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GRAPEVINE, Texas -- Women with inadequate health literacy had higher maternal and neonatal health risks, researchers said here.

Low health literacy -- the degree by which individuals retain, process, and understand basic health information -- among pregnant women was associated with greater odds of having to have delivery by cesarean section and major perineal lacerations, reported Lynn Yee, MD, of the Feinberg School of Medicine at Northwestern University in Chicago.

Babies born to women with low health literacy had a higher frequency of preterm birth before 34 weeks, small for gestational age status, low birth weight, and an Apgar score less than 4, she said at the .

"After adjusting for demographic factors, inadequate health literacy is associated with small but potentially clinically meaningful differences in maternal and neonatal outcomes," Yee said, calling health literacy an important yet often under-recognized social determinant of health.

Health literacy is not simply a reflection of education level, she emphasized. "Even individuals with strong educational attainment and linguistic skills may have trouble obtaining, understanding, and using health information given the complexity of the healthcare system."

Yee noted that an individual's level of health literacy can impact interactions with their provider as well as healthcare access and health behaviors, yet nearly half of individuals in the U.S. have low or marginal health literacy.

Study Details

The researchers performed a secondary analysis of the , a large, multicenter cohort study that evaluated first-trimester pregnant women from 2010 to 2013. Literacy levels were determined through use of REALM-SF, a seven-word recognition test commonly used to evaluate for health literacy.

Based on their health knowledge, women were grouped by grade levels, including less than third grade, grades four to six, grades seven to eight, and grades nine and older. Low health literacy was defined as less than a high school level.

Out of 9,341 women in the study, 17.5% had low health literacy. Yee said that women with inadequate health literacy tended to be younger, more likely to be non-Hispanic black or Hispanic, and more likely to have public insurance. They were also less likely to be married or have some college education. Women with low health literacy were also more likely to be obese, but less likely to have used tobacco or have a mental health diagnosis before pregnancy.

Women with inadequate health literacy had a greater adjusted odds of cesarean delivery (1.17, 95% CI 1.01-1.36) and major perineal laceration (1.49, 95% CI 1.02-2.16).

Babies whose mothers had inadequate health literacy were 1.4 times more likely to be small for gestation age. These infants also had a higher frequency of preterm birth before 34 weeks gestation (AOR 1.15, 95% CI 0.82-1.61), and they had a higher chance of having low birthweight (AOR 1.37, 95% CI 1.09-1.73).

Neonates of mothers with low health literacy were almost three times as likely to have an Apgar score less than 4 (AOR 2.82, 95% CI 1.17-6.80).

Ashanda Saint Jean, MD, director of obstetrics and gynecology at NewYork-Presbyterian's Ambulatory Care Network in New York City, who was not involved with the study, said there is not enough discussion in the medical community about how social determinants of health may affect outcomes. She added that overlooking social determinants allow racial health disparities to persist.

"I don't think we have enough programs that promote health literacy," Saint Jean told MedPage Today in an interview. She suggested an increase in classes for pregnant women, one-on-one sessions for breastfeeding support, and group prenatal care to close the knowledge gap among patients.

"There needs to be a customized approach to the demographic you serve," Saint Jean said.

In their study, Yee and colleagues provided best practice tips for physicians, including the adoption of a "low health literacy for all" approach when educating patients. This includes limiting the number of messages to four or less, supplementing written materials with graphics, and using simple language in the exam room.

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