Knowledge of Prenatal Health Care Among Costa Rican and Panamanian Women

Investigación original / Original research

Knowledge of prenatal health care among Costa Rican and Panamanian women

William Harold Guilford,1 Kara Elizabeth Downs,1 and Trevor Joseph Royce1

Suggested citation Guilford WH, Downs KE, Royce TJ. Knowledge of prenatal health care among Costa Rican and Pana- manian women. Rev Panam Salud Publica. 2008;23(6):369–76.

ABSTRACT Objectives. There is evidence that health care during pregnancy is a crucial component in ensuring a safe delivery. Because the infant mortality rate in Costa Rica is almost half the rate of Panama, the researchers tested the hypothesis that women in Costa Rica are more knowledgeable about prenatal health care than women in neighboring Panama. Methods. A multiple-choice survey was used to evaluate women’s knowledge of prenatal care using WHO recommendations as the nominal standard. Oral surveys were administered to 320 women in Costa Rican and Panamanian health care clinics. The surveys consisted of multiple-choice questions designed to assess four specific domains of knowledge in prenatal care: nutrition, danger signs, threats from illness, and acceptable activities during pregnancy. Survey answers were scored, and significant factors in assessing women’s knowledge of prenatal care were determined using analysis of variance and general linear models. Results. Costa Rican women scored higher than Panamanian women in most domains of knowledge in prenatal health care. Only country of origin and educational level were significant factors in determining knowledge of prenatal care. However, country of origin was a stronger predictor of knowledge of prenatal care than was having completed high school. Conclusions. These data suggest that Costa Rican women are more knowledgeable about necessary prenatal care than Panamanian women, and that this difference is probably related to direct education about and promotion of prenatal care in Costa Rica. This suggests an influence of cultural health care awareness that extends beyond the previously established negative correlation between maternal educational level and infant mortality.

Key words Maternal health services; prenatal care; health knowledge, attitudes, practice; Costa Rica; Panama.

While both Costa Rica and Panama rates have declined across Central Rica (160 per 100 000 live births com- are developing nations with limited America over the past 50 years, and a pared with 25 per 100 000 live births) access to health care services, the dis- further decrease in infant mortality re- (3). The reasons for these differences parities in infant and maternal mortal- mains an objective in Panama and are unclear, but may be related to ap- ity rates are striking. Infant mortality Costa Rica (1, 2). In Costa Rica the plication of prenatal care. infant mortality rate is 11 per 1 000 There is substantial evidence that live births compared with Panama’s, health care during pregnancy is a cru- 1 University of Virginia, Biomedical Engineering, Charlottesville, Virginia, U.S.A. Send correspon- where the infant mortality rate is cial component of ensuring a safe de- dence to: W.H. Guilford, Associate Professor, Uni- nearly double (19 per 1 000 live births). livery and a healthy mother and baby. versity of Virginia, Biomedical Engineering, Box 800759, Charlottesville, VA 22908, U.S.A.; Tel: 434- Likewise, Panama’s maternal mortal- The World Health Organization has 243-2740; e-mail: [email protected]. ity rate is over six times that of Costa published fundamental practices for a

Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 369 Original research Guilford et al. • Knowledge of prenatal care successful pregnancy, which include Panama to assess their knowledge of roughly 5 minutes in duration, was visiting a skilled health care worker at prenatal health care. In Costa Rica, the performed. The investigators assisted least four times during pregnancy, interviews were conducted daily in six the interviewer (the hired translator) maintaining a healthy diet, knowing local Caja Costaricense de Seguro So- and recorded participants’ answers in the signs of labor so as to seek delivery cial (CCSS) public health clinics in the an organized grid in handwritten field care at the appropriate time, and un- San José and Alajuela regions. The notes. Additional observations, opin- derstanding danger signs during preg- CCSS is the Costa Rican government’s ions, local stories, and histories from nancy (4). Women who receive prena- social security organization which pro- individual conversations with the tal care have lower rates of maternal vides health care at a relatively low women were recorded in the field and infant mortality, as well as better cost to all insured citizens. In Panama, notes and on tape. No identifying in- pregnancy outcomes (5), and utiliza- interviews were conducted in five dif- formation was recorded. tion of prenatal care is correlated with ferent rural banana plantation commu- The research protocol was approved higher mean birthweight and gesta- nities in the Bocas del Toro province. by the Social and Behavioral Sciences tional age (6). Low birthweight and The plantation communities, known as Institutional Review Board at the Uni- premature delivery have been shown “fincas,” were within an approximate versity of Virginia, Charlottesville, to contribute to infant distress in three-hour drive of the city of Chan- Virginia, U.S.A. Panama (7). Furthermore, children of guinola. One urban clinic was held in a mothers who did not receive prenatal local church in Changuinola. The clin- care are twice as likely to die during ics where interviews were conducted Survey design infancy as children of mothers who re- were run by Global Medical Training ceived prenatal care (8). (GMT), a medical service organization. A 15-question oral survey (see the Higher levels of general education GMT provides free health care to un- Appendix) was developed to assess among women are associated with im- derserved populations in Central participants’ knowledge of prenatal proved birth outcomes (9–14). Indeed, America and works closely with local health care practices. The researchers the educational level of the mother is an health care providers of the Panaman- also collected basic demographic data especially significant factor in predict- ian Ministry of Health. on the subject populations (Table 1). ing infant mortality in Panama (15, 16). The survey consisted primarily of Whether education in general, or knowledge-based, multiple-choice knowledge of prenatal care in particu- Field procedures questions that required no previous lar, is the key factor in improving birth participant preparation. Respondents outcomes remains an open question. All survey participants had come to were asked to qualify the level of im- As a first step toward answering this free clinics seeking attention of a med- portance of particular prenatal care question, we used an oral survey to ical doctor and agreed to answer our practices (e.g., a = very important, b = evaluate women’s knowledge of prena- survey while waiting. Local Spanish- little importance, c = not important). tal care in Costa Rica and Panama using speaking translators were hired to con- “Distracter” answer choices (e.g., the World Health Organization’s rec- duct the personal interviews to over- “headaches” as a potential danger ommendations as the nominal stan- come language barriers and make the sign) were included in each section to dard. We find that the country of origin participants more comfortable. In Pan- ensure that participants were focused is a better predictor of knowledge of ama, a second translator was used to and answering after critical thought. prenatal care than is general educa- interpret for speakers of the local Simple, fifth-grade level vocabulary tional level, though both are factors. Ngöbe tribe dialect; 6 of the 127 Pana- was used and, because of the low liter- The results of our study support our manians interviewed spoke this di- acy rates characteristic of both Costa hypothesis that Costa Rican women are alect. The Ngöbe are an indigenous Rica and Panama, an oral survey de- more knowledgeable about prenatal people originating in the central moun- sign was chosen. Standardized ques- health care than women in Panama. tains of Panama. tion format and answer choices were This is consistent with knowledge of Permission to interview was translated into Spanish by a local prenatal care contributing to the differ- granted by the directors of the facili- Costa Rican, so that consistent word- ences in infant and maternal mortality ties before the study was commenced ing was used by the translators. between these neighboring countries. each day. To select participants, the re- The knowledge to be assessed in the searchers and a translator approached survey was derived from several individuals who appeared to be above sources. The World Health Organiza- MATERIALS AND METHODS the age of 18, without pre-selection tion’s critical criteria for care during based on pregnancy history, formal pregnancy were used as the nominal Locations education, or overall health. If the standard. In addition, the investiga- woman was interested in participat- tors consulted an obstetrics and gyne- In June and July of 2006, 320 women ing, informed consent was recorded cology specialist (personal communi- were surveyed in Costa Rica and on audio tape and the interview, cation, Y. Newberry, Family Nurse

370 Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 Guilford et al. • Knowledge of prenatal care Original research

TABLE 1. Characteristics of study samples of women surveyed about knowl- such signs, including painful contrac- edge of prenatal health care, Costa Rica and Panama, 2006 tions, broken water, or bloody and sticky discharge. The corresponding Costa Rica Panama Total Characteristic (n = 193) (n = 127) (n = 320) section of the survey included five potentially significant indications of Age (± σa) 33 ± 11 31 ± 9 32 ± 11 labor. Graduated high school 66 (34.2%) 51 (40.1%) 117 (37.3%) Thirteen of the 15 questions on the Pay for water supply 180 (93.2%) 64 (50.4%) 244 (76.5%) survey were standard, multiple-choice High incomeb 56 (29.0%) 8 (6.3%) 64 (20.4%) Medium incomeb 85 (44.0%) 22 (17.3%) 107 (34.2%) format. The remaining two questions Low incomeb 49 (25.4%) 93 (73.2%) 142 (45.4%) were about the participant’s age, and an open-ended commentary on the a σ = standard deviation. b Study subjects were categorized as having “high” income if they reported a weekly household income of over study. US$ 140; “medium” income was less than US$ 140 weekly; “low” income was less than US$ 50 weekly.

Data analysis

As interviews were completed, each Practitioner, University of Virginia, ing pregnancy (17). The survey fo- participant’s responses were recorded Charlottesville, Virginia; April 2006), cused on foods that would meet these in an Excel database. The survey an- the American College of Obstetrics requirements and were available to swers were converted into a numerical and Gynecology (ACOG) guidelines the local population. scoring system ranging from 0 to 2, in- on prenatal nutrition (17), and the Uni- WHO also recommends that preg- dicating their degree of correspon- versity of Michigan guidelines for pre- nant women learn and recognize dan- dence with best practices. 0 indicated natal clinical care (18). ger signs, so that they will know when an incorrect answer, 2 indicated a cor- The prenatal care information eval- to seek the aid of a skilled health care rect answer, and 1 indicated answer uated in the survey was organized into worker. Therefore, potentially danger- choices that could apply in some situa- five major categories: diet, danger ous conditions, as well as illnesses that tions (e.g., a “maybe” response). After signs, illnesses, positive and negative could have adverse effects on both assigning each response a score, the av- activities, and labor signs. These as- mother and unborn baby, were in- erage score of each category for each pects of prenatal care are most effec- cluded in the survey. Women who are individual was calculated. This tech- tively encouraged and monitored informed of dangerous signs and ill- nique assigned each category the same through meetings with a skilled health nesses that would require special at- statistical weight while the number of care worker before, during, and after tention will ideally be able to prevent questions in each category varied. Sta- pregnancy. WHO advises that women negative outcomes for their babies and tistics were calculated in Microsoft should visit a health center at least themselves. Excel (Microsoft Inc., Redmond, Wash- four times during pregnancy (4); how- Pregnancy differs from other “con- ington, U.S.A., 2003) and SPSS soft- ever, ACOG recommends at least ditions” in which consistent medical ware (SPSS Inc., Chicago, Illinois, twelve routine visits (17). A common care is advised because it is not an ill- 2006). Specific statistical tests are noted theme encountered in global health is ness. It is recommended that women in the results. P-values less than 0.05 the dilemma that arises when the stan- maintain their respective normal were considered significant. dards of developed countries exceed lifestyles during pregnancy, but avoid those possible in the developing harmful activities such as using to- world. Therefore, we designed the sur- bacco, alcohol, and medications not RESULTS vey to take into account the potentially approved by a health care worker limited access to health care of the sub- (over-the-counter or illicit), and partic- A total of 320 women were inter- ject population. This was accom- ipating in overly strenuous activities. viewed; 193 were Costa Rican (60%) plished by assessing the minimum Practices that can positively affect the and 127 were Panamanian (40%) (Table level of knowledge and recommenda- health of mother and baby include tak- 1). The mean age of Costa Rican respon- tions for a safe, healthy pregnancy. ing multivitamins, folic acid and iron dents was 33, ranging from 18 to 74 The dietary section of the survey supplements, and drinking plenty of years old. The mean age of Panamanian was designed based on the recommen- purified water (5). A number of these subjects was 31 with a range from 18 to dation for pregnant women to main- positive and negative activities were 61 years old. Women under the age tain a healthy, well-balanced diet (18). evaluated in the survey. of 18 were excluded from the partici- Foods particularly high in nutrients, Finally, recognizing signs of labor is pant pool. Neither the age nor the edu- such as spinach, are stressed because a vital part of preventing adverse out- cation level of participants differed sig- the Recommended Daily Allowance comes in childbirth. The WHO recom- nificantly between the two countries (RDA) of most nutrients increases dur- mends that women be able to identify (analysis of variance [ANOVA] and

Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 371 Original research Guilford et al. • Knowledge of prenatal care

TABLE 2. Mean score per question about knowledge of prenatal care in study TABLE 4. Univariate analysis of variance for samples of women, Costa Rica and Panama, 2006 determining the effects of several indepen- dent variables on overall knowledge of pre- Costa Rica Panama natal health care, Costa Rica and Panama, Question category Mean scorea σb Mean scorea σb 2006

Diet 1.78 0.20 1.43 0.34 Factor dfa Fb P Danger signs 1.57 0.27 1.33 0.39 Illness 1.58 0.27 1.26 0.41 Country 1 5.172 0.025c Good/bad activities 1.91 0.19 1.75 0.26 Education 1 6.153 0.015c Signs of labor 1.63 0.31 1.58 0.34 Income 2 2.362 0.100 Total 1.69 0.14 1.46 0.26 Pays for water 2 .545 0.582 Age 45 .710 0.900 a The highest score was 2, indicating a correct answer; a score of 1 indicated an answer that could apply in certain situations; a score of 0 indicates an incorrect answer. a df = degrees of freedom. b σ = standard deviation. b F = F statistic. c P < 0.05, indicating that among those measured, only education and country of origin are significant factors in determining knowledge of prenatal care among women.

TABLE 3. Z-test values comparing differences in specific domains of knowledge of prenatal health care between women surveyed in Costa Rica and Panama, 2006 nor age were significant factors. When the countries are considered sepa- Danger Good/bad Signs of rately, education emerges as the only Statistic Diet signs Illness activities labor Overall significant factor among Costa Rican Z-test 10.37a 6.05a 7.67a 5.80a 1.37 9.07a women, whereas there were no signif- Mann-Whitney 9.46a 6.19a 7.07a 6.33a 1.71 8.34a icant factors differentiating Panaman- a The difference in knowledge about prenatal health care between women in Costa Rica and Panama is significant (P < 0.05). ian women (data not shown) in terms of their knowledge of prenatal care. Considered in those terms, the Pana- manian women interviewed more z-test); 34.2% of the Costa Rican and except “signs of labor,” the mean closely resemble Costa Rican women 40.1% of the Panamanian subjects had scores of Costa Ricans are higher than in the sample who had not completed finished high school. Panamanians as determined by z-tests high school. The economic difference between and the Mann-Whitney test (Table 3). To further understand educational our two sample populations was much This suggests that the Costa Ricans level and country of origin as factors in larger than might be expected, consid- and Panamanians interviewed are determining knowledge of prenatal ering the similarity in their education similarly knowledgeable of signs of care, a multivariate GLM was utilized. levels. Of the Costa Ricans, 29% fell into labor. In a separate question (question The significance of these factors in the our “high income” bracket, whereas 13; see Appendix) there was no sig- GLM is given in Table 5. While both only 6.3% of Panamanians were cate- nificant difference between Costa Ri- country and educational level are sig- gorized as having “high income.” can and Panamanian women in their nificant factors, the country of origin Whether or not the respondents pay for knowledge of the best place to give has a larger effect than having gradu- their water was another economic mea- birth (i.e., hospital, local clinic, or at ated from high school. The low partial η 2 sure used. This information is also an home). eta-squared ( p ) suggests that educa- indicator of the quality of water sup- Univariate ANOVA in a general tion is a weak factor in the GLM com- plied to the respondents’ households. linear model (GLM) was used to de- pared to country. We can further dis- Of the Costa Ricans surveyed, 93.2% termine what factors are most predic- sect the relationship between these pay for their water, while only 50.4% of tive of overall knowledge of prenatal factors and individual measures of the Panamanians do. care. The results are given in Table 4. knowledge (see Table 6). Education is The numeric results of tests of Only country and educational level a significant factor in every area of knowledge in both countries were nor- were significant factors in determining knowledge except good and bad prac- mally distributed, as determined by overall knowledge of prenatal care. tices during pregnancy. Country is a Lilliefors test. Mean scores for each This is in general agreement with significant factor in every area of category are given in Table 2. The other researchers who found that edu- knowledge except signs of labor. overall knowledge of prenatal care cational level is a significant predictor (un-weighted mean of categories) dif- of infant mortality in the two coun- fered significantly between Panama tries (15), but especially significant in DISCUSSION and Costa Rica, suggesting a large dis- Panama (15,16). Neither income, pay- parity in maternal knowledge between ing for water (an indicator of both The data are consistent with our hy- the two countries. In every category income and clean water availability), pothesis that women in Costa Rica are

372 Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 Guilford et al. • Knowledge of prenatal care Original research

TABLE 5. Multivariate analysis of variance for determining the While almost every participant in both relative effects of country of origin and educational level as countries was willing to participate, in factors in determining knowledge of prenatal care, Costa Rica some cases the Costa Rican women ap- and Panama, 2006 proached us showing interest in partici- η 2a b pating and often requested feedback on Effect p F P their scores. Several participants com- Country 0.232 34.007 0.000c mented that they would remember c Education 0.098 7.659 0.000 what they had learned for future use. Education × country 0.020 2.110 0.064 Willingness to learn and a general posi- a η 2 p (eta-squared) is a practical measure of the impact of a factor in the model. tive attitude toward health care seem to Higher values indicate a larger impact of that factor on the dependent variable (knowledge). Thus country of origin has a stronger influence in determining knowl- be closely related to women’s interest in edge of prenatal care than does educational level. prenatal care. b F = F statistic. c P < 0.05, indicating that both country of origin and education are significant factors While culture certainly influences in the model. these opinions, access to health care providers plays an invaluable role. Both Costa Rica and Panama offer uni- TABLE 6. Multivariate analysis of variance in a linear model assuming only versal social insurance, but access is country of origin and educational level as factors in determining specific more limited in Panama (19). In Costa domains of knowledge of prenatal care, Costa Rica and Panama, 2006 Rica, the CCSS public health facilities appear to be effectively reaching a Factor Variable Fa P wide range of their citizens. This is Education Diet 15.95 0.000b due in part to the decentralized nature Danger signs 12.77 0.000b of the health care system, in which b Illness 29.03 0.000 hospitals and large clinics are located Good/bad activities 3.48 0.063 Signs of labor 12.81 0.000b in central areas, and smaller clinics, often one or two rooms in size (locally Country Diet 123.18 0.000b known as EBAIS or basic care health Danger signs 38.54 0.000b teams), are located in the rural areas. b Illness 71.20 0.000 In this way, secluded villages and Good/bad activities 33.40 0.000b Signs of labor 1.29 0.255 women without access to transporta- tion are able to receive health care. In Education × country Diet 7.54 0.006b Panama, the Ministry of Health has or- Danger signs 1.67 0.196 ganized primary, secondary, and ter- Illness 3.74 0.054 tiary levels of care, but with less exten- Good/bad activities 2.19 0.140 Signs of labor 3.31 0.069 sive management (20). The small number of Ngöbe partici- a F = F statistic. bP < 0.05, indicating that the given factor has a significant influence on the dependent variable—the pants (6 of 127 Panamanians inter- specific domain of knowledge of prenatal care. viewed) within our data set does not affect the results. The small Ngöbe sample does not differ significantly in any of the knowledge categories from more knowledgeable about prenatal and children. Our data suggest that a the rest of the Panamanians surveyed, health care than women in Panama. solid starting point for reducing the though in absolute terms they scored Since Costa Rica has lower rates of in- number of infant and maternal deaths somewhat lower in every knowledge fant and maternal mortality, and since may be the education of women about category. It has been suggested by the it is accepted that prenatal care has basic prenatal care practices. Bhutta United Nations Population Fund positive impacts on pregnancy out- (9) pointed out that while such ap- (UNFPA) that in the rural, mountain- comes, there is reason to believe that proaches have been tried in industrial- ous regions of Panama, where the in- improving knowledge of prenatal care ized countries, little is known about its digenous Ngöbe reside, lack of trans- will improve both maternal and infant efficacy in either industrialized or de- portation to health care facilities and health. While we cannot make a direct veloping nations. Our study, while of- rugged lifestyle contribute to complica- correlation between higher rates of fering no experimental interventions, tions with childbirth (21). Regardless, mortality and lower levels of knowl- does predict an impact of prenatal the authors believe that lack of access edge, it is important to recognize the health care education. to medical services does not necessarily potentially influential aspects of pre- We encountered considerably greater predict a lower level of prenatal care natal health care awareness for the interest and awareness about prenatal knowledge, though additional studies health and well-being of both mothers care in Costa Rica than in Panama. will be needed to test this hypothesis.

Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 373 Original research Guilford et al. • Knowledge of prenatal care

This study complements previous tion with recommended practices that natal care and improved pregnancy work suggesting that higher levels of were organized into similar categories outcomes. To more directly assess general education among women are as those in our survey. Pamphlets with such a relationship it would be neces- associated with improved birth out- information were often readily avail- sary to question each subject about her comes (9, 11–14). We find that mater- able at the clinic and a billboard on the pregnancy outcome. We chose not to nal educational level is a significant side of a busy street encouraged moth- question women on their childbirth factor in determining the knowledge ers to care for themselves during preg- experiences for two reasons. First, an of prenatal care even in the face of nancy. This approach has been shown estimated six instances of infant mor- large disparities in economic status to be effective for promoting postnatal tality would be expected in our sample and urban versus rural populations. care in Nepal (24). size, making correlative statistics im- However, the country of residence possible. A much larger sample size outweighs educational level as a factor Limitations of the study. It is evi- would be required. The second reason in predicting knowledge. This is re- dent that citizens with higher incomes was concern for the participants’ social flected in the statistically equal frac- (and perhaps a greater degree of and mental welfare when responding tion of Costa Rican and Panamanian maternal knowledge) see doctors in to such questions could be traumatic. participants who had completed high private clinics that are not paid by Now that baseline relationships have school, yet they displayed a significant the government (personal communi- been established, such a study may be gap in knowledge about prenatal care. cation, G.C. Galliano, M.D., Global justifiable. This suggests an indirect effect of edu- Medical Training, 20 June 2006). We cation on knowledge of prenatal care. therefore chose to obtain our sample For example, an educated local popu- population from public clinics, be- Conclusion lace can give rise to culturally or so- cause this is where all citizens, regard- cially imbued knowledge of prenatal less of socioeconomic status, can re- We conclude that Costa Rican care (22). Educated women may also ceive equal care. This possibly biased women are more knowledgeable be more comfortable interacting with a our sample toward populations in a about necessary prenatal care than modern health care system (13). It is lower economic bracket. In addition, it Panamanian women, and that this equally possible that Costa Rica’s gov- should be considered that all women difference is probably related to direct ernment is working successfully to in- were interviewed in a medical setting. education about and promotion of form women about prenatal care. This would suggest that they have a prenatal care in Costa Rica. While An interesting observation is that predisposition to health care and a de- additional studies will be needed to despite a significant knowledge gap sire to keep both themselves and their separate prenatal health care educa- between the two countries in many children healthy, and may, therefore, tion from other activities that affect areas, all women, regardless of coun- possess a greater degree of maternal pregnancy outcomes, our data suggest try of residence, appear to be equally knowledge. that focused educational efforts may knowledgeable about signs of labor. We reported the education level of prove a straightforward and relatively This may be due to knowledge of labor participants based on whether they inexpensive approach to decreasing being inherent, being based on per- had graduated from high school. perinatal mortality. Peer education sonal experience, or being passed be- While our survey instrument was not subsequent to such government inter- tween family or community members. designed to assess educational level in ventions may benefit local communi- Furthermore, according to surveys more detail, standard levels of edu- ties as well as entire nations with min- done in 1998, 90% or more of all births cation seemed to be at least through imal resources. in Panama and Costa Rica were as- primary school; attending high school sisted by a skilled birth attendant, sug- was less common and considered gesting great labor awareness in both something of a privilege. Very few Acknowledgments. The researchers countries (23). It should also be noted participants mentioned that they had would like to thank Yvonne New- that knowledge of the signs of labor, attended college. Maternal education berry, University of Virginia, for her while beneficial to care, is not neces- for women who have completed pri- dedication and advice in the develop- sarily indicative of being better in- mary school but not high school is cor- ment of the project. We would also like formed about prenatal care. related with reduced infant mortality to thank Karen Schmidt (University of Recently the CCSS of Costa Rica (9–16). However, it remains to be de- Virginia) and the Global Medical made efforts to promote health care termined whether lower educational Training Staff, including Santiago and prevention strategies as part of its levels (e.g., women who have com- Mora, Gian-Carlo Galliano, Wil John- services (20). For example, in a clinic in pleted primary school versus those son, Curtis Larsen, and Sondra Elizon- Higuito, Costa Rica, the nurses publi- who have not) affect knowledge of dro. We are most appreciative of the cized a series of free weekly informa- perinatal care. generous support of the Stull family tion sessions for pregnant women. We This study does not demonstrate a and the Harrison Special Collection In- observed posters displaying informa- causal link between knowledge of pre- stitute of the University of Virginia.

374 Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 Guilford et al. • Knowledge of prenatal care Original research

APPENDIX. English text for survey administered to Costa Rican and Panamanian women about their knowledge of prenatal health care

Working through an interpreter, the investigators verbally explained the study. If the participant was interested, the investigators (with the aid of an interpreter) said: “As you know, I am a student from the University of Virginia in the United States. I am conducting a study on health care awareness regarding pregnancy and I would like to ask you some questions about that. I am tape-recording our conversation right now for my own records. But, if you would like to participate in the study, I will turn off and put away this tape-recorder while I ask you questions. If at any time during our talk a question is upsetting or if you feel uncomfortable answering a question, please tell me and you do not have to answer that question. Also, if at any time you want to stop answering questions and withdraw from this study, please tell me, and I will discard the information I have written down. I will not be capturing your name or any aspect of your identity as part of this study. I am doing this in order to ensure protection of your personal information. I will not reveal the content of our conversation beyond myself and people helping me, whom I trust to maintain your confidentiality, meaning no one will be told of your answers to this survey. Now I would like to ask you if you agree to participate in this study, and to talk to me about health care during pregnancy. Do you agree to participate?” If the participant agrees, the following questions were asked verbally:

Part I—Background 8. Do you consider any of the following to be Activities: danger signs for pregnant women requiring i. Taking a multi-vitamin 1. How old are you? a health care worker’s help? ii. Strenuous activities a. Yes iii. Smoking tobacco 2. Did you graduate from high school? b. Maybe iv. Taking a folic acid supplement a. Yes c. No v. Taking an iron supplement b. No Danger Signs: and/or eating foods high in 3. Do you pay for your water? i. Headache iron (such as meat) a. Yes ii. Blurred vision/ change in vi. Drinking alcohol b. No vision vii. Drinking lots of safe water iii. Vaginal bleeding viii. Taking un-prescribed 4. What is your family’s weekly income? iv. Extreme weakness medications such as Aspirin, (US$1.00 = 1 Panamanian Balboa = v. Convulsions or “fits” cold syrup, or antibiotics 511.85 Costa Rican colones) vi. Swelling of hands, fingers, a. < CRC 25,000 or < US$ 50 face, and/or ankles 11. Do you consider any of the following to be b. < CRC 70,000 or < US$ 140 vii. Nausea and vomiting labor signs for pregnant women? c. > CRC 70,000 or > US$140 viii. Sore throat a. Yes ix. Severe stomach pains (upper b. Maybe 5. Which country do you live in? right side, close to lungs) c. No a. Costa Rica x. A premature labor and delivery Signs of Labor: b. Panama xi. High blood pressure i. Nausea ii. Bloody vaginal discharge 6. If you live in Costa Rica, which province do 9. Do you think that a pregnant woman’s iii. Headache you live in? baby would be affected by any of the iv. Back pain a. Alajuela following illnesses? v. Contractions b. Cartago a. Yes c. Guanacaste b. Maybe 12. How often should you see a health care d. Heredia c. No worker during your pregnancy? e. Limón d. Unknown a. Only if there are complications f. Puntarenas Illnesses: b. 4–5 times during the pregnancy g. San José i. STDs c. Only during labor ii. Headache d. More than 5 times Part II—Knowledge iii. Rubella iv. Cough 13. What do you consider to be the ideal place 7. Please rate the importance for pregnant v. HIV for a pregnant woman to give birth? women to eat the foods listed. vi. Diabetes a. Hospital a. Very important vii. Anemia b. Local clinic b. Somewhat important viii. Gastritis c. Home c. Not important ix. Flu d. Does not matter Sample Diet: i. Chicken 10. Do you believe that the following have a 14. How important is prenatal care? ii. Plantains or bananas positive or negative impact upon a. Very important iii. Chocolate pregnancy? b. Of little importance iv. Coffee a. Positive c. Not important v. Rice b. Negative vi. Spinach c. Neutral, no impact 15. Would you like to comment on having vii. Red beans participated in this study? viii. Cheese

Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008 375 Original research Guilford et al. • Knowledge of prenatal care

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RESUMEN Objetivos. El cuidado de la salud durante el embarazo es un componente crucial para garantizar un parto sin riesgo. Como la mortalidad infantil en Costa Rica es casi la mitad de la registrada en Panamá, se probó la hipótesis de que las mujeres costarri- Conocimientos de las mujeres censes conocen más acerca de los cuidados durante el embarazo que las panameñas. de Costa Rica y Panamá Métodos. El conocimiento de las mujeres acerca de los cuidados de la salud durante el embarazo se evaluó mediante una encuesta, con las recomendaciones de la Orga- sobre el cuidado de la salud nización Mundial de la Salud como estándar nominal. La encuesta se aplicó verbal- durante el embarazo mente a 320 mujeres en clínicas de Costa Rica y Panamá. Las preguntas de selección múltiple evaluaron el conocimiento en cuatro dominios específicos: nutrición, señales de alarma, amenazas por enfermedades y actividades aceptables durante el embarazo. Se asignaron puntuaciones a las respuestas. Se emplearon el análisis de va- rianza y modelos lineares para establecer los factores significativos que determinaron el conocimiento sobre los cuidados prenatales. Resultados. Las mujeres costarricenses tuvieron una mayor puntuación que las panameñas en la mayoría de los dominios del conocimiento sobre los cuidados de la salud durante el embarazo. Los únicos factores significativos que determinaron esos conocimientos fueron el país de origen y el nivel educacional. El país de origen fue un factor de predicción de estos conocimientos más potente que haber completado la en- señanza media. Conclusiones. Los resultados indican que las mujeres costarricenses tienen más conocimientos sobre los cuidados necesarios durante el embarazo que las panameñas y que esa diferencia puede estar relacionada con la educación directa sobre los cuidados prenatales y su promoción en Costa Rica. Esto podría indicar que hay una influencia de la cultura de concientización del cuidado de la salud que va más allá de la correlación negativa ya conocida entre la mortalidad infantil y el nivel de educación de la madre.

Palabras clave Servicios de salud materna; atención prenatal; conocimientos, actitudes y práctica en salud; Costa Rica, Panamá.

376 Rev Panam Salud Publica/Pan Am J Public Health 23(6), 2008