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Determinants of well-being in pregnancy: the impact of sociodemographic and obstetric variables and maternal health literacy, cross sectional study

BMC Pregnancy and Childbirth volume 25, Article number: 524 (2025) Cite this article

Abstract

Background

Maternal well-being is paramount in elevating maternal, fetal, and societal health. This study aimed to examine the impact of pregnant women’s sociodemographic and obstetric variables, as well as maternal health literacy, on well-being during pregnancy.

Methods

A cross-sectional study was conducted between April and October 2024 at a public hospital in a southeastern province of Türkiye. The study was completed with the participation of 456 pregnant women who met the inclusion criteria. Data were collected utilizing the “WHO-5 Well-Being Index”, the “Maternal Information Form,” and the “Maternal Health Literacy Inventory in Pregnancy (MHELIP)”. The statistical significance level was defined as p<0.05 for all analyses.

Results

The study identified maternal health literacy as the most significant predictor of well-being during pregnancy (β=0.320). Additionally, perceiving income as insufficient (B=-1.872), residing in urban centers (B=-1.708), and the presence of pregnancy-related risks (B=-2.145) were found to contribute substantially to diminished well-being during pregnancy (p<0.05).

Conclusion

This study found that maternal health literacy along with various maternal socio-demographic and obstetric variables are important determinants of well-being in pregnancy. These findings may provide essential insights to better comprehend the necessities for improving well-being during pregnancy, guiding policymakers and healthcare providers in developing targeted solutions. This understanding could also inform the adaptation of existing health and community services to create a health literacy-sensitive environment more likely to address the diverse health needs of pregnant women and mothers.

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Background

The enhancement of well-being during pregnancy is of paramount importance in elevating maternal, fetal, and even societal health [1]. Well-being, broadly conceptualized as an individual’s quality of life and current state [2], is a dynamic construct encompassing subjective, social, and psychological dimensions, as well as cognitive and emotional components [3]. Consequently, well-being constitutes an integral facet of health, defined not merely as the absence of disease or infirmity but as a state of complete physical, mental, and social well-being [4, 5]. The burgeoning literature on well-being [6], coupled with the explicit public [7, 8] and societal interest [9] in addressing subjective well-being, attests to the widespread recognition of its significance. Notwithstanding this acknowledgment, there is a notable paucity of studies evaluating well-being during pregnancy. Extant studies has predominantly focused on the impact of well-being on fetal development [10] and its associations with preterm labor risk [11], obesity [12,13,14], sleep quality [15], depression [12, 16], physical activity [17], and breastfeeding [18]. A limited number of studies have explored the efficacy of exercise [19], dietary [20], and psychological [21] interventions in augmenting maternal well-being. Even fewer studies have addressed well-being levels during pregnancy, proposing that certain factors during the COVID-19 pandemic [15, 22, 23], such as employment status, psychiatric illness [24], age, body mass index, and educational level [18], contribute to gestational well-being. However, a comprehensive examination of the impact of modifiable variables and maternal health literacy on antenatal well-being for each pregnant woman remains conspicuously absent from the literature.

The effective management of health during pregnancy and the adoption of salubrious lifestyle behaviors possess the potential to mitigate maternal mortality [25]. This assertion is substantiated by literature underscoring the association between unhealthy lifestyle behaviors and certain maternal factors with adverse neonatal and perinatal outcomes [26,27,28,29]. Maternal health literacy exemplifies the capacity of women to seek, comprehend, evaluate, and apply health information to maintain and enhance their health status during pregnancy [30]. This capacity empowers expectant mothers to manage both their own health and that of their fetus. Such empowerment can be achieved by establishing a healthier gestational lifestyle and implementing strategies to prevent potential complications during this period [31, 32]. Adequate maternal health literacy during pregnancy facilitates timely prenatal care, informed decision-making, and self-preparation for childbirth [33]. Conversely, insufficient maternal health literacy in pregnancy is known from the literature to potentially result in cesarean delivery, major perineal laceration, preterm birth, low birth weight, small-for-gestational-age newborns, macrosomia, and neonatal intensive care unit admission or readmission [34, 35].

For the enhancement of maternal-fetal-neonatal and child health, it is imperative to comprehensively understand the impact of modifiable variables—potentially present in every woman—and maternal health literacy during pregnancy on gestational well-being. The existing body of knowledge underscores the importance of evaluating the influence of sociodemographic and obstetric variables and maternal health literacy on the well-being of pregnant women. However, a thorough literature review reveals a conspicuous absence of such studies. The present study, which examines factors that may support the amelioration of well-being during pregnancy, is posited to have the potential to address a significantly prioritized issue in the literature. Consequently, this study endeavors to examine the effects of pregnant women’s sociodemographic and obstetric variables, as well as maternal health literacy, on well-being during pregnancy by addressing the following study question:

  1. 1.

    Can maternal socio-demographic and obstetric variables and maternal health literacy predict well-being in pregnancy?

Methods

This cross-sectional study was conducted between April and October 2024 at a public hospital in a southeastern province of Türkiye. The study population comprised pregnant women receiving routine antenatal care at the obstetrics and gynecology outpatient clinics of this public hospital. As the number of pregnant women seeking routine prenatal care at the public hospital where the study was conducted was unknown, the sample size was calculated using the formula for unknown population sample size [Formula: n=(p.q).t2/d2; where p represents prevalence; q, (1-p); t, (1-α/2); d, confidence interval width]. Accordingly, assuming a prevalence of 0.5% and a sampling error of 5%, it was determined that data obtained from a minimum of 385 pregnant women would be representative of the population. Anticipating the possibility of incomplete data collection forms from the pregnant women, 462 participants, representing a 20% increase from the calculated sample size, were initially included in the study. Data from six pregnant women who submitted incomplete forms were subsequently excluded from the sample. The study was ultimately completed with the participation of 456 pregnant women. Participants were included in the study when they met the inclusion criteria and voluntarily consented to participate. The inclusion criteria were as follows: (1) being ≥19 years of age, (2) having a single and healthy fetus (3) ability to speak and comprehend Turkish and capability to respond to the study questions, and (4) voluntary participation in the study. Exclusion criteria were (1) unable to understand and/or answer questions on the data collection forms due to sensory and/or cognitive difficulties.

Data collection

The study data were collected using the “WHO-5 Well-Being Index”, the “Maternal Information Form” and the “Maternal Health Literacy Inventory in Pregnancy (MHELIP)”.

Data collection tools

World health organization well-being index (WHO-5)

This index was initially developed in 1998 as part of the DepCare project for primary care settings [36]. The Turkish validity and reliability study was conducted by Eser et al. in 1999. The index, comprising five self-rated statements, assesses subjective well-being over the preceding two-week period. It is scored on a scale from “0- at no time” to “5- all the time.” The raw score ranges from 0 to 25, with “0” representing the worst possible quality of life and “25” representing the best possible quality of life. In the Turkish validity and reliability study, Cronbach’s Alpha value was found to be 0.81 [37]. In the present study, it was determined to be 0.82.

Maternal information form

This form was prepared by the researcher based on extant literature [38,39,40,41]. It comprised 13 questions, addressing sociodemographic (7 questions) and obstetric (6 questions) variables of the pregnant women.

The maternal health literacy inventory in pregnancy (MHELIP)

Originally developed by Taheri et al. in 2020 [39], the Turkish validity and reliability of this scale were established by Abay et al. in 2023 [41]. This five-point Likert-type scale, which evaluates pregnancy-related health information and functional health literacy, consists of 48 items. The scale is composed of four sub-dimensions: “(1) Maternal Health Knowledge,” “(2) Search for Maternal Health Information,” “(3) Assessment of Maternal Health Information,” and “(4) Maternal Health Decision Making and Behavior.” Raw scores are initially determined to calculate the total scale and individual sub-dimension scores. Subsequently, these raw scores are transformed into a score ranging from 0–100 using a formula [Score = (raw score - the minimum possible raw score)/(maximum possible raw score - the minimum possible raw score) x 100]. The scores obtained from the scale are categorized into four levels: (1) Inadequate: 0–50 points, (2) Problematic: 50.1–66 points, (3) Adequate: 66.1–84 points, (4) Excellent: 84.1–100 points. The inadequate and problematic categories denote limited health literacy, while the adequate and excellent categories represent desired health literacy. In the Turkish validity and reliability study, Cronbach’s Alpha values for the sub-dimensions ranged from 0.86 to 0.96, with a total value of 0.96 [41]. In the present study, the Cronbach’s Alpha value for the entire scale was calculated as 0.95.

Data collection procedure

After elucidating the study’s purpose, scope, ethical considerations, and potential benefits to pregnant women, the study process commenced with participants who provided informed consent by signing the voluntary participation form. The self-reported forms were administered through face-to-face interviews with each pregnant woman, with completion time averaging approximately 10–15 minutes.

Data analysis

This study utilized SPSS software (IBM Corp., Armonk, NY, v. 24.0). Prior to analysis, the normality of data distribution was assessed using the Kolmogorov-Smirnov test and histogram graphs. Descriptive statistics were presented as numbers, percentages, arithmetic means, standard deviations, and minimum-maximum values. Based on the histogram graph and the Central Limit Theorem, which posits that the distribution tends to normalize as the sample size approaches 30 per cell [42], parametric tests were employed to compare pregnant women’s MHELIP and WHO-5 scores with independent variables. Independent sample t-tests were used for comparisons between two independent groups, while one-way analysis of variance (ANOVA) tests were utilized for comparisons among three or more independent groups. Pearson correlation analysis was employed to determine the relationship between two continuous variables. Depending on the homogeneity of variances, Tukey or Tamhane’s T2 post-hoc tests were utilized for pairwise comparisons among three or more groups with statistically significant different variables. Multiple linear regression (Stepwise) analysis was conducted to determine the impact of sociodemographic and obstetric variables and maternal health literacy scores during pregnancy on well-being. All independent variables were included in the regression model to identify predictors of well-being for all participating pregnant women. Throughout all analyses, statistical significance was defined as p<0.05 at a 95% confidence interval.

Results

Table 1 presents the sociodemographic and obstetric variables distribution among pregnant women. The mean age of the pregnant women was 26.60±5.40 years, with a mean pre-pregnancy body mass index of 28.29±4.90 and an average gestational weight gain of 8.02±5.87 kg. The majority of participants reported having completed senior high school education (36.8%), being unemployed (89.9%), perceiving their income level as adequate (77.4%), residing in urban centers (74.8%), and belonging to nuclear families (86.8%). The mean gestational week and number of pregnancies were 29.48±9.27 and 2.32±1.26, respectively. More than half of the participants (64.7%) were multigravida and had planned their current pregnancy (63.6%). The vast majority of pregnant women (95.0%) reported no pregnancy-related risks (Table 1).

Table 1 Distribution of sociodemographic and obstetric variables of pregnant women (n=456)
Full size table

Table 2 indicates the association between sociodemographic and obstetric variables of pregnant women and MHELIP and WHO-5 scores. The findings of the study indicated that pregnant women who held a university or master’s degree, were employed, and lived in a nuclear family structure had significantly higher MHELIP scores (p<0.01). In contrast, no statistically significant relationship was found between MHELIP scores and variables such as age, pre-pregnancy BMI, gestational weight gain, gestational week, perceived income level, current place of residence, number of pregnancies, pregnancy planning status, and the presence of risk in pregnancy (p>0.05). A weak, negative correlation was identified between pre-pregnancy body mass index and WHO-5 scores (p=0.039). Significantly higher WHO-5 scores were observed among women who had completed university or postgraduate education, were employed, perceived their income level as adequate, lived outside urban centers, and had no pregnancy-related risks (p<0.01). No statistically significant associations were found between WHO-5 scores and age, gestational weight gain, family type, gestational week, number of pregnancies, or pregnancy planning status (p>0.05) (Table 2).

Table 2 Distribution of sociodemographic and obstetric variables of pregnant women association with MHELIPb and WHO-5c scores (n=456)
Full size table

Table 3 illustrates the distribution of maternal health literacy scores during pregnancy and their relationship with WHO-5 scores. The mean scores for maternal health knowledge, search for maternal health information, assessment of maternal health information, and maternal health decision making and behavior sub-dimensions, as well as the total score, were 69.01±18.29, 63.63±19.55, 70.03±21.18, 78.24±16.48, and 71.35±15.58, respectively, indicating that health literacy levels ranged from limited to adequate. Weak, positive correlations were identified between WHO-5 scores and the sub-dimensions of research for maternal health information, assessment of maternal health information, and maternal health decision making and behavior. A moderate, positive correlation was observed between WHO-5 scores and both the maternal health knowledge sub-dimension and the total maternal health literacy score (p<0.001) (Table 3).

Table 3 Distribution of maternal health literacy scores among pregnant women and their correlation with WHO-5 scores (n=456)
Full size table

Table 4 presents multiple linear regression analysis results examining the impact of sociodemographic and obstetric variables and maternal health literacy on well-being during pregnancy. In the presence of all variables, maternal health literacy during pregnancy was identified as the most significant predictor of pregnant women’s well-being (β=0.320). The well-being of pregnant women was found to decrease by approximately 2 points in the presence of diagnosed risks in the current pregnancy (B=−2.145, p=0.045), perceived inadequate income level (B=−1.872, p=0.001), and urban residence (B=−1.708, p=0.001). Conversely, maternal health literacy during pregnancy was associated with an increase of approximately 0.2 point in well-being scores (B=0.110, p<0.001) (Table 4).

Table 4 Impact of sociodemographic and obstetric variables and maternal health literacy on the well-being of pregnant women (n=456)
Full size table

Discussion

It is well-established that adherence to healthy lifestyle behaviors during pregnancy and the amelioration of modifiable maternal factors play a crucial role in preventing adverse neonatal and perinatal outcomes [26,27,28,29]. Identifying the factors influencing well-being during pregnancy, an essential aspect of targeted maternal, fetal, neonatal, and community health, is crucial for developing effective strategies in this area.

This study, conducted to determine the impact of maternal variables and health literacy on well-being during pregnancy, found that completing university or higher education, working, and having a nuclear family structure were important factors for maternal health literacy during pregnancy. However, the study revealed that factors such as age, pre-pregnancy BMI, gestational weight gain, gestational week, perception of income level, current place of residence, number of pregnancies, pregnancy planning status, and presence of risk in pregnancy did not significantly contribute to maternal health literacy during pregnancy. A recently published conceptual analysis study on this topic indicated that maternal health literacy is influenced by numerous individual and situational factors, including variables such as age, education level, gestational age, parity, employment status, household income, place of residence, previous birth management, media exposure, and social support [1]. Several studies have suggested that culture and language spoken are factors that negatively affect maternal health literacy in pregnancy [43, 44]. One study found that antenatal education intervention improved maternal health literacy in pregnancy [45]. However, another study revealed that while pregnant women reported understanding general health information provided by healthcare professionals, they encountered challenges in translating this knowledge into specific, healthy behaviors [46]. The current results align with some of the findings of this study, but differ from others. The evidence suggests a link between low maternal health literacy during pregnancy and adverse maternal-fetal-neonatal health outcomes [34, 35]. It is imperative to enhance of maternal health literacy among pregnant women to facilitate access to antenatal care, promote healthy pregnancies, and manage high-risk pregnancies [1]. These results suggest the need for further examination of factors contributing to maternal health literacy in pregnancy. Concurrently, these findings hold the potential to inform the development of a roadmap for targeted interventions, thereby highlighting the challenges faced by diverse demographic groups in health literacy during pregnancy.

This study pre-gestational weight, the highest level of education attained, engagement in income-generating employment, perception of adequate income, residence outside urban centers, and absence of pregnancy-related risks were significantly associated with gestational well-being. However, regression analysis revealed that the determinants of well-being during pregnancy were the perception of adequate income, current residence outside urban centers, and the absence of pregnancy-related risks. These variables contributed to higher well-being in pregnancy. One study reported that financial distress was associated with the mental health of pregnant women [47]. Another study found that low family income and employment status increased anxiety among pregnant women [22]. Another study identified a correlation between better economic status and better well-being during pregnancy [48]. A systematic review and meta-analysis reported an association between low-income levels and the mental health of pregnant women [49]. Another systematic review determined that the current place of residence elevates individuals’ mental health and well-being, life satisfaction, quality of life, subjective health, and cognitive function [50]. A recently published study proposed that the well-being of high-risk pregnant women has physical, mental-emotional, social, and mental dimensions and reported that perceived threat is significant for well-being [51]. These existing studies support the present study findings, which aimed to identify determinants of well-being during pregnancy. Since there is limited research in the literature examining the relationship between place of residence and the presence of risk during pregnancy and maternal well-being, it was unable to make a comprehensive comparison for these variables. These results of the study represent an original contribution to the existing body of literature. Furthermore, this study has underscored the importance of carefully evaluating sociodemographic and obstetric variables to enhance well-being during pregnancy.

In the present study, maternal health literacy levels among pregnant women were determined to be either limited or adequate. The highest scores in maternal health literacy were observed in the domain of maternal health decision making and behavior, while the lowest scores were found in search for maternal health information. Furthermore, all sub-domains and the total health literacy score during pregnancy were positively correlated with well-being. Critically, maternal health literacy emerged as the most significant determinant of well-being during pregnancy. A limited number of studies report that pregnant women demonstrate the lowest performance in accessing health information and the highest performance in maternal health decision making and behavior [39]. An existing study suggests that maternal health literacy among pregnant women is adequate [52], while another posits that it is insufficient [53]. A systematic review on health literacy in pregnant women reported that limited health literacy ranged from 6.8% to 85%, while adequate health literacy varied between 15% and 91.5% [54]. Study findings on health literacy among pregnant women present conflicting results. The outcome of the current study aligns with some previous studies [39, 52] while contradicting another [53]. Moreover, the findings in this area are limited, indicating a need for further study to determine priorities for intervention to enhance maternal health literacy during pregnancy. Furthermore, a comparative analysis of the results obtained in this context could not be performed due to the absence of studies examining the relationship between maternal health literacy and well-being during pregnancy. However, one study associated health literacy with the empowerment of women during pregnancy [55]. The World Health Organization also recommends health literacy education and promotion for women as a fundamental component of maternal health improvement programs to achieve a sustainable future, regulate policies and laws, and raise awareness on this issue [56]. In light of this information, the findings of this study regarding maternal health literacy and its sub-domains during pregnancy have contributed novel insights to the literature. Notably, this study has revealed the significance of maternal health literacy in enhancing well-being throughout the gestational period.

Strengths and limitations

This study is significant in providing important data regarding the impact of maternal health literacy and various sociodemographic and obstetric variables on well-being during pregnancy. Another strength of this study is that it provides a unique contribution to the literature by examining well-being during pregnancy together with maternal socio-demographic and obstetric variables and maternal health literacy. The study provides important data in the context of social inequalities by analyzing the effects of socio-demographic and obstetric differences on maternal well-being. This research has the potential to guide future intervention and education programs in terms of its results revealing the impact of maternal health literacy on well-being during pregnancy. In addition, a large and diverse sample group was reached. This increases the generalizability of the findings of the study. Moreover, collecting data with valid and reliable scales strengthened the methodological soundness of the study. On the other hand, the fact that it is based on data from a clinical sample facilitates the evaluation of the findings in terms of practical applications. However, the interpretation of the study’s findings must be contextualized within certain limitations. Primarily, due to its cross-sectional design, causal relationships between the observed results and their potential antecedents cannot be established. An additional limitation is the study’s confinement to a single center in one Turkish city, conducted within specific inclusion and exclusion criteria. Consequently, the generalizability of the study findings is limited to pregnant women who align with the methodological scope of the study.

Conclusions

This study has identified maternal health literacy as the most significant determinant of well-being during pregnancy. Moreover, certain maternal sociodemographic and obstetric variables commonly encountered among pregnant women, such as perceived low-income levels, residence outside urban centers, and the presence of pregnancy-related risks, were found to be predictive of gestational well-being. Low health literacy can worsen maternal-fetal-neonatal health outcomes. Implementing interventions aimed at improving maternal health literacy during pregnancy can reduce health inequalities in maternal and neonatal outcomes. The findings of this study may provide healthcare professionals with opportunities to offer effective support in developing maternal health literacy during antenatal care. Furthermore, conducting quantitative and qualitative studies with the objective of enhancing maternal health literacy during pregnancy, while accounting for maternal variables, has the potential to broaden the existing body of literature and offer more comprehensive insights on this subject. Exploring the various maternal and situational variables that contribute to maternal health literacy during pregnancy may facilitate the development of a clear pathway to improve maternal well-being. Repeated, regular and ongoing education and counseling of nurses, midwives and obstetricians about maternal health literacy in pregnancy for women of reproductive age can improve maternal well-being in pregnancy. To obtain evidence-based data, update pregnancy care protocols, and facilitate systematic reviews and meta-analyses, it is advised to conduct randomized controlled trials in different populations and cultures aiming to improve maternal health literacy and well-being in pregnancy.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The author would like to thank all pregnant women who participated in the study.

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

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  1. Nursing Department, Faculty of Health Sciences, Kahramanmaraş İstiklal University, Karacasu Campus, Dulkadiroğlu, Kahramanmaraş, 46100, Türkiye

    Pınar Kara

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Author contributed to the study conception and design. Material preparation, data collection and analysis were performed by PK. The first draft of the manuscript was written by PK and author commented on previous versions of the manuscript. Author read and approved the final manuscript.

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Correspondence to Pınar Kara.

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The principles of the Declaration of Helsinki were adhered to throughout the study process. The study commenced after obtaining ethical committee approval from Kahramanmaraş İstiklal University (number: 2024/04-04, date: February 23, 2024) and permission from the Provincial Health Directorate for the institution where the study was to be conducted. Pregnant women were informed of their right to withdraw from the study at any time. Verbal and written informed consent was obtained from each participant.

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The authors declare no competing interests.

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Kara, P. Determinants of well-being in pregnancy: the impact of sociodemographic and obstetric variables and maternal health literacy, cross sectional study. BMC Pregnancy Childbirth 25, 524 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07654-5

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BMC Pregnancy and Childbirth

ISSN: 1471-2393

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