountered difficulties
in recruiting nulliparous women of AMA, hence the two groups were not equal in size.
The smaller sample size for the older group should be considered in the interpretation of
the results. Although confining the sample to nulliparous women helped minimize the
effect of previous pregnancy experiences on risk perception, this limits generalization of
the results to multiparous women.
Future research is warranted to explore the role of risk perception on maternal
request for cesarean section. Furthermore, research is encouraged to identify predictors of
pregnancy-related anxiety and to determine the roles of maternal age and risk perception
in maternal anxiety.
Conclusion
According to our results, women of AMA perceive a higher risk for their
pregnancies than do younger women. Although this perception is consistent with the
increased risk of adverse maternal, fetal, and neonatal outcomes associated with AMA
(Cleary-Goldman et al., 2005; Huang et al., 2008; Jacobsson et al., 2004; Joseph et al.,
2005), more research is warranted to situate medical risk in relation to perception of
65
pregnancy risk. It is important that in prenatal care visits, health care providers consider a
woman's risk perception and assist her in understanding her individual risk based on
personal health factors. For instance, women of AMA in this study perceived a higher
risk of cesarean section. Current knowledge indicates that even at AMA, cesarean section
is often not a necessary intervention (Treacy et al., 2006). Discussing these issues with
pregnant women and clarifying any misconceptions will help them to acquire a better
understanding of their risk. On the other hand, providing appropriate risk communication
and offering pregnancy and childbirth education along with acknowledging womens
personal experiences may empower women to include their own understanding in
pregnancy risk appraisal (Jordan & Murphy, 2009). These approaches might be beneficial
in making more informed choices and avoiding unnecessary interventions.
66
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Table 1. Comparison of Characteristics of Younger (Aged 20-29 years) and Older (Age >35 years) Nulliparous Women Using
Independent t-test
Maternal Age
Variable
Age 20-29 (n=105)
Age > 35 (n=54)
M (SD)
M (SD)
Gestational age
34.95 (3.63)
33.01 (3.94)
3.09
.002
Education (years of formal)
15.00 (3.02)
17.33 (4.19)
-3.96
< .001
Work hours before pregnancy
38.00 (10.21)
41.15 (12.35)
-1.67
.100
Work hours during pregnancy
35.98 (9.18)
40.03 (11.92)
-2.25
.020
73
Table 2. Comparison of Characteristics of Younger (Aged 20-29 years) and Older (Age >35 years) Nulliparous Women Using
Fishers Exact Test (Two-sided)
Maternal Age
Characteristics
Marital status
Married or Living common-law
Single (widowed, separated, divorced,
or single)
Race/ethnicity
White
Aboriginal (Mtis or First Nations)
Other
Age 20-29 (n=105)

n (%)
Age > 35 (n=54)

n (%)
94 (89.5)
11 (10.5)
52 (96.3)
2 (3.7)
.22
76 (72.4)
12 (11.1)
17 (16.8)
40 (74.1)
2 (3.7)
12 (22.2)
.53
Education
Incomplete high school
Complete high school or less than four
years university degree
Four years university degree or higher
Family income
$0-$39,999
$40,000-$99,999
$100,000 and above
7 (6.7)
60 (57.1)
1 (1.9)
21 (38.9)
38 (36.2)
32 (59.3)
.016
25 (25.0)
60 (60.0)
15 (15.0)
3 (5.8)
20 (38.4)
29 (55.8)
< .001
74
Working at a paid job before pregnancy

Yes
No
100 (95.2)
5 (4.8)
53 (98.1)
1 (1.9)
.67
Working at a paid job during pregnancy

Yes
No
87 (82.9)
18 (17.1)
52 (96.3)
2 (3.7)
.02
75
Table 3. Comparison of Scores on Study Variables of Younger (Aged 20-29 years) and Older (Age >35 years) Nulliparous Women
Using Independent t-test
Maternal Age
Variable
29.67 (16.55)
-3.37
.001
21.40 (16.29)
30.97 (15.86)
-3.29
.001
20.15 (16.94)
28.50 (18.89)
-2.83
.005
Pregnancy-related Anxiety
1.91 (0.43)
1.87 (0.39)
0.54
.593
Knowledge of Maternal Age-related

Risks of Childbearing
4.59 (1.93)
4.81 (2.30)
-0.65
.517
SF-12v2 Physical Component Summary
43.77 (8.52)
42.83 (10.03)
0.62
.84
SF-12v2 Mental Component Summary
50.51 (8.17)
50.24 (7.47)
0.21
.54
SF-12v2 Physical Functioning
59.52 (31.08)
59.26 (36.44)
0.05
.960
SF-12v2 Role Physical
60.19 (22.53)
53.00 (26.26)
1.79
.075
Age 20-29
Age > 35
(n=105)
(n=54)
M (SD)
M (SD)
PPRQ total score
20.71 (15.40)
PPRQ subscale - Risk for Self

PPRQ subscale - Risk for Baby
76
SF-12v2 Bodily Pain
77.14 (18.38)
75.46 (23.54)
0.50
.621
SF-12v2 General Health
77.88 (17.32)
79.70 (15.73)
-0.63
.533
SF-12v2 Vitality
49.76 (19.14)
44.44 (20.98)
1.61
.111
SF-12v2 Social Functioning
75.71 (23.12)
74.06 (25.46)
0.41
.681
SF-12v2 Role Emotional
81.67 (20.66)
79.17 (21.58)
0.71
.478
SF-12v2 Mental Health
70.19 (15.61)
71.93 (16.61)
-0.65
.519
Perceived Control (Internal)
25.53 (4.03)
26.49 (4.05)
-1.40
.163
Perceived Control (Chance)
16.03 (4.17)
15.15 (4.58)
1.18
.239
Perceived Control (Powerful Others)
18.32 (5.01)
17.69 (5.66)
0.71
.481
Medical Risk a
2.52 (1.75)
3.35 (1.97)
-2.64
.009
After deletion of the two points assigned for maternal age > 35 years
77
Table 4. Comparison of Scores on Each Item in the Perception of Pregnancy Risk Questionnaire of Younger (Aged 20-29 years) and
Older (Age >35 years) Nulliparous Women Using Independent t-test
Maternal Age
Variable
29.42 (18.85)
-1.37
.191
26.09 (21.12)
33.85 (20.63)
-2.21
.028
Risk of hemorrhaging
20.86 (20.34)
26.20 (19.05)
-1.64
.111
Risk of cesarean section
30.69 (24.42)
52.07 (28.00)
-4.97
< .001
Risk of dying
9.18 (14.22)
13.85 (12.37)
-2.25
.026
Risk of baby being born prematurely
23.23 (27.69)
32.46 (27.99)
-1.98
.049
Risk of baby having a birth defect
17.29 (19.59)
28.39 (22.38)
-3.22
.002
Risk of baby needing to go to the NICU
20.36 (20.85)
30.22 (23.95)
-2.68
.008
Risk of baby dying
13.81 (17.26)
17.57 (16.18)
-1.33
.185
Age 20-29
Age > 35
(n=105)
(n=54)
M (SD)
M (SD)
Risk for myself during pregnancy
24.88 (21.27)
Risk for my unborn baby
78
Table 5. Pearson Correlation Coefficients between Perception of Pregnancy Risk Score and Major Study Variables
Maternal Age
Variable
Age 20-29
(n=105)
Age > 35
(n=54)
Gestational Age
-.08
-.30*
Education
.03
.04
.59***
.60***
Knowledge of Maternal Age-related Risks of Childbearing
-.11
.30*
SF-12v2 Physical Component Summary
-.16
-.17
SF-12v2 Mental Component Summary
-.10
-.38**
SF-12v2 Physical Functioning
-.13
-.35*
SF-12v2 Role Physical
-.24*
-.16
SF-12v2 Bodily Pain
.04
-.04
SF-12v2 General Health
-.14
-.15
SF-12v2 Vitality
-.18
-.32*
79
SF-12v2 Social Functioning
-.004
-.9
SF-12v2 Role Emotional
-.04
-.26
SF-12v2 Mental Health
-.21*
-.50***
-.32**
-.14
.09
.16
Perceived Control (Powerful Others)
.06
.004
.41**
.18
Medical Risk Score

*p < 0.05 ** p < 0.01 *** p < 0.001
80
81
Chapter Six: Manuscript Two

Introduction to Chapter Six
In the previous chapter, it was found that differences between nulliparous women
of AMA and younger age go beyond their demographic characteristics and include a
higher perception of pregnancy risk for women of AMA and their fetuses.
The manuscript presented in this chapter, "Predictors of Perception of Pregnancy
Risk among Nulliparous Women," presents the central findings of this dissertation. The
first several paragraphs of this manuscript present a review of the literature on factors
contributing to perception of pregnancy risk, followed by introducing the conceptual
framework underlying this research. Subsequent to this, there is an explanation of data
analysis and reporting the results. The findings of this manuscript address the second and
the third questions of the quantitative component. The discussion section of this report
discusses the arrangement of conceptual framework factors and relates them to the
current literature.
The student wrote this article, while the students advisor and her committee
members provided constructive suggestions on the manuscript. The potential journal for
this manuscript will be determined later.
82
Manuscript 2: Predictors of Perception of Pregnancy Risk among Nulliparous

Women
Abstract
Objectives: The literature suggests that perception of pregnancy risk impacts pregnant
womens health care use, health behaviors, and adherence to medical procedures and
recommendations. Yet, a gap remains in the understanding of perception of pregnancy
risk and its contributing factors. The objectives of this study were to determine factors
associated with perception of pregnancy risk and to examine the role of maternal age in
pregnancy risk assessment, using a new conceptual framework based on a review of
relevant literature and the Psychometric Model of risk perception.
Methods: Between December 2009 and January 2011, a convenience sample of
nulliparous pregnant women in their third trimester with a singleton pregnancy was
recruited from variety of settings in Winnipeg, Manitoba. Stepwise multivariate linear
regression analyses were conducted to achieve the research objectives.
Results: Of the eight proposed factors in the conceptual framework, five factors were
significant predictors of perception of pregnancy risk, including pregnancy-related
anxiety, maternal age, medical risk, perceived control (internal), and gestational age. An
interaction between the pregnancy-related anxiety score and maternal age was
determined.
Conclusion: There are several factors contributing to perception of pregnancy risk, of
which at least half are not yet identified. Future studies are warranted to explore these
83
factors. This knowledge may have implications for developing more effective risk
communication models.
Introduction
Risk is defined as "uncertainty about and severity of the consequences or
outcomes of an activity with respect to something that humans value" (Aven & Renn,
2009, p.2). Although risk is a common concept, there are considerable variations in its
definition, perception, and evaluation (Hampel, 2006). Risk perception is about capturing
the myriad meanings and weights that an individual assigns to the experience of being at
increased risk (Pilarski, 2009) and is something quite different from risk (Sjoberg, 2000).
Originally, risk perception was introduced by Bauer in1960 as a two dimensional
structure that included uncertainty and adverse consequences. Currently, risk perception
is defined as "ones expectancy about the probability of an event" (Weinstein et al., 2007,
p.147) or "beliefs about potential harm" (Brewer et al., 2007, p.136).
The concept of risk during pregnancy has grown in recent years, which is partly
due to advances in pregnancy risk knowledge and technologies within antenatal care and
also to increasing community knowledge (Carolan & Nelson, 2007). A high risk
pregnancy has been defined as a pregnancy in which there is a likelihood of an adverse
outcome for the mother or baby that is greater than for the general pregnant population
(James & Stirrat, 1988). Advanced maternal age (AMA), defined as pregnancy at age 35
years or older, is a known risk factor for adverse pregnancy outcomes (Cleary-Goldman
et al., 2005; Huang, Sauve, Birkett, Fergusson, & Walraven, 2008; Jacobsson, Ladfors, &
Milsom, 2004; Joseph et al., 2005). Research suggests that pregnancy risk perception is
84
significant, because it can affect pregnant womens health care use, motivations to seek
prenatal care, decisions about place of birth or choice about intensive medical
interventions, adherence to medical procedures and recommendations, and health
behaviors (Atkinson & Farias, 1995; Kowalewski, Jahn, & Kimatta, 2000; Suplee,
Dawley, & Bloch, 2007). The importance of risk perception has been also emphasized by
its central placement as a concept in several theories of health behavior such as the
Health Belief Model (Janz & Becker, 1984), Protection Motivation Theory (Maddux &
Rogers, 1983), and Prospect Theory (Kahneman & Tversky, 1979).
Although current knowledge indicates that pregnancy risk perception is highly
individualized and that it is not exclusively based on medical diagnoses (Heaman,
Gupton, & Gregory, 2004), a gap remains in the understanding of perception of
pregnancy risk and its contributing factors. While health care providers understandings
of risk are the result of their knowledge, training, experiences, and values, pregnant
womens understandings of risk are more contextual and individualized (Handwerker,
1994), reflecting their values, education, and social class (Saxell, 2000; Searle, 1996). A
study by Gray in 2006 demonstrated an incongruity in risk appraisal by pregnant woman
and their primary nurses in which pregnant women tended to underestimate their
pregnancy risk compared to their nurses. These variations imply that the current risk
communication approach, which is mainly based on epidemiological risk factors without
attention to womens perceptions, might not entirely meet the needs of high risk women
(Kowalewski et al., 2000).
85
Understanding how women perceive pregnancy risk can assist health care
providers and policy makers in providing high quality prenatal care and developing better
guidelines and more effective programs in areas involving communication of risk and
risk management. The objectives of this study were to determine factors associated with
the perception of pregnancy risk and to explore the impact of maternal age on risk
perception.
Conceptual Framework
Risk perception is an area with many unsolved and poorly understood issues.
There is no widely accepted model of risk perception that identifies which factors are
related to risk perception and in what manner (Hawkes & Rowe, 2008). Experts in the
field of risk perception believe that current theories applied in risk perception are not
comprehensive and can only explain a small part of this concept (Sjoberg, 1996). The
Psychometric Model of risk perception is one of the well known and practical theories in
this area (Slovic, Monahan, & MacGregor, 2000) that has been previously employed in
studying risk perception of pregnancy (Chuang et al., 2008). The current study is based
on this theory; however, additional concepts identified in the literature review were also
added to the model to strengthen the conceptual framework.
Psychometric Model of risk perception. The Psychometric Model focuses
mainly on cognitive factors that influence an individuals risk perception. In the
psychometric approach, risk is considered as a subjective issue, which "does not exist
out there, independent of our minds and cultures, waiting to be measured"(Slovic, 1992,
p.119). The Psychometric Model was introduced in 1978 by Fischhoff and colleagues
86
who conducted a study in which there was an emphasis on the importance of people's
judgment about risk. In their study, two dimensions were identified: one dimension was
typified by new, involuntary, poorly known activities, often with delayed consequences
(the degree to which a risk is unknown) and the second dimension mostly revealed the
certainty of death given that adversity occurs (the degree to which a risk induces dread)
(Fischoff, Slovic, Lichtenstein, Read, & Combs, 1978; Gerend, Aiken, & West, 2004).
Today, the dread factor and the unknown factor are considered as two main cognitive
aspects of this paradigm dictating individuals perception of risk (Slovic, Fischoff, &
Lichtenstein, 1980; Slovic, 1987). In this study, risk knowledge and pregnancy-related
anxiety represented the "unknown" and "dread factor" respectively. The degree of
familiarity with risk or risk knowledge is considered as part of the wider construct of
"unknown risk" in the Psychometric Model (Boholm, 1998; Fischoff et al., 1978;
Williamson & Weyman, 2005). Anxiety represents the dread factor in our conceptual
framework, because a greater feeling of dread may be observed in women who have
more anxious feelings about having a healthy pregnancy with desirable outcomes. This
placement is supported by the findings of a previous study that demonstrated state
anxiety predicted perception of pregnancy risk (Gupton, Heaman, & Cheung, 2001).
Summary of the literature review. Numerous factors have been identified in
previous research that can influence an individual's risk perception including the social
and cultural contexts (Douglas & Wildavsky, 1982; Weyman & Kelly, 1999), familiarity
with (Fischoff et al., 1978; Williamson & Weyman, 2005), and availability of the risk
(Gerend, Aiken, West, & Erchull, 2004), risk representativeness (Kahneman & Tversky,
87
1973), perceived control (Gerend et al., 2004), gender (Boholm, 1998; Hawkes & Rowe,
2008), age (Gerend et al., 2004), and trust in the source of risk information (Williamson
& Weyman, 2005).
There is growing evidence regarding the significance of a persons self-image
(Heaman et al., 2004) and perceived control (Kolker et al., 1993) in risk perception.
People tend to see a potential hazard as less risky if they have some measure of control
over the risk. In other words, people believe that controllable risks that may pose a high
degree of risk are safer than others which are less risky but uncontrollable (Nordgren,
Van Der Pligt, & Van Harreveld, 2007). A study by Kolker and Burke in 1993 was
conducted to describe the relationship between risk perception and decision making about
prenatal diagnosis. They found that perceived control, the severity or impact of the
outcome (dread factor), and the psychological availability of the risk (through individual
or indirect experiences) can influence risk perception.
Cognitive heuristics, mental guidelines that are used to process whether risk
knowledge is available or represented (Boholm, 1998), is another significant concept
arising from the literature review. Availability and representativeness heuristics are found
to be relevant to risk perception. The availability heuristic refers to "a cognitive shortcut
used for judging the probability of an event by the ease with which examples of the event
come to mind" (Gerend et al., 2004, p.248). In other words, the availability heuristic is a
cognitive scheme for processing information. In fact, it relates to what people remember,
not to what actually has happened (Boholm, 1998). The similarity or representativeness
88
heuristic reflects "a cognitive shortcut used for judging the probability of an event by its
similarity to events with comparable features" (Gerend et al., 2004, p.248).
A few studies have been conducted to identify factors influencing perception of
pregnancy risk. Heaman, Gupton, and Gregory (2004) reported that their participants
considered four areas in assessment of their pregnancy risk including: self image of their
own general health, health and family history, the healthcare system, and the odds of the
unforeseen and unknown complications. Patterson in 1993 found that black pregnant
women determined their pregnancy risk based on their own experiences of the risk
(pregnancy complication), the assessment of the health care provider, and the counsel of
other black women (Patterson, 1993). From a quantitative perspective, Gupton, Heaman,
and Cheung (2001) explored the relationship between biomedical, psychosocial, and
demographic risk factors with perception of pregnancy risk. Results of their study
revealed that biomedical risk and state anxiety were predictors of perception of
pregnancy risk. In their study, women with complicated pregnancies perceived their risk
as significantly higher than those with uncomplicated pregnancies. Current knowledge
suggests that biomedical risk might be important in the determination of perception of
pregnancy risk (Gerend et al., 2004; Gupton et al., 2001; Heaman et al., 2004) and that a
womans health status may influence her assessment of the risk (Gupton et al., 2001).
In the review of the literature, perception of pregnancy risk appears to be
influenced by perceived control, cognitive heuristics (availability and similarity), health
status, and medical risk. Because the Psychometric Model does not include some of these
concepts, a new conceptual framework to study perception of pregnancy risk was
89
developed based on the literature review and guided by the Psychometric Model of risk
perception. Figure 1 illustrates the conceptual framework of the study. In addition to
anxiety and risk knowledge, five new factors were included in the framework based on
the literature review. Later, through in-depth interviews of women in the qualitative
component of this mixed methods study, gestational age was identified as another
important factor in perception of pregnancy risk and was included in the analysis as the
eighth variable. We believe that due to the complex and multidimensional nature of risk
perception, adding these concepts to the main theory may be beneficial in achieving a
better understanding of risk perception. As such, this study sought to answer the
following questions: 1. What is the relationship of maternal age, risk knowledge,
pregnancy-related anxiety, cognitive heuristics, perceived control, medical risk, health
status and gestational age with perception of pregnancy risk among nulliparous women?
2. What are the most significant predictors of perception of pregnancy risk? 3. How does
maternal age interact with risk knowledge, pregnancy-related anxiety, cognitive
heuristics, perceived control, medical history, and health status in relationship to
perception of pregnancy risk?
Methods
This study was part of a larger mixed methods research study. The quantitative
component of the research was designed to compare risk perception of women of AMA
and younger age; hence two groups of women were recruited, aged 20-29 years and aged
35 years or older. The results of the comparative analyses were reported elsewhere
90
(Bayrampour, Heaman, Tough, & Duncan, 2011), while the focus of this report is to
describe the factors associated with perception of pregnancy risk.
We employed a descriptive correlational design to address the research questions.
A convenience sample of nulliparous pregnant women in their third trimester (> 28
weeks) with a singleton pregnancy who could speak, read, and write in English was
recruited. Data were collected between December 2009 and January 2011, from selected
physician's offices, prenatal classes, and outpatient departments and antepartum units of
two tertiary hospitals in Winnipeg, Manitoba. Two approaches were used for participant
recruitment. In the first approach, the researcher provided written and verbal explanations
about the study to potential participants in the hospital settings and private physician's
offices, and those who were willing to participate signed a consent form and completed
the questionnaires. In the second approach, the staff members in other settings were
asked to screen for women who met the inclusion criteria, and to determine their
willingness to consider participating in this study. If potential participants agreed to learn
more about the study, a package of questionnaires with a cover letter was handed to them
to be completed and returned to the researcher in a stamped addressed envelope. The
completion and return of the questionnaire signified implied consent. This project was
approved by the University of Manitoba Education/Nursing Research Ethics Board,
Health Sciences Centre Research Impact Committee, St. Boniface Hospital Research
Review Committee, and Winnipeg Regional Health Authority Research Review
Committee.
91

Questionnaire (PPRQ), Knowledge of Maternal Age-related Risks of Childbearing
Questionnaire, the Pregnancy-related Anxiety scale, the Multidimensional Health Locus
of Control (MHLC) Questionnaire, the SF-12v2 Health Status Survey, the Prenatal
Scoring Form, and a demographic and childbirth data collection form. To measure the
cognitive heuristics of availability and representativeness (similarity), two questions were
developed by the authors, adapted from questions used by Gerend et al. (2004). To
examine the availability heuristic, we asked women to report the number of female
friends they knew with a complicated pregnancy. To examine the representativeness
heuristic, we asked women to rate their perceived similarity to a typical pregnant woman
of the same age who developed pregnancy complications.
each item, yielding a score ranging from 0 to 100. Scores for the nine items are added
consistency reliability, with a Cronbachs coefficient alpha of 0.87 for the total scale, an
alpha of 0.84 for the "Risk for Baby" subscale, and an alpha of 0.81 for the "Risk for
Self" subscale (Heaman & Gupton, 2009). Validity of the scale was assessed using a
sample of 199 women in the third trimester of pregnancy. The concurrent validity of the
92
scale was confirmed by its correlation with the Spielberger State Anxiety Inventory
(Spielberger & Gorsuch, 1983) (r=.46, p<.001). In addition, construct validity was
demonstrated using the known-groups technique and through convergent validity
(Heaman & Gupton, 2009).
worries about her babys health, her own health, and labor and delivery (Rini, DunkelSchetter, Wadhwa, & Sandman, 1999). The scale consists of ten items rated on a 4-point
Likert scale ranging from one (1 = never or not at all) to four (4 = a lot of the time or
very much). The internal consistency reliability of the scale is acceptable (alpha = 0.78).
An exploratory factor analysis by Rini et al. (1999) revealed that the items were best
represented by a single score. The total score is computed by reversing scores where
applicable and calculating the mean of responses to all items, yielding a score ranging
from one to four. Higher scores indicate higher levels of pregnancy-related anxiety (Rini
et al., 1999; Wadhwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993).
by Tough et al. (2006) was utilized to measure risk knowledge. This scale consists of ten
correct responses was tabulated, yielding a score from zero to nine. According to Tough
et al. (2006), the face and content validity of the scale was ensured through focus group
testing, pilot interviews, and consultation with medical experts.
93
The SF-12v2 Health Status Survey is a shorter version of the SF-36v2 Health
Survey (Ware, Jr., Kosinski, & Keller, 1996). The SF-12v2 measures functional health
and well-being from the patients point of view. The SF-12v2 is useful in measuring two
components including physical health (PCS) and mental health (MCS) functioning and
covers the same eight health domains as the SF-36v2 with one or two questions per
domain. These domains include: physical functioning, role limitations due to physical
health problems, bodily pain, general health perceptions, vitality, social functioning, role
limitations due to emotional problems, and mental health. The reliability and validity
tests of the SF-12v2 have been proven to be satisfactory. Its Cronbachs coefficient alpha
is 0.88 for the physical component summary (PCS) and 0.82 for the mental component
summary (MCS) (Cheak-Zamora, Wyrwich, & McBride, 2009).
This instrument is composed of 18 items about perceived control over health outcomes
measured on a six-point Likert scale ranging from one (1 = strongly disagree) to six (6 =
strongly agree). The instrument includes three subscales that measure health-specific
perceived control in the following areas: internal, chance, and powerful others. Based on
Wallston et al. (1978), there is no such thing as a "total" MHLC score. Higher scores in
each subscale indicate greater belief in that subscale domain of control over health.
According to Wallston et al. (1978), correlations in the predicted direction of the MHLC
scales with health status confirmed some evidence of predictive validity of the scale.
94
Cronbach's coefficient alpha for the MHLC subscales (six-item forms) ranges from 0.67
to 0.77.
her present medical condition, and complications of the present pregnancy. Each factor is
scored with a numerical value ranging from zero to three according to its presence or
absence. The total score is calculated by adding each factors score and may range from
zero to 49. Women with risk scores of 0-2 are considered at low risk, those with scores of
3-6 at high risk, and those with scores of 7 or more at extreme risk. In this scale, two
points are assigned for maternal age > 35 years. In the current study, to avoid a linear
effect of maternal age distribution on this score, the two points assigned for maternal age
> 35 years were deleted.
A demographic and childbirth data collection form was used to collect
information related to the sample and potentially confounding variables that may affect
risk perception. These variables include marital status, family income, education,
race/ethnicity, childbirth education, and information about the pregnancy.
Data analysis. An alpha level of 0.05 was used for all statistical tests. All
descriptive and inferential statistics were conducted using PASW (Predictive Analytics
Software) Statistics for Windows version 18.0.2. Descriptive statistics were conducted to
describe the sample and scores on the measures. The proportion of participants with
95
missing values was low, with the exception of the income variable (4.4%). Missing data
were excluded from the analyses.
Pearson's r correlation matrices were constructed to explore linear associations
among the perception of pregnancy risk score, the medical risk score, pregnancy-related
anxiety score, the subscales of the perceived control score (i.e., internal, chance, and
powerful others), subscales of health status (i.e., physical functioning, role limitations due
to physical health problems, bodily pain, general health perceptions, vitality, social
functioning, role limitations due to emotional problems, and mental health), cognitive
heuristics subscales (i.e., familiarity and similarity), and selected demographic and
childbirth variables (i.e., maternal age and gestational age). Next, partial correlations
controlling for age were conducted to assess linear associations of the perception of
pregnancy risk score with other independent variables and to determine the strength and
direction of significance.
Both backward and forward stepwise multivariate linear regression analyses were
conducted to investigate relationships between risk perception and various predictors, and
to determine the strength of significant predictors in the sample. The perception of
pregnancy risk score was the dependent variable in regression models. Only those factors
that had a significant bivariate relationship with the criterion were entered in the
equations (Abu-Bader, 2006). In the stepwise regression model, variables were
sequentially removed from or included in the model. The deletion or addition was based
on the variable's association with the outcome after adjusting for any other variables in
the model (Katz, 2006). In the first model, perceived control (internal), pregnancy-related
96
anxiety, cognitive heuristics (availability), five subscales of health status variable (i.e.,
physical functioning, role limitations due to physical health problems, general health
perceptions, vitality, and mental health), medical risk, gestational age, and maternal age
(as a continuous variable) were entered. Prior to developing the second model, several
interaction terms were defined between maternal age and the independent variables
entered in the first model. The second model was conducted to determine whether the
effects of these factors on perception of pregnancy risk score were modified by maternal
age. In addition, a multiple line plot was created to investigate the interaction pattern
between maternal age and anxiety score with the perception of risk score. Maternal age
was entered in regression models as a continuous variable. However it was entered as a
dichotomous variable in the plot to demonstrate the interaction effects across younger and
older groups.
Although there is no clear agreement on the optimum sample size for regression
analysis, an absolute minimum of 10 participants per predictor variable has been
recommended for regression equations when using six or more predictors (Harris, 2001).
In the current study, variables that were correlated with the dependent variable were
entered in the first step of the analysis (11 variables including subscales), therefore, a
minimum sample of 110 participants was required.
Results
The final sample consisted of 159 participants: 105 nulliparous women aged 2029 years and 54 nulliparous women aged 35 years or older. Participants ranged in age
from 20 to 44 years. The majority of participants (91.8%) were married or living
97
common-law and the rest (8.2%) were single. Seventy two percent of participants
reported an annual family income of $40,000 or higher. The mean number of years of
formal education was 15.77 (SD=3.61). Almost 72% of participants were White and the
majority of women reported working before and during pregnancy. The mean gestational
age at the time of participation was 34.29 weeks (SD = 3.84) and ranged from 28 to 41
weeks.
The PPRQ score for the total sample ranged from 0 to 75.89 (M= 23.64,
SD=16.20) and "risk for self" ranged from 0 to 90.75 (M=24.45, SD=16.49) and "risk for
baby" varied from 0 to 89.40 (M=22.99, SD=18.01). Table 1 illustrates descriptive
statistics, including means and standard deviations, for the other variables measured in
the study.
Significant positive correlations were found between the perception of pregnancy
risk score and the medical risk score, pregnancy-related anxiety score, and maternal age.
There were significant negative correlations between the perception of pregnancy risk
score and physical functioning, role physical, vitality, mental health, and perceived
control (Table 2). However, after controlling for maternal age in partial correlations,
there were no significant correlations between physical functioning, role limitations due
to physical health problems, or vitality and the perception of risk score. On the other
hand, by controlling for maternal age, the cognitive heuristic (availability) and general
health variables became significantly correlated with the perception of risk score (Table
2). The sociodemographic characteristics of income and education were not correlated
with risk perception.
98
In order to answer research questions two and three, two stepwise multivariate
linear regression analyses were conducted to estimate a model that best predicts
perception of pregnancy risk among pregnant women.
Model 1: The results of this model revealed that four factors were significant
predictors of perception of risk, F (5, 145) = 26.35, p <0.001. With a standardized beta of
0.45 (p <0.001), pregnancy-related anxiety emerged as the strongest predictor of
perception of pregnancy risk, accounting for 30% of the variance in the perception of
risk. The second strongest factor was medical risk (=.25; p <0.001). The third and the
fourth strongest variables were maternal age (=.22; p <0.01) and gestational age (=.16;
p <0.05), respectively. The results indicated that a higher perception of pregnancy risk
was a function of higher levels of pregnancy-related anxiety, higher medical risk, older
maternal age, and lower gestational age (Table 3). Overall, the model explained almost
47% of the variance in perception of pregnancy risk (R2adjusted =0.45). The resulting
regression equation was as follows: Perception of pregnancy risk= 0.98 + (17.08 x
anxiety) + (2.16 x medical risk) + (0.57x age) + (- 0.64 x gestational age in weeks).
Model 2: In this model, the effect of maternal age on other predictors was
examined using interaction terms. The resulting regression analysis demonstrated that
medical risk, gestational age, and perceived control (internal) significantly predicted the
perception of pregnancy risk score. In addition, results demonstrated an interaction
between pregnancy-related anxiety score and maternal age (Table 4), indicating that the
relationship between each of the interacting variables (maternal age and anxiety) and
perception of pregnancy risk may depend on the value of the other interacting variable. In
99
the other words, the variances in the risk perception score due to anxiety level depend on
maternal age. A comparison of model 1 and model 2 illustrates that the simultaneous
influence of these variables on the risk perception score is greater than their additive
values. In fact, maternal age works in a synergistic fashion with anxiety score to increase
the perceived risk score. Figure 2 illustrates the estimated marginal means of perception
of pregnancy risk score by anxiety levels for the younger (20-29 years) and older (> 35
years) group of women. At the same level of anxiety, women aged 35 years or older had
higher perception of risk scores than younger women.
In the second model, medical risk, gestational age, and perceived control
(internal), and the interaction of maternal age and anxiety, which works in a
multiplicative way (age x anxiety), were predictors of the perception of pregnancy risk.
This model accounted for 49% (R2adjusted =0.47) of the variance in risk perception score
and indicated that the perception of pregnancy risk score increased when medical risk
increased and gestational age and perceived control decreased.
Discussion
This study was conducted to identify factors contributing to perception of
pregnancy risk among nulliparous women using a conceptual framework developed
based on a literature review and the Psychometric Model of risk perception. Of the eight
proposed factors in the conceptual framework, four factors were significant predictors of
perception of pregnancy risk in the first model, including pregnancy-related anxiety,
medical risk, maternal age, and gestational age. In the model incorporating interactions
with maternal age, perceived control (internal) also approached significance (p=.054).
100
Thus, overall, five of the factors in the conceptual framework were supported. These
models accounted for 47-49% of the variance in risk perception. This finding is
noteworthy, because current theories of risk perception only account for five to 20
percent of variations in risk perception (Sjoberg, 1996). Results of research by Gupton et
al. (2001), who examined the role of anxiety, medical risk, stress, self-esteem, and social
support in predicting perception of pregnancy risk, revealed that the predictive power of
their models varied from 19-31%. In their study, state anxiety and medical risk predicted
perception of pregnancy risk. This suggests that the addition of perceived control,
maternal age and gestational age into our conceptual framework has significantly
improved the predictive power of the model.
Current research suggests that emotions are important factors in risk perception
and stronger emotions may led to a higher level of perceived risk (Xie, Wang, Zhang, Li,
& Yu, 2011). Our findings determined pregnancy-related anxiety as the strongest
predictor of perception of pregnancy risk, supporting its role as a dread factor in the
conceptual framework. Chuang et al. (2008), who also employed the Psychometric Model
to study risk perception, examined the feeling of dread using psychosocial stress or lower
health status variables. They did not find a significant association between risk perception
and these defined dread factors. Furthermore, in another study of perception of pregnancy
risk, stress was not a predictor for risk perception among women with complicated
pregnancies, while state anxiety was a significant predictor (Gupton et al., 2001). These
results imply that pregnancy-related anxiety might be an appropriate measure of the dread
factor and may be a more reliable factor than stress to predict perception of pregnancy
101
risk. However, careful consideration needs to be given to selecting a measurement of

anxiety and also to differentiate the contribution of trait, state, and pregnancy-related
anxiety (Spielberger, Rickman, & Sartorius, 1990). In the current study, pregnancyrelated anxiety had a stronger association with perception of pregnancy risk than state
anxiety measured as a general concept by Gupton et al. (2001) (r =0.56 vs. r =0.36),
suggesting that these concepts measure different aspects of anxiety.
In our study, maternal age was determined to be a predictor of perception of
pregnancy risk. Although women of AMA had higher medical risk scores than younger
women, even after controlling for medical risk, maternal age remained as a significant
predictor of perception of pregnancy risk suggesting that this association was
independent from the effect of medical risk. In addition, a significant interaction effect
was revealed between maternal age and pregnancy-related anxiety in relation to
perception of risk. In other words, while anxiety may contribute to a higher perceived risk
in pregnant women, its effect will be more prominent in women of AMA than younger
women. Some researchers believe that AMA might be associated with higher anxiety due
to awareness of several risks associated with older age such as fertility issues, coexisting
obstetric complications, and also competing social roles and responsibilities (Neumann &
Graf, 2003; Suplee et al., 2007). Although our findings suggest that an anxious woman at
AMA may have higher perception of risk than her younger counterpart, as Xie et al.
(2011) stated, it is not evident whether emotions such as anxiety lead to higher risk
perception or vice versa. Because the causal relationship between anxiety and risk
perception is not clear, a precise conclusion requires further research.
102
As expected, objective medical risk was a significant predictor of risk perception.

This result is consistent with the results of another Canadian study of pregnant women
who had various parities (Gupton et al., 2001) and also with the results of a U.S. study
that used the PPRQ to assess risk perception in a group of pregnant women. The latter
study reported that higher PPRQ scores were associated with patients enrolment in a
high risk clinic (Headley & Harrigan, 2009).
In the current study, health status was not a significant predictor of perception of
pregnancy risk. This result is consistent with findings of Chuang et al. in 2008 who
reported that general health measured by the SF-12v2 Health Survey was not a significant
predictor of increased risk perception of adverse pregnancy outcomes.
According to our findings, perception of pregnancy risk altered over the course of
the pregnancy, with women having higher perceptions of risk at earlier gestational ages.
This pattern could be due to women becoming more optimistic about the outcome of their
pregnancy as it advances and women pass gestational ages where miscarriage and very
early preterm birth are likely. Although there is no previous study to examine changes in
risk perception over the duration of pregnancy, Buist, Gotman, and Yonkers (2011), who
explored the changing nature of generalized anxiety disorder in relation to the course of
pregnancy, found that anxiety symptoms were highest in the first trimester and decreased
across pregnancy. Similarly, Ohman, Grunewald, and Waldenstrom (2009) reported that
worry about the babys health subsided continuously from early pregnancy to the
postpartum period.
103
Previous research suggested that perceived control plays an important role in risk
appraisal. Results of our study determined a border line position as predictor for one of
the perceived control subscales (internal). In a study by Audrain et al. (1997), low levels
of perceived control over cancer were related to high levels of perceived risk. The authors
stated that women with high levels of perceived risk and low levels of perceived control
may be most vulnerable to distress. However, Gerend et al. (2004) reported that they did
not find a relationship between perceived risk and the controllability and preventability of
the risk. This might be explained by the fact that their study focused on characteristics of
the risk rather than the degree of the individual's perceived control.
Interestingly, in our study, knowledge of age-related risks of childbearing was not
a significant predictor of perceived risk, even after testing for its interaction with
maternal age. This finding is consistent with a previous study that examined womens
risk perception for developing chronic disease. Their results indicated that perceived risk
does not completely reflect womens knowledge of objective risk of disease (Gerend et
al., 2004). Similarly, Kim et al. (2007), who examined risk perception for diabetes among
women with a history of gestational diabetes mellitus (GDM), found that knowledge of
GDM as a risk factor for diabetes is not necessarily sufficient to increase risk perception.
In their study, although the majority of women were aware that gestational diabetes was a
risk factor for future diabetes, only 16% had high perception of risk for developing the
disease. Similarly, Dearborn, Lewis, and Mino (2010) conducted a study to assess
pregnant womens knowledge about HIV, their perception of personal risk, and
willingness to be tested. They reported no relationship between HIV knowledge and risk
104
perception or test acceptance. In contrast, Chuang et al. (2008) reported that increased
familiarity with preterm or low-birthweight birth through experience with the outcome
(personal or family history) or known predictors (smoking, being underweight) correlated
with greater perceived risk. They concluded that predictors that did not contribute to risk
perception in their analysis were not well known to be associated with preterm/lowbirthweight birth by women. This discrepancy draws attention to one aspect of risk
assessment that can be especially challenging and that is to distinguish risk knowledge
from risk experience. The latter has been also identified as "risk representativeness" by
Kahneman & Tversky (1973), stating that often the most representative outcomes will be
predicted by people. Findings from the qualitative component of this study also supported
this perspective by suggesting that risk knowledge had a limited impact on risk
perception, while risk experience might dramatically contribute to the perception of
pregnancy risk.
Although some research suggests that the cognitive heuristics of availability and
similarity of the risk might contribute to perceived risk, we did not observe similar
relationships. This result might be due to using a single item measure (developed by the
authors for this study) that has not been previously psychometrically evaluated and may
not have accurately measured the concept. Also, availability and similarity may be
attributable to other experiences that we did not measure in this study. Because these
variables have emerged in previous research on risk perception, the role of cognitive
heuristics in risk perception will need further study. Also developing a valid and reliable
scale to measure this concept in relation to pregnancy risk is encouraged.
105
This study has both strengths and limitations. One of its strengths is that we
recruited only nulliparous women to minimize the effect of previous pregnancy
experiences on risk perception. Furthermore, our conceptual framework was based on the
literature on perception of pregnancy risk. The comprehensiveness of our conceptual
framework can be supported by its high predictive power in the regression models. Also,
the majority of variables were measured using valid and reliable instruments. Limitations
of the study that require consideration when interpreting the results include the use of
convenience sampling for collecting data. Due to a non-random method of sample
selection, those who volunteered to participate might have been different than those who
did not, resulting in selection bias. Because our sample included two distinct age groups
of women, some variables might be affected by the larger proportion of the sample
between the ages of 20-29 years. In addition, because the sample was recruited from a
nulliparous population of women, the results might not be generalizable to multiparous
women.
Implications for Practice
Results of this study have implications for efforts to improve prenatal care and
risk communication and also provide the impetus for future research. Our findings
supported that womens risk assessments are not only based on information and cognitive
processes, but are also affected by psychological factors and social values (Fischhoff,
Bostrom, & Quadrel, 1993; Tversky & Kahneman, 1974). A woman's perception of
pregnancy risk is not identical with her medical risk condition. There are several other
factors contributing to her risk perception, of which at least half are not identified yet.
106
Future studies should be conducted to discover these factors. Our findings also suggest
that merely offering information about risk might not contribute to alterations in risk
perception to any great extent. An effective risk communication might benefit from
strategies other than providing factual information about risk. Although providing
information is fundamental and is often considered the first step in changing behaviour or
intervening, information should be offered in a way that can be related to a woman's life
experiences. As Carolan (2009) stated, some women might benefit from translating
epidemiological risk into real life instances in order to help them to process the risk.
Health care providers should be aware that a womans perception of pregnancy
risk is highly individualized and could be different from medical risk assessment;
therefore, a discussion about the woman's risk perception should be integrated into the
prenatal care visit. This communication will enhance the quality of care by incorporating
the women's perspective in planning their own care and also providing an opportunity to
identify women with higher anxiety levels. Women with high levels of perceived risk and
of AMA may be more vulnerable for higher anxiety and should be targeted for
interventions to foster accurate risk perceptions and decrease anxiety levels. Detection of
anxious pregnant women may provide an opportunity to refer them to mental health
services to engage them in appropriate interventions prenatally and postnatally. Anxiety
during pregnancy has been associated with several adverse outcomes. In general, women
with high levels of anxiety are at higher risk of spontaneous early labour, preterm
delivery, lower birth weight, fetal distress, and operative or instrumental deliveries. In
addition their newborns are more likely to have a poor neonatal adaptation, admission to
107
neonatal ICU, and excessive crying, irritability, hostility, and erratic sleep (Consonni et
al., 2010; Fishell, 2010). Hosseini et al. (2009) reported that trait anxiety during
pregnancy predicted shortened gestational age and lower birthweight. In another study,
pregnancy-related anxiety was associated with decreased gestational age (Wadhwa et al.,
1993). Taking into consideration the association between anxiety and adverse perinatal
outcomes and also its central situation in perception of pregnancy risk, understanding of
the nature of the relationship between risk perception and anxiety requires further
research.
Conclusion
This study confirmed that previously known factors in risk perception (e.g.,
perceived control and medical risk) may be applicable in the state of pregnancy.
Although earlier qualitative research suggested that AMA might contribute to a higher
risk perception, our study provided a quantitative verification for these statements by
identifying maternal age as a significant predictor for perception of pregnancy risk. Our
study contributed to the perception of pregnancy risk literature by identifying a new
predictor (i.e., gestational age) and also proposing pregnancy-related anxiety as a
pregnancy dread factor in risk perception theories. Furthermore, our findings draw
attention to the interactive effects of maternal age and pregnancy-related anxiety in
increasing perception of pregnancy risk. This result emphasizes that health care
professionals need to take extra caution in risk communication with women of AMA.
Future research should be conducted to situate anxiety and perception of pregnancy risk
more accurately in relation to each other. This knowledge may have implications in
developing more effective risk communication models.
108
109
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Table 6. Descriptive Statistics for Major Study Variables
Variable
Range
(Min-Max)
M (SD)
PPRQ score
158
75.8
(0-75.8)
23.64 (16.20)
Risk for Self
158
90.7
(0-90.7)
24.45(16.49)
Risk for Baby
159
89.4
(0-89.4)
22.99 (18.01)
156
27.0
(9.0-36.0)
25.86 (4.05)
150
21.0
(6.0-27.0)
15.73 (4.32)
Perceived Control (Powerful

Others)
154
28.0
(6.0-34.0)
18.11 (5.23)
157
2.1
(1.1-3.2)
1.90 (.42)
Risk Knowledge
159
9.0
(0-9.0)
4.67 (2.06)
SF-12 (Physical Functioning)
159
100.0
(0-100.0)
59.43 (32.88)
SF-12 (Role Physical)
157
100.0
(0-100.0)
57.72 (24.04)
SF-12 (Bodily Pain)
159
100.0
(0-100.0)
76.57 (20.22)
SF-12 (General Health)
149
75.0
(25.0-100.0)
78.49 (16.77)
SF-12 (Vitality)
159
75.0
(0-75.0)
47.96 (19.88)
SF-12 (Social Functioning)
158
100.0
(0-100.0)
75.16 (23.86)
SF-12 (Role Emotional)
159
87.5
(12.5-100.0)
80.82 (20.94)
SF-12 (Mental Health)
157
75.0
(25.0-100.0)
70.78 (15.92)
Medical Risk
157
8.0
(1.0-9.0)
2.86 (1.85)
120
121
Table 7. Pearson Correlation Coefficients between Perception of Risk Score and Major
Study Variables and Partial Correlation Coefficients (Controlling for Maternal Age)
Variable
Not Adjusted
Controlling for Age
.29***
Cognitive Heuristics (availability)
.11
.20*
Cognitive Heuristics (similarity)
.10
.13
Gestational Age
- .21**
-.17*
- .21**
-.20*
.56***
.47*
.06
.11
SF-12 (Physical Functioning)
- .21*
-.16
SF-12 (Role Physical)
- .24**
-.12
SF-12 (General Health)
-.12
-.22*
SF-12 (Vitality)
- .25**
-.21
SF-12 (Mental Health)
- .29***
-.26**
Medical Risk Score
.36***
.25**
Maternal Age
Risk Knowledge
* p<0.05
** p<0.01
*** p<0.001
122
Table 8. Multiple Regression Analysis (without Interactions) - Perception of Pregnancy

Risk as the Dependent Variable
Unstandardized Coefficients
2.36
.45
7.23
<.001
2.16
.54
.25
4.00
<.001
Maternal Age
.57
.16
.22
3.52
.001
Gestational Age
-.64
.26
.25
-2.49
.014
Perceived Control
(Internal)
-.42
.24
-.11
-1.74
.084
Predictor
B
SE B
17.08
Medical Risk
Note. N=159. R2=.47, Adjusted R2 = .45, F = 26.00, p <.001. Variables entered into
model included: perceived control (internal), pregnancy-related anxiety, cognitive
heuristics (availability), five subscales of health status variable (i.e., physical
functioning, role limitations due to physical health problems, general health perceptions,
vitality, and mental health), medical risk, gestational age, and maternal age (as a
continuous variable).
123
Table 9. Multiple Regression Analysis (With Interactions) - Perception of Pregnancy

Risk as the Dependent Variable
Unstandardized Coefficients
11.76
-.26
-.82
.41
2.22
.53
.26
4.17
<.001
Maternal Age
-1.08
.73
-.43
-1.48
.14
Gestational Age
-.59
.26
-.14
-2.31
.02
-.47
.24
-.12
-1.96
.05
Maternal Age x Pregnancyrelated Anxiety
.90
.39
.99
2.32
.02
Predictor
B
SE B
-9.66
Medical Risk
Note. N=159. R2=.49, Adjusted R2 = .47, F = 33.27, p <.001. Variables entered into the
model included: maternal age, perceived control (internal), pregnancy-related anxiety,
medical risk, gestational age, and their interactions with maternal age.
Maternal Age
Risk Knowledge
Operationalized by Knowledge of
Maternal Age-Related Risks of
Childbearing (Tough et al., 2006)
Operationalized by Pregnancyrelated Anxiety (Rini, DunkelSchetter, Wadhwa, & Sandman,
1999)
Perceived Control
Operationalized by MHLC
(Wallston, Wallston, & DeVellis,
1978)
Health Status
Operationalized by the SF-12v2
Health Status Survey (Ware, Jr.,
Kosinski, & Keller, 1996)
Medical Risk
Operationalized by Prenatal
Scoring Form (Coopland et al.,
1977)
Cognitive Heuristics
Operationalized by a questionnaire
adapted from Gerend et al.
(Gerend, Aiken, West, & Erchull,
2004)
Gestational Age
(Emerged through qualitative
findings)
Figure 1. Conceptual framework of the study
Risk Perception
Operationalized by
PPRQ (Heaman &
Gupton, 2009)
124
125
Figure 2. The effect of maternal age on the perception of pregnancy risk-anxiety scores
Graph of estimated marginal means of perception of pregnancy risk score by anxiety
levels for the younger (20-29) and older (35>) maternal age (age as a dichotomous
variable).
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Chapter Seven: Manuscript Three

Introduction to Chapter Seven
The preceding two chapters presented the results of the quantitative component of
the study. The following chapter reports the findings of the qualitative component.
Similar to the two previous chapters, it has been formatted into a publishable manuscript
entitled "Advanced Maternal Age and Risk Perception: A Qualitative Study". The
manuscript begins with an introduction and explanation of the methods, followed by
presenting results and discussing their implications.
Although this manuscript mainly focused on the qualitative component, its results
have been combined with some data in the first paper to enrich interpretation of data.
Selected quantitative measures including the Perception of Pregnancy Risk Questionnaire
(PPRQ), perceived control, and pregnancy-related anxiety measures have been
incorporated with the qualitative data to enrich background information about
participants. The content of this paper along with the findings of the second manuscript
(Chapters Six and Seven) formed the foundation for the development of the final
conceptual framework of the study that will be presented in Chapter 8.
The student wrote this article, while the students advisor and her committee
members provided constructive suggestions on the manuscript. The potential journal for
this manuscript will be determined later.
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Manuscript 3: Advanced Maternal Age and Risk Perception: A Qualitative Study

Abstract
Objectives: Advanced maternal age (AMA) is associated with several adverse pregnancy
outcomes, hence these pregnancies are considered to be "high risk." A review of the
empirical literature suggests that it is not clear how women of AMA evaluate their
pregnancy risk. This study aimed to address this gap by exploring the risk perception of
pregnant women of AMA.
Methods: A qualitative descriptive study was undertaken to obtain a rich and detailed
source of explanatory data regarding perceived risk from 15 women of AMA. The sample
was recruited from a variety of settings in Winnipeg, Canada. In-depth interviews were
conducted with nulliparous women > 35 years, in the third trimester, and with singleton
pregnancies. Interviews were recorded and transcribed verbatim, and content analysis
was used to identify themes arising from the data.
Results: Four main themes emerged: definition of pregnancy risk, factors influencing risk
perception, risk alleviation strategies, and risk communication with health professionals.
Conclusion: Several factors may influence the perception of pregnancy risk including
physiological aspects, gestational age, psychological elements, cognitive heuristics,
predictability of risk, and health care providers opinion. Consideration of these
influential factors may help individuals who care for pregnant women of AMA to gain
insight into how these women perceive their pregnancy risk.
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Introduction
In the past three decades, a growing number of women have delayed their
childbearing for educational, social, and economic reasons (Benzies et al., 2006; Tough,
Benzies, Fraser-Lee, & Newburn-Cook, 2007). Pregnancy at advanced maternal age
(AMA) is associated with several adverse pregnancy outcomes (Cleary-Goldman et al.,
2005; Hung, 2008; Jacobsson, Ladfors, & Milsom, 2004; Joseph et al., 2005; Joseph et
al., 2007); therefore, it is considered a "high risk" pregnancy. The concept of risk at AMA
may be composed of two components: the physiological challenges because of an aging
reproductive system, and the social discourse of risk and timing of childbearing (Carolan
& Nelson, 2007).
Pregnancy risk perception may affect pregnant womens health care use,
motivations to seek care, pregnancy and labour decisions, adherence to medical
recommendations, and health behavior (Atkinson & Farias, 1995; Kowalewski, Jahn, &
Kimatta, 2000; Suplee, Dawley, & Bloch, 2007). Risk perception is incorporated as a key
concept in constructing several theories of health behavior such as the Health Belief
Model (Janz & Becker, 1984), Protection Motivation Theory (Maddux & Rogers, 1983),
and Prospect Theory (Kahneman & Tversky, 1979).
Although pregnancy at age 35 years or older is considered a medically high risk
situation, little is known about perception of pregnancy risk of women of AMA. Most
previous work on risk perception at AMA has focused on increased risk of genetic
abnormalities, while the general concept of pregnancy risk perception has received less
consideration. Current knowledge of risk perception at AMA is based on a few studies,
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most of them primarily focused on pregnancy experiences and in which risk perception
was discussed as part of the pregnancy experiences. In a qualitative study, Saxell (2003)
explored the understandings and beliefs of ten women of AMA about the risks associated
with their pregnancies. The author reported that these women found being labeled high
risk very challenging; hence, several participants rejected this labeling as part of their
coping mechanism. Probably, Saxells study is the only research that primarily focused
on understanding the risk perception of women of AMA; however, the limitations of this
study, such as retrospective data collection (36 months after delivery) and its unique
population (participants who chose midwifery care), should be considered in the
interpretation of the results. Windridge and Berrymans (1999) study of 107 British
womens experiences of giving birth at AMA demonstrated that women of AMA may
perceive a higher risk for their babies during labor because of their older age.
Another notable study in this field is an Australian qualitative study of 22
primigravid women of AMA. This study was initially conducted to understand the
experiences of women of AMA (Carolan, 2005). Later, in 2007, Carolan and Nelson
published a secondary analysis based on that research. They identified four themes
central to perception of pregnancy risk including "realizing I was at risk," "hoping for
reassurance," "dealing with uncertainty," and "getting through it/negotiating risk"
(p.540). The authors observed high levels of concern and anxiety among participants, in
spite of these women having healthy pregnancies, and suggested that the notion of risk
may have negative impacts on these women.
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Considering the lack of literature in this area and limitations associated with the
previous studies, we conducted a mixed methods research study to further the existing
knowledge about risk perception and its contributing factors at AMA. The study reported
here is the qualitative component of the mixed methods study. The goals of this
qualitative study were to explore how nulliparous women of AMA evaluate and define
their pregnancy risk and to arrive at a detailed understanding of their risk perception. To
achieve these objectives, the following questions were explored: 1. How do nulliparous
women of AMA define pregnancy risk? 2. Why do women of AMA feel that their
pregnancy is, or is not, at risk? Which factors influence perception of pregnancy risk of
women of AMA? 3. What are the experiences of women of AMA with risk
communication from health care providers during pregnancy? How do women feel their
perceptions of risk differ from those of their health care providers, if at all? 4. What
impact, if any, did being labeled high risk have on these womens lives and behaviors?
Methods
A qualitative descriptive study was undertaken to obtain a rich and detailed source
of explanatory data regarding risk perception from women of AMA. As described by
Sandelowski (2000), a qualitative descriptive study provides "a comprehensive summary
of an event in the everyday terms of those events." (p.336). Qualitative descriptive
method is a distinctive and valuable technique that offers a direct description of
phenomena, which is still interpretive (Sandelowski, 2010). In other words, as
Sandelowski (2000) stated, this kind of research can address both descriptive and
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interpretive validity to account for participants' observations and their understandings of

these events.
The sample consisted of 15 nulliparous women aged 35 years or older.
Participants were chosen purposefully from among the participants in the quantitative
component of the mixed methods research study. In purposeful sampling, participants are
intentionally selected according to the needs of the study (Coyne, 1997). Other criteria
for participation in the larger mixed methods study were singleton pregnancy, ability to
speak, read, and write in English, and gestational age of 28 weeks or greater. Any known
severe psychological disorder was an exclusion criterion. Data were collected over 14
months (December 2009 to January 2011) from selected physician's offices and
outpatient prenatal care clinics at two tertiary hospitals in Winnipeg, Manitoba.
Participants were selected to ensure diversity in demographic and obstetric
characteristics, most notably gestational age, and pregnancy complications. In addition,
participants were recruited to reflect a range of scores using the Perception of Pregnancy
Risk Questionnaire (Heaman & Gupton, 2009) used in the quantitative component, to
ensure including participants with different levels of perception of pregnancy risk. In
qualitative inquiry, sample size relies on the concept of "saturation" which is the point at
which no new information or themes are observed in the data (Guest, Bunce, & Johnson,
2006). Saturation was reached after interviewing 15 participants.
This project was reviewed and approved by four committees prior to commencing
data collection: the University of Manitoba Education/Nursing Research Ethics Board,
Health Sciences Centre Research Impact Committee, St. Boniface Hospital Research
132
Review Committee, and Winnipeg Regional Health Authority Research Review

Committee. The researcher asked selected women who had participated in the
quantitative component of the study if they were willing to participate in the qualitative
component. Potential participants were provided with a written and verbal explanation of
the qualitative component of the study. Each participant signed a consent form. A
mutually convenient time and place were arranged to conduct the interviews. In-depth,
semi-structured, face to face interviews, using an interview guide, were conducted by the
researcher. All interviews were audio-recorded and transcribed verbatim.
Data analysis was carried out concurrently with data collection. Transcripts were
analyzed using a content analysis technique. Content analysis is defined as any technique
for making inferences by objectively and systematically identifying specified
characteristics of messages (Holsti, 1969). In other words, content analysis is a
systematic and replicable method used for condensing many words of text into fewer
content categories based on explicit rules of coding (Stemler, 2001). In this method, first
the transcripts were read in full; then, analysis proceeded using the standard qualitative
analysis techniques of open coding by inputting and sorting codes using NVivo version 9.
Next, the definition of each code was created and identified codes were clustered into
categories, and finally the categories were grouped into themes. Descriptive statistics
were used to summarize the demographic data from the participants. As mentioned
earlier, this study was part of a mixed methods research study in which several
instruments were administered. In this report, selected quantitative measures including
the Perception of Pregnancy Risk Questionnaire (PPRQ) (Heaman & Gupton, 2009),
133
perceived control (internal) (Wallston, Wallston, & DeVellis, 1978), and pregnancyrelated anxiety (Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999) scores have been
reported to enrich background information about participants and enhance the
interpretations of findings. The scores on these scales, taken from the respondents age 35
or older in the larger mixed methods study (n=54), were divided into tertiles representing
low, middle, and high scores (Table 1). Table 2 illustrates the number of participants in
each tertile. Diversity in the sample allowed for the documentation of variations in risk
appraisal and also the identification of important issues that were common across
participants.
According to Davies and Dodd (2002), rigor refers to the reliability and validity
of qualitative research; however it does not necessitate the sense of replicability of the
research in different situations that is common in quantitative research. In fact, visibility
of research practices and accountability of the data analysis are the essence of rigor in
qualitative research. In the current study, a validation process for the qualitative
component was performed during and after conducting the research using two strategies.
In the first method, member checking was used in which the results were verified with
participants by asking them to confirm the researcher's interpretations during interviews
and after obtaining interpretations. Second, the results were confirmed with peer review
and debriefing through regular meeting with the dissertation advisor to achieve a jointly
developed interpretation of the data. Dependability was obtained through use of an audit
trail. In this strategy, contextual information and participants reflections were
134
documented. The ways to address confirmability in this study were using direct quotes
and confirming the findings with participants during interviews.
Results
The sample for this study consisted of 15 participants. The age range of
participants was 35 to 44 years (Mage= 37.6 years). The majority of women were highly
educated with a mean educational level of 18.7 years. All participants were married or
living common-law. All except one had been working during pregnancy. Over half
(53.3%) of the women reported an annual family income of $100,000 or over. All
participants were in the last trimester of their pregnancies, with a mean gestational age of
35.6 weeks (ranging from 32 to 40 weeks). All participants except one considered their
pregnancy to be planned. Table 3 and Table 4 illustrate selected demographics and
obstetrics characteristics of the sample.
Participants delayed their childbearing for a variety of reasons. The primary
reason for some women was lifestyle choices (n=6). This group of women described
being focused on their career, education, travel, or that they did not feel that they were
ready to have children until they reached an older age. Delayed marriage was the primary
reason for six other participants. Finally, three women identified infertility issues as their
primary reason for postponed childbearing. It should be noted that infertility was also
reported among participants in the delayed marriage and lifestyle choices groups,
however it was not their prime reason for delayed childbearing.
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The findings of this study were categorized into the following themes: definition
of pregnancy risk, factors influencing risk perception, risk alleviation strategies, and risk
communication with health professionals.
Definition of pregnancy risk. This theme describes participants understandings
of pregnancy risk and explains how they defined risk. Most women acknowledged that
there are some increased risks at AMA; however, a number of them felt that the risk has
been overestimated. For example, one of the participants stated that "those numbers dont
matter," and another mentioned that "its an overreaction, frankly." Womens
understandings of risks associated with AMA were reflected most often in comments
about their awareness of infertility issues and genetic abnormalities. A big concern for
most women was infertility problems associated with delayed childbearing rather than
pregnancy-related issues. Most of the women who delayed marriage reported that they
decided to become pregnant soon after getting married to minimize the effect of age
factor on their fecundity. Almost all participants in our study were aware of increased
risk of genetic abnormalities, particularly Down syndrome, with AMA.
It was noted that participants' understanding of risk tended to be extensive and
comprehensive; they considered their pregnancy as more of a societal issue in which
personal, interpersonal, and societal elements were significant, rather than merely a
biomedical matter. For our participants, the meaning of risk was broader than medical
issues and included the extent of their support network, their ability to control situations,
and whether they had a secure relationship, a planned pregnancy, a flexible job or healthy
lifestyle and behavior. It is noteworthy that some of these elements were also identified
136
by participants as factors influencing their timing of pregnancy. The following quote is an

example of the comprehensiveness of risk definition by one of participants with an
uncomplicated pregnancy:
"A high risk pregnancy to me would have been if I had no control over my work
environment . . . So even just the ability to be able to work from home . . . if I was
working in more a violent situation, if I was in a bad relationship I think that
would make me more of a high risk pregnancy, than my personal age or my
personal health . . . I think its more my surroundings than, than me . . . cause I
can control what I do right? I control what I eat, I can control when I go to bed, I
can control the people around me, like I can control those things, but if I cant
control those things then potentially my environment would be more my risk
factor." Participant 13
Factors influencing risk perception. The magnitude of the perception of
pregnancy risk differed among our participants. In data analysis, nine factors were
identified that determined perception of pregnancy risk including: cognitive heuristics
(availability and similarity of the risk), predictability of the risk, health status, pregnancy
complications, gestational age, perceived control, poor fertility history, anxiety, and
health care providers opinion.
Cognitive heuristics. The concept of "availability of risk" is a cognitive heuristic
and refers to "a cognitive shortcut used for judging the probability of an event by the ease
with which examples of the event come to mind" (Gerend, Aiken, West, & Erchull, 2004,
p.248). Based on participants explanations, this concept appeared to be very fundamental
in risk appraisal. One participant with high perception of pregnancy risk score explained:
"if it [risk] happens to other people, then it could happen to me." Accordingly, womens
understandings of risk were mostly based on their experiences of real cases in life, and
they mainly relied on these data in pregnancy risk assessment:
137
"From my experience in Europe, where most women are having their children in
their thirties and not their twenties and, to be honest, I didnt, and I lived there for
a long time, I didnt see the amount of Downs Syndrome or other physical
abnormalities that you see here." Participant 11
Most participants had an example of pregnancy at AMA among one of their
family members, friends or colleagues. An interesting point was that most participants
were not concerned about the parity of these women in order to compare their pregnancy
with them. Availability of a positive example in mind or a favorable family history of
fertility at AMA was often reported as a reassuring factor that increased women's
perceived ability to conceive at AMA and to have a successful pregnancy.
"I know a lot of women that are having their first child in their forties . . . and
everything has worked out fantastic, so I always looked at them as sort of my
mentors or role models." Participant 5
These participants often perceived their pregnancy as being low risk. Another
participant with both low perception of pregnancy risk score and anxiety score and an
uncomplicated pregnancy commented:
"Both like my mother had me when she was thirty-six, I think, and my partners
mother had her last one when she was forty-one, so its, it doesnt seem that
abnormal in my . . . and actually my grandma had my mother at forty-four so.
And I think maybe that, that as well, like, made me feel less risky as well cause I
had, you know, generations before me that had late babies and with no
complications." Participant 8
On the other hand, participants who were familiar with the risks associated with
AMA, through personal or vicarious experiences, expressed more concerns and had an
increased perceived risk. One of the participants with a fairly healthy pregnancy and high
perception of pregnancy risk score and high anxiety score mentioned:
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"A friend of mine got pregnant; I think she was 36, and she did have a baby who
had so many problems that they were surprised the babys heart was even still
beating in her womb, so she ended up terminating that pregnancy, and shes still
broken up about . . . so I was debating this . . . So yeah I did have that one friend,
and of course, the woman who told me about her near death experience in
labour." Participant 4
The "similarity" is another component of cognitive heuristics and reflects "a
cognitive shortcut used for judging the probability of an event by its similarity to events
with comparable features" (Gerend et al., 2004, p.248). Although the concept of
similarity was frequently used by participants to evaluate the likelihood of the risk, they
also assessed their pregnancy risk by comparing their critical characteristics with those
who developed a pregnancy complication. The following comment is an example of
using the similarity heuristic in risk appraisal by a 37 year-old participant:
"I had that friend who was thirty-six and had a baby who had Trisomy 18, and she
felt that it was because of her age, I wont say advanced age, but she is not as
healthy as I am. She actually may have an alcohol problem, and shes taken a lot
of medications in her life for depression and all kinds of things, and she doesnt
really work out very much, and she just wasnt as healthy [as I am]."Participant 4
Predictability of the risk. Based on our participants explanations, predictability
of the risk was an important element in pregnancy risk appraisal; a predicted pregnancy
complication was perceived as a low risk situation by women than a non-predicted and
unexpected problem. One participant with a low perceived risk score, who had severe
morning sickness in early pregnancy, described it as a "typical pregnancy symptom" that
could happen in "every pregnancy." On the other hand, another participant with high
perception of risk and low perceived control scores, who had to stop working for an
unexpected, threatened premature labour stated:
139
Its been challenging, so its not what I expected . . . the (risk) perception was
higher because I did not expect to feel an almost arthritic pain the last two
months, I didnt expect that morning sickness would be 24 hours a day for five
months instead of three, neither of us were expecting this . . . I was expecting to
work until my due date and come to the hospital and you know I was ready to be
like every other mom, well most other moms where you work till the end and
sometimes you just go from work straight to the hospital in labour." Participant 6
A 37 year-old participant with a high perception of risk score who was diagnosed
with gestational diabetes explained that:
"Both of my parents have adult onset diabetes, and my mother had gestational
diabetes with my brother when she was roughly the same age as me, and so I, I
pretty much expected to have gestational diabetes, so I was careful right from the
beginning, making sure that I was exercising and trying to eat healthfully and so
on . . . so I was cautious about that . . . [however] I was surprised to find that I had
needed the insulin for it as opposed [to] control by diet; that was a bit of a shock.
It was a shock to discover that it was that severe to begin with and that I would
need the insulin." Participant 9
Health status. Good health was frequently identified as a factor that decreased
risk when participants assessed their pregnancy risk in relation to age. Most women in
our study considered themselves healthy and felt that they had control over their physical
health. They often emphasized their good health as a balancing capacity in pregnancy risk
assessment. A 35 year-old participant at 30 weeks of gestation with a low perception of
risk score commented:
"Because I was, Im always, Ive always been a quite a healthy person, it, it never
really concerned me that much that I was older and having a baby." Participant 8
Pregnancy complications. Among our participants, three women had gestational
diabetes, one had vaginal bleeding before 20 weeks, and one had both vaginal bleeding
140
before 20 weeks and threatened preterm labor. Based on participants comments,

pregnancy complications had some influence on the perception of pregnancy risk;
depending on the type of complication, its impact on the woman's life, and the degree to
which the woman felt that complication had been controlled. For instance, the woman
with threatened preterm labor who had to quit work expressed a high risk perception. On
the other hand, the other three women, who described their gestational diabetes as a wellcontrolled situation, had low to moderate perception of risk scores. The following
statement was made by one of participants who had a moderate perceived risk score:
"Ive developed gestational diabetes in the end but that's probably due to the fact
that I already had polycystic ovary syndrome, so there was already insulin
resistance . . . there was nauseous initially but no vomiting, um a lot of weight
gain, but again that's the insulin resistance, so its been an easy pregnancy, I
suppose." Participant 11
Women with pregnancy complications often had higher pregnancy-related anxiety
scores. One of the participants with gestational diabetes expressed concerns regarding
having a larger baby than average and also long-term consequences of diabetes:
"The first week [after diagnosis] I was very very sad, I was very sad because I, I
was concerned, you know, having a big baby and, and he has any complication
[in] the pregnancy, um I was very sad for him that I may be passing this gene."
Participant 12
Gestational age. Most participants pointed out that they felt more relaxed about
risk and related problems as their pregnancy progressed. The participants described
pregnancy as having several milestones, and passing each phase seemed to increase their
confidence to have a healthy pregnancy:
141
"As time went on, it got a little bit easier to feel like I wasnt at as much risk in
terms of the pregnancy." Participant 7
"As I get closer [to delivery] and I havent had any problems Im getting more
and more confident and I feel a little bit better." Participant 1
Most women's explanations reflected that their perception of risk was consistent
with the actual probability of risk according to gestational age. They expressed concerns
in every phase of pregnancy starting with miscarriage and genetic risk and leading to
third trimester risks such as preeclampsia. Toward the end of pregnancy, the meaning of
an older age as a risk factor for women with uncomplicated pregnancies remained simply
a number. Some women used phrases such as "it was just that number and that's it!"
Perceived control. Participants comments reflected that most of them had a good
sense of internal control, both over their life situations and their health. Considering the
pregnancy-related anxiety and risk perception scores of participants and their
explanations, it is apparent that high perceived control may be related to a lower
perceived risk. The following quote was expressed by a 39 year-old participant who had
high perceived control and low perception of risk scores:
"I just [know] the way my body responds to things . . . I understand my body, Im
very in tune with how my body works and I can always tell when somethings not
right." Participant 1
Conversely, low perceived control was often observed with high perceived risk,
although sometimes religious beliefs changed the equation. The following statement was
made by a 44 year-old participant who had both low perceived control and low perceived
risk scores:
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"Both of us felt strongly that um you know we believe strongly in God and that he
was in control." Participant 7
Poor fertility history. A number of participants mentioned that they lost a sense of
control over their bodies and health to a great extent after enduring infertility experiences.
Based on our participants explanations, it was noted that a history of infertility or
miscarriage contributed to loss of perceived control and resulted in increased risk
perception in pregnancy. The impact of previous fertility issues on the current pregnancy
was expressed by words such as worry, stress, and fear. A 37 year-old woman with a high
risk perception score and a history of infertility commented:
"I planned to get pregnant . . . and I wasnt able to, like the first thing that came
to my mind, Im not a life giver, its not because you wanted to get pregnant at
this month youll get pregnant, I am not in control. If Im not given that then I
cant do, its beyond my powers." Participant 15
The following quote was expressed by a 37 year-old woman with a previous
miscarriage who had a high perception of risk:
"I wasnt at [risk] first, but then after I lost the first baby, I thought well maybe
this is because Im old . . . I was stressed, I didnt really deal with it." Participant
4
A 44 year-old participant believed that infertility treatments had a negative impact
on her physical health. This belief was also tracked in other participants' explanations
who had also dealt with infertility experiences:
"I think what plays into how I perceive my pregnancy is, is not just my age, its
the journey I took to get here, it was because it took four years to get here . . . and
it was a hard four years. My body wasnt [at risk], I wasnt, when we first started
trying I was extremely healthy and in shape and, and felt ready, and then as I went
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through all the fertility procedures my health, it affected my health . . . and I

didnt feel myself, I didnt feel as strong as I was, so coming into a pregnancy
now where I was coming off of all that fertility stuff, it made me feel like I might
be at a higher risk." Participant 7
Anxiety. Although most participants in this study expressed some degree of
concern for the health and well-being of their babies, only a few women were actually
very anxious about this matter. Nevertheless, we found that these women often did not
use "anxiety" as a term to describe their anxious feelings. For instance, the following
quote comes from a 39 year-old participant who had a high anxiety score:
"There still is a little bit in the back of my mind, once the baby is born . . . is the
baby going to, is everything going to be okay with the baby and through delivery
and through labour? So there is a little bit, not anxiety, I wouldnt say anxiety, but
a little bit of concern." Participant 5
"Being emotional" was another term that a 35 year-old participant with high
anxiety and moderate perception of risk scores used to express her feelings:
"Im a little bit emotional, I think that's my biggest, been my biggest struggle
throughout the entire pregnancy is my emotional state. First with being so worried
and then hormones, I wasnt, I was depressed, and now Im having trouble
sleeping, which is causing a lot of frustration, and Im really uncomfortable."
Participant 2
According to participants' explanations, waiting for screening results, bed rest and
limiting physical activities due to pregnancy complications (e.g., morning sickness)
contributed to their risk perception. One participant with high perceived risk and high
anxiety scores who experienced morning sickness in early pregnancy explained:
"I didnt feel very good for many months, so I couldnt eat, I was barfing a lot, so
that probably added to my stress being home all day cause I couldnt work and
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not being able to eat, so that always, you know, increases your stress, and it
lowers your resistance too." Participant 4
Feeling that this pregnancy might be their last chance to have a biological child
might increase anxiety for these women and add to the dilemma. A 40 year-old
participant with complicated pregnancy who had high perception of risk and low
perceived control scores explained:
"High risk mostly is, or my perception of high risk is if something happened to
myself or my child, this may be my only chance to be pregnant and deliver a
child." Participant 6
Health care providers opinion. Health care providers perspectives about risk
and their reaction to, and interpretation of, risk had a considerable influence on the
women's understandings and assessments of their own risk. Participants' explanations
revealed that health care providers opinions, as experts in risk assessment, were very
valuable and relied upon by women. Although care providers do not usually disclose their
personal opinion, women may grasp this by observing care providers reactions and body
language. Women may include this information in determination of their risk levels,
especially if there is an uncertainty associated with the level of vulnerability. Taking into
consideration that several participants in this study did not have major discussions with
their health care providers about risks associated with AMA, it might give these women a
degree of confidence that there are no serious concerns. A 37 year-old participant with
low perception of risk and low anxiety scores stated:
"My family doctor called me to tell me that the baby has to have an ultrasound
after a month, but the doctor here doesnt seem, doesnt seem bothered by it, so I
dont think its got anything to do with the baby having, like, mental or physical
145
disability of any sorts; I think its just more, just something for them to look at." P
13
Risk alleviation strategies. Several strategies were reported by the participants to
alleviate and/or cope with their pregnancy risk. This process, for our participants,
involved educating themselves and engaging in a healthy lifestyle, reassuring
surveillance tests, overlooking the risk, religious beliefs, and balancing their risk by
emphasis on positive social aspects of AMA.
Educating themselves and engaging in a healthy lifestyle. Some participants
spoke of gathering information to know "what actual risks are and to be prepared."
Participants with low perceived risk scores and high or moderate perceived control scores
often reported that they had prepared themselves for pregnancy complications to "not be
surprised by risk." A 39 year-old participant with low perception of risk and high
perceived control scores stated:
"Im healthy, Im fine and Ive prepared myself, Ive educated myself . . . Yeah I
think it would be less stressful [if I were younger ] because I wouldnt have to
educate myself so much. I would have educated myself but I feel like I had to do
that extra little bit of research because I was in that high risk group, I was in that
you know 'more chance of something going wrong group.' So I educated myself a
little bit more." Participant 1
The participants were also focused on improving their lifestyle and engaging in
healthy behaviors. Healthy behavior and lifestyle were perceived as protective factors
against pregnancy risk.
Reassuring surveillance tests. Because most women were aware of the
association between genetic problems with AMA, receiving reassuring screening tests
146
results were reported as a relieving factor. A desire to seek actual and tangible signs of
baby's health to confirm that "it's a normal baby" was evident in the interviews:
"When I had one [ultrasound], and I saw that everything was okay, he was
developing okay, then I had the tests done, the blood test, I said okay, hes a
normal baby, so I stopped worrying." Participant 12
Some participants chose to take screening tests as part of their preparation to deal
with anticipatory issues and to decrease concerns related to fetal health. Undertaking
screening tests was a result of women's tendency to plan and be prepared and was
reported by several participants:
"We just wanted to do it for our own sake of mind, just for our own peace of
mind. I like planning my life, I like preparing for things, I like being educated and
ready for whatever, I wanted to know, if Im going to have a baby with Downs
syndrome. I want to know so that Im prepared, so that I can educate myself as to
what this babys needs are going to be. At least if youve prepared a little bit, you
might be able to handle it differently." Participant 1
Overlooking (ignoring) the risk. Some participants reported an inclination to
disregard the risk to avoid excessive stress and anxiety. In fact, overlooking the risk was
a very common approach among our participants, even among those who educated
themselves and were engaged in a healthy lifestyle:
"Ive been trying not to let research or other reports or what I read influence my
way of thinking . . . I know they exist, Im not saying that ignorance is bliss, but I
just dont focus on it." Participant 1
The following quote describes this approach by a 44 year-old participant who had
low perceived risk and low perceived control scores. She and her partner decided not to
undergo genetic screening tests.
147
"I did a fair bit of reading but then at the same time I also got to a point where
when I was pregnant I put the reading aside because. . . I just found it was starting
to increase a lot of anxiety about all the things that could go wrong or be wrong. .
. considering my age and considering the risks . . . I started having too much fear
about everything that could go wrong, and I didnt want to go into the constant
anxiety about it . . . we didnt want to be ignorant about it, like we, we did all our
research and awareness, uh like I said, we made sure we were eating healthy, but I
mean other than that ,theres [not much] else you can do, you cant, its out of our
control . . . once we talked through some of those anxieties, we took all the
necessary precautions to make sure that it was a healthy pregnancy and other than
that, the rest is out of our hands." Participant 7
Religious beliefs and hope. Religious beliefs and hope were other alleviating
factors described by some participants. They reported that these beliefs helped them to
stay calm and feel that they were not alone. A woman with a high perceived risk score
commented that:
"I think my, my faith in, in God somehow kind of like helps me go to sleep at
night, you know like I mean I pray..." Participant 15
Another participant with high perceived risk and low perceived control scores
expressed that her religious beliefs were important in how she dealt with the risk. This
participant also decided not to undergo genetic screening tests.
"I think that's a matter of our faith and our belief, um that you know, I mean, if
God created this child, if God chooses to take this child, then that's his decision to
make and not ours, so were not playing God by taking that childs life."
Participant 9
Emphasis on positive social aspects of AMA. A trend to emphasize positive
aspects of pregnancy at AMA was tracked in the interviews. From some of our
participants' perspectives, an older age improved their readiness to be a parent by having
an established relationship and career, being mature both emotionally and personally, and
148
developing problem solving skills through having various life experiences. Our
participants weighed these advantages against biomedical risk in their risk assessment.
The following quotes are from participants who had moderate perceived risk scores:
"Theres a risk, and its high risk. But if, if you ask me if I would prefer being
pregnant [at this age] or at twenty-four, I would say right now. I was not
emotionally prepared at that time to have a baby, I dont think . . . I was not
strong, a strong woman that Im right now, I have much more to offer my son
[now] than if I was young." Participant 12
"I do think that I would probably have more energy ten years ago, but at the same
time, emotionally, I wasnt ready. I was immature and irresponsible still ten years
ago. Now Im more mature and more emotionally ready for it." Participant 2
Communication with health professionals. Communication about risk from
health professionals mostly focused on recommending screening tests. Participants'
explanations reflected that, in the majority of cases, there was not a discussion about
other age-related risks. On the other hand, most women preferred not to initiate risk
communication. They reported receiving extra information about risk associated with
AMA as pointless and most likely stressful, because they believed they would not be able
to change their risk factor, age:
"There was no real discussion or anything like that, that came into play. It was
just more focused on your health and taking care of yourself and eating well and
exercising." Participant 3
"I was aware, and I knew, and he was extremely open to questions; hes very
approachable, so I knew that if I had concerns, or if I had questions about it, I
could talk to him, but I didnt feel the need." Participant 7
Some participants found risk discussions with their health care provider stressful.
In reviewing participants statements and their anxiety scores, it was apparent that
149
anxiety may influence the way a pregnant woman interprets risk information and the
contents of risk communication. The following quote was offered by a 37 year-old
participant who had both high anxiety and high perceived risk scores:
"I was scared after talking to the genetic counsellor for sure. The nurse with my
GP always mentioned it, every visit, she would say, well you do have high risks
because of your age. Every week. I know my age; you dont have to keep driving
the point home . . . Cause I had a lot of fear actually, when I was meeting with the
genetic counsellor and with the nurse at my family doctors office. I was strongly
encouraged to go for genetic counselling because of my advanced age. The
terminology that the doctors and nurses and everybody [used], advanced age,
advanced age, Im not eighty, but okay, I suppose Im over 35 . . . And they
would show me charts, like, oh this is how your risk increases once youve
reached 35, and you kind of feel a fear that you know somethings going to go
wrong cause youre over 35. And the genetic counsellor drew all these charts and
showed me my risk. But after the genetic counselling and the results came back
from all the tests, it turns out I have an extremely low risk, so Im not sure why
they try to scare you like that." Participant 4
Discussion
Women of AMA delayed their childbearing for a variety of reasons. The most
common factors for late childbearing among our participants were lifestyle choices and
late marriage, followed by fertility issues. Although only a few participants identified
fertility problems as their primary reason for delayed pregnancy, several women who
delayed their childbearing intentionally also had fertility issues prior to becoming
pregnant. Some of these findings are consistent with those of previous Canadian studies
(Tough et al., 2007; Benzies et al., 2006). Tough et al. found that timing of childbearing
among Canadian men and women was influenced by not finding the right partner, not
having financial stability, and lack of awareness about the risks associated with AMA
(Tough et al., 2007).
150
One of the objectives of this study was to determine the definition of pregnancy
risk from perspectives of women of AMA. Based on the findings, the definition of risk
for women of AMA, similar to that of pregnant women of other ages (Heaman, Gupton,
& Gregory, 2004), had a broader scope than medical risks or physical challenges and
encompassed various social and personal characteristics. As such, the definition of
pregnancy risk for our participants also included consideration of the extent of their
support networks, ability to control situations, and whether they had an established
relationship, a planned pregnancy, a flexible job or healthy lifestyle and behavior. These
findings support the position that approaches to understanding perception of health risks
should be comprehensive and broad (Atkinson & Farias, 1995) and suggest that an
inclusive risk communication might benefit from including women's criteria of risk
definition.
The findings revealed that nulliparous women of AMA were not a homogenous
group in their pregnancy risk assessment. Indeed, the perception of pregnancy risk varied
considerably among these women. Several issues were identified in the interviews that
influenced the perception of pregnancy risk including cognitive heuristics (risk
availability and similarity), predictability of risk, physiological aspects (health status,
pregnancy complications, gestational age, and personal reproductive history),
psychological elements (perceived control and anxiety), and health care providers
opinion.
In the current study, as is the case in previous research (Carolan, 2004),
pregnancy at AMA was frequently acknowledged to be high risk due to an increased risk
151
of genetic abnormalities. However, other medical risks associated with AMA received
less consideration. Carolan & Nelson (2007) reported that their Australian participants
realized they were at higher risk only after becoming pregnant and through
communication with their health care providers. However, our participants described
risks associated with AMA as "common knowledge in society," which is consistent with
another Canadian study (Saxell, 2003). Although our participants were mostly aware of
risks associated with AMA, the majority of them did not consider themselves to be high
risk. This apparent disconnect can be explained by the fact that general risk and personal
risk differ, and people typically tend to rate their personal risk lower in comparison to
general risk (Sjoberg, 2000). For instance, the results of a study on perceived risk of
osteoporosis illustrated that two thirds of women aged 40 to 86 years perceived their risk
of developing this condition as lower than other women at their ages (Gerend, Erchull,
Aiken, & Maner, 2006). The underestimation of personal risk is referred as an
"unrealistic optimism" (Weinstein, 1980), and might be related to one's perceived control
(Sjoberg, 2000).
The majority of women in our study were well-educated and perceived
themselves to be prepared to accept child raising responsibilities. They frequently spoke
of having a good sense of control over their bodies and life circumstances. A link has
been identified between perceived control and risk perception in previous research
(Audrain et al., 1997). In our study, those participants who believed they had good
control over their physical health also perceived a lower risk for their pregnancy. We also
noticed that a woman's perceived control over health may be important in engaging in
152
various actions to maintain the balance between risk and health. In this regard, a
relationship between perceived control and health service utilization has been
documented in previous research (Chipperfield & Greenslade, 1999).
Women reported that having a poor reproductive history contributed to increased
risk perception. Failure to become pregnant in initial attempts or previous loss of
pregnancy may have threatened these women's beliefs in their abilities to manage their
own health. This statement is supported by Campbell, Dunkel-Schetter, and Peplau
(1991) who reported that infertility may be perceived as a threat to an infertile person's
life's goals, contributing to a low perception of control. These findings imply that poor
reproductive history may be a significant factor in increasing perception of pregnancy
risk. Further research is needed to substantiate this result. In addition, results of a recent
U.S. study demonstrated that previous prenatal loss was a predictor of depression and
anxiety in a subsequent pregnancy, independent of other psychosocial and obstetric
factors (Blackmore et al., 2011). This highlights a need to address the concerns of women
who have had a poor pregnancy outcome in the past to minimize their stress and anxiety
in following pregnancies.
Based on our results, pregnancy complications may alter risk perception. This
effect might vary depending on the type of complication, its manageability, and its
consequences for a woman's daily life. Alternatively, good physical health and healthy
behaviours and lifestyles were reported as risk alleviating factors. This finding echoes
that of Gerend et al. (2004) who reported that personal health actions from the women's
perspectives can reduce their risk. Carolan (2004) reported that their participants were
153
very keen to know "what they were facing" by seeking more information; our participants
rather were focused on risk reducing behaviour and, in fact, their information seeking
patterns were mostly based on improving health rather than merely investigating potential
risks. In our study, the "information quests"(Carolan, 2004), in which women sought out
a wide range of information, were commonly reported in the preconception period. After
becoming pregnant, however, women mostly limited seeking information to avoid
increased anxiety.
Women experienced a decrease in their perceived risk with advancing gestational
weeks. This could be due to women becoming adapted to the state of being pregnant or
becoming more positive about the outcome of their pregnancy as it advanced. An
uncomplicated pregnancy and favourable screening results may contribute to decreased
perception of risk over the course of pregnancy as well. A decline in worry about the
babys health from early pregnancy to the postpartum period has been reported in
previous research (Ohman, Grunewald, & Waldenstrom, 2009).
Similar to other studies (Carolan, 2004; Carolan, 2005; Saxell, 2003; Yuan et al.,
2000) , our participants reported concerns about fetal health and well-being, particularly
genetic abnormalities. While some participants decided not to undergo genetic screening
tests, most women in our study chose to know if their fetus had any health problem by
doing ultrasound scans and genetic screening tests. Most participants found the screening
tests reassuring about their baby's health. This tendency has been described as "hoping
for reassurance" in previous research (Carolan & Nelson, 2007). Although receiving
comforting screening results was recognized as a relief factor by most women, as Baillie,
154
Smith, Hewison, and Mason (2000) have noted, for a number of women, feelings of
anxiety remained throughout the pregnancy.
There were notable variations among participants in expressing and wording their
feelings of anxiety. Anxiety was described vaguely by our participants; in fact, it was
sometimes hard for women to identify and name these feelings. This suggests that some
women with high levels of anxiety might use different terms to communicate their
feelings. This attitude makes the identification of anxiety in these women a challenge.
There is evidence that antenatal anxiety is very prevalent and can increase the odds of
postnatal depression (Heron, O'Connor, Evans, Golding, & Glover, 2004). Therefore,
identification of women with anxiety is crucial so that effective interventions can be
targeted appropriately. Although creating a relaxed environment and establishing a non
judgmental communication pattern in prenatal care visits may be beneficial for anxious
women in disclosing their actual feelings about potential risks, there is growing evidence
suggesting that prenatal screening should include both depression and anxiety (Furber,
Garrod, Maloney, Lovell, & McGowan, 2009; Matthey, 2004; Swalm, Brooks, Doherty,
Nathan, & Jacques, 2010). We support this perspective and believe that using a reliable
screening tool to assess anxiety in pregnant woman may be useful to identify women who
would benefit from strategies to reduce anxiety. A recent study in Australia demonstrated
that the anxiety subscale of the Edinburgh Postnatal Depression Scale might be a reliable
measure to screen antenatal anxiety (Swalm et al., 2010).
Women described being hopeful despite having higher perceived risk and anxiety
levels. It appeared that the struggle between hoping for a desirable pregnancy outcome
155
and anxiety about potential risks can lead to a state of uncertainty. Sun, Hsia, and Sheu
(2008), in a qualitative study of women of AMA, reported similar ambivalent and
conflicted feelings, characterized by apparent pleasure and hidden fear. This attitude has
been called a "jubilant apprehension" by Yuan et al. (2000), which describes feelings of
great joy and satisfaction, but also worry about childbirth outcomes.
Consistent with research in other fields, our results demonstrated that pregnant
women's personal or vicarious experience with a risk may increase the psychological
availability of the risk and consequently, its perceived probability (Gerend et al., 2004;
Weinstein, 1987). In fact, being familiar with risk, through researching information or
indirect experiences, may contribute to womens risk perception. We also noticed that
predicting risk and expecting it influenced participants' risk perception. A risk that is
expected might be perceived as less risky than an unexpected risk. In the literature, the
perceived characteristics of the risk such as prevalence, controllability, preventability,
and seriousness along with the availability and representativeness heuristics are important
elements in constructing risk perception (Weinstein, 1980; Weinstein, 1982). A
qualitative study by Patterson (1993) demonstrated that an unexpected shift in health
situation or pregnancy outcomes was identified as a high risk condition by pregnant
women, while the expected changes were considered as no risk. One explanation is that
anticipating the risk and being prepared to deal with it may increase a woman's perceived
control and, consequently, decrease her risk perception.
Comparison was a common risk appraisal strategy among our participants.
However, their evaluations were distinct from those of health professionals in that
156
women often compared their risk to a known population such as their family members,
friends, or stories from real people, which is completely different from risks determined
by epidemiological studies at a population level. This discrepancy can be explained by
the fact that pregnant womens understanding of risk is mostly based on their personal
data from real cases of their life experiences (Tversky & Kahneman, 1974; Heaman et al.,
2004).
While discrepancies between pregnant womens and health care providers
appraisals of risk were documented in previous research (Corbin, 1987; Gray, 2006;
Heaman, Beaton, Gupton, & Sloan, 1992), what appears to be less emphasized is the
influence of health care providers' attitudes towards the risk on pregnant women's risk
perception. Several women in this study reported no risk communication with their health
care providers that focused on age as a risk factor. This has been interpreted by most
participants as there not being any serious concern and may imply that pregnant women
trust their health care providers opinion. In this regard, Heaman et al. (2004) reported
that women with or without pregnancy complications rely on their health care providers
in assessing risk status. A few participants reported negative risk communication with
their health care providers. These participants also reported higher anxiety and concern
about the well-being of their fetus and pregnancy outcomes. Whether risk communication
patterns can affect the anxiety or whether anxiety itself will alter women's interpretation
of risk communication is not clear and needs further research.
157
Implications
In the experience of our participants, any emphasis on mothers good health by
their care providers was described as reassuring. Conversely, negative messages about
age by purely emphasizing pregnancy risks were described as very destructive and
challenging, particularly for women with high levels of anxiety. Although offering risk
information is part of risk communication process, the womans mental health should be
considered to avoid unnecessary stress.
Our results suggest that real stories can alter risk perception. This finding has
important implications for practice and public health education. Risk must be tangible for
women in order to be recognized and potentially addressed. Interventions to decrease
unhealthy behaviours should target this concept to alter risk perception. As Williamson &
Weyman (2005) suggested when individuals have less experience or knowledge of risks,
the media (e.g., documentary movies) can play an important role in increasing their
understanding of those risks.
The following advantages informed our interpretations of the results. First, the
data were analyzed based on the literature and previously known factors in risk
perception. Furthermore, the addition of quantitative measures (i.e., perception of
pregnancy risk, anxiety, and perceived control) enabled us to achieve a better
understanding of the qualitative data. Another major strength was the contemporaneous
exploration of risk perception during the pregnancy.
158
It is important to consider the following limitations when interpreting and

applying the results. First, our sample was representative of a middle class and married
population; these characteristics may limit the generalization of the results. This is a
small study based on 15 interviews in one geographical area in Canada; therefore, the
results may not be generalizable to other populations. Finally, we recognize that selection
bias may have been introduced as those who volunteered to participate might have been
different than those who did not.
Conclusion
Pregnancy at AMA within a healthy context and in the absence of other risk
factors was perceived as a low risk pregnancy by our participants. Their understanding of
the age factor in these healthy pregnancies remained only as a "number" or "common
knowledge in society." However, in the presence of risk factors such as pregnancy
complications, limited physical activity, unfavourable screening tests results, previous
poor reproductive history, and anxiety, the risk associated with age was highlighted, and
women were inclined to recognize their age as a risk factor for their pregnancy. The
findings of our study verified results of previous research (Atkinson & Farias, 1995;
Heaman et al., 2004) in that pregnant womens definition of risk goes beyond biomedical
considerations.
This study contributes to the AMA literature by identifying several factors that
influence the perception of pregnancy risk including cognitive heuristics (risk availability
and similarity), predictability of risk, physiological aspects (health status, pregnancy
complications, gestational age, and personal reproductive history), psychological
159
elements (perceived control and anxiety), and health care providers opinion. These
influential factors may help individuals who care for pregnant women of AMA to gain
insight into their perception of pregnancy risk and improve the quality and efficiency of
prenatal care.
160
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Table 10. Classifications of the PPRQ, Pregnancy-related Anxiety, and Perceived Control
(internal) Scores in Tertiles Using Data for Women of AMA from the Advanced
Maternal Age and Risk Perception Study (n=54)
Instrument
Range of
Low
Middle
High
Scores
Tertile
Tertile
Tertile
3.56-69.44
<18.68
18.68-35.33
>35.33
1.10-3.20
<1.71
1.71-2.00
>2.00
Perceived Control (internal)
16.00-36.00
<24.01
24.01-28.00
>28.00
Perception of Pregnancy Risk

Questionnaire
Table 11. Frequency of Participants in each Tertile (N=15)
Instrument
Low
Moderate
High
Perception of Pregnancy Risk Questionnaire
Perceived Control (internal)
169
170
Table 12. Demographic Characteristics of Participants (N=15)

Characteristic
Marital Status
Married
14
Living common-law
Race/ethnicity
White
11
Other (non-White or Aboriginal)
Education
Incomplete high school
Complete high school or less than four years university degree
Four years university degree or higher
13
Family Income
$0-$39,999
$40,000-$99,999
$100,000 and above
Working at a Paid Job before Pregnancy

Yes
15
No
Working at a Paid Job during Pregnancy

Yes
14
No
Table 13. Obstetrics Characteristics of Participants (N=15)

Characteristic
Wanted to Become Pregnant

Sooner
Now
Not at all
Number of Previous Miscarriages

None
10
One
Two
Three or more
Use of Fertility Medications to Become Pregnant

Yes
No
12
171
172
Chapter Eight: Discussion

The rate of pregnancy at age 35 years or older has increased in recent decades.
Yet, a gap remains in the understanding of perception of pregnancy risk of women of
AMA. This mixed methods study was designed to address this gap by testing a new
conceptual framework guided by the Psychometric Model of risk perception and a review
of the literature. This chapter first describes how the two components of the study were
integrated, followed by a general discussion to link the manuscripts and outline the
contributions of this study to the field as a whole. Next, the strengths and limitations of
the study are addressed. Finally, recommendations for future research and implications
for practice are discussed.
Integration of Findings
As Bryman (2007) stated, the end product of a mixed methods project should be
"more than the sum of the individual quantitative and qualitative parts" (p.8). In fact, the
two components of this type of research must be integrated, linked, and connected to each
other (Bryman, 2007). The integration, as Creswell and Tashakkori (2007) declared, may
be in the form of "comparing, contrasting, building on, or embedding one type of
conclusion with the other" (p.108).
This concurrent mixed methods study integrated analysis of quantitative data
collected by using several instruments with qualitative data from semi-structured
interviews. Using a mixed methods approach, the student compared or integrated the
factors contributing to perception of pregnancy risk (obtained from descriptive data and
173
multiple regression analyses) with the women's perspectives (obtained from 15

qualitative interviews). In the current study, the integration of the two components mainly
occurred at the interpretation level. However, in data analysis, the two components also
influenced each other by incorporating a few elements of the other component.
Integrations of findings at the data analysis level. As Sandelowski (2000a)
stated, in combining of data, either qualitative and quantitative data sets can be linked
together while each data set remains analytically separate from the other (linking), or
these data can be taken together to create a single data set (transforming). In the current
study, quantitative and qualitative data sets were linked together. The following section
explains how the two components influenced each other at this level.
How did qualitative data influence quantitative analysis? The original
conceptual framework of the study, which was based on the Psychometric Model of risk
perception and findings from the literature review, consisted of seven concepts. Later,
through in-depth interviews of women in the qualitative component, gestational age was
identified as an important factor in perception of pregnancy risk. Therefore, this variable
was incorporated into the conceptual framework as the eighth variable and was included
in the quantitative analyses.
How did quantitative data influence qualitative analysis? Selective data
measured in the quantitative component were linked to qualitative data to enrich
background information about participants. These measures included perception of
pregnancy risk (Heaman & Gupton, 2009), perceived control (internal) (Wallston et al.,
1978), and pregnancy-related anxiety (Rini et al., 1999) scores. Through this step,
174
quantitative data were linked with the qualitative data set to assist in analysis of the
interviews. This approach enhanced the understanding of qualitative data and
consequently improved the quality of the interpretation of the findings. For example,
none of the qualitative participants communicated directly about their anxious feelings
associated with increased pregnancy risk. However, quantitative scores identified three
participants with high anxiety levels. These women used words other than anxiety to
describe their feelings, such as "being emotional" or "having a little bit of concern". With
combination of these two data sets, it was revealed that some women of AMA may not
communicate their anxious feelings directly, and health care providers should be aware of
the use of these alternate wordings by pregnant women. Another example is that the
student grouped qualitative participants based on their perception of pregnancy risk
scores into three groups: participants with low, moderate, or high perception of
pregnancy risk. Being aware of participants perception of pregnancy risk scores
impacted the entire process of qualitative data analysis and enhanced the explication of
data; in fact, tracking patterns of participants understandings of risk was made possible
by this approach. It was also helpful to recognize and situate factors influencing pregnant
womens risk perception more accurately. Due to the complex nature of risk perception,
it is apparent that embedding quantitative information into the qualitative data set
advanced the study of this phenomenon.
Integrations of findings at data interpretation level. The results of the two
components were integrated at the discussion level. The following section illustrates how
the findings of the two studies were put together to create a more comprehensive
175
conclusion than relying solely on those of the separate components. Mainly, the findings
of the two components were combined to modify the conceptual framework. In addition,
an inclusive understanding of perception of pregnancy risk at AMA was developed by
merging the findings of the two components.
Conceptual Framework
Quantitative results. Based on findings of the quantitative component of the
study, of the eight proposed factors in the conceptual framework, four factors were
significant predictors of perception of pregnancy risk in the first regression model,
including pregnancy-related anxiety, maternal age, medical risk, and gestational age. In
the interaction model, perceived control (internal) also approached significance (p=.054).
Therefore, five of the factors in the conceptual framework were supported in this
component.
In addition, results demonstrated an interaction between pregnancy-related
anxiety score and maternal age. It was found that the simultaneous influence of these
variables on the risk perception score was greater than their additive values. This implied
that the variances in the risk perception score due to anxiety level depend on maternal age
and that maternal age works in a synergistic manner with anxiety score to increase the
perceived risk score.
Qualitative results. In the qualitative component, ten factors were discussed by
women as influencing their perception of pregnancy risk, including: poor fertility history,
health status, pregnancy complications, gestational age, maternal age, anxiety, cognitive
176
heuristics (availability and similarity of the risk), predictability of the risk, perceived
control, and health care providers opinion. Of these factors, five factors represented the
significant factors of the quantitative component (i.e., anxiety, medical risk, maternal age,
perceived control, and gestational age).
Discrepancies between the two components. Qualitative findings supported two
factors in the conceptual framework that were not supported by quantitative findings
including cognitive heuristics (availability and similarity) and health status. There is
inconsistency in the literature regarding the role of health status in risk perception. For
instance, Chuang et al. in 2008 reported that in their study, general health measured by
the SF-12v2 Health Survey was not a significant predictor of increased risk perception of
adverse pregnancy outcomes. Alternatively, the findings of a qualitative study by
Heaman et al. (2004) demonstrated that women considered their own general health in
their pregnancy risk appraisal.
Qualitative results demonstrated that being aware of risk, through researching
information or individual and non individual experiences (e.g., through a friends illness
or the media), may contribute to pregnant womens risk perception. These findings are
consistent with literature on risk perception in that personal or vicarious experience with
a risk may increase the psychological availability of the risk and, consequently, its
perceived probability (Gerend et al., 2004; Weinstein, 1987). Nevertheless, none of the
cognitive heuristic variables were supported in the quantitative component.
New factors emerging from qualitative data. Three new factors were identified
in the qualitative data. Predictability of risk was one of these new factors addressing a
177
risk attribute. Two other factors were more specific to the health context and included
poor fertility history and health care providers opinion.
Product of Compared or Integrated Findings
Based on compared or integrated findings, a new conceptual framework for
perception of pregnancy risk was proposed (Figure 2). As illustrated in Figure 2, there are
ten factors that contribute to perception of pregnancy risk at AMA including cognitive
heuristics (availability and similarity of the risk), predictability of the risk, health status,
medical risk, gestational age, maternal age, perceived control, poor fertility history,
anxiety, and health care providers opinion. Based on findings of this mixed methods
research, five factors of this conceptual framework, including pregnancy-related anxiety,
medical risk, perceived control, maternal age, and gestational age, explain 47-49% of the
variance in perception of pregnancy risk. Future research is warranted to examine the
contribution of the remaining five factors, identified through qualitative analysis, to
perception of pregnancy risk. The following section expands discussion of common
findings of the two components.
178
Maternal Age
Health Care
Providers
Opinion
Pregnancyrelated
Anxiety
Perceived
Control
(Internal)
Predictability
of the Risk
Risk
Perception
Poor Fertility
History
Medical Risk
Gestational
Age
Cognitive
Heuristics
Health Status
Figure 2. Modified conceptual framework

All variables presented in this framework were supported by the qualitative findings;
however, only variables in the shaded area were supported by the quantitative findings (in
the model with interactions between maternal age and pregnancy-related anxiety)
179
Current knowledge suggests that emotions are important factors in risk perception
and stronger emotions may lead to a higher level of perceived risk (Xie, Wang, Zhang,
Li, & Yu, 2011). Quantitative findings determined pregnancy-related anxiety as the
strongest predictor of perception of pregnancy risk, supporting its role as the dread factor
in the conceptual framework. Similarly, the majority of participants in the qualitative
component who were concerned or anxious about their pregnancy also perceived higher
risk for their pregnancy and fetuses.
In both components, objective medical risk was a significant predictor of risk
perception, which is consistent with previous research (Gupton et al., 2001; Headley &
Harrigan, 2009). Although women of AMA had higher medical risk scores than younger
women, maternal age remained as a significant predictor of perception of pregnancy risk
even after controlling for medical risk. This finding suggests that the association of
perception of risk and maternal age is independent of the effect of medical risk, and older
maternal age contributes to increased perception of pregnancy risk. However, results of
the qualitative component revealed that the perception of pregnancy risk varied
considerably among participants, indicating that nulliparous women of AMA are not
homogeneous in their assessment of pregnancy risk.
Findings of both components supported the idea that perception of pregnancy risk
altered over the course of the pregnancy, with women having higher perceptions of risk at
earlier gestational ages. This could be due to women becoming adapted to the state of
being pregnant or becoming more positive about the outcome of their pregnancy as it
advanced. Although there is no previous study to examine changes in risk perception over
180
the course of pregnancy, results of a study by Buist, Gotman, and Yonkers (2011)
demonstrated that in pregnancy, anxiety symptoms were highest in the first trimester and
decreased over pregnancy. Likewise, another study showed that concern about the babys
health abated continuously from the beginning of pregnancy to the postpartum period
(Ohman, Grunewald, & Waldenstrom, 2009).
In the literature, low levels of perceived control over risk were reported to be
related to high levels of perceived risk (Audrain et al., 1997). In the quantitative
component, one of the perceived control subscales (internal) remained in the final model
and approached statistical significance (p=.054); with a larger sample size, it may have
been significant. Similarly, those participants in the qualitative component who believed
they had good control over their physical health also perceived a lower risk for their
pregnancy.
Contribution to the Field
The findings of this study extended our understandings about pregnancy at AMA,
and its results may serve as the foundation to enhance the quality of care for this growing
cohort. Although this research enhanced the current knowledge about perception of
pregnancy risk at age 35 years or older, its most significant contribution was to develop a
conceptual framework to study risk perception in pregnancy. The findings from the two
components were utilized to modify and redesign the initial conceptual framework in
order to construct a new model (Figure 2). The regression models of the quantitative
component accounted for about half of the variance in risk perception. This level is high,
considering that the predictive power of models in an earlier study varied from 19% to
181
31% (Gupton et al, 2001). In that study, state anxiety and medical risk were significant
predictors of perception of pregnancy risk (Gupton et al., 2001). This suggests that
including perceived control, maternal age and gestational age significantly improved the
predictive power of models in the current study. Taking into consideration that theories of
risk perception only account for a small proportion of variations in risk perception
(Sjoberg, 1996), these findings are noteworthy.
The current study also verified that previously known factors in the risk
perception field, such as perceived control and medical risk, may be applicable in the
state of pregnancy. This study added to the literature on perception of pregnancy risk by
identifying a new predictor (i.e., gestational age) and also highlighting the interactive
effects of maternal age and pregnancy-related anxiety in increasing the perception of
pregnancy risk.
Furthermore, the study contributed to the literature on perception of pregnancy
risk by proposing pregnancy-related anxiety as a pregnancy dread factor in risk
perception theories. In 2008, Chuang et al. examined the feeling of dread in pregnancy
using psychosocial stress or lower health status variables and did not find any significant
association between risk perception and these defined dread factors. Another study of
perception of pregnancy risk showed that stress was not a predictor for risk perception
among women with complicated pregnancies, while state anxiety was a significant
predictor (Gupton et al., 2001). In the current study, pregnancy-related anxiety was
determined as the strongest predictor of perception of pregnancy risk. These findings
182
suggest that pregnancy-related anxiety is a more reliable factor than stress to predict
perception of pregnancy risk.
Future Research
Although the results of the current study extended knowledge about perception of
pregnancy risk, it also raised many more questions and indicated new directions for
future research:
1. While this study contributed to the initial development of a conceptual
framework for perception of pregnancy risk, the model requires further refinement and
testing. Research is encouraged to test the relationships proposed in this model.
Specifically, there were three new factors that emerged from the qualitative data,
including predictability of risk, poor fertility history, and health care providers opinion.
Future studies are needed to quantify these factors and determine their contribution to
perception of pregnancy risk.
2. Neither of the cognitive heuristic variables was supported in quantitative study,
while they were identified in qualitative findings. This discrepancy may be attributable to
using a single item measure (developed by the student for this study), which has not been
previously psychometrically evaluated and may not have accurately measured the
concept. Also, availability and similarity may be caused by other experiences that were
not measured in this study. Because these variables emerged from the qualitative data and
the literature on risk perception also supports their contribution, future research should
183
focus on developing a valid and reliable scale to measure cognitive heuristics in relation
to pregnancy risk to determine their role in perception of pregnancy risk.
3. Findings of the current study demonstrated that women of AMA perceived
their risk of having a cesarean section to be significantly higher than did younger women.
Research indicates that women of AMA have higher rates of cesarean section than
younger women (Bayrampour & Heaman, 2010). There is growing evidence signifying
that along with medical indications, psychological factors may also contribute to higher
rates of cesarean section (Wagner, 2000). Findings of a recent study demonstrated that a
womans desire for choosing cesarean section increases considerably as worries about the
delivery and its safety for the fetus increase (Romero, Coulson, & Galvin, 2011). Because
women of AMA are more likely to request a cesarean birth from their health care
providers at any point during their pregnancy, or to have a cesarean birth recommended
by their health care provider before labor (Bayrampour & Heaman, 2011), it is advisable
to investigate whether risk perception influences maternal request for cesarean section.
4. In the current study, pregnancy-related anxiety was the strongest predictor of
risk perception. However, as Xie et al. (2011) stated, it is not apparent whether emotions
such as anxiety cause higher risk perception levels or vice versa. The causal relationship
between anxiety and risk perception may not be fully realized until further research is
conducted.
5. In this study, risk knowledge was not a significant predictor of risk perception
in the quantitative component. However, familiarity with risk appeared as an important
factor in the qualitative analysis. In the literature, familiarity with risk is a broad concept
184
that includes both risk knowledge and personal experiences of risk (Williamson &
Weyman, 2005). These results suggest that integrating the measures of familiarity with
risk into the measure of risk knowledge may better address the "unknown factor" in the
Psychometric Model. In other words, the combination of both familiarity with risk
(through individual and non individual experiences) and risk knowledge may
appropriately represent this concept. Future research is warranted to explore this
proposition.
Strengths and Limitations of the Study
This study had a number of positive features that allowed for a contribution to the
research literature. For instance, the study contained high quality measures, and the
majority of variables were measured using valid and reliable instruments. Another
strength of the study was the exclusive recruitment of nulliparous women to minimize the
effect of previous pregnancy experiences on risk perception. Furthermore, the study was
built upon a conceptual framework based on the literature review and a well-known risk
perception theory. The comprehensiveness of this conceptual framework was supported
by its moderate to high predictive power in the regression models. Employing mixed
methods research was another major strength of the study. The embedding of quantitative
measures into qualitative data was useful in achieving a better understanding of data.
Moreover, because previous research on perception of pregnancy risk was mainly
retrospective, the contemporaneous exploration of risk perception during the pregnancy
was another strength for this study.
185
Despite these strengths, the study also contained a number of limitations that
require consideration when interpreting the results. A convenience sampling method was
employed for collecting data. Due to a non-random method of sample selection, those
who volunteered to participate might have been different than those who did not,
resulting in selection bias. However, the characteristics of the two groups in this study
were comparable to the characteristics of participants in a recent secondary analysis of a
national survey of maternity experiences (Bayrampour & Heaman, 2011). Due to
challenges in recruiting nulliparous women of AMA, the two groups were not equal in
size and some variables might be affected by the larger proportion of the sample between
the ages of 20-29 years. Therefore the smaller sample size for the older group should be
considered in the interpretation of the results. Use of instrument without established
reliability and validity (i.e., Knowledge of Maternal Age-related Risks of Childbearing
Questionnaire and cognitive heuristics questions) was another limitation of this study. In
the current study, the knowledge scale had a Cronbachs coefficient alpha of .60. Finally,
confining the sample to nulliparous women may limit generalization of the results to
multiparous women.
Implications for Practice
It is hoped that the results will increase the understanding of the perception of
pregnancy risk and improve the quality of care for pregnant women, particularly women
of AMA. The current research represents a step forward towards this goal, as the results
have several implications for efforts to improve prenatal care and risk communication.
186
Findings supported that womens risk evaluations are not only based on
information, but also affected by psychological factors and social values (Fischhoff,
Bostrom, & Quadrel, 1993; Tversky & Kahneman, 1974). A woman's perception of
pregnancy risk may be different than her actual medical risk or the care provider's risk
assessment. There are several factors, other than medical risk, that contribute to
perception of pregnancy risk. Health care providers should be aware that a womans
perception of pregnancy risk is highly individualized and could be different from medical
risk assessment; therefore, a discussion about the woman's risk perception should be
integrated into the prenatal care visits. This communication will improve the quality of
care by integrating the woman's perspective in planning her own care.
Proper risk communication is an important element of developing care plans for
women of AMA. It is important that in prenatal visits, health care providers help the
pregnant woman to understand her individual risk based on personal health factors. For
instance, women of AMA in this study perceived a higher risk of cesarean section.
Current knowledge indicates that even at AMA, cesarean section is often not a necessary
intervention (Treacy et al., 2006). Discussing these issues with pregnant women and
explaining any misconceptions will help them to attain a better understanding of their
risk. On the other hand, efforts should be concentrated on offering pregnancy and
childbirth education, along with acknowledging womens personal experiences, to
empower women to incorporate their own understandings in pregnancy risk appraisal
(Jordan & Murphy, 2009). These strategies will be valuable in assisting women in
making more informed decisions.
187
Although providing information in risk communication is essential and is often

considered as the first step in changing behavior or intervening, findings suggest that
simply offering risk information might not alter risk perception to any great extent. An
effective risk communication will benefit from strategies other than providing factual
information by instead offering information in a way that can be related to a woman's life
experiences. As Carolan (2009) stated, translating epidemiological risk into real life
examples can help pregnant women to understand and process the risk. A risk message
must be tangible for women in order to be recognized and potentially addressed. Results
of this study suggested that real stories can influence risk perception. Targeting this
concept in clinical practice and public health education programs may contribute to a
decrease in unhealthy behaviours through risk perception alteration. Although media are
in a position to play an important role in this regard, most of their messages about
pregnancy at AMA have been favorable and encouraging (Heffner, 2004). Developing
documentaries that highlight several risks associated with AMA, through presenting real
stories of women, may increase public awareness and understanding of the risk.
In the experience of the participants, any emphasis on mothers good health by
their care providers was described as reassuring, while negative messages about age were
reported as being disturbing, particularly for women with high anxiety levels. Women
with high levels of perceived risk and of AMA may be at a higher risk for excessive
anxiety. Anxiety during pregnancy has been associated with several adverse outcomes
(Consonni et al., 2010; Fishell, 2010). Detection of anxious pregnant women may provide
an opportunity to refer them to mental health services to engage them in appropriate
188
interventions prenatally and postnatally. It is recommended that in risk communication

sessions, a womans mental health be considered to avoid unnecessary stress and worry.
Conclusion
Findings revealed that women of AMA had a higher perception of pregnancy risk
than younger women. This study provided a quantitative verification for previous
qualitative studies by identifying maternal age as a significant predictor for perception of
pregnancy risk. However, results of the qualitative component clarified that nulliparous
women of AMA were not a homogenous group in their pregnancy risk assessment and
the perception of pregnancy risk varied considerably among these women. An
uncomplicated pregnancy at AMA in the absence of factors such as pregnancy
complications, limited physical activity, unfavourable screening tests results, previous
poor reproductive history, and anxiety was perceived as a low risk pregnancy by the
participants. However, in the presence of medical or social risk factors, the risk
associated with age was highlighted, and women then tended to identify their age as a
risk factor for their pregnancy.
A woman's perception of pregnancy risk is not identical with her medical risk
condition. There are several other factors contributing to her risk perception, of which at
least half are not identified yet. Future studies should be conducted to discover these
factors.
189
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Appendix A: Questionnaire
ID No
Business Name
Date:
Research Project: Pregnancy Risk

Perception
Booklet of Questionnaires
208
209
PERCEPTION OF PREGNANCY RISK QUESTIONNAIRE
The following questions ask you to rate your perception of personal risk during
this pregnancy, and your perception of risk for your unborn child. There are no right or
wrong answers. We are only seeking your opinion. Make your best guess of your risk
and your unborn childs risk for a poor health outcome. Do not put your name on the
form. On each of the following rating scales, please put a vertical mark through the line
to indicate your assessment of risk for each item (see example).
EXAMPLE:
My chances of winning the lottery are:
No Chance
At All
Extremely High
Chance
If you thought your chances of winning the lottery were very high, you might
place your vertical mark through the line as follows:
No Chance
At All
Extremely High
Chance
1. The risk for myself during this pregnancy is:

No Risk
At All
Extremely High
Risk
2. The risk for my unborn baby during this pregnancy is:

No Risk
At All
Extremely High
Risk
210
3. My risk of hemorrhaging (losing too much blood) during this pregnancy is:
No Risk
At All
Extremely High
Risk
4. My risk of having a caesarean section is:

No Risk
At All
Extremely High
Risk
5. My risk of dying during this pregnancy is:

No Risk
At All
Extremely High
Risk
6. My babys risk of being born prematurely is:

No Risk
At All
Extremely High
Risk
7. My babys risk of having a birth defect is:

No Risk
At All
Extremely High
Risk
8. My babys risk of needing to go to the Neonatal Intensive Care Unit is:

No Risk
At All
Extremely High
Risk
9. My babys risk of dying during this pregnancy is:

No Risk
At All
Extremely High
Risk
211
COGNITIVE HEURISTICS
The following questions are about sources which can be important in risk
perception. On each of the following questions, please circle the option that best
describes your situation for each item.
1. During the last three months, how many media communications (for example
information from the TV, radio, newspaper, or a magazine) do you recall hearing
or seeing on the topic of pregnancy complications in relation to mother's age?
(1) None
(2) One or two
(3) Three or four
(4) Five or six
(5) Seven or more
2. Did you receive any information on pregnancy complications in relation to
mother's age from your doctor or another health care professional in the last
twelve months?
(1) No
(2) Yes
3. How many of your female relatives or friends have had pregnancy complications
in the past 2 years?
(1) None
(2) One
(3) Two
(4) Three
(5) Four or more
4. How similar do you believe you are to the typical woman who gets pregnancy
complications at your age?
(1) Not at all similar
(2) A little similar
(3) Somewhat similar
(4) Similar
(5) Very similar
5. To what extent do you agree with the following statement? Pregnant women at
your age, who havent had any pregnancy complications, are not likely to get
them.
(1)
(2)
(3)
(4)
(5)
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
212
213
MULTIDIMENSIONAL HEALTH LOCUS OF CONTROL

The following questions ask you to rate your sense of control. For each of the
following statements, please circle the number which indicates the extent to
which you agree or disagree with the statement.
1=STRONGLY DISAGREE (SD)
2=MODERATELY DISAGREE (MD)
3=SLIGHTLY DISAGREE (D)
4=SLIGHTLY AGREE (A)

5=MODERATELY AGREE (MA)
6=STRONGLY AGREE (SA)
SD MD
MA SA
1
If I get sick, it is my own behavior which
determines how soon I get well again.
No matter what I do, if I am going to get sick,

I will get sick.
Having regular contact with my physician is

the best way for me to avoid illness.
Most things that affect my health happen to

me by accident.
Whenever I don't feel well, I should consult a

medically trained professional.
I am in control of my health.
My family has a lot to do with my becoming

sick or staying healthy.
When I get sick, I am to blame.
Luck plays a big part in determining how soon

I will recover from an illness.
10
Health professionals control my health.
214
11
My good health is largely a matter of good

fortune.
12
The main thing which affects my health is

what I myself do.
13
If I take care of myself, I can avoid illness.
14
Whenever I recover from an illness, it's

usually because other people (for example,
doctors, nurses, family, friends) have been
taking good care of me.
15
No matter what I do, I 'm likely to get sick.
16
If it's meant to be, I will stay healthy.
17
If I take the right actions, I can stay healthy.
18
Regarding my health, I can only do what my

doctor tells me to do.
The SF-12v2 Health Status Survey has been removed due to copyright
restrictions; see: http://www.qualitymetric.com
215
216
PREGNANCY-RELATED ANXIETY SCALE
The next set of questions is about your feelings and expectations about the birth
and your baby. Please indicate your own feelings about each statement below by
choosing one of the options. Circle your response.
1. I am confident of having a normal childbirth. Would you say
(1) NOT AT ALL
(2) SOMEWHAT
(3) MODERATELY
(4) VERY MUCH
2. I think my labor and delivery will go normally.
(1) NOT AT ALL
(2) SOMEWHAT
(3) MODERATELY
(4) VERY MUCH
3. I have a lot of fear regarding the health of my baby.
(1) NOT AT ALL
(2) SOMEWHAT
(3) MODERATELY
(4) VERY MUCH
4. I am worried that the baby could be abnormal.
(1) NOT AT ALL
(2) SOMEWHAT
(3) MODERATELY
(4) VERY MUCH
217
5. I am afraid that I will be harmed during delivery.
(1) NOT AT ALL
(2) SOMEWHAT
(3) MODERATELY
(4) VERY MUCH
The following statements are about things about pregnancy and new babies that
might concern you. Please indicate whether these things never concern you,
concern you some of the time, most of the time, or a lot of the time. Circle your
response.
6. I am concerned (worried) about how the baby is growing and developing inside
me. Would you say
(1) NEVER
(2) SOMETIMES
(3) MOST OF THE TIME
(4) ALMOST ALL OF THE TIME
7. I am concerned (worried) about losing the baby.
(1) NEVER
(2) SOMETIMES
8. I am concerned (worried) about having a hard/difficult labor and delivery.
(1) NEVER
(2) SOMETIMES
218
9. I am concerned (worried) about taking care of a new baby.
(1) NEVER
(2) SOMETIMES
10. I am concerned (worried) about developing medical problems during the
pregnancy.
(1) NEVER
(2) SOMETIMES
219
KNOWLEDGE OF MATERNAL AGE-RELATED RISKS OF CHILDBEARING
The following questions ask you to rate your knowledge about medical risks
associated with pregnancy. Please check off whether you think the statement is
true or false.
Question
True
False Don't
Know
1. Women 35 years and older experience more
problems getting pregnant than younger women.
2. Women 35 years and older are more likely to have a
baby with Down Syndrome compared to younger
women.
baby with a congenital anomaly than younger
women.
4. Women 35 years and older are more likely to develop
medical problems during pregnancy than younger
women.
multiple birth than younger women (even if not using
fertility treatment).
6. Women 35 years and older are eligible for
amniocentesis during pregnancy.
cesarean section than younger women.
preterm baby than younger women.
low birth weight baby than younger women.
10. Women 20 years and younger are at higher risk of
having a low birthweight baby than women 20-29
years.
220
DEMOGRAPHIC AND CHILDBIRTH DATA COLLECTION

FORM
The following questions ask you about your current pregnancy and your
demographic characteristics.
1. What is your age? _______years

2. How many weeks pregnant are you? _______ weeks
3. Thinking back to just before you became pregnant, would you say that you
wanted to be pregnant...?
(1) Sooner
(2) Later
(3) Then
(4) Not at all
4. Did you use any fertility medications (for example Clomid) to help you get
pregnant?
(1) Yes
(2) No
5. Did you use any fertility medical procedures (for example IVF, ICSI, or IUI) to help
you get pregnant?
(1) Yes
(2) No
6. Including your current pregnancy, how many times have you been pregnant?
This includes pregnancies ending in a miscarriage, abortion, or a tubal
pregnancy. ____
7. How many pregnancies ended in a miscarriage?_____
8. How many pregnancies ended in a tubal or ectopic pregnancy? _____
9. How many pregnancies ended in a therapeutic or induced abortion? _____
10. How old were you when you became pregnant for the first time? ____
11. Have you attended any prenatal classes with this pregnancy?
(1) Yes
221
(2) No
If yes, how many classes have you attended? _______
12. Did you have any problems or complications during this pregnancy?
(1) Yes
(2) No
If yes, please specify __________________________________________
13. What is your current marital status?
(1) Married and living with spouse
(2) Common-law relationship or live-in partner
(3) Single - never married
(4) Divorced
(5) Separated
(6) Widowed
14. If you are living with a partner or husband, how long have you been living
together with your current husband or partner?
________ years
15. What is your highest level of education? This includes complete and incomplete
(Please circle highest level).
1. No schooling
2. Incomplete Elementary school
3. Complete Elementary school
4. Incomplete Junior High School
5. Complete Junior High School
6. Incomplete High School
7. Complete High School
8. Incomplete Non-University (Vocational/technical)
9. Complete Non-University (Vocational/technical)
10. Incomplete University
11. Diploma/Certificate (e.g. hygienists)
12. Bachelor's Degree
13. Professional Degree (Vet, Dr., Lawyer)
14. Master's Degree
15. Doctorate
16. How many years of formal education have you completed starting with grade
one and not counting repeated years at the same level? _______ Years
222
17. Did you work at a paid job of any kind before your current pregnancy?
(1) Yes
(2) No
a. If yes, on average, how many hours did you work for pay each week
before your pregnancy? (This total includes all of your jobs: full-time and
part-time) ________ hours
18. Have you worked at a paid job of any kind during your current pregnancy?
(1) Yes
(2) No
a. If yes, on average, how many hours did you work for pay each week
during your pregnancy? (This total includes all of your jobs: full-time and
part-time)________ hours
19. We would like to know the total income of all the members of your household
for this past year before tax and deductions. Please remember that your
response will be kept confidential.
1. No income
2. Under $10,000
3. $10,000-19,999
4. $20,000-29,999
5. $30,000-39,999
6. $40,000-49,999
7. $50,000-59,999
8. $60,000-69,999
9. $70,000-79,999
10. $80,000-89,999
11. $90,000-99,999
12. $100,000 or over
20. Which of the following best describes your racial/ethnic background? Would
you say...
1.
2.
3.
4.
5.
6.
Aboriginal - Inuit
Aboriginal - Metis
Aboriginal - First Nations
Arab/West Asian (e.g., Armenian, Egyptian, Iranian, Lebanese, Moroccan)
Black (e.g., African, Haitian, Jamaican, Somali)
Chinese
223
7. Filipino
8. Japanese
9. Korean
10. Latin American
11. South Asian (e.g., East Indian, Pakistani, Punjabi, Sri Lankan)
12. South East Asian (e.g., Cambodian, Indonesian, Laotian, Vietnamese)
13. White (Caucasian)
14. Other (please specify _____________________________ )
224
Appendix B: Prenatal Scoring Form
225
Appendix C: Permission to use the Perception of Pregnancy Risk
Questionnaire
Ms. Hamideh Bayrampour
Doctoral Student, PhD in Applied Health Sciences Program
University of Manitoba
Dear Hamideh:
I am pleased to grant you permission to use the Perception of Pregnancy Risk
Questionnaire (PPRQ) as an instrument for your dissertation research project entitled,
Advanced Maternal Age and Risk Perception. Permission for use of the revised 9-item
PPRQ is given with the understanding that the instrument will be administered in its
complete form with all scales intact, and that the source of the questionnaire will be
appropriately referenced in all documents and publications pertaining to the study:
Heaman, M., & Gupton, A. (In press). Psychometric testing of the Perception of
Pregnancy Risk Questionnaire. Research in Nursing and Health.
Other references related to the PPRQ are as follows:
Heaman, M., Gupton, A., & Gregory, D. (2004). Factors influencing pregnant
womens perception of risk. MCN The American Journal of Maternal Child
Nursing, 29(2), 111-116.
Gupton, A., Heaman, M., & Cheung, L. (2001). Complicated and uncomplicated
pregnancies: Womens perception of risk. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 30(2), 192-201. (Note that this study used the former 11-item
version of the PPRQ)
Please feel free to contact me if you have any questions. Good luck with your project.
Sincerely,
Maureen Heaman, RN, PhD

Professor and CIHR Chair in Gender and Health
226
Appendix D: Permission to use the Pregnancy-related Anxiety Scale
At Thu, 20 Aug 2009 13:06:20 -0400, Rini, Christine wrote:
Dear Hamideh,
I'm attaching a handout with the scale. The items that need to be
reverse coded are numbers 1 and 2. Please let me know if you need
any more information. Good luck with your project!
Best regards,
Christine
Christine Rini, Ph.D.
Assistant Professor
Department of Oncological Sciences
Program for Cancer Prevention and Control
Mount Sinai School of Medicine
One Gustave L. Levy Place, Box 1130
New York, NY 10029
Phone: 212-659-5555
227
Appendix E: Permission to use the Knowledge of Maternal Age-related Risks
of Childbearing Questionnaire
Inbox: RE: Knowledge of Maternal Age-Related Risks of Childbearing Questionnaire (1 of 854)

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Suzanne Tough <[email protected]>
To:
Hamideh Bayrampour <[email protected]>
Subject: RE: Knowledge of Maternal Age-Related Risks of Childbearing Questionnaire
Headers: Show All Headers
Hi Hamideh,
Please accept this as permission to use the Knowledge of Maternal Age Related Risks of
Childbearing Questionnaire.
The questions were scored as correct or incorrect based on the following:
Women 35 or older experience more porblemns getting pregnant than women in their 20's = true
Women 35 or older are more likely to have a baby with Down's syndrome than women in their 20's = true
Women 35 or older are more likely to have a baby with a congenital anomaly than women in their 20's =
true
Women 35 or older are more likely to develop medical problems during pregnancy than women in their
20's = true
Women 35 or older are more likely to have twins or triplets than women in their 20's, even if not using
fertility treatment = true
Women 35 or older are eligible for amniocentesis or other genetic screening during their pregnancy= true
Women 35 or older are more likely than women under 35 to need a caesarian section when they give birth
= true
Women 35 or older are more likely to have a premature baby than women under 35 = true
Women 35 or older are more likely to have a low birth weight baby than women under 35 = true
Women who are 20 or younger are at higher risk of having a low birth weight baby than women aged 20 to
29 = true
The chance of having a low birth weight baby depends on the fathers age= false
Cheers,
Suzanne
Suzanne Tough, PhD

Professor, Departments of Paediatrics and Community Health Sciences, Faculty of
Medicine, University of Calgary
Health Scholar, Alberta Heritage Foundation for Medical Research
Scientific Director, Alberta Centre for Child, Family and Community Research
T. 403.955.2272 F. 403.955.5979 [email protected]
228
Appendix F: Script for Approaching Potential Participants
The charge nurse or his/her designate were asked to approach potential
participants to obtain their permission to explain the study:
"A researcher, a doctoral student from the University of Manitoba, is
conducting a study about perceived risk during pregnancy. Women who are currently
pregnant, at age 20-29 years or at age 35 years and older, and are in the third trimester
of pregnancy are being approached to participate in the study. Would you be
agreeable to have the Researcher tell you more about the study? You dont have to
decide whether to participate until you have received an explanation about the study
and have had the opportunity to ask questions."
229
Appendix G: In-Person Contact with Potential Participants
"Hello, my name is Hamideh Bayrampour. I am a doctoral student from the
University of Manitoba conducting a study to understand women's perceived pregnancy
risk. Would you be willing to read this written explanation about the study? You do not
have to decide whether to participate until after you read the explanation." (If the
potential participant agreed, she was provided with a copy of the "Research Information
and Consent Form and given time to read it.)
"Do you have any questions? Would you like to participate in the study?" (If the
answer was no, the woman was thanked and contact ended. If the answer was yes,
informed consent was obtained.)
230
Appendix H : Research Subject Information and Consent Form (For
Quantitative Component)
231
232
233
234
235
Appendix I : Invitation Letter
236
237
Study Information
Research Project Title: Advanced Maternal Age and Risk Perception
Researcher: Hamideh Bayrampour, PhD Student, Department of Applied Health
Sciences, University of Manitoba
Thesis Advisor: Dr. Maureen Heaman, Professor, Faculty of Nursing, Room 268 Helen
Glass Centre for Nursing, University of Manitoba, Winnipeg, MB R3T 2N2. Phone 204474-6222.
Purpose of the Study:
The purpose of this study is to compare perception of pregnancy risk in pregnant women
at aged 35 years and older to pregnant women at aged 20 to 29 year and to identify
factors that affect these women's pregnancy risk perception. This study is being
conducted for the researchers thesis research project.
Women Who May Participate in the Study:
Women are being asked to take part in this study if they are currently pregnant (no
previous pregnancies greater than 20 weeks gestation), age 20-29 or 35 and older, in the
third trimester of pregnancy with a singleton pregnancy, and receiving prenatal care from
variety of settings within Winnipeg.
Procedures:
There are a series of questionnaires in this package. These questions are about your
pregnancy, your perception of risk about this pregnancy, and your current health status.
You will also be asked about things that might contribute in forming your perceived risk
of this pregnancy, and basic demographic questions about yourself. This will take about
30 minutes of your time. If you agree to take part in this study, please answer these
questions either at the clinic or your home and return it in the stamped addressed
envelope to the researcher.
Confidentiality:
All information gathered for this study will be kept strictly confidential. No names are
requested on the questionnaire and therefore all responses will be anonymous and
confidential. You will not be identified in any reports or presentations about the study.
Your questionnaire forms will be identified with a unique code number that has been
assigned only to you. The questionnaire forms will be stored in a locked filing cabinet at
the University of Manitoba. Your completed questionnaire forms will stay in a locked
cabinet and then be destroyed 7 years after the study ends. Only the researcher, Hamideh
Bayrampour, her thesis advisor, Dr. Maureen Heaman, and a data entry clerk will have
access to the answers on your questionnaires.
238
Representatives of the sponsor (funding agency), the Education/Nursing Research Ethics
Board at the University of Manitoba, and Research Review Committee of Winnipeg
Regional Health Authority (WRHA), St. Boniface General Hospital or Health Sciences
Center (if you are a patient of these institutions) may review your research-related
records to make sure this study meets quality guidelines.
Your completion and return of the attached questionnaire indicates that you have
understood to your satisfaction the information regarding participation in the research
project and agree to participate as a subject. In no way does this waive your legal rights
nor release the researchers, sponsors, or involved institutions from their legal and
professional responsibilities.
Risks:
There are no known risks to participating in this study.
Benefits:
There are no direct benefits involved in participating in this study. However, your
answers may help to improve prenatal care for other women at your age.
Voluntary Participation and Withdrawal:
Your participation in this study is completely voluntary. Your decision about whether or
not to take part will not affect the care and service you receive in any way. You have the
right to not answer any of the questions you are asked. You should feel free to ask
questions at any time during or after the study from either Hamideh Bayrampour,
doctoral student, (Ph. 204-272-1604) or her thesis supervisor, Dr. Maureen Heaman (Ph.
204-474-6222).
Qualitative Phase:
If you are at age 35 years and older, you are also eligible to take part in a second phase of
this research study that involves participating in an in-depth interview with the
researcher, which will take about 60 minutes of your time and would be conducted at a
time and place convenient to you. If you are willing to be approached at a later date to
learn more about this phase and to determine your interest in participating in this
interview, please call the researcher at 272-1604 or e-mail [email protected].
Feedback to Participants:
We will send you a summary of the results of the study, if you would like one. Please
call researcher at 272-1604, or e-mail [email protected], if you would like to
receive a summary of the results.
This research has been approved by the Education/Nursing Research Ethics Board of the
University of Manitoba. If you have any concerns or complaints about this project you
239
may contact any of the above-named persons or the Human Ethics Secretariat at 204-4747122, or e-mail [email protected]. Please keep this information sheet for
your records.
240
Appendix J: Research Subject Information and Consent Form (For
Qualitative Component)
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244
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Appendix K: Interview Guide
1. Please tell me a little bit about yourself?
a) When did you become pregnant?
2. Please tell me about your decision to get pregnant?
a) When did you decide to start your family?
b) Why did you decide to get pregnant?
c) If you have a partner, how did your partner influence this decision?
d) Why didnt you want to get pregnant sooner?
e) What is the primary reason you decided to delay pregnancy?
f) What/who influenced your decision to being pregnant?
g) What is the primary reason you decided to get pregnant now?
3. Please describe for me your understanding about your pregnancy after age
35?
a) If you had gotten pregnant before age 35, do you think your pregnancy
would be different from this pregnancy? Why or why not?
b) Please describe for me your opinion about the risks associated with your
pregnancy (try to find thoughts and worries).
4. Some studies show that pregnancy at age 35 and above is more complicated
than pregnancy at younger ages. Do you think that you are at a higher risk for
pregnancy complications compared to a younger woman? Why or why not?
a) In decision making about pregnancy, was this issue important for you?
Were there other factors that you considered in advance?
5. Could you please describe to me your experiences with how your health care
providers informed you about the risks associated with your pregnancy?
a) Do you consider your pregnancy to be at high risk? If so, when did you
first realize that your pregnancy is a high risk pregnancy?
b) Does your partner consider your pregnancy to be at high risk? Why or
why not?
c) Who indicated that your pregnancy is a high risk pregnancy?
d) What was your reaction to that? Please describe what your feelings were
after that?
e) What does it mean for you to be at higher risk?
f) Did you feel you needed more description about your situation? Which
questions came to mind? Did you ask these questions? Were you satisfied
with the answers?
g) What were your wishes about this communication?
246
h) Had this communication any impact on your beliefs about your
pregnancy?
247
Appendix L: Contact Summary Sheet for Interviews
Contact date:__________
Participant Number: _______
1. Brief description of interviewee and anyone else present during interview:
2. Place of interview:
3. Context of interview (anything noteworthy that might influence responses):
4. What were the main themes or issues in this contact?
5. What new themes, speculations or hunches were suggested by the contact?
6. Where should energy be placed during the next contact, and what kinds of
information should be sought?
248
Appendix M: Education/Nursing Research Ethics Board Approval
Certificate
249
Appendix N: Education/Nursing Research Ethics Board Renewal Approval
Certificate
250
Appendix O: Health Sciences Center Research Access Approval Certificate
251
Appendix P: St. Boniface Hospital Research Access Approval Certificate
252
Appendix Q: Winnipeg Regional Health Authority Research Access
Approval Certificate

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ADVANCED MATERNAL AGE & RISK PERCEPTION

Advanced Maternal Age and Risk Perception

A Dissertation submitted to the Faculty of Graduate Studies of

Department of Applied Health Sciences

Copyright 2011 by Hamideh Bayrampour

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

interacted in a synergistic manner with pregnancy-related anxiety to increase perception

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

To my son, and my parents

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

Study setting. ............................................................................................. 32

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

Risk alleviation strategies........................................................................ 145

ADVANCED MATERNAL AGE & RISK PERCEPTION

Appendix H : Research Subject Information and Consent Form (For Quantitative

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

Chapter One: Introduction

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

Pregnancy risk perception is important because it affects pregnant womens health

ADVANCED MATERNAL AGE & RISK PERCEPTION

Purpose of the Study

ADVANCED MATERNAL AGE & RISK PERCEPTION

Chapter Two: Literature Review

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

The Psychometric Model was introduced in 1978 by Fischhoff et al. They

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

From a quantitative perspective, Gupton, Heaman, and Cheung (2001) explored

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

Chapter Three: Conceptual Framework

ADVANCED MATERNAL AGE & RISK PERCEPTION

ADVANCED MATERNAL AGE & RISK PERCEPTION

Cognitive heuristics. Cognitive heuristics, mental guidelines that are used to

ADVANCED MATERNAL AGE & RISK PERCEPTION

the review of the literature, perception of pregnancy risk appears to be influenced by

ADVANCED MATERNAL AGE & RISK PERCEPTION

Figure 1. Conceptual framework of the study

ADVANCED MATERNAL AGE & RISK PERCEPTION