ABSTRACT

Background: Birth preparedness and complication readiness (BPCR) is a globally recognised strategy for reducing maternal and neonatal mortality. Despite substantial investment in antenatal health education programmes across Nigerian tertiary hospitals, significant knowledge gaps and low birth-preparedness scores persist among pregnant women attending public facilities. This study assessed the impact of structured health education on birth preparedness among pregnant women attending the antenatal clinic of the University of Uyo Teaching Hospital (UUTH), Uyo, Akwa Ibom State, Nigeria.

Methodology: A quasi-experimental pre-test–post-test research design was employed. A stratified random sampling technique was used to recruit 320 pregnant women in their second and third trimesters from the UUTH antenatal clinic between January and June 2024. A validated, pretested, structured questionnaire adapted from the WHO Birth Preparedness Checklist and the JHPIEGO BPCR scale was administered before and eight weeks after a structured health-education intervention delivered by trained midwives. Data were analysed using IBM SPSS version 27. Descriptive statistics, paired t-tests, and multivariate logistic regression were performed; a p-value of ≤0.05 was considered statistically significant.

Findings: At baseline, only 36.3% of participants demonstrated adequate birth-preparedness knowledge, and 28.1% had saved money for delivery. Following the eight-week health-education intervention, knowledge scores increased significantly from a mean of 11.4 ± 3.2 to 21.7 ± 2.8 (t = 18.64; p < 0.001). The proportion of women who identified a skilled birth attendant rose from 42.5% to 87.8%, while those who had identified a blood donor increased from 19.7% to 61.3%. Multivariate analysis identified educational level (AOR = 3.41; 95% CI: 1.87–6.22), parity (AOR = 2.18; 95% CI: 1.14–4.17), and attendance at all four ANC sessions (AOR = 4.02; 95% CI: 2.09–7.73) as independent predictors of adequate birth preparedness post-intervention.

Conclusions: Structured health education delivered by skilled midwives at UUTH significantly improved birth-preparedness knowledge and practice among pregnant women. The findings underscore the imperative for institutionalising evidence-based BPCR education in all antenatal contacts. Healthcare administrators should integrate culturally tailored BPCR modules into routine ANC, with special attention to primigravidae and women with lower educational attainment.

Keywords: Birth preparedness, complication readiness, health education, antenatal care, maternal mortality, UUTH, Nigeria.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Maternal mortality remains one of the most critical public-health challenges confronting sub-Saharan Africa. Nigeria continues to bear a disproportionate share of the global maternal mortality burden, accounting for approximately 34% of all maternal deaths worldwide (WHO, 2023). The United Nations Sustainable Development Goal 3.1 targets a global maternal mortality ratio (MMR) of fewer than 70 per 100,000 live births by 2030; however, Nigeria's MMR was estimated at 1,047 per 100,000 live births in 2022, a figure that reflects deep systemic, socioeconomic, and educational inequities (NDHS, 2023; Alkema et al., 2022).

Birth preparedness and complication readiness (BPCR) is a proactive demand-side strategy designed to motivate pregnant women, their families, and communities to plan for a skilled birth and to recognise and respond appropriately to obstetric complications. The BPCR framework, promoted by JHPIEGO and endorsed by the WHO, encompasses the identification of a skilled birth attendant, selection of an appropriate delivery facility, financial planning for delivery costs, organisation of transportation, identification of a compatible blood donor, and recognition of danger signs in pregnancy (Kaso & Addisse, 2022; Mgata & Maluka, 2023).

Health education in the antenatal period represents the primary conduit through which evidence-based BPCR information is transmitted to pregnant women. Systematic reviews have consistently demonstrated that well-structured antenatal health education improves women's BPCR knowledge, attitude, and practice scores, translates into higher rates of skilled birth attendance, reduces delays in seeking emergency obstetric care, and ultimately contributes to reductions in preventable maternal and perinatal deaths (Hailu et al., 2022; Tiruneh et al., 2024). Nevertheless, the quality, consistency, and content of antenatal health education vary substantially across Nigerian healthcare facilities, and evidence from the South-South geopolitical zone where UUTH is situated remains sparse.

The University of Uyo Teaching Hospital serves as the apex referral centre for Akwa Ibom State and the broader Niger Delta region. The hospital's antenatal clinic registers an average of 4,500 new pregnancies annually and serves a diverse population with varying educational, socioeconomic, and cultural backgrounds. Previous facility-level audits at UUTH have identified low institutional delivery rates, late presentation to emergency obstetric care, and inadequate community awareness of obstetric danger signs as recurring challenges (Ekanem et al., 2023). These findings suggest that existing health-education efforts may be insufficient or inadequately evaluated, providing the impetus for the present study.

This study therefore examined the pre-intervention birth-preparedness status of pregnant women at UUTH, designed and implemented a structured health-education programme, and rigorously evaluated its impact on knowledge, attitude, and birth-preparedness practices over an eight-week follow-up period. The results have direct implications for antenatal care policy, midwifery education, and hospital-quality-improvement initiatives across Nigeria.

1.2 Statement of the Problem

Despite decades of investment in maternal health programmes in Nigeria, preventable maternal deaths attributable to delays in decision-making, delayed transport, and late arrival at health facilities continue to occur at alarming rates. The 'Three Delays Model' delay in deciding to seek care, delay in reaching the facility, and delay in receiving adequate care remains the dominant explanatory framework for these deaths, and the first two delays are directly modifiable through effective birth-preparedness interventions (Thaddeus & Maine, 1994; Ibrahim et al., 2023).

In Akwa Ibom State, studies have reported that fewer than 40% of pregnant women attending public antenatal clinics could correctly identify three or more obstetric danger signs, and fewer than 30% had made financial provisions for delivery at the time of their first antenatal visit (Udoh & Archibong, 2022). These deficiencies persist despite the existence of routine health-education sessions in antenatal clinics, suggesting that current approaches may be didactic, inconsistent, or insufficiently tailored to the literacy and cultural context of the target population. No published study has rigorously evaluated the impact of a structured, theory-driven health-education intervention on BPCR specifically at UUTH, creating an evidence gap that this study addressed.

1.3 Objectives of the Study

The broad objective of this study was to assess the impact of health education on birth preparedness among pregnant women at UUTH, Uyo. The specific objectives were to:

i. Determine the baseline level of birth-preparedness knowledge among pregnant women attending the UUTH antenatal clinic before the health-education intervention.

ii. Assess the birth-preparedness practices (financial savings, skilled birth attendant identification, transport arrangement, blood donor identification, and danger-sign recognition) of participants before the intervention.

iii. Design and implement a structured health-education programme on birth preparedness and complication readiness for pregnant women at UUTH.

iv. Evaluate changes in birth-preparedness knowledge and practice scores eight weeks following the health-education intervention.

v. Identify sociodemographic and obstetric factors that independently predict adequate birth preparedness among the study participants.

1.4 Research Questions

i. What is the baseline level of birth-preparedness knowledge among pregnant women attending the UUTH antenatal clinic?

ii. What birth-preparedness practices have pregnant women at UUTH adopted prior to a structured health-education intervention?

iii. What is the effect of a structured health-education programme on the birth-preparedness knowledge scores of pregnant women at UUTH?

iv. What is the effect of the health-education intervention on the birth-preparedness practices of pregnant women at UUTH?

v. What sociodemographic and obstetric characteristics are significantly associated with adequate birth preparedness at post-intervention?

1.5 Hypotheses

H01: There is no statistically significant difference in the mean birth-preparedness knowledge scores of pregnant women at UUTH before and after the health-education intervention.

H02: There is no statistically significant difference in the birth-preparedness practice scores of pregnant women at UUTH before and after the health-education intervention.

H03: There is no statistically significant association between sociodemographic characteristics and adequate birth preparedness among pregnant women at UUTH post-intervention.

1.6 Significance of the Study

The findings of this study carry profound significance for multiple stakeholders. For clinical midwives and obstetric nurses at UUTH and similar tertiary facilities, the evidence generated provides a validated, structured BPCR curriculum that can be immediately operationalised within existing antenatal contact schedules. For hospital administrators and quality-improvement officers, the study offers quantifiable benchmarks for evaluating the effectiveness of antenatal health-education programmes. For the Akwa Ibom State Ministry of Health, the evidence base supports advocacy for the scale-up of structured BPCR education across primary, secondary, and tertiary healthcare facilities. At the national level, the study contributes to the growing body of evidence needed to revise the Nigeria Integrated Maternal, Newborn and Child Health Strategy and to inform the operationalisation of the National Health Act provisions on antenatal care. Lastly, for researchers and academics, the validated instrument and methodology provide a replicable framework for future quasi-experimental health-education research in Nigerian clinical settings.

1.7 Scope of the Study

This study was limited to pregnant women in the second and third trimesters attending the antenatal clinic of the University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria. The study period spanned January to June 2024. The intervention consisted of eight structured group health-education sessions delivered over eight weeks, covering all seven BPCR components as defined by JHPIEGO. The study did not extend to community-dwelling women, women attending private facilities, or women in the first trimester. The outcome assessment was conducted eight weeks after the baseline, and long-term outcomes such as actual delivery at a skilled facility or maternal mortality were not within the study's scope.

1.8 Definition of Terms

Birth Preparedness: A proactive process by which pregnant women and their families make arrangements before delivery to ensure access to skilled care at birth, including identifying a skilled attendant, choosing a delivery facility, saving money, arranging transport, identifying a blood donor, and recognising obstetric danger signs (Kaso & Addisse, 2022).

Complication Readiness: The knowledge and practical capacity of a pregnant woman and her family to promptly recognise obstetric complications and take appropriate action to seek skilled emergency care (Mgata & Maluka, 2023).

Health Education: A planned process involving a combination of educational and social activities designed to create conditions that lead to health-promoting behaviour. In this study, it refers specifically to structured, midwife-delivered antenatal group sessions focused on BPCR content (WHO, 2022).

Antenatal Care (ANC): Systematic surveillance provided to pregnant women to monitor foetal growth and development, to detect and manage maternal complications, and to prepare women for labour, delivery, and the postpartum period (WHO, 2023).

Skilled Birth Attendant (SBA): An accredited health professional doctor, midwife, or nurse who has been educated and trained to proficiency in the skills needed to manage normal pregnancies, childbirth, and the immediate postnatal period, and in the identification, management, and referral of complications in women and newborns (ICM/FIGO, 2023).

Danger Signs in Pregnancy: Warning symptoms and signs that indicate a serious obstetric complication requiring immediate skilled medical attention. These include severe vaginal bleeding, severe headache with blurred vision, convulsions/fits, prolonged labour, high fever, and decreased or absent foetal movement (Hailu et al., 2022).

Obstetric Emergency: An acute, life-threatening complication arising during pregnancy, labour, or the puerperium that requires immediate medical or surgical intervention, including postpartum haemorrhage, eclampsia, obstructed labour, and sepsis (Ibrahim et al., 2023).

Parity: The total number of times a woman has given birth to a foetus with a gestational age of 24 weeks or more, regardless of the outcome (live birth, stillbirth) (Udoh & Archibong, 2022).

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