“It has been well established that health literacy is a key social determinant of health in many areas of medicine, but it has been relatively understudied in pregnancy,” explains Lynn M. Yee, MD, MPH. “However, pregnancy is important to study for several reasons. It provides a window of opportunity to optimize health, as pregnant individuals are often more engaged in healthcare, have access to care, and improvements in health that occur during pregnancy can have lifelong maternal and child health benefits. In addition, pregnancy is a time of enhanced vulnerability, with the need to learn significant amounts of health information within a short period of time. This information can be complex and requires intense engagement with the healthcare system, which require health literacy skills.”

For a paper published in JAMA Network Open, Dr. Yee and colleagues aimed to study the role of health literacy as a social determinant of maternal and neonatal health. “Specifically, we wanted to understand whether inadequate health literacy, measured in early pregnancy, is associated with adverse maternal and neonatal outcomes,” she says. “We conducted a secondary analysis of nuMoM2b, a large, multicenter, cohort study of more than 10,000 nulliparous individuals, conducted from 2010-2013. Participants underwent three antenatal study visits, one of which assessed health literacy. They were then followed up through pregnancy with detailed maternal and neonatal data recorded.”

Healthcare literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Short Form, a validated seven-item word recognition test. In accordance with standard scoring, results were dichotomized as inadequate versus adequate health literacy.

 17.5% of Participants Had Inadequate Health Literacy

“Our study team found that 17.5% of participants had inadequate health literacy on the assessments performed in nuMoM2b, a high proportion, but overall consistent with the general adult population,” Dr. Yee says. “This key finding shows that health literacy poses just as much challenge in a population of young pregnant individuals as it does in older cohorts, where it has been more commonly studied. Second, we discovered that inadequate health literacy was associated with multiple adverse perinatal outcomes, including cesarean delivery, major perineal laceration, low birthweight, and small for gestational age status. These findings suggest that, even after controlling for other social determinants of health, health literacy remains independently associated with poorer health outcomes.”

Dr. Yee notes that it has been hypothesized that health literacy assessments are simply a reflection of education or language. “In our analyses, we showed that the findings were essentially the same—that is, even after removing education from the models, or restricting the population to individuals who spoke English as a first language—the associations of health literacy with adverse outcomes remained consistent,” she says. “This illustrates that health literacy is not simply a reflection of educational attainment or primary language but a distinct social determinant (Table).”

Health Literacy As a Universal Precaution

These findings shed light on the high prevalence of inadequate health literacy among pregnant individuals and the potential consequences. “It’s important for OB/GYNs to take action in their everyday clinical practice to promote health literacy,” Dr. Yee says. “One way to do this is to consider health literacy as a universal precaution—that is, consider that all individuals may have inadequate health literacy. This approach can help raise knowledge and understanding for all patients, not just those with low health literacy. Other strategies include asking open-ended questions to check for understanding, limiting the number of messages delivered in an interaction, focusing on action, and using supplemental pictures and diagrams.”

Dr. Yee and colleagues agree there are certain areas on which future research should focus. “We need to better understand the mechanisms underlying these relationships, as well as how these mechanisms may differ depending on each patient’s context,” she says. “For example, are these issues related to health literacy most pronounced among people having their first baby, or among people with chronic diseases? Developing and testing health literacy-promoting tools are critical next steps.”