Improvement in maternal health literacy among pregnant women who did not complete compulsory education: policy implications for community care services

Abstract

This paper examined factors that influence the improvement in maternal health literacy among pregnant women in Paraguay, including those who did not complete compulsory education but participated in a community-based antenatal care program. Structured interviews were conducted to evaluate the pregnant women's maternal health literacy during their first, second, and third visits to the program in the Caazapa Region. The associations between individual maternal health knowledge scores and its gains, healthcare personnel capabilities, available health facility equipment, community social network, and living environment were analyzed by multiple regression analysis. The mean maternal health knowledge score from 124 women who completed three-consecutive assessments increased between the first and third interviews. Higher capabilities of healthcare personnel and better living environment were significantly related to gains in the maternal health knowledge score (p < 0.01). Wider application of a community-based antenatal care program to meet the needs of those who are functionally illiterate in the standard language of the country, training for community healthcare personnel to improve capabilities, and resources for social network in the community would contribute to the improvement in maternal health literacy.

Introduction

It is commonly known that antenatal care is important for a healthy maternity, and for risk assessment to avoid complications during pregnancy and delivery. The level of knowledge relates to healthy maternity of women who do not participate in formal education; healthy maternity of women of low functional literacy depend on their attendance of antenatal care given by healthcare personnel, and upon practicing other healthy habits [1], [2]. Other studies indicated difficulties of gaining appropriate knowledge by women with low educational status even when they participate in some health education programs aiming for their behavioral changes [3], [4], [5]. Therefore, it is needed to identify factors to lead positive outcomes of antenatal care services where the majority of a population has no experience of formal education or has low educational status. These factors will be analyzed for a discussion of policy implications based on a study in a rural area of Paraguay.

Health literacy is defined as the cognitive and social skills, which determine the motivation and ability of individuals in ways which promote and maintain good health; it relates to the achievement of a level of knowledge, personal skills, and confidence to take action to improve personal and community health [6]. Particular cognitive and social skills required for healthy maternity include abilities to detect risk signs during pregnancy, to take action for a healthier lifestyle and better nutrition, and to avoid a harmful lifestyle and unsuitable nutrition [7]. Therefore, the results of assessment of knowledge to reflect these cognitive and social skills are regarded as a measurement of maternal health literacy.

The various studies demonstrated the association between poor literacy and poor health [8], [9], [10], [11]. Functional literacy is related to the reduction of maternal and child mortality [12], [13], [14], and poor maternal education and low socio-economic status are risk factors for child mortality [15]. Renkert and Nutbeam mentioned that knowledge not only transforms, but also empowers women and improves their self-esteem [16]. In areas where the majority did not complete compulsory education, appropriate education to improve women's knowledge and understanding related to safe maternity and attitude towards healthy life would improve maternal health.

Apart from the socio-economic status, the quality of healthcare services and living environment conditions are considered to influence the health of the population [17]. Taking advantage of healthcare services is associated with the levels of education, area of residence, economic status and cultural beliefs [2]. Quality of healthcare personnel and available equipment at health facilities may have influence on safe motherhood. However, evidence of this association has not adequately been demonstrated.

Paraguay's maternal mortality rate in 1993 was reported to be 124.5 per 100,000 live births by the Ministry of Health [18]. This number is among the highest in Latin American countries. Although the Gross National Income per capita was US$ 4400, and the average female illiteracy rate of the country was 8% [19], there was a large discrepancy between rural and urban areas. The development of appropriate health education programs to meet the needs of communities in rural areas is a prime concern in this country. Caazapa Region is a prototypical remote area of Paraguay, and the proportion of people with low educational status was the greatest among all regions in the country. To prepare for effective antenatal care program to meet the needs of rural communities, scientific evidence of the factors promoting maternal health literacy among pregnant rural women who did not complete compulsory education, was required.

The objectives of this study were: (1) to measure the improvement of health literacy related to safe maternity and healthy life among pregnant women, including those who did not complete compulsory education, but participated in a community-based antenatal program and (2) to examine the association between the capabilities of healthcare personnel and the quality of health services against the health literacy of pregnant women and gain in health literacy.