Javanmardi et al.

Reproductive Health (2019) 16:128

https://doi.org/10.1186/s12978-019-0789-3

RESEARCH Open Access

Challenges to access health information

during pregnancy in Iran: a qualitative
study from the perspective of pregnant
women, midwives and obstetricians
Marzieh Javanmardi1, Mahnaz Noroozi2*, Firouzeh Mostafavi3 and Hasan Ashrafi-rizi4

Abstract
Background: Appropriate health information seeking behavior can play an effective role in self-care and promotion
of women’s quality of life during pregnancy. However, different barriers can impede pregnant women while
accessing health information. The aim of this research was to explain challenges to access health information
during pregnancy.
Methods: The present qualitative study was carried out on 28 participants who were selected using the purposeful
sampling technique. Data were collected through in-depth interviews, field notes, and daily notes; data were
analyzed using conventional content analysis.
Results: The main barriers to access health information during pregnancy were as follows: many duties of women
at home as well as out-of-home education and employment, inability to make distinction between correct and
incorrect information, insufficient interactions between women and healthcare providers, failure to access to various
information resources, common complaints of pregnancy, and stress and anxiety of confronting the problems
during pregnancy.
Conclusion: Based on the results, pregnant women experienced personal, social, and structural barriers when
accessing health information. Therefore, policymakers and health planners should remove the barriers, encourage
self-care, and enhance the quality of life for pregnant women, thus, promoting their health status in the end.
Keywords: Information seeking behavior, Pregnant women, Barriers, Qualitative study

Plain English summary themes identified were: many duties of women at home
Pregnant women need health information to increase as well as out-of-home education and employment, in-
their empowerment while practicing preventive health ability to make distinction between correct and incorrect
behaviors and boosting self-care capabilities. Although information, insufficient interactions between women
women desire to receive information during pregnancy, and healthcare providers, failure to access to various in-
they are often faced with challenges when accessing formation resources, common complaints of pregnancy,
health information; therefore, this study was conducted and stress and anxiety of confronting the problems dur-
to explain challenges to access health information during ing pregnancy. In conclusion, these results could be
pregnancy. Results in this field were achieved through helpful for health policymakers in designing strategies to
interviews with pregnant women and healthcare pro- increase the access of pregnant women to health infor-
viders (midwives and obstetricians). The top six research mation, thereby, promoting their self-care capability, and
quality of life, which will ultimately improve the health
* Correspondence: [email protected]
of the mothers.
2
Department of Midwifery and Reproductive Health, School of Nursing and
Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Javanmardi et al. Reproductive Health (2019) 16:128 Page 2 of 7

Background between them [11]. Hence, the aim of this research was
Information seeking is a complex activity that requires to explain challenges to access health information during
access to various information resources to solve per- pregnancy.
sonal, social, and occupational problems. A review of re-
lated literatures on information needs and health Methods
information seeking behavior (HISB) revealed more at- Study design
tention to a specific user groups in recent years [1]. One This study is a qualitative research that was conducted
of these groups that are of great importance in terms of from June to November 2016.
their information seeking includes women. Undoubtedly,
women’s health and their updated level of awareness Settings, sample, and recruitment
and knowledge will have tremendous effect on society The approval letter of the research was obtained from the
[2]. Pregnancy is not only a period of physical changes; Ethics Committee of the Vice-Chancellor of Research of
it is also a phase in the life of a woman where health- Isfahan University of Medical Sciences (Ethics code:
related behaviors are critical to decisions made and can IR.MUI.REC.1395.3.955). Participants in the present study
affect the life of the mother and her neonatal outcomes were 22 pregnant women and six healthcare providers
[3]. Pregnant women need health information to in- (midwives and obstetricians) in Isfahan, Iran; which were
crease their empowerment while practicing preventive selected through purposive sampling method. The preg-
health behaviors, boosting self-care capabilities, and re- nant women were selected with a maximum variation
ducing anxiety in case of new health issues or stressful sampling strategy based on age, level of education, job sta-
situations [4]. Merrell et al. showed that exploring HISB tus, gestational age, and number of pregnancies and the
of pregnant women is the first step in understanding the ability to understand and express their experiences. Partic-
health literacy in this significant population [5]. In this ipants were accessed through prenatal clinics, healthcare
regard, researchers believed that healthcare providers centers, and midwife or obstetrician offices. They were re-
should allocate efficient amount of time for discussing cruited through face-to-face meeting or telephone calls.
information-seeking methods with pregnant women [6]. The first author (MJ) did not have any role or relationship
The results of some studies suggested that although with the centers or participants.
women desire to receive information during pregnancy,
they are often faced with challenges when accessing Data collection
health information [1, 2]. Nwagwu and Ajama pointed Semi-structured in- depth interviews, field notes and
out to factors such as distance, high costs, and language daily notes were used to collect data. The time and place
differences as the barriers that pregnant women face of the interviews were determined based on the conveni-
when accessing health information [7]. Das and Sarka ence of the participants. Considering the participants
stated in their study that pregnant women experienced were required to have first-hand experiences and in-
different barriers when accessing health information; formation about the research topic in the qualitative
these challenges include poor quality of care provided in research [11], firstly, interviews carried out on pregnant
the hospital, long waiting time, fear and embarrassment women. In interview sessions, questions were different
to discussing pregnancy with a physician and shortage of for the each group of the participants. Interviews with
time [8]. Although providing pregnant women with pregnant women were started by posing a general ques-
health information is a critical component of the process tion “Please explain the barriers you faced while seeking
of pregnancy management, there is no leading national the health information during pregnancy?” and then the
health policy and strategy to promote health information open and interpretive responses of the participants
system for women during pregnancy in Iran. Under- guided its process. Interviews with other participants
standing the nature of obstacles for health information (midwives and obstetricians) were begun by posing
seeking will help healthcare policymakers to provide another general question “Based on your experiences,
evidence-based and reliable information to encourage please explain the barriers that pregnant women faced
pregnant women involvement in management and treat- while seeking the health information during pregnancy?”
ment decisions. Although the importance of this issue Since the official language in Iran is Persian, the specific
cannot be overemphasized, studies on HISB in pregnant language used for data collection was Persian. The inter-
women are a few in Iran [1, 9, 10]. Since qualitative re- views lasted between 30 and 90 min and were recorded
search is an approach to discover and describe the expe- using a digital voice recorder. Interviews continued until
riences of individuals and give meaning to them, on the data saturation point was reached, i.e. when new findings
one hand, it leads to increased insight, understanding, were not added to the existing data.
and awareness of human experiences. On the other In this study, the first author (MJ) documented her ob-
hand, it is used to explain the concepts and relationships servations of the non-verbal behaviors of participants
Javanmardi et al. Reproductive Health (2019) 16:128 Page 3 of 7

during the interview (field notes). Participants were also sub-categories, and one main category developed. Six
asked to note, if they were willing, their information sub-categories were as follows: “insufficient interactions
requirements, sources of information, and problems in between pregnant women and healthcare providers”,
acquiring health information during pregnancy and to “stress and anxiety of confronting the problems”,
hand these notes (daily notes) to the first author (MJ). In “pregnancy-related common complaints”, “busy life and
the present study, obtaining informed consent, the right shortage of time”, “problems with access to various
of anonymity, confidentiality of the information and the information resources” and “failure to make distinction
right of withdrawal from the study at any desired time between correct and incorrect information” (Table 2).
were respected.
Insufficient interactions between pregnant women and
Data analysis healthcare providers
The data were analyzed manually and the authors did As noted by the participating pregnant women, they
not use any type of software for analysis. Data analysis trusted the information provided by obstetricians and
was carried out using the conventional content analysis midwives and considered them as a reliable source for
method [12]. Interviews were transcribed verbatim and their information needs. However, most of them were
were repeatedly reviewed to achieve a complete under- dissatisfied with the short-term visits by the obstetricians
standing. Then, the sentences and phrases were coded (due to workload), the presence of several pregnant
and the same codes were merged and the ones having women in the visiting room at the same time and pro-
the same concept were placed in the same category (in viding the insufficient information. They believed the
the inductive manner), which formed the sub-categories afore-mentioned items were barriers to accessing health
and eventually the main category. information. In addition, a number of pregnant women
considered the young age of healthcare providers or the
Rigor and trustworthiness fact that they are un-married as barriers in communi-
To ensure the credibility of the findings, various cating appropriately with them to receive information
methods including in-depth interviews at different times about sexual matters during pregnancy.
and places, a combination of several data collection
methods such as individual interviews, daily notes, and “I think they (obstetricians) could not manage us very
field notes were applied. To ensure the confirmability well and they do not talk with us much about our
and to approve the accuracy of the codes and interpreta- pregnancy” (Pregnant woman, 29 years old).
tions, it was shared with five participants at different ses-
sions and their opinions were sought to conduct a “The level of knowledge of pregnant women is very low.
member check. To ensure dependability, the views of The obstetricians only give them simple prenatal care.
four experts were also used to match the consistency of … Pregnant women have lots of questions when they go
the findings with the statements of the participants. To to a health center, but we do not have enough time to
ensure the transferability, the findings of the present answer them properly” (Midwife, 35 years old).
study were presented to 11 individuals who did not
participate in the study, but had characteristics similar
to the participants to judge the similarity of the results Stress and anxiety of confronting the problems
of the study with their own experiences. Some pregnant women said that consultation with fam-
ily members and relatives made them anxious and thus
Results they tend to consult with an obstetrician or midwife for
The demographic characteristics of the 28 participants information instead. Some pregnant women stated that
are shown in Table 1. During data analysis, 84 codes, six obtaining information about warning signs in pregnancy,

Table 1 Demographic characteristics of participants

Pregnant women (n = 22) Age (years) 16–35
Level of education Secondary (4), Diploma (5), Associate’s degree and
B.S. (11), M.S. and Ph.D. (2)
Job status Employed (7), Housewife (15)
Pregnancy trimester First trimester (3), Second trimester (8), Third trimester (11)
Pregnancy number 1–3
Healthcare providers (n = 6) Age (years) 35–47
Working experience (years) 5–24
Javanmardi et al. Reproductive Health (2019) 16:128 Page 4 of 7

Table 2 The examples of codes, sub-categories and main category

Code Sub-category Main category
* Failure to receive adequate information through Insufficient interactions between The challenges to access
an obstetrician and midwife pregnant women and healthcare health information during
* Failure to consult to pregnant women via phone call providers pregnancy
* The crowds of obstetrician office and the lack of enough time to visit clients
* Fear of complication during pregnancy Stress and anxiety of confronting the
* Creating fear after observing normal vaginal delivery movies problems
* Making worries due to received information from family
members and relatives
* Fear following by receiving information on how to get normal delivery
* Nausea and vomiting in pregnancy Pregnancy-related common
* Feeling boredom in pregnancy complaints
* Feeling tired in pregnancy
* Out-of-home employment and lack of time Busy life and shortage of time
* Education in college and not having enough time
* Taking care of the children
* Busy life and several duties and responsibilities in home
* The high cost of buying books Problems with access to various
* The lack of up-to-date libraries information resources
* Trouble in finding the book
* Non-scientific information received from family members and relatives Failure to make distinction between
* Confusion after observation of conflicting information on websites correct and incorrect information

complications of pregnancy, and normal delivery Busy life and shortage of time
(through watching movies) were factors causing stress Some pregnant women referred to the duties of women
and fear of confronting these problems. They believed at home and taking care of the spouse and other chil-
that familiarity with these issues increased their sensitiv- dren as a barrier to seeking information, while others
ity and it would make them anxious with the smallest stated that it was not possible for them to participate in
symptom. They considered this stress as a barrier to “childbirth preparation classes” and refer to healthcare
seek more information. centers because of their out-of-home employment. A
number of pregnant women also narrated that they did
“When I got informed, it would make me distressed. not have enough time to seek health information during
Sometimes, I decided to be ignorant and less informed. pregnancy due to their education.
I told to myself: ‘It’s better not to get informed!’ if
makes me frustrated, I would rather not know them at “... A woman has many responsibilities: cooking, taking
all …” (Pregnant woman, 31 years old). care of the child, taking care of husband, she shoulders
all of these (responsibilities). So, there is no time left
for her to read books.” (Pregnant woman, 35 years old).
Pregnancy-related common complaints
Some pregnant women referred to common complaints
of pregnancy as the barriers to accessing health informa- Problems with access to various information resources
tion. Among the complaints frequently noted by the ma- Pregnant women and healthcare providers referred to
jority of participants included: nausea and vomiting, difficulty in accessing the various resources, such as
which, as stated by them, disrupted their daily routine insufficient printed materials (book etc.), high cost of
activities and made them became more bored. Some printed materials, the lack of up-to-date libraries, and
pregnant women also stated that fatigue, and the pre- the lack of prenatal educational movies tailored to the
sence of sleep problems, followed by lethargy throughout culture of society (about exercises in pregnancy etc.),
the day would prevent them from meeting their infor- as other barriers for accessing health information
mation needs. during pregnancy. Some pregnant women complained
about the lack of possibility to use remote (telephone)
“I was sometimes tired of everything due to difficulties counseling.
of pregnancy (morning sickness) and I wished I had
not been pregnant at all and never followed it “In case of exercises during pregnancy, I searched a lot
accordingly (seeking information)” (Pregnant woman, on the internet. There were some online films, none of
23 years old). which was Iranian... All the existing movies were made
Javanmardi et al. Reproductive Health (2019) 16:128 Page 5 of 7

by the non-Iranian producers. I was worried if it is ok; dissatisfied with the information provided by healthcare
because some of them (exercises) were very heavy ...” providers, and they made use of the internet because
(Pregnant women, 31 years old). healthcare providers spend insufficient time to provide in-
formation [13]. Today, crowded physician’s office and in-
appropriate methods used for visiting patients in Iran,
Failure to make distinction between correct and incorrect such as “group visit of patients,” have led obstetricians not
information to spend enough time to visit pregnant women. This issue
Despite the high and easy use of the internet and social has not only led to the reduction of the quality of health
networks, many of pregnant women and healthcare pro- services but has also caused an increased level of clients’
viders pointed to the existence of inaccurate and non- dissatisfaction. One of the reasons for “group visit of
scientific information on various websites and stated that patients” is the lack of implementation of the referral
pregnant women were unable to make distinction system for medical services. So, implementation and
between correct and incorrect information were received adherence to the referral system for medical services
from different sources. Pregnant women sometimes had seems to be the only solution [14–16].
to use several sources to investigate the validity of the In the present study, pregnant women referred to
information, or to determine the accuracy of the re- stress and fear of confronting the problems following in-
ceived information by referring to the health centers and formation acquisition as another barrier to accessing
asking the obstetrician or midwife. They also expressed health information. Feltwell and Rees showed that some
dissatisfaction with the failure to provide reliable sources individuals were afraid of seeking information and
on behalf of media and healthcare providers. believed that this would increase their concern. They
avoided seeking information to reduce their levels of fear
“Unfortunately, superstitions, which are commonplace and to maintain a sense of normality [17]. Therefore, it
among the common people, have priority and higher is essential to pay attention to stress management using
effectiveness over the information given by the midwife solutions such as psychological supporting and providing
and the obstetrician, and in my opinion, they believe education and awareness-raising programs on preg-
in the words of others, while the information given by nancy, delivery, and familiarity with the hospital environ-
family, mother or sister is non-scientific!!!” (Midwife, ment, especially labor and delivery room.
42 years old). In the present study, participants referred to the pres-
ence of common complaints such as nausea, vomiting,
Many pregnant women expressed concern about and fatigue during pregnancy as another barrier to
wrapping of the umbilical cord around the fetus’s neck accessing health information. This finding can be justi-
and choking, and believed that this is related to the pos- fied considering the high prevalence of these problems
ition of the mother during sleep and rest. Healthcare and their impact on the daily activities of pregnant
providers believed that misinformation given to pregnant women [18]. Therefore, measures should be taken to
women by different individuals with different experi- reduce the most common complaints in women during
ences, and the inability of women to distinguish between pregnancy so that they can carry out their daily chores
correct and incorrect information can cause anxiety in and get health information during pregnancy.
these women. The results of the present study showed that women en-
gagement in out-of-home employment as well as doing
“There are misconceptions about pregnancy among household chores could limit the opportunity for informa-
pregnant women that cause their concern. Many tion seeking. Onuoha and Amuda referred to shortage of
mothers believe that squirming in bed would cause the time as a challenge to seeking information among preg-
umbilical cord to wrap around the neck of the fetus. nant women [2]. It seems that women need special atten-
Some also believe that raising the hands by the tion and support from the family and the community
pregnant woman would cause the fetus’s umbilical during pregnancy. This support should be especially given
cord to tear …” (Obstetrician, 40 years old). to women who are working and studying.
Participants in the present study referred to problems
such as the high cost of printed materials, out-of-date
Discussion libraries, and lack of prenatal educational movies tailored
The aim of this research was to explain challenges to ac- to community culture as the barriers to accessing health
cess health information during pregnancy. Participants in information during pregnancy. Nwagwu and Ajama also
the present study emphasized the insufficient interactions pointed to some of these barriers to accessing informa-
between pregnant women and healthcare providers. Lagan tion such as distance and high cost [7]. Therefore, the
et al. showed that about half of the mothers (48.6%) were health system is needed to find solutions to enhance the
Javanmardi et al. Reproductive Health (2019) 16:128 Page 6 of 7

welfare of low-income pregnant women and take more Abbreviation

serious measures for providing free counseling and health HISB: Health Information Seeking Behavior

information services for pregnant women through health Acknowledgments

centers. It is also very useful and effective to provide infor- This article was based on the doctoral dissertation on reproductive health
mation services to pregnant women using printed mate- (395955) approved by the Research Council of Isfahan University of Medical
Sciences. We should thank the pregnant women and healthcare providers
rials. Radio and television, as cheap and easy-accessed (midwives and obstetricians) in Isfahan for their sincere participation in the
resources can be used to transfer information; they can interviews.
play an important role in removing the above barriers.
In the present study, another barrier to accessing health Authors’ contributions
All the authors contributed to the conception and design of the study. MJ
information was the participants’ unfamiliarity with useful drafted the first version of the manuscript. MN, FM, and HA revised the
resources and failure to make distinction between correct manuscript. MN critically reviewed the manuscript for important intellectual
and incorrect information. According to the participants, content. All authors approved the final version.
plenty of websites caused confusion among pregnant
Funding
women and; they expressed dissatisfaction with the in- This paper is adopted from a Ph.D. thesis in reproductive health which was
significant role of obstetricians and midwives as well as the conducted with the financial support of Isfahan University of Medical
media in introducing useful and credible references. Bert et Sciences (Research proposal No: 395955).

al. reported that some patients wanted to investigate the in- Availability of data and materials
formation received from the internet and the needed to The datasets generated and analysed during the current research are not
compare this information with other sources [19]. Given publicly available as individual privacy could be compromised but are
available from the corresponding author on reasonable request.
the increasing use of internet by pregnant women to obtain
health information and the inability of women to assess the Ethics approval and consent to participate
validity of internet sources [6, 20, 21], academia, healthcare The Ethics Committee of the University of Medical Sciences in Isfahan, Iran
providers, media, and other actors are required to review approved the protocol of this study (code number: IR.MUI.Rec. 1395.3.955).
Written informed consent is taken from each participant.
the online content, and single out valid websites to intro-
duce them to their clients. In addition, healthcare providers, Consent for publication
upon designing valid websites should try to guide women Not applicable.
to access high-quality web-based information taking into
Competing interests
account the information needs of pregnant women. The authors declare that they have no competing interests.
The generalization of the results of this qualitative study
should be done with caution. Considering qualitative stud- Author details
1
School of Nursing and Midwifery, Isfahan University of Medical Sciences,
ies do not have any claim regarding generalizability of the Isfahan, Iran. 2Department of Midwifery and Reproductive Health, School of
findings, it may be important for the people who wish to Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
3
apply the results of the study and be considered as a Department of Health Education and Promotion, School of Health, Isfahan
University of Medical Sciences, Isfahan, Iran. 4Library and Information Science,
limitation. In this regard, efforts were made to increase Health Information Technology Research Center, Isfahan University of
the rigor and trustworthiness of the findings through the Medical Sciences, Isfahan, Iran.
selection of participants with the maximum variations,
Received: 3 April 2019 Accepted: 6 August 2019
guidance, and supervision of experts as well as external
review.
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