The Effect of Individual Counseling Intervention on Health Practices in Pregnancy: A Randomized Controlled Trial

This research was carried out to determine the effect of individual counseling intervention on health practices in pregnancy. This research is a single-blind randomized controlled experimental and follow-up design. Population of the research consisted of 126 pregnant women in total, with 64 of them being in the training group and 64 being in the control group. The research data were collected by using a 'Pregnant Identifying Information Form' and 'Health Practices in Pregnancy Questionnaire (HPQ)'. In this research, it was found that there was no significant difference in total score average of the HPQ before the individual counseling training between the pregnant women in the training and control groups (P  > 0.05). It was also determined that there was a statistically significant difference in total score average of the HPQ after the individual counseling training during the second trimester between the two groups (P  < 0.05). It was determined that there was a statistically significant difference in total score average of the HPQ during the third trimester between two groups (P  < 0.05). It has been determined that the training provided with individual counseling to pregnant women is an effective initiative in increasing the health practices of pregnant women.

Pregnancy represents a critical time period during which maternal health practices contribute significantly to maternal, neonatal and early childhood outcomes [1]. Many factors influence the health of pregnant women and their fetuses and, ultimately, may affect infant outcomes. Positive health practices, or health behaviors, are actions a woman takes during pregnancy that may affect maternal or fetal health or the outcome of the pregnancy. These health practices can have positive effects by decreasing risk factors [2]. Health-promoting behaviors during pregnancy, including adequate physical activity, sleep, and consuming a nutritious diet, contribute to better birth outcomes [3, 4].

Favorable health practices associated with positive outcomes include maintaining a health pre-pregnancy weight, gaining an appropriate amount of weight during pregnancy, consuming a variety of foods with adequate intake of specific nutrients, engaging in regular physical activity, limiting alcohol consumption, avoiding tobacco and illicit substance use, taking appropriate vitamin and mineral supplementation, and using safe food handling practices [1]. Maintaining good health practices during pregnancy is critical to maternal and fetal well-being and the subsequent health of the newborn.

Failure to follow positive health practices can have negative effects, increasing the chance that the infant will have poor birth outcomes, such as low birth weight, prematurity or congenital anomalies, or that the pregnant woman will develop problems such as gestational diabetes [2]. There is also accumulating evidence that consuming caffeine during pregnancy is harmful. Although pregnant women typically practice health-promoting behaviors [5, 6] and reduce health-impairing behaviors, such as caffeine consumption during pregnancy [5, 7], approximately half of the women who smoke cigarettes continue to do so throughout their pregnancies [8].

Overwhelming evidence demonstrates that prenatal care, skilled attendance at birth and adequate postpartum care could dramatically reduce maternal (and infant) mortality rates [9]. However, the use of these services is low among some Asian populations. For example, the United Nations (UN) estimates that only 42% of women in South Asia receive the recommended four or more antenatal care visits and only 49% give birth with a skilled birth attendant. Put into perspective, antenatal care coverage (four or more visits) in Laos is only at 37%, while it is much higher for Cambodia and Indonesia, at 72% and 84%, respectively. Rates of birth with a skilled attendant is another example of inadequate care, reaching 42% in Laos, 92% in Cambodia, 87% in Indonesia and 73% in the Philippines [10]. The utilization of formal maternal healthcare also varies greatly within countries. According to Turkey Demographic and Health Survey (TDHS) 2018 data, 96% of women in Turkey receive antenatal care [11].

Prenatal care is a part of preventive health services and is given by regular monitoring before birth. It is important for the evaluation of the health status of the mother and fetus, for the reduction of morbidity and mortality before, after and after birth, starting from the first month of pregnancy and continuing at regular intervals until the end of pregnancy. Pregnancy and birth preparation education, support and counseling given to women during pregnancy are very important [12]. The education of expectant mothers is an important condition affecting children's health and family health as well as affecting their own health. The education provided during the perinatal period helps to meet the care and support needs of the pregnant woman and her family to adapt physically and psychosocially [13]. Therefore, the importance given to prenatal care and education of expectant mothers in Turkey has accelerated in recent years. However, education and counseling services, which are one of the important elements of prenatal care, are not yet at the desired level [14].

The study is a single-blind, randomized controlled and follow-up trial. The study was conducted on pregnant women at a public hospital in the central district of Manisa. The research population was 6289 pregnant women. The research was conducted with 126 pregnant women by determining the number of individuals needed to serve as a sample from the clinic by the Random Sampling Method. The inclusion criteria were: Turkish pregnant women who (i) were in their first trimester of pregnancy, (ii) undertaken at least primary school education, (iii) spoke Turkish, (iv) were minimum 18 years of age and (v) were undergoing an uncomplicated pregnancy.

Power analysis was performed with 95% confidence interval and P = 0.05 significance level. As a result of the completion of the study, 64 people were recruited to the experimental group and 62 to the control group, the power of the study was determined to be 100% when the data obtained according to the health practices scale in pregnancy were used in the G-Power program.

For the collection of research data, we used a Pregnant Information Form, which consisted of 30 questions and the Health Practices in Pregnancy Questionnaire.

The form consisted of questions about their socio-demographic and marital features, income status, residence, family type (nuclear, extended, etc.) and educational background [15–18].

Health Practices in Pregnancy Questionnaire was developed by Lindgreen (2005). The HPQ is a 34-item self-report questionnaire developed to assess health practices during pregnancy that are related to pregnancy outcomes. The HPQ asks about health practices in six domains including balance of rest and exercise, safety measures, nutrition, substance use, health care access and access to pregnancy-related information. The HPQ is scored using a five-point Likert format. Responses range from 1 ('never') to 5 ('always' or 'daily') or a word or phrase that indicates the woman's level of engagement in a specific activity. The HPQ has 11 items (5-6-7-11-21-22-23-24-25-32-33) that are negatively worded. The total scale score ranges from 34–170, with a higher score indicative of greater engagement in favorable health practices. Consistent with scoring recommendations, this scale was analyzed as a continuous measure. Internal consistency for the overall scale was with Cronbach's α of 0.81. The validity and reliability of the HPQ were tested by Er (2006) and Cronbach Alpha value was found to be 0.74 for the HPQ [15, 19]. Turkish version of the scale has 33 items. The total scale score ranges from 33–165, with a higher score indicative of greater engagement in favorable health practices. Cronbach's for the current study was 0.93.

In this study, Pregnant Information Form and HPQ were applied by using the face-to-face interview technique after the necessary explanations were made by the researcher. The data were collected within 20–30 min in total (Pregnant Information Form 10–15 min and HPQ 10–15 min, on average).

The block randomization method was used to determine which group of pregnant women would be included. Six different possibilities numbered in six blocks were determined by the help of a computer program that produces random numbers.

The researcher who collected the data learned about the group of each pregnant woman only after she was included in the research, in the data collection phase. Individual files were created for each pregnant woman. These files were enclosed in opaque envelopes. After determining the pregnant women who met the sample criteria of the study and agreed to participate in the study, envelopes were opened and the woman was determined to be either in the education or control group. The pregnant women in the sample of the study learned which group they were in during the data collection phase after they were included in the study. Knowledge about the education and control groups had also been hidden from employees at the hospital. In order to prevent pregnant women in the education and control group from contacting each other, appointments were made at different times.

The pregnant women who were included in the research were divided into two groups: education and control (Fig. 1). Health Practices in Pregnancy Scale was applied to the pregnant women in the education group during the prenatal period (first-trimester average: 8.08 weeks). During the first interview with the Pregnant Information Form and in accordance with the data collected, the point averages of the pregnant women in the Health Practices in Pregnancy Scale were determined.

The education was prepared in three sessions with subjects such as pregnancy, pregnancy follow-up, drug use and immunization in pregnancy, rest and sleep in pregnancy, hygiene and general care in pregnancy and was given by the researcher individually for each pregnant woman in the pregnancy information class of the designated hospital. The education was done using question-answer, lecture, slide show, showing on the figure and showing and making methods. The pregnancy education booklet covering the educational content was given to the women in the education group. After individual education for each pregnant woman, they were able to receive counseling support by phone from the researcher at any time.

In the education group, the HPQ was re-applied during pregnancy by meeting the pregnant women face-to-face in the second trimester (Avg: 18.63 weeks) and in the third trimester (Avg: 30.00 weeks).

During the prenatal period (first-trimester average: 7.10 weeks), the HPQ was applied to the control group by means of the Pregnancy Information Form, and in accordance with the data collected, the mean scores of HPQ were determined.

The control group was not given any education by the researcher other than the standard care offered at the health institution. The pregnant women in the control group in second trimester (Avg: 18.90 weeks) and in third trimester (Avg. 30.92 weeks) were interviewed face-to-face and the Health Practices in Pregnancy Scale was re-applied. After the last measurement, pregnant women in the control group were given a pregnancy education booklet covering the educational content.

Descriptive data are presented as number, percentage, mean, Kolmogorov–Smirnov test, Chi-square test and Fisher's Chi-square test. The data gathered from the groups were compared with the one-sample t-test, independent sample t‐test, Bonferroni test and Pearson correlation test. All analyses were carried out using the SPSS for Windows, release 15.0 (SPSS, Inc. Chicago, IL, USA). A P value of <0.05 was thought to be crucial for all analyses.

Considering the descriptive features of individuals comprising the study group, the training group had a mean age of 25.25 ± 4.45, and the mean age of control group was 26.00 ± 4.86. Of all the women in the training group, 51.6% of them graduated from elementary school, 76.6% of them have middle income, 53.1% of them have first pregnancy, first delivery mean age of them is 22.44 ± 3.49 and all of them were housewives and all of them had social security. In the control group, 59.7% of women graduated from elementary school, 69.4% of them have middle income, 50.0% of them have first pregnancy, first delivery mean age is 21.29 ± 4.26 and all of them were housewives and all of them had social security. There was no significant difference between the groups (P > 0.05).

Comparing training group and control group before training, it was determined that the total score average of Health Practices in Pregnancy Questionnaire was 111.76 ± 10.84 in training group, 110.17 ± 12.37 in the control group and a significant difference was not obtained in the statistical analysis which was performed to compare the groups (t = 0.767, P > 0.05) (Table I).

Table I. The distribution of pregnant women's total mean scores on HPQ before and after the training

1 SD, standard deviation; t, independent sample t-test.

Comparing training group and control group after training in second trimester, it was determined that the total score average of Health Practices in Pregnancy Questionnaire was 142.12 ± 8.63 in training group, 124.48 ± 11.53 in control group and a significant difference was obtained in the statistical analysis which was performed to compare the groups (t = 9.735, P < 0.05) (Table I).

Comparing training group and control group after training in third trimester, it was determined that the total score average of Health Practices in Pregnancy Questionnaire was 149.31 ± 6.72 in training group, 125.66 ± 11.65 in control group and a significant difference was obtained in the statistical analysis which was performed to compare the groups (t = 14.017, P < 0.05) (Table I).

There was no significant difference between the mean HPQ scores of the pregnant women in the training and control groups before the training (P = 0.455). After the training, it was determined that the total score average of training group and control group had significant difference in the second trimester and third trimester (P = 0.000; Table II).

Table II. The distribution of pregnant women's Between Groups scores on HPQ before and after the training

• 2 a Bonferroni t-test.
• 3 b Independent-samples t-test.

When the total scores of pregnant women in both the training and control groups were compared, significant differences were determined between the first trimester and the second trimester and also between the second trimester and the third trimester (P = 0.000; Table II).

According to the analysis conducted to determine whether there is a difference between the mean scores of the training and control groups, there was a significant difference in terms of group, time and group * time interaction (P < 0.05; Table III).

Table III. The distribution of pregnant women's In-group scores on HPQ before and after the training

The difference between the total mean scores of the training group (three trimester periods) was analyzed by repeated-variance analysis. There was a statistically significant difference between the measurements (F = 659.941; P = 0.000). Bonferroni comparison test was applied to find out which group the difference originated from. There was a statistically significant difference between first trimester, second trimester and third trimester mean scores (P < 0.05) (Table III). In the training group, the second group scored more than the first group and the third group scored more than the first group.

The difference between the total mean scores of the control group (three trimester periods) was analyzed by repeated-variance analysis. There was a statistically significant difference between the measurements (F = 111.594; P = 0.000). Bonferroni comparison test was applied to find out which group the difference originated from. There was a statistically significant difference between first trimester, second trimester and third trimester mean scores (P < 0.05) (Table III). In the control group, the third group scored more than the first group.

Multiple regression analysis was conducted to explain the effect of individual counseling training on HPQ scores in the research groups. It is seen that the established model is statistically significant (F = 94.777; P < 0.005). In the second trimester, it was determined that 43% of the change in HPQ scores of training and control groups could be explained by individual counseling training (R2 = 0.433, P < 0.05) (Table IV).

Table IV. The effect of individual counseling training on health practices in pregnancy

4 *Variance Inflation Factors

In the third trimester, it was determined that 61% of the change in HPQ scores of training and control groups could be explained by individual counseling training (R2 = 0.613, P < 0.05) (Table IV).

In our study, it was determined that there was no significant difference between the scores of the education group (111.76 ± 10.84) and the control group (110.17 ± 12.37) on the Health Practices in Pregnancy Scale before education and individual counseling.

In Er's (2006) research it was revealed that pregnant women's Health Practices in Pregnancy Scale total average score was 127.197 ± 11.84; in Tirkes' (2012) research it was 121.57 ± 10.53 and in the study of Özcan and Beji (2015) it was 111.76 ± 18.53; in the study of Maddahi et al. (2015) it was 123.57; in the study of Çelik and Derya (2019) it was 114.43 ± 17.90 [16–18, 20]. When the results of these studies were evaluated, it was found that they were similar with this study, and the results of the study performed by Tirkes (2012) and Er (2006) on pregnant women had high values according to the results of the study obtained [15, 16]. This difference is thought to be due to the different possibilities of regions and groups where research is applied.

The goal of prenatal care is to protect the health of pregnant women and the developing fetus and improve the quality of life, correct the wrong habits, obtain accurate and new information on the correct behavior and practices to ensure the sustainability of parents in their new role, and to prepare for the period of processes of pregnancy and childbirth. Pregnant women who receive prenatal care adapt to the pregnancy period and the role of motherhood more quickly and easily [21]. To improve maternal and infant health in prenatal care, reduce maternal mortality rates and facilitate the adaptation of parents to pregnancy, birth and the postpartum period, education and individual counseling provided to pregnant women is important. The baby's healthy start to life is provided by the mother's healthy pregnancy process [22].

In the study, it was determined that the average score of the total score in the second and third trimester of pregnancy was higher in the group given individual counseling and education than in the control group and that there was a significant difference (P < 0.05). When the data were evaluated, it was determined that there was a positive change in the health practices of pregnant women who received education on subjects such as pregnancy, pregnancy follow-up, drug use, immunization, sleep and rest and hygiene, and that the education program was successful.

When the literature is examined, the level of knowledge of the pregnant women who receive education on subjects such as pregnancy, pregnancy follow-up, medication, immunization, sleep and rest and hygiene was more than the pregnant women who do not receive such an education [14, 23–32].

When studies were evaluated, it can be said that prenatal education has a positive impact on protecting the pregnant women and the developing fetus and improving the quality of life, correcting the wrong habits, obtaining accurate and new information ensuring the sustainability of correct behavior and applications, adapting the parents in their new role, to the period of pregnancy and birth.

During the natural process of pregnancy, some physiological and psychological changes occur in the body of the pregnant woman. The pregnant women should be informed about the changes that occur during the pregnancy and about the procedures that should be done routinely. Information about the pregnancy period, the frequency of going to check-up and what tests will be done in which month should be given. Most of the causes of maternal death during pregnancy are preventable causes such as prenatal care (PC) and malnutrition and inability to adequately utilize health services. The midwives provide education on health practices in pregnancy by providing individual counseling to the pregnant woman and her family and will ensure that the family has information about the pregnancy and the babies that will be born and that the pregnancy process is comfortable. Preventive health and counseling services within the scope of mother and child health is necessary. The education of the pregnant woman is very important in terms of raising the mother's awareness and contributing to the baby's and mother's health in addition to the routine controls performed during pregnancy [33].

In our study, there was a significant difference between first, second and third trimester scores when the pregnant women in the education group and control group compared themselves. In the education group and control group, significant differences were found in terms of interactivity between group, time and group*Time. In the study, it is thought that the significant change in the education group is due to individual counseling education, the significant change in the control group is due to the prenatal care given to the pregnant women in the first and second step and the information received from various sources.

The pregnancy period gives them time to adapt to their parenting role. During this period, mother and father candidates take various initiatives such as counseling from health institutions, reading books, following the written press and attending birth preparation classes [34]. However, in recent years, especially with the ease of access to the internet through mobile phones and computers, they have started to look for answers on issues such as pregnancy and childbirth on the internet. However, parents want to get accurate and reliable information about pregnancy, birth and baby care from health personnel. Many studies are showing that pregnant women and their families prefer to receive information/counseling and care from a health care provider [35, 36]. In our study, it was observed that the scale scores of both the trained group and the control group increased during pregnancy. But it is also a fact that the scores of the group receiving education and counseling are higher than those of the control group.

The main objectives of the education carried out in order to inform the pregnant women are to provide knowledge and skills on important issues such as ensuring harmony in pregnancy, birth and puerperant processes, conscious birth and adoption of new roles [37]. Education that will meet the needs of pregnant women and provide the right information during this period is defined as a behavior change process. It is very important for pregnant women to be able to turn their education into behavior and to meet their needs with a good education and to be supported by all sides.

In our study, it was determined that 43% of the change in the second-trimester scale scores of pregnant women in the education group and 61% in the third trimester could be explained by individual counseling and education.

Education is defined as the process of gaining desired behaviors in accordance with the education given about a subject in individuals, rather than loading information. It is aimed that the information given through education, which is not a static but a dynamic process, is converted into behavior and that these behaviors are maintained and made into a way of life. As shown in the literature, it has been determined that the pregnant women who receive education turn their education into correct practices by bringing them into the way they behave [14, 23–32].

Since the general purpose of education is to change behavior in the individual, it is expected that the behavior of the individual going through the education process will change in the direction of education and in the desired direction. When the research is evaluated, it can be said that it parallels our research that individual counseling education during pregnancy creates behavior change and positively affects her life permanently.

As a result of the research, it has been determined that there is a significant difference between the health practices of pregnant women who receive individual counseling training and those who are not trained and that individual counseling and training positively affects the health practices of pregnant women. It has been determined that the training provided with individual counseling to pregnant women is an effective initiative in increasing the health practices of pregnant women.

Supplementary data are available at HEAL online.

None declared.

This research was approved by the Ethical Board of Celal Bayar University. The necessary written permissions for using the 'Health Practices in Pregnancy Questionnaire' were obtained from ER, who makes its validity and reliability. Governor of Manisa and Manisa Directorate of Public Health approved the study protocol. The participants were recruited to the study on a voluntary basis. Before any meetings took place, the researchers informed the participants about the purpose, length and benefits of the study, and the written, informed consent of the participants was obtained.

Graph: Fig. 1. class="chapter-para">Consort chart of the study. Reference: Consort Diagram, 2010 , Moher D, Schulz KF, Altman D. The Consort Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomised Trials.