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Aims: Communication barriers in healthcare encounters contribute to ethnic inequality in health outcomes. This study aimed to examine, in a large national Danish sample of women, whether ethnicity was associated with pregnant women's Active engagement with healthcare providers. Methods: A cross-sectional survey of 1898 pregnant women attending 19 Danish maternity wards. The key variable of interest was maternal ethnicity among ethnic Danish, European, African and Asian immigrant women and their descendants. Syrian immigrant women were studied as a subgroup. The outcome was the health literacy questionnaire domain Ability to engage actively with healthcare providers (five-item domain scored from 'cannot do/always difficult' (1) to 'always easy' (5)) which is a reflection of a respondent's lived experiences of engaging with healthcare providers. Adjusted mixed effect multivariate linear regression was used to compare Active engagement across groups expressed as the mean difference (95% confidence interval). Results: Lower means of Active engagement were reported for immigrant women compared to ethnic Danish women in all models. When adjusting for age, parity, complications and occupation, the difference between ethnic Danish women's Active engagement and other groups was smallest among European –0.15 (–0.26 to –0.05), slightly larger in African –0.19 (–0.40 to 0.02), and largest in Asian immigrant women –0.31 (–0.41 to –0.21). Syrian immigrant women had the largest difference –0.42 (–0.58 to –0.27). Conclusions: Pregnant immigrant women reported lower means of Active engagement than ethnic Danish women did. Increased health literacy responsiveness in maternity care is required to mitigate the potential for differential care and health inequity. [ABSTRACT FROM AUTHOR]