Abstract
Pregnancy and childbirth are two significant events for women and families, that readiness for these two events is linked to its successful outcomes. Worldwide, most of pregnancies are unplanned, which in some cases, limit the optimum pregnancy care affecting the prevention for maternal morbidity and mortality. This protocol aims to describe a method to develop a pocketbook for women and family for preparing pregnancy and childbirth. The study design follows the model of Research and Development (R&D) using 4D development model: namely define, design, develop and disseminate. Data collection applied up-to focus group (FG) discussion with women, families and healthcare professionals in Bantul District Yogyakarta. The first and second FG will discuss about the importance of the pocketbook for women, and its expected content. The third-and fourth FG will finalize the book and its potential implementation in practice. Analysis of the data applied thematic models. The study period will take place from July 2024-July 2025. This study is expected to develop a comprehensive and easy-to-understand family pocketbook, containing important information related to pregnancy and childbirth preparation. Subsequently the pocketbook is expected to help prepare families’ readiness in supporting women during pregnancy and childbirth in Indonesia.
Three points:
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There is a need to prepare women and families about planned pregnancy and childbirth, aiming to provide information and appropriate arrangements.
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This protocol aims to describe a method to develop a pocketbook for women and family for preparing pregnancy and childbirth using 4D development model.
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The expected developed pocketbook is able to assist women and families’ readiness during pregnancy and childbirth and subsequently optimize the success of pregnancy care.
Keywords: Preconception care, Education, Pocketbook, Family support
Method name: Designing Preconception Family Pocketbook
Graphical abstract
Specifications table
| Subject area: | Medicine and Dentistry |
| More specific subject area: | Preconception care |
| Name of your method: | Designing Preconception Family Pocketbook |
| Name and reference of original method: | NA |
| Resource availability: | NA |
Background
Pregnancy is a physiological process for women and marks the beginning of life for the next generation. Physical and mental readiness are essential for achieving a healthy pregnancy [1]. Many women plan to conceive but do not prepare adequately, increasing the risk of miscarriage, premature birth, unintended pregnancy, and death. Unplanned pregnancies account for 40 % of the 85 million pregnancies worldwide, with 38 % resulting in miscarriage, abortion, or unplanned childbirth [2]. In Indonesia, the incidence of unintended pregnancy remains high (17.5 %) [3].
Preparing for pregnancy is crucial as it affects the women condition, as well as fetal development throughout pregnancy [4]. Family preparation for pregnancy in Indonesia is complex and involves multiple aspects. Unprepared pregnancies can lead to significant negative consequences [5]. Research shows a strong association between unplanned pregnancy and poor maternity care, such as, health seeking behaviour and prenatal care were suboptimal among women with less planned pregnancies such as delayed booking, fewer than the recommended clinic visits, not attending antenatal classes, peri‑conceptional folic acid consumption [6].
Therefore, it is crucial to emphasize proper pregnancy planning and preparation to reduce risks associated with unintended pregnancies. While it is also necessary to promote health through communication; information and health education regarding the importance of family planning and unplanned pregnancies are also essential to improve the health behavior of women in reproductive ages in Indonesia [7]. Strategies of promoting preconception care to expectant couples, especially to young and multipara women should also be developed to further enhance the utilization of the services at the community level [8]. Furthermore, access equity for all women as the key to succeeding the preconception care in LMICs [9].
One of the strategies to improve preconception education is using pocketbooks, which was previously shown as effectively used as preconception nutrition education for women [10]. Currently, the promotion book related to maternal health is also given for women during their pregnancy periods in Indonesia, or known as the Kesehatan Ibu dan Anak (KIA, Eng: maternal and child health) book. This book provides the essential information needed for pregnant women and child health; however, it only covers limited information before the pregnancy occurs or during the preconception periods. Furthermore, strategies for improving the awareness of the importance of pregnancy planning and the benefits of preconception care among reproductive-age couples need to be further explored, such as their preparation as pregnant couples, roles, and transition, as well as socio economic preparation to welcome the children [8]. Therefore, the need to provide this information is essential; this study protocol then describes the methods of developing family guide in preparing for pregnancy and birth.
Method details
Study design and study periods
This study uses qualitative approach. The design of this research is development research which refers to the model research and development or Research and Development (R&D). Development research is method research used to produce certain products and test the effectiveness of the product. This study adapts the 4D development model (four-D) by Thiagarajan (1974) [20]. The study process begins from formulating of the book design and ends with assisting implementation for the families. The development of products will be arranged based on the need of mothers and families, and designed attractively and interactively, following the current trend Fig. 1.
Fig. 1.
Stages of the study.
The 4D development model consists of 4 stages FGs, namely define, design, develop and disseminate. Below are the research steps adapted from the four-D.
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Stage 1: Define
Define stage aims to define the material to be included in pocketbook. Definition step includes first focus group discussion (FGD) from women to explore their needs about pregnancy and childbirth information. The first discussion with health care professionals is also conducted to formulate information that is usually conveyed to patients based on education experiences. All the arguments will be added and considered to the content of the books.
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Stage 2: Design
This stage involves completing materials from World Health Organization (WHO) and Indonesian Ministry of Health recommendation, outlining the draft content for the pocketbook, designing the draft layout, and developing the text and images for the guide. Advice that is gathered from potential users—patients, pregnant mothers, bride to be validated by material experts, including obstetricians, gynecologists, family medicine specialists, general practitioners, and midwives, as well as by media experts.
This pocketbook will also be designed and compiled considering trends such as using colorful designs, adding graphic images, and choosing simple words for families. The book will be equipped with a reader's checklist that helps users to record and remember the content they have finished reading. Here, the second discussion group forum was held to provide reviews and ask for advice regarding the draft book that had been designed.
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Stage 3: Development
In the development stage, the pocketbook is tested with small groups of women, families and the health care professionals to gather the feedback. Revisions are made based on this feedback in third FGD, followed by large-group testing. The final product is prepared after these evaluations. This process will identify, weaknesses, strengths, barriers and supports in the use of this book.
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Stage 4: Distribution
The final pocketbook is distributed to three Puskesmas (Primary Health Care Clinics) locations used as research facilities in Bantul District, Yogyakarta. This book will be given to mothers who are planning to get pregnant and women who are going to get married. They will be identified through examination records at the Puskesmas and given this book at the first visit. Therefore, during the pregnancy process and preparing for childbirth, mothers and families have adequate information. This stage is planned to be conducted once the pocketbook has been finalized.
Study setting
This study will be conducted in three Puskesmas in urban and rural regions of Bantul, Yogyakarta, Indonesia, for five-months during July 2024-July 2025. Puskesmas serves as an ideal setting, as supported by literature indicating that primary health care is the most suitable for preconception care and services [9]. Moreover, the high patient attendance at Puskesmas enhances opportunities for preconception counseling, including pregnancy preparation [9]. The locations were chosen based on the Maternal Mortality Rate (MMR) data that Bantul Regency is the highest MMR in the Special Province of Yogyakarta [11]. The MMR in Bantul saw a significant increase from 2018 to 2021 which it raised from 10–11 cases to 14 cases. In 2019 decrease to 13 cases but rising again to 20 cases in 2020 and peaking at 43 cases in 2021. Several factors contribute to this rate, including bad medical conditions, unwise maternal pregnancy risk management, early marriage, and a lack of maternal awareness regarding their pregnancy risk.
Study sample and recruitment
A purposive sampling strategy Is used to recruit participants who were considered to have relevant experiences and insights aligned with the objectives of the study. Woman participated in the study are those attending pregnancy classes at Puskesmas, as they were actively involved in antenatal care. Their partners or family members are also invited to participate in FGD to capture diverse perspective. In addition, health workers who participated in the discussions were specifically selected based on their direct involvement in providing maternal and child health services in Puskesmas. This research is attended by up to 20 women, their partner or family and up to 30 primary healthcare professionals (general practitioners (GPs), nurses, midwives, and dieticians). The sample size was determined based on feasibility and its participation in conception care program in Puskesmas. Each of the different participant groups will only participate in FGD according to their background, i.e. women participants will only participate in women FGD, family members with family members FGD, midwives with midwives FGD, etc.
They will participate in separate focus group discussions (FGDs) three times, In the first FGD, participants will discuss key topics for a book of pregnancy and childbirth preparation. The insights from first session shape the next FGDs. Second meeting aims to refine the pocketbook content based on feedback. Finally, in the last session, participant finalize and review the pocketbook. All of participant were identified from three Puskesmas which are recommended by the local health office in Bantul. They have all been provided with information about the research, and consent has been sought for their participation. These participants are actively providing opinions/input regarding the material to be included in the pocketbook at the discussion.
Data collection
Data collection was carried out by asking questions to participants through forum group discussion (FGD) which is conducted in three stages. This discussion will be conducted after obtaining approval from the ethics committee which take place between July-November 2024. Participants will attend a FGD which is in three stages according to participant criteria, both offline and face to face in three Puskesmas in Bantul, as well as online via the zoom meeting application for 60–90 mins. In the third discussion all participants will be combined into 1 session. The questions guide for the discussion in this study showed in Table 1. The detailed plan for implementing the discussion is as follows.
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FGD 1: The goal is to brainstorm the material for the family guide pocketbook on preparing for pregnancy and childbirth. The outcomes of FGD 1 will serve as input for FGD 2.
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FGD 2: The aim is to further develop the contents of the pocketbook and identify any additional material or inputs not covered in the first discussion.
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FGD 3: This discussion focuses on finalizing the family guide pocketbook for preparing for pregnancy and childbirth. Discussions from each discussion will be recorded, and a summary report will be shared with participants, with their consent.
Table 1.
Discussion guide.
| Forum Group Discussion 1 |
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For women
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For healthcare professionals
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| Forum Group Discussion 2 |
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For women and healthcare professionals
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| Forum Group Discussion 3 |
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For women, partners, and their family
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Trustworthiness
Several strategies are adopted to ensure the trustworthiness of the qualitative data. Credibility will be enhanced through member checking [12] which conducted after each discussion with selected participants by summarizing key points and asking participants to confirm the accuracy of interpretations. Dependability will be ensured by maintaining audit trial [12] based on data collection in Puskesmas and involving independent peer debriefing [13]. Two researchers will independently code all transcripts. Coding discrepancies will be discussed collaboratively until consensus is reached. To support transferability, thick descriptions of the research context [12,13], participants characteristic, and data collection process will be used to draw conclusions about the results of FGD.
Ethical considerations
All participants will be asked to provide written informed consent prior to participation, including explicit consent for Zoom and for audio recording of FGD. At the beginning of each discussion, the researcher informs participants that discussion will be recorded and stored securely and accessible only to the research team. To ensure confidentiality during online sessions, FGD will be conducted via password-protected Zoom meetings that only invited participants and team. Transcriptions will be anonymized, with all identifying information removed during data processing stage. Finally, all data are managed in accordance with ethical standards for confidentiality and data protection.
Data analysis
Analysis of the data obtained from the discussions carried out thematic and or according to the chronology with the following steps by Patton (2015) [14]. An inductive approach will be used to allow themes to emerge directly from the data rather than being guided by predefined categories. Firstly, the recordings of discussions with healthcare professionals and patients, as well as those from the evaluation stage, will be transcribed and uploaded into NVIVO software, including important notes on discussion progress and participant gestures and non-verbal cues will be noted and discussed with the research team members. Then, the transcripts will be coded to capture key points expressed by participants to develop themes and subthemes independently by two research members. The themes and subthemes will be organized and discussed with the research team to establish the main themes, and to ensure mirroring and member checking strategies. Finally, validation of the main themes and narrative of the research results will be conducted until agreement on codes developed [14].
Method validation
This study will produce a complete and easy-to-understand family pocketbook, containing important information related to pregnancy and childbirth preparation. This book is expected to help women, partner, and families in facing the pregnancy and childbirth process better. With this pocketbook there will be an increase in knowledge and family readiness in supporting pregnancy and childbirth. Data collection through FGDs will obtain positive acceptance from health professionals and families regarding the contents and usefulness of this pocketbook. Validation from health professionals, such as obstetricians, midwives, and general practitioners, is expected to strengthen the accuracy of the information presented.
An explanation of how this pocketbook is designed to be an easy-to-understand resource for families. In compiling the preconception education book, the results showed positive appreciation from women of childbearing age through trial use [15]. Based on previous research, there was an effect of preconceptions nutrition education by presenting a pocketbook on knowledge, attitudes, and values of those using it [10]. This book helps health professionals in providing preconception-related health promotion to allow for risk assessment, intervention, and medical optimization before pregnancy to reduce the chances of poor obstetric, maternal, and fetal outcomes [15,16].
In Indonesia, the government has launched a book for pregnant mothers, namely the KIA (Kesehatan Ibu dan Anak; Eng: maternal and child health) book, which is essential to monitor the health of the mother, baby, and child up to the age of six [17]. The KIA book contains information and education materials on maternal and child nutrition and health, a pregnancy card, a growing monitoring chart (KMS) for toddlers and records of maternal and child health services. This book is usually attached only to mother in its utilization, and they consider the book as a notebook only. In fact, only about 58.7 % mothers occasionally use the KIA book, and 33.3 % read the KIA book together with a midwife [18]. Therefore, the development of this pocketbook is expected to bridge the knowledge gap among women and families.
The KIA book will be distributed to pregnant women when they register their pregnancy [19]. In Indonesia, women usually receive the KIA book when they check their pregnancy at the Puskesmas. On the other hand, this pocketbook is designed to serve as a comprehensive guide for women and partners, not only throughout the continuum of pregnancy to early parenting, but also during the preconception period, By making the pocketbook accessible to couples shortly after marriage, it aims to enhance preconception knowledge, promote early health seeking-behaviors, and support informed decision-making regarding future pregnancy. The awareness and insight of being a couple of husband and wife need to be elevated to prepare themselves for the beginning of pregnancy [10]. Moreover, the pocketbook is designed to be more accessible, portable and engaging than the traditional KIA book.
This study design contains of upstream to downstream concepts. Discussions with women and health professionals in this study were an important reference to develop this book based on the needs of the target. This book is designed by considering current issues and based on the experiences of mothers; therefore, this pocketbook is considered applicable. In addition, the visualization of the book will be designed attractively, and the use of easy-to-understand words will help users to apply it easily. There are some details about key content, such as pregnancy preparation, the birth process, and the roles of family members. Some preconception health promotion content explains about how medical management of all chronic diseases before conception, knowledge related to immunization status, the importance of screening patients for sexually transmitted infections and genetics, assessing nutritional status and nutrients and exposure to substances in the environment [15].
Because of its comprehensiveness, this pocketbook is expected to provide a significant impact compared to other methods. In other studies, it is stated that education with pocketbooks is more effective than the lecture method in increasing knowledge and in improving attitudes [10]. The novelty of this pocketbook lies in its design which is based on women’s experiences and need, as well as directly validated by healthcare professionals in the community.
In conclusion, this study protocol describes the structured process of the development of a comprehensive, practical, and easy-to-understand family pocketbook for pregnancy and childbirth preparation. This book is designed to improve family knowledge and readiness in supporting women during pregnancy and childbirth through a series of focus group discussion and validation by health professionals, this pocketbook is expected to be well received by users and health professionals and has high information accuracy. And subsequently to prepare women with a more positive pregnancy experience.
Limitations
This study emphasizes the design of a contemporary pocketbook for mothers and families; thus, it can serve as a reminder of the importance of knowledge and preparation for pregnancy and childbirth for mothers, spouse, and families. While the design of this book development involves the users themselves, making it considered practical for implementation, in the first stage it only identified the information needs of mothers. To make the book more comprehensive, further studies need to consider the opinions of partners or families about the book.
Ethics statements
This study has received ethics approval from Human Ethics Committee Faculty of Medicine Public Health and Nursing Universitas Gadjah Mada number KE/FK/0598/EC/2024, as well as permission from the Bantul Local Government and selected primary health care (Puskesmas).
CRediT author statement
All authors contributed to the study design. DAN and FME wrote the initial draft for the manuscript development, as well as NNR, HRAL provided methods feedback. All authors have agreed to submit and publish this manuscript in this academic journal.
Funding
This study received funding from the Community Research Grant 2024, Faculty of Medicine, Public Health and Nursing, universitas Gadjah Mada.
CRediT authorship contribution statement
Dhiana Ayu Novitasari: Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. Novita Nur Rohma: Visualization, Writing – review & editing. Harti Rahmi Aunurul Lisa: Conceptualization, Data curation, Writing – review & editing. Fitriana Murriya Ekawati: Conceptualization, Data curation, Investigation, Methodology, Validation, Supervision, Writing – review & editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Related research article: None
For a published article: None
Data availability
No data was used for the research described in the article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No data was used for the research described in the article.