Knowledge and engagement in health-promoting behaviors among women planning pregnancy: a cross-sectional study

Abstract

Background

Lifestyle and health behaviors affect a woman’s overall health, including reproductive health. Leading a health-promoting lifestyle is crucial for optimizing conditions for conception, embryo and fetal development, and minimizing risks for both mother and child.

Methods

This cross-sectional study examined the relationship between women’s knowledge of health-promoting behaviors and their engagement in such behaviors during the pregnancy planning period. A diagnostic survey was conducted using an original questionnaire and the Health Behavior Inventory by Zygfryd Juczynski. The study included 100 women attending preconception visits at obstetrics and gynecology clinics between March and May 2024.

Results

Most respondents (64%) agreed that health-promoting behaviors during the preconception period influence pregnancy success. The most common behaviors included giving up stimulants (86%), visiting a gynecologist (83%), and supplementing folic acid (81%). The least common were completed (29%) or planned (9%) vaccinations. Women were primarily motivated by the desire to increase their chances of conception (38%) and ensure the health of their child (20%). The majority (65%) demonstrated an average level of knowledge regarding recommended health behaviors. Knowledge and behavior intensity were influenced by sociodemographic factors such as age, education, residence, and marital status. A significant relationship was found between knowledge level and engagement in health-promoting activities - women with greater knowledge were more likely to adopt behaviors supporting reproductive health.

Conclusions

Women planning pregnancy show awareness of the impact of health-promoting behaviors on pregnancy outcomes and child health, which is reflected in their actions. However, the predominance of average knowledge levels indicates a need for further education, particularly in less commonly addressed areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-025-04162-8.

Background

Health is a fundamental resource for both the individual and society, as well as a fundamental right of every person [1]. As defined by the World Health Organization (WHO), it is a state of complete physical, mental, and social well-being, rather than merely the absence of disease or disability [1, 2]. From a holistic perspective, health represents a “whole” composed of multiple interconnected dimensions: physical, mental, social, spiritual, emotional, sexual, and procreative [1]. All actions undertaken by an individual, which constitute his/her lifestyle, directly or indirectly influence the preservation of health and the enhancement of personal potential, or conversely, may be detrimental [1–4].

Health attitudes are conceptualized as specific forms of behavior and responses, expressed positively or negatively, toward a particular object or stimulus in the context of health. They encompass three components: emotional, cognitive, and behavioral [5]. Well-developed attitudes and the resulting health behaviors influence all dimensions of health, which are interrelated and mutually reinforcing [1, 4, 5]. Education plays a pivotal role in shaping and modifying health attitudes [1, 5, 6].

Health behaviors refer to actions taken by individuals that directly or indirectly affect their health, either promoting or compromising it [1–5]. Recommended pro-health behaviors may vary depending on an individual’s health status and circumstances, and should be tailored to maximize health benefits [1, 7, 8]. Anti-health behaviors, also referred to as health risk behaviors, are defined as negative, harmful, and self-destructive actions that contrast with pro-health behaviors and may contribute to the development of diseases and health disorders [2, 4]. The adoption of specific health behaviors is influenced by a range of factors, including social, cultural, media-related, socio-demographic, personality traits, and individual resources [1, 2, 4]. All health-related behaviors form a distinctive lifestyle, defined as a way of living shaped by identifiable behavioral patterns, personal characteristics, social interactions, and socioeconomic and environmental conditions [1, 2]. Developing positive health behaviors and reinforcing their regular practice is essential throughout life [1–4]. This becomes particularly critical during the reproductive period, especially for women actively planning pregnancy, as their health-related decisions may directly influence fertility, pregnancy outcomes, and the long-term health of the child. Parental health, and especially maternal health, is closely linked to fetal development and later life stages [1, 2, 9].

Recent global evidence further reinforces these principles, highlighting the effectiveness of preconception interventions and the need for integrated care models. Preconception health is increasingly recognized as a critical determinant of maternal and child outcomes. Recent evidence emphasizes that interventions before conception can significantly reduce risks associated with pregnancy complications and improve neonatal health. A 2025 systematic review highlighted that behavioral change programs - including individual counseling, group education, and digital interventions - effectively improve knowledge and adoption of health-promoting behaviors in the preconception period, particularly regarding folic acid supplementation, nutrition, and vaccination [10]. Similarly, WHO consultations in 2024 underscored the need for integrated preconception care models that address not only biomedical but also psychosocial and lifestyle factors, advocating for culturally sensitive and coordinated approaches [11]. Despite these advances, gaps remain in comprehensive strategies that include mental health, physical activity, and social determinants of health, especially in low- and middle-income countries [12]. These findings reinforce the importance of tailored education and accessible services for women planning pregnancy, aligning with global efforts to reduce maternal and neonatal morbidity and mortality.

The goal of preconception care, provided during the pregnancy planning phase, is to optimize mental and physical health, promote healthy lifestyles, prevent and identify factors that may negatively impact fertility and pregnancy outcomes, and offer professional support and guidance [9, 11, 13, 14]. This care is part of a broader perinatal framework, encompassing the preconception, pregnancy, postpartum, and early childhood periods. The responsibility for delivering preconception care and counseling lies with healthcare professionals, particularly obstetricians and midwives. Promotional and educational initiatives related to preconception care, targeting both medical personnel and women, have the potential to significantly improve the quality of care, provided they are culturally sensitive, respectful, individualized, and continuous.

Conducting the present study enabled us to assess women’s knowledge of health-promoting behaviors associated with pregnancy planning, the extent to which these behaviors are practiced, and the relationships between knowledge and behavior. To date, no comprehensive studies have addressed these specific aspects of health behavior among women planning pregnancy. Most existing research includes women of various ages, not exclusively those of reproductive age, or focuses on women who are already pregnant, likely due to the challenges of accessing such a narrowly defined population. This may also be influenced by social factors, such as the high proportion of unplanned pregnancies in Poland, estimated at 40–50% [15, 16].

The aim of this study was to examine the relationship between women’s knowledge of pro-health behaviors and the extent to which they engage in such behaviors during the pregnancy planning period.

Methods

Study design and research tools

This cross-sectional study employed a diagnostic survey method. Data were collected using two research tools: author’s questionnaire (Additional file no. 1), developed specifically for this study based on a literature review and expert consultation and Health Behavior Inventory (HBI) by Zygfryd Juczyński [17].

The author’s questionnaire consisted of 25 items, mostly closed-ended (single- and multiple-choice questions), and one open-ended question exploring motivations for behavioral change. It was administered in Polish, as the study was conducted among Polish-speaking participants.

The questionnaire assessed respondents’ knowledge of health-promoting behaviors recommended during pregnancy planning, their opinions on the impact of these behaviors on pregnancy outcomes, intentions to modify specific behaviors, and sources of information.

Thirteen items focused on key areas of reproductive health - nutrition, supplementation, physical activity, preventive examinations, and immunizations - and were used to evaluate factual knowledge. The remaining items addressed sociodemographic characteristics: age, education, medical education (defined as formal education in health-related fields such as medicine, nursing, midwifery, and pharmacy), place of residence, marital status, and obstetric history: number of deliveries and adverse pregnancy outcomes (defined as miscarriage, stillbirth, or preterm birth).

The author’s questionnaire was developed as a novel tool based on a comprehensive literature review and expert consultations in the field of obstetric and neonatal care. Its content validity was assessed by a team of midwives, including a regional consultant in obstetric and neonatal nursing, who reviewed all items for relevance, clarity, and alignment with current clinical guidelines.

Prior to the main study, a pilot test was conducted to ensure clarity and comprehensibility of the items. Cronbach’s alpha was calculated for knowledge-related items and indicated low internal consistency (α = −0.7754), reflecting the multidimensional nature of the questionnaire. Items were therefore analyzed individually.

The Health Behavior Inventory (HBI) comprises 24 statements describing health-related behaviors. Respondents rated the frequency of each behavior on a five-point scale. Scores were summed to calculate the overall intensity of health-promoting behaviors across four categories: proper eating habits, preventive behaviors, health practices, and positive mental attitude. Higher scores indicated greater intensity of declared health behaviors. The total score was converted into standardized units (stens) for interpretation (Table 1): 1–4 sten = low, 5–6 = average, 7–10 = high [17]. Separate indices were calculated for each category (range: 16–30 points).

Table 1.

Conversion of Health Behavior Inventory (HBI) scores to stens and level behavior [17]

Sten	Raw score (points)	Level
1	24–53	Low
2	54–62
3	63–70
4	71–77
5	78–84	Average
6	85–91
7	92–98	High
8	99–104
9	105–111
10	112–120

Scoring system for knowledge assessment

A maximum of 84 points could be obtained for correct answers across all knowledge-related items. Participants were categorized into four knowledge levels: insufficient: <42 points, low: 42–55 points, medium: 56–69 points, high: 70–84 points. For single-choice questions, one point was awarded for each correct response. For multiple-choice questions, points were granted only when all correct options were selected without marking incorrect ones. Selecting an incorrect option resulted in no points for that item, even if a correct option was also chosen. This approach was applied to prevent inflation of knowledge scores.

Analysis of open-ended responses

The single open-ended question explored participants’ motivations for adopting health-promoting behaviors (Addional file no. 2). Responses were analyzed descriptively and grouped into thematic categories based on content similarity (e.g., improving chances of conception, ensuring child’s health, following medical advice). Formal qualitative frameworks were not applied.

Organization and conduct of the survey

The study involved women planning to conceive within the following year, attending preconception visits at two obstetrics-gynecology outpatient clinics in Krakow (Medical Center “Ujastek” Sp. z o.o. and Hospital on Siemiradzki im. Rafał Czerwiakowski Sp. z o.o.) between March and May 2024. Only Polish citizens were included. Ethical approval was obtained from the Research Ethics Committee of the Jagiellonian University – Collegium Medicum, along with institutional permissions.

These facilities were selected because they offer preconception counseling, which remains relatively uncommon in Poland. Awareness of comprehensive preconception care is still low, limiting access to women actively preparing for pregnancy. The sample size was determined pragmatically, based on the number of eligible women attending these clinics during the study period.

A total of 111 questionnaires were collected; 100 were qualified for analysis. Eleven were excluded due to incomplete or incorrect completion. The survey was conducted in person and responses were reviewed at the time of collection to ensure completeness. The final dataset contained no missing values.

Eligibility criteria

Women were eligible if they: attended a preconception counseling visit at one of the selected clinics, planned to conceive within the next 12 months, were not pregnant at the time of recruitment and provided informed consent.

The study focused on natural conception. Assisted reproductive techniques were not considered. Exclusion criteria included current pregnancy and incomplete or incorrectly completed questionnaires.

Recruitment process

Participants were recruited through a stepwise process, illustrated in Fig. 1. Women attending obstetrics-gynecology outpatient clinics were screened for eligibility. Pregnant women were excluded, and only those planning pregnancy within the next year were invited to participate. After receiving detailed information about the study, participants provided informed consent and completed the questionnaire.

Fig. 1.

Flow diagram of participant recruitment and sample selection

Statistical analysis

Non-parametric significance tests were used for statistical analysis. Pearson’s chi-square test assessed relationships between two qualitative variables; the Mann-Whitney U test examined associations between a quantitative variable and a binary qualitative variable; and the Kruskal-Wallis ANOVA was applied to mixed traits or when the qualitative variable had more than two categories. A significance level of α = 0.05 was adopted. Analyses were performed using Statistica 13.3 and Microsoft Excel.

Results

Characteristics of the study group

The largest group of respondents (36%) were women aged 30–34, followed by those aged 25–29 (32%). Women aged 20–24 and over 35 each accounted for 14%, while the smallest group (3%) were under 20. Most participants (67%) lived in large cities (over 100,000 residents), 22% in rural areas (under 5,000) 7% in medium-sized cities (20,000–100,000), and 4% in small towns (under 20,000). The majority of respondents (74%) were married, 15% were in informal relationships, 9% were single, and 2% were divorced. Most women (74%) had higher education, 24% had completed secondary education, and 2% had only elementary education. Medical education was reported by 23% of participants. Regarding obstetric history, 45% had never been pregnant, 28% had experienced one pregnancy, 12% two, and 15% three or more. Most respondents (80%) reported no history of obstetric complications or difficulties conceiving. Detailed characteristics of the study group are presented in Table 2.

Table 2.

Characteristics of the study group

Variable	n	%
Age
< 20 aged	3	3%
20–24 aged	14	14%
25–29 aged	32	32%
30–34 aged	36	36%
> 34 aged	14	14%
Education level
Primary/secondary	2	2%
Vocational/secondary	24	24%
Tertiary/higher	74	74%
Medical education
Yes	23	23%
No	77	77%
Place of residence
Village (< 5 000 residents)	22	22%
Small town (< 20 000 residents)	4	4%
Medium city (20–100 000 residents)	7	7%
Large city (> 100 000 residents)	67	67%
Marital status
Single	9	9%
Informal relationship	15	15%
Married	74	74%
Divorced	2	2%
Number of former pregnancies
0	45	45%
1	28	28%
2	12	12%
3 and more	15	15%
Adverse pregnancy outcomes/difficulties getting pregnant
Yes	20	20%
No	80	80%

Self-assessed knowledge and respondents’ opinions on the importance of health behaviors during the preconception period

According to the analysis, 58% of women rated their knowledge of pro-health behaviors as good, 16% as very good, 24% as sufficient, and only 2% as insufficient. The majority (64%) strongly agreed that engaging in pro-health behaviors during pregnancy planning could significantly influence conception success, while 30% tended to agree. In contrast, 2% rather disagreed, 1% categorically denied any impact, and 3% had no opinion. Detailed analysis (Fig. 2) shows that the most commonly undertaken behaviors included giving up stimulants such as alcohol and cigarettes (86%), attending gynecological appointments (83%), and introducing folate-rich foods and folic acid supplementation (81%). Dental check-ups were reported by 69% of respondents. Maintaining a healthy body weight (67%), dietary changes (61%), and regular physical activity (48%) were also frequently declared. Among behaviors not undertaken, the most common were completing vaccinations (62%), engaging in regular physical activity (34%), and changing diet (30%). In turn, regular physical activity (18%) and maintaining a healthy weight (16%) were most often planned. Only 9% of women intended to update vaccinations. Full dataset is presented in Fig. 2.

Fig. 2.

Analysis of health behaviors: undertaken, not undertaken and planned by respondents during preconception period. Data expressed as percentages (%)

Statistical analysis (Table 3) showed that age, education, place of residence, and marital status were associated with certain decisions regarding pro-health behaviors.

Table 3.

Sociodemographic characteristics and obstetric history of respondents and their undertaking of pro-health behaviors during the pregnancy planning period

Behaviour	Significant Variables (p < 0.05)
Changing diet	-
Undertaking regular physical activity	Education level (p = 0,0185) *
Maintaining an optimal body weight	Education level (p = 0,0413)*
Introducing folate-rich foods into diet and folic acid supplementation	Age (p = 0,0449)* Marital status (p = 0,0075)**
Getting a dental check-up	Education level (p = 0,0218)*
Giving up stimulants (alcohol, cigarettes)	Place of residents (p = 0,0326)*
Visiting a gynecologist	-
Completing immunizations	Marital status (p = 0,0009***

*p – test probability; *p < 0.05, **p < 0.01, ***p < 0.001. Asterisks indicate statistical significance

Age was correlated with the introduction of folate-rich foods and folic acid supplementation (p < α; p = 0.0449). Women over 25 were more likely to report implementing this behavior (94%, 81%, and 86% in the 25–29, 30–34, and > 34 age groups, respectively) compared to those under 25 (50% and 67% in the 20–24 and < 20 groups).

Educational level was associated with engagement in regular physical activity (p < α; p = 0.0185). This behavior was reported by 53% of women with higher education, 38% with secondary education, and none among those with primary education. Education level was also linked to efforts to maintain a healthy body weight (p < α; p = 0.0413): 74% of women with higher education had already taken such actions, compared to 50% with secondary education. Among those with primary education, 50% indicated plans to take action, while the remaining 50% did not intend to do so. These findings suggest a positive association between higher education and engagement in weight management behaviors. A similar trend was observed for regular dental check-ups (p < α; p = 0.0218): 77% of women with higher education had undergone such check-ups, compared to 50% with secondary education. Among those with primary education, 50% planned to attend, while 50% had no intention to do so. Thus, higher education was associated with more frequent or planned dental visits.

The data did not reveal any statistically significant links between medical education and health-promoting actions.

Respondents’ place of residence correlated with their decision to give up stimulants (p < α; p = 0.0326). In the group of women from larger cities, almost all of them had already given up stimulants (100% in a medium-sized city and 88% in a large city), while in small cities up to half of the respondents had not taken such action.

Marital status was associated with women’s decisions to introduce folate-rich foods and folic acid supplementation (p < α; p = 0.0075). Married women were most likely to have already adopted this behavior (89%), while the highest proportion of non-adopters was among divorcees (50%). Marital status also correlated with decisions regarding vaccination (p < α; p = 0.0009). This behavior had already been implemented by 40% of married and 33% of single women. However, a substantial proportion of women in all groups had not planned to complete vaccinations: 68% of married women, 60% in informal relationships, 50% of divorcees, and 22% of single women.

Analysis did not reveal a significant association between obstetric history and the initiation of health-promoting behaviors during pregnancy planning (Table 3), although a trend was observed for gynecological visits (p = 0.0626), which may reflect specific characteristics of this subgroup.

Assessment of respondents’ knowledge of health behaviors recommended during the preconception period

To assess participants’ objective knowledge of pro-health behaviors, responses to 13 items from the author’s questionnaire were analyzed. Scores ranged from 45 to 73 points; none of the respondents achieved the maximum score of 84. The most frequent score was 58, obtained by 8 women (8% of the sample). Both the mean and median scores were 60, indicating a symmetrical distribution of result - half of the respondents scored below or equal to 60, and half above. The coefficient of variation was 10.5%, suggesting a relatively low dispersion and a homogeneous distribution of results (Table 4).

Table 4.

Basic descriptive statistics of respondents’ level of knowledge on pro-health behaviors recommended during the preconception period 

	N	M	Me	Mo	N Mo	Min	Max	SD	CV
Knowledge’s index	100	60	60	58	8	45	73	6,3	10,5%

N number, M mean, Me median, Mo moda, SD standard deviation, CV coefficient of variation

Based on the scores, participants were classified into corresponding knowledge levels. The majority (65%) demonstrated intermediate knowledge of pro-health behaviors, 23% showed low knowledge, and only 5% achieved a high level. Notably, none of the respondents fell into the category indicating lack of knowledge.

To assess whether sociodemographic characteristics and obstetric history were associated with knowledge levels regarding pro-health behaviors during pregnancy planning, statistical analysis was conducted using the non-parametric Kruskal-Wallis ANOVA test (Table 5).

Table 5.

Sociodemographic characteristics vs. knowledge’s level on health-promoting behaviors undertaken during pregnancy planning period by respondents

Characteristics	p-value	Significance
Age	0,7022	-
Education level	0,0011	**
Medical education	0,0001	***
Place of residence	0,0133	*
Marital status	0,1333	-
Number of deliveries	0,3785	-
Experience of adverse pregnancy outcomes położniczych	0,1378	-

*p – test probability; *p < 0.05, **p < 0.01, ***p < 0.001. Asterisks indicate statistical significance

Analysis revealed that respondents’ knowledge levels were statistically associated with education (p < α; p = 0.0011) and place of residence (p < α; p = 0.0133). Higher education was associated with greater knowledge of pro-health behaviors - participants with primary education scored lowest (mean: 51 points), while those with higher education scored highest (mean: 61.4 points). Women living in small towns (up to 20,000 residents) had the highest average knowledge score (64.5 points), whereas those in medium-sized towns (20,000–100,000 residents) scored lowest (56.4 points). Respondents from large cities averaged 60.5 points, and those from rural areas 58.9 points.

The influence of medical education on respondents’ knowledge of health-promoting behaviors during pregnancy planning was assessed using the Mann–Whitney U test. The result was statistically significant (p < α; p = 0.0001), indicating that women with medical education had higher average knowledge scores (mean: 64.6 points) compared to those without medical education (mean: 58.6 points).

No statistically significant relationships (p > α) were found between knowledge level and other demographic variables, including age, marital status, or obstetric history (Table 5).

Statistical analysis also examined the association between knowledge level and actual engagement in pro-health behaviors (Table 6).

Table 6.

Respondents’ level of knowledge versus actions undertaken during the pregnancy planning period

Pro-health behaviors	p-value	Significance
Changing diet	0,3733	-
Undertaking regular physical activity	0,0527	-
Maintaining an optimal body weight	0,0936	-
Introducing folate-rich foods into diet and folic acid supplementation	0,4229	-
Getting a dental check-up	0,0096	**
Giving up stimulants (alcohol, cigarettes)	0,3870	-
Visiting a gynecologist	0,1192	-
Completing immunizations	0,3110	-

*p – test probability; *p < 0.05, **p < 0.01, ***p < 0.001. Asterisks indicate statistical significance

A significant association was found with dental check-ups (p < α; p = 0.0096); the highest average knowledge score (61.3 points) was observed among women who had already undergone a dental check-up (Fig. 3).

Fig. 3.

Respondents’ level of knowledge about health behaviors vs. their performance of dental check-ups

Health behaviors of preconception subjects according to Zygfryd Juczynski’s Health Behavior Inventory (HBI) index

Based on the study, the HBI index was calculated for all participants. The overall mean score was 85.19 ± 11.41. Nearly half of the women (45%) demonstrated an average level of health behaviors, 26% a low level, and 29% a high level. The highest mean score was observed in the area of proper eating habits (21.44 ± 3.31), followed closely by health practices (21.39 ± 3.74) and preventive behaviors (21.31 ± 3.82). The lowest score was recorded in the domain of positive mental attitude (17.86 ± 3.57). Detailed results are presented in Fig. 4.

Fig. 4.

Index of intensity of health behaviors in the four areas according to Zygfryd Juczynski’s Health Behavior Inventory (HBI) index

As described in the Methods section, respondents selected one of five frequency categories for each of the 24 statements in the Health Behavior Inventory (HBI): almost never, rarely, occasionally, often, or almost always. The highest “almost always” responses were recorded for reducing smoking (83%), maintaining friendships and family balance (52%), following medical recommendations (46%), and consuming fruits and vegetables (35%). Behaviors most frequently marked as “often” included eating healthily (60%), monitoring body weight (53%), consuming fruits and vegetables (47%), and following medical advice (46%).

The “occasionally” category was most often selected for avoiding negative emotions such as anger, anxiety, and depression (47%), avoiding excessive stress (46%), ensuring adequate rest, and limiting salt intake (45% each). Behaviors marked “rarely” included avoiding overwork (23%), limiting animal fats and sugar (20%), and avoiding preservatives (19%).

In the “almost never” category, the most common responses were: keeping emergency contact numbers (35%), seeking information on how others avoid illness (13%), avoiding negative emotions (9%), and avoiding overwork (8%). Detailed results from the HBI analysis are presented in Fig. 5.

Fig. 5.

Frequency of specific health behaviors according to Zygfryd Juczynski’s Health Behavior Inventory (HBI) index

Subsequently, the correlation between respondents’ objective knowledge and the intensity of health behaviors (HBI index) was examined. The analysis confirmed a statistically significant relationship (p < α; p = 0.0436), indicating that higher knowledge levels were associated with higher HBI scores. As shown in Fig. 6, the greater the knowledge, the higher the health behavior index.

Fig. 6.

Health behavior severity index vs. knowledge level

Motivations for changing health behaviors and sources of knowledge about them among respondents

Responses to the open-ended question about motivations for changing health behaviors were largely similar, though phrased differently (Additional file no. 2). They were grouped into categories with percentage distributions shown in Fig. 7.

Fig. 7.

Reasons motivating respondents planning pregnancy to change health behaviors

The most frequently cited motivation (38%) was the desire to increase the chances of conceiving and having a healthy pregnancy. Other common reasons included concern for the child’s health and awareness of the benefits of a healthy lifestyle and proper preparation for pregnancy (20% each).

Regarding sources of knowledge about pro-health behaviors during pregnancy planning, respondents most often relied on specialist advice (92%) and online blogs or forums (69%). Books (63%) and social media (51%) were also frequently mentioned (Table 7).

Table 7.

Sources of information on health-promoting behaviors during pregnancy planning (n = 100)

Source of information	n	%
Specialists (doctor, midwife)	92	92%
Blogs or online forums	69	69%
Books	63	63%
Social media	51	51%

percentages do not sum to 100% because respondents could select multiple sources

Discussion

In most societies and cultures, health holds a high position in the hierarchy of values [1, 2]. According to a 2016 report by the Center for Public Opinion Research (CBOS), maintaining good health ranked second (57%) among the most important aspects of daily life for Poles [18]. Contemporary social transformations, including changes in lifestyle and health-related behaviors, particularly affect women. Literature and research consistently confirm that women’s lifestyle choices - both pro- and anti-health - impact their own health, including reproductive and perinatal outcomes, as well as the health of their children [1–3, 9, 13, 19–24].

Self-assessment results show that most women preparing for pregnancy demonstrate intermediate knowledge (65%), with 58% rating it as good. Compared to findings by Borkowska and Ostrowska (2016/2017), who surveyed 115 university students aged 19–26, women planning pregnancy appear to have greater awareness of recommended preconception health behaviors [25]. In that study, only 17–50.9.9% (average 35.7%) strongly agreed that pre-pregnancy weight affects child development. In contrast, 82% of our respondents correctly identified BMI, and 88% recognized the need for weight reduction in cases of overweight or obesity before conception.

According to the National Institute of Public Health (2022), only 28.4% of Polish women believed they ate healthily, while 48.9% did not use nutrition information sources, and 45.1% did not apply nutritional knowledge. Barriers to healthy eating included high costs, lack of motivation, time constraints, and unappealing taste [26]. Pieszko et al. found that 84% of pregnant women became more attentive to their diet after conception [27]. This increased interest may stem from beliefs about the benefits of a healthy lifestyle and its influence on pregnancy (38%) and child health (20%), as reported in our study. Only 10% cited their own health as a motivation, aligning with Duda’s findings that women often prioritize the health of loved ones over their own [3].

Questions related to vaccinations, physical activity, and supplementation proved most challenging for respondents.

Only 25% correctly identified the recommended amount of physical activity for women planning pregnancy, aligning with Kruszewski et al., who found that just 27% of women maintained adequate activity in the six months prior to conception [28]. Knowledge of permitted and prohibited forms of physical activity was also insufficient among both planning and pregnant women. This may stem from previously vague recommendations - until 2015, moderate exercise during pregnancy was generally advised without specific guidance for the preconception period. In December 2015, the American College of Obstetricians and Gynecologists (ACOG) emphasized the importance of physical preparation before pregnancy, including weight control and regular activity. In 2018, the U.S. Department of Health (HHS) updated its Physical Activity Guidelines for Americans, recommending at least 150 min of moderate activity per week and strength training twice weekly - guidelines later adopted in Poland [29].

Respondents’ knowledge of recommended preconception vaccinations was also low. Similar findings were reported by Dąbek et al., who surveyed 700 individuals (including 511 women) and found that 26.57% believed vaccination during pregnancy was unsafe, while 49.14% lacked knowledge on the topic [30]. In our study, only 29% planned to complete recommended immunizations before pregnancy, and 20% considered any vaccination during this period contraindicated.

Statistical analysis revealed an association between immunization behavior and marital status. Women in informal relationships and single women were more likely to plan vaccinations (40% and 33%, respectively) than married (27%) or divorced women (0%). Conversely, the proportion of women not planning vaccinations was highest among married women (68%), followed by those in informal relationships (60%), divorcees (50%), and single women (22%). These findings suggest that unpartnered women may be more inclined to complete immunizations.

However, these results should be interpreted with caution due to the small number of participants in certain marital status subgroups. The limited sample sizes, particularly among divorced (n = 2), single (n = 9), and informally partnered women (n = 15), increase the risk of random variation and reduce the statistical stability of the observed associations. This limitation may affect the reliability of the findings and should be considered when drawing conclusions. While the trend is noteworthy, further research with a larger and more balanced sample is needed to verify these preliminary observations and explore underlying factors, such as partner influence on health decisions, differing perceptions of risk or lifestyle differences.

Our study showed that 81% of women planning pregnancy had introduced folate-rich foods into their diets and were supplementing folic acid. Other studies highlight a clear difference between pregnant and preconception women in this regard. Grzelak et al. found that 42.86% of pregnant women used folic acid, compared to only 7.8% of non-pregnant women [31]. Pegnant women were also more likely to take complex supplements (70% vs. 54%). Similarly, Kurzawińska et al. reported that 52.9% of women used folic acid before pregnancy, while 89.1% did so during pregnancy [32]. Their study also linked folic acid use to economic status and general attitudes toward supplementation.

In our study, marital status was associated with folic acid use - married women were more likely to supplement than divorcees (89% vs. 50%). This finding indicates a statistical association rather than a causal relationship. The high rate of folic acid use (81%) in our sample may also be due to the fact that all participants were actively planning pregnancy and under gynecological care, likely receiving professional recommendations.

Interestingly, only 51% of respondents knew that a 0.4 mg dose of folic acid is recommended for all women of reproductive age. When asked to identify recommended supplements, they most frequently selected omega-3 fatty acids (79%), magnesium (56%), iron (51%), and iodine (51%). These choices may reflect the popularity of multivitamin use, which can obscure awareness of nutrients specifically relevant to the preconception period. According to a 2024 report by the Polish Economic Institute, 72% of Poles use dietary supplements, with 48% doing so regularly [33].

When analyzing health behaviors related to stimulants, it is worth citing Dworak and Dąbrowska-Wnuk, who found that 97.6% of women agreed alcohol and smoking significantly impact health [19]. In our study, 74% of respondents believed that giving up stimulants was necessary before pregnancy, and 86% declared they had done so in preparation for pregnancy. However, the rising scale of alcohol consumption among women of reproductive age is concerning [34]. Globally, around 10% of pregnant women consume alcohol, with the figure reaching 25% in Europe [34]. A similar trend is observed in Poland: in 2019, 93% of women aged 25–34 reported alcohol use [35]. According to the National Sanitary Inspectorate (2017), 62.82% of Polish women abstained from alcohol in the three months before pregnancy, 23.04% drank occasionally, and 4.86% admitted to drinking during pregnancy [36]. Worldwide, 1.7% of pregnant women smoke (about 250 million), with 8.1% in Europe [37]. In Poland, 5.86% of women smoked during pregnancy [36].

Recommendations and numerous studies emphasize that proper pregnancy planning includes preventive health check-ups [9, 14, 36]. In our study, 83% of women indicated the need to visit a gynecologist when planning pregnancy. Most respondents correctly identified recommended preconception tests, such as cytological, gynecological, and ultrasound exams, but often overlooked blood pressure measurement. In Dworak and Dąbrowska-Wnuk’s study, 70.2% of women reported regular gynecological visits [19], while the National Sanitary Inspectorate noted that 84.23% had a cytological exam before pregnancy and 78.75% during pregnancy [36]. However, only 52.38% of pregnant women had a dental check-up [36], compared to 77.9% in Dworak and Dąbrowska-Wnuk’s study [19] and 61% in our own. Importantly, the decision to undergo dental care was significantly influenced by awareness of health-promoting behaviors related to pregnancy planning.

Research shows that the intensity of pro-health behaviors among women varies depending on life stage [2, 3, 20, 37]. Mandziuk’s study of 65 Polish nursing students revealed that nearly half (49.84%) showed low levels of health behaviors [38]. Similarly, Duda found that 53% of active women had low health behavior intensity [3]. In our study, women planning pregnancy most often presented average levels (45%), though 26% showed low intensity. Bien et al. found that pregnant women exhibit higher levels of health behaviors than non-pregnant women [2]. Kiersnowska et al., studying 177 pregnant women (128 after natural conception and 49 after assisted reproduction), reported the highest levels of health behaviors in both groups (57% and 60%, respectively) [20]. No link was found between health behavior intensity and obstetric history, which aligns with our findings. However, both Bien’s study and ours confirmed correlations between age, education, residence, marital status, and engagement in pro-health behaviors [2]. These results suggest that health behavior intensity increases with pregnancy planning and peaks during pregnancy.

Our results indicate that greater knowledge of recommended preconception health behaviors among women planning pregnancy significantly correlates with higher engagement in such behaviors, as shown by HBI analysis. This knowledge was strongly linked to education level. However, despite the positive impact of medical education on awareness, it did not consistently translate into healthier practices. Mandziuk and Duda noted that professionally active, educated women often struggle to maintain a healthy lifestyle due to busy schedules and numerous responsibilities [3, 38]. This is highlighted in our own study, as according to the HBI analysis, only 7% and 27% of respondents declared that they “almost always” and “often” avoid overwork. Such findings may illustrate the image of the modern woman who, while preparing for motherhood, attempts to adopt health-promoting behaviors while simultaneously pursuing professional and social fulfillment. In a 2018 study by Dworak and Dąbrowska-Wnuk, only 62.4% of working women aged 25–40 believed that career work does not necessarily hinder a healthy lifestyle [19], though it clearly demands greater effort.

According to the National Institute of Public Health, women most often rely on the Internet and family or acquaintances for health information, while specialists such as doctors, nurses, or nutritionists are consulted less frequently [30]. In contrast, Nowakowska et al., studying 400 individuals of reproductive age (including 194 women), found that the most common sources of nutritional knowledge were school or university, followed by nurses, parents, and social media [39]. In our study, however, 92% of women planning pregnancy reported seeking advice from specialists. This suggests a high level of awareness regarding the importance of the pregnancy period and strong trust in medical professionals - especially doctors and midwives - who are perceived as reliable sources of information. In today’s reality of information overload, turning to experts may also reflect a preference for verified guidance over independent searching.

Although women demonstrate growing health awareness and increasing attention to their bodies, diet, and safety with age, the risk of fertility issues and pregnancy complications also rises [2, 9, 20]. Considering Poland’s demographic trends, the lifestyle of modern women, and the findings presented above, health education tailored to the individual needs of women planning pregnancy appears crucial [2, 5, 19]. Supporting women in pursuing education and careers while maintaining health goals requires initiatives that strengthen both internal and external resources [3]. In the long term, this may positively influence the development of a healthier society [2, 5, 19].

Given that women planning pregnancy most often seek advice from specialists, the role of midwives and other healthcare professionals in preconception education should be emphasized [40, 41]. Midwife-led interventions, combining clinical expertise with personalized support, may be effective in addressing gaps in knowledge and practice. Additionally, digital tools such as e-learning platforms and mobile health applications offer promising opportunities for expanding access to reliable information. These resources can complement traditional care by providing flexible, self-paced education tailored to individual needs. Integrating such approaches into routine preconception care may enhance both reach and effectiveness, especially among younger women and those living in areas with limited access to specialized services [42–44].

This study has several limitations that should be considered when interpreting the results. First, the sample was relatively narrow, consisting of women planning pregnancy and attending preconception visits at selected clinics. Although these facilities were chosen because they offer preconception counseling, such visits remain uncommon in Poland and are often limited to basic preventive tests or folic acid supplementation. Awareness of comprehensive preconception care is still low, which makes it challenging to recruit women actively preparing for pregnancy. Consequently, the findings may not be fully generalizable to all women of reproductive age, particularly those who do not seek preconception care or live in rural areas without access to specialized services.

Second, the stationary method of conducting the survey and the use of time-consuming standardized instruments restricted the sample size to 100 respondents. A total of 111 questionnaires were collected, but 11 were excluded due to incomplete or incorrect completion. Although this proportion is relatively small, the exclusion of these questionnaires may introduce selection bias and affect representativeness.

Third, the data were self-reported, which raises the possibility of response bias. Self-reported measures may be subject to social desirability bias, particularly in responses concerning health-promoting behaviors. Participants may have provided answers they perceived as socially favorable, which could influence the accuracy of reported beliefs and practices. Additionally, BMI and knowledge-related responses were self-reported without a “don’t know” option. This decision was intentional to avoid excessive use of neutral responses and ensure timely completion. Questionnaires were completed in the presence of the researcher, and participants could request assistance at any time, which was provided when needed. Nevertheless, the absence of a neutral option may have introduced information bias.

Fourth, the custom questionnaire, while reviewed by experts and pilot-tested for clarity and comprehensibility, was not subjected to formal psychometric validation. This may affect the interpretability of some findings and should be considered when evaluating the results.

Fifth, the cross-sectional design limits the ability to draw causal conclusions. Multivariate analysis was not included in the final manuscript because the study was exploratory and based on a relatively small sample, which restricts the robustness of such models. Preliminary calculations indicated that knowledge remains an important factor; however, future research with larger samples should incorporate multivariate modeling to provide more precise estimates of associations and better control for confounding factors.

Finally, the analysis could not account for potential confounding factors such as income or other socioeconomic variables, as these were not collected. Future studies should include a more comprehensive dataset to allow adjustment for these components and explore additional determinants such as mental health, access to healthcare, and cultural influences.

These limitations highlight the need for caution in interpreting the findings and underscore the importance of conducting future studies on a larger scale, with more diverse populations and advanced statistical approaches.

Conclusions

The study led to the following conclusions:

1. Most women planning pregnancy recognize the importance of pro-health behaviors and demonstrate a generally average level of knowledge in this area. Education level, especially medical, and place of residence significantly were linked to knowledge, which in turn correlated with the intensity of health behaviors undertaken.

2. The most frequently adopted behaviors include giving up stimulants, attending gynecological check-ups, and introducing folate-rich foods and folic acid supplementation. Immunizations are the least chosen, which may be due to limited awareness and the influence of anti-vaccine narratives.

3. Age, marital status, education, and place of residence were associated with the implementation of specific health behaviors. For example, older and married women tended to include folate-rich foods and supplements, while women with higher education were more likely to maintain a healthy weight and engage in physical activity. Women from medium-sized cities most often reported giving up stimulants, while single and informally partnered women were more likely to complete immunizations, though overall vaccination uptake remained low.

4. According to HBI analysis, nearly half of the women present a moderate level of health behavior intensity, with positive mental attitude being the least represented. Key motivations include increasing the chances of conception, ensuring a healthy pregnancy, and awareness of the benefits of a healthy lifestyle.

5. Since women most often seek guidance from specialists, healthcare professionals - including midwives - should be actively involved in providing comprehensive and reliable health education during the preconception period.

Abbreviations

ACOG

American Society of Obstetricians and Gynecologists

HBI

Health Behaviour Index

HHS

U.S. Department of Health and Human Services

WHO

World Health Organization

Authors’ contributions

ALS was responsible for planning and coordination of the study, provided critical revisions, and approved the final version of the manuscript. KJ contributed to the study design, collected the data, and drafted the initial version of the manuscript. JS conducted the data analysis, prepared tables and figures, and formatted the manuscript according to journal requirements. DM supervised and coordinated the research proces. All authors revised the manuscript critically for important intellectual content, and approved the final version.

Funding

Not applicable.

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

The study was approved by the relevant institutional ethics committee (approval of the Research Ethics Committee of the Jagiellonian University – Medical College No. 118.0043.1.38.2024 dated 29.02.2024). Informed consent to participate was obtained from all participants prior to their inclusion in the study. Participants were informed about the purpose of the study, the voluntary nature of participation, the possibility to withdraw at any time, and the anonymity of their responses.

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Participation posed no physical, psychological, or privacy-related risks to respondents.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.