Maternal Health Literacy, Antenatal Care Engagement, and Wellbeing Among Pregnant Women in Jordan: A Cross-Sectional Study

Maternal Health Literacy, Antenatal Care Engagement, and Wellbeing Among Pregnant Women in Jordan: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Maternal Health Literacy, Antenatal Care Engagement, and Wellbeing Among Pregnant Women in Jordan: A Cross-Sectional Study Eman Alqadi, Arwa Oweis This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9193979/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Maternal health literacy influences women’s engagement with antenatal care (ANC) and wellbeing during pregnancy. In Jordan, gaps persist between service availability and meaningful utilization. These findings highlight the need for literacy-sensitive interventions tailored to Jordan's sociocultural context, where family influence and public sector structures strongly shape maternal experiences. Aim: To examine the relationship between maternal health literacy, ANC engagement, and maternal emotional wellbeing among Jordanian pregnant women. Methods: A correlational cross‑sectional study was conducted among 140 pregnant women attending governmental primary healthcare centers in four Jordanian governorates. Maternal health literacy was measured using the Maternal Health Literacy Inventory in Pregnancy (MHELIP), ANC engagement through utilization indicators, and maternal wellbeing using the Wellbeing in Pregnancy (WiP) scale. Data were analyzed using descriptive statistics, Pearson correlation, and multiple linear regression. Results: Overall maternal health literacy was moderate, with higher scores in health‑related decision making (80%) and lower scores in knowledge (54%) and information‑seeking (57%). Barriers to literacy were high (77%). ANC engagement was significantly predicted by household income, maternal and paternal education, and maternal employment, explaining 23.2% of the variance. Maternal wellbeing was positively correlated with the number of ANC visits (r = 0.312, p = .001). Conclusion: Maternal health literacy, socioeconomic factors, and emotional wellbeing are closely linked to ANC engagement. Addressing literacy gaps, structural barriers, and emotional support within ANC services may improve maternal health outcomes in Jordan. maternal health literacy antenatal care maternal wellbeing socioeconomic factors Jordan 1. Introduction Health literacy has emerged as a central determinant of maternal and reproductive health, shaping women’s capacity to access, understand, appraise, and apply health information across the continuum of pregnancy and childbirth (Sørensen et al., 2021 ; Nutbeam, 2008 ). Within maternal health contexts, adequate literacy allows women to interpret antenatal recommendations, recognize warning signs, navigate appointment systems, and adhere to preventive strategies, whereas limited literacy constrains autonomy and compromises care utilization (Paasche-Orlow & Wolf, 2007; Guler et al., 2021 ). In Jordan, these challenges are compounded by cultural expectations and family dynamics, which often determine whether women can act on the information they receive (Hijazi et al., 2018 ). Global evidence consistently links health literacy with antenatal care (ANC) engagement, demonstrating that women with higher literacy levels initiate care earlier, attend more visits, and demonstrate better understanding of pregnancy-related advice (Downer et al., 2020 ). In Turkey and Afghanistan, insufficient health literacy has been associated with delayed ANC initiation, reduced service utilization, and limited comprehension of maternal health information, even in settings where services are available (Guler et al., 2021 ; Harsch et al., 2021 ). Beyond service attendance, maternal health literacy is strongly associated with positive maternal behaviors, including nutritional adherence, supplementation compliance, birth preparedness, and informed decision making during pregnancy (Tavananezhad et al., 2022; Zibellini et al., 2020 ). Studies further show that women with stronger literacy skills report greater empowerment, higher self-efficacy, and more active participation in healthcare encounters, reinforcing the behavioral pathways proposed in established health literacy models (Tavananezhad et al., 2022; Paasche-Orlow & Wolf, 2007). Importantly, health literacy also influences maternal wellbeing, as limited ability to interpret health information has been associated with heightened anxiety, depressive symptoms, and psychological distress during pregnancy (Nawabi et al., 2021 ; Basu et al., 2021 ). Systematic reviews have confirmed that inadequate health literacy is linked to poorer mental health outcomes, reduced coping capacity, and diminished confidence in navigating health systems, particularly among socioeconomically disadvantaged populations (Nawabi et al., 2021 ; Stormacq et al., 2023). The COVID-19 pandemic further amplified maternal mental health vulnerabilities worldwide, with pregnant women reporting elevated levels of stress, uncertainty, and reduced access to support services, while those with stronger literacy demonstrated greater resilience and adaptability (Basu et al., 2021 ; Thibaut & van Wijngaarden-Cremers, 2020). These findings underscore the interconnectedness of informational access, healthcare engagement, and emotional wellbeing in pregnancy (Bergunde et al., 2022 ; Jagtap et al., 2023 ). Despite this global recognition, evidence examining health literacy as a multidimensional determinant of ANC engagement and maternal wellbeing remains uneven across regions, particularly in Middle Eastern contexts (Ningrum et al., 2024; Salameh et al., 2024 ). While global studies emphasize literacy as a determinant of care, its manifestation varies across regions. Understanding how these dynamics unfold in Jordan requires attention to both structural health system factors and sociocultural norms. In Jordan, maternal healthcare coverage is relatively high, and governmental primary healthcare centers provide widespread access to ANC services; however, disparities persist in the quality, continuity, and meaningful engagement with these services (Hijazi et al., 2018 ; Hussein et al., 2020 ). Research from northern Jordan indicates that socioeconomic disadvantage, limited education, and suboptimal provider patient communication significantly affects ANC attendance and women’s understanding of maternal health information (Hijazi et al., 2018 ). Although service availability has improved, evidence suggests that attendance alone does not guarantee comprehension, empowerment, or positive pregnancy experiences, highlighting the distinction between access and effective engagement (AlModallal et al., 2014 ; Salameh et al., 2024 ). Moreover, Jordanian studies have primarily focused on sociodemographic predictors of ANC utilization rather than examining health literacy as an explanatory construct linking knowledge, engagement, and wellbeing (Hijazi et al., 2018 ; Al-Shdaifat et al., 2021). Limited research has integrated maternal health literacy, ANC engagement, and maternal wellbeing within a single conceptual framework, leaving a gap in understanding how informational competencies translate into behavioral and psychological outcomes during pregnancy (Oweis et al., 2020; Salameh et al., 2024 ). Given global findings that literacy influences both service utilization and mental health, the absence of context-specific evidence in Jordan restricts the development of culturally tailored interventions that address informational, structural, and psychosocial barriers simultaneously (Nawabi et al., 2021 ; Ningrum et al., 2024). Furthermore, the socioeconomic diversity across Jordanian governorates, combined with educational inequalities and evolving healthcare delivery systems, necessitates localized investigation to identify determinants of effective ANC engagement and maternal wellbeing (Hijazi et al., 2018 ; Hussein et al., 2020 ). While international research highlights the protective role of health literacy in strengthening ANC adherence and emotional resilience, these associations may manifest differently within Jordan’s sociocultural and health system context, where family influence, gender norms, and public sector service delivery shape maternal experiences (Tavananezhad et al., 2022). Therefore, there is a critical need for empirical research that simultaneously examines maternal health literacy, antenatal engagement, and wellbeing among Jordanian pregnant women using validated instruments and theoretically grounded models (Wilson & Cleary, 1995). Generating such evidence will inform literacy-sensitive maternal health strategies, support policy efforts aligned with global maternal health goals, and contribute to reducing inequities in maternal outcomes within Jordan and comparable middle-income settings (Sørensen et al., 2021 ; WHO, 2022 ). 2. Aim of the Study To examine the relationship between maternal health literacy, antenatal care engagement, and maternal wellbeing among pregnant women attending governmental primary healthcare centers in Jordan. 3. Methods 3.1. Study Design This study employed a correlational cross-sectional design to examine the relationships between maternal health literacy, ANC engagement, and maternal wellbeing among pregnant women in Jordan. A cross-sectional approach involves collecting data at a single point in time, allowing for the assessment of existing levels of variables and their interrelationships within a defined population (Sharma, 2022 ). However, reliance on convenience sampling may limit 3.2. Settings The study was conducted in selected governmental primary healthcare centers located across four major governorates in Jordan: Amman, Al Balqa, Madaba, and Al Zarqa. These centers provide comprehensive antenatal care services, including routine pregnancy monitoring, health education, laboratory investigations, and maternal counseling. The selected governorates represent both urban and rural populations, ensuring socioeconomic and cultural diversity within the sample. 3.3. Population and Sample The target population comprised pregnant women in Jordan, while the accessible population included pregnant women attending antenatal care clinics at the selected primary healthcare centers during the data collection period. Eligible participants were women aged 18 years or older, in any trimester of pregnancy, able to communicate in Arabic, and willing to provide informed consent. Women were excluded if they had documented severe psychiatric illness (e.g., psychosis), high-risk pregnancies requiring specialized tertiary care, or cognitive or language barriers preventing questionnaire completion. A convenience sampling technique was used to recruit pregnant women who were readily available and met the eligibility criteria in antenatal care settings (Golzar et al., 2022 ). This method is practical and feasible in clinical environments and aligns with the study’s descriptive correlational design, which aims to explore associations rather than establish causation (Etikan et al., 2016 ). Although it may limit generalizability, it is appropriate for cross-sectional studies examining relationships within accessible healthcare populations (Stratton, 2021 ). 170 pregnant women who met the inclusion criteria were recruited from selected centers across four Jordanian governorates. After data collection, questionnaires were reviewed for completeness and accuracy. Thirty questionnaires were excluded due to substantial missing data in key variables, including maternal health literacy, antenatal care utilization indicators, or maternal wellbeing measures. Therefore, the final analytical sample consisted of 140 pregnant women. The final sample size was sufficient to detect moderate associations between study variables and was consistent with the sample size estimated using G*Power for correlational and multiple regression analyses (Kang, 2021 ). 3.4. Instruments 3.4.1. Sociodemographic and Obstetric Questionnaire 3.4.2. Antenatal Care Utilization Questionnaire ANC engagement was assessed using a structured questionnaire based on World Health Organization (WHO) antenatal care indicators. The instrument captured timing of the first ANC visit, total number of visits during the current pregnancy, type of healthcare provider, and services received (e.g., blood pressure measurement, laboratory tests, supplementation, vaccinations, and health education). These items were used to evaluate level of engagement rather than generate a single composite score. 3.4.3. Maternal Health Literacy Inventory in Pregnancy (MHELIP) Maternal health literacy was measured using the Maternal Health Literacy Inventory in Pregnancy (MHELIP), a 48-item instrument assessing four domains: maternal health knowledge, information search, skills in understanding health information, and health decision-making/behavior. Items are rated on Likert-type scales and frequency scales, and total and subscale scores are standardized to a 0–100 scale using the recommended scoring formula. Higher scores indicate higher levels of maternal health literacy. In the current study, the instrument demonstrated strong internal consistency, with a total Cronbach’s alpha of 0.89. 3.4.4. Wellbeing in Pregnancy (WiP) Questionnaire Maternal wellbeing was assessed using the 12-item Wellbeing in Pregnancy (WiP) questionnaire. The instrument measures three domains: positive pregnancy experience, confidence about motherhood, and concerns regarding support after birth. Responses are scored and transformed to a 0 − 100 scale, with higher scores indicating better wellbeing. In this study, the WiP demonstrated good reliability, with a total Cronbach’s alpha of 0.87. 3.5. Translation and Cultural Adaptation The MHELIP and WiP instruments were translated into Arabic using forward – backward translation procedures to ensure linguistic and conceptual equivalence (Ozolins et al., 2020 ). Two bilingual translators independently translated the instruments into Arabic, followed by back-translation into English by an independent translator blinded to the original versions. Discrepancies were resolved through consensus. An expert panel comprising maternal health and research methodology specialists reviewed the translated instruments for clarity, cultural relevance, and content validity. Content validity index (CVI) values were calculated, and pilot testing was conducted with a small group of pregnant women to assess clarity and feasibility. Internal consistency reliability was assessed using Cronbach’s alpha. 3.6. Data Collection Process Data were collected between using paper-based questionnaires administered during routine antenatal visits at the selected primary healthcare centers. Eligible women were approached by trained research assistants, informed about the study, and invited to participate. After providing written consent, participants completed the questionnaire in a private area within the clinic to ensure confidentiality. The average completion time was approximately 15–20 minutes. Completed questionnaires were placed in sealed envelopes and securely stored. 3.7. Ethical Considerations This study adhered to strict ethical guidelines to ensure the protection and dignity of participants. Ethical approval was obtained from the Institutional Review Boards (IRBs) of the MOH and the Institutional Review Board (IRB) of Jordan University of Science and Technology (IRB No.183 − 59). Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were informed of their right to withdraw at any time without affecting their care. Questionnaires were coded anonymously, and no identifying information was collected. A referral pathway was established for participants who exhibited signs of emotional distress during data collection, ensuring access to appropriate healthcare support if needed. 3.8. Statistical Analysis Data were analyzed using IBM SPSS version 26. Descriptive statistics, including means and standard deviations for continuous variables and frequencies and percentages for categorical variables, were used to summarize participant characteristics and scale scores. Internal consistency reliability was assessed using Cronbach’s alpha. Correlation analyses (Pearson or Spearman, as appropriate) were conducted to examine associations between maternal health literacy, ANC engagement, and wellbeing. Multiple linear regression analysis was performed to identify predictors of ANC utilization and maternal wellbeing. Statistical assumptions were evaluated, including normality, multicollinearity using variance inflation factor (VIF), and independence of residuals using the Durbin–Watson statistic. A two-tailed significance level of p < .05 was adopted for all analyses. 4. Results 4.1. Sociodemographic and Clinical Characteristics of Participants The sample (N = 140) had a mean age of 31.35 years (SD = 7.76) and an average monthly household income of 491.43 JD (SD = 100.58). On average, participants reported 3.21 pregnancies (SD = 1.91), 2.70 living children (SD = 1.94), and 0.51 previous abortions (SD = 0.79). Regarding educational and socioeconomic characteristics, 37.9% of women had no formal education, 44.3% were unemployed, and the majority were married (87.1%). These findings reflect a predominantly married sample with moderate reproductive history and notable socioeconomic vulnerability. The demographic characteristics of participants are presented (Table 1 here). Table 1 Key Sociodemographic and Clinical Characteristics of Participants (N = 140) Variable Mean ± SD or n (%) Age (years) 31.35 ± 7.76 Monthly income (JD) 491.43 ± 100.58 Total pregnancies 3.21 ± 1.91 Living children 2.70 ± 1.94 Abortions 0.51 ± 0.79 No formal maternal education 53 (37.9%) Unemployed mothers 62 (44.3%) Married 122 (87.1%) Note. SD = Standard deviation; JD = Jordanian Dinar. 4.2. Research Question 1: What are the levels of maternal health literacy among Jordanian pregnant women? Descriptive analysis of the Maternal Health Literacy Inventory in Pregnancy (MHELIP) revealed overall moderate levels of maternal health literacy among the participating women (N = 140). When raw scores were transformed to percentages to allow standardized comparison across domains, knowledge scored 54.09%, and use of information sources scored 57.44%, indicating modest levels of functional literacy. Skills in understanding health information reached 68.19%, reflecting moderate comprehension abilities, while health decision-making and behavior demonstrated the highest score at 80.00%, suggesting strong engagement in recommended maternal health practices. Notably, structural barriers to literacy were high (76.57%), indicating that many women faced considerable obstacles in accessing or utilizing health information and services. In contrast, enabling factors were comparatively low (68.03%), reflecting limited supportive resources within their environment. Categorization based on established cutoffs showed that most women fell within low to moderate categories for knowledge and information access, whereas decision-making was predominantly moderate to high. Overall, the findings indicate moderate maternal health literacy characterized by relatively strong behavioral engagement but constrained by high barriers and limited enablers. The maternal health literacy domain scores are presented (Table 2 here). Table 2 Descriptive Statistics and Percentage Scores for Maternal Health Literacy Domains (N = 140) Domain Mean (Raw) SD Percentage (%) Knowledge 56.79 18.44 54.09% Information Sources 15.51 6.10 57.44% Skills in Understanding 21.82 3.68 68.19% Health Decision-Making/Behavior 30.40 3.02 80.00% Barriers 33.69 3.83 76.57% Enablers 20.41 3.02 68.03% Note. Percentages were calculated using the formula (Mean ÷ Maximum Observed Score) × 100. 4.3. Research Question 2: What factors influence antenatal care engagement? Multiple linear regression analysis indicated that the overall model significantly predicted antenatal care (ANC) engagement, explaining 23% of the variance in ANC utilization (R² = 0.232, p < .001). Higher monthly income was associated with increased ANC engagement (β = 0.194, p = .006), indicating that women with greater financial resources attended more visits and utilized services more consistently. Maternal education demonstrated a graded positive effect, with secondary (β = 0.142, p = .005) and higher education (β = 0.166, p = .003) significantly predicting greater ANC engagement compared to no formal education. Similarly, paternal education was positively associated with ANC use, particularly at secondary (β = 0.109, p = .013) and higher levels (β = 0.132, p = .009). Maternal employment also contributed positively, with full-time (β = 0.111, p = .042) and part-time employment (β = 0.124, p = .028) increasing engagement. In contrast, widowhood was negatively associated with ANC utilization (β = − 0.096, p = .025), indicating reduced engagement among widowed women. Overall, socioeconomic and educational factors emerged as the strongest determinants of ANC participation. This may reflect both financial vulnerability and reduced social support, as widowed women often face barriers in accessing transportation and decision-making autonomy. The correlations between study variables are presented (Table 3 here). Table 3 Multiple Linear Regression Analysis Predicting Antenatal Care Engagement (N = 140) Predictor B β p-value Monthly Income (JD) 0.003 0.194 .006** Maternal Education – Primary 0.214 0.093 .043* Maternal Education – Secondary 0.318 0.142 .005** Maternal Education – Higher 0.402 0.166 .003** Maternal Employment – Full-time 0.261 0.111 .042* Maternal Employment – Part-time 0.309 0.124 .028* Paternal Education – Primary 0.119 0.071 .049* Paternal Education – Secondary 0.205 0.109 .013* Paternal Education – Higher 0.268 0.132 .009** Widowhood (vs. married) –0.318 –0.096 .025* Model Summary : R = 0.482; R² = 0.232; Adjusted R² = 0.198; F = 6.87; p < .001 *Note. β = Standardized coefficient. *p < .05; *p < .01. 4.4. Research Question 3: How is ANC engagement related to maternal wellbeing? Pearson correlation analysis demonstrated a statistically significant moderate positive relationship between antenatal care (ANC) engagement and maternal wellbeing (r = 0.312, p = .001). This finding indicates that women with higher wellbeing scores were more likely to attend a greater number of ANC visits. Conversely, lower levels of emotional wellbeing were associated with fewer ANC visits. The strength and direction of the correlation suggest that maternal psychological status is meaningfully linked to health-seeking behavior during pregnancy. The predictors of maternal wellbeing are presented (Table 4 here). Table 4 Pearson Correlation Between Antenatal Care Engagement and Maternal Wellbeing (N = 140) Variables 1 2 1. Maternal Wellbeing 1.000 0.312** 2. Number of ANC Visits 0.312** 1.000 Note. Pearson correlation coefficient (r) reported. p = .001. ** Correlation is significant at the 0.01 level (2-tailed). 5. Discussion The findings of this study highlight a complex pattern of maternal health literacy among Jordanian pregnant women, characterized by moderate overall literacy levels but relatively strong decision-making behaviors, a pattern that may be described as “doing without fully knowing” (Nutbeam, 2008; Sørensen et al., 2021). In practice, many Jordanian women reported following provider instructions faithfully, even when their understanding of the underlying rationale was limited. This pattern reflects reliance on trust in healthcare providers rather than independent appraisal of (Paasche-Orlow & Wolf, 2007; Nawabi et al., 2021). Similar patterns have been documented in Turkey, where pregnant women demonstrated insufficient knowledge of antenatal care despite regular service attendance (Guler et al., 2021). Comparable findings were also reported in Afghanistan, where limited maternal literacy was associated with gaps in understanding reproductive health information even when services were available (Harsch et al., 2021). Systematic reviews confirm that inadequate health literacy among pregnant women is widespread globally and frequently coexists with routine healthcare contact (Nawabi et al., 2021; Ningrum et al., 2024). The relatively strong scores in health decision-making and behavior observed in this study suggest that women may effectively apply provider instructions even when their conceptual understanding remains incomplete (Paasche-Orlow & Wolf, 2007; Tavananezhad et al., 2022). Tavananezhad et al. (2022) demonstrated that higher health literacy is positively correlated with empowerment and decision-making capacity during pregnancy. However, behavioral adherence may sometimes reflect trust in providers or cultural norms rather than independent critical appraisal of information (Nutbeam, 2008; Stormacq et al., 2023). The high barrier scores and comparatively lower enabler scores in this study indicate that structural and socioeconomic obstacles constrain women’s ability to fully exercise critical health literacy (Sørensen et al., 2021; Gelberg et al., 2000). Such constraints align with evidence suggesting that disadvantaged populations often rely heavily on provider guidance due to limited informational autonomy (Stormacq et al., 2023; Nawabi et al., 2021). The Paasche-Orlow and Wolf (2007) model further explains that health literacy influences outcomes through access, interaction, and self-management pathways, all of which may be restricted by structural barriers. Thus, maternal literacy in this context appears embedded within broader social determinants of health (Sørensen et al., 2021; Gelberg et al., 2000). The regression analysis identifying socioeconomic predictors of antenatal care engagement is consistent with Andersen’s Behavioral Model of Health Services Use, which emphasizes predisposing, enabling, and need factors as determinants of healthcare utilization (Gelberg et al., 2000). Education emerged as a significant enabling resource, reinforcing evidence that educational attainment enhances comprehension, confidence, and navigation skills within healthcare systems (Nutbeam, 2008; Guler et al., 2021). Higher maternal education has been consistently associated with improved ANC attendance in Jordan and other middle-income settings (Hijazi et al., 2018; Escañuela Sánchez et al., 2022). Paternal education also significantly predicted ANC engagement, underscoring the influence of household-level literacy and shared decision-making within sociocultural contexts (Hussein et al., 2020). Similar findings have been reported internationally, where partner involvement enhances maternal healthcare engagement (Escañuela Sánchez et al., 2022). Income and employment further function as enabling resources, facilitating transportation, service access, and healthcare affordability (Gelberg et al., 2000; Stormacq et al., 2023). The negative association between widowhood and ANC engagement reflects the vulnerability of women lacking spousal support, consistent with research showing that marital instability or absence of partner support reduces healthcare access and continuity (Steen & Francisco, 2019; Gelberg et al., 2000). In patriarchal or family-centered societies, husbands often facilitate financial and logistical access to care, making widowhood a potential risk factor for reduced service utilization (Hussein et al., 2020; Hijazi et al., 2018). Andersen’s model conceptualizes such factors as enabling resources that mediate access to care (Gelberg et al., 2000). From a quality-of-care perspective, Donabedian (1988) emphasizes that structural characteristics of healthcare systems, including social and economic support, influence health outcomes. Thus, ANC engagement in this study reflects not only individual literacy but also broader socioeconomic structures (Donabedian, 1988). The moderate positive correlation between ANC engagement and maternal wellbeing further underscores the interconnectedness of psychosocial and behavioral dimensions of maternal health (Wilson & Cleary, 1995; Ferrans et al., 2005). Women with higher wellbeing scores attended more ANC visits, suggesting that psychological stability may facilitate proactive health-seeking behavior (Basu et al., 2021; Steen & Francisco, 2019). Basu et al. (2021) documented that elevated stress during the COVID-19 pandemic was associated with reduced healthcare engagement among pregnant women. Steen and Francisco (2019) similarly emphasized that untreated maternal mental health problems impair service utilization and adherence. Conversely, consistent ANC visits provide reassurance, symptom clarification, and emotional validation, which may enhance wellbeing (Wilson & Cleary, 1995; Donabedian, 1988). The Wilson and Cleary (1995) model proposes that healthcare processes influence quality of life through symptom perception and functional health. Ferrans et al. (2005) further expanded this model, linking care processes directly to patient-reported wellbeing outcomes. 6. Implications and Recommendations 7. Strengths and Limitations This study possesses several notable strengths that enhance the credibility and contribution of its findings. First, the use of validated, pregnancy-specific instruments MHELIP and the WiP questionnaire strengthens the reliability and construct validity of the measurements. Both tools demonstrated strong internal consistency in the current sample, supporting the robustness of the collected data. Second, the study was guided by well-established theoretical frameworks linking health literacy, healthcare utilization, and wellbeing, which allowed for a comprehensive and conceptually integrated interpretation of the findings. This theoretical grounding strengthens the explanatory depth of the results and situates them within broader maternal health research. Third, the use of multivariate regression analysis enabled identification of independent predictors of antenatal care engagement while controlling for potential confounding variables, thereby enhancing the internal validity and analytical rigor of the study. Importantly, the research focuses on an understudied population Jordanian pregnant women within a regional context where limited empirical evidence exists integrating maternal health literacy, antenatal engagement, and wellbeing. By addressing this gap, the study contributes meaningful, context-specific insights relevant to both regional and global maternal health discussions. Despite these strengths, certain limitations should be acknowledged. The cross-sectional design restricts causal inference and does not allow conclusions regarding the directionality of relationships between literacy, engagement, and wellbeing. The use of convenience sampling from selected governmental primary healthcare centers may limit the generalizability of findings to all pregnant women in Jordan, particularly those in remote or private healthcare settings. Additionally, reliance on self-reported measures introduces the potential for recall bias or social desirability bias, especially in reporting health behaviors and emotional wellbeing. Finally, although the study included multiple governorates to enhance diversity, the geographic scope remains limited and may not fully capture regional variations across the country. Nonetheless, the methodological rigor, theoretical grounding, and focus on a previously underexplored population provide a strong foundation for future research and practice in maternal health literacy and antenatal care engagement. 8. Conclusion This study concludes that maternal health literacy among Jordanian pregnant women is generally moderate, yet significantly constrained by structural barriers that limit access to information and supportive resources. While many women demonstrated relatively strong decision-making behaviors during pregnancy, their knowledge levels and access to diverse information sources were less robust, indicating gaps in functional literacy despite behavioral adherence. Socioeconomic factors particularly maternal and paternal education, employment status, and household income emerged as key drivers of antenatal care (ANC) engagement, highlighting the critical role of enabling resources in facilitating consistent service utilization. Conversely, social vulnerability, such as widowhood, was associated with reduced engagement, underscoring the importance of household and relational support systems. Furthermore, maternal emotional wellbeing was positively associated with ANC attendance, suggesting that psychological health and healthcare utilization are interconnected and potentially mutually reinforcing. Together, these findings emphasize that improving maternal outcomes requires more than expanding service availability alone. Future strategies should integrate health literacy training into routine ANC visits, strengthen spousal and family involvement, and address structural barriers such as transportation and clinic accessibility. Literacy-sensitive communication within ANC, routine mental health screening, community-based educational initiatives, and targeted support for vulnerable women represent essential components of a comprehensive maternal health strategy. Addressing informational, emotional, and structural determinants in tandem is crucial to enhancing equitable and meaningful engagement with antenatal services in Jordan and similar middle-income settings. Declarations Funding: This research received no external funding. Data Availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Author Contributions: E.A. conceptualized the study, conducted data collection, performed data analysis, and drafted the manuscript. A.O. supervised the study, contributed to the study design, and critically revised the manuscript. All authors read and approved the final manuscript. Ethics Approval and Consent to Participate: Ethical approval was obtained from the Institutional Review Board (IRB) of Jordan University of Science and Technology. Written informed consent was obtained from all participants prior to data collection. Consent for Publication: Not applicable. 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Wellbeing in Pregnancy (WiP) Questionnaire: EnglishUK sample. https://innovation.ox.ac.uk/wpcontent/uploads/2023/11/WellbeinginPregnancyWiPEnglishUKFullSAMPLE.pdf Ozolins, U., Hale, S., Cheng, X., Hyatt, A., & Schofield, P. (2020). Translation and backtranslation methodology in health research–a critique. Expert review of pharmacoeconomics & outcomes research , 20 (1), 6977. PaascheOrlow, M. K., & Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes. American journal of health behavior , 31 (1), S19S26. Salameh, T., Bdair, R., & Mrayan, L. (2024). Jordanian Women’s Experiences of Natural Childbirth Using a MidwifeLed Care Unit: A Qualitative Study. Jordan Journal of Nursing Research , 1 , 11. Sharma, S. (2022). Nursing research and statisticsebook . Elsevier Health Sciences. Shee, A. W., Frawley, N., Robertson, C., McKenzie, A., Lodge, J., Versace, V., & Nagle, C. (2021). Accessing and engaging with antenatal care: an interview study of teenage women. BMC Pregnancy and Childbirth , 21 , 18. Simpson, N., Wepa, D., & Bria, K. (2020). Improving antenatal engagement for Aboriginal women in Australia: A scoping review. Midwifery , 91 , 102825. Sommer, J. L., Shamblaw, A., Mota, N., Reynolds, K., & ElGabalawy, R. (2021). Mental disorders during the perinatal period: Results from a nationally representative study. General hospital psychiatry , 73 , 7177. Sørensen, K., LevinZamir, D., Duong, T. V., Okan, O., Brasil, V. V., & Nutbeam, D. (2021). Building health literacy system capacity: a framework for health literate systems. Health promotion international , 36 (Supplement_1), i13i23. Steen, M., & Francisco, A. A. (2019). Maternal mental health and wellbeing. In (Vol. 32, pp. IIIIVI): SciELO Brasil. Stratton, S. J. (2021). Population research: convenience sampling strategies. Prehospital and disaster Medicine , 36 (4), 373374. Sunay, Z., Sabancı Baransel, E., & Uçar, T. (2022). The adaptation of the WellBeing in Pregnancy (WiP) Questionnaire into Turkish: validity and reliability of a questionnaire. Journal of Obstetrics and Gynaecology , 42 (6), 18971904. Taheri, S., Tavousi, M., & Taghizadeh, Z. (2020). Manual for scoring the Maternal Health Literacy Inventory in Pregnancy (MHELIP). Figshare. https://plos.figshare.com/articles/journal_contribution/12468320 Taheri, S., Tavousi, M., Momenimovahed, Z., DirekvandMoghadam, A., Tiznobaik, A., Suhrabi, Z., & Taghizadeh, Z. (2020). Development and psychometric properties of maternal health literacy inventory in pregnancy. Plos one , 15 (6), e0234305. Thibaut, F., & van WijngaardenCremers, P. J. (2020). Women's mental health in the time of Covid19 pandemic. Frontiers in global women's health , 1 , 588372. WHO. (2022). Perinatal mental health . Zibellini, J., Muscat, D. M., Kizirian, N., & Gordon, A. (2020). Effect of health literacy interventions on pregnancy outcomes: A systematic review. Women and Birth, 34(2), 180–186. https://doi.org/10.1016/j.wombi.2020.01.010 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 29 Apr, 2026 Editor invited by journal 30 Mar, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 27 Mar, 2026 First submitted to journal 22 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9193979","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631917303,"identity":"a0240bc9-dcc3-425d-9612-4646d8503116","order_by":0,"name":"Eman Alqadi","email":"data:image/png;base64,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","orcid":"","institution":"Jordan University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Eman","middleName":"","lastName":"Alqadi","suffix":""},{"id":631917306,"identity":"d4577149-f3bf-4e6b-8d6a-4b5fb0dfb8ec","order_by":1,"name":"Arwa Oweis","email":"","orcid":"","institution":"Jordan University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Arwa","middleName":"","lastName":"Oweis","suffix":""}],"badges":[],"createdAt":"2026-03-22 23:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9193979/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9193979/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108805551,"identity":"f3528547-f7e0-47c6-b499-3ff9620c29a1","added_by":"auto","created_at":"2026-05-08 15:26:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":314199,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9193979/v1/aec5358f-69f6-462b-94fa-8819735f61ee.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Maternal Health Literacy, Antenatal Care Engagement, and Wellbeing Among Pregnant Women in Jordan: A Cross-Sectional Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHealth literacy has emerged as a central determinant of maternal and reproductive health, shaping women\u0026rsquo;s capacity to access, understand, appraise, and apply health information across the continuum of pregnancy and childbirth (S\u0026oslash;rensen et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nutbeam, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Within\u003c/p\u003e \u003cp\u003ematernal health contexts, adequate literacy allows women to interpret antenatal recommendations, recognize warning signs, navigate appointment systems, and adhere to preventive strategies, whereas limited literacy constrains autonomy and compromises care utilization (Paasche-Orlow \u0026amp; Wolf, 2007; Guler et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In Jordan, these challenges are compounded by cultural expectations and family dynamics, which often determine whether\u003c/p\u003e \u003cp\u003ewomen can act on the information they receive (Hijazi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGlobal evidence consistently links health literacy with antenatal care (ANC) engagement, demonstrating that women with higher literacy levels initiate care earlier, attend more visits, and demonstrate better understanding of pregnancy-related advice (Downer et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In Turkey and Afghanistan, insufficient health literacy has been associated with delayed ANC initiation, reduced service utilization, and limited comprehension of maternal health information, even in settings where services are available (Guler et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Harsch et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Beyond service attendance, maternal health literacy is strongly associated with positive maternal behaviors, including nutritional adherence, supplementation compliance, birth preparedness, and informed decision making during pregnancy (Tavananezhad et al., 2022; Zibellini et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies further show that women with stronger literacy skills report greater empowerment, higher self-efficacy, and more active participation in healthcare encounters, reinforcing the behavioral pathways proposed in established health literacy models (Tavananezhad et al., 2022; Paasche-Orlow \u0026amp; Wolf, 2007). Importantly, health literacy also influences maternal wellbeing, as limited ability to interpret health information has been associated with heightened anxiety, depressive symptoms, and psychological distress during pregnancy (Nawabi et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Basu et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Systematic reviews have confirmed that inadequate health literacy is linked to poorer mental health outcomes, reduced coping capacity, and diminished confidence in navigating health systems, particularly among socioeconomically disadvantaged populations (Nawabi et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stormacq et al., 2023).\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic further amplified maternal mental health vulnerabilities worldwide, with pregnant women reporting elevated levels of stress, uncertainty, and reduced access to support services, while those with stronger literacy demonstrated greater resilience and adaptability (Basu et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Thibaut \u0026amp; van Wijngaarden-Cremers, 2020). These findings underscore the interconnectedness of informational access, healthcare engagement, and emotional wellbeing in pregnancy (Bergunde et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Jagtap et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite this global recognition, evidence examining health literacy as a multidimensional determinant of ANC engagement and maternal wellbeing remains uneven across regions, particularly in Middle Eastern contexts (Ningrum et al., 2024; Salameh et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile global studies emphasize literacy as a determinant of care, its manifestation varies across\u003c/p\u003e \u003cp\u003eregions. Understanding how these dynamics unfold in Jordan requires attention to both structural\u003c/p\u003e \u003cp\u003ehealth system factors and sociocultural norms. In Jordan, maternal healthcare coverage is relatively high, and governmental primary healthcare centers provide widespread access to ANC services; however, disparities persist in the quality, continuity, and meaningful engagement with these services (Hijazi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Hussein et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Research from northern Jordan indicates that socioeconomic disadvantage, limited education, and suboptimal provider patient communication significantly affects ANC attendance and women\u0026rsquo;s understanding of maternal health information (Hijazi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough service availability has improved, evidence suggests that attendance alone does not guarantee comprehension, empowerment, or positive pregnancy experiences, highlighting the distinction between access and effective engagement (AlModallal et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Salameh et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Moreover, Jordanian studies have primarily focused on sociodemographic predictors of ANC utilization rather than examining health literacy as an explanatory construct linking knowledge, engagement, and wellbeing (Hijazi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Al-Shdaifat et al., 2021). Limited research has integrated maternal health literacy, ANC engagement, and maternal wellbeing within a single conceptual framework, leaving a gap in understanding how informational competencies translate into behavioral and psychological outcomes during pregnancy (Oweis et al., 2020; Salameh et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven global findings that literacy influences both service utilization and mental health, the absence of context-specific evidence in Jordan restricts the development of culturally tailored interventions that address informational, structural, and psychosocial barriers simultaneously (Nawabi et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ningrum et al., 2024). Furthermore, the socioeconomic diversity across Jordanian governorates, combined with educational inequalities and evolving healthcare delivery systems, necessitates localized investigation to identify determinants of effective ANC engagement and maternal wellbeing (Hijazi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Hussein et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). While international research highlights the protective role of health literacy in strengthening ANC adherence and emotional resilience, these associations may manifest differently within Jordan\u0026rsquo;s sociocultural and health system context, where family influence, gender norms, and public sector service delivery shape maternal experiences (Tavananezhad et al., 2022).\u003c/p\u003e \u003cp\u003eTherefore, there is a critical need for empirical research that simultaneously examines maternal health literacy, antenatal engagement, and wellbeing among Jordanian pregnant women using validated instruments and theoretically grounded models (Wilson \u0026amp; Cleary, 1995). Generating such evidence will inform literacy-sensitive maternal health strategies, support policy efforts aligned with global maternal health goals, and contribute to reducing inequities in maternal outcomes within Jordan and comparable middle-income settings (S\u0026oslash;rensen et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; WHO, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Aim of the Study","content":"\u003cp\u003eTo examine the relationship between maternal health literacy, antenatal care engagement, and maternal wellbeing among pregnant women attending governmental primary healthcare centers in Jordan.\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Study Design\u003c/h2\u003e \u003cp\u003eThis study employed a correlational cross-sectional design to examine the relationships between maternal health literacy, ANC engagement, and maternal wellbeing among pregnant women in Jordan. A cross-sectional approach involves collecting data at a single point in time, allowing for the assessment of existing levels of variables and their interrelationships within a defined population (Sharma, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, reliance on convenience sampling may limit\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Settings\u003c/h2\u003e \u003cp\u003eThe study was conducted in selected governmental primary healthcare centers located across four major governorates in Jordan: Amman, Al Balqa, Madaba, and Al Zarqa. These centers provide comprehensive antenatal care services, including routine pregnancy monitoring, health education, laboratory investigations, and maternal counseling. The selected governorates represent both urban and rural populations, ensuring socioeconomic and cultural diversity within the sample.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Population and Sample\u003c/h2\u003e \u003cp\u003eThe target population comprised pregnant women in Jordan, while the accessible population included pregnant women attending antenatal care clinics at the selected primary healthcare centers during the data collection period. Eligible participants were women aged 18 years or older, in any trimester of pregnancy, able to communicate in Arabic, and willing to provide informed consent. Women were excluded if they had documented severe psychiatric illness (e.g., psychosis), high-risk pregnancies requiring specialized tertiary care, or cognitive or language barriers preventing questionnaire completion.\u003c/p\u003e \u003cp\u003eA convenience sampling technique was used to recruit pregnant women who were readily available and met the eligibility criteria in antenatal care settings (Golzar et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This method is practical and feasible in clinical environments and aligns with the study\u0026rsquo;s descriptive correlational design, which aims to explore associations rather than establish causation (Etikan et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Although it may limit generalizability, it is appropriate for cross-sectional studies examining relationships within accessible healthcare populations (Stratton, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). 170 pregnant women who met the inclusion criteria were recruited from selected centers across four Jordanian governorates. After data collection, questionnaires were reviewed for completeness and accuracy. Thirty questionnaires were excluded due to substantial missing data in key variables, including maternal health literacy, antenatal care utilization indicators, or maternal wellbeing measures. Therefore, the final analytical sample consisted of 140 pregnant women. The final sample size was sufficient to detect moderate associations between study variables and was consistent with the sample size estimated using G*Power for correlational and multiple regression analyses (Kang, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Instruments\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1. Sociodemographic and Obstetric Questionnaire\u003c/h2\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2. Antenatal Care Utilization Questionnaire\u003c/h2\u003e \u003cp\u003eANC engagement was assessed using a structured questionnaire based on World Health Organization (WHO) antenatal care indicators. The instrument captured timing of the first ANC visit, total number of visits during the current pregnancy, type of healthcare provider, and services received (e.g., blood pressure measurement, laboratory tests, supplementation, vaccinations, and health education). These items were used to evaluate level of engagement rather than generate a single composite score.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3. Maternal Health Literacy Inventory in Pregnancy (MHELIP)\u003c/h2\u003e \u003cp\u003eMaternal health literacy was measured using the Maternal Health Literacy Inventory in Pregnancy (MHELIP), a 48-item instrument assessing four domains: maternal health knowledge, information search, skills in understanding health information, and health decision-making/behavior. Items are rated on Likert-type scales and frequency scales, and total and subscale scores are standardized to a 0\u0026ndash;100 scale using the recommended scoring formula. Higher scores indicate higher levels of maternal health literacy. In the current study, the instrument demonstrated strong internal consistency, with a total Cronbach\u0026rsquo;s alpha of 0.89.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.4.4. Wellbeing in Pregnancy (WiP) Questionnaire\u003c/h2\u003e \u003cp\u003eMaternal wellbeing was assessed using the 12-item Wellbeing in Pregnancy (WiP) questionnaire. The instrument measures three domains: positive pregnancy experience, confidence about motherhood, and concerns regarding support after birth. Responses are scored and transformed to a 0 \u0026minus;\u0026thinsp;100 scale, with higher scores indicating better wellbeing. In this study, the WiP demonstrated good reliability, with a total Cronbach\u0026rsquo;s alpha of 0.87.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Translation and Cultural Adaptation\u003c/h2\u003e \u003cp\u003eThe MHELIP and WiP instruments were translated into Arabic using forward \u0026ndash; backward translation procedures to ensure linguistic and conceptual equivalence (Ozolins et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Two bilingual translators independently translated the instruments into Arabic, followed by back-translation into English by an independent translator blinded to the original versions. Discrepancies were resolved through consensus. An expert panel comprising maternal health and research methodology specialists reviewed the translated instruments for clarity, cultural relevance, and content validity. Content validity index (CVI) values were calculated, and pilot testing was conducted with a small group of pregnant women to assess clarity and feasibility. Internal consistency reliability was assessed using Cronbach\u0026rsquo;s alpha.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.6. Data Collection Process\u003c/h2\u003e \u003cp\u003eData were collected between using paper-based questionnaires administered during routine antenatal visits at the selected primary healthcare centers. Eligible women were approached by trained research assistants, informed about the study, and invited to participate. After providing written consent, participants completed the questionnaire in a private area within the clinic to ensure confidentiality. The average completion time was approximately 15\u0026ndash;20 minutes. Completed questionnaires were placed in sealed envelopes and securely stored.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.7. Ethical Considerations\u003c/h2\u003e \u003cp\u003e This study adhered to strict ethical guidelines to ensure the protection and dignity of participants. Ethical approval was obtained from the Institutional Review Boards (IRBs) of the MOH and the Institutional Review Board (IRB) of Jordan University of Science and Technology (IRB No.183\u0026thinsp;\u0026minus;\u0026thinsp;59). Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were informed of their right to withdraw at any time without affecting their care. Questionnaires were coded anonymously, and no identifying information was collected. A referral pathway was established for participants who exhibited signs of emotional distress during data collection, ensuring access to appropriate healthcare support if needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.8. Statistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS version 26. Descriptive statistics, including means and standard deviations for continuous variables and frequencies and percentages for categorical variables, were used to summarize participant characteristics and scale scores. Internal consistency reliability was assessed using Cronbach\u0026rsquo;s alpha. Correlation analyses (Pearson or Spearman, as appropriate) were conducted to examine associations between maternal health literacy, ANC engagement, and wellbeing. Multiple linear regression analysis was performed to identify predictors of ANC utilization and maternal wellbeing. Statistical assumptions were evaluated, including normality, multicollinearity using variance inflation factor (VIF), and independence of residuals using the Durbin\u0026ndash;Watson statistic. A two-tailed significance level of p \u0026lt; .05 was adopted for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Sociodemographic and Clinical Characteristics of Participants\u003c/h2\u003e \u003cp\u003eThe sample (N\u0026thinsp;=\u0026thinsp;140) had a mean age of 31.35 years (SD\u0026thinsp;=\u0026thinsp;7.76) and an average monthly household income of 491.43 JD (SD\u0026thinsp;=\u0026thinsp;100.58). On average, participants reported 3.21 pregnancies (SD\u0026thinsp;=\u0026thinsp;1.91), 2.70 living children (SD\u0026thinsp;=\u0026thinsp;1.94), and 0.51 previous abortions (SD\u0026thinsp;=\u0026thinsp;0.79). Regarding educational and socioeconomic characteristics, 37.9% of women had no formal education, 44.3% were unemployed, and the majority were married (87.1%). These findings reflect a predominantly married sample with moderate reproductive history and notable socioeconomic vulnerability. The demographic characteristics of participants are presented (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey Sociodemographic and Clinical Characteristics of Participants (N\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.35\u0026thinsp;\u0026plusmn;\u0026thinsp;7.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly income (JD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e491.43\u0026thinsp;\u0026plusmn;\u0026thinsp;100.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbortions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal maternal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (44.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122 (87.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eNote. SD\u0026thinsp;=\u0026thinsp;Standard deviation; JD\u0026thinsp;=\u0026thinsp;Jordanian Dinar.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Research Question 1: What are the levels of maternal health literacy among Jordanian pregnant women?\u003c/h2\u003e \u003cp\u003eDescriptive analysis of the Maternal Health Literacy Inventory in Pregnancy (MHELIP) revealed overall moderate levels of maternal health literacy among the participating women (N\u0026thinsp;=\u0026thinsp;140). When raw scores were transformed to percentages to allow standardized comparison across domains, knowledge scored 54.09%, and use of information sources scored 57.44%, indicating modest levels of functional literacy. Skills in understanding health information reached 68.19%, reflecting moderate comprehension abilities, while health decision-making and behavior demonstrated the highest score at 80.00%, suggesting strong engagement in recommended maternal health practices. Notably, structural barriers to literacy were high (76.57%), indicating that many women faced considerable obstacles in accessing or utilizing health information and services. In contrast, enabling factors were comparatively low (68.03%), reflecting limited supportive resources within their environment. Categorization based on established cutoffs showed that most women fell within low to moderate categories for knowledge and information access, whereas decision-making was predominantly moderate to high. Overall, the findings indicate moderate maternal health literacy characterized by relatively strong behavioral engagement but constrained by high barriers and limited enablers. The maternal health literacy domain scores are presented (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics and Percentage Scores for Maternal Health Literacy Domains (N\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (Raw)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.09%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformation Sources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57.44%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkills in Understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68.19%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Decision-Making/Behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.57%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnablers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68.03%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote. Percentages were calculated using the formula (Mean\u0026thinsp;\u0026divide;\u0026thinsp;Maximum Observed Score) \u0026times; 100.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Research Question 2: What factors influence antenatal care engagement?\u003c/h2\u003e \u003cp\u003eMultiple linear regression analysis indicated that the overall model significantly predicted antenatal care (ANC) engagement, explaining 23% of the variance in ANC utilization (R\u0026sup2; = 0.232, p \u0026lt; .001). Higher monthly income was associated with increased ANC engagement (β\u0026thinsp;=\u0026thinsp;0.194, p = .006), indicating that women with greater financial resources attended more visits and utilized services more consistently. Maternal education demonstrated a graded positive effect, with secondary (β\u0026thinsp;=\u0026thinsp;0.142, p = .005) and higher education (β\u0026thinsp;=\u0026thinsp;0.166, p = .003) significantly predicting greater ANC engagement compared to no formal education. Similarly, paternal education was positively associated with ANC use, particularly at secondary (β\u0026thinsp;=\u0026thinsp;0.109, p = .013) and higher levels (β\u0026thinsp;=\u0026thinsp;0.132, p = .009). Maternal employment also contributed positively, with full-time (β\u0026thinsp;=\u0026thinsp;0.111, p = .042) and part-time employment (β\u0026thinsp;=\u0026thinsp;0.124, p = .028) increasing engagement. In contrast, widowhood was negatively associated with ANC utilization (β = \u0026minus;\u0026thinsp;0.096, p = .025), indicating reduced engagement among widowed women. Overall, socioeconomic and educational factors emerged as the strongest determinants of ANC participation. This may reflect both financial vulnerability and reduced social support, as widowed women often face barriers in accessing transportation and decision-making autonomy. The correlations between study variables are presented (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple Linear Regression Analysis Predicting Antenatal Care Engagement (N\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly Income (JD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.006**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Education \u0026ndash; Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.043*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Education \u0026ndash; Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.005**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Education \u0026ndash; Higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.003**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Employment \u0026ndash; Full-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.042*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Employment \u0026ndash; Part-time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.028*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaternal Education \u0026ndash; Primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.049*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaternal Education \u0026ndash; Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.013*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaternal Education \u0026ndash; Higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.009**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowhood (vs. married)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;0.318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.025*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eModel Summary\u003c/b\u003e: \u003cem\u003eR\u0026thinsp;=\u0026thinsp;0.482; R\u0026sup2; = 0.232; Adjusted R\u0026sup2; = 0.198; F\u0026thinsp;=\u0026thinsp;6.87; p \u0026lt; .001\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*Note. β\u0026thinsp;=\u0026thinsp;Standardized coefficient. *p \u0026lt; .05; *p \u0026lt; .01.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Research Question 3: How is ANC engagement related to maternal wellbeing?\u003c/h2\u003e \u003cp\u003ePearson correlation analysis demonstrated a statistically significant moderate positive relationship between antenatal care (ANC) engagement and maternal wellbeing (r\u0026thinsp;=\u0026thinsp;0.312, p = .001). This finding indicates that women with higher wellbeing scores were more likely to attend a greater number of ANC visits. Conversely, lower levels of emotional wellbeing were associated with fewer ANC visits. The strength and direction of the correlation suggest that maternal psychological status is meaningfully linked to health-seeking behavior during pregnancy. The predictors of maternal wellbeing are presented (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson Correlation Between Antenatal Care Engagement and Maternal Wellbeing (N\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Maternal Wellbeing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.312**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Number of ANC Visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.312**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote. Pearson correlation coefficient (r) reported.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ep = .001. ** Correlation is significant at the 0.01 level (2-tailed).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThe findings of this study highlight a complex pattern of maternal health literacy among Jordanian pregnant women, characterized by moderate overall literacy levels but relatively strong decision-making behaviors, a pattern that may be described as \u0026ldquo;doing without fully knowing\u0026rdquo; (Nutbeam, 2008; S\u0026oslash;rensen et al., 2021). In practice, many Jordanian women reported following provider instructions faithfully, even when their understanding of the underlying rationale was limited. This pattern reflects reliance on trust in healthcare providers rather than\u003c/p\u003e\n\u003cp\u003eindependent appraisal of (Paasche-Orlow \u0026amp; Wolf, 2007; Nawabi et al., 2021). Similar patterns have been documented in Turkey, where pregnant women demonstrated insufficient knowledge of antenatal care despite regular service attendance (Guler et al., 2021). Comparable findings were also reported in Afghanistan, where limited maternal literacy was associated with gaps in understanding reproductive health information even when services were available (Harsch et al., 2021). Systematic reviews confirm that inadequate health literacy among pregnant women is widespread globally and frequently coexists with routine healthcare contact (Nawabi et al., 2021; Ningrum et al., 2024).\u003c/p\u003e\n\u003cp\u003eThe relatively strong scores in health decision-making and behavior observed in this study suggest that women may effectively apply provider instructions even when their conceptual understanding remains incomplete (Paasche-Orlow \u0026amp; Wolf, 2007; Tavananezhad et al., 2022). Tavananezhad et al. (2022) demonstrated that higher health literacy is positively correlated with empowerment and decision-making capacity during pregnancy. However, behavioral adherence may sometimes reflect trust in providers or cultural norms rather than independent critical appraisal of information (Nutbeam, 2008; Stormacq et al., 2023). The high barrier scores and comparatively lower enabler scores in this study indicate that structural and socioeconomic obstacles constrain women\u0026rsquo;s ability to fully exercise critical health literacy (S\u0026oslash;rensen et al., 2021; Gelberg et al., 2000). Such constraints align with evidence suggesting that disadvantaged populations often rely heavily on provider guidance due to limited informational autonomy (Stormacq et al., 2023; Nawabi et al., 2021). The Paasche-Orlow and Wolf (2007) model further explains that health literacy influences outcomes through access, interaction, and self-management pathways, all of which may be restricted by structural barriers. Thus, maternal literacy in this context appears embedded within broader social determinants of health (S\u0026oslash;rensen et al., 2021; Gelberg et al., 2000).\u003c/p\u003e\n\u003cp\u003eThe regression analysis identifying socioeconomic predictors of antenatal care engagement is consistent with Andersen\u0026rsquo;s Behavioral Model of Health Services Use, which emphasizes predisposing, enabling, and need factors as determinants of healthcare utilization (Gelberg et al., 2000). Education emerged as a significant enabling resource, reinforcing evidence that educational attainment enhances comprehension, confidence, and navigation skills within healthcare systems (Nutbeam, 2008; Guler et al., 2021). Higher maternal education has been consistently associated with improved ANC attendance in Jordan and other middle-income settings (Hijazi et al., 2018; Esca\u0026ntilde;uela S\u0026aacute;nchez et al., 2022). Paternal education also significantly predicted ANC engagement, underscoring the influence of household-level literacy and shared decision-making within sociocultural contexts (Hussein et al., 2020). Similar findings have been reported internationally, where partner involvement enhances maternal healthcare engagement (Esca\u0026ntilde;uela S\u0026aacute;nchez et al., 2022). Income and employment further function as enabling resources, facilitating transportation, service access, and healthcare affordability (Gelberg et al., 2000; Stormacq et al., 2023).\u003c/p\u003e\n\u003cp\u003eThe negative association between widowhood and ANC engagement reflects the vulnerability of women lacking spousal support, consistent with research showing that marital instability or absence of partner support reduces healthcare access and continuity (Steen \u0026amp; Francisco, 2019; Gelberg et al., 2000). In patriarchal or family-centered societies, husbands often facilitate financial and logistical access to care, making widowhood a potential risk factor for reduced service utilization (Hussein et al., 2020; Hijazi et al., 2018). Andersen\u0026rsquo;s model conceptualizes such factors as enabling resources that mediate access to care (Gelberg et al., 2000). From a quality-of-care perspective, Donabedian (1988) emphasizes that structural characteristics of healthcare systems, including social and economic support, influence health outcomes. Thus, ANC engagement in this study reflects not only individual literacy but also broader socioeconomic structures (Donabedian, 1988).\u003c/p\u003e\n\u003cp\u003eThe moderate positive correlation between ANC engagement and maternal wellbeing further underscores the interconnectedness of psychosocial and behavioral dimensions of maternal health (Wilson \u0026amp; Cleary, 1995; Ferrans et al., 2005). Women with higher wellbeing scores attended more ANC visits, suggesting that psychological stability may facilitate proactive health-seeking behavior (Basu et al., 2021; Steen \u0026amp; Francisco, 2019). Basu et al. (2021) documented that elevated stress during the COVID-19 pandemic was associated with reduced healthcare engagement among pregnant women. Steen and Francisco (2019) similarly emphasized that untreated maternal mental health problems impair service utilization and adherence. Conversely, consistent ANC visits provide reassurance, symptom clarification, and emotional validation, which may enhance wellbeing (Wilson \u0026amp; Cleary, 1995; Donabedian, 1988). The Wilson and Cleary (1995) model proposes that healthcare processes influence quality of life through symptom perception and functional health. Ferrans et al. (2005) further expanded this model, linking care processes directly to patient-reported wellbeing outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Implications and Recommendations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Strengths and Limitations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study possesses several notable strengths that enhance the credibility and contribution of its findings. First, the use of validated, pregnancy-specific instruments MHELIP and the WiP questionnaire strengthens the reliability and construct validity of the measurements. Both tools demonstrated strong internal consistency in the current sample, supporting the robustness of the collected data. Second, the study was guided by well-established theoretical frameworks linking health literacy, healthcare utilization, and wellbeing, which allowed for a comprehensive and conceptually integrated interpretation of the findings. This theoretical grounding strengthens the explanatory depth of the results and situates them within broader maternal health research. Third, the use of multivariate regression analysis enabled identification of independent predictors of antenatal care engagement while controlling for potential confounding variables, thereby enhancing the internal validity and analytical rigor of the study. Importantly, the research focuses on an understudied population Jordanian pregnant women within a regional context where limited empirical evidence exists integrating maternal health literacy, antenatal engagement, and wellbeing. By addressing this gap, the study contributes meaningful, context-specific insights relevant to both regional and global maternal health discussions.\u003c/p\u003e\n\u003cp\u003eDespite these strengths, certain limitations should be acknowledged. The cross-sectional design restricts causal inference and does not allow conclusions regarding the directionality of relationships between literacy, engagement, and wellbeing. The use of convenience sampling from selected governmental primary healthcare centers may limit the generalizability of findings to all pregnant women in Jordan, particularly those in remote or private healthcare settings. Additionally, reliance on self-reported measures introduces the potential for recall bias or social desirability bias, especially in reporting health behaviors and emotional wellbeing. Finally, although the study included multiple governorates to enhance diversity, the geographic scope remains limited and may not fully capture regional variations across the country. Nonetheless, the methodological rigor, theoretical grounding, and focus on a previously underexplored population provide a strong foundation for future research and practice in maternal health literacy and antenatal care engagement.\u003c/p\u003e"},{"header":"8. Conclusion","content":"\u003cp\u003eThis study concludes that maternal health literacy among Jordanian pregnant women is generally moderate, yet significantly constrained by structural barriers that limit access to information and supportive resources. While many women demonstrated relatively strong decision-making behaviors during pregnancy, their knowledge levels and access to diverse information sources were less robust, indicating gaps in functional literacy despite behavioral adherence. Socioeconomic factors particularly maternal and paternal education, employment status, and household income emerged as key drivers of antenatal care (ANC) engagement, highlighting the critical role of enabling resources in facilitating consistent service utilization. Conversely, social vulnerability, such as widowhood, was associated with reduced engagement, underscoring the importance of household and relational support systems. Furthermore, maternal emotional wellbeing was positively associated with ANC attendance, suggesting that psychological health and healthcare utilization are interconnected and potentially mutually reinforcing. Together, these findings emphasize that improving maternal outcomes requires more than expanding service availability alone. Future strategies should integrate health literacy training into routine ANC visits, strengthen spousal and family involvement, and address structural barriers such as transportation and clinic accessibility. Literacy-sensitive communication within ANC, routine mental health screening, community-based educational initiatives, and targeted support for vulnerable women represent essential components of a comprehensive maternal health strategy. Addressing informational, emotional, and structural determinants in tandem is crucial to enhancing equitable and meaningful engagement with antenatal services in Jordan and similar middle-income settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eE.A. conceptualized the study, conducted data collection, performed data analysis, and drafted the manuscript. A.O. supervised the study, contributed to the study design, and critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board (IRB) of Jordan University of Science and Technology. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlModallal, H., Hamaideh, S., \u0026amp; Mudallal, R. (2014). 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Women and Birth, 34(2), 180\u0026ndash;186. https://doi.org/10.1016/j.wombi.2020.01.010\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"maternal health literacy, antenatal care, maternal wellbeing, socioeconomic factors, Jordan","lastPublishedDoi":"10.21203/rs.3.rs-9193979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9193979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Maternal health literacy influences women’s engagement with antenatal care (ANC) and wellbeing during pregnancy. In Jordan, gaps persist between service availability and meaningful utilization. These findings highlight the need for literacy-sensitive interventions\u003c/p\u003e\n\u003cp\u003etailored to Jordan's sociocultural context, where family influence and public sector structures\u003c/p\u003e\n\u003cp\u003estrongly shape maternal experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e To examine the relationship between maternal health literacy, ANC engagement, and maternal emotional wellbeing among Jordanian pregnant women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A correlational cross‑sectional study was conducted among 140 pregnant women attending governmental primary healthcare centers in four Jordanian governorates. Maternal health literacy was measured using the Maternal Health Literacy Inventory in Pregnancy (MHELIP), ANC engagement through utilization indicators, and maternal wellbeing using the Wellbeing in Pregnancy (WiP) scale. Data were analyzed using descriptive statistics, Pearson correlation, and multiple linear regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Overall maternal health literacy was moderate, with higher scores in health‑related decision making (80%) and lower scores in knowledge (54%) and information‑seeking (57%). Barriers to literacy were high (77%). ANC engagement was significantly predicted by household income, maternal and paternal education, and maternal employment, explaining 23.2% of the variance. Maternal wellbeing was positively correlated with the number of ANC visits (r = 0.312, p = .001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Maternal health literacy, socioeconomic factors, and emotional wellbeing are closely linked to ANC engagement. Addressing literacy gaps, structural barriers, and emotional support within ANC services may improve maternal health outcomes in Jordan.\u003c/p\u003e","manuscriptTitle":"Maternal Health Literacy, Antenatal Care Engagement, and Wellbeing Among Pregnant Women in Jordan: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 09:34:57","doi":"10.21203/rs.3.rs-9193979/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-29T16:14:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-30T13:46:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-28T01:13:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-28T01:13:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-03-22T22:58:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d68ee97a-7865-483f-8b1b-ea94f9226fe1","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"4","date":"2026-04-29T16:14:43+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T09:34:57+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 09:34:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9193979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9193979","identity":"rs-9193979","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}