IJG-08733; No of Pages 5

International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Predictive value of self-rated health in pregnancy for childbirth

complications, adverse birth outcomes, and maternal health
Irena Stepanikova a,b,, Lubomir Kukla a, Jan Svancara a,c
a
Research Centre for Toxic Compounds in the Environment, Masaryk University, Brno, Czech Republic
b
Sociology Department, University of Alabama Birmingham, Birmingham, AL, USA
c
Institute of Biostatistics and Analysis, Masaryk University, Brno, Czech Republic

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To investigate whether self-rated health (SRH) in pregnancy can predict childbirth complications,
Received 23 November 2015 adverse birth outcomes, and maternal health problems up to 3 years after delivery. Methods: A retrospective
Received in revised form 10 March 2016 analysis was performed of data obtained in a prospective longitudinal population-based birth cohort study.
Accepted 9 June 2016 Pregnant women resident in the Brno or Znojmo regions in the Czech Republic were included if they were
expected to deliver between March 1991 and June 1992. SRH data were collected between 1991 and 1995 via
Keywords:
pen-and-paper questionnaires administered in mid-pregnancy, and at 6 months, 18 months, and 3 years after
Birth outcomes
Childbirth complications
delivery. Medical records were reviewed for pregnancy complications, childbirth complications, and birth
Maternal health outcomes. Multivariate regression analysis was performed. Results: Overall, 4811 women were included. Better
Pregnancy SRH in pregnancy predicted fewer childbirth complications (b=0.03; P=0.036); lower odds of cesarean deliv-
Self-rated health ery (odds ratio 0.81; P = 0.003); and fewer maternal health problems at 6 months (b =0.32; P b 0.001),
18 months (b=0.28; Pb 0.001), and 3 years after delivery (b=0.30; Pb0.001). The effects of SRH were inde-
pendent of diagnosed complications and self-reported health problems in pregnancy. Conclusion: SRH in preg-
nancy has predictive value for subsequent health outcomes, and might be an additional tool for assessment of
pregnant womens health.
2016 Published by Elsevier Ireland Ltd on behalf of International Federation of Gynecology and Obstetrics.

1. Introduction
Self-rated health (SRH) is an increasingly popular indicator of health
status. It has been employed since the 1950s [1], but its use has in-
creased rapidly in recent years. A PubMed-based search in February
2016 showed that publications with self-rated health in the title or
abstract increased from 424 in the period 19802000 to more than
2000 in the past 5 years.
Arguably, SRH owes its popularity to several advantages. From a
practical point of view, its main strength is its simplicity and ease of
use. Typically, SRH is assessed via one item asking respondents to rate
their health on a Likert-type scale. This brief measure has an undeniable
appeal both for researchers concerned with respondent burden and cost
[2], and for practitioners interested in perceived health.
From a conceptual perspective, SRH captures a broader, more com-
prehensive view of health as compared with objective measures such
Corresponding author at: Sociology Department, University of Alabama
Birmingham, 1401 University Blvd, Birmingham, AL 35233, USA. Tel.: + 1 205 934
3308; fax: + 1 205 975 5614.
E-mail address: irena@uab.edu (I. Stepanikova).
as clinical diagnoses and biomarkers of risk. Ratings of own health rep-
resent a complex human judgement and reect an array of factors, some
of which are inherently subjective [3], such as bodily sensations, subjec-
tively experienced symptoms, perceptions of health history, awareness
of risks (hereditary, environmental, and behavioral), social compari-
sons, and perceived cultural conventions [1,4]. When making judge-
ments about their own health, individuals actively lter subjective
somatic sensations and medical events, discounting experiences such
as recent acute illness that are not meaningful indicators of long-term
health [5]. SRH captures nonspecic symptoms of various illness states
that can be overlooked in routine clinical practice, such as hyperalgesia,
weakness, changes in sleep and eating patterns, and decreased motiva-
tion [6]. In summary, SRH reects physical, emotional, and social well-
being, not just absence or presence of disease. This makes it compatible
with WHOs holistic denition of health [7].
Given the subjective nature of SRH and the as-yet incomplete un-
derstanding of what it is that SRH captures precisely [1], the exami-
nation of its predictive value for objective health outcomes has
been a central part of the effort to justify its scientic use. In 1997,
a review of 27 representative community studies in 13 countries
[8] revealed that SRH consistently predicted mortality after
adjusting for morbidity. More recent work corroborates this

http://dx.doi.org/10.1016/j.ijgo.2016.03.029
0020-7292/ 2016 Published by Elsevier Ireland Ltd on behalf of International Federation of Gynecology and Obstetrics.

Please cite this article as: Stepanikova I, et al, Predictive value of self-rated health in pregnancy for childbirth complications, adverse birth
outcomes, and maternal health, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.03.029
2 I. Stepanikova et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx
conclusion and claries how the association between SRH and mor-
tality varies by sociodemographic characteristics [911].
The predictive value of SRH is largely unknown in pregnancy be-
cause most prospective studies focus on midlife and older age. For
example, poorer SRH has been shown to predict: future onset of coro-
nary heart disease, diabetes, stroke, lung disease, and arthritis among
individuals aged 5161 years [12]; higher rates of physical disability
after a major medical event among elderly people [13]; and more phy-
sician visits and hospitalization among elderly Canadians [14]. A Danish
prospective study [15] linked SRH in pregnancy with a higher risk
of rheumatic arthritis. In cross-sectional studies, poorer SRH in pregnan-
cy has been associated with objective diagnoses, higher body mass
index, psychologic stress, past smoking, and inammation [16], and
retrospective ratings of own health during pregnancy have been linked
with preterm birth, low birth weight (LBW), and small-for-gestational-
age neonates [17].
However, the predictive value of SRH, as previously documented
for more stable life periods, cannot be assumed for pregnant women.
Pregnancy represents a dynamic life phase with unique features. The
bodily changes are profound, and symptoms that would probably indi-
cate illness in nonpregnant womene.g. nausea, vomiting, fatigue, and
painoccur frequently in otherwise healthy pregnancies [18]. Changes
in health behaviors during pregnancy are common [19], because many
women limit risks such as smoking and alcohol consumption and obtain
health care if available. At the same time, bodily changes make physical
activity challenging for some women, and emotional changes can add to
stress. Given this complex picture, the aim of the present study was to
evaluate the value of SRH in pregnancy for prediction of birth complica-
tions, birth outcomes, and subsequent maternal health problems.
2. Materials and methods
Data were retrospectively assessed from the European Longitudinal
Study of Pregnancy and Childhood in the Czech Republic (ELSPAC-CZ), a
population-based prospective birth cohort study conducted in the Brno
and Znojmo regions of the country between 1991 and 2011. ELSPAC-CZ,
which aims to assess childrens health from the fetal period until the
age of 19 years, is part of ELSPAC, a multisite study initiated by WHO
to identify factors that affect pregnant womens and childrens health
in Europe [20]. Before data collection, ELSPAC-CZ was approved by the
Scientic Council of Pediatric Research Institute in Brno concerning
the adherence to ethical standards. In 2002, the study was moved to
Masaryk University and approved by its Ethical Council. All participants
gave written informed consent.
Eligibility criteria for ELSPAC-CZ included a permanent address in
the districts of Brno or Znojmo, and an expected date of delivery be-
tween March 1, 1991, and June 30, 1992. Recruitment to ELSPAC-CZ
was conducted in collaboration with local gynecologic practices identi-
ed in a central registry. The goal was to reach the whole population
of pregnant women in Brno and Znojmo districts within the specied
period. Gynecologists were contacted with a request to identify poten-
tial participants, inform them about the purposes of the study, and ask
about interest in participation. Consent forms and pen-and-paper ques-
tionnaires were distributed to prospective participants, either by staff
during a prenatal visit or by mail. Most baseline questionnaires were
distributed around week 20 of pregnancy. Women were asked to
complete questionnaires within 4 weeks and return them during a
prenatal visit or by mail using a pre-addressed envelope. Follow-up sur-
veys were collected at 6 months, 18 months, 3 years, 5 years, 7 years,
11 years, 13 years, 15 years, 18 years, and 19 years after delivery. At
each timepoint, a reminder was mailed to non-respondents. Women
who did not respond to the reminder were contacted to schedule an
at-home visit. As incentives, participants received discount cards spon-
sored by local businesses.
The present analysis was based on a record review of a subset of
data collected between 1991 and 1995 from women who completed
Please cite this article as: Stepanikova I, et al, Predictive value of self-rated health in pregnancy for childbirth complications, adverse birth
outcomes, and maternal health, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.03.029
self-administered questionnaires during pregnancy in 19911992.
SRH was measured as part of the baseline questionnaire using the ques-
tion: How would you rate your health in the last 2 weeks? The answer
was rated on a scale of 1 to 5 (always poor, often poor, occasionally
poor, usually good, or excellent). On the basis of prior research
[7,10], this variable was treated as continuous. During a pilot study,
pregnant women had been asked to comment on clarity of survey
instruments, problems with understanding, sensitivity of questions,
time demands, and other issues. Revisions based on these comments
were incorporated into the nal survey instrument.
Pregnancy complications were extracted from medical charts,
including: vaginal bleeding during the rst trimester; vaginal bleeding
during the second trimester; placenta previa; placental abruption;
hyperemesis gravida; genital herpes; urinary tract infection; glycosuria;
edema, proteinuria, or hypertension; eclampsia; diabetes; suspected
fetal growth retardation; polyhydramnios; oligohydramnios; and a
threat of premature delivery. A dichotomous variable for each complica-
tion was coded as 0 (not present) or 1 (present). A summary indicator
was constructed as the mean across individual complications and
rescaled to the range 015 to facilitate interpretation.
Birth outcomes included LBW (b 2500 g) and mode of delivery (coded
as cesarean or other). Childbirth complications extracted from the
medical charts included edema, fever, prolonged rst stage of labor,
prolonged second stage of labor, arrested labor, alterations in fetal
heartbeat, meconium in amniotic uid, uterine abruption, eclampsia,
umbilical cord prolapse, umbilical cord coiled around neck, and
obstructed labor. Each complication was coded as 0 (not present) or
1 (present). As above, a summary indicator was constructed as the
mean across individual complications and rescaled to 012.
Self-reported maternal health problems were assessed in mid-
pregnancy and at 6 months, 18 months, and 3 years after delivery. At
each time, respondents were presented with a list of health problems
and asked to report whether they had experienced each problem. At
mid-pregnancy, participants reported the following problems experi-
enced since the beginning of their pregnancy: nausea, vomiting, diar-
rhea, bleeding from vagina, urinary tract infection, u, yeast infection,
and herpes on genitals. Problems reported at each observation time
after delivery included headache, backache, digestive problems, cough
or cold, u, bronchitis, breathing problems, urinary tract infection,
and hemorrhoids or piles. At 6 months, participants were asked about
problems experienced since the delivery. At 18 months and 3 years,
they reported problems experienced since 6 months and 18 months, re-
spectively. Each problem was coded 0 (no) or 1 (yes). A summary indi-
cator for each observation period was calculated as the mean across
conditions and rescaled to the range 08 for mid-pregnancy and 09
for postdelivery observation times.
Control variables included the highest level of education (basic/
vocational, secondary school, university), age in years, marital status,
household size, singleton versus multiple pregnancy, and smoking.
A parity indicator was based on womens reports of whether they
had children.
Owing to funding limitations, an electronic database of the ELSPAC-
CZ data was compiled only recently, facilitating the present analysis.
Analyses were done with Stata version 14 (StataCorp, College Station,
TX, USA) and in three steps. First, sample characteristics were estimated.
To account for missing data, all analyses used multiple imputation with
chained equations, also known as imputation using fully conditional
specications [21] or sequential regression multivariate imputation [22].
Second, multivariate analyses were performed using general linear
models with robust variance estimators to account for deviations from
normality. The models assessed how SRH in pregnancy was related to
adverse birth outcomes, the index of childbirth complications, and indi-
ces of self-reported maternal health problems at the three timepoints
after delivery. An identity link function was used for indices of birth
complications and health problems; a logit link function was used for
birth outcomes.
 I. Stepanikova et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx 3

Table 1 study vs 13.7% in the National Birth Registry) and had fewer LBW
Characteristics of study participants (n=4811). neonates (4.8% vs 5.7%).
Characteristics Value a Standard error Overall, SRH in pregnancy was high, with a mean of 3.81 (standard
Self-rated health in pregnancy 3.81 (15) 0.01
error 0.01; range 15). Nonetheless, most women reported experienc-
Pregnancy-related characteristics ing some health problems; the most common were nausea and vomiting
Parity 1 2330 (48.4) 0.01 (Table 2). With the exception of the threat of premature delivery, each
Singleton 4719 (98.1) 0.002 pregnancy complication was present in less than 5% of cases (Table 3).
Sociodemographic characteristics
Notably, self-reports of vaginal bleeding and urinary tract infection
Age at delivery, y 25.20 (1546) 0.07
Household size 3.36 (114) 0.02 were higher than noted in medical records.
Education Adverse birth outcomes were uncommon, appearing in fewer
Basic/vocational 2078 (43.2) 0.01 than 10% of cases (Table 3). Similarly, among childbirth complications,
Secondary 1888 (39.3) 0.01 only nuchal umbilical cord was noted in more than 10% of cases. It
University 845 (17.6) 0.01
Married 4164 (86.6) 0.01
was followed by meconium in amniotic uid, alterations in fetal heart-
Never smoked 2762 (57.4) 0.01 beat, edema, arrested labor, and prolonged second stage of labor, each
a appearing in 1%10% of cases. Fever, umbilical cord prolapse, eclampsia,
Values are estimates of mean (range) or number (percentage), obtained using mul-
tiple imputations with chained equations. obstructed labor, and prolonged rst-stage labor were each reported in
less than 1% of cases.
The mean number of self-reported health problems for 6 months,
Third, as supplementary analyses, separate models of each individ- 18 months, and 3 years after delivery ranged between 2 and 4 out of
ual self-reported health problem at each postdelivery time were esti- 9 examined problems (Table 3). Common problemse.g. cough/cold,
mated using general linear models with a logit link function. Models headache, and backachewere reported by most participants at each
of each individual childbirth complication were also estimated: be- timepoint (Table 2).
cause of low rates of individual complications, some models did not Multivariate models indicated that better SRH in pregnancy inde-
converge and others showed poor t raising concerns about potential pendently predicted fewer childbirth complications (P = 0.036) and
bias; therefore, these models are not reported. All models controlled lower odds of cesarean delivery (P = 0.003) (Table 4). Additionally,
for physician-reported pregnancy complications, self-reported health compared with nulliparous participants, women who had previous
problems in pregnancy, parity, singleton versus multiple pregnancy, children had signicantly fewer childbirth complications (P b 0.001),
maternal age, education, marital status, household size, and smoking. lower odds of cesarean delivery (P b0.001), and lower odds of LBW
Pb 0.05 was taken to be statistically signicant. (P = 0.020) (Table 4). Cesarean delivery and LBW were less common
among singleton pregnancies than among multiple pregnancies
3. Results (P b0.001 for both) (Table 4). Compared with participants with a sec-
ondary school education, women with basic or vocational education
During the study period, baseline questionnaires were distributed had more childbirth complications (Pb 0.001) and higher odds of LBW
to 7262 women, of whom 5167 returned questionnaires (71.2% re- (P= 0.004) (Table 4). Finally, the number of childbirth complications
sponse rate). Overall, 356 (6.9%) women were excluded owing to increased signicantly with age (P = 0.001), as did odds of cesarean
missing identication (e.g. no name given), yielding a nal sample of delivery (Pb0.001) (Table 4).
4811 pregnant women. The relationships between SRH in pregnancy and the indices of self-
The characteristics of the participating women are reported in reported health problems at 6 months, 18 months, and 3 years are
Table 1. Most pregnancies were singleton, and approximately half the shown in Table 5. SRH in pregnancy predicted fewer health problems
women were nulliparous. Most participants were married and had at all timepoints (P b0.001 for all). Covariates associated with more
never smoked. As compared with the whole population of 7895 births health problems up to 3 years after delivery included more self-
registered in the National Birth Registry for Brno and Znojmo regions reported health problems in pregnancy (P b 0.01 for all timepoints),
(which includes survey participants) [20], the survey participants smoking (P b0.05 for all), and having had previous children (P b 0.05
at baseline were more educated (university education 17.6% in our for 18 months and 3 years). Compared with women with a secondary

Table 2
Self-reported health problems in pregnancy and up to 3 years after delivery (n=4811).a

Pregnancy 6 months 18 months 3 years

Problem
Value b SE Value b SE Value b SE Value b SE

Headache 2598 (54.0) 0.008 2745 (57.0) 0.009 3191 (66.3) 0.009
Backache 3058 (63.6) 0.008 2798 (58.2) 0.009 3116 (64.8) 0.011
Digestive problems 939 (19.5) 0.006 1325 (27.5) 0.007 1541 (32.0) 0.007
Nausea 3680 (76.5) 0.006
Vomiting 2389 (49.7) 0.007
Diarrhea 655 (13.6) 0.005
Hemorrhoids (piles) 664 (13.8) 0.005 561 (11.7) 0.006 599 (12.4) 0.005
Breathing problems 210 (4.4) 0.003 202 (4.2) 0.004 324 (6.7) 0.004
Bronchitis 156 (3.2) 0.003 277 (5.8) 0.004 504 (10.5) 0.005
Cough/cold 2933 (61.0) 0.009 3484 (72.4) 0.008 4114 (85.5) 0.007
Flu 1247 (25.9) 0.007 1113 (23.1) 0.006 1797 (37.3) 0.007 2591 (53.8) 0.009
Urinary tract infection 154 (3.2) 0.003 143 (3.0) 0.003 238 (4.9) 0.004 378 (7.9) 0.005
Yeast infection 262 (5.4) 0.004
Herpes on genitals 42 (0.9) 0.001
Bleeding from vagina 526 (10.9) 0.005
Health problem index 2.15 (08) 0.028 2.52 (09) 0.026 2.83 (09) 0.031 3.48 (09) 0.034

Abbreviation: SE, standard error.

a
Not all measures available for all timepoints.
b
Values are estimates of mean (range) or number (percentage) obtained using multiple imputations with chained equations.

Please cite this article as: Stepanikova I, et al, Predictive value of self-rated health in pregnancy for childbirth complications, adverse birth
outcomes, and maternal health, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.03.029
4 I. Stepanikova et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx

Table 3 observation times. For cough/cold and hemorrhoids, the association

Adverse birth outcomes, childbirth complications, and pregnancy complications obtained was signicant at 6 months only. Higher SRH predicted lower odds of
from health records (n=4811).
breathing problems at 18 months and 3 years and bronchitis and uri-
Complications and outcomes Value a Standard error nary tract infection at 3 years. The magnitudes of signicant effects
Adverse birth outcomes associated with a unit increase in SRH ranged from a 10% decrease in
Cesarean delivery 390 (8.1) 0.004 the odds of cough/cold at 6 months (P = 0.047) to a 31% decrease in
Low birth weight 232 (4.8) 0.003 the odds of headache at 6 months (Pb 0.001).
Childbirth complications
Alterations in fetal heartbeat 245 (5.1) 0.003
Edema 205 (4.3) 0.003
Fever 21 (0.4) 0.001 4. Discussion
Umbilical cord prolapse 6 (0.1) 0.001
Nuchal cord 543 (11.3) 0.005 The present study has found that better SRH in mid-pregnancy pre-
Eclampsia 4 (0.1) 0.0004
Uterine abruption 0 (0)
dicts a lower likelihood of cesarean delivery, fewer childbirth complica-
Meconium in amniotic uid 430 (8.9) 0.004 tions, and fewer self-reported maternal health problems up to 3 years
Obstructed labor 5 (0.1) 0.001 after delivery. The individual health problems most consistently associ-
Arrested labor 158 (3.3) 0.003 ated with SRH in pregnancy were headache, backache, digestive prob-
Prolonged rst-stage labor 16 (0.3) 0.001
lems, and u.
Prolonged second-stage labor 69 (1.4) 0.002
Childbirth complications index 0.35 (012) 0.009 The present ndings suggest that a single-item measure of SRH ad-
Pregnancy complications ministered in mid-pregnancy has predictive value for subsequent objec-
Vaginal bleeding, rst trimester 197 (4.1) 0.003 tive and subjective health outcomes. These results are consistent with
Vaginal bleeding, second trimester 80 (1.7) 0.002 previous studies reporting associations between SRH and various health
Placenta previa 13 (0.3) 0.001
outcomes in midlife or older populations [5,8,11,13,15]. The present
Placental abruption 21 (0.4) 0.001
Nonspecic edema/proteinuria/hypertension 153 (3.2) 0.003 ndings indicate that the predictive value of SRH extends to a younger
Hyperemesis gravida 162 (3.4) 0.003 population, specically pregnant women. It is particularly noteworthy
Genital herpes 3 (0.1) 0.001 that, in the present study, the effects of SRH on future health persisted
Urinary tract infection 107 (2.2) 0.002
after taking into account diagnosed pregnancy complications and self-
Glycosuria 72 (1.5) 0.002
Suspected fetal growth restriction 113 (2.3) 0.002
reported health problems during pregnancy. This suggests that SRH
Polyhydramnios 8 (0.2) 0.001 captures information that is clinically relevant but might be obscured
Oligohydramnios 67 (1.4) 0.002 when other methods of health assessment are used.
Threat of premature delivery 568 (11.8) 0.005 Some limitations of the study must be noted. First, the health prob-
Eclampsia 5 (0.1) 0.00005
lems that were measured do not represent an exhaustive list of all con-
Diabetes 25 (0.5) 0.001
Pregnancy complications index 0.34 (015) 0.011 ditions encountered in gynecologic or obstetric practice. Although the
a assessment was strengthened by combining maternal reports and
Values are estimates of mean (range) or number (percentage) obtained using multi-
ple imputations with chained equations. chart extraction, both these methods have limitations and might not
completely capture health issues known to the mother and her physi-
cian at the time of the study. Second, the response categories for SRH
school education, participants with basic or vocational education had differ from those used in English-speaking contexts, where labels
fewer health problems at all three postdelivery timepoints (Pb 0.05). typically include poor, fair, good, very good, and excellent.
Supplementary analyses tested relationships between SRH in preg- The Czech labeling was consulted with linguists to best convey the orig-
nancy and individual postdelivery health problems (Supplementary inal meaning. The distribution on the SRH variable is similar to other
Material S1). In fully adjusted models, SRH in pregnancy predicted a countries, with most respondents choosing the second highest category.
decrease in the likelihood of each health problem at one or more obser- This observation, along with the evidence on predictive effects of
vation times. For headache, backache, digestive problems, and u, SRH reported previously, suggests that the Czech labeling adequately
a signicant negative association with SRH was evident at all three captured the intended meaning.

Table 4
Factors associated with childbirth complications and birth outcomes.a

Factor Childbirth complications index Low birth weight Cesarean delivery

b b
b (95% condence interval) P value Odds ratio (95% condence interval) P value Odds ratio (95% condence interval) P value b

Self-rated health in pregnancy 0.03 (0.06 to 0.00) 0.036 0.85 (0.68 to 1.06) 0.139 0.81 (0.71 to 0.93) 0.003
Health problems index, pregnancy c 0.01 (0.00 to 0.02) 0.125 0.86 (0.72 to 1.06) 0.094 1.03 (0.85 to 1.09) 0.291
Pregnancy complication index d 0.03 (0.00 to 0.07) 0.054 1.42 (0.72 to 1.03) 0.263 1.06 (0.96 to 1.16) 0.268
Parity 1 0.16 (0.20 to 0.11) b0.001 0.34 (0.14 to 0.85) 0.020 0.35 (0.24 to 0.51) b0.001
Singleton delivery 0.02 (0.02 to 0.43) 0.749 0.03 (0.02 to 0.06) b0.001 0.07 (0.04 to 0.12) b0.001
Age 0.01 (0.00 to 0.01) 0.001 1.04 (0.98 to 1.12) 0.199 1.11 (1.08 to 1.15) b0.001
Education e
Basic/vocational 0.08 (0.04 to 0.13) b0.001 2.26 (1.31 to 3.94) 0.004 0.98 (0.71 to 1.36) 0.922
University 0.06 (0.00 to 0.12) 0.053 0.57 (0.07 to 5.00) 0.613 1.38 (0.97 to 1.96) 0.076
Married 0.04 (0.02 to 0.10) 0.159 0.78 (0.41 to 1.45) 0.428 1.05 (0.72 to 1.55) 0.793
Household size 0.00 (0.01 to 0.02) 0.898 1.02 (0.82 to 1.27) 0.865 1.06 (0.94 to 1.20) 0.348
Never smoked 0.00 (0.04 to 0.04) 0.913 0.91 (0.59 to 1.41) 0.681 0.87 (0.66 to 1.13) 0.292

Abbreviation: b, unstandardized coefcient.

a
Values are estimates from general linear models using multiple imputations with chained equations.
b
Two-tailed tests.
c
Self-reported.
d
From medical chart review.
e
Reference category: secondary school.

Please cite this article as: Stepanikova I, et al, Predictive value of self-rated health in pregnancy for childbirth complications, adverse birth
outcomes, and maternal health, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.03.029
 I. Stepanikova et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxxxxx 5

Table 5
Factors associated with maternal health problems at 6 months, 18 months, and 3 years after delivery.a

Factor 6 months 18 months 3 years

b (95% condence interval) P value b b (95% condence interval) P value b b (95% condence interval) P value b

Self-rated health in pregnancy 0.32 (0.39 to 0.25) b0.001 0.28 (0.35 to 0.20) b0.001 0.30 (0.38 to 0.22) b0.001
Health problems index, pregnancy c 0.11 (0.08 to 0.14) b0.001 0.07 (0.04 to 0.10) b0.001 0.07 (0.03 to 0.11) 0.002
Pregnancy complications index d 0.03 (0.04 to 0.10) 0.453 0.02 (0.19 to 0.06) 0.685 0.03 (0.11 to 0.06) 0.549
Parity 1 0.10 (0.02 to 0.22) 0.102 0.21 (0.08 to 0.33) 0.002 0.19 (0.03 to 0.34) 0.017
Singleton pregnancy 0.14 (0.30 to 0.58) 0.521 0.13 (0.60 to 0.34) 0.574 0.16 (0.81 to 0.28) 0.456
Age 0.01 (0.01 to 0.08) 0.200 0.00 (0.01 to 0.02) 0.792 0.01 (0.01 to 0.03) 0.274
Education e
Basic/vocational 0.17 (0.30 to 0.04) 0.011 0.28 (0.42 to 0.13) b0.001 0.20 (0.34 to 0.06) 0.005
University 0.08 (0.06 to 0.22) 0.258 0.11 (0.05 to 0.27) 0.162 0.19 (0.03 to 0.35) 0.018
Married 0.01 (0.19 to 0.18) 0.954 0.16 (0.34 to 0.02) 0.086 0.12 (0.35 to 0.12) 0.317
Household size 0.04 (0.01 to 0.08) 0.084 0.02 (0.03 to 0.07) 0.389 0.01 (0.05 to 0.06) 0.810
Never smoked 0.16 (0.28 to 0.04) 0.011 0.23 (0.36 to 0.10) 0.001 0.25 (0.37 to 0.13) b0.001

Abbreviation: b, unstandardized coefcient.

a
Values are estimates from general linear models using multiple imputations with chained equations.
b
Two-tailed tests.
c
Self-reported.
d
From medical chart review.
e
Reference category: secondary school.

A third limitation concerns the characteristics of the sample, which
consisted mostly of fairly young women with uncomplicated pregnan-
cies and deliveries. The maternal age (mean 25.2 years) and rate of ce-
sarean delivery (8.1%) were similar to characteristics reported
elsewhere for the Czech population [23]. Cesarean rates in the Czech
Republic were among the lowest in Europe [24], but increased from
3.5% to 11.9% between 1978 and 1997 [25], along with an increase in
the average age of Czech mothers. These data suggest that the present
sample reected the Czech population at the time of the study. Never-
theless, the ndings should be further evaluated with older and at-risk
populations, and in contexts where higher rates of cesarean delivery
are typical.
In conclusion, the present study indicates that SRH in pregnancy
consistently predicts future health outcomes. It supports the use of
SRH as an additional tool to assess the overall health of pregnant
women. With its low cost and low time requirements, this tool has
the potential to provide additional information that is relevant to gyne-
cologic or obstetric outcomes and long-term maternal health.
Supplementary data to this article can be found online at
http://dx.doi.org/10.1016/j.ijgo.2016.03.029.
Acknowledgments
Our thanks go to Dr Lubomr Kukla (ELSPAC national coordinator
19902012) and Tomas Prusa for help with manuscript preparation.
The ELSPAC-CZ study is currently supported by Masaryk University
(CETOCOEN PLUS project and CELSPAC project: Central European
Longitudinal Study of Pregnancy and ChildhoodMUNI/M/1075/2013)
and the Ministry of Education of the Czech Republic (LM2015051
and LO1214).
Conict of interest
The authors have no conicts of interest.
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Please cite this article as: Stepanikova I, et al, Predictive value of self-rated health in pregnancy for childbirth complications, adverse birth
outcomes, and maternal health, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2016.03.029