Knowledge of pregnancy care behaviors, complications, and urgent maternal warning signs up to one year postpartum among Georgia residents

Abstract

Objectives
Maternal mortality in the U.S. continues to increase, and the State of Georgia has one of the highest maternal mortality rates among the 50 states at 33.9 deaths per 100,000 live births, disproportionately affecting Black and rural populations. This study sought to ascertain knowledge of adults living in Georgia about proper pregnancy care behaviors and their ability to identify warning signs and symptoms (WSS) of life-threatening complications during pregnancy and up to 1-year postpartum.

Methods
In 2022, using a cross-sectional study design, a questionnaire including items from validated instruments was distributed to adults residing in Georgia through social media and email. Questions were grouped into categories: total pregnancy knowledge, general pregnancy care behaviors, and pregnancy and postpartum WSS. Based on correct answer choices, scores were created for each of the four categories and compared by gender, age, education, race, and ethnicity using multiple linear regressions.

Results
Participants (n = 588) ranged from 18 to 76 years old and were primarily female (80%). The vast majority (83.3%) failed to identify important pregnancy care behaviors. More than half of all participants were unable to recognize pregnancy and postpartum WSS of complications, 52% and 56% respectively. Male, Black, and Hispanic self-identified adults exhibited lower recognition of pregnancy care behaviors and WSS of pregnancy and postpartum complications, relative to other genders, races, and ethnic groups, respectively (p < 0.001).

Conclusions
This research identified important gaps in maternal health knowledge among adults living in the State of Georgia, highlighting specific opportunities for intervention and offering evidence-based information that can help improve health literacy for better maternal outcomes.

Full text

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Fagan et al. BMC Public Health (2024) 24:2598
https://doi.org/10.1186/s12889-024-19931-7 BMC Public Health
†Evelyn Fagan and Ana M. Palacios contributed equally to this work.
*Correspondence:
Ana M. Palacios
apalacios@georgiasouthern.edu
1Mercer University School of Medicine, 1250 E 66th St, Savannah,
GA 31405, USA
2Jiann-Ping Hsu College of Public Health, Georgia Southern University,
11935 Abercorn St, Savannah, GA 31419, USA
Abstract
Objectives Maternal mortality in the U.S. continues to increase, and the State of Georgia has one of the highest
maternal mortality rates among the 50 states at 33.9 deaths per 100,000 live births, disproportionately aecting Black
and rural populations. This study sought to ascertain knowledge of adults living in Georgia about proper pregnancy
care behaviors and their ability to identify warning signs and symptoms (WSS) of life-threatening complications
during pregnancy and up to 1-year postpartum.
Methods In 2022, using a cross-sectional study design, a questionnaire including items from validated instruments
was distributed to adults residing in Georgia through social media and email. Questions were grouped into
categories: total pregnancy knowledge, general pregnancy care behaviors, and pregnancy and postpartum WSS.
Based on correct answer choices, scores were created for each of the four categories and compared by gender, age,
education, race, and ethnicity using multiple linear regressions.
Results Participants (n = 588) ranged from 18 to 76 years old and were primarily female (80%). The vast majority
(83.3%) failed to identify important pregnancy care behaviors. More than half of all participants were unable to
recognize pregnancy and postpartum WSS of complications, 52% and 56% respectively. Male, Black, and Hispanic
self-identied adults exhibited lower recognition of pregnancy care behaviors and WSS of pregnancy and postpartum
complications, relative to other genders, races, and ethnic groups, respectively (p < 0.001).
Conclusions This research identied important gaps in maternal health knowledge among adults living in the State
of Georgia, highlighting specic opportunities for intervention and oering evidence-based information that can help
improve health literacy for better maternal outcomes.
Keywords Maternal health, Health literacy, Perinatal health, Pregnancy care, Pregnancy complications, Postpartum
complications, Pregnancy, Postpartum, Knowledge, Health knowledge
Knowledge of pregnancy care behaviors,
complications, and urgent maternal warning
signs up to one year postpartum among
Georgia residents
Evelyn F.Fagan1†, Ana M.Palacios2*†, Helen W.Bland2, Ariel A.Alston2 and DziyanaNazaruk2
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 2 of 9
Fagan et al. BMC Public Health (2024) 24:2598
Introduction
Deaths related to pregnancy, birth, and the postnatal
period are largely preventable [1]. e global health com-
munity has taken steps to reduce maternal and infant
mortality rates, but the United States remains stead-
fastly behind [2]. While the global maternal mortality
rate dropped by 45% from 1990 to 2017, the U.S. rate
increased by 57% during the same time period [3]. In
2022, the U.S. maternal mortality rate decreased to 22.3
deaths per 100,000 live births, but it remains signicantly
higher than that of other high-income countries. [4]. e
State of Georgia has one of the highest maternal mortal-
ity rates among the 50 states at 33.9 deaths per 100,000
live births [5]. With most pregnancy-related deaths due
to cardiovascular complications, cardiomyopathy, hem-
orrhage, infection, and cerebrovascular accidents; it is
estimated that 87% of pregnancy-related deaths could
have been prevented [6].
Many pregnancy-related deaths occur during the post-
partum period; in 2017, 81% of reported pregnancy-
related deaths occurred up to 1 year after birth [7]. In
Georgia, maternal mortality rates disproportionately
aect Black and rural populations [8]. For Black birthing
parents in Georgia, the number of maternal deaths is 66.6
per 100,000, nearly 4 times the U. S. maternal mortality
rate [9].
Maternal health challenges in Georgia are likely due
to the interplay of a myriad of highly complex and inter-
twined factors: individual, cultural, and societal. Systemic
issues within the current healthcare system include:
maternity care deserts in rural areas with limited access
to maternal-skilled health care providers [10], potential
inadequate preparation of medical sta to address cul-
tural competency, systemic racism, and unconscious bias
among providers and institutions. Fragmented health-
care services may result in suboptimal care for vulnerable
birthing parents, thus contributing to adverse health out-
comes and further increasing health disparities among
marginalized sociodemographic groups [11].
Individual factors that may increase maternal health
disparities and undesired behaviors, such as delaying or
avoiding seeking medical assistance, include socioeco-
nomic status, education and health literacy [12], and
burden of chronic diseases and obesity [9]. Cultural and
societal factors, such as mistrust, prior negative experi-
ences with the healthcare system, or inherent cultural
norms [13–15] are additional considerations that may
lead to dierences in health outcomes.
Addressing maternal mortality in Georgia requires a
comprehensive, multisystemic approach that considers
all these interconnected individual, cultural, and soci-
etal factors. Although health literacy is only one of the
many aspects that may shape successful maternal and
infant health outcomes, to date, little has been done to
characterize the knowledge of adults about maternal
health. is study sought to examine the knowledge of
adults residing in Georgia about appropriate pregnancy
care behaviors and to ascertain their ability to identify
warning signs and symptoms of life-threatening preg-
nancy and postpartum complications that require imme-
diate medical care seeking behaviors.
Methods
Methodology employed was a quantitative, cross-sec-
tional research design. Previously established instru-
ments were utilized to assess adults’ knowledge of
maternal pregnancy care behaviors and identication of
pregnancy and post-partum symptoms of life-threaten-
ing complications that require immediate medical care
seeking behaviors [16–19]. Non-probability sampling
methodologies utilized were convenience and snowball
techniques is research was reviewed and approved by
the Georgia Southern University Institutional Review
Board Protocol Number H22228. All study procedures
were done in accordance with the Helsinki Declaration
of 1975 as revised in 1983. e informed consent was
included as the rst question in the survey and included
a statement that certied that by proceeding with the
survey, participants acknowledged agreement to the
consent. Data collection occurred with questionnaires
designed in Qualtrics XM, Provo, UT that were distrib-
uted electronically by all the study sta who reside in
Georgia (n = 16) via personal emails and social media out-
puts including Meta, and Twitter. Study sta also encour-
aged personal contacts to share the IRB approved posts
among their social media sites, and to contact additional
participants via email. Participants were prompted to
complete the survey once, and eligibility criteria included
age of 18 years or older, current residency within the state
of Georgia, and declared prociency in English. Data col-
lection occurred between February and June of 2022.
Instrumentation
To assess the knowledge of pregnancy care behaviors,
complications, and recognition of urgent maternal WSS
during pregnancy and up to 1-year postpartum, previ-
ously established instruments were identied in the liter-
ature and adopted [16–19]. e most common pregnancy
complications that account for maternal mortality dis-
parities were also included (pre/eclampsia, cardiovascu-
lar complications, self-harming thoughts, bleeding, and
wound complications) [8]. For purposes of this research,
the following constructs were assessed: (1) identication
of appropriate pregnancy care behaviors (nutrition, phys-
ical activity, weight management, potential sources of-
and exposure to harmful substances including mercury,
alcohol, smoking, recreational drugs, and others) and
(2) identication of WSS of pregnancy and postpartum
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Fagan et al. BMC Public Health (2024) 24:2598
complications that could endanger the lives of the par-
ent, embryo/fetus or infant (pre/eclampsia, cardiovascu-
lar complications, self-harming thoughts, bleeding, and
wound complications).
After consolidating the sociodemographic variables of
all surveys into a few, and addition of false answer options
in the pregnancy and postpartum complications section
a total of 72 questions were consolidated into a single
instrument and beta tested to assess for understand-
ability among a diverse sample of adults (n = 15) from
Georgia with varying sociodemographic and educational
backgrounds [see Supplementary le 1 for the nal ques-
tionnaire]. Face content validity was established by two
maternal health experts. After data collection, internal
consistency reliability was conducted for each of the four
domains 1). Total pregnancy and postpartum knowledge,
2) General pregnancy care behaviors, 3) Identication of
pregnancy complications, and 4). Identication of post-
partum complications, with reported Cronbach alphas
of 0.941, 0.746, 0.927, and 0.921, respectively. Cronbach
alphas larger than 0.70 are considered reliable [20]. Data
were exported from Qualtrics XM® (Provo, UT) to IBM-
SPSS® version 25 (Armonk, NY). Data were carefully
inspected for invalid entries, plausibility, duplicity, and
errors. Responses were dichotomized for each answer
as follows: correct=”1” or incorrect=”0”, and aggregated
knowledge scores were generated for each of the follow-
ing four domains: (a) total pregnancy and postpartum
knowledge [knowledge within the followship 3 domains
with additional common pregnancy diseases], (b) gen-
eral pregnancycare behaviors, [knowledge of proper
nutrition and exercise behaviors, and identication of
exposures that could be harmful for the pregnancy dyad,
range 0–27]; (c) identication of WSS of common or
life-threatening pregnancy complications including ges-
tational diabetes, hypertensive disorders of pregnancy
[preeclampsia/eclampsia], gestational diabetes, infec-
tions, other cardiovascular complications [signs and
symptoms associated with deep vein thrombosis, pulmo-
nary embolism, and cardiomyopathy], range (0–20); and
(d) identication of WSS of common or life-threatening
postpartum complications [up to 1-year] including pre-
eclampsia or eclampsia, other cardiovascular complica-
tions [signs and symptoms associated with deep vein
thrombosis, pulmonary embolism, and cardiomyopathy],
and bleeding and infection-associated symptoms, range
0–17. Details on the variables in this study are detailed in
the supplementary material and tables [see Supplemen-
tary le 2]. Scores and sub scores were transformed into
a 0-100 scale for ease of interpretation, where greater
scores indicate greater knowledge in each domain.
Statistical analysis
Data were inspected, and implausible or repeated
responses were addressed. Multivariable linear regression
models were constructed to examine participants’ knowl-
edge in each domain: (a) total pregnancy and postpartum
knowledge; (b) pregnancy care behaviors; (c) identica-
tion of WSS during pregnancy, and (d) identication of
WSS up to 1 year postpartum. All models included the
following factors: participant’s age in years, participant
self-reported race, ethnicity and gender, and personal
history of pregnancy or parenting experience. Individual
model assumptions of normality and equal variance of
residuals were evaluated for each outcome and consid-
ered normal when presented with skewness <|2| [21].
To compare the proportion of participants who iden-
tied WWS during pregnancy and postpartum across
sociodemographic groups, Chi-square tests were
calculated.
Results
Sociodemographic characteristics of study participants
A total of 588 adults residing in the State of Georgia
participated in this study. Participants could select to
respond or not respond to any question. e mean age of
respondents was 28.5 ± 10.4 years (range 18 to 76),, 67.2%
were ≤ 30 years old, 80.3% self-identied as women, 68.2%
White, and 49.0% had previously either been pregnant or
parented a child. Table 1 details the sociodemographic
characteristics of study participants and summarizes the
standardized scores of the knowledge domains assessed
in the study.
Maternal health knowledge
Overall, mean knowledge scores among all participants
for each scale included: total pregnancy and postpar-
tum knowledge (49.9 ± 18.5), pregnancy care behaviors
(55.1 ± 16.3), pregnancy WSS (40.6 ± 24.6), and postpar-
tum WSS (38.4 ± 25.5).
After adjustment, Black and Hispanics were sig-
nicantly more likely to exhibit lower scores across all
domains: total pregnancy knowledge, pregnancy care
behaviors, and both pregnancy and postpartum urgent
WWS (p < 0.05) compared to female, white, non-Hispanic
participants, and those self-identied as men (p < 0.001).
Respondents with prior history of pregnancy or parent-
ing experience were signicantly more likely to have
greater general knowledge (p = 0.001), knowledge of preg-
nancy care behaviors (p < 0.001), and of postpartum WSS
(p < 0.004) compared to those without prior pregnancy or
parenting experience. No dierences were observed for
WSS during pregnancy for this sociodemographic group,
p = 0.150. Detailed model results are included in Table2.
Almost three quarters of survey respondents (72.20%)
incorrectly perceived that birth control was more
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Fagan et al. BMC Public Health (2024) 24:2598
Table 1 Sociodemographic characteristics of study participants, and means (standard deviations) of the following domains:
pregnancy and postpartum knowledge, pregnancy care behaviors, WSS of pregnancy complications, and WSS of postpartum
complication [1]
Characteristics Descriptive
statistics
n (%)
Total Pregnancy &
Postpartum
Knowledge2
Pregnancy Care
Behaviors2Pregnancy WSS of
Complications2Postpar-
tum WSS
of Compli-
cations2
Age
18.0 to 20.9 years 76 (12.9%) 39.5 (20.4) 45.8 (16.1) 33.4 (27.5) 28.5 (27.5)
21.0 to 29.9 years 317 (53.9) 51 (18.6) 54.9 (16.7) 42.3 (24.6) 39.4 (26.1)
30 years or more 192 (32.7) 51.5 (16.7) 58.9 (14.3) 40.7 (23.2) 40.4 (22.9)
Self-identied gender
Women 465 (80.3) 52.6 (17.2) 57.8 (14.8) 44.0 (23.6) 41.9 (24.8)
Men 107 (18.5) 37.2 (19.6) 43.5 (17) 27.2 (23.9) 25.0 (23.9)
Non-binary, other 16 (2.7) 41.7 (20.4) 42.9 (20.8) 42.9 (27.5) 34.5 (27.0)
Education attainment
Highschool 85 (14.5) 48.1 (19.9) 51.4 (18.5) 41.9 (25.0) 37.6 (26.9)
Partial or complete Bachelor’s 372 (63.4) 49.1 (18.7) 53.8 (16) 39.8 (25.2) 37.6 (25.8)
Masters or above 130 (22.1) 53.1 (16.9) 60.8 (14.2) 42.4 (23.0) 41.5 (23.8)
Self-identied race
Black 141 (24.0) 38.1 (19.1) 45.0 (18.7) 28.9 (23.0) 25.9 (22.6)
White 401 (68.2) 54 (16.5) 58.8 (13.7) 46.1 (23.2) 44.0 (24.5)
Other, multiple, or undeclared 12 (2.0) 42.4 (20.3) 47.8 (17.4) 29.3 (26.1) 27.0 (26.4)
Self-identied ethnicity
Hispanic 118 (20.5) 41.8 (10.9) 55.0 (9.0) 25.9 (16.8) 26.0 (16.5)
History of previous pregnancy or parenting experience
Yes 281 (49.0) 53.1 (16.0) 60.0 (12.9) 42.8 (22.9) 42.0 (23.5)
1 Except for th e column titled “descripti ve statistics, which a re n (%), all other valu es are means (standard dev iations).
2 Values were tran sformed in a 0-100 scale for e ase of interpretation , where greater scores indi cate more knowledge .
Table 2 Characteristics of respondents associated with knowledge scores of total pregnancy and postpartum knowledge, pregnancy
care behaviors, pregnancy WSS, and postpartum WSS in multivariable linear regression
Total Pregnancy and Post-
partum Knowledgean = 435
Pregnancy Care Behaviorsb
n = 473
Pregnancy WSSc
n = 564
Postpartum WSSd
n = 568
Characteristics Standardized
coecients
(Beta)
P value Standardized
coecients
(Beta)
P value Standardized
coecients
(Beta)
P value Standardized
coecients
(Beta)
P value
Age (years) -0.03 0.598 -0.03 0.493 0.03 0.489 -0.03 0.568
Gender (reference variable:” women”)
Male -0.22 < 0.001 -0.19 < 0.001 -0.23 < 0.001 -0.20 < 0.001
Nonbinary or other -0.06 0.145 -0.09 0.029 0.00 0.983 -0.03 0.448
Education (reference variable: “Master’s or above”)
High School -0.02 0.663 -0.08 0.130 0.04 0.398 -0.01 0.823
Partial or complete
Bachelor’s
-0.06 0.217 -0.10 0.045 -0.01 0.761 -0.04 0.427
Race(reference variable: “White”)
Black -0.30 < 0.001 -0.28 < 0.001 -0.24 < 0.001 -0.25 < 0.001
Other or undeclared -0.11 0.015 -0.12 0.006 -0.08 0.055 -0.08 0.042
Hispanic1-0.34 < 0.001 -0.15 0.001 -0.40 < 0.001 -0.36 < 0.001
Previous1 pregnancy 0.17 0.001 0.24 < 0.001 0.07 0.150 0.14 0.004
a R2 = 0. 28; Standard Error: 15.6
b R2 = 0. 25; Standard Error: 13.8
c R2 = 0. 27; Standard Error: 20.8
d R2 = 0. 24; Standard Error: 22.3
1 Reference f or Hispanic: Non- Hispanic, and for Previo us Pregnancy is “no pregn ancy or parenting ex perience”.
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Fagan et al. BMC Public Health (2024) 24:2598
hazardous to a person’s health than pregnancy. A small
percentage (39.50%) correctly responded that the embryo
was at greatest risk from exposure to drugs and alcohol
during the rst trimester of pregnancy. Only 16.70% had
knowledge of the maximum amount of recommended
daily caeine during pregnancy. Additionally, 21.10%
of participants could identify 4 or more exposures that
could be harmful to the pregnant person, developing
embryo/fetus during pregnancy (Data not presented in
table). Table3 provides the proportion of participants by
sociodemographic group that correctly identied nega-
tive behaviors or complications during pregnancy, and
Table4 during the postpartum period.
Less than a quarter of participants (23.70%) were aware
of the healthy weight gain ranges during pregnancy and
only about half (48.30%) indicated that if a person is over-
weight or obese, losing weight prior to pregnancy may
have a positive impact on the pregnancy. Most partici-
pants (65.50%) did not recognize to avoid contact sports
such as basketball during pregnancy Data not presented
in table.
Signs and symptoms of pregnancy complications
About half of the participants identied warning signs of
complications that may occur during pregnancy, includ-
ing vision changes (47.5%), severe nausea and vomiting
(47.7%), vaginal discharge (55.1%), and abdominal pain
(57.1%). Almost half of participants (43.4%) failed to rec-
ognize self-harming thoughts as an important warning
sign which could endanger the life of the pregnant parent
or embryo/fetus during pregnancy. A little over a third of
the participants (37.2%) recognized signs of cardiovascu-
lar complications that require immediate medical health
seeking behaviors, and only half of participants properly
identied 4 signs of preeclampsia or eclampsia (50.4%)
Data not presented in table.
Signs and symptoms of postpartum complications
Almost half of participants (43.8%) recognized vision
changes as a warning sign of complications while 51.9%
failed to identify tachycardia as an alarm sign. Other
warning signs that respondents recognized included
severe nausea and throwing up (45.6%), a persistent
headache that cannot resolve and worsens with time, and
chest pain (52.3%). Overall, only 31.7% could identify 4
or more signs of cardiovascular complications during the
postpartum period. Additionally, one third (34.30%) of
individuals knew at least 4 signs of wound complications,
and only 40.1% knew 4 signs of pre-eclampsia Data not
presented in table.
Table 3 Proportion of participants by sociodemographic variables with correct identication of signs and symptoms of potentially
harmful exposures or common complications during pregnancy [1]
Demographics Harmful
exposures
P-value CV Complications2P-value Pre/eclampsia P-value Self-
harming
thoughts
P-value
Age, years 0.13 0.21 0.17 0.02
18 to < 21 12.3% 34.3% 40.3% 40.3%
21 to < 30 21.4% 40.5% 52.9% 59.2%
≥ 30 24.4% 33.0% 50.0% 57.4%
Gender 0.02 < 0.001 < 0.001 < 0.001
Male 10.8% 21.0% 27.0% 37.0%
Female 23.5% 41.1% 56.0% 61.1%
Nonbinary or other 18.2% 28.6% 35.7% 50.0%
Education 0.13 0.32 0.73 0.37
High School 14.7% 36.1% 54.2% 53.0%
Partial or complete
Bachelor’s
20.6% 35.5% 49.4% 55.4%
≥ Masters 26.6% 43.0% 50.8% 61.7%
Race < 0.001 < 0.001 < 0.001 < 0.001
Black 10.4% 20.4% 29.9% 35.8%
White 25.5% 44.4% 59.5% 64.4%
Multiracial 9.10% 33.3% 58.3% 50.0%
Other or
undeclared
16.0% 23.3% 23.3% 53.3%
Hispanic 6.3% < 0.001 12.9% < 0.001 13.8% < 0.001 37.9% < 0.001
Parenting experience 26.6% < 0.001 36.9% 0.67 53.0% 0.37 60.9% 0.08
1 Χ2 tests, *p ≤ 0.05.
2 “CV”: Cardiovascular.
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Fagan et al. BMC Public Health (2024) 24:2598
Discussion
is research identied opportunities to improve overall
perinatal health literacy among adults residing in Geor-
gia. In this sample, those who self-identied as male,
Black, other or unspecied race, Hispanics, and not hav-
ing prior experience parenting a child exhibited signi-
cantly lower knowledge scores across all domains: total
pregnancy care behaviors, and identication of compli-
cations, pregnancy care behaviors, and identication of
signs and symptoms associated with complications dur-
ing pregnancy and the postpartum period.
Maternal mortality is a serious and complex health
concern in the State of Georgia and in the US that needs
a comprehensive, multisystemic and socio-ecological
approach. Health literacy is a distinct social determinant
of perinatal health [22], with low levels associated with
many adverse health behaviors and outcomes [23]. To
our knowledge, this is the rst study to examine maternal
health literacy in Georgia in a diverse population.
Our study highlighted important disparities in mater-
nal health literacy, and multiple opportunities to improve
overall perinatal health literacy among adults residing
in Georgia. In this sample, those who self-identied as
male, black, other/multiple or unspecied race, and of
Hispanic ethnicity exhibited signicantly less knowl-
edge scores across all four domains. ese subgroups
had consistently lower scores in identifying appropriate
pregnancy care behaviors and identication of pregnancy
and postpartum WSS associated with complications that
would require immediate medical care seeking behav-
iors from the pregnant or postpartum parent, relative to
women, white, and non-Hispanic participants. Our nd-
ings are comparable to a nation-wide study, which found
that 1 in 5 pregnant individuals had inadequate maternal
health literacy and were more likely to identify as Black
or Hispanic [23]. Another study reported similar ndings
with misconceptions of pregnancy weight gain, which
were particularly pronounced in self-identied Black
populations [24]. Additionally, only a small proportion of
individuals in our study were able to recognize that preg-
nancy is more hazardous to a person’s health than birth
control pills. is nding aligns with two other studies
which both showed an under-appreciation of health haz-
ards during pregnancy that may be aecting reproductive
choices, including contraceptive use [16, 25].
Table 4 Proportion of participants by sociodemographic variables that correctly identied signs and symptoms of common
postpartum complications
Demographics CV1 Complications P-value Pre/
eclampsia
P-value Self-
harming
thoughts
P-value Bleeding
Complications2P-value
Age, years 0.18 0.06 < 0.001 0.19
18 to < 21 22.1% 27.9% 47.1% 27.9%
21 to < 30 33.7% 43.4% 67.6% 37.5%
≥ 30 31.9% 39.4% 58.5% 31.4%
Gender < 0.001 < 0.001 < 0.001 < 0.001
Male 13.7% 18.6% 43.1% 18.6%
Female 36.2% 45.7% 67.1% 38.2%
Nonbinary or other 15.4% 15.4% 46.2% 23.1%
Education 0.20 0.78 0.57 0.94
High School 27.7% 41.0% 67.5% 33.7%
Undergrad/
Bachelors
30.4% 39.2% 61.4% 34.1%
≥ Masters 38.0% 42.6% 61.2% 35.7%
Race < 0.001 < 0.001 < 0.001 < 0.001
Black 15.3% 18.2% 48.9% 16.8%
White 38.2% 49.5% 68.5% 41.3%
Multiracial 25.0% 33.3% 66.7% 25.0%
Other or
undeclared
24.1% 20.7% 41.4% 27.6%
Ethnicity < 0.001 < 0.001 < 0.001 < 0.001
Hispanic 10.3% 10.3% 39.3% 12.8%
Non-Hispanic 37.8% 48.6% 69.1% 40.5%
Pregnancy or parent-
ing experience
0.08 0.43 0.50 0.58
Yes 35.7% 42.5% 64.3% 36.1%
No 28.8% 39.2% 61.5% 33.8%
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Fagan et al. BMC Public Health (2024) 24:2598
An alarming proportion of participants who responded
to the survey were unable to identify many urgent, life-
threatening warning signs and symptoms that during
pregnancy and postpartum, would require immediate
healthcare-seeking behavior. Our results were similar
to other studies demonstrating poor knowledge of WSS
during pregnancy and postpartum [16, 26, 27]. Knowl-
edge was particularly limited regarding signs and symp-
toms of preeclampsia, cardiovascular complications,
bleeding/wound complications, and mental health com-
plications. Importantly, all pregnancy-related deaths
attributed to hemorrhage, mental health conditions, car-
diomyopathy, cardiovascular and coronary conditions,
and preeclampsia and eclampsia were determined by
the Georgia Maternal Mortality Review Committee to
be preventable [28]. is report emphasizes the impor-
tance of recognizing warning signs during pregnancy,
childbirth, and the postpartum period to rule out serious
complications and quickly initiate treatment.
Among survey participants, black and Hispanic indi-
viduals had signicantly less knowledge of WSS of com-
plications during and after pregnancy. ese ndings are
consistent with a study in Indiana, which documented
that Black mothers were associated with having a lim-
ited knowledge of maternal postpartum urgent warning
signs [29]. Unfortunately, Black populations are dispro-
portionally burdened by poor pregnancy and postpartum
outcomes (Harris, 2023) and are also more likely to be
readmitted to the hospital during the postpartum period
and suer life-threatening complications [30]. Lack of
knowledge of maternal complications may be an impor-
tant driver for these disparities within the state of Geor-
gia and other Southern states.
Compared to women, men exhibited signicantly less
knowledge of both general pregnancy care behaviors and
WSS of complications during pregnancy and postpar-
tum. While most maternal health knowledge surveys are
limited to mothers, the role of partners during pregnancy
and postpartum care is key in the prevention of adverse
perinatal complications and the support of a success-
ful pregnancy [31, 32]. Partners oer vital psychological
and social support before-, during-, and after pregnancy,
and can help recognize, encourage, facilitate and sup-
port pregnant parents to pursue immediate perinatal care
[33]. e present study ndings highlights a great oppor-
tunity to identify strategies to include males and partners
in maternal and perinatal health. Finally, we observed an
important disparity in knowledge between those without
parenting or prior pregnancy experience, highlighting the
need to devise strategies to reach to those who are not
pregnant. is is especially important for birth-defect
prevention and pregnancy planning to increase repro-
ductive health outcomes. Reaching such populations may
require dierent education strategies relative to those
who are already seeking obstetric care.
Strengths and limitations
Study strengths include the incorporation of a vast array
of maternal health topics in the survey- from general
pregnancy care behaviors to the identication of warn-
ing signs of complications during pregnancy and the
postpartum period. Importantly, this is an area within
maternal health research that is largely lacking in the
United States, with very few studies directly address-
ing knowledge of warning signs of complications, timely
identication of signs and symptoms of pregnancy and
postpartum complications and immediate care-seeking
behaviors have a tremendous potential to reduce the
maternal morbidity and mortality burden and is recom-
mended by the Surgeon General [34]. To our understand-
ing, this is the only study that examines disparities among
diverse sociodemographic groups, including racial and
ethnic dierences in knowledge, across all individu-
als, not just mothers. Additionally, this is the rst study
within the state of Georgia addressing maternal health
literacy. Even though our study has a limited sample size,
and the use of convenience sampling may aect gener-
alizability to the entire adult population of Georgia, we
recruited a diverse group of individuals, more than 30%
self-identied as Black or other than white, and over 20%
of Hispanic background, increasing our belief that we
included a range of voices and experiences in our study.
Further research will be needed to conrm our ndings,
to identify barriers and facilitators to access maternal
health information in Georgia and the US, and to develop
and evaluate meaningful interventions to address mater-
nal health literacy from a health equity lens.
Conclusion
e current study unearthed a strikingly low general
knowledge level of pregnancy care behaviors and iden-
tication of urgent WSS during pregnancy and up to
1 year postpartum in adults living in the State of Geor-
gia. In addition, this study highlighted the importance
of addressing disparities in maternal health literacy, a
critical issue moving forward. Limited maternal health
literacy among the study participants could be the result
of several factors including but not limited to: the lack of
comprehensive educational eorts within schools, de-
ciency of public education campaigns, limited access to
care in rural populations, limited time and energy spent
in education eorts by medical professionals, politi-
cal and religious views, limited participation or interest
in maternal health from other genders, social marginal-
ization, systemic racism, and discrimination. Not only
do these ndings highlight a need to improve maternal
health knowledge with a specic focus on vulnerable
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Page 8 of 9
Fagan et al. BMC Public Health (2024) 24:2598
sociodemographic groups, but also exemplies an urgent
exigency to including partners and men in the maternal
health conversation.
is comprehensive study oers specic details on gaps
in the knowledge of adults living in Georgia that could be
easily incorporated into public health education eorts
and inform practitioners at the State and county level to
focus on such topics while attending their patients. s. Pri-
mary care settings and oces of prenatal care providers
could be an essential outlet for patient education eorts,
while incorporation of technological innovations in the
eld might be needed to successfully increase mater-
nal health literacy levels among adults living in Geor-
gia. Additionally, considering including curriculum on
maternal and perinatal health in high schools and using
faith-based organizations to increase maternal health lit-
eracy may improve pregnancy and reproductive health
outcomes.
Lastly, future studies are needed to characterize dier-
ences between urban and rural participants and to iden-
tify feasible and potentially scalable platforms to increase
maternal health literacy and other approaches that may
improve pregnancy and reproductive health outcomes in
Georgia and similar states.
Abbreviations
WSS Warning signs and symptoms
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12889-024-19931-7.
Supplementary Material 1
Supplementary Material 2
Supplementary Material 3
Supplementary Material 4
Acknowledgements
The researchers are grateful with Dr. Yenupini Joyce Adams for sharing her
data collection tool and with the Georgia Southern University Jiann Ping
Hsu College of Public Health students who supported the data collection
procedures.
Author contributions
AP and HB created and distributed the survey to participants. EF also
distributed the survey. EF and AP analyzed the data. AP, EF, HB, and AA
interpreted the data. EF, AA, and AP were major contributors in writing
the manuscript. DN contributed to the conclusion of the article and with
reference collection. All authors read, reviewed and approved the nal
manuscript.
Funding
This study did not receive any funding.
Data availability
All data generated or analyzed during this study are included in this published
article and its supplementary information les.
Declarations
Ethics approval and consent to participate
All participants completed informed consent to be included in the study.
The Georgia Southern University Institutional Review Board reviewed and
approved this research project on 2/15/2022, Protocol No. H22228.
Consent for publication
Not applicable.
Competing interests
Dr. Palacios’ institution, Georgia Southern University, and The Georgia Southern
University foundation have received funds to support her research from
WeightWatchers International, Inc. The rest of the authors declare no conicts
of interest.The rest of the authors declare no competing interests.
Received: 22 November 2023 / Accepted: 29 August 2024
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