Pregnancy is one of the most sensitive and important periods in a woman’s life. The health and well-being of the mother directly affect the life of the fetus during this period [1]. Initiating prenatal care during the early stages of pregnancy will lead to early detection of most related complications and the prevention of problems that may occur in the mother and the infant, therefore improving the pregnancy and birth outcomes [2,3]. However, certain factors can prevent proper and timely care during pregnancy. One of these factors is an insufficient level of maternal health literacy (MHL) during pregnancy [3-5].

MHL refers to the skills (motivational, cognitive, and social) needed by a pregnant woman to obtain, understand, and apply the knowledge that she needs to protect and advance the health of herself and her baby [3]. In addition, MHL includes the skills to recognize dangerous symptoms during the pregnancy period, manage a healthy lifestyle and proper nutrition, focus on the realities of pregnancy, and learn birth and baby care skills [6]. Adequate MHL is essential for a pregnant woman so that she can effectively monitor her own health and make correct decisions regarding the baby’s health [4,5]. Studies have shown that high MHL results in better maternal and child health behaviors and outcomes, such as efforts to obtain health information, more effective use of prenatal care services, more effective and longer breastfeeding, efforts to find appropriate solutions to health problems, and decreased health-related expenditures [4-8].

Pregnant women with low MHL experience unplanned pregnancies more often, do not have timely prenatal tests performed, miss their appointments more often, experience postpartum depression more frequently, take fewer vitamin supplements, use more drugs, have difficulty managing the pregnancy period, have babies with lower birthweight and Apgar scores, experience more birth trauma, and are more likely to stop breastfeeding and using maternal milk in the first 6 months after birth [4-11].

The level of health literacy falls into four categories based on the index values obtained: 0–25, inadequate/poor; >25–33, problematic-limited health literacy/poor; >33–42, adequate health literacy/good; and >42–50, excellent health literacy [4,12]. Health literacy levels vary across countries. Some studies have reported the prevalence of MHL to vary between 10% and 45.5% [4,8-10]. According to the European Health Literacy Survey (2015), Bulgaria had the highest rate of inadequate health literacy (27%), while the Netherlands had the highest rate of excellent general health literacy (25%) [4]. A study from Iran found that only 18% to 24% of pregnant women had good health literacy, and 31% to 34% had poor health literacy [11]. The rates for inadequate, problematic, sufficient, and excellent health literacy rates in Turkiye have been reported to be 24.5%, 40.1%, 27.8%, and 7.6%, respectively [12].

A review of the MHL-related studies in Turkiye showed that MHL levels closely parallel general health literacy levels. Other studies revealed that approximately one-third of pregnant women have “inadequate or limited” health literacy levels [13-15]. Pregnant women with low MHL levels have been shown to have a poor understanding of prenatal care, use prenatal services less, gain less weight during pregnancy, pay less attention to their nutrition, know less about the danger signs during pregnancy, rely more on traditional health practices, and need more help during the birth and postnatal baby care process [13-16]. These results of low MHL significantly increase healthcare and treatment costs, negatively impacting the healthcare system in Turkiye.

Identifying current MHL levels is the first and most important step in increasing those levels and improving maternal and infant health. Increasing MHL will increase the patient’s efficacy in understanding and using health-related information and their ability to benefit from healthcare services. Increasing the healthcare literacy of pregnant women can be achieved by developing communication between healthcare professionals and these women. Providing healthcare training to pregnant women with low MHL levels will enable them to use and benefit from healthcare services, thus protecting the health of the mother and baby at the highest level [13-16]. The objectives of healthcare services should include determining and increasing the healthcare literacy of pregnant women.

There are several tools that measure general health knowledge [12,15,17-19]. However, using group or situation-specific scales, instead of those that measure general health information during pregnancy, will provide more valid and reliable results. There was no Turkish MHL scale at the time this study was started. The aim of the current study was to translate the Maternal Health Literacy Inventory in Pregnancy (MHELIP) scale [3], which is used to measure pregnant women’s MHL levels, and to determine its validity and reliability.

For research to yield healthy results, the validity and reliability of the scales used in the research are important factors. For this reason, we felt it was useful to explain in this paper how the reliability and validity of the scale were measured. Our study showed that our Turkish version of the MHELIP was a valid and reliable tool for use with pregnant women.

At the time of this study, there was no Turkish version of the MHELIP available to our knowledge. Thus, this study was conducted with permission from the developers Taheri et al. [3]. After data collection was completed for this study, the study by Abay et al. [29] was published, which translated the MHELIP and performed psychometric testing with data from 2021 to 2022. In this point, our work results were evaluated using the findings of both Taheri et al. [3] and Abay et al. [29]. After translation-reverse translation of the scale, content validity, construct validity, criterion validity, internal reliability, and test-retest reliability were established.

In this study, participants were slightly older (32.02±4.15 years) than those in the studies by Taheri et al. [3] (28.32±5.59 years) and Abay et al. [29] (29.24±5.77 years). In addition, the educational status of the women in this study (86.0% university and higher education) was higher than in the studies by Taheri et al. [3] (41.6% high school) and Abay et al. [29] (42.2% high school). When considering pregnancy status, 69.6% of the women in this study, 51.3% in Taheri et al.’s study [3], and 32.2% in Abay et al.’s study [29] were nulliparous. The rates of mean age, education level, and first pregnancy status were higher in our study, likely due to the fact that the hospital where our study was conducted was a private hospital. Our findings demonstrated that the MHELIP-TR scale can be used as a valid and reliable measurement tool to determine the level of health literacy in pregnant women of different ages, educational status, and number of pregnancies.

Content validity is the extent to which a measurement tool encompasses the content it is supposed to measure. Ten expert opinions were obtained in this study. The CVI score of all expressions in the scale was 0.99; therefore, no items were removed. Our results showed that the Turkish version of the MHELIP demonstrated construct validity. Taheri et al. [3], who developed the original scale, consulted 14 experts and obtained scope validity after extracting an item with a KMO value lower than .51. Abay et al. [29] used 16 experts in their study, and their scale had content validity ratios and a CVI >0.50; therefore, no items were removed.

A holistic scale should cover all dimensions of the concept [3]. In this study, the KMO value was .89 and the Bartlett value was B=7,857.79 (p<.001). These findings demonstrate the construct validity of the MHELIP-TR scale. The MHELIP items in the study by Abay et al. [29] had factor loadings of 0.57 to 0.92, also demonstrating construct validity. As for criterion-related validity, both this study and Abay et al.’s study [29] found significant correlation coefficients of moderate strength. In this study, the relationship between the MHELIP-TR and HSL-SF12 (r=.42, p<.005) was comparable to the correlation between the MHELIP and health literacy index (HLI) used in Abay’s study (r=.57, p<.001) [29]. In both studies, the higher the MHELIP score, the higher the HLS-SF12 and HLI scores, indicating that the Turkish version of the MHELIP was a reliable measurement tool. Given that the goodness of fit indicators was found to be at the levels of “good fit” and “excellent fit,” the MHELIP-TR was approved and the structure validity of the scale was ensured.

The Cronbach’s alpha of the MHELIP-TR was .94 in this study, which indicated excellent internal consistency. It was comparable to the Cronbach’s alpha values of Taheri et al.’s original scale (.94) [3] and Abay et al.’s version (.96) [29]. The subscales also had acceptable and desirable Cronbach’s alpha values, suggesting that the MHELIP-TR was a consistent measurement tool.

The original developer used the test-retest reliability method with a 2-week interval and reported appropriate stability for the scale (intraclass correlation coefficient=.96) [3]. Our study also included test-retest reliability, while it was not performed in Abay et al.’s study [29]. The analysis results revealed a high positive correlation between the measurements (p<.001) after a 15-day interval. The correlation was also found to be significantly positive for the total scale score (r=.73, p<.001).

The study had some limitations. First, the study was conducted at one private hospital based in the capital city of Turkiye. The pregnant women included in this study were highly educated and above the national average for 2022 (46.2% with primary and secondary education, 21.6% with university level or higher) [30]. Thus, the level of MHL may not be applicable to other samples of pregnant women and requires further study. Another limitation was that most of the pregnant women in our study were primiparous (69.6%); thus, the findings may not directly apply to nulliparous women.

In conclusion, the Turkish version of the MHELIP (consisting of 48 questions and four subdimensions) is a valid and reliable measure of MHL during pregnancy. Thus, health professionals can use this scale to identify MHL levels in the Turkish population. It can also contribute to helping patients identify and understand healthcare information, learn to use this information, and benefit from healthcare services. More studies, with larger samples of pregnant women, are needed to further evaluate health literacy using the MHELIP-TR scale.