Socio-demographic inequalities across a range of health status indicators and health behaviours among pregnant women in prenatal primary care: a cross-sectional study

Our study aimed to assess the health status and health behaviours of pregnant women
in primary care. Although the vast majority of women rated their general health as
good to excellent, two-thirds of all women indicated having health complaints.

There were many sizable disparities in unbeneficial health status indicators and health
behaviours according to educational level and ethnicity. In educational level these
were low health control beliefs, obesity and underweight, depression/anxiety, smoking,
passive smoking exposure, no antenatal class attendance, no folic acid supplementation,
skipping breakfast daily, unplanned pregnancy and no daily fruit consumption. In ethnicity
these were low health control beliefs, depression/anxiety, back pain and dizziness
(?20 weeks), nausea (20 weeks), no folic acid supplementation, no antenatal class
attendance and passive smoking exposure.

The most prominent health status indicator showing differences across both education
level and ethnicity was low health control beliefs. Low health control means that
one believes that health is influenced by causes outside of their own control. This
perceived lack of control may be due to the higher rate of detrimental health issues
they may experience. Additionally, facing daily struggles, such as the stresses associated
with low income, has been found to negatively influence such control beliefs 26]; women from more vulnerable groups, such as those with lower incomes or certain migrant
groups are more likely to have to deal with such daily struggles 19]. This may reflect the ‘fundamental social causes’ theory, which posits that as health
and illness potentially come more under the control of people through biomedical knowledge
and technology, social inequalities increase because of the unequal distribution of
this control 27]. An advisory committee for the Ministry of Health, which was assembled to reduce
social inequalities in the Netherlands in 2001 also recognized that individuals do
not have complete control over their health and health behaviours 28]. In our study, low health control beliefs may be related to all the other health
status indicators and behaviours in which social inequality is apparent.

Our study showed that women with lower education were more likely to be obese or to
be underweight. Differences in nutritional consumption, physical activity and meal
and smoking patterns are likely to be contributing causes. Earlier studies have reported
the relationship of education with pre pregnancy obesity 29], 30]; reports on socio-demographic factors associated with pre pregnancy underweight are
scarce, however, possibly due to underweight not being considered a real health issue
in high income countries. Women of mid and low education as well as non-western ethnic
minority more frequently reported pains or other complaints, poor mobility and especially
back pains, which are similar to the findings of other studies and may be associated
with occupation type 31].

In our study, the most prominent health behaviours with educational disparities were
smoking, followed by passive smoking, which is in line with previous studies 32], 33]. Smokers with higher education are more likely to stop smoking, upon finding out
they are pregnant 34] leading in turn to more disparity in smoking. Smoking during pregnancy may be an
important mediator between low education and various adverse perinatal outcomes 35], 36]. Major health gains may therefore be achieved by making smoking cessation a priority
in perinatal health promotion.

Our study also showed inequalities in antenatal class attendance, possibly reflecting
earlier findings that lower educated groups and immigrants are less likely to seek
(extra) health care 31], 37], 38]. They may be missing an opportunity to be exposed to maternal health promotion and
to be in contact with other pregnant women for social support, which in turn is associated
with pregnancy outcomes 39].

Similar to our study, earlier studies have reported the relationship of educational
level with health behaviours during pregnancy such as folic acid supplementation 40], unplanned pregnancy 41] and daily fruit consumption (22). Skipping breakfast was also more likely in those
of lower education in our study and may be a proxy for other factors associated with
those groups. The only health behaviour more favourable among both lower educated
and non-western ethnic minority women was no alcohol consumption. A higher mean alcohol
intake among higher educated people in the Netherlands has also been reported for
the general population 42].

Awareness of social inequalities in health has been present for decades, and although
efforts carried in the Netherlands have made progress in reducing the gap between
social groups in general 13], our findings confirm that social inequalities in health continue to persist in pregnancy.
Theories proposed for this persistence of health inequalities include inadequate income
redistribution, health inequalities being more related to immaterial factors such
as cultural factors, and people of higher socio-economic status benefiting relatively
more from improvements in healthcare than people of lower socio-economic status 43].

As pregnancy may be the only time that many women have regular contact with health
care providers, such as midwives, this is an opportunity to help increase the quality
of life for women and their families beyond the care of their pregnancies. A report
entitled ‘A Good Beginning’ (2010) written by an advisory committee for the Ministry
of Health in the Netherlands to improve perinatal health and reduce inequalities,
underlined the importance of screening women for risks related to poverty, lifestyle
and psychosocial factors besides medical risks 44]. A greater understanding by prenatal health care providers of the non-medical risks
of adverse pregnancy outcomes may benefit those social groups at greater risk. Continued
training in cultural differences, assessing and responding to different levels of
health literacy in clients, building empathic and trusting relationships, conveying
to clients a sense of personal control over their health, and keeping up-to-date with
research on health and health promotion, may help to reduce health inequalities 37], 45]–47]. Additionally, increased strategies should be employed to target the social determinants
of health inequality, such as forming stronger relationships with other relevant branches
in housing, employment, social work and working in multidisciplinary teams with other
health fields such as nutrition and physiotherapy 45], 47].

Limitations and strengths

While interpreting the findings, we acknowledge some limitations. Health status and
behaviours were self-reported in this study, and bias may have occurred if women provided
socially desirable answers despite knowing their contributions would be made anonymous.
Our study also had relatively more respondents of high education and of Dutch ethnicity
than the general population of pregnant women in the Netherlands. There were enough
respondents, however, to be able to identify differences between the various socio-demographic
groups. We also divided ethnic minority groups into western and non-western, which
does not do justice to differences between first and second-generation minority groups
or between specific ethnic groups.

Including the relationships of various health indicators with pregnancy outcomes may
have been illustrative; however, due to the large number of variables, we chose to
focus on the maternal health indicators during pregnancy. Similarly studying how various
health issues are related to each other and to socio-demographics was also beyond
the scope of this study. Studies have found that those believing in destiny (related
to having low health beliefs), for instance, are more likely to smoke during pregnancy
48] and not to take folic acid 49]. The role of health control beliefs could be elucidated further by mediation analyses.
Our study, therefore, however, hopes to lay a foundation for more research into these
complex interactions of socio-demographics and health issues.

The main strengths of our study lie in the large study population recruited throughout
the Netherlands and the broad range of health indicators. As all women were starting
out in prenatal primary care, our study enabled us to provide an insight into potential health
gains to be achieved in uncomplicated pregnancies.