This study aimed at assessing the level of maternal health literacy (MHL) and factors affecting it. In this study, health literacy was measured based on a pretested questionnaire developed from different pieces of literature. The mean literacy level of participants in the study was 23.85±2.87 with a minimum health literacy of 17 and a maximum of 33. More than half, 336 (53.5%)( 95%CI: 49.1, 58.1) of the study participants had a good MHL level or above the mean score. According to the findings, a significant number of pregnant women had poor MHL. Comparable pieces of literature were missing because this was the first study of its kind at the country level to measure MHL. By proxy, however, the level of MHL in the current study was lower than studies conducted in Iran, where 98.2% and 61.3% of pregnant women, respectively, had excellent and adequate MHL levels. This could be attributed to differences in respondents' educational status: in the current study, 48.9% of study participants had no formal education, whereas, in the Iranian study, 61% of study participants graduated from high school or higher. It could also be owing to differences in the study area, with the study in Iran being conducted among women from urban areas, where there is a greater likelihood of acquiring information through media and other sources. On the other hand, the finding was higher than another study conducted in brazil Iran in which 24.8% and 45.4% of the study participants had adequate health literacy[26, 39]. This could be attributed to differences in study participants and sample sizes, as one of the studies with a 24.8% was conducted among nulliparous women with a small sample size(185).
On the other hand, the finding was higher than other studies conducted in Brazil(20.4%) and Iran in which 24.8% and 45.4% of the study participants had adequate health literacy[41, 42]. This might be due to variation in the study participants and the sample size in which one of those studies with 24.8% was conducted among nulliparous women and with a relatively small sample size(n=185).
Level of education, frequency of ANC visits, Gravidity (number of pregnancies), Being a model household, and enrolment in the CBHI scheme were identified as significant predictors of MHL.
The results of the current study showed that health literacy had a direct relationship with education level. This means that, with an increase in education level, the mean score of the MHL and was in line with the results of studies conducted in Iran[38, 43–45], Brazil, and Taiwan. This could be because a woman with a higher educational level is more exposed to different sources of information and has better information access and comprehension skills[38, 47]. Furthermore, this could be explained by the assumption that education is one of the key factors that improve maternal autonomy in decision-making, leading to improved maternal health-seeking behavior and possibly increased MHL. This may strengthen the premise that years of schooling might be associated with a higher level of maternal health literacy. The findings suggest that pregnant women's educational levels play an important role in helping them in deciding when to commence prenatal visits, attend health educational sessions, and attend conferences organized by midwives and nurses. As a result, investing in women's education could be used as a mid-and long-term strategy to improve women's health literacy, and local governments should place a strong emphasis on achieving higher educational levels. In addition, as nearly half of the study participants had no formal education, health care providers (Health extension workers, nurses, and midwives) should urge them to participate in adult education or learning centers in their communities.
Respondents who got adequate ANC of four or more visits had significantly higher MHL scores (β:1.418; p<0.001), which was consistent with a study conducted in Brazil and Ghana, and Nigeria, which found that adequate ANC visits improve women's ability to retain, understand, and apply health messages[10, 34, 40, 49]. This could be because women who had more ANC visits had the opportunity to meet with health care providers and discuss maternal and newborn concerns during ANC visits, and all of those interventions could lead to a higher MHL.
The current study also revealed that a woman's number of pregnancies is positively associated with having adequate maternal health literacy, which is consistent with findings from a Ugandan and Kenya study that found that women with high pregnancy order had better maternal health literacy than women who were pregnant for the first time[51, 52]. This could be because a woman who has been pregnant several times had various ANC Visits in her previous pregnancies and could retain information from her experience, resulting in a high MHL. Furthermore, women with high pregnancy orders have a greater level of physical, psychological, social, and self-efficacy, implying they can effectively implement the health information provided to ensure better health outcomes for themselves and their children[52, 53]. Studies also indicate that primigravida women lack the knowledge and motivation to access, comprehend and use available health services for themselves and their children.
Women's enrolment status in community-based health insurance (CBHI) scheme was another predictor with a significant relationship to MHL level(β: 2.282; p<0.001). Persons who faced financial difficulties were known to experience major obstacles in navigating the health system and resulted in low health literacy. Despite a lack of data on the relationship between this variable and MHL, a study conducted in the United States (US) found that individuals who were not enrolled in a health insurance scheme had more difficulty finding providers and were more likely to delay or forego needed care, resulting in inadequate health literacy. This could be because once they were enrolled in the CBHI scheme, the agency covered all fees, so they don't have to worry about payment, which enhances their interaction and involvement with community health workers and health facilities. This could improve the chances of getting access, comprehending, and using health information.
Finally, the study revealed that there is an association between maternal health literacy and being a model household (β = 1.681, P< 0.001). This could be because community health workers devote more time to building capacity for those chosen to be model HHs through a 96-hour intensive training program that includes 30 hours on hygiene and environmental sanitation, 42 hours on family health care, and 24 hours on disease prevention and control. That model house should have completed at least 75% of the training, which may pave the way for accessing, comprehending, and practicing suggested health information throughout pregnancy, which tends to improve MHL. Thus, to improve the level of MHL in the current study area, continuous training and home visits for non-model households, as well as follow-up for existing model households, and strengthening the information, education, and communication package are needed.
There were both strengths and shortcomings of this study. There was insufficient evidence on the national level of MHL, and the current study's findings might be used as a reference point for improving maternal and child health at the local and policy levels through a variety of interventions. The lack of studies, particularly in developing countries and at the national level, makes it difficult to compare the study's findings. Because this was a cross-sectional study, no cause-and-effect relationship was reported. Finally, because the study relied on self-reports, there is a chance that social desirability bias was introduced. Even though respondents were given as much time as they needed for a good recall of long-term memory, questions were asked in a specific order, beginning with the present and working backward in time, the possibility of recall bias due to the time elapsed between the event and data collection time should be considered.