**Background:** Chronic noncommunicable diseases (NCDs) account for 74% of deaths worldwide, and mounting evidence links maternal lifestyle during pregnancy to long-term health outcomes in offspring via 'nutritional programming.' Despite this, suboptimal maternal nutrition and weight gain are increasingly common. In the Czech Republic, no national data existed on pregnant women's nutritional knowledge, and there are no standardized nutritional recommendations or dedicated nutritional counseling requirements during prenatal care. This study aimed to describe the nutritional knowledge level of Czech pregnant women and identify sociodemographic and anamnestic factors associated with knowledge and nutrition literacy.
**Methods:** This analytical cross-sectional survey was conducted between April and June 2022 at two facilities: the Gynaecology and Obstetrics Clinic in Pilsen and the Institute for Maternal and Pediatric Care in Prague. Inclusion criteria were Czech citizenship, ≥36th week of singleton pregnancy, and age ≥18 years. A total of 457 questionnaires were completed; 31 were discarded for incomplete demographic data and 25 for low gestational age (<38 weeks), leaving 401 for analysis. The in-house 40-item multiple-choice nutrition knowledge test (NKT) covered micronutrients, macronutrients, nutritional recommendations, food supplements, and food safety. Each item had one correct answer and a 'do not know' option. A satisfactory knowledge level was defined as >80% correct. The questionnaire was pilot-tested on 30 women (test–retest kappa = 0.914). Statistical analyses used chi-squared, Fisher's exact, Mann–Whitney, and Kruskal–Wallis tests, with significance at p < 0.05.
**Key Results:** Only 5% of women achieved a knowledge score >80%. The mean total score was 24.9 ± 5.4 out of 40. The ten questions with the highest error rates included mercury content in fish (84% incorrect), promotion of iron absorption (74.3% incorrect), energy content of food (73.8% incorrect), vitamin A needs (70% incorrect), vitamin D sources (50.9% incorrect), optimal weight gain (66.3% incorrect), plant sources of calcium, recommended daily folic acid intake (60.8% incorrect), reason for iodine need, and reason for folic acid intake (56.6% incorrect). University-educated women scored significantly higher than pre-university women (mean 26.3 ± 4.8 vs. 23.0 ± 5.5, p < 0.001). Women in Prague scored higher than those in Pilsen (25.5 ± 5.3 vs. 23.7 ± 5.3, p < 0.001). Primiparous women scored higher than multiparous women (25.5 ± 5.1 vs. 24.4 ± 5.5, p = 0.041). Women with extreme BMI (underweight or extremely obese) scored lower than those with normal weight, overweight, or obesity (22.5 ± 6.0 vs. 25.3 ± 5.2, p = 0.005). Women with NCDs scored higher than those without (25.7 ± 5.1 vs. 24.5 ± 5.5, p = 0.044). In linear regression, education level (aOR 3.06, CI 95%: 1.97–4.15, p < 0.001) and NCD presence (aOR 1.13, CI 95%: 0.03–2.23, p = 0.043) remained significant, while city and pregnancy order did not. For health literacy, university-educated women reported greater difficulty in information appraisal (p = 0.036), utilization (p = 0.031), and help-seeking (p = 0.036) compared to pre-university women.
**Clinical Implications:** The study reveals critically low nutritional knowledge among Czech pregnant women, particularly regarding energy intake, weight gain, and key micronutrients (iron, folic acid, vitamin D). The strong association with education level suggests that women with lower educational attainment are at highest risk and should be prioritized for interventions. The finding that women with extreme BMI (underweight and extremely obese) had the lowest knowledge scores is especially concerning given their elevated obstetric risk. The results underscore the absence of standardized nutritional counseling in Czech prenatal care and the need for national dietary guidelines, routine knowledge assessment, and accessible dietitian services. Healthcare providers should be trained to deliver evidence-based nutritional education, and public health campaigns should target young women preconceptionally. The study's limitations include overrepresentation of university-educated women (57.4%) and data collection only in two large cities, which may limit generalizability. Nonetheless, this first-ever Czech study provides a critical baseline for developing interventions to improve maternal nutritional literacy and, ultimately, pregnancy outcomes.