Health literacy and attitudes toward prenatal screening tests among pregnant women: a cross-sectional study in Turkey

Abstract

Background

Due to the widespread use of screening methods and the increase in advanced age pregnancies, interest in prenatal screening tests is increasing day by day. In Türkiye, the Ministry of Health recommends that pregnant women be informed about prenatal screening tests and ultrasonographic examinations for fetal anomalies and chromosomal aneuploidy. Although these tests are not mandatory, it is important for pregnant women to understand their purpose and scope before making a decision. This requires having sufficient health literacy (HL). This study aimed to examine the HL levels of pregnant women and their perspectives on prenatal screening tests.

Methods

This cross-sectional study was conducted with 477 pregnant women in the pregnancy follow-up clinic of a university hospital in Turkey. Data were obtained through the Descriptive Information Form—comprising items on sociodemographic characteristics, pregnancy, and prenatal screening—and the Health Literacy Scale (adaptation from HLS-EU-47).

Results

The average age of pregnant women was 27.55 ± 5.56. Pregnant women were most familiar with the double screening test (25.3%). Pregnant women most frequently received information or counseling on prenatal screening tests from obstetricians (44.2%) and the internet/social media (26.3%). The mean HL score was 116.11 ± 11.47, with higher levels observed among those without consanguinity with their spouses and without a family history of hereditary diseases. HL also differed significantly by regular antenatal follow-up, screening practices, and certain sociodemographic factors (p < 0.05). Higher HL was associated with greater uptake of screening. Pregnant women who underwent screening tests and those who wanted to undergo screening tests had higher HL levels.

Conclusions

Findings suggest that strategies to improve pregnant women’s HL should focus on those with low socioeconomic status and advanced age. Integrating HL assessment into routine primary care monitoring and providing visually supported, simplified education on prenatal screening may be beneficial. Midwives should strengthen communication skills suited to pregnant women’s HL levels. Further research is recommended on the links between HL, screening tests, and related counseling and interventions among different groups.

Introduction

Although pregnancy is a natural process, it may involve risks that can lead to adverse outcomes for both the mother and the baby. Today, many prenatal screening tests help assess early pregnancy [1]. Screening tests are crucial for the detection of congenital anomalies, which are a significant cause of perinatal morbidity and mortality. When a high-risk result is identified in screening tests, diagnostic tests are recommended to pregnant women [2].

Today, prenatal screening tests are grouped into traditional tests based on maternal blood hormones and ultrasound, and genetic tests like cell-free fetal DNA testing. Traditional prenatal screening tests consist of the double, triple, and quadruple screening tests. These tests are performed between the 11th and 20th weeks of pregnancy using specific biochemical markers and ultrasound findings to screen for Trisomy 13, 18, 21, and neural tube defects [3]. The cell-free fetal DNA test, also called non-invasive prenatal testing (NIPT), looks at fetal DNA in the mother’s blood. It can detect genetic problems in the fetus from the 10th week of pregnancy. In addition, during pregnancy, the oral glucose tolerance test is also performed to screen for gestational diabetes, which poses a high risk for both the pregnancy and the postpartum period [4].

The need for and interest in prenatal screening methods is increasing steadily. This is mainly due to the rising number of advanced maternal age pregnancies and the widespread use of screening methods and detailed obstetric ultrasonography [5]. In Turkey, the Ministry of Health also recommends that pregnant women be informed about tests and ultrasonographic evaluations for the screening of fetal anomalies and chromosomal aneuploidies [6]. Prenatal screening tests are implemented on an optional (voluntary basis) basis in Turkey, and there is no data on the rate of use of these tests in the general population.

Health literacy (HL) refers to the level of an individual’s ability to understand information and services that are necessary for making informed decisions regarding their health [7, 8]. Low HL can negatively affect pregnant women’s ability to obtain, understand, and use essential health information, potentially leading to adverse outcomes for maternal and infant health (Seven et al., 2019). Screening tests enable the diagnosis of hereditary diseases that cause severe physical and mental disabilities and are untreatable, providing families with the opportunity to pursue a management plan or legally terminate the pregnancy [9]. Individuals with inadequate HL may have difficulty understanding information about genetic risks and prenatal screening tests [7, 8]. It is also reported that prenatal screening tests for fetal health cause anxiety among pregnant women, and that they often lack sufficient knowledge about these tests [9]. Considering the relationship between patient participation in decision-making and HL [10], it is evident that pregnant women’s understanding of screening tests is important. It is known that religious beliefs, cultural factors [2, 11], personal values, cost [12], and education [7] influence the utilization of screening tests. However, in the uptake of these tests, it is thought that sufficient HL may also play an important role in understanding the purpose of the tests, the meaning of their results, the options provided to the pregnant woman, and the procedures involved. On the other hand, it is reported that most research on HL during the prenatal period has been conducted in the United States, with some studies in Iran and Europe, and a few in Australia and Africa [13]. Additionally, consanguineous marriage is known to be an important risk factor for hereditary diseases. The higher rates of consanguineous marriages in Turkey compared to Western countries further emphasize the need for better understanding of prenatal screening tests [14]. On the other hand, given the high rate of consanguineous marriage in Turkey, which increases the risk of hereditary diseases, understanding HL in this population is particularly critical. This study was conducted to examine pregnant women’s perspectives on prenatal screening tests and their levels of HL.

Materials and methods

Type of study

The research was conducted as a cross-sectional study.

Participants

The study population consisted of 5,786 pregnant women who presented to the obstetrics clinic within the last six months. Based on the known population size, the minimum sample size was calculated as 361, based on a 95% confidence interval and 5% deviation in the OpenEpi online database [15]. The study was completed with 477 pregnant women.

Measurement tools

Data for the study were collected using a Descriptive Information Form and the Health Literacy Scale.

Descriptive information form

This form, developed by the researchers, consists of questions about sociodemographic information (age, education, income, etc.), obstetric history (number of pregnancies, miscarriages, stillbirths, etc.), and knowledge/attitudes regarding prenatal screening (information sources, familiarity with tests, testing status, etc.).

Health Literacy Scale (HLS)

The original scale (Health Literacy Survey in Europe-47 items) was developed by Sorensen et al. [16] and was later simplified by Toçi et al. (Health Literacy Index-25 items) [17]. It was determined that the HLS items, which were adapted to Turkish and evaluated for validity and reliability, were at a reliable level, their consistency over time was acceptable, and the factor structure was similar to the original form. Adapted into Turkish by Temel and Aras (2017) [18], the scale is a 25-item Likert-type scale. It consists of four sub-dimensions: accessing information, understanding information, evaluating/evaluating, and applying/using. The lowest possible score on the scale is 25, and the highest is 125. Low scores indicate inadequate, problematic, or weak HL, while high scores indicate adequate or very good HL. It has been stated that health professionals can use this scale to assess the level of health literacy in the process of diagnosing healthy or sick individuals in health institutions. The scale’s Cronbach’s alpha coefficient is 0.92, and the alpha values for its subdimensions range between 0.62 and 0.79 [18]. In this study, the Cronbach’s alpha was found to be 0.946.

Data collection

The study was conducted between February and June 2024 at the prenatal outpatient clinic of a university hospital. Pregnant women who volunteered to participate were informed about the study and provided written informed consent. Data were collected through face-to-face interviews.

Statistical analysis

Statistical analysis was performed using the IBM SPSS software (Version 23.0). Frequencies and percentages were calculated for descriptive data. The normality of the data was tested using the Kolmogorov-Smirnov test and Skewness/Kurtosis values (HLS K-S: 0.228, p = 0.000; Skewness: -3.043; Kurtosis: 11.145). Since the data did not show normal distribution, the Mann-Whitney U test and Kruskal-Wallis test were used for analysis. In this study, the Cronbach’s alpha coefficients of the subscales of the HLS were as follows: access to information, 0.920; understanding information, 0.810; appraisal/evaluation, 0.862; application/use, 0.830. The overall Cronbach’s alpha of the scale was 0.946. For post-hoc pairwise comparisons following Kruskal–Wallis tests, Bonferroni correction was applied.

Ethical considerations

Ethical approval for the study was obtained from the Health Sciences Ethics Committee of the Faculty of Medicine at a public university (08/03/2023 / 20.478.486 / 1717). Prior to data collection, participants were informed about the study and both written and verbal informed consent were obtained. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Results

The mean age of the pregnant women was 27.55 ± 5.56 years. It was found that 88.7% were not related to their spouses, 89.5% had no family history of hereditary diseases, and 81.6% had no chronic illnesses. The descriptive characteristics of the pregnant women are presented in Table 1.

Table 1.

Descriptive characteristics of pregnant women (n = 477)

Descriptive Characteristics		n	%
Age range in years *27.55 ± 5.56 (min-max:17.00–48.00)	Under 20 years old 20–29 30–39 40 years and older	48 304 110 15	10.1 63.7 23.1 3.1
Level of education	Primary education Secondary education University Postgraduate	94 241 127 15	19.7 50.5 26.6 3.1
Employment status	Yes No	174 303	36.5 63.5
Income status (household income)	Income is less than expenses Income is equal to expenses Income is greater than expenses	54 409 14	11.3 85.7 2.9
Residency	Urban Semi-urban Rural	211 226 40	44.2 47.4 8.4
Family type	Extended family Nuclear family Single-parent family	34 436 7	7.1 91.4 1.5
Consanguineous marriage status	Yes No	54 423	11.3 88.7
Presence of genetically transmitted disease in the family	Yes No	50 427	10.5 89.5
Chronic disease status	Yes No	88 389	18.4 81.6

* Mean±standard deviation

83.4% of pregnant women reported that they had become pregnant intentionally. Regarding their previous pregnancies, 21.2% had experienced a spontaneous abortion, 4% had experienced a stillbirth, and 2.5% had a child diagnosed with a genetic disease. 76.1% of pregnant women reported no problems with their current pregnancies. A total of 154 responses were received regarding problems experienced during pregnancy, 27.9% of which reported threatened miscarriage. All findings related to obstetric characteristics are presented in Table 2.

Table 2.

Obstetric characteristics of pregnant women (n = 477)

Obstetric Characteristics		n	%
Number of pregnancies	One Two Three Four and above	180 138 93 66	37.7 28.9 19.5 13.8
Planned pregnancy	Yes No	398 79	83.4 16.6
Pregnancy week *19.96 ± 6.26 (min-max:2.00–34.00)	First trimester Second trimester Third trimester	66 331 80	13.8 69.4 80
Miscarriage (Previous pregnancies)	Yes No	101 376	21.2 78.8
Having a stillbirth (Previous pregnancies)	Yes No	19 458	4.0 96.0
Having a child diagnosed with a genetic disease (Previous pregnancies)	Yes No	12 465	2.5 97.5
Having any problems during pregnancy? (Current pregnancy)	Yes No	114 363	23.9 76.1
Problems experienced during pregnancy ** (n = 154) (Current pregnancy)	Threat of miscarriage Threat of premature birth Preeclampsia / hypertension Gestational diabetes Bleeding Anemia Infection Other	43 14 15 15 12 21 24 10	27.9 9.1 9.7 9.7 7.8 13.6 15.6 6.5

* Mean±standard deviation

** Multiple response number percentage distribution

It was determined that 97.3% of the pregnant women regularly attended prenatal follow-ups, the most commonly known screening test was the double screening test (25.3%), 85.1% had received information or counseling about prenatal screening tests, and 92.7% had undergone or intended to undergo a screening test during their current pregnancy. A total of 1,131 responses were given to the question, “Which screening tests have you had or do you plan to have during this pregnancy?” Of these responses, 36.2% referred to the double screening test. In addition, 50.9% of pregnant women reported that they had a screening test in their previous pregnancies, and 99.2% of them reported that the tests were normal (Table 3).

Table 3.

Characteristics of pregnant women regarding prenatal screening tests (n = 477)

		n	%
Regular pregnancy follow-up	Yes No	464 13	97.3 2.7
Heard screening tests ** (1795 responses)	Double Screening Test Triple Screening Test Quadruple marker screening test NIPT test/Fetal DNA test Detailed ultrasound Oral glucose screening test	447 370 147 69 386 346	25.3 21.0 8.3 3.9 21.9 19.6
Getting information or counseling about prenatal screening tests	Yes No	406 71	85.1 14.9
People who received information about prenatal screening tests ** (849 responses)	Obstetrician/Gynecologist Midwife/Nurse Family members/ Relatives Friends Press (TV, newspapers, magazines, etc.) Internet/social media	375 121 40 74 16 223	44.2 14.3 4.7 8.7 1.9 26.3
Status/desire to have a screening test in the current pregnancy	Yes No	442 35	92.7 7.3
What tests have you had/want to have done in your current pregnancy? ** (1131 responses)	Double Screening Test Triple Screening Test Quadruple marker screening test NIPT test/Fetal DNA test Detailed ultrasound Oral glucose screening test	409 131 38 26 326 201	36.2 11.6 3.4 2.3 28.8 17.8
Status of having screening tests in previous pregnancies	First pregnancy Yes No	180 246 51	37.7 51.6 10.7
Having problems with screening tests in previous pregnancies (n = 243)	Yes No	2 241	0.8 99.2

** Multiple response number percentage distribution

The pregnant women’s mean score on the HLS was found to be 116.11 ± 11.47. The mean scores for the subdimensions of the scale were as follows: access to information 24.14 ± 2.32; understanding information 31.40 ± 3.81; appraisal/evaluation 37.40 ± 3.80 and application/use 23.15 ± 2.82. HLS scores are presented in Table 4.

Table 4.

Health Literacy Scale Mean/Median Score Distributions (n = 477)

Scale and its sub-dimensions	Mean ± sd	Median (IR)	Min-Max
Accessing information	24.14 ± 2.32	25.00 (0.00)	10.00–25.00
Understanding information	31.40 ± 3.81	32.00 (4.00)	10.00–35.00
Evaluating/Assessing	37.40 ± 3.80	39.00 (3.00)	13.00–40.00
Application/Using	23.15 ± 2.82	24.00 (3.00)	10.00–25.00
Scale total score	116.11 ± 11.47	119.00 (7.00)	44.00-125.00

IR Interquartile Range

The comparison of HLS scores according to the characteristics of pregnant women is presented in Table 5. There were statistically significant differences in HLS scores according to participants’ age, education level, employment status, income level, place of residence, family type, consanguinity with spouse, and the presence of a hereditary disease in the family (p values are presented in Table 5; Bonferroni-adjusted significance levels were applied for multiple comparisons). Median HLS scores increased with education level, with women with primary education having the lowest scores, followed by those with secondary education, while university and postgraduate graduates had the highest scores. Working pregnant women had higher median HLS scores than those who were not working. Pregnant women whose income was lower than their expenses had lower median HLS scores, whereas no significant difference was observed between those whose income was equal to or greater than their expenses. Median HLS scores decreased from urban to semi-urban and rural areas. The median HLS scores were higher among pregnant women from nuclear families compared to those from extended and single-parent families, with no significant difference between the latter two groups. Pregnant women with consanguineous marriages had lower median HLS scores than those without, and those with a family history of genetically transmitted diseases also had lower median HLS scores compared to those without such a history.

Table 5.

Health Literacy Scale Scores According to the Characteristics of Pregnant Women (n = 477)

		n	Median (IR)	Test statistics
Descriptive Characteristics of Pregnant Women
Age range in years	Under 20 years old (a) 20–29 (b) 30–39 (c) 40 years and older (d)	48 304 110 15	119.00 (17.75) 120.00 (7.00) 118.00 (8.00) 100.00 (43.00)	KW: 25.756 p < 0.001 a = b=c > d†
Level of education	Primary education (a) Secondary education(b) University (c) Postgraduate (d)	94 241 127 15	114.00 (18.75) 120.00 (7.00) 122.00 (6.00) 122.00 (5.00)	KW: 92.696 p < 0.001 a < b< c = d†
Employment status	Yes No	174 303	120.00 (8.00) 119.00 (8.00)	z:-3.216 p < 0.001
Income status (household income)	Income is less than expenses (a) Income is equal to expenses (b) Income is greater than expenses (c)	54 409 14	108.00 (21.50) 120.00 (7.00) 122.50 (8.25)	KW: 57.173 p < 0.001 a < b = c††
Residency	Urban (a) Semi-urban (b) Rural (c)	211 226 40	121.00 (5.00) 119.00 (8.00) 109.00 (20.25)	KW: 72.383 p < 0.001 a > b> c††
Family type	Extended family (a) Nuclear family (b) Single-parent family (c)	34 436 7	114.00 (15.25) 120.00 (7.00) 97.00 (46.00)	KW: 38.812 p < 0.001 a = c < b††
Consanguineous marriage status	Yes No	54 423	115.50 (13.50) 120.00 (8.00)	z:-3.755 p < 0.001
Presence of genetically transmitted disease in the family	Yes No	50 427	114.50 (20.75) 120.00 (8.00)	z: -4.874 p < 0.001
Obstetric Characteristics of Pregnant Women
Number of pregnancies	One (a) Two (b) Three (c) Four and above(d)	180 138 93 66	119.00 (7.00) 121.00 (7.00) 118.00 (8.00) 118.00 (7.25)	KW: 9.946 p = 0.019
Planned pregnancy	Yes No	398 79	119.00 (8.00) 118.00 (8.00)	z: -2.289 p = 0.022
Having a stillbirth (Previous pregnancies)	Yes No	19 458	122.00 (7.00) 119.00 (8.00)	z: -2.363 p = 0.018
Having a child diagnosed with a genetic disease (Previous pregnancies)	Yes No	12 465	92.50 (44.75) 119.00 (7.00)	z: -3.676 p < 0.001
Pregnant Women’s Prenatal Screening Test Characteristics
Regular pregnancy follow-up	Yes No	464 13	119.00 (7.75) 75.00 (31.00)	z: -5.645 p < 0.001
The most commonly known test
Double Screening Test	Yes No	447 30	120,00 (8,00) 98,50 (40,00)	z: -6,420 p < 0.001
Triple Screening Test	Yes No	370 107	120,00 (7,00) 113,00 (19,00)	z: -7,441 p < 0.001
Quadruple marker screening test	Yes No	147 330	121,00 (6,00) 119,00 (8,25)	z: -4,218 p < 0.001
NIPT test/Fetal DNA test	Yes No	69 408	122,00 (11,00) 119,00 (7,00)	z: -2,480 p = 0.013
Detailed ultrasound	Yes No	386 91	120,00 (7,00) 114,00 (15,00)	z: -8,656 p < 0.001
Oral glucose screening test	Yes No	346 131	121,00 (6,00) 114,00 (10,00)	z: -7,993 p < 0.001
Getting information or counseling about prenatal screening tests	Yes No	406 71	120.00 (7.00) 112.00 (21.00)	z: -8.193 p < 0.001
Sources of information
Obstetrician/ Gynecologist	Yes No	375 102	120,00 (7,00) 115,00 (12,75)	z: -6,298 p < 0.001
Midwife/Nurse	Yes No	223 254	121,00 (5,00) 117,00 (10,00)	z: -7,109 p < 0.001
Family members/ Relatives	Yes No	121 356	121,00 (6,00) 119,00 (8,00)	z: -5,224 p < 0.001
Friends	Yes No	74 403	120,50 (6,25) 119,00 (8,00)	z: -3,068 p = 0.002
Press (TV, newspapers, magazines, etc.) Internet/social media	Yes No	40 437	121,00 (6,50) 119,00 (8,00)	z: -2,252 p = 0,024
Status/desire to have a screening test in the current pregnancy	Yes No	442 35	120.00 (8.00) 110.00 (17.00)	z: -5.179 p < 0.001
Status of having screening tests in previous pregnancies	First pregnancy(a) Yes (b) No (c)	180 246 51	120.00 (7.25) 119.00 (7.00) 115.00 (26.75)	KW: 12.845 p = 0.002 a = b > c††

Overall p values were obtained using the Kruskal–Wallis or Mann–Whitney U test. Multiple comparisons were adjusted using the Bonferroni correction

For variables with more than two groups, pairwise post hoc comparisons were adjusted using the Bonferroni correction and interpreted according to adjusted significance levels (four groups: p < 0.008; three groups: p < 0.016)

IR Interquartile Range, KW Kruskal Wallis test, z Mann Whitney U test

†Bonferroni-adjusted significance level p < 0.008

††Bonferroni-adjusted significance level p < 0.016

Although a statistically significant difference was observed between groups based on the number of pregnancies (p = 0.019), no significant pairwise differences were found between groups after Bonferroni correction. Median HLS scores were higher among women with planned pregnancies compared to those with unplanned pregnancies. Pregnant women with a history of stillbirth had higher median HLS scores than those without, whereas those who had a child diagnosed with a genetic disease had lower median HLS scores than those who did not. Pregnant women who regularly attended prenatal follow-ups had higher median HLS scores than those who did not.

In terms of prenatal screening, pregnant women who were familiar with screening tests, including double, triple, and quadruple screening tests, NIPT/Fetal DNA testing, detailed ultrasound, and oral glucose screening tests, had higher median HLS scores compared to those who were not familiar with these tests. Similarly, pregnant women who received information or counseling about prenatal screening tests had higher median HLS scores than those who did not. Pregnant women who obtained information from obstetricians/gynecologists, midwives/nurses, family members or relatives, friends, and the press or internet/social media had higher median HLS scores compared to those who did not use these sources. In addition, pregnant women who had undergone or intended to undergo screening tests during the current pregnancy had higher median HLS scores than those who did not. Regarding previous screening behavior, women experiencing their first pregnancy and those who had undergone screening tests in previous pregnancies had higher median HLS scores than those who had not undergone screening tests previously (Table 5).

Discussion

A review of the literature reveals that there are few studies examining prenatal screening tests from the perspective of HL [7, 10, 12]. In Turkey, the topic of prenatal screening has been addressed mainly in terms of pregnant women’s opinions, attitudes, and genetic literacy [2, 8], but no other studies combining prenatal screening tests and HL have been found. In this study, HL was examined both in relation to prenatal screening and certain sociodemographic and pregnancy characteristics. Accordingly, the discussion of the research findings also draws on other studies conducted with pregnant women that addressed prenatal screening and HL alongside other topics.

The prevalence of low HL among pregnant women has been reported to range from 15% to 44% [19]. The results of the study showed that the HL score for the pregnant women participating in the study was 116.11 ± 11.47. Considering that the scale’s minimum and maximum possible scores are 25 and 125 respectively, these findings indicate that the pregnant women had a good level of HL. In their systematic review aimed at determining pregnant women’s HL levels and their relationship with pregnancy outcomes, Nawabi et al. reported that most studies were conducted in Western countries, and although HL levels varied, pregnant women generally exhibited limited HL [20]. In a meta-analysis study conducted to examine the HL status of Iranian women, it was reported that women generally had borderline HL levels, but pregnant women exhibited higher HL. The authors attributed this to pregnant women initiating prenatal care and benefiting from free reproductive health services [21]. Research conducted in different regions of Turkey shows varying results regarding pregnant women’s HL levels. In a study examining HL and self-efficacy among pregnant women, HL was found to be at a moderate level, but more than half of the participants were reported to have inadequate or problematic HL [22]. A study conducted at a hospital in the Central Anatolia region of Turkey found that pregnant women’s HL was not at a good level [23] while another study reported that 33.9% of pregnant women had adequate HL [24]. The variation in HL levels is reported to depend on the measurement tools used, the sample size, and the characteristics of the participants [20]. Accordingly, it is considered that the good/adequate HL level found in this study may also be related to the characteristics of the participants. The study was conducted in a tertiary care institution (university hospital), where the care, treatment, and counseling approaches in place may have positively influenced pregnant women’s understanding of health-related information. Additionally, due to the necessity of attending this facility (for advanced tests, specialist consultations, etc.), the increased exposure of pregnant women to medical topics may have enhanced their skills in understanding and evaluating health information. Therefore, the single-center nature of the study may contain a sampling bias leading to high HL scores. On the other hand, prenatal care services are widespread in Turkey, with 96% of pregnant women benefiting from these services [25]. It is thought that all these factors may be reflected in HL levels.

Low HL during the prenatal period is emphasized to be associated with various factors such as education, employment, ethnicity, socioeconomic status, and age [13]. In this study, a significant difference was found between pregnant women’s ages and their HL levels, with those aged 40 and above having lower HL. The literature reports a significant association between older age and low/limited HL indicating that HL decreases with advancing age [21, 26]. However, some studies also indicate that pregnant women with low HL tend to be younger [27, 28]. A study conducted in Turkey found that women aged 24–29 had lower HL levels [29]. On the other hand, some studies have found no significant relationship between age and HL among pregnant women [22, 30]. Overall, the literature shows varying results regarding the relationship between age and HL, suggesting that this association cannot be generalized.

Individuals’ general education level has been shown to affect HL [31]; however, it is also noted that a higher education level does not always translate into adequate HL skills [28]. In this study, it was found that as the education level of pregnant women increased, their HL levels also increased. Although some studies have not found a significant relationship between education level and HL among pregnant women [22], the literature generally reports that pregnant women with low HL tend to have lower education levels [23, 28].

In this study, pregnant women who were employed and had a good income level were found to have higher HL levels. It is reported that HL is significantly associated with employment, and employed pregnant women tend to have higher HL levels [29, 32]. Akça et al. found that pregnant women with higher economic status had higher HL, but there was no significant relationship between employment status and HL [30]. On the other hand, Astantekin et al. reported no significant relationship between HL and employment or income [22]. Overall, the literature generally shows that employment and income are factors that positively affect HL.

The variability in pregnant women’s HL levels between countries or regions can be attributed to many factors [28]. In this study, it was found that pregnant women living in urban areas and having nuclear families had higher HL levels. In a multinational study including 18 countries such as Australia, Russia, the United States, and several European countries, pregnant women’s HL results were classified according to their country of residence. The study reported that low HL was more prevalent in South American countries such as Uruguay, Peru, Venezuela, Argentina, Bolivia, Chile, and Ecuador [28]. Studies on HL conducted with pregnant women generally inquire about place of residence, while fewer also examine family type. This may be due to the rarity of extended family structures in Western countries or the long-established adoption of nuclear family types in the countries where the research was conducted. However, research conducted in Turkey shows no relationship between pregnant women’s HL levels and place of residence or family type [22, 33]. HL levels may be affected in regions or communities where access to healthcare services is difficult, and internet use is limited. The high HL levels of pregnant women living in urban areas, obtained in the study, can be explained by the existence of advantages in terms of ease of access to health services and diversity of opportunities. Additionally, the fact that most of the pregnant women had a high school education or higher may have supported this outcome.

Approximately 10% of marriages worldwide occur between cousins. In communities where consanguineous marriages are common, the risk of any congenital anomaly is reported to be approximately doubled. Consanguineous marriages are more frequently observed in regions such as the Middle East and countries including Pakistan, Bangladesh, India, Turkey, and Lebanon [34]. In Turkey, in 2024, the proportion of individuals who entered into consanguineous marriage with their first-degree cousins among all official marriages was 8.1%. When consanguineous marriages are examined by type of kinship, it is observed that 46.4% of individuals married the children of their maternal uncle (maternal brother), 27.2% married the children of their paternal uncle (father’s brother), and 26.4% married the children of their maternal aunt (mother’s sister) [35]. In this study, pregnant women who were not consanguineous with their spouses and had no family history of hereditary diseases were found to have higher HL levels. Research examining the relationship between HL and consanguineous marriage is limited. In a study by Sahin et al. 8.6% of pregnant women were found to be consanguineous with their spouses, but no significant relationship was observed between HL and consanguinity [29]. Similarly, a study conducted with postpartum women reported that 41.9% of participants had consanguineous marriages, yet no significant association was found between consanguinity and HL [36]. Additionally, consanguineous marriage is occasionally observed among the White British population in the United Kingdom but is more common among minority ethnic populations living there. It is emphasized that HL interventions related to this issue need to be developed [34]. In a study conducted in Turkey examining pregnant women’s genetic literacy and the use of prenatal screening/diagnostic tests, it was found that those without consanguineous marriages had higher genetic literacy levels [8]. Because multivariate analysis was not possible in this study, it is not possible to establish a causal relationship between HL and consanguineous marriages or a history of hereditary diseases. However, it is thought that education and awareness may have an indirect impact on this situation. It would be beneficial to expand research examining consanguineous marriages in terms of both HL and prenatal screening tests.

Although significant differences were observed between groups based on the number of pregnancies in this study, no significant pairwise differences were found between the groups after Bonferroni correction. HL levels have been reported to be higher in primiparous and multiparous women compared to grand multiparous women [23], and pregnant women experiencing their first pregnancy and first birth were found to have adequate or higher HL levels [24, 33]. On the other hand, there are studies reporting no significant relationship between HL and the number of pregnancies [30], as well as studies indicating that pregnant women without previous children tend to have lower HL [28]. Additionally, a study conducted in Canada examining pregnant women’s knowledge about prenatal screening for Trisomy 21 found that multiparity was positively and significantly associated with knowledge scores [37]. Accordingly, differences in HL levels related to the number of pregnancies may have arisen not only from the personal characteristics of the pregnant women but also from their exposure to health-related topics and services, the quality of prenatal care received, and their previous pregnancy, birth, and postpartum experiences.

HL is an important factor in women’s pregnancy planning and accessing related health services [30]. In this study, the HL scores of women who became pregnant intentionally were found to be higher than those who became pregnant unintentionally, and literature findings also support this result [28, 29].

It is stated that HL deficiency can lead to adverse outcomes for maternal and infant health and may increase risks such as stillbirth and congenital malformations [13]. In this study, pregnant women who had experienced stillbirth were found to have higher HL, while those with children diagnosed with hereditary diseases had lower HL levels. A qualitative study conducted in the United States to examine pregnant women’s knowledge and opinions about prenatal genetic testing found that having a child with a genetic abnormality increased familiarity with prenatal tests [38]. Our finding of higher HL among pregnant women who experienced stillbirth may be attributed to their prior exposure to various examinations, treatments, and counseling as a result of this adverse experience. In an effort to avoid further loss, these women may become more open to receiving and applying accurate health information, thereby increasing their HL levels. However, our finding regarding pregnant women with children diagnosed with hereditary diseases does not align with this perspective. We hypothesize that these women may have underutilized healthcare services and lacked support systems, or that other individual factors may have contributed to this outcome. Conducting more research with pregnant women from different populations who have experienced issues related to genetic diseases would be beneficial.

Individuals with limited HL are reported to visit emergency departments more frequently, have longer hospital stays, and utilize preventive services less often [20]. Prenatal care services are important preventive health services for both maternal-child health and public health. In this study, pregnant women who regularly attended prenatal check-ups and received information or counseling about prenatal screening tests were found to have significantly higher HL levels. The literature supports this finding, indicating that pregnant women who receive prenatal care, counseling, and health check-ups tend to have higher HL [21–24]. A study conducted in Australia examined the effectiveness of education accompanied by a booklet to improve knowledge about Down syndrome screening. It was reported that knowledge levels increased from 4% to 69% after the education [1]. A qualitative study conducted in the United States with pregnant Hispanic women to understand their knowledge perceptions about prenatal genetic testing indicated that the women were unclear about the reasons for needing testing and the risks involved, and that they expected counseling to be provided in everyday language [38]. On the other hand, it has been stated that HL interventions have the potential to improve knowledge and pregnancy outcomes, but there is insufficient research on the topic [19]. This situation highlights the necessity of conducting studies that examine the effects of HL interventions on both pregnancy outcomes and prenatal screening tests. Additionally, it is considered important that effective counseling be provided and that midwives, who play an active role in prenatal care services, become well-equipped to deliver such counseling effectively.

Women with adequate HL make more informed decisions regarding prenatal screening tests [20]. The findings of this study showed that pregnant women who had undergone or wished to undergo prenatal screening tests in their current pregnancy, as well as those who had screening tests in previous pregnancies, had higher average HL scores. Participation in screening tests is optional. The potential risk indicators revealed by the test underscore the importance of informed consent [37]. However, understanding the informed consent obtained before the screening test also requires that pregnant women possess adequate HL. On the other hand, it has been noted that some women with adequate HL refuse prenatal screening tests, and that the primary reasons for these decisions relate to personal values and beliefs [12]. In a study conducted with pregnant women attending family health centers, although most were aware that the test was not mandatory, the majority reported they would undergo screening tests. Additionally, four out of five multiparous women had undergone prenatal screening tests in previous pregnancies [2]. Participation in screening tests is influenced by ethical perspectives, beliefs, and certain sociocultural factors; differing views may arise regarding pregnancy termination, potential disabilities in the baby, or continuation of the pregnancy [37]. However, above all, it is clear that an adequate level of HL is required to understand the purposes and results of these tests.

Strengths and limitations

This study was conducted in a tertiary healthcare facility. Because the study sample consisted of pregnant women receiving care at a university hospital, the participants’ education and health literacy levels may have been relatively higher than those in other healthcare facilities, limiting the generalizability of the findings to the broader population. Additionally, because the study used a cross-sectional design, causal relationships among variables cannot be inferred; therefore, results should be interpreted as descriptive relationships rather than cause-and-effect relationships. Because only bivariate analyses were conducted in the study, associations between sociodemographic variables (e.g., education and consanguinity) were not investigated. Another limitation of this study is that it did not examine specific knowledge levels (e.g., knowing test names correctly) and reasons for test acceptance/rejection. Therefore, the relationship between HL and these variables could not be analyzed. Future studies are recommended to use scales and question sets that provide detailed information about pregnant women’s knowledge levels and decision-making processes. Nonetheless, this study contributes to the existing body of literature by offering insights into pregnant women’s attitudes toward prenatal screening tests in Turkey and by presenting findings related to their HL levels. It further provides a comparative perspective with current literature. It further provides evidence on the association between consanguineous marriage and HL. Counseling that takes into account the HL levels of pregnant women and the factors influencing those levels may enhance both awareness of prenatal screening and HL itself. In this regard, the education and training of healthcare professionals is of critical importance. The findings of this study are expected to serve as a valuable reference in guiding such efforts.

Conclusion

This study found that pregnant women generally have a good level of HL. Pregnant women with higher education levels, who are employed, have a good income, and live in urban areas, as well as those who are unrelated to their spouses, have a nuclear family structure, and have no family history of genetic disease, have higher HL levels. Additionally, HL levels were found to be higher in pregnant women who had conceived intentionally, had experienced stillbirth in previous pregnancies, had regular pregnancy follow-up, received information or counseling about prenatal screening tests, and had these tests. HL levels were also higher in women who were pregnant for the first time and had screening tests in previous pregnancies.

In contrast, pregnant women aged 40 and older and those with four or more pregnancies have lower HL levels. Furthermore, pregnant women who have a child diagnosed with a genetically transmitted disease have been found to have lower HL levels.

Research findings suggest that strategies to improve HL in pregnant women should focus on those with lower socioeconomic status and older age. HL may act as both a determinant and a mediator in shaping attitudes towards prenatal screening. Focusing on women’s HL at an early stage, especially in societies where consanguineous marriage is common, will be an important approach that will benefit both women’s and public health. Therefore, it is essential for healthcare professionals to enhance their ability to understand the pregnant women’s health knowledge base and perceptions. It should not be forgotten that the pregnancy process offers opportunities to improve HL. Therefore, education and counseling programs planned by considering the factors related to HL levels can be more effective. Midwives, who serve as a crucial source of information for mothers during pregnancy, play an important role in prenatal screening test counseling and in approaches aligned with HL. This study contributes to the limited literature on prenatal screening and HL. It would be beneficial to examine the relationship between prenatal screening and HL in different pregnant groups, including partners, and to conduct randomized controlled trials.

Abbreviations

HL

Health Literacy

NIPT

Non-invasive Prenatal Testing

HLS

Health Literacy Scale

Authors’ contributions

DH conceived the study, designed the survey, supported data analysis and interpretation, and wrote the first draft of the manuscript. NÇO helped design the survey, collected data, and performed data analysis and interpretation. PSH collected data, supported data analysis and interpretation. All authors reviewed and revised the manuscript. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The data underlying the article are available upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by the Health Sciences Ethics Committee [Turkey- Manisa Celal Bayar University Faculty of Medicine Dean’s Health Sciences Ethics Committee, Decision Date and number: 08/03/2023 / 20.478.486 / 1717]. Prior to data collection, participants were informed about the study and both written and verbal informed consent were obtained. The research was conducted in accordance with the Helsinki Declaration.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.