Knowledge of Prenatal Health Care Among Costa Rican and Panamanian Women
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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 knowl- edgeable 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 pre- natal 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 signifi- cant 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 in- fluence of cultural health care awareness that extends beyond the previously established nega- tive 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