CHAPTER ONE

INTRODUCTION
Background to the Study
Maternal health remains a major global health priority, particularly in low- and middle-
income countries, where maternal mortality rates are still unacceptably high. According
to the World Health Organization (2022), approximately 287,000 women die annually
due to pregnancy-related complications, and a significant proportion of these deaths
occur in sub-Saharan Africa. Nigeria alone contributes about 20% of the global
maternal mortality burden, making it one of the countries with the highest risk for
women during pregnancy and childbirth (Adewuyi et al., 2022). Many of these deaths
result from preventable complications such as postpartum hemorrhage, eclampsia,
obstructed labour, and sepsis—all of which can be effectively managed or avoided
through adequate birth preparedness.
Birth preparedness and complication readiness (BPCR) is a strategy recommended
globally to reduce delays associated with childbirth emergencies. These delays
include: delay in deciding to seek care, delay in reaching a health facility, and delay in
receiving appropriate care (WHO, 2022). Birth preparedness ensures that women and
their families make timely decisions about where to give birth, how to get there, what
to bring, how to finance the delivery, and who to turn to if emergencies arise. A
woman who is adequately prepared for childbirth is more likely to access skilled birth
attendance and emergency obstetric care promptly, thereby reducing maternal and
neonatal risks (Ojong et al., 2022).
Health education offered during antenatal care (ANC) has been widely recognized as
a major determinant of improved birth preparedness. ANC health education equips
pregnant women with essential knowledge about pregnancy danger signs, the
importance of planning for delivery, and steps to take in case of complications
(Oladimeji & Bello, 2021). It empowers women with the ability to make informed
decisions concerning their pregnancy and delivery. Studies conducted in different
parts of Nigeria have consistently shown that pregnant women who receive
structured ANC health education demonstrate higher levels of birth preparedness and
improved health-seeking behaviour (Oghenekaro & Ebiere, 2022).
In Delta State, antenatal clinics such as the one at Central Hospital Agbor play a
central role in disseminating health information to pregnant women from surrounding
communities. Central Hospital Agbor is a major referral health facility providing ANC,
delivery services, and emergency obstetric care. Despite the availability of these
services, there is evidence that many pregnant women attending the clinic still exhibit
low levels of birth preparedness. Some women fail to identify skilled birth attendants
early, while others do not make arrangements for transportation, delivery items, or
emergency funds (Ezeanya & Obiora, 2023). A number of these women also present
late in labour, creating avoidable complications for themselves and their babies.
Cultural norms, socio-economic barriers, misinformation, and limited understanding
of pregnancy risks continue to influence birth preparedness practices among
pregnant women in the region (Okoro & Umeh, 2023). These challenges indicate
that although health education is being provided during ANC visits, its actual impact
on birth preparedness among the women attending Central Hospital Agbor remains
unclear. This study therefore seeks to examine the
extent to which health education influences birth preparedness within this population.
Statement of the Problem
Despite the existence of antenatal health education sessions in healthcare facilities
across Nigeria, including Central Hospital Agbor, many pregnant women still
demonstrate inadequate birth preparedness. This inadequate preparation remains a
major contributor to preventable maternal and neonatal complications. Observations
and hospital records show that some women arrive at the labour ward without
essential delivery materials, insufficient funds for treatment, lack of transportation
arrangement, and without identifying a skilled birth attendant in advance. These gaps
often lead to delays in receiving timely care, which in turn increases the risk of
adverse pregnancy outcomes.
Studies from various parts of southern Nigeria reveal that pregnant women still have
limited knowledge of birth preparedness concepts, and many lack a clear
understanding of danger signs during pregnancy and childbirth (Nwafor et al., 2021).
In Delta State, reports indicate that socio-cultural norms, low educational levels,
irregular ANC attendance, and inadequate communication between healthcare
providers and pregnant women contribute significantly to poor birth preparation
(Omodamwen & Eze, 2023). These factors persist even when health education is
supposedly being offered at ANC clinics.
In Central Hospital Agbor, anecdotal evidence suggests that some pregnant women do
not take the health education sessions seriously or fail to apply the information
provided. This leads to poor planning for childbirth, which compromises their ability to
respond promptly to emergencies. The resulting delays can be fatal, given that
complications such as haemorrhage or eclampsia require immediate intervention.
Despite ongoing health education, the continued reports of low birth preparedness
raise critical questions: Is the health education effective? Are women assimilating the
information? Is the method of teaching adequate?
These gaps highlight the need for this study, which focuses on examining the impact
of health education on birth preparedness among pregnant women attending ANC at
Central Hospital Agbor. Understanding this relationship is essential for developing
effective strategies to improve maternal health outcomes in the region.
General Objectives
The purpose of this study is to examine the impact of health education on birth
preparedness among women attending antenatal clinic in Central Hospital Agbor,
Delta State.
Specific Objectives
The specific objectives of this study are to:
[Link] the level of knowledge of birth preparedness among pregnant women
attending ANC at Central Hospital Agbor.
2. Determine the extent of health education received by pregnant women
regarding birth preparedness.
3. Examine the impact of health education on birth preparedness practices for
pregnant women. Research Questions
[Link] is the level of knowledge of birth preparedness among pregnant women
attending ANC at Central Hospital Agbor?
 2. To what extent do pregnant women receive health education on birth
preparedness at the facility?
3. What is the impact of health education on birth preparedness practices among
these women? Significance of the Study
The findings of this study will be of immense value to different stakeholders in the
maternal healthcare system. The significance is explained under the following
subheadings:
Benefits to Pregnant Women: This study will enlighten pregnant women about the
crucial role of birth preparedness and the importance of applying the health
education they receive during ANC. It will help them understand how proper
preparation—such as identifying danger signs, arranging transportation, saving funds,
and choosing a skilled birth attendant—reduces complications during labour and
delivery. Ultimately, the study will contribute to improving their safety, confidence, and
overall birth experience.
Benefits to Health Workers: The study will provide healthcare workers with insights
into how effective their health education strategies are and whether they are
influencing women’s birth preparedness. It will highlight areas where reinforcement,
improved communication, or better teaching methods are needed. This feedback will
enhance the quality of ANC health education, helping health workers deliver more
targeted, comprehensive, and impactful counselling to pregnant women.
Benefits to Hospital Management: For hospital administrators, the study will serve as
an evaluative tool to assess the effectiveness of antenatal health education
programmes within the hospital. The findings will help the management identify gaps in
service delivery, allocate resources appropriately, and design policies that enhance
maternal health services. Improved birth preparedness among pregnant women also
reduces emergency complications, easing the workload on healthcare staff and
improving hospital efficiency.
Benefits to the Society: A society with properly prepared pregnant women experiences
fewer maternal and neonatal deaths. This study will contribute to raising awareness
on the importance of birth preparedness, thereby promoting healthier families and
communities. Reduced maternal mortality strengthens the workforce, lowers
healthcare costs, and contributes to socio-economic development within Agbor and
Delta State at large.
Benefits to Policy Makers: For policy makers, the study provides evidence-based
information needed for designing or modifying maternal health policies. It will
highlight the current realities surrounding ANC health education and its influence on
birth preparedness, thereby informing better strategies to reduce maternal and
neonatal mortality. The study may also influence decisions regarding training, funding,
and structural improvements in antenatal health education programmes nationwide.
Scope of the Study
The study focuses on women attending antenatal clinic at Central Hospital Agbor,
examining the health education they receive and how this influences their birth
preparedness. It covers issues relating to knowledge of danger signs, planning for
delivery, transportation, emergency funds, and skilled birth attendance.
Operational Definition of Terms
• Antenatal Clinic (ANC): A healthcare service where pregnant women receive
monitoring, education, and support before childbirth.
• Birth Preparedness: Actions taken by pregnant women to plan for a
normal birth and emergencies (e.g., saving money, arranging transport,
identifying blood donors).
• Health Education: Information and counselling given during ANC to promote safe
pregnancy and childbirth.
• Pregnant Women: Women attending ANC at Central Hospital Agbor, regardless of
gestational age.

CHAPTER TWO
LITERATURE
REVIEW
Introduction
This chapter presents a comprehensive review of relevant literature on the impact of
health education on birth preparedness among pregnant women. The chapter is
organized into four major sections: conceptual review, theoretical review, empirical
review, and summary of the reviewed literature.
Conceptual Review
Concept of Antenatal Care (ANC)
Antenatal care refers to the systematic supervision of pregnant women to ensure safe
pregnancy, delivery, and postpartum outcomes. It involves screening, monitoring,
counselling, and preventive interventions aimed at reducing maternal and neonatal
risks. According to WHO (2022), effective ANC includes early registration, routine
assessments, vaccinations, nutritional guidance, and health education. ANC is crucial
because it creates opportunities for pregnant women to interact with healthcare
providers, receive timely information, and engage in practices that promote healthy
pregnancy outcomes. Ojong et al. (2022) added that ANC enables early detection of
risks such as hypertension, infections, and fetal complications, thereby improving
prognosis.
ANC also serves as a platform for educating women about danger signs, planning for
birth, preparation for emergencies, and making informed decisions about delivery.
Regular ANC attendance increases the likelihood that pregnant women will utilize
skilled birth attendants and reduce complications associated with childbirth (Adewuyi
et al., 2022).
Concept of Health Education in Pregnancy
Health education during pregnancy is a structured method of providing pregnant
women with relevant information that enhances their knowledge, improves their
attitudes, and shapes their health behaviours. It is one of the most essential
components of antenatal care because it supports informed decision-making and
risk reduction (Oladimeji & Bello, 2021).
Health education in ANC typically covers:
• Nutrition during pregnancy
• Birth preparedness
• Danger signs of pregnancy
• Hygiene and infection prevention
 • Breastfeeding practices
• Emotional/psychological well-being
• Newborn care
Health education empowers pregnant women to understand their bodies, recognize
danger signs, and seek timely medical care. According to Ezeanya and Obiora (2023),
when health education is effectively delivered, it increases women’s confidence,
improves their sense of control, and encourages adherence to clinical
recommendations. This makes health education a vital tool for improving maternal
outcomes.
Concept of Birth Preparedness
Birth preparedness refers to the strategic planning undertaken by pregnant women,
their families, and communities to ensure safe delivery and timely response to
complications. It is a core maternal health intervention that reduces the three delays
associated with maternal mortality: delay in deciding to seek care, delay in reaching a
facility, and delay in receiving care (WHO, 2022).
According to Oghenekaro and Ebiere (2022), birth preparedness includes:
[Link] a skilled birth attendant
2. Choosing a place of delivery
3. Saving money for delivery and emergencies
4. Arranging transportation ahead of time
5. Preparing essential delivery materials
G. Identifying a blood donor if needed
Birth preparedness equips women to respond promptly to emergencies such as
haemorrhage, obstructed labour, or eclampsia. Women who prepare adequately are
more likely to reach healthcare facilities early, reducing the risk of complications.
Concept of Knowledge of Danger Signs
Danger signs are warning symptoms that indicate life-threatening complications
during pregnancy, labour, or postpartum. Knowledge of such signs is central to
reducing maternal morbidity and mortality because early recognition triggers
immediate help-seeking behaviour. Common danger signs include:
• Severe vaginal bleeding
• Severe abdominal pain
• Convulsions
• Difficulty breathing
• High fever
• Reduced fetal movement
• Severe headache and blurred vision
Nwafor et al. (2021) assert that lack of awareness of danger signs is a leading cause of
delay in seeking appropriate care. Health education provides pregnant women with the
ability to identify these signs early, increasing their chances of survival during
pregnancy and childbirth.
Components of Effective ANC Health Education
Effective health education during ANC must be structured, interactive, and culturally
sensitive.
Ezeanya and Obiora (2023) argue that communication should be simplified and
supported with demonstrations to ensure comprehension. Effective health education
also relies on:
• Use of visual aids
• Allowing questions and discussions
• Repetition of key information
• Addressing cultural beliefs
• Encouraging partner/family involvement
When education is interactive and supportive, pregnant women are more likely to
internalize and practice the information. Research shows that health education
directly influences birth preparedness by changing attitudes and strengthening
decision-making (Oladimeji & Bello, 2021).

Theoretical Review
Health Belief Model (HBM)
The Health Belief Model (HBM) originated in the 1U50s through the work of social
psychologists Hochbaum, Rosenstock, and Kegels in the United States Public Health
Service. The model was initially developed to understand why individuals failed to
engage in disease prevention and screening practices. Over time, it evolved and has
become one of the most widely applied theories in health behaviour research.
According to Rosenstock and colleagues (as cited by Oladimeji & Bello, 2021), the
model explains how personal beliefs about health problems, perceived benefits of
action, and barriers to action determine health behaviours.
Components of the Health Belief
Model The HBM comprises six major
components:
a. Perceived Susceptibility: This refers to an individual’s belief about their likelihood of
experiencing a health problem. For pregnant women, perceived susceptibility may relate
to their understanding of pregnancy risks and complications.
b. Perceived Severity: This involves the belief about the seriousness of a condition
and its potential consequences. Women who believe pregnancy complications can
lead to disability or death are more likely to take preventive actions.
c. Perceived Benefits: This refers to the belief in the effectiveness of
recommended health actions. When pregnant women understand the benefits of
preparing for childbirth, they are more likely to adopt birth preparedness
practices.
d. Perceived Barriers: Barriers are factors that hinder health-seeking behaviour.
These may include cost of care, cultural beliefs, or distance to health facilities.
e. Cues to Action: These are triggers that motivate individuals to engage in health
behaviour. Examples include health education from healthcare workers, community
campaigns, or personal experiences.
f. Self-Efficacy: This refers to the confidence in one’s ability to take action. Women
with high self-efficacy are more likely to plan ahead for childbirth and respond
appropriately to emergencies.
 Application of the Health Belief Model to the Study
The Health Belief Model is relevant to this study because it explains how pregnant
women’s beliefs and perceptions influence their birth preparedness practices. Health
education received during ANC serves as a cue to action, motivating women to plan
effectively for childbirth. The model also highlights the importance of addressing
perceived barriers, such as financial constraints or cultural misconceptions, to improve
preparedness. By applying HBM, this study examines how health education shapes
women’s understanding of their susceptibility to pregnancy complications, their
perception of the severity of risks, and the benefits of being adequately prepared.
Ultimately, the model supports the argument that improved health education leads to
enhanced birth preparedness among pregnant women in Central Hospital Agbor.
Empirical Review
To assess the level of health education received by pregnant women attending ANC
According to Oladimeji and Bello (2021) their study in southwestern Nigeria
revealed that structured and repeated health education significantly improved
pregnant women's
understanding of birth preparedness. They found that women who attended ANC
regularly were more likely to benefit from comprehensive health education.
Ezeanya and Obiora (2023) In Delta State, they observed that although health
education was provided during ANC, many women reported that health talks were too
brief and sometimes inconsistent due to staff shortages. This affected their overall
comprehension.
Ojong et al. (2022) their research indicated that the majority of pregnant women who
received detailed health education could recall key information on nutrition, danger
signs, and birth planning. They concluded that health education positively influenced
knowledge levels.
To determine the level of birth preparedness among pregnant women
According to Nwafor et al. (2021) Their study found that less than half of the women
were adequately prepared for birth, with many unable to identify a skilled birth
attendant or save money for emergencies despite attending ANC.
Oghenekaro and Ebiere (2022) In the Niger Delta region, they reported low levels of
birth preparedness, attributing this to inadequate awareness, cultural norms, and
financial constraints. Ezeanya and Obiora (2023) their findings showed that many
pregnant women in Delta State lacked basic birth preparedness practices such as
arranging transportation or preparing delivery items in advance.
To determine the impact of health education on birth preparedness
Oladimeji and Bello (2021) they reported a strong positive relationship between
structured health education and improved birth preparedness. Women exposed to
repeat health talks planned better for delivery.
Ojong et al. (2022) the study demonstrated that health education significantly
increased a woman's likelihood of recognizing danger signs and preparing ahead for
emergency situations. Okoro and Umeh (2023) their study in Delta State found that
lack of clear communication from health workers negatively affected birth
preparedness. They concluded that improving health education delivery would
enhance maternal readiness.
Summary of Literature Review
The reviewed literature highlights the essential role of ANC, health education, and
birth preparedness in promoting positive maternal health outcomes. The conceptual
review established that health education empowers women with knowledge and skills
needed for safe childbirth. The Health Belief Model provided a strong theoretical
foundation showing how beliefs and perceptions influence maternal behaviours.
Empirical studies also showed that although health education improves birth
preparedness, many women still demonstrate low levels of readiness due to
inconsistent health education, cultural barriers, and financial limitations. These gaps
justify the current study examining the impact of health education on birth
preparedness among women attending ANC at Central Hospital Agbor.

CHAPTER THREE
RESEARCH
METHODOLOGY
Research Design
This study will adopt a descriptive cross-sectional survey research design. This design
is considered appropriate because it enables the researcher to collect data from a
sample of antenatal women at a single point in time in order to determine the impact
of health education on their level of birth preparedness. The design also allows the
researcher to describe existing conditions, analyze relationships between variables,
and generalize findings to the target population. It is widely used in maternal health
studies involving knowledge, attitudes, and practices of pregnant women.
Study Setting
The study will be conducted at the Antenatal Clinic of Central Hospital, Agbor,
located in Ika South Local Government Area of Delta State, Nigeria. Central Hospital
Agbor is one of the major secondary health facilities serving Agbor and its
neighboring communities such as Owa, Umunede, Abavo, and Boji-Boji.
The hospital has a functional Maternal and Child Health (MCH) unit that provides
antenatal care, delivery services, postnatal care, neonatal care, family planning,
immunization, and health education. The antenatal clinic runs weekly and attracts a
large number of pregnant women from both urban and rural communities.
The people living around the hospital are predominantly traders, civil servants, farmers,
artisans, and small-scale business owners. The environment is semi-urban with a
mixture of residential and commercial settlements. The presence of the hospital offers
easy access to maternal health services, which makes it an appropriate location for
studying birth preparedness and the impact of health education.
Target Population
The target population for this study consists of all pregnant women attending
antenatal clinic at Central Hospital Agbor during the period of data collection. Hospital
records show that an estimated 250 women attend antenatal clinic monthly. This
population is appropriate for assessing the impact of health education since antenatal
women are the primary beneficiaries of birth preparedness counselling.
Sample Size
The sample size for this study will be determined using the Yamane (1UG7) formula
for finite populations:

Therefore, a sample size of 154 respondents will be used for the study.
Sampling Technique
A systematic random sampling technique will be used to select respondents from the
antenatal clinic. This method is appropriate because the clinic uses a register to
record attendance, making it easy to select participants at regular intervals.
The sampling procedure will be as follows:
[Link] estimated antenatal attendance list will be obtained from clinic records.
2. The sampling interval (k) will be determined by dividing the total number of
antenatal attendees by the required sample size (250 ÷ 154 ≈ 1.G). Therefore,
every 2nd woman will be selected.
3. The first respondent will be chosen randomly, and subsequent respondents will be
selected at the set interval until the required sample size is reached.
This technique ensures equal chances of selection and reduces bias.
Instrument for Data Collection
A structured, self-administered questionnaire will be used to collect data. The
questionnaire will consist of four sections:
• Section A: Socio-demographic characteristics
• Section B: Knowledge of Birth Preparedness Among Pregnant Women (Likert scale:
SA–SD)
• Section C: Extent of Health Education Received on Birth Preparedness (Likert scale:
SA–SD)
• Section D: Impact of Health Education on Birth Preparedness Practices (Yes/No)
The questionnaire will be simple, clear, and designed to capture all relevant
variables in alignment with the research objectives.
Validity of Instrument
To ensure validity, the questionnaire will be submitted to experts in nursing, maternal
health, and research methodology for review. Their suggestions will be used to
improve clarity, relevance, structure, and content. This expert validation will ensure
the instrument adequately measures the constructs of the study.
Reliability of Instrument
A pilot study will be conducted among 20 pregnant women attending antenatal clinic
at a different health facility within Ika South Local Government Area. The responses
will be subjected to Cronbach Alpha reliability test, which is expected to yield a
reliability coefficient of 0.70 and
above, indicating acceptable internal
consistency. Method of Data Collection
Data will be collected through face-to-face administration of questionnaires during
antenatal clinic days. The researcher and two trained assistants will distribute the
questionnaires, explain the purpose, and guide respondents where necessary.
Completed questionnaires will be retrieved immediately to ensure a high response
rate.

Method of Data Analysis

Data collected will be analyzed using the Statistical Package for Social Sciences
(SPSS) version 2G. Descriptive statistics such as frequency tables, percentages, and
mean scores will be used to analyze demographic characteristics and responses to
research questions.
Hypotheses (if any) will be tested using appropriate inferential statistics such as Chi-
square at a
0.05 level of significance.
Ethical Consideration
Ethical approval will be obtained from the Ethics Committee of Central Hospital Agbor.
The purpose of the study will be explained to participants, and informed consent will
be obtained. Participation will be voluntary, and respondents will be free to withdraw at
any time.
Confidentiality and anonymity will be strictly maintained, and information obtained will
be used solely for academic purposes.