KEY DETERMINANTS INFLUENCING THE HEALTH LITERACY OF PREGNANT WOMEN IN THE CZECH REPUBLIC KLJUČNE DETERMINANTE, KI VPLIVAJO NA ZDRAVSTVENO PISMENOST NOSEČNIC NA ČEŠKEM Radka WILHELMOVA1'2'*, Drahoslava HRUBA2, Lenka VESELA1 1 Masaryk University, Faculty of Medicine, Department of Midwifery, Komenskeho nam. 2, 66243 Brno, Czech Republic 2 Masaryk University, Faculty of Medicine, Department of Preventive Medicine, Kamenice 5, 62500 Brno, Czech Republic Received/Prispelo: Apr 24, 2014 Accepted/Sprejeto: Nov 14, 2014 Original scientific article/Izvirni znanstveni članek UDC/UDK 618.7(437.3):613:374 ABSTRACT Keywords: health literacy, pregnancy, prenatal care, primary prevention, midwife Background. Health literacy is a critical determinant of women's and children's health and therefore has immense consequences for the health of society as well. Ev'dence from epidemiological, clinical and experimental studies indicates that unhealthy lifestyles and risky behavioural habits of parents before conception and during pregnancy influence the etiology of various health defects. Decreasing primary risk factors, practicing physical wellness, monitoring physiological markers and preparing for labour, breastfeeding and newborn care should be the main parental responsibilities during the prenatal period. Methods. Our study focused on specifying the main determinants of health literacy among 360 pregnant Czech women by using an anonymous questionnaire and selected anthropometric data of mothers. The criteria for study participation produced a sample representing 1.41% of Czech women in labour during a given 2012 reference period. Results. Despite quite adequate knowledge of both risks and supporting factors for pregnancy and foetal development, the lifestyles of a majority of the women surveyed were far from optimum: only 30% reported good dietary and physical activity habits, 24% were active or passive smokers and one third of the women occasionally drank alcohol, more often among those who were university educated. Conclusion. Our results have confirmed prevously published data noting that health literacy and a healthier lifestyle of pregnant women are associated with a higher level of education (except for alcohol drinking) and with contact with a midwife (in some examined parameters) in prenatal courses. IZVLEČEK Ključne besede: zdravstvena pismenost, nosečnost, predporodna nega, primarno preprečevanje, babice Uvod. Zdravstvena pismenost je ključna determinanta zdravja žensk in otrok, ki ima ogromne posledice tudi na zdravje družbe. Dokazi iz epidemioloških, kliničnih in eksperimentalnih študij kažejo, da nezdravi življenjski slogi ter tvegano vedenje staršev pred zanositvijo in med nosečnostjo vplivajo na etiologijo različnih zdravstvenih okvar. Zmanjševanje dejavnikov tveganja, skrb za fizično dobro počutje, spremljanje fizioloških markerjev ter priprava na porod, dojenje in nego novorojenčka bi morali biti glavna odgovornost staršev v predporodnem obdobju. Metode. Naša študija je bila namenjena določitvi glavnih determinant zdravstvene pismenosti med 360 češkimi nosečnicami s pomočjo anonimnega vprašalnika in izbranih antropometričnih podatkov o materah. Na podlagi meril za sodelovanje v študiji je bil izbran vzorec, ki je predstavljal 1,41 % nosečih žensk na Češkem v zadevnem obdobju leta 2012. Rezultati. Kljub dokaj dobremu poznavanju tveganj in podpornih dejavnikov za nosečnost in razvoj zarodka so se življenjski slogi večine žensk, vključenih v raziskavo, močno razlikovali od optimalnih: samo 30 % jih je poročalo o dobrih prehranskih navadah in telesni aktivnosti, 24 % je bilo aktivnih ali pasivnih kadilk, ena tretjina žensk je občasno pila alkohol, pogosteje univerzitetno izobražene. Zaključki. Naši rezultati so potrdili predhodno objavljene podatke, ki kažejo, da sta zdravstvena pismenost in bolj zdrav življenjski slog nosečnic povezana z višjo stopnjo izobrazbe (razen pitja alkohola) in stikom z babico (pri nekaterih proučenih parametrih) na predporodnih tečajih. 'Corresponding author: Tel: +420 54 949 53 90; E-mail: rwilhelm@med.muni.cz 1 INTRODUCTION The experience of pregnancy and labour is a significant factor in the global development of both women and children. Recent research results affirm that the future health of an individual is influenced during the early prenatal period. Sources considering epigenetical mechanisms specifically refer to the preconceptional influence resulting from gene environment interactions (1, 2). Prenatally, a mother positively or negatively determines both the physical and mental health of her child through her decisions and behaviour, which in turn affect her general health conditions later in life. It was recently confirmed that an unfavourable prenatal environment could facilitate vulnerability to cardiovascular and metabolic diseases, which are presently at near epidemic levels among the general population (3, 4). When efficiently utilised, the health-care system can significantly eliminate risks for the mother and child and encourage practices that protect the woman's health and the child's capacity for development. In the Czech Republic, a long history of high levels of prenatal and neonatal care has resulted in low perinatal mortality and morbidity. On the other hand, the prevalence of low-birth-weight newborns has increased significantly from 5% to 8% (5). The Czech system of preventive observations by obstetricians in physiological pregnancies uses the officially recommended and unified secondary prevention methods at one-month intervals: monitoring of anthropometric parameters, blood pressure and kidney functions and ultrasound examination. Care oriented towards primary prevention is neither adequate nor effective. Current prenatal care recommends extra examinations for women with physiological pregnancy, and it faces the risk of overmedicalisation. Prenatal care provided by a midwife is not covered by any health insurance in the Czech Republic. Pregnant women can be exposed to many physical and psychological burdens as well as sources of stress, fear and anxiety. Too many women deal with this stress by smoking, consuming alcohol and eating inappropriate foods, which are recognised risk factors for worst-case pregnancy outcomes. Alcohol and smoking are considered to be preventable risk factors for human reproduction with no safe threshold, human neuro-teratogens (6, 7). However, many prenatal care providers in the Czech Republic do not ask about this risk behaviour and some of them even tolerate it. Questions about nutrition, physical activity, stress and occupational hazard exposure are also not included into the routine treatment schedule of many prenatal care providers. They do not offer professional advice for promoting health changes either. One recommended technique for decreasing the levels of prenatal anxiety and stress is aerobic exercise, which has a wide spectrum of additional benefits: better oxygenation both for mother and foetal tissues, improves mobility and better coordination as a suitable preparation for labour and birth and shortens active phase of labour. Physical activity enhances the capacity to deal with everyday issues related to stress and unexpected situations, and the risk of depression after delivery is lower (8). Adequate activity has no negative impact on a newborn's weight. Women involved with special pregnancy exercise programs had significantly higher life wellbeing scores (9). According to the experiences reported in some other countries, a new approach to prenatal care is "Group care pregnancy", where an individual check-up is replaced by a longer group session. The basic prenatal examination is accompanied by education, sharing of personal experiences and discussions with a midwife. The Dutch model incorporates somatical and psycho-social needs, and support involves focused attention on a woman's individuality, and the level of responsibility for women's health is increased (10). This model typifies a complex type of care that, when practiced, supports a healthy pregnancy process (11). In the 1970s, a similar model was successfully implemented in daily practice in Sweden and resulted in positive lifestyle changes for women and an overall improvement of family well-being (12). Attention is currently focused even on the preconceptional period, when the health problems of both potential parents should be identified and treated (13). This new point of view offers a new role for midwives: they can provide information to expectant parents about a healthy lifestyle and the detrimental factors that could negatively influence healthy foetal development and potential and try to help with changes. The midwives can also prepare the couple for labour, the postnatal period, breastfeeding and parenthood. This new trend includes focus on perinatal outcomes along with the woman's prenatal care and the psychosocial needs of women's and children's health not only during pregnancy but also after delivery and throughout their lifetimes as well (14, 15). Evidence about increased smoking, alcohol consumption, malnutrition and hypoactivity, especially among young women, indicate that primary prevention should be a part of standard prenatal care (16-18). Participation in primary prevention lessons is an opportunity for a woman to deal with the changes associated with her lifestyle and expectations regarding pregnancy, labour and motherhood; all of this can be a potential source of anxiety and stress. Educational intervention should include the documentation of positive experiences, the dissemination of pregnancy-related information (including reproductive process physiology) and the strengthening of faith in individual abilities (19, 20). In many countries, including the Czech Republic, there is an increasing interest in "schools for mothers". Unfortunately, the majority of such lessons are offered as an additional, self-paid service of standard secondary prevention, without officially unified and supervised content. This education is not available for lower-income women, who are usually undereducated and are more likely to have adopted an unhealthy lifestyle. Voluntary courses for pregnant women, managed by midwives, are oriented towards preparation for delivery, breastfeeding and newborn care, but they do not yet include lifestyle factors. The fact that pregnancy may be the new source of stress for some women, who therefore need special psychological support, is also ignored (21, 22). Our survey goals were to determine the current health literacy of pregnant women (i.e. their awareness of critical and protective procedures, the risk factors in their lifestyles and the changes they made during pregnancy) and to identify the main determining factors of health literacy (education, parity, place of residence and participation in prenatal courses). 2 METHODS AND SAMPLE A retrospective anonymous questionnaire and a data analysis, collected from July to October 2012, were used. We created a random and proportional sample of women. The primary sample included the 108,000 single babies born in 2011 in Czech hospitals. The second basic sample included the approximately 25,000 single babies born during the quarter when our study was organised. According to these data, the number of participants for our study was established at 540 women (2% of the second basic sample). Five of a total of fourteen Czech districts were chosen by random selection and the particular maternity hospitals in each district were chosen in the same manner. To keep the proportionality of the sample, the number of participating women from each individual clinic was related to the annual/quarterly number of newborns. Women were contacted during the postpartum period. Of the 540 women contacted, a total 393 returned the completed questionnaire (response rate was 72.77%), of which 33 had to be excluded due to incomplete data. The final sample thus consisted of 360 women representing 1.41% of women who had given birth during the study period. All of the women participating in the study signed an informed consent form and an agreement with the Ethics Committee of University Hospital, Faculty of Medicine, Masaryk University. Fully trained medical staff collected the data. The main sample characteristics are shown in Table 1. There was a nearly proportional rate of primiparous and multiparous women as well as those with university and high school education; one fifth had only a basic level of education. The level of education was the marker of socioeconomic status. The average age was 30.5 years (median = 31). In terms of parity and age (in comparison with statistical data for the Czech Republic), it is possible to consider the sample as representative. The majority (81%) gave birth vaginally; 19% had a Caesarean section. Twice as many participants lived in towns as in villages. The structure of the questionnaire was based on the Health Promotion Model (23) and on certain items from the standardised questionnaire used in the ELSPAC (European Longitudinal Study of Pregnancy and Childhood) (24).In addition to demographic data, particular blocks of questions were oriented towards factors important for a woman's health and the healthy development of the foetus during pregnancy. These blocks of questions covered both the woman's knowledge and her behaviour (dietary habits, time and type of active physical exercise, body weight and weight gain during pregnancy, smoking, alcohol consumption, il- licit drug use and emotional challenges). A dietary habits index with 10 questions and 32 possible answers (questions focused on the frequency of intake of protective and risk foods) was created, and for each correct answer (according to the food pyramid), one point was counted. Index distribution values ranged from 0 (the worst habits) to 10 (the best habits), index distribution: median = 6. A risk factors awareness index was created with values ranging from 0 to 21, index distribution: median = 18. A Likert scale was used to evaluate the feeling of stress during pregnancy and the postpartum period. Self-reported data were not objectively confirmed, with the exception of BMI and weight gain. The questionnaire was completed with data from obstetrician's protocols and included weight and height before pregnancy, weight gain during pregnancy, the form of delivery and newborn status. Pearson's x2 (chi-square) test and the ANOVA variance analysis were used to evaluate differences between groups with (a) varied educational levels and (b) frequency of participation in prenatal lessons with midwives; the acceptable value for significance was p < 0.05, sampling error 5.4%. Table 1. The characteristic of the sample. Item N % Number of participants 360 100 Age Average 30.5 y Median 31 y Education Basic 69 19.1 High school 145 40.3 University 146 40.6 Residence Town 259 71.9 Village 101 28.1 Parity Primipara 178 49.4 Secundipara 1 46 40.6 Multipara 36 1 0.0 Smoking Never 230 63.6 Former 1 09 30.0 Current 22 6.1 Alcohol in pregnancy (occasionally) 112 31.1 Illicit drugs Never 299 83.0 Former 32 8.9 Current 29 8.1 3 RESULTS The majority of participants had a revealing family health history. The most frequent disease was hypertension (in 51% of families), 40% had diabetes mellitus in the family, 30% of families had atopy and 60% reported a background of smokers within their family of origin. More than one half of participants (55%) reported positive unhealthy personal histories: allergies, asthma, recurrent urinary tract infections and anaemia were among the most frequent issues. Nearly two thirds (62%) reported gynaecological problems including repeated gynaecological inflammation, spontaneous abortion and menstrual cycle problems. The interruption of a previous pregnancy was reported by 12%. Nearly two thirds (64%) used hormonal contraception. The body mass index (BMI) values of the surveyed women at the beginning of pregnancy reflected a Gaussian curve distribution. The average BMI was inversely related to the level of education and place of residence; see Table 2. More participants with the lowest level of education were overweight or obese before pregnancy (BMI 25.0 and higher) compared to those with a university education (40% vs. 24% respectively, p < 0.001). Women living in villages had a BMI of 25.0 and higher more often than women living in towns (35% in villages vs. 24% in towns, p = 0.006). Table 2. Average BMI before pregnancy. N BMI Mean Std. deviation Education: Basic 69 24.5 4.6 High school 145 23.2 4.5 University 146 22.8 3.4 Residence: Town 259 22.9 4.0 Village 101 24.2 4.5 Total 360 23.3 4.2 The average weight gain was 13.4 kg. The highest prevalence of low, optimal and high weight gain is presented in Table 3. More women with the lowest education had higher (more than 15 kg) weight gain (36% vs. 23% women with university education, p = 0.005). A tendency towards higher weight gain was found among primiparous women (35% vs. 28% multiparous women) and among women living in villages (35% vs. 30% in towns). BMI and pregnancy weight gain were influenced by dietary habits; better dietary habits (with higher index value) lowered the first-input BMI of women and their pregnancy weight gain to the recommended optimal range (p < 0.001; p = 0.021 respectively). Half of the participants (50%) reported some preconcep-tional preparation; 25% six months or more. Preconcep-tional preparation was reported more often by primiparous and women with higher education than multiparous and women with lower education. A majority of them considered the omission of contraceptive pills to be a type of preparation for pregnancy. Prenatal preparation lessons were attended by 39% of respondents; 17% attended only a one-time course (focused on information about the labour process and breastfeed- Table 3. Education, place of residence, parity and weight gain in pregnancy. Count Weight gain Percent* Suboptimal Optimal High Total Education: Basic N 12 32 25 69 % 16.7 47.0 36.4 100.0 High school N 11 83 51 145 % 7.6 57.2 35.2 100.0 University N 20 91 35 146 % 14.0 62.2 23.8 100.0 Total N 43 207 110 360 % 11.9 57.3 30.8 100.0 Residence: Town N 32 152 75 259 % 12.2 58.8 29.0 100.0 Village N 11 54 36 101 % 11.3 53.6 35.1 100.0 Total N 43 206 111 360 % 11.9 57.4 30.7 100.0 Parity: Primipara N 21 95 62 178 % 11.9 53.4 34.7 100.0 Secundipara N 18 89 39 146 % 12.5 61.1 26.4 100.0 Multipara N 3 22 11 36 % 8.8 61.8 29.4 100.0 Total N 42 206 112 360 % 11.9 57.3 30.8 100.0 * Row percentages presented ing); 21% attended only a couple of theoretical lessons and 62% completed both theory lessons and exercise and practical skills (on average 10 lessons focused on pregnancy, labour, puerperium, infant care and breastfeeding). In most cases, lessons were led by midwives (96%) with a bachelor's education. In 4% of cases, the courses were led by a doula (an informed nonmedical person who accompanies and emotionally supports the pregnant woman but who must not interfere with the competencies of a midwife). Factors determining the participation in prenatal courses attendance were mainly contact with a midwife during previous pregnancy (p < 0.001), preconceptional preparation (p < 0.001), a higher level of education (p < 0.001) and primiparity (p <0.001). Place of residence was not a determining factor (p = 0.089). Determinants of prenatal course visitation are shown in Table 4. Table 4. Determinants of prenatal course visitations. Count Attendance of prenatal courses Percent* Yes No Total Education: Basic N 9 60 69 % 13.0 87.0 100.0 High school N 54 91 145 % 37.2 62.8 100.0 University N 76 70 146 % 52.1 47.9 100.0 Total N 139 221 360 % 38.6 61.4 100.0 Residence: Town N 108 151 259 % 41.7 58.3 100.0 Village N 32 69 101 % 31.3 68.7 100.0 Total N 140 220 360 % 38.8 61.2 100.0 Parity: Primipara N 95 83 178 % 53.4 46.6 100.0 Secun- N 36 110 146 dipara % 24.7 75.3 100.0 Multipara N 8 28 36 % 22.2 77.8 100.0 Total N 139 221 360 % 38.6 61.4 100.0 * Row percentages presented According to the respondents' reports, the content of the courses was focused mostly on labour and pain management, breastfeeding information, the postpartum period and infant care. About two-thirds (67%) noted that the obtained information related to healthy lifestyle during pregnancy, and approximately half of them (57%) received information about risk factors affecting healthy foetal development. None of the respondents mentioned any intervention for changing risk factors in the lifestyle. Nevertheless, the majority were satisfied with the lessons. According to self-reported data, the majority of respondents (85%) were informed about principal risk factors (Table 5 and 6). Their knowledge increased in proportion with educational level (Table 5); almost all differences in the frequency of correct answers between women with basic and university education were significant. Contact with a midwife during pregnancy (Table 6) seems to be very informative, but the imbalance in participation of women with different levels of education is an important confounding factor. The prevalence of those exposed to preventable risk factors was (inversely) associated with the level of education. The most common source of information for 75% of respondents was the internet, 50% relied on their gynaecologist or special literature and 32% reported friends or mother as a source of information. A prenatal course provided information for 26% of the women. The lowest numbers of women listed school (6%) or doula (3%) as their information source. A majority of respondents (80%) believed that information obtained during prenatal check-ups was sufficient for a healthy pregnancy. Nearly all participants had been informed about cardinal risk factors: drug abuse, smoking (both active and passive), stress, excessive physical load, alcohol in any amount, high levels of caffeine and malnutrition (Table 5 and 6). A majority (86%) of the respondents were aware of the positive impact of adequate physical activity during low risk pregnancy on both the mother's and infant's health. Unfortunately, 10% believed that physical activity has no impact and another 3% believed that physical activity positively influences only the mother's health while negatively affecting the infant's health; 1% was convinced that physical activity during pregnancy can have a negative impact on both mother and infant. Regarding the questions about changes to a healthier lifestyle, more than half of the participants (56%) thought they improved their diet in terms of quality and diversity, with 2.5% following a special medical diet. A majority consumed milk products (and occasional junk food) daily (85%), favoured white meat (75%), wholegrain bakery products (73%) and vegetable oils (73%) and ate at least 3 portions of fresh fruit (55%) and fresh or steamed vegetables daily (58%). Nearly three quarters (73%) focused on healthy food shopping and prioritised better methods of cooking (boiling and stewing). Half (43%) consumed fish at least once a week, but 33% stated frequent consumption of smoked meat products. Nearly one third (30%) attained very good dietary habits (index: 8 to 10 points), and 6% of respondents fulfilled all the main dietary recommendations. Nevertheless, one quarter (25%) had an index value of 5 or less. About one third (31%) modified habits before they became pregnant, and another 50%made positive changes during pregnancy. Some women (24%) said that information received from a midwife was an impulse to improve their lifestyle. A majority (83%) reported multivitamin supplement consumption during the whole pregnancy; 38% daily and 45% occasionally. Almost all of these women (75%) had consulted with a professional about the vitamin supplementation. Table 5. Awareness of pregnant women of risk factors for healthy infant development (education). Education Risk factors Basic High school University Pearson's x2 test proportion of YES responses Count Percent Count Percent Count Percent p-value Large or small weight gain in pregnancy 35 55.6 76 56.3 97 70.8 0.024 Obesity of mother 46 70 ,8 121 85.2 134 95.7 <0.001 Malnutrition of mother 57 86.4 139 97.2 138 97.2 <0.001 Non-acceptance of pregnancy 45 71.4 118 88.7 124 89.9 <0.001 Smoking during pregnancy 55 84.6 140 97.9 144 99.3 <0.001 Partner's smoking at home 46 73.0 126 90.6 142 98.6 <0.001 Lack of physical activity 38 60.3 88 64.7 109 82.0 <0.001 Huge physical load 55 83.3 130 92.9 133 95.7 0.008 Mother's negative emotions (anger, rage, fear) 50 76.9 119 83.8 118 86.8 0.210 Mother's stress 57 86.4 134 93.7 140 97.9 0.005 Reduction diet or non-consulted vegetarian diet 37 56.1 130 93.5 134 95.0 <0.001 Alcohol consumption (of any amount) 57 86.4 134 94.4 121 88.3 0.105 Higher amount of coffee/caffeine 50 76.9 122 87.8 120 89.6 0.042 Illegal drugs 62 93.9 142 99.3 143 98.6 0.028 Workload, including prolonged standing at work (more than 2 hours) 48 72.7 97 71.3 103 77.4 0.501 Lack of knowledge about risks for infant's development 40 60.6 94 69.1 110 79.7 0.012 Lack of rest and sleep 50 76.9 115 83.9 121 89.0 0.083 Table 6. Awareness of pregnant women of risk factors for healthy infant development (contact with midwife). Contact with midwife in course Risk factors Yes No Pearson's x2 test proportion of YES responses Count Percent Count Percent p-value Large or small weight gain in pregnancy 87 62.6 121 54.8 0.309 Obesity of mother 128 92.1 173 78.3 0.034 Malnutrition of mother 139 100.0 195 88.2 0.012 Non-acceptance of pregnancy 125 89.9 162 73.3 0.020 Smoking during pregnancy 139 100.0 200 90.5 <0.001 Partner's smoking at home 136 97.8 178 80.5 0.019 Lack of physical activity 104 78.2 131 59.3 0.015 Huge physical load 134 94.4 184 83.3 0.205 Mother's negative emotions (anger, rage, fear) 126 89.4 161 72.9 0.017 Mother's stress 139 100.0 192 86.9 0.031 Reduction diet or non-consulted vegetarian diet 128 90.8 173 78.3 0.083 Alcohol consumption (of any amount) 131 92.3 181 81.9 0.337 Higher amount of coffee/caffeine 125 89.3 167 75.6 0.192 Illegal drugs 139 100.0 208 94.1 0.136 Workload, including prolonged standing at work (more than 2 hours) 101 75.4 147 66.5 0.647 Lack of knowledge about risks for infant's development 103 74.6 141 63.8 0.331 Lack of rest and sleep 122 89.7 164 74.2 0.033 Inadequate physical activity was a typical phenomenon for most participants; 29% engaged in regular recommended levels before pregnancy; 55% participated in occasional physical activity; and 16% admitted to "no physical activity". During pregnancy, 38% of the women reduced their physical activity; 17% of respondents stated no change and kept good physical habits; 37% had no or insufficient physical activity and 8% enhanced their exercise activities in comparison with the situation before pregnancy. Patterns of smoking were significantly influenced by educational level: 64% never smoked, out of which 78% were university educated women and 22% had a lower level of education (p < 0.001), while 6% kept smoking even during pregnancy (no university educated women continued to smoke); 4% of the non-smokers were exposed to passive smoking (Table 7). In the whole sample, 24% of foetuses were exposed to cigarette smoke for various lengths of time. These relationships were highly significant (p < 0.001), especially with long term lessons involving skill practice (Table 8). In this survey sample, no relationship was seen between smoking and medical problems during pregnancy and labour. Nearly 10% of respondents had abstained from alcohol throughout their lifetimes; the number of abstained has increased during pregnancy. Nearly1% drank alcoholic beverages every day. The frequency of alcohol drinkers was significantly higher among university educated women. Neither prenatal lessons attendance nor parity influenced alcohol consumption. A majority (90%) stated they had never tried any illegal drugs; 10% reported elimination of this habit before or during pregnancy (Table 7); and 2.5% of women declined to answer questions regarding drug consumption. Some stress was very often experienced by 41% of women at the beginning of pregnancy, by 19% during the whole pregnancy and by nearly one half (44%) before labour. Medium and very high levels of stress were experienced by Table 7. Most critical risk factors based on education level. Education Basic High school University Pearson's x2 Risk factor (smoking, alcohol consumption, drugs) test: p-value Never smoked Count 14 83 114 Percent 20.6 59.7 78.1 Gave up before pregnancy Count 14 26 18 Percent 20.6 18.7 12.3 Gave up during pregnancy Count 19 20 11 <0.001 Percent 27.9 14.4 7.5 Current smoker (even during pregnancy) Count 16 4 0 Percent 23.5 2.9 0.0 Passive smoking during pregnancy Count 5 6 3 Percent 7.4 4.3 2.1 Never drank alcohol Count 11 10 6 Percent 16.4 7.0 4.1 Gave up before pregnancy Count 42 88 86 Occasionally during pregnancy Percent Count 62.7 14 62.0 44 58.9 52 0.017 Percent 20.9 31.0 35.6 Current alcohol consumption (even during pregnancy) Count 0 0 2 Percent 0.0 0.0 1.4 Never tried illicit drugs Count 57 130 129 Percent 87.7 92.9 88.4 Gave up before pregnancy Count 6 9 17 Gave up during pregnancy Percent Count 9.2 2 6.4 1 11.6 0 0.117 Percent 3.1 0.7 0.0 Occasionally during pregnancy Count 0 0 0 Percent 0.0 0.0 0.0 * Column percentages presented 60% of those reporting stress. No stress during pregnancy was reported by 19%. To cope with stress, one third of women used daily relaxation techniques including psycho-hygienic prevention and stress management, and another 50% used these methods occasionally. Participation in prenatal courses had a statistically insignificant effect on stress before labour (Table 8). Table 8. Influence of prenatal course on lifestyle during pregnancy. information and skills were related to labour. Since women must pay for course participation, opportunities for this specialised education may be limited or inaccessible for the unemployed or economically-challenged. In our study, determining factors for prenatal course participation were primiparity, previous contact with a midwife and holding a university degree. These conditions result in health education and prenatal behaviour. Women with lower education had poorer health literacy (knowledge and habits) Item Participation in prenatal course: None One lesson Theoretical lessons Whole course Total Average index of dietary habit N 221 24 29 86 360 Mean 6.19 6.67 6.38 7.27 6.49 Std. Deviation 1.99 1.66 1.59 1.79 1.94 Index of dietary habit* Poor 54.5 33.3 41.7 25.5 44.9 Good 45.5 66.7 58.3 74.5 55.1 Total 100.0 100.0 100.0 100.0 100.0 Change of physical activity* The same 51.0 47.8 53.8 42.2 48.8 Reduced 45.0 30.4 42.3 37.3 41.9 Enhanced 4.0 21.7 3.8 20.5 9.3 Total 100.0 100.0 100.0 100.0 100.0 Smoking* Never or quit during planning 69.4 75.0 89.7 89.3 76.2 Quit during pregnancy 18.5 8.3 6.9 7.1 14.2 Still smoking (or smoking environment) 12.0 16.7 3.4 3.6 9.6 Total 100.0 100.0 100.0 100.0 100.0 Alcohol* No 70.8 62.5 58.6 67.4 68.5 Yes 29.2 37.5 41.4 32.6 31.5 Total 100.0 100.0 100.0 100.0 100.0 Stress reduction techniques Yes, before the pregnancy 16.3 17.4 22.2 30.5 20.2 change* Yes, during the pregnancy 40.2 47.8 33.3 37.8 39.6 No 43.5 34.8 44.4 31.7 40.2 Total 100.0 100.0 100.0 100.0 100.0 * Column percentages presented 4 DISCUSSION Pregnancy is a very important time for both the mother and the child. A well-planned pregnancy should consider optimal timing according to parental age, health condition, mental maturity, supporting social environment and acceptance of recommendations for healthy lifestyle with necessary supplementation (25). Many contemporary women feel that physical observations by an obstetrician alone are insufficient care and some of them ask for prenatal education that will help them to be prepared for labour and parenthood (26, 27). The best course curriculum should also involve educational lessons, effective interventions for lifestyle change, training methods for coping with stress and anxiety and useful skills during delivery and postnatal care of newborns and infants. Such complex subjects should be prepared by professionals, comprehensively unified and presented by midwives upon completion of their certification. The content of prenatal courses is not yet unified in the Czech Republic and in many other countries. Our study indicates that the largest amount of available and participated in prenatal courses less often. The most frequent sources of information are mass media and the internet. This should be a signal for health educators to monitor the accuracy of the information available on the internet and to motivate less educated women to attend prenatal courses. In our entire sample, nearly all of the participants were well informed about critical health risk factors for mother and child: smoking, alcohol, drugs and stress. The knowledge index value increased with higher education and long-term midwife contact in a course, but not with prenatal obstetrician visits. Despite this knowledge, one quarter of the respondents were exposed actively or passively to cigarette smoke during pregnancy. Those women were more frequently less educated and involved with a smoking family. As such exposure represents important risks for pregnancy and the foetus, comprehensive anti-smoking education and intervention must be focused on this vulnerable group of women: younger, less educated with lower social status and low social support, without a partner or with a smoking partner, with many children, living with stress, experiencing life trauma and lacking love in their lives (28). These conditions restrict access to socially acceptable dopamine resources, minimising participation in pleasant daily events, and these women tend, therefore, to smoke significantly more often during pregnancy (29). Intervention should be oriented towards fathers as well, since their smoking is a source of environmental toxins and can initiate hereditary malformations and reproduction malfunctions (30). In contrast to pregnant smokers, women consuming alcohol during pregnancy are more often older (>35 years), mul-tiparas and with higher educational levels and socio-economic status (31). Our study confirmed these data. Neither visiting prenatal courses nor parity were significant determinants for alcohol consumption during pregnancy. The most significant determinant was the level of education. In our sample, knowledge about dietary recommendations and nutritional habits were not optimal. Concordant with foreign studies (32), the obese respondents were usually less educated and smoked. The majority obtained no individual recommendation during early pregnancy for optimal weight gain, although high entry BMI value negatively influences the woman's health and the pregnancy with a higher risk of hypertension, gestational diabetes, preec-lampsia, prolonged pregnancy, macrosomia and late foetal death, Caesarean delivery, infectious complications in the postnatal period and obesity and diabetes for both mother and child. It is important to note that imperfect maternal nutrition can be a risk factor even during preimplantation and placental development (33, 34). We found that age, parity and experience from a previous pregnancy are significant predictors of prenatal stress and anxiety, so very young and less educated primiparas and multiparas with traumatic experiences are at a higher risk of stress, even when their actual pregnancy is physiological. Although the current health care model is not sufficiently developed to identify these at-risk women (35), participation in prenatal lectures during our study reduced the number of anxious mothers before labour. A lower incidence of stress was identified in the group of higher-educated women. The results of a US study showed that many family doctors and obstetricians are not familiar with the latest recommendations for physical activity during pregnancy. Many women reduce their physical activity during pregnancy, especially in the third trimester when they consider passive relaxation and rest to be more important (36, 37). In our study, the quality of physical activity was higher within the group of highly educated women, findings similar to those of a Swiss survey (38), but in general, exercise during pregnancy did not correspond with the current recommendations for optimal levels. Special education and training for midwives in consulting, intervention methods and skill training is essential, as it can be the best way for them to become valuable sources of information, motivation and support (39). In the Czech Republic, most prenatal courses are provided by midwives (with certification from the regular educational state system), but they can be provided by almost anybody who arranges a business certificate for educational activities, which can be obtained without any proof of professional qualifications at the Trade Office. In our sample, only one third (32%) were in long-term contact with a midwife in prenatal courses. These participants reported that they were better prepared overall for labour and birth and felt less stressed at the end of pregnancy; more of them opted for breastfeeding. The feeling of readiness for labour and birth proportionally increased with the length of contact with a midwife, initiated through the women's higher knowledge index value and higher degree of education. These enlightened and well-educated women clearly stated that the information provided to them by midwives helped them to manage the postnatal period, and that they plan to be in contact with midwives during future pregnancies. A serious limitation of our study is the selection of the subgroup of pregnant women who decided to participate in prenatal courses: the majority of them were university educated and thus of higher social strata. Due to this selection, we were able to describe determinants of their knowledge, behaviour and attendance but not to clearly assess the influence of prenatal courses on pregnancy, labour and early maternal care for newborns. We think it possible that economic barriers are the main reason for this selection, as lectures are offered as paid services, above standard secondary prevention. 5 CONCLUSION Our results from the sample of pregnant women in the Czech Republic confirmed previously published data noting that health literacy and healthier lifestyle of pregnant women are associated with a higher level of education and long-term contact with a midwife in prenatal courses. Professional intervention and advice on primary prevention topics are necessary in order to achieve the goals of decreasing smoking, alcohol consumption and bad nutritional habits and improving support and skills for coping with stress. 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