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<div><p>Objective</p><p>As Nepalese pregnant women vary widely in literacy levels and cultural backgrounds and are reluctant to make decisions about their health, general interventions are insufficient to improve maternal anemia. This study aimed to assess the effectiveness of “face-to-face health education using educational material created using pictures, photos, and nomograms” in reducing anemia and improving health literacy.</p><p>Methods</p><p>A total of 156 Nepalese pregnant women with hemoglobin (Hb) levels below 11.0 g/dl were divided into three groups: the education group received three sessions of face-to-face health education using art-based material unaffected by literacy skills; the distribution group received material used in the education group; and the control group underwent general perinatal checkups. Hb levels and health literacy scores were assessed at baseline early pregnancy (8–12 weeks) and late pregnancy (36–40 weeks). A Nepalese version of the 14-item Health Literacy Scale (HLS-14) was developed to assess health literacy.</p><p>Results</p><p>The post-intervention three-group comparison showed a statistically significant difference (P < 0.042) in mean Hb levels after the intervention. Dunnett’s test showed a statistically significant difference (P < 0.044) between the education and control groups but no significant difference between the distribution and control groups (P = 0.972). No significant differences in health literacy (total scores and subscales) were observed among the three groups before the intervention in the Kruskal-Wallis test and after the intervention (although there was a trend towards improvement). Total health literacy scores before and after the intervention were statistically significantly different for the total group and all three groups (P<0.001). Only the education group showed statistically significant differences in functional (P<0.012), communication (P<0.004), and critical (P<0.014) literacy subscale scores.</p><p>Conclusion</p><p>Continuous face-to-face health education using literacy material significantly reduced anemia and improved health literacy among Nepalese pregnant women.</p><p>Trial registration</p><p>UMIN Clinical Trials Registry (UMIN-CTR), URL: <a href="https://www.umin.ac.jp/ctr/" target="_blank">https://www.umin.ac.jp/ctr/</a> (Registration number: <a href="https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=UMIN000049603" target="_blank">UMIN000049603</a>).</p></div>