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Perspectives of Italian pregnant women on pregnancy examinations and pregnancy care: is the caregiver more important than the care?

Aim: Assessing awareness of Italian low-risk pregnant patients on low-risk pregnancy care and what do they feel about their own pregnancy. Methods: A questionnaire was administered to 382 low-risk pregnant women. This questionnaire assessed general knowledge of low-risk pregnancy, low-risk pregnancy care, and how much patients rated ten topics of low-risk pregnancy care. It would be expected that the knowledge of each topic would associates with the patient’s perceived importance of that topic. Results: Poor knowledge of pregnancy care was proven. Patients seem to incorrectly overrate vaginal examinations and obstetric and gynecologist-led care, while they attribute appropriate importance to midwife-led care. The more examinations performed (vaginal examinations, sonographic checks, cardiotocographies), the higher their rating. Conclusions: In Italy, expectations of pregnant women about their own pregnancy are incorrectly trusted in the obstetrics and gynecologists. Both poor knowledge of pregnancy care and cultural perspectives on the birth process amongst Italian people explain the finding. Referring low-risk pregnant women to midwives would help them to rate more the care than the caregiver. (www.actabiomedica.it)


Introduction
A 2010 study carried out in a large Italian hospital facility reported that medical intervention during labor and delivery seemed excessive, even in low-risk pregnancies (1). In that study, the authors postulated that the hospital's policy to medicalize low-risk pregnancies likely caused the unnecessary rise in Cesarean sections. Evidence suggests that midwife-led pregnancy care results in fewer unnecessary medical interventions in Italy (2). This is also what the World Health Organization has suggested (3). However, there is little published clinical evidence from Italy regarding midwife-led pregnancy care. For example, a search of "midwife led care" and "Italy" on the Pubmed search engine (the 9 of January 2021) resulted in only 17 publications. Of the 17 publications, only seven were published from Italy (2,(4)(5)(6)(7)(8)(9). Three of the publications assessed birth outcome of the midwifeled natal care (5,7) but none reported data on midwifeled pregnancy care. This finding may be explained by poor awareness or acceptance by Italian people of the management role of midwives in pregnancy and birth.
Italian health workers can be held criminally liable in the event of a bad pregnancy outcome (see for example 10-12). Therefore, Italian midwives may be hesitant to provide pregnancy care out of fear of litigation and behaviors of defensive medicine (13,14).
The midwives' hesitancy may strengthen the perception amongst Italian people that pregnancy care must be provided by obstetrics and gynecologists.
Other factors that can influence the use of midwife-led pregnancy care include different policies and criticality in Italian hospitals (15,16), regional and local perspectives of patients and other stakeholders about the birth process (17)(18)(19), threats of litigation and violence by some patients to health workers (17)(18)(19)(20), and flaws in counseling (21,22). Together, all of these factors contribute to the heterogeneous feelings of Italian people about pregnancy and birth.
It is thus perhaps not surprising that Italian pregnant women are at least confused about their pregnancy care options and make decisions for their pregnancy care based on their cultural perceptions, instead of based on appropriate information.

Aim
The aim of this study is to assess how aware lowrisk Italian pregnant women are of the pregnancy care options available to them and their perception about their own pregnancy management experience.

Study design
A questionnaire was developed targeting low-risk pregnant women. In the first section of the questionnaire, patients were asked to provide general information about their age, occupation, education, parity, nationality, marital status, zone of Italy where they came from (North, Center, South or Islands), and type of care (specifically: public care, private care, both public and private). In the second section, patients were assessed on their general knowledge of ten topics regarding pregnancy and pregnancy care. The ten topics investigated were: vaginal examinations, sonographic checks, blood lab analyses, cardiotocography, midwife-led care, obstetrics and gynecologist-led care, vitamins and iron supplementation in the third trimester, delivery courses, food cooking and feeding care, and physical activity during pregnancy (Table 1, questions  7 to 29). The patients were then asked to rate their perceived importance of the topics using a 5-point Likert scale, from 1 (lowest importance) to 5 (highest importance). The third section of the questionnaire (Table 1, questions 30 to 39) assessed the patients' knowledge of each of the ten topics reported above, using information from the Italian guidelines for low-risk pregnancy care available at the time of questionnaire (23-25) or evidence-based literature (26)(27)(28)(29)(30). We expected that the knowledge of each item would associates with the patient's perceived importance of that item.

Sample
Patients were prospectively enrolled at the Fabia Mater Clinic of Rome (www.fabiamater.it) between February 2018 and September 2018. Women between 37 and 42 weeks of pregnancywere screened for obstetric risk and patients with high risk pregnancies (pregnancy complications and/or pre-gestational diseases) were excluded from the interview. After screening, a printed questionnaire was administered to the selected low-risk patients. From June 2019 to October 2019, more patients were added to the study by diffusing an online version of the questionnaire. The questionnaire was shared on social networks and pregnancy blogs. The online version of the questionnaire screened for obstetric-risk and only enrolled low-risk patients between 37 and 42 weeks if pregnancy, for consistency with the 2018 sample. The three sections of the questionnaire used for the study were the same regardless of whether the patient joined in 2018 or online in 2019.

Statistical analysis
The relationship between patients' knowledge of the ten pregnancy care topics and their perceived importance of each topic was determined by performing odds ratio calculations with the Likert score attributed to each topic. A Likert rating of 4 or 5 points was categorized as a high Likert score, whereas a Likert rating of 1, 2, or 3 points was categorized as a low Likert score.
As an additional analysis, odds ratios between Likert score (high Likert score or low Likert score) and -number of vaginal examination performed, number of sonographic checks, -number of blood lab analyses, number of cardiotocographies, -midwifeled care, -obstetrics and gynecologist-led care, -vitamins and iron supplementation in the third trimester, -delivery courses, -food cooking and feeding care, -physical activity were calculated. The analysis assessed the then main topics from a quantitative view, aiming to determine if patients who received more examinations during their pregnancy or who followed specific items overrated the importance of the examinations or of items in pregnancy care. Statistical analyses were performed using Libre Office 6.4 Calc (for descriptive calculations) and IBM SPSS statistics 27 (for odds ratio calculation, with inference).

Ethics
The Ethical Committee of the Fabia Mater Clinic authorized this study. Patients were informed that the data would be used for scientific investigation in aggregate format, according to current Italian law, and provided their permission.

Results
A sample of 404 pregnant women was surveyed in this study. Twenty-one patients were excluded because they were not at term, while one more patient was excluded as she disclosed she took heparin during pregnancy after the interview. Therefore, 382 low-risk pregnant patients constituted the sample for this study. The mean age of patients was 31.2 years (± 5.37 ages, limits 18-48). Two-hundred-twenty-eight (59.7%) women were married, and 348 were Italians (91.1%). Eight patients (2.1%) came from other countries, 148 (38.7%) came from the North of Italy, 126 (33.0%) came from the Center of Italy, and 100 (26.2%) came from the South of Italy. Two-hundred-eighty-eight women (75.4%) were employed, and 150 (39.3%) were multiparas. One-hundred-forty-three women (37.4%) received private care, 75 (19.6%) received public care, and 164 (42.9%) both public and private care. Table 1 reports the results of the answers to the second and third section of the questionnaire. Table 2 reports the odds ratio values (and 95% CI) among number of examinations performed and perception of the importance attributed to examinations. Table 3 reports the odds ratio values (and 95% CI) for patients' knowledge of the topics and their importance rating. We found that two of the ten topics did not have a knowledge level that seemed to coordinate with the patient's perceived importance of that topic: vaginal examinations and obstetrics and gynecologistled care ( Table 3). The last column of Table 3 reports the interpretation of odds ratios for understanding.

Discussion
This study assesses Italian pregnant women awareness of low-risk pregnancy care. Results suggest that Italian women generally have poor knowledge about low-risk pregnancy care and overrate the role of obstetrics and gynecologists in managing their pregnancy (Table 3).
The importance of vaginal examinations was also overrated by the surveyed patients. We suggest that overrating the importance of vaginal examinations during pregnancy led patients to overrate the importance of the obstetric and gynecologists' role in pregnancy, as pregnant patients receive these vaginal examinations from a physician. This issue is complicated by the legal system in Italy (31). In low-risk pregnancies, the counseling on pregnancy examinations and care should be appropriate to produce an appropriate perception of obstetric risk of adverse outcomes. If patients understood that even low-risk pregnancies may have unpredictable adverse outcomes, they may be more accepting of bad outcomes when they occur, and less likely to pursue criminal litigation from their health-care providers. With education, the culture in Italy may shift such that a good pregnancy outcome is not perceived to be a physician's merit and a bad pregnancy outcome is not perceived to be a physician's failure.
Patients seem interested to learn more about pregnancy, as they reported that they have sought information on pregnancy on the Internet and have been *The choice of 3 vaginal examinations as cut-off has been arbitrary. It was judged appropriate at least 1 vaginal examination for trimester. **Italian law allows to have for free 3 sonographic examinations in low-risk pregnancies (one sonographic check for trimester). ***The median value of the number of blood lab analyses was 9 (limits 0-15): the limit for dichotomizing variable was set to 8 aribitrarely, basing on median value. Table 3. Assessment of concordance between higher importance attributed (Likert score 4 and 5) and knowledge of each topic.

Topic Questions (number)
Odds ratio 95% CI Interpretation conditioned by the experiences of friends and parents (Questions 5 and 6). Moreover, patients seemed to be aware that midwife-led pregnancy care is advisable for low-risk pregnancies (Table 3).
As a consequence of physicians dominating the provision of pregnancy care in Italy, more unnecessary examinations in pregnancy are performed. The high number of examinations increases the odds ratio of rating the examinations as more important ( Table 2), suggesting that medicalizing low-risk pregnancy leads to incorrectly overrate the importance of examinations in achieving a good outcome during delivery.
This study is not able to explain why patients receive many vaginal examinations during pregnancy. An Italian survey on the roots of the failure of the socalled "choosing wisely" has suggested that patients' queries and legal pressure may influence the behavior of performing more unnecessary examinations (32). Thus, it seems that both cultural perspectives and liability issues drive pregnant patients to seek out Knowledge that avoiding to eat some foods or cooking them may prevent some infectious diseases in pregnancy (Q38)

Exercise
High rating of importance to make physical activity****** (Q28) Knowledge that moderate physical activity does not affect pregnancy outcome (Q39) *One answer was not given. **Five answers were not given. ***Two answers were not given. **** Eight answers were not given. *****Thirteen answers were not given. ******Twenty-four answers were not given.
Odds ratios were calculated exluding cases with one or more missing data.
physicians for their pregnancy care instead of midwives. The obstetrics and gynecologists recommend more unnecessary examinations, resulting in patients overestimating the importance of not only the obstetrics and gynecologist role, but the examinations as well. Overrating the obstetrics and gynecologist may cause patients to believe that adverse pregnancy outcomes are always due to malpractice and reinforce cultural beliefs that good pregnancy outcomes are always a direct result of a physician's skills. These beliefs ultimately increase legal pressure on both physicians and midwives, as well as other health care providers who may be held criminally liable for adverse outcomes despite them being outside of the provider's control. Selection bias of the study may have occurred due to the recruitment of at least some patients into the study from a private health care facility. The answers provided by these patients would be heavily influenced by their experiences using private care. However, many Italian women choose private care to manage their pregnancies (33). This choice strengthens our hypothesis that Italian pregnant patients attribute excessive importance to the caregiver rather than to the care itself, as found in our survey.
In conclusion, low-risk pregnant women have generally poor knowledge about pregnancy care and place more importance on the caregiver, the obstetrics and gynecologist physicians, than the care itself. Italian Governmental Institutions should better inform low-risk pregnant women on the most appropriate pregnancy care, such as the benefits of using midwifeled instead of physician-led pregnancy care. Italian Governmental Institutions must concurrently develop policies that ease the legal pressure on Italian health workers.
The study was conducted at the Fabia Mater Clinic of Rome (Italy) and online.