ABSTRACT
Background and Aims
Health literacy is an important determinant of maternal health and may influence improving pregnancy outcomes. This study aimed to assess the health literacy levels of pregnant women and explore their relationship with empowerment and self‐care practices.
Method
This cross‐sectional study included 350 pregnant women receiving prenatal care at 12 health service centers in Langroud, northern Iran. Participants were recruited through convenience sampling and provided written informed consent. Data were collected from March to September 2024 using the Health Literacy for Iranian Adults Questionnaire (HELIA), the Pregnancy Empowerment Questionnaire (PEQ), and the Pregnancy Self‐Care Questionnaire (PSCQ). Stepwise multiple linear regression analyses were conducted to identify independent predictors of pregnancy self‐care. The mediating effect of pregnancy empowerment on the association between health literacy and self‐care was examined using PROCESS macro (Model 4) with bootstrap confidence intervals.
Results
The mean scores of health literacy, pregnancy empowerment, and self‐care were 66.67 ± 13.56, 76.26 ± 9.83, and 118.45 ± 24.54, respectively. Higher health literacy was significantly associated with greater pregnancy empowerment (B = 0.344, p < 0.001) and better self‐care behaviors (B = 1.15, p < 0.001). Family income and planned pregnancy were identified as significant correlates of both empowerment and self‐care. Mediation analysis demonstrated a significant indirect effect of health literacy on self‐care through pregnancy empowerment, indicating partial mediation.
Conclusion
This study highlights the critical role of health literacy as an independent predictor of both women's empowerment and self‐care during pregnancy. Higher levels of health literacy not only directly contribute to better self‐care practices but also indirectly promotes empowerment. Pregnancy empowerment partially mediated the association between health literacy and self‐care among pregnant women. These findings emphasize the potential value of integrating health literacy and empowerment strategies into prenatal care programs to support maternal self‐care and well‐being.
Keywords: empowerment, health literacy, pregnant women, self‐care
1. Introduction
Health literacy serves as a critical social determinant of public health and playing a pivotal role across all societal strata [1]. Among these, pregnant women constitute a particularly vulnerable population, requiring heightened attention due to their increased sensitivity and susceptibility within community health frameworks [2]. The World Health Organization (WHO) recognizes health literacy as a fundamental element of 21st‐century health policy and strategy [3].
Health literacy encompasses an individual's capacity to acquire a set of skills—including reading, listening, analyzing, understanding basic information about health services—and applying these skills to make decisions about health‐related situations to navigate healthcare systems effectively, independent of general literacy levels [4]. Low health literacy contributes to a 3%–5% annual increase in healthcare expenditures [5].
Health literacy is critical for pregnant women in understanding pregnancy risks and can significantly influence improving pregnancy outcomes. Therefore, the early identification of pregnant women with limited health literacy is essential for targeted interventions and equitable healthcare delivery [4]. When pregnant women first access healthcare services, low health literacy can significantly impair their ability to navigate and utilize the healthcare system effectively [6]. Conversely, women with higher health literacy demonstrate better pregnancy outcomes, including reduced incidence of low birth weight, preterm delivery, and neonatal mortality [2].
Research consistently shows that 15%–44% of pregnant women exhibit limited or inadequate health literacy [5, 7]. Research in Iran has also demonstrated that approximately 30–40% of pregnant women exhibit limited health literacy [8, 9].
Health literacy serves as a critical determinant that enables women to actively participate in self‐care practices, thereby enhancing overall health outcomes [2]. Enhanced empowerment and self‐care capacity during pregnancy are associated with reduced maternal complications [10]. Contemporary research demonstrates that empowerment significantly influences multiple domains of women's health through both direct and indirect pathways [11]. However, Iranian studies reveal that women's reproductive health empowerment remains at a moderate level [10, 12]. Pregnant women need to be empowered to care for themselves to ensure the health of both themselves and their infants. This necessitates the acquisition of relevant knowledge and skills [13]. Current epidemiological data indicate suboptimal self‐care practices globally, with national studies reporting moderate to poor self‐care compliance among pregnant women [1].
To advance maternal health outcomes, there is a critical need to address existing knowledge gaps regarding the interplay among health literacy, empowerment, and self‐care in pregnancy. Current evidence examining these relationships remains limited. This study seeks to: (1) assess health literacy levels among pregnant women, and (2) examine potential associations between health literacy and both empowerment and self‐care practices during pregnancy. The findings provide essential evidence to guide the development of targeted, evidence‐based interventions aimed at enhancing empowerment and self‐care capacity in this vulnerable population.
2. Methods
2.1. Study Design and Participants
This cross‐sectional study included 350 eligible pregnant women receiving prenatal care at comprehensive health service centers (12 centers) in Langroud, a region in northern Iran. The required sample size was estimated using G*Power software (version 3.1.9.2). Based on anticipated correlations between health literacy and empowerment (r = 0.26) and self‐care parameters (r = 0.37) according to similar studies with a 95% confidence level and 90% power, the calculated sample sizes were 313 and 141, respectively [14, 15]. To ensure adequate power for the primary outcome (empowerment) and account for a potential 10% attrition rate, a final sample size of 350 was selected.
2.2. Data Collection
Participants were selected via convenience sampling from the target population. Eligible individuals were enrolled after meeting the inclusion criteria and providing written informed consent. During prenatal clinic visits, the researcher conducted face‐to‐face sessions to identify eligible women, explain the study's purpose, methodology, and emphasize data confidentiality. Participants were informed of their right to withdraw at any time. Data collection occurred between March 20 and September 20, 2024, using structured questionnaires administered in accordance with the study objectives.
Inclusion criteria included willingness to participate, low‐risk pregnancy (no self‐reported chronic medical conditions, mental illnesses, or diagnosed complications such as placenta previa, preeclampsia, or congenital anomalies), having at least an elementary education, and the ability to comprehend and communicate effectively. Exclusion criteria also included incomplete questionnaires (> 20% missing data) and women educated in medical and paramedical fields (to minimize selection bias) (Figure 1: Participant flow).
Figure 1.
Participant flow.
2.2.1. Descriptive Information Form
A structured questionnaire was used to collect sociodemographic and fertility‐related data, including: age, education level, occupation, household income status, gestational age, gravidity, history of abortion, pregnancy planning status, participation in childbirth preparation classes, and the source of health literacy information.
2.2.2. Health Literacy for Iranian Adults Questionnaire (HELIA‐33)
Health literacy was measured using the validated Health Literacy for Iranian Adults (HELIA‐33) questionnaire. This 33‐item instrument evaluates five key dimensions: (1) access to health information (items 1–6), (2) reading skills (items 7–10), (3) understanding (items 11–17), (4) appraisal (items 18–21), and (5) decision making and application (items 22–33). Participants responded using a 5‐point Likert scale (1 = never to 5 = always), with total scores converted to a 0‐100 scale for interpretation. Based on established cut‐offs, health literacy levels were categorized as inadequate (0–50), problematic (50.1–66), sufficient (66.1–84), or excellent (84.1–100). The HELIA‐33 has demonstrated strong reliability across domains (Cronbach's α = 0.72–0.89) and has been validated for multidimensional health literacy assessment in Iranian populations [16]. In this study the sample‐specific reliability coefficients using Cronbach's α was = 0.947.
2.2.3. Pregnancy Empowerment Questionnaire
The Pregnancy Empowerment Questionnaire, consisting of 27 items across five domains—self‐efficacy (6 items), future image (6 items), self‐esteem (7 items), understanding of others’ support (4 items), and pleasure of adding a new person (4 items)—was administered using a 4‐point Likert scale ranging from “strongly disagree” (1) to “strongly agree” (4). Total empowerment scores ranged from 27 to 108, with higher scores indicating greater empowerment. The instrument demonstrated excellent reliability (Cronbach's α = 0.84) [12]. In this study the sample‐specific reliability coefficients using Cronbach's α was = 0.856.
2.2.4. Pregnancy Self‐Care Questionnaire
The Pregnancy Self‐Care Questionnaire was used to evaluate five domains of pregnancy self‐care behaviors: nutrition performance (15 items), exercise and physical activity (4 items), smoking and drug use (4 items), personal hygiene (23 items), and routine pregnancy care (11 items). Responses were recorded on a 4‐point frequency scale from “never” (0) to “always” (3), with higher scores reflecting better self‐care practices. This questionnaire showed excellent reliability (Cronbach's α = 0.86) [17]. In this study the sample‐specific reliability coefficients using Cronbach's α was = 0.962.
2.3. Data Analysis
Data analysis was performed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, NY, USA) and PROCESS macro version 4.2 (Model 4). Descriptive statistics were used to summarize participants’ characteristics and study variables. Continuous variables were presented as means and standard deviations (SD), whereas categorical variables were reported as frequencies and percentages.
Prior to inferential analyses, the assumptions of linear regression were evaluated. The normality of continuous variables and model residuals was assessed using skewness and kurtosis indices, histograms, and normal probability plots. Multicollinearity among independent variables was examined using variance inflation factors (VIF) and tolerance statistics. Independence of residuals was assessed using the Durbin–Watson statistic, and homoscedasticity was evaluated through visual inspection of standardized residual plots. Bivariate analyses were initially conducted to explore associations between demographic, socioeconomic, and obstetric variables and the study outcomes. Depending on the type and distribution of variables, Pearson correlation coefficients, independent‐samples t‐tests, and one‐way analysis of variance (ANOVA) were employed. Variables demonstrating a statistically significant association with the outcome variables at the bivariate level were considered candidates for multivariable modeling.
To identify independent predictors of pregnancy empowerment and self‐care, separate multivariable linear regression models were constructed for each outcome. Covariates were prespecified based on the study objectives, previous literature, and their potential clinical, sociodemographic, and obstetric relevance. Health literacy was retained in all models as the primary explanatory variable. Bivariate analyses were performed as an initial descriptive assessment and were not used as the sole criterion for covariate inclusion. Accordingly, variables were included in the multivariable models based on their prespecified conceptual and clinical relevance rather than an automated stepwise selection procedure. Regression coefficients (B), standard errors (SE), standardized beta coefficients (β), 95% confidence intervals (CI), adjusted coefficients of determination (Adjusted R2), and p‐values were reported
To identify independent predictors of pregnancy empowerment and self‐care, separate stepwise multiple linear regression models were constructed. Predictor variables were entered sequentially according to the stepwise selection procedure, allowing variables that significantly improved model fit to remain in the final model. Regression coefficients (B), standard errors (SE), standardized beta coefficients (β), 95% confidence intervals (CI), adjusted coefficients of determination (Adjusted R 2), and p values were reported.
The mediating role of pregnancy empowerment in the relationship between health literacy and self‐care was examined using a regression‐based mediation approach implemented through PROCESS macro (Model 4). In this model, health literacy was specified as the independent variable (X), pregnancy empowerment as the mediator (M), and self‐care as the dependent variable (Y). Direct, indirect, and total effects were estimated. The significance of the indirect effect was evaluated using bias‐corrected bootstrap confidence intervals generated from 5000 bootstrap resamples. Mediation was considered statistically significant when the 95% bootstrap confidence interval for the indirect effect did not include zero. All statistical tests were two‐tailed, and a p < 0.05 was considered statistically significant.
2.4. Ethical Considerations
This study received ethical approval from the Research Ethics Committee of Babol University of Medical Sciences (Ref: IR.MUBABOL.REC.1402.241) on March 16, 2024. Prior to data collection, administrative approval was secured from the respective clinics. All participants were informed of the study's objectives and provided written informed consent before the interviews. Participation was entirely voluntary, and confidentiality was strictly maintained. Furthermore, the research was conducted in adherence to the Declaration of Helsinki and all applicable institutional guidelines. We used the STROBE reporting guideline to draft this manuscript, and the STROBE reporting checklist when editing, included in supplement A.
3. Results
3.1. Sociodemographic and Fertility Characteristics in Relation to Health Literacy
In this study of 350 pregnant women, 41.43% demonstrated problematic health literacy, 35.71% sufficient, 12.00% excellent, and 10.86% inadequate health literacy. Educational attainment was significantly related to health literacy (p = 0.001); women with more than 12 years of education had markedly higher levels of sufficient and excellent health literacy, whereas those with fewer than 6 years of schooling predominantly exhibited inadequate or problematic levels. Employment status (p = 0.002) and insurance coverage (p = 0.001) were significantly associated with health literacy, with employed and insured women demonstrating more favorable literacy levels. Family income also showed a positive association (p = 0.001), as women with sufficient income were more likely to have sufficient or excellent health literacy. Gestational age was significantly related to health literacy (p = 0.001), with women in the third trimester exhibiting higher proportions of adequate literacy compared to those in the other trimester. History of abortion was also significantly associated with health literacy, such that women with higher health literacy had a lower history of abortion (p = 0.029). In contrast, age, planned pregnancy, gravidity and the most common source of health information were not significantly associated with health literacy, whereas attendance at childbirth preparation classes was significantly associated (p = 0.001), with attendees demonstrating higher levels of sufficient and excellent health literacy (Table 1).
Table 1.
Distribution of the health literacy according to some sociodemographic and fertility characteristics.
| Variables | Total N (%)b 350 (100) | Health literacy | Test value χ2 p | |||
|---|---|---|---|---|---|---|
| Inadequate n (%)a 38 (10.86) | Problematic n (%)a 145 (41.43) | Sufficient n (%)a 125 (35.71) | Excellent n (%)a 42 (12.00) | |||
| Age (year) | ||||||
| < 24 | 69 (19.71) | 6 (8.69) | 32 (46.38) | 27 (39.13) | 4 (5.80) | X2 = 9.64 p = 0.14 |
| 25–34 | 191 (54.57) | 18 (9.42) | 72 (37.70) | 72 (37.70) | 29 (15.18) | |
| 35 and above | 90 (25.72) | 14 (15.55) | 41 (45.55) | 26 (28.89) | 9 (10.00) | |
| Education (Year) | X2 = 66.89 p = 0.001 | |||||
| ≤ 6 | 62 (17.71) | 16 (25.81) | 31(50.00) | 13 (20.97) | 2 (3.22) | |
| 7‐12 | 153 (43.72) | 18 (11.76) | 77(50.33) | 51 (33.33) | 7 (4.58) | |
| ˃12 | 135 (38.57) | 4 (2.96) | 37(27.41) | 61 (45.19) | 33 (24.44) | |
| Employment (n = 349) | X2 = 14.35 P = 0.002 | |||||
| Unemployed | 295 (84.53) | 37 (12.54) | 128(43.39) | 100 (33.90) | 30 (10.17) | |
| Employed | 54 (15.47) | 1 (1.85) | 16(29.63) | 25 (46.30) | 12 (22.22) | |
| Insurance status | X2 = 18.77 p = 0.001 | |||||
| Yes | 271 (77.43) | 20 (7.38) | 111 (40.96) | 102 (37.64) | 38 (14.02) | |
| No | 79 (22.57) | 18 (22.78) | 34 (43.04) | 23 (29.12) | 4 (5.06) | |
| Family income | X2 = 57.44 p = 0.001 | |||||
| Sufficient | 67 (19.15) | 1 (1.49) | 18 (26.87) | 31 (46.27) | 17 (25.37) | |
| Relatively sufficient | 249 (71.14) | 23 (9.24) | 116 (46.59) | 87 (34.94) | 23 (9.23) | |
| Insufficient | 34 (9.71) | 14 (41.18) | 11 (32.35) | 7 (20.59) | 2 (5.88) | |
| Gestational age (week) | X2 = 21.93 p = 0.001 | |||||
| ≤ 14 (First trimester) | 58 (16.57) | 8 (13.79) | 24 (41.38) | 21 (36.21) | 5 (8.62) | |
| 15‐28(Second trimester) | 161 (46.00) | 22 (13.66) | 80 (49.69) | 41 (25.47) | 18 (11.18) | |
| 29‐40 (Third trimester) | 131 (37.43) | 8 (6.11) | 41 (31.30) | 63 (48.09) | 19 (14.50) | |
| Planning pregnancy | X2 = 5.70 p = 0.127 | |||||
| Yes | 308 (88.00) | 31 (10.06) | 123 (39.93) | 115 (37.35) | 39 (12.66) | |
| No | 42 (12.00) | 7 (16.67) | 22 (52.38) | 10 (23.81) | 3 (7.14) | |
| Gravidity | X2 = 8.56 p = 0.200 | |||||
| 1 | 170 (48.57) | 15 (8.82) | 64 (37.65) | 67 (39.42) | 24 (14.11) | |
| 2 | 113 (32.29) | 11 (9.73) | 54 (47.79) | 38 (33.63) | 10 (8.85) | |
| 3 and above | 67 (19.14) | 12 (17.91) | 27 (40.30) | 20 (29.85) | 8 (11.94) | |
| History of abortion | X2 = 9.00 P = 0.029 | |||||
| Yes | 54 (15.43) | 11 (20.37) | 21 (38.89) | 13 (24.07) | 9 (16.67) | |
| No | 296 (84.57) | 27 (9.12) | 124 (41.89) | 112 (37.84) | 33 (11.15) | |
| Attending childbirth classes | X2 = 27.37 p = 0.001 | |||||
| Yes | 41 (11.71) | 3 (7.31) | 5 (12.20) | 20(48.78) | 13 (31.71) | |
| No | 309 (88.29) | 35 (11.32) | 140 (45.31) | 105(33.99) | 29 (9.38) | |
| The most common source of health information | X2 = 8.04 p = 0.235 | |||||
| Doctor/Healthcare provider | 166 (47.43) | 11 (6.63) | 71 (42.77) | 61 (36.74) | 23 (13.86) | |
| Internet | 56 (16.00) | 6 (10.71) | 25 (44.64) | 20 (35.72) | 5 (8.93) | |
| Otherc | 128 (36.57) | 21 (16.41) | 49 (38.28) | 44 (34.37) | 14 (10.94) | |
Note: Bold values indicate p < 0.05.
Percent by row total.
Percent by column total.
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3.2. Distribution of Main Study Variables (Health Literacy, Empowerment and Self‐Care) in Pregnant Women
The mean total health literacy score was 66.67 ± 13.57 (range: 20–96), with the highest domain score observed in understanding (71.51 ± 15.82) and the lowest in appraisal (61.08 ± 15.49). The mean total empowerment score was 76.26 ± 9.83 (range: 47–106), with self‐esteem demonstrating the highest subscale mean. The overall mean self‐care score was 118.45 ± 24.55 (range: 40–168), with the highest mean in personal hygiene and the lowest in exercise and physical activity. These findings indicate moderate levels of health literacy, empowerment, and self‐care among the participants (Table 2).
Table 2.
Distribution of health literacy, empowerment and self‐care mean scores of the pregnant women.
| Scales | Mean ± SD | Possible lower values‐upper values | Marked lower values‐upper values |
|---|---|---|---|
| Health literacy | |||
| Reading | 71.09 ± 17.463 | 0–100 | 20–100 |
| Access to information | 62.88 ± 18.268 | 0–100 | 4–100 |
| Understanding | 71.51 ± 15.815 | 0–100 | 7–100 |
| Appraisal | 61.08 ± 15.494 | 0–100 | 13–100 |
| Decision making | 68.01 ± 14.164 | 0–100 | 19–100 |
| Total score | 66.67 ± 13.568 | 0–100 | 20–96 |
| Pregnant women empowerment | |||
| Self‐efficacy | 17.06 ± 2.986 | 6–24 | 6–24 |
| Future image | 15.94 ± 2.213 | 6–24 | 6–23 |
| Self‐esteem | 18.99 ± 2.004 | 7–28 | 10–25 |
| Understanding of others’ support | 11.83 ± 1.963 | 4–16 | 4–16 |
| Pleasure of adding a new person | 12.58 ± 1.944 | 4–16 | 4–16 |
| Total score | 76.26 ± 9.831 | 27–108 | 47–106 |
| Pregnancy self‐care | |||
| Nutrition performance | 29.38 ± 7.293 | 0–45 | 3–45 |
| Exercise and physical activity | 4.90 ± 2.304 | 0–12 | 0–12 |
| Smoking and drug use | 10.87 ± 1.419 | 0–12 | 6–12 |
| Personal hygiene | 48.32 ± 11.140 | 0–69 | 15–69 |
| Routine pregnancy care | 24.74 ± 5.883 | 0–33 | 5–33 |
| Total score | 118.45 ± 24.548 | 0–171 | 40–168 |
3.3. Predictors of Women's Empowerment: Multivariate Linear Regression Analysis
Based on the multivariate linear regression analysis, health literacy remained a significant independent predictor of women's empowerment after controlling for potential confounders (B = 0.344, 95% CI: 0.28–0.40, p = 0.001). Family income (sufficient vs. insufficient) was also significantly associated with empowerment in the adjusted model (B = 2.381, 95% CI: 0.33–4.43, p = 0.023), as was planned pregnancy (B = 3.616, 95% CI: 1.22–6.00, p= 0.003). Other variables, including age, education level, employment status, gravidity, gestational age, abortion history, attendance at childbirth classes, and main source of health information, were not significantly associated with empowerment in the multivariate model. These findings indicate that health literacy independently contributes to higher empowerment among pregnant women, even after accounting for sociodemographic and obstetric factors (Table 3). Notably, the inclusion of health literacy substantially increased the explanatory power of the model, with the adjusted R 2 increasing from 0.19 in the demographic‐only model to 0.34 after adding health literacy (ΔR 2 = 0.15). This indicates that health literacy explained an additional 15% of the variance in women's empowerment beyond that explained by the demographic and obstetric characteristics.
Table 3.
Variables predicted to affect empowerment by multivariate linear regression analysis.
| Variable | Full model | Adjusted model | ||||
|---|---|---|---|---|---|---|
| B(SE) | 95% CI | p value | B(SE) | 95% CI | p value | |
| Health literacy | 0.32 (0.036) | 0.25 to 0.39 | 0.001 | 0.344 (0.030) | 0.28 to 0.40 | 0.001 |
| Age (Year) | 0.32 (0.67) | −1.01 to 1.66 | 0.632 | |||
| Education (Year) | ||||||
| ≤ 6 | −1.27 (1.29) | −3.82 to 1.27 | 0.326 | — | — | — |
| 7–12 | o.46 (1.00) | −1.510 to 2.43 | 0.645 | — | — | — |
| > 12 | Ref | |||||
| Family income | ||||||
| Sufficient | 3.27 (1.67) | −0.06 to 6.53 | 0.054 | 2.381 (1.042) | 0.33 to 4.43 | 0.023 |
| Relatively sufficient | 0.72 (1.41) | −2.05 to 3.50 | 0.608 | — | — | — |
| Insufficient | Ref | |||||
| Job (Housewife/Employed) | −1.93 (1.16) | −4.23 to 0.36 | 0.099 | — | — | — |
| Planning status of pregnancy (No/Yes) | 3.29 (1.27) | 0.78 to 5.81 | 0.010 | 3.616 (1.216) | 1.22 to 6.00 | 0.003 |
| Gravidity | ||||||
| First | 0.98 (1.48) | −1.93 to 3.90 | 0.509 | — | — | — |
| Second | 0.45 (1.32) | −2.15 to 3.06 | 0.731 | — | — | — |
| Third or more | Ref | |||||
| Gestational age (week) | 0.06 (0.04) | −0.03 to 0.15 | 0.208 | — | — | — |
| Abortion history (No/Yes) | 1.27 (1.40) | −1.48 to 4.03 | 0.363 | — | — | — |
| Attending childbirth classes (No/Yes) | 0.70 (1.38) | −2.00 to 3.42 | 0.608 | — | — | — |
| Most common source of health information | ||||||
| Healthcare Providers | 1.14 (0.89) | −0.60 to 2.89 | 0.200 | — | — | — |
| Internet | −0.63 (1.23) | −3.05 to 1.78 | 0.605 | — | — | — |
| Othera | Ref | |||||
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3.4. Predictors of Women's Self‐Care: Multivariate Linear Regression Analysis
In the multivariate linear regression analysis, health literacy emerged as a significant positive predictor of pregnancy self‐care (B = 1.15, 95% CI: 1.01–1.29, p = 0.001), indicating that higher levels of health literacy were associated with better self‐care behaviors. Among sociodemographic variables, women with sufficient family income demonstrated significantly higher self‐care scores compared to those with insufficient income (B = 6.20, 95% CI: 1.38–11.02, p = 0.012). Planned pregnancy was also an independent predictor of improved self‐care (B = 7.60, 95% CI: 1.97–13.22, p = 0.008). Additionally, obtaining health information primarily from healthcare providers was significantly associated with higher self‐care scores (B = 5.61, 95% CI: 1.97–9.26, p = 0.003). Other variables, including age, education level, gravidity, gestational age, abortion history and attending childbirth classes were not significant predictors in the adjusted model. These findings highlight the central role of health literacy and modifiable contextual factors in promoting pregnancy self‐care behaviors (Table 4). Notably, the inclusion of health literacy substantially increased the explanatory power of the model, with the adjusted R 2 increasing from 0.27 in the demographic‐only model to 0.51 after adding health literacy (ΔR 2 = 0.24). This indicates that health literacy explained an additional 24% of the variance in women's self‐care beyond that explained by the demographic and obstetric characteristics.
Table 4.
Variables predicted to affect pregnancy self‐care by multivariate linear regression analysis.
| Variable | Full model | Adjusted model | ||||
|---|---|---|---|---|---|---|
| B(SE) | 95% CI | p value | B(SE) | 95% CI | p value | |
| Health literacy | 1.09 (0.085) | 0.92 to 1.26 | 0.001 | 1.15 (0.07) | 1.01 to 1.29 | 0.001 |
| Age (Year) | −0.50 (1.600) | −3.64 to 2.64 | 0.754 | — | — | — |
| Education (Year) | ||||||
| ≤ 6 | −0.09 (3.054) | −6.10 to 5.91 | 0.975 | — | — | — |
| 7–12 | −2.52 (2.363) | −7.17 to 2.11 | 0.285 | — | — | — |
| > 12 | Ref | |||||
| Family income | ||||||
| Sufficient | 6.09 (3.952) | −1.68 to 13.85 | 0.124 | 6.20 (2.44) | 1.38 to 11.02 | 0.012 |
| Relatively sufficient | 0.58 (3.331) | −5.97 to 7.13 | 0.862 | — | — | — |
| Insufficient | Ref | |||||
| Job (Housewife/Employed) | 1.66 (2.753) | −3.74 to 7.08 | 0.545 | — | — | — |
| Planning status of pregnancy (No/Yes) | 5.60 (3.014) | −0.32 to 11.53 | 0.064 | 7.60 (2.85) | 1.97 to 13.22 | 0.008 |
| Gravidity | ||||||
| First | 5.25(3.497) | −1.62 to 12.13 | 0.134 | — | — | — |
| Second | 3.57 (3.126) | −2.57 to 9.72 | 0.253 | — | — | — |
| Third or more | Ref | |||||
| Gestational age (week) | 0.12 (0.11) | −0.09 to 0.34 | 0.258 | — | — | — |
| Abortion history (No/Yes) | 3.98 (3.30) | −2.52 to 10.48 | 0.230 | — | — | — |
| Attending childbirth classes (No/Yes) | 2.36 (3.25) | −4.04 to 8.75 | 0.469 | — | — | — |
| Most common source of health information | ||||||
| Healthcare Providers | 5.516 (2.09) | 1.39 to 9.64 | 0.009 | 5.61 (1.85) | 1.97 to 9.26 | 0.003 |
| Internet | −0.313 (2.89) | −6.01 to 5.38 | 0.914 | — | — | — |
| Othera | Ref | |||||
Interactive Voice Response, Radio and TV, Newspaper, Magazine and Journal, ask from Friends and Relatives, Booklet and Educational Brochure, I don't know where to get the information I need.
3.5. Mediation Analysis: The Mediating Role of Empowerment
A mediation analysis was performed using PROCESS Macro version 4.2 (Model 4) with 5,000 bootstrap resamples to examine whether empowerment mediated the relationship between health literacy and pregnancy self‐care. Health literacy was positively associated with empowerment (B = 0.375, SE = 0.029, t = 12.77, p < 0.001), explaining 31.9% of the variance in empowerment (R 2 = 0.319). In turn, empowerment was positively associated with self‐care after controlling for health literacy (B = 1.109, SE = 0.113, t = 9.81, p < 0.001). The direct effect of health literacy on self‐care remained statistically significant (B = 0.836, SE = 0.075, t = 11.14, p < 0.001), indicating that women with higher health literacy demonstrated better self‐care behaviors during pregnancy.
Importantly, the indirect effect of health literacy on self‐care through empowerment was statistically significant (Effect = 0.416, Boot SE = 0.073, 95% Bootstrap CI: 0.280 to 0.570). Because the confidence interval did not include zero, empowerment was confirmed as a significant mediator. These findings indicate partial mediation, suggesting that health literacy improves pregnancy self‐care both directly and indirectly through enhancing women's empowerment (Figure 2). The corresponding total effect was B = 1.252. Thus, approximately 33.2% of the total effect of health literacy on pregnancy self‐care was transmitted through empowerment, highlighting the substantial contribution of empowerment as an explanatory mechanism linking health literacy to self‐care behaviors.
Figure 2.
Bootstrap mediation model (PROCESS Model 4; 5000 bootstrap samples). Direct effects represented by β in figure. Indirect effect (95% Boot CI) was 0.416 (0.280, 0.570) and total effect was 1.252.
4. Discussion
The present study revealed that a considerable proportion of pregnant women (41.43%) exhibited problematic health literacy, while 35.71% had sufficient health literacy and only 12% had excellent health literacy. Other studies conducted in Iran also reported that sufficient health literacy among pregnant women ranged from 45% to 70.4% [8, 9, 18]. This discrepancy may be attributed to differences in sociodemographic characteristics. In the international context, Vila Candel in Valencia, Spain, reported that 32.6% of pregnant women had problematic health literacy and 58% had sufficient health literacy [19]. Similarly, Elbarazi's study in the United Arab Emirates found lower rates of problematic (22.8%) health literacy, with 71.6% of women demonstrating sufficient health literacy [20]. These cross‐national differences likely stem from variations in healthcare systems, literacy levels, cultural norms and the availability of prenatal education. Overall, these findings underscore the need for targeted health literacy interventions tailored to the specific vulnerabilities of pregnant women, particularly in settings where problematic health literacy is highly prevalent.
Our study shows that higher education, employment, insurance coverage, and adequate income are strongly linked to better health literacy among pregnant women, consistent with prior researches [7, 8, 21, 22]. Women in the third trimester also demonstrated higher literacy, while those with a history of miscarriage had lower levels. Notably, attendance at childbirth preparation classes was associated with higher health literacy—though this contradicts another study's findings [8].
In our study, the mean health literacy score was 66.67 ± 13.57 (range: 20–96). Notably, the highest score was in “understanding” (71.51 ± 15.82), whereas the lowest was in “appraisal” (61.08 ± 15.49)—a pattern echoed by earlier work. For instance, Izadirad et al. reported a similar mean score (65.97 ± 17.49) [1]. Likewise, Tavananezhad et al. found a higher overall mean (80.03 ± 12.79), but with the same trend: understanding (88.52 ± 13.48), and appraisal (73.78 ± 17.52) [14]. This consistent finding across studies suggests that pregnant women are generally better at grasping basic health information than at critically evaluating it. Strengthening these higher‐order skills—especially the ability to appraise information from diverse sources—should be a priority for prenatal health literacy interventions.
Our study found a mean empowerment score of 76.26 ± 9.83, reflecting a moderate level among participants—a result consistent with Houshmandpour et al., who similarly reported moderate empowerment in pregnant women [10]. Among the empowerment dimensions, “self‐esteem” scored highest (18.99 ± 2.00) in our study—a finding consistent with Tavananezhad et al., who also reported self‐esteem as the top domain (19.50 ± 2.08) [14]. This pattern aligns with earlier work by Haji Pour et al. and Borghei et al., further reinforcing the robustness of our results [23, 24]. The prominence of self‐esteem may reflect positive psychological adaptation during pregnancy or the effectiveness of prenatal care in boosting women's confidence. However, the moderate overall empowerment score suggests that other domains still warrant targeted attention.
Our participants also reported a moderate level of self‐care behavior (mean: 118.45 ± 24.55), with “personal hygiene” scoring highest (48.32 ± 11.14) and “exercise and physical activity” scoring lowest (4.90 ± 2.30). This pattern mirrors global trends: physical activity during pregnancy is consistently suboptimal. However, findings vary—Rezaei et al. recorded higher self‐care scores (151.59 ± 26.79) in Iran [18], while Eltomy et al. reported optimal or fairly good self‐care in 85.6% of Egyptian women [25], contrasting with Kadar et al., who found 54.1% of Indonesian women had inadequate self‐care [26]. These discrepancies likely stem from differences in socioeconomic status, cultural norms, healthcare access, and prenatal education content across settings.
Multivariate linear regression showed that health literacy remained a significant predictor of empowerment among pregnant women, even after adjusting for sociodemographic and obstetric confounders. This highlights a robust, direct link between health literacy and maternal empowerment—beyond the influence of education, income or parity. Our findings align with Tavananezhad et al., who reported a positive association between health literacy and multiple empowerment dimensions, suggesting that educational interventions during pregnancy can strengthen women's inner resources [14]. Supporting this, a meta‐analysis of 27 Iranian studies found that adequate health literacy was significantly tied to self‐efficacy—the core component of empowerment [27]. Together, these results indicate that health literacy independently enhances empowerment, even after accounting for a wide range of background factors. This underscores the potential of health literacy‐focused interventions as effective tools for promoting empowerment and, in turn, improving maternal health. Accordingly, healthcare providers should prioritize assessing and strengthening health literacy as an integral part of prenatal care.
Regarding the other aim of the study, the relationship between health literacy and self‐care, multivariate linear regression identified health literacy as a significant positive predictor of self‐care during pregnancy—meaning women with higher health literacy engaged in better self‐care behaviors. This aligns with Rahimi et al. and Tira et al., who reported similar associations [15, 28]. Further supporting our findings, Izadirad et al. (2017) demonstrated a significant link between health literacy and prenatal care performance [1]. Interestingly, Sajjadi et al. found no such relationship [29].
Our multivariate regression analysis identified only two factors significantly associated with empowerment and self‐care: adequate family income (compared to inadequate income) and planned pregnancy. After adjustment, other variables—including maternal age, education, employment, gravidity, gestational age, miscarriage history, childbirth class attendance, and source of health information—lost their significance. This suggests that economic security and intentional pregnancy may be particularly powerful determinants of empowerment and self‐care, likely because they afford women greater control over their circumstances and access to resources that support autonomous decision‐making. Similar patterns have been reported in other studies [30, 31].
The results of the mediation analysis revealed that health literacy had a significant total effect on pregnancy self‐care (effect size = 1.252). Specifically, health literacy was positively associated with empowerment (effect size = 0.375), and empowerment, in turn, demonstrated a strong positive association with self‐care (effect size = 1.109). These findings indicate that empowerment serves as a mediating variable in the relationship between health literacy and self‐care during pregnancy. The mediation analysis provides evidence that empowerment represents an important psychological mechanism through which health literacy translates into improved self‐care behaviors. Approximately one‐third of the total effect of health literacy on self‐care was explained through empowerment. In other words, higher health literacy not only directly promotes better self‐care behaviors but also indirectly enhances self‐care by fostering greater empowerment. This dual pathway suggests that health literacy equips women with the knowledge and skills to take control of their health, which in turn strengthens their sense of self‐esteem and self‐efficacy—key components of empowerment—leading to more proactive self‐care practices.
4.1. Limitation
The findings of this study should be interpreted within the context of several limitations. First, due to the cross‐sectional nature of the study, we cannot infer causal relationships between health literacy, empowerment, and self‐care practices; future longitudinal or prospective research is warranted to elucidate the temporal dynamics of these associations. Second, while we adjusted for a range of sociodemographic factors, we could not fully account for all potential confounders, such as social support networks and specific cultural influences, which may impact the study outcomes. Additionally, the lack of center‐level identifiers precluded the assessment of potential clustering effects; therefore, we were unable to calculate the interclass correlation coefficient (ICC) or employ multilevel modeling to account for between‐center variability. Further studies addressing these methodological constraints are encouraged to provide a more comprehensive understanding of the complex interplay between health literacy, empowerment, and self‐care in diverse obstetric populations.
5. Conclusions
In conclusion, this study underscores the critical importance of health literacy as a determinant of women's empowerment and self‐care during pregnancy. The findings suggest that addressing health literacy can foster greater empowerment and improved self‐care behaviors, particularly through targeted interventions. To translate these findings into practice, prenatal care models should transition from passive information delivery to active, skill‐based education that specifically enhances women's ability to critically appraise health information. Notably, factors such as adequate family income and planned pregnancies were also identified as influential determinants, highlighting the multifaceted nature of empowerment and self‐care in maternal health. Consequently, healthcare providers should implement routine health literacy screening during early prenatal visits to identify high‐risk individuals, while clinicians should establish proactive referral pathways for women facing socioeconomic challenges, such as low income or unplanned pregnancies, to ensure holistic support. By integrating these operational strategies, healthcare systems and policymakers can move beyond generic guidance toward comprehensive, evidence‐based approaches that empower pregnant women to engage actively in their self‐care practices and optimize maternal and neonatal health outcomes.
Author Contributions
Zahra Rezaee: conceptualization, data collection, and drafting of the manuscript. Fatemeh Bakouei: project administration, study design, and final approval of the version to be published. Hajar Adib‐Rad: conceptualization and study design. Soraya Khafri: methodology, statistical analysis, and data interpretation. Farzaneh Khorsand: data collection.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author, Fatemeh Bakouei, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Supporting information
Supporting File
Acknowledgments
This study was supported by Babol University of Medical Sciences. The authors hereby thank the honorable Research Vice‐Chancellor of Babol University of Medical Sciences.
Data Availability Statement
The datasets that will generate and/or analyze during the current study are not publicly available, but are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supporting File
Data Availability Statement
The datasets that will generate and/or analyze during the current study are not publicly available, but are available from the corresponding author on reasonable request.