Health Literacy, Psychological Distress and Fertility Attitudes Among Postpartum Women: A Mediation Analysis

Background/Objectives: Declining fertility rates pose a major demographic and public health challenge across Europe, including Croatia. Although health literacy and psychological well-being may influence reproductive decision-making, their relationships with fertility attitudes remain insufficiently understood. This study examined the associations between health literacy, psychological distress, and fertility attitudes among postpartum women and investigated whether anxiety and depressive symptoms mediate the relationship between health literacy and fertility attitudes. Methods: A cross-sectional study included 1656 postpartum women from seven coastal counties in Croatia. Participants completed validated measures of health literacy (NVS-HR), anxiety (STAI), depressive symptoms (BDI-M), and breastfeeding attitudes (IIFAS). Correlation analyses, multivariable logistic regression, and mediation analyses were performed. Results: Higher health literacy was associated with more positive fertility attitudes (r = 0.18, p < 0.001), whereas anxiety and depressive symptoms were negatively associated with fertility attitudes (all p < 0.001). Health literacy was also negatively correlated with anxiety and depressive symptoms. Multivariable logistic regression demonstrated that higher health literacy (OR = 1.24, 95% CI 1.12-1.35), older age (OR = 1.08, 95% CI 1.05-1.12), and more positive breastfeeding attitudes (OR = 1.04, 95% CI 1.01-1.09) were independently associated with preferences corresponding to above-replacement fertility, whereas higher levels of depressive symptoms were independently associated with lower odds of this outcome (OR = 0.78, 95% CI 0.66-0.90; all p < 0.05). Mediation analysis demonstrated a significant direct association between health literacy and fertility attitudes (β = 0.020, p = 0.004), whereas no significant indirect effects through anxiety or depressive symptoms were observed. Conclusions: Health literacy was independently associated with fertility attitudes and with preferences corresponding to above-replacement fertility, while psychological distress did not mediate this relationship. These findings suggest that health literacy may serve as an important cognitive resource for reproductive decision-making and a potential target for future reproductive health promotion among postpartum women.