Vulnerability in maternity services through the eye of the beholder

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The impact of limited interactive health literacy in pregnancy disproportionally affects lower socio-economic groups and/ or including minority groups, affecting perinatal outcomes.

Addressing health capabilities and skills in the antenatal period is regarded as a midwifery competency.  

Relationship-based care contributes to the quality of maternal and newborn care. Utilizing the woman-midwife relationship and its elements of interaction and collaboration between the woman and her midwife is fundamental to the success of optimizing health outcomes through addressing interactive health literacy.

Pregnant women in the Dutch west area from all (ethnic) backgrounds will be invited to fill in a questionnaire (online, paper, face-to-face) containing questions about their demographic/ personal details, adverse life events, health literacy, personal and emotional wellbeing, sense of coherence, distress, social support, self-esteem, self-management, risk perception and satisfaction with life.

Multiple linear regression analysis models the relationship between level of interactive health literacy and its determinants in order to inform midwifery practice.

This study will contribute to improve the health status within and across childbearing populations and will contribute to improving health outcomes for mothers and babies, populations and to make a positive change for birthing women globally. Performing this study enhances relationship-based care – reflecting the midwife’s identity, values and integrity. Hereby strengthening the midwifery profession and the midwife’s position in practice.


This cross-sectional study aims (1) to measure levels of interactive health literacy during pregnancy in a sample of diverse women; (2) to explore the relationship between interactive health literacy and the predisposing, enabling or reinforcing determinants (3) to draw recommendations for midwifery practice.


What are levels of of interactive health literacy during pregnancy among women with a non-Dutch background and what are the determinants?


There is an existing chasm of knowledge between what midwives know about childbearing women’s interactive health literacy and their influencing factors. Research focus has been predominantly on functional and critical literacy2. To save lives through the woman-midwife relationship, we need to understand how pregnant women make use of their coping mechanisms, self-management abilities, personal use of resources, sense of coherence, social cohesion and risk perception in the face of challenges of pregnancy and birth – and how these psychosocial and behaviourial aspects influence the level of utilization of women’s health literacy capacities and skills, interactive health literacy in particular.

Improving maternal and newborn health requires participation of pregnant women – in order to inform midwives to provide adequate care. With regard to the multicultural and vulnerable populations, pregnant women in Rotterdam are a relevant group to participate in health literacy-related midwifery research. Using the childbirth period as a window of opportunity, will help women and their children to live healthier throughout their lifespan; not only concerning the primary maternal and infant health outcomes, but also those concerning later life.

This study offers a twofold opportunity: To add to the knowledge domain of woman-centred care and to the domain of vulnerable pregnant women. The combination of both will strengthen midwifery care in order to improve perinatal health.




Dr. J.A.C.A. Fontein-Kuipers

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