Inadequate health literacy in nulliparous individuals is associated with worse maternal and neonatal outcomes

1. 17.5% of individuals giving birth for the first time were found to have inadequate health literacy.

2. Individuals with inadequate health literacy were at greater risk themselves for C-section delivery and major peritoneal laceration, with their neonates at greater risk for being small for gestational age, having low birth weight, and having a 5-minute APGAR score of less than 4.

Evidence Rating Level: 2 (Good)

Study Rundown: Health literacy refers to the ability for individuals to comprehend basic information about health, so that they can make suitable, informed decisions for their own health care. Past research has shown that even well-educated individuals may not necessarily be health literate. In the United States, around 50% of the population is considered to have inadequate health literacy. This is associated with increased mortality, less usage of preventive healthcare services, and lower adherence to treatments. However, no research has been done on how health literacy may influence maternal and neonatal health outcomes, which was the aim of the current study. This was an observational cohort study with over 10,000 nulliparous individuals from 8 medical centres in the US. Literacy was assessed using a validated test that asked patients to correctly pronounce 7 health related words: However, this test may have relied on reading skills rather than comprehension of medical terminology. Overall, the study found that 17.5% of individuals had inadequate health literacy: These individuals were more likely to be younger, identify as Black or Hispanic, have public insurance, and not have college education, compared to those with adequate literacy. As well, there was a greater risk of a C-section, major perineal laceration, a small for gestational age (SGA) baby, low birth weight, and a 5-minute APGAR score of less than 4. Therefore, these results demonstrate the importance of improving communication between healthcare professionals and patients, since nearly 1 in 5 patients may be inadequately health literate, and having better health literacy is associated with improved maternal and neonatal outcomes.

Click here to read the article in JAMA Open Network

Relevant Reading: Low health literacy and health outcomes: an updated systematic review

In-Depth [retrospective cohort study]: The study population consisted of 10,038 patients with singleton pregnancies, who did not previously have a pregnancy for more than 20 weeks’ gestation. The validated health literacy assessment was the Rapid Estimate of Adult Literacy in Medicine- Short Form (REALM-SF), which was administered between 16 and 21 weeks’ gestation.  The 7 words were: Behaviour, exercise, menopause, rectal, antibiotics, anemia, and jaundice. This test was only done with patients who had sufficient knowledge of English, and any score less than 7 was considered to be an inadequate health literacy score. Overall, the study found that although there was an association between health literacy and education, even more highly educated individuals were vulnerable, with 14.0% of the inadequate literacy cohort having done some college education, and 4.0% being college graduates. As well, the mean [SD] age was younger in the inadequate literacy group (22.9 [5.0] years compared to 27.9 [5.3] years), and more likely to identify as Black (30.9% vs 10.1%) or Hispanic (31.5% vs 12.3%). In terms of maternal outcomes, the inadequate literacy group had a higher risk of C-section delivery (relative risk 1.11, 95% CI 1.01-1.23) and major peritoneal laceration (RR 1.44, 95% CI 1.03-2.01). Hypertensive disorders from pregnancy and chorioamnionitis were both more prevalent in the inadequate literacy group, but were not statistically significant. Furthermore, gestational diabetes, postpartum hemorrhage, and postpartum readmission were the same across both groups. In terms of neonatal outcomes in the inadequate literacy group, there was a greater risk of SGA status in neonates (RR 1.34, 95% CI 1.14-1.58, p < 0.001), low birth weight (RR 1.33, 95% CI 1.07-1.65), and having a 5-minute APGAR score of less than 4 out of 10 (RR 2.78, 95% CI 1.16-6.65). Outcomes such as very low birth weight, preterm birth, and macrosomia were more frequent, but not statistically significant, compared to the adequate literacy group. Overall, the study found that better health literacy is associated with improved maternal and neonatal outcomes.

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