HL is an important challenge for public health. Low HL has various negative consequences for both individuals and for society as a whole [20,21,22]. Understanding HL in the context of pregnancy is important because it can influence how women deal with the greater need for health information associated with pregnancy and ANC [10].

In the present study, the majority of participants had limited HL (79.8%). There were no available data on the rate of low HL among Egyptian pregnant women as a whole. However, our result is similar to that of an Egyptian study of outpatient attendees at the El-Demerdash University Hospital, which reported a high prevalence of limited HL (81%) [17].

Likewise, the results found here resemble the prevalence of limited HL (66.1%) found among pregnant Turkish women [23]. Similarly, more than three-quarters of pregnant women showed low HL in Iran and Laos [24, 25].

This study identified a significant association between the age of a pregnant woman age and her HL level: younger women had lower HL. Young women are usually less experienced with health issues in general, which might explain this finding. This result is in agreement with results of some Iranian studies in which increased age was associated with higher HL level [26, 27]. By contrast, a study in Afghanistan showed that low HL was significantly higher among older women [28]. This discrepancy may be attributed to the historical context and the drastic changes that have recently taken place in Afghan women’s access to education. While girls were officially banned from schools in the 1990s, school attendance has increased considerably since 2001 [29].

The current study also showed that limited HL was more common among less educated women. People with lower educational attainment have difficulty understanding and using health information and instructions, which contributes to their low HL. Similarly, studies in Iran [24, 30, 31], Japan [32], and the UK [14] confirm this relationship. However, the fact of a high level of education does not always imply a high level of HL. HL involves steps apart from reading and writing, such as understanding complex information, being able to use technology, seeking information, and interpreting acquired knowledge. Other studies revealed that the HL level of Turkish pregnant women is not associated with their educational level [23, 33].

The current research revealed a significant association between women HL level and husband educational level where the risk of limited HL was higher with lower husband education. This relationship may lie in spouses’ role towards each other and educational effects that they achieve from one another. The high level of husband’s literacy increases mother’s awareness and trains her during the married life. Similar results were reported in Iran where the level of women HL got higher along with higher husband education [31, 34].

This study shows that limited HL was more common among housewives. Similar results were reported in Turkey and Afghanistan [23, 28]. In general, employment status logically implies superior socioeconomic level, accompanied by higher HL. On the other hand, a study in Iran found no significant differences between housewives and working women in relation to their HL level, which may be due to social differences between societies [34].

This study indicated a significant relationship between family income and women’s HL level, such that limited HL was more common among women who reported insufficient family income. This relationship can be explained by the limited accessibility of education and treatment services to those with a low salary and poor economic and social conditions. This finding is supported by research in Japan and Iran [32, 34], as well as by work in China [35].

This research found a higher proportion of limited HL among women who do not frequently use the Internet as a source for health information. That is, HL involves steps apart from reading and writing, and using the Internet helps people develop HL. This finding is in harmony with the report of Astantekin et al. that pregnant women’s HL score was lower among those who did not use the Internet for health-related research [33]. Similarly, another study in the UK reported that individuals with no access to the Internet were more likely to have low HL than those who had access [14].

This study found that limited HL is more common among women who either married or had their first child at young age. In fact, women with lower levels of education and lower incomes tend to marry and become pregnant at younger ages, neglecting the consequences of such practices. These results are in harmony with the findings of Guler et al. in Turkey [23].

This study identified a significant relationship between the HL level of pregnant women and pregnancy planning. It was found that limited HL was more common among women with unplanned pregnancies. Women with low HL tend to be unaware of the importance of contraceptive methods, resulting in higher rates of unplanned pregnancy. Similarly, it was reported in Afghanistan that most women with inadequate HL do not know how to prevent unwanted pregnancy [28]. However, the study conducted by Safaie et al. in Iran found no association between pregnancy planning and HL level of women [34]. This divergence can be explained by the high contraceptive prevalence rate (CPR) among Iranian married women (81%) and low unmet need for family planning (5%), which is far different from the figures for Egypt (61% for CPR and 12% for unmet need) [36].

The current study showed that limited HL was more prevalent among women with no history of abortion. It is expected that the experience of abortion may lead women to become more interested in gaining information about abortion and healthy pregnancy, as well as improving their HL. However, this finding is not consistent with the results of some Iranian studies that reported no significant association between abortion history and HL level; here, different social dimensions may play a role [24, 30].

This study revealed that the majority of participants who reported health problems during previous pregnancies had limited HL level. It is expected as those with low HL often find verbal and written health information difficult to comprehend and have a poorer chance of following health guidelines, therefore becoming be more susceptible to health problems. This result is consistent with what was reported in Nigeria, which found a significant association between maternal HL and healthy pregnancy [37]. Furthermore, another study in Iran indicated that low HL was related to low glycemic control in pregnant women [24].

Logistic regression analysis in this research showed that family income (unsatisfactory), educational attainment (lower than university education), and pregnancy planning (unplanned) were significant predictors of limited HL. These results are logical and could be explained by the fact that women with lower levels of education usually find verbal and written health information difficult to comprehend. In addition, they lack skill in making appropriate decisions regarding health issues, and they must deal with this challenge throughout their lives. Usually, women with low educational level have low access to adequate working opportunities, so they either become housewives or work in occupations with low salaries. In both conditions, women suffer from unsatisfactory incomes and lack sufficient financial means to have access to appropriate health services and may seek health advice from untrusted sources, which plays a vital role in shaping their HL. Moreover, women with a low level of HL tend to have limited knowledge of and access to appropriate contraception, as well as having a higher frequency of unplanned pregnancies.

Predictors for problematic HL were studied by Pirdehghan et al. in Iran, and it was found that academic education was a protective factor, while being a housewife was a risk factor. However, this study found that age was not a significant predictor for HL [24]. Another study, conducted in Thailand, reported family income and social support among the significant predictors for women’s HL, while age and educational level were not significant predictors [38].

This study identified the level of HL and its associated demographic and reproductive factors in pregnant women attending governmental health facilities, so its results cannot be generalized to the all pregnant women. Further studies are recommended to evaluate HL in women attending nongovernmental hospitals and clinics. Another limitation was that, due to the cross-sectional method applied, the research outcomes can only be described as associations, and causation could not be proven.