Perceptions and behaviour of pregnant women in socioeconomic deprivation in rural areas. A qualitative study in France

Abstract Background Socioeconomic deprivation (SED) is a risk factor for complications during pregnancy and childbirth, the impact of which has been studied poorly in rural areas. Aims To explore the perceptions and behaviour of women living in SED in a rural area with regard to their pregnancy follow‐up. Methods A qualitative study using semi‐structured individual interviews was carried out in a rural area in central France. To participate, the women had to have an Evaluation of Deprivation and Inequalities in Health Examination Centres deprivation score ≥ 30.17, be living in a rural area and have given birth during the month before the interview. The interviews were analysed using a thematic approach inspired by grounded theory. Results Seventeen women were interviewed. The difficulties of life in a rural area were linked to geographical remoteness, travel costs, lack of public services, inadequacy of nearby healthcare and social isolation. In all cases, pregnancy was an additional difficulty. The adaptive capability was related to the presence of an efficient family and social network. Most of the time, any increase in the limitations exceeded the ability to adapt and affected the medical follow‐up of the pregnancy, although follow‐up appointments were rarely abandoned altogether. Perceptions of birth preparation and parenting sessions were often limited to advice on pain management. Due to their affiliation with their rural area or their choice of lifestyle, the women complained only minimally. Conclusion Women often minimize any limitations and implement adaptive techniques that make identification by social and medical services more difficult. Patient or Public Contribution Eighteen women in SED were contacted by Childhood Medical Protection, midwives and general practitioners practising in rural areas. One woman declined participation and seventeen were interviewed.


| INTRODUCTION
In France, 20% of the population live in rural communities and 5% live in isolated areas. 1 This is partly the result of an urban exodus that began in the 1980s. In parallel, there has been an increase in the number of young families living in rural areas. 2 Among the deprived social categories in rural areas are farmers in financial trouble, people who have been victims of deindustrialization, neorurals, young people without qualifications or from broken families and lowincome families searching for cheap accommodation. These categories benefit from minimum social rights. 3 Social minima are allocated by the government and aim to ensure a minimum income for certain categories of people with low resources.
Rural areas suffer the disadvantage of having fewer medical gynaecologists, obstetrician-gynaecologists, general practitioners (GPs) and midwives. 4 As was the case in other developed countries, 20% of French maternity units closed between 1998 and 2003, and the hospitals that remain still offer insufficient capacity to handle all pregnancies. 5 Recommendations made by the French National Health Authority (Haute Autorité de Santé) in 2010 improved pregnancy follow-up. Nevertheless, access to care for populations characterized by socioeconomic deprivation (SED) remains a matter of grave concern. 6 The latest national perinatal surveys show that SED has increased recently among pregnant women. 7 The socioeconomic difficulties of rural compared with urban populations are linked to poor antenatal follow-up 8 and more maternal-foetal complications. 9 The outcomes of pregnancies in women who live in rural areas are characterized by more maternal and perinatal complications. 10,11 The interplay between life in rural areas and uncertainty of pregnancy follow-up has been studied only rarely. The objective of this study was to explore the perceptions and behaviour of pregnant women in SED living in rural areas.

| Study design
We chose a qualitative method based on an exploratory approach, suitable for collecting information on life experiences. Harsh living conditions and the possible discriminating effect of SED perceived by some women meant that this investigation was conducted via individual interviews. The region chosen for this study was the Auvergne region, consisting of four counties with a population density of half the national average (50 inhabitants/m²), 3 being more severely affected by SED, at 18.2% in the four counties versus 14.1% for metropolitan France. 12 The Auvergne region is poor in terms of primary healthcare provision and lacks gynaecologists, midwives and sometimes GPs. The closure of local hospitals, emergency services and nearby maternity hospitals has created additional difficulties of healthcare access for these populations. 13 A positive Consultative Ethics Opinion was obtained Comité de Protection des Personnes Sud Est VI, Clermont-Ferrand, IRB 8526.

| Participant recruitment
The study was intended to apply to adult women living in rural areas in Auvergne, in SED and having given birth a maximum of 1 month beforehand, as well as being sufficiently fluent in French for the survey. The Evaluation de la Précarité et des Inégalités de santé pour les Centres d'Examen de Santé-Evaluation of Deprivation and Inequalities in Health Examination Centres (EPICES) score was chosen to assess SED because it accounts for the multidimensional nature of SED. EPICES is a validated obstetrics score, 14 established using an 11-question questionnaire with binary responses (yes/no) to show a score-vulnerability-dependent relationship. 15 On a scale of 0-100, a score of 30.17 defines the deprivation threshold.
Participants were recruited according to the theoretical sampling technique. 16 The criteria for the sample included the main indicators of social position, lifestyle and health in connection with the research question, namely age, marital status, socioprofessional category, level of education, financial positioning, geographical isolation (time to the maternity unit ≥30 min), social isolation, parity, planned pregnancy, declaration of pregnancy before 15 weeks of amenorrhoea, high-risk pregnancy, pregnancy complications and referral to healthcare professionals for pregnancy follow-up (midwife, GP, medical gynaecologist or obstetrician-gynaecologist). Recruitment took place in all four counties of Auvergne. Childhood Medical Protection (CMP) were contacted, together with midwives and GPs practising in rural areas.
An information sheet about the study and methodology used was provided to each woman contacted. An informative questionnaire was completed by each participant before her recruitment, allowing the researchers to calculate the EPICES score and check the variables determining the sociological profile. These sheets were given out by the midwives, GPs and gynaecologists during pregnancy follow-up or childbirth. Participation in these interviews was voluntary and signed informed consent was obtained. The women were included until data saturation was reached.  The discussion was enhanced without substantial disagreement.

| RESULTS
Seventeen women were interviewed between January and April 2016; eight interviews took place in the maternity ward and nine at home. Only one woman refused to participate due to her fatigue.
Data saturation was reached after 15 interviews. Two additional interviews were performed to confirm the saturation. The EPICES scores varied between 30.18 and 57.39, and the characteristics of the participants are shown in Table 2. Three themes emerged from the analysis. Our desire to change our life, to be more ecological, to offer that to our children.
[…] and above all, due to our professional activities. P12, 29 years old I think it's because we were born near here. It's as I said: you need to be born there to stay there and that's that. P14, 28 years old For most women, the main advantage of living in a rural area was the low cost of real estate and the healthy environment, which they deemed beneficial to their children. Nevertheless, they also reported the difficulties linked to geographical remoteness, travel costs, lack of public services, shortage of local healthcare professionals and social isolation.
Obviously when the car breaks down, we postpone (the appointment

| Pregnancy: An additional difficulty
Apart from the course of the pregnancy itself, several women were apprehensive about the consequences and mentioned the fear of losing their job, of being socially stigmatized, of having a complication detrimental to their health and a lack of confidence as far as feeling that they may be a bad mother. They expressed a lack of confidence towards themselves and others.

| GP as a local solution
Most of the women thought that the follow-up of their pregnancy was within the competency of the obstetrician and midwife rather than of the GP. Some experienced a reluctance from the GP to follow up on their pregnancy, especially given a tendency to refer them to specialists. The lack of use of ultrasound and foetal monitoring represented an obstacle to pregnancy follow-up by a GP. Several studies have analysed rurality and vulnerability, separately.
In a Canadian qualitative study in 2006, rural women complained of the financial costs generated by transport, childcare and loss of earnings. 19 They described their need to adapt to geographical remoteness and winter conditions.
With the closure of numerous rural maternity wards in France between 2002 and 2012, waiting times for access to maternity wards have increased, which has adversely affected medical follow-up of pregnancies. 10,20 This impact has particularly been studied in Canada where there has also been, since 2000, a severe decline in the number of maternity wards in rural areas, despite the considered reliability of the healthcare provided. 21 The isolation linked to rural areas and neighbourhood deprivation are associated with poorer quality of pregnancy follow-up and an increase in stillbirths, as well as neonatal and postnatal mortality. [22][23][24] There were several contradictions in the women's statements in the study, however, in that they described real difficulties but did not immediately perceive them as such. There are several possible explanations for this behaviour.
Després et al. 25 found that the use of care was less prevalent among people with SED. They often have a poor opinion of their health, which can accentuate a tendency to deny themselves care. 8,26 Any pre-existing material restrictions are accentuated by the medical follow-up of pregnancy, in which study participants develop adaptive capabilities to best organize their pregnancy follow-up. The resilience that this represents is an original result of the present study.
The study by Brugier et al. 27 highlighted that the organization of the care pathway is often difficult for vulnerable populations regarding the quality of any prenatal diagnosis.
Our study reveals the importance of the familial and social environment to overcome geographical isolation. Bertin et al. 28 showed that the deprivation of neighbourhoods in rural areas was associated with a risk of lower weight and head circumference at The participants did not always identify all healthcare professionals, CMP midwives and GPs as possible resources for their follow-up, implying a need for better coordination between all the healthcare professionals who could be involved with a pregnancy. 32 Our study highlights the need for investment in strategies for reducing social inequalities in rural areas to improve perinatal health.
Women who reside in rural areas should receive high-quality AURÉLIE ET AL.
| 2261 maternity care as close to home as possible. GPs, who are the closest health professionals, can play a role in identifying these pregnant women in SED. The use of a questionnaire adapted to this identification in this particular context could be helpful. 33  the investment of midwives is to be favoured, as well as their collaboration with GPs, which is not always self-evident. 21,34 Bringing antenatal care closer to these women would allow them to come out of social isolation, provide them with psychological support and avoid the costs and risks of travel to maternity wards.
This requires creating a system that is accessible, affordable, riskappropriate, patient-centred, coordinated, innovative and equitable.
In this objective, the data from our study will be used to create a questionnaire to collect the expectations of a large population of women. This will allow us to adapt healthcare networks as accurately as possible to their needs.

| CONCLUSIONS
The difficulties of pregnant women in SED living in rural areas are linked to geographical remoteness, an inadequate supply of specialist local healthcare, fear of additional financial limitations and anxiety about parenthood. In developing numerous adaptive capabilities, they often minimize any limitations and implement adaptive techniques that make identification by social and medical services more difficult. When the adaptive capabilities are exhausted, there is a negative impact on the medical follow-up of a pregnancy.
The women in our study did not approach their GPs due to lack of confidence in his or her abilities, but they appreciated the proximity and psychological support that was offered.