First-time Turkish mothers who participated in a community-based antenatal education program were more likely than nonparticipants to adopt behaviors beneficial to their infants' and their own health soon after delivery.1 Women who attended the program had significantly elevated odds of beginning to breast-feed within two hours after giving birth and of taking their infant for a checkup within seven days. Contraceptive use in general was not associated with program participation, but the odds of using a method that required male involvement (i.e., condoms or withdrawal) three months after delivering were increased among participants.
The program, located in a community center in a lower-middle-class area of Istanbul, was designed for women who had had minimal if any sex and reproductive health education. Its eight two-hour sessions were led by a nurse, a facilitator and a trained member of the community; among the topics covered were health and nutrition during pregnancy, childbirth (including stages of labor and delivery, and interventions that might be needed in various circumstances), infant health and care, and postpartum health and contraception. As part of a program evaluation, researchers conducted in-home interviews with program participants and with nonparticipants who had had their first child at the same hospitals, and compared the results using chi-square tests and logistic regression. All women were interviewed 2.5-3.0 months after they delivered.
The analyses included 100 program participants and 157 controls who completed interviews between October 1998 and March 2000. Overall, roughly 40-50% of the women were older than 24, had been married less than two years and were natives of Istanbul. Nearly two-thirds had had more than eight years of formal schooling, but only one-quarter had ever worked outside the home; three in 10 lived in the same apartment building as some of their relatives. Half were married to men younger than 30, and three-quarters had a husband with at least a middle school education. The majority of women had health insurance, saw a private-sector provider for antenatal care and had delivered in a private hospital.
Program participants and controls had generally similar background characteristics. However, higher proportions of participants than of controls were older than 24 (60% vs. 40%), had been born in Istanbul (62% vs. 41%) and had gone to school for more than eight years (75% vs. 57%); a lower proportion had relatives who lived in their building (20% vs. 34%).
Interview data revealed several differences between program participants' and controls' postpartum health-related behaviors. Women who had attended the antenatal program were more likely than nonparticipants to have begun breast-feeding within two hours after delivery, to currently be breast-feeding, to currently be feeding their infant only breast milk and to have taken the baby for a checkup within a week after delivery (unadjusted odds ratios, 1.9-2.9). They also were more likely to be using a contraceptive and to be using a method requiring their partner's cooperation (1.9-2.1).
Notably, although the program encouraged women to choose vaginal birth unless a cesarean delivery was medically indicated and to have a postpartum checkup, the proportions of participants reporting these outcomes were only 43% and 59%, respectively, and were statistically indistinguishable from the proportions among controls. Likewise, despite the program's aim of preparing women for childbirth, only 27% of participants—the same proportion as among controls—said that the experience was as they had expected it to be.
In analyses that controlled for background characteristics and other factors that might influence women's health-related behaviors, only three behaviors remained significantly associated with program participation. Women who had attended the program were more likely than controls to have begun nursing within two hours after delivering (odds ratio, 2.2), to have taken the infant for a checkup within the first week (3.6) and to be using a contraceptive that involves male cooperation (1.9).
A number of factors besides program participation were associated with these behaviors. Women living in the same building as relatives had reduced odds of having begun to breast-feed within two hours (odds ratio, 0.5), and those aged 24 or younger were less likely than their older counterparts to be using a contraceptive requiring male involvement (2.0). The odds of beginning to nurse within two hours were elevated among women who had had a vaginal delivery (2.8) and were reduced among those whose baby weighed less than 3,000 g at birth (0.5). Women who gave birth in public hospitals were less likely than those who delivered in private facilities both to begin breast-feeding shortly after delivery (0.4) and to have their infant checked by a health provider within a week after birth (0.1). Those who had previously practiced contraception were more likely than those who had never done so to be using a method that involved their partner (2.5).
The researchers observe that the health behaviors that were associated with program participation are "new" ones that, because of provider misinformation, routine hospital practices or traditional societal norms, are "not widely practiced in the population." By contrast, some outcomes that were not associated with program attendance "are not completely under women's control." For example, many obstetrician-gynecologists in Istanbul prefer cesarean delivery and may recommend it for nonmedical reasons. Thus, the researchers conclude that "antenatal education is not the only answer [to Turkey's persistent maternal and child health problems], but it can be part of the answer"; increased demand for and quality of reproductive health services is another important part.
—D. Hollander
1. Turan JM and Say L, Community-based antenatal education in Istanbul, Turkey: effects on health behaviours, Health Policy and Planning, 2003, 18(4):391-398.