The World Health Organization recommends a minimum of 5 prenatal visits during pregnancy and a cesarean delivery rate of between 10% and 15% [1]. Smoking during pregnancy is related to adverse pregnancy and neonatal outcomes, and can be used as an indicator of the use of preventive healthcare services by pregnant women [2]. Little research into smoking rates and use of healthcare services among pregnant women in Southern Europe has been conducted, and the demographic profile of pregnant women in this region has changed considerably as a result of sizeable immigration.
The present study examined the use of healthcare services and smoking rates among Greek and non-Greek women who gave birth in 2 large hospitals in Crete, Greece. This analysis forms part of a wider birth cohort study (the Rhea study: www.birthcohorts.net/Cohort.Show.asp?cohortid=75) ongoing in Crete.
Consecutive pregnant women (n
=196) who gave birth in the 2 public hospitals of Heraklion (Venizelion General Hospital and PAGNI University Hospital) over a 1-month period between June 6 and July 6 2006 were included in the study. The Ethics Committee of the University Hospital approved the study protocol and informed consent was obtained from the participants. Structured face-to-face interviews were conducted with the women to retrieve information on their sociodemographic characteristics, whether they smoked or were exposed to passive smoking, and whether they had used maternity healthcare services. Multivariate regression analyses were performed adjusting for age, education, and place of residence unless otherwise specified, using SPSS version 14 (SPSS, Chicago, IL, USA) and Stata software (StataCorp, College Station, TX, USA).
The number of women giving birth during the study period was similar in the 2 hospitals: 100 at Venizelio Hospital and 96 at University Hospital. A high percentage of women were of non-Greek ethnicity (28%), primarily from Albania (16%) and Bulgaria (5%). Greek women were older than non-Greek women (28.9 vs 26.2 years, respectively; P<0.01). Education level was higher among Greek women, with 32.3% of Greek women having obtained a university degree compared with 14.8% of non-Greek women (P<0.01).
Almost half of the women, both Greek and non-Greek, gave birth by cesarean delivery (Table 1). No statistically significant differences in cesarean delivery rates compared with vaginal delivery were found for educational level, urban or rural residence, work before or during pregnancy, smoking or passive smoking, and healthcare use during pregnancy.
Twenty percent of non-Greek women and 5% of Greek women were not covered by health insurance. During pregnancy, Greek women were seen more than once per month by an obstetrician for a mean of 12.3 visits compared with 9 visits for non-Greek women (P<0.01). Greek women also had more ultrasound scans than non-Greek women (9.1 vs 5.6 scans respectively, P<0.01) (Table 1).
Smoking prevalence before pregnancy was as high as 41% for Greek women, and 22% for non-Greek women (P=0.02). Smoking rates decreased during pregnancy, however 25% of Greek and 15% of non-Greek women reported smoking throughout pregnancy. The prevalence of passive smoking during pregnancy was high, particularly among Greek women (69%). The prevalence of smoking and passive smoking was lowest among highly-educated women. The same associations were found in the multivariate regression models. The adjusted prevalence odds ratio (OR) for smoking in pregnant Greek women compared with non-Greek pregnant women was 2.12 (95% CI, 0.88–5.09) and the OR for passive smoking was 1.82 (95% CI, 0.87–3.76) (Table 1).
We found clear differences between the 2 groups regarding sociodemographic parameters, lifestyle, and use of health services. This included lower rates of health insurance in non-Greek women; increased use of personal and laboratory pregnancy diagnosis testing in Greek women; low numbers of obstetric visits by non-Greek women, possibly reflecting late attendance related to lack of insurance; higher prevalence of smoking before and during pregnancy in Greek women; and increased likelihood for Greek women to be employed before and during pregnancy. The non-Greek sample included a variety of ethnic groups, including Albanians, Bulgarians and others, and the small sample size made it difficult to identify whether any particular ethnic group was at an increased risk.
An alarming finding of the present study was the high percentage of cesarean deliveries. Around 45% of women underwent a cesarean, in contrast to the WHO recommended rate of 10%–15% [1]. The only other recent study in Greece found a similar rate, while an earlier study reported a lower rate [3]. This high prevalence of cesarean deliveries may be due to maternal request, physicians' convenience, or no recommendation from a physician that a woman should not undergo the procedure. Obstetricians in Greece have little or no financial gain from carrying out cesarean rather than vaginal deliveries.
The present study shows a very high prevalence of smoking and passive smoking among pregnant women in Crete. Studies conducted in Australia and Russia have reported high prevalences of smoking and exposure to tobacco during pregnancy [4], [5], although the findings were lower compared with the present study. Greek women were more likely to be exposed to both passive and active smoking, and this may be explained by differences between Greek and non-Greek women's sociocultural perceptions regarding their position, social taboos, and attitude toward smoking and lifestyle habits.
We found clear sociodemographic disparities in the use of healthcare services during pregnancy between Greek and non-Greek women in Crete, an extremely high rate of cesarean delivery, and a high prevalence of smoking and passive smoking, particularly among Greek women. The findings demonstrate the urgent need to implement a systematic approach to healthcare and health policy among pregnant women in Crete.
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