Background: Preconception care (PCC) can contribute to reducing maternal and childhood mortality and morbidity, but the association is inadequately studied in Ethiopia, particularly in relation to the six Health Belief Model constructs. Therefore, this study aimed to determine the level of preconception care knowledge and associated factors among pregnant mothers. Methods: A hospital-based cross-sectional study was conducted at Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital from May to August 2022. A total of 332 pregnant women were selected through a systematic random sampling method. Data were collected using a structured, interviewer-administered, and pretested questionnaire. The data was entered into EpiData and exported into SPSS for analysis. Bivariate and multivariate analyses identified factors influencing preconception care knowledge (p < 0.05, 95% CI). Results: From 332 participants, less than one-half, 158 (47.6%, 95% CI: 42.3, 53.0%), participants had good knowledge of PCC. Knowledge scores varied across the Health Belief Model constructs, with participants showing the highest understanding of perceived benefits (53.3%) and self-efficacy (56%), and lower awareness for perceived susceptibility (40%) and cues to action (36.6%). Participants with college and above educational level (AOR = 4.17; 95% CI: 1.56, 11.18), previous cesarean delivery (AOR = 3.31; 95% CI: 1.29, 8.46), and husband support (AOR = 2.54; 95% CI: 1.12, 5.81) were factors that were significantly related to preconception care knowledge. Conclusions: Less than half of the participants had good knowledge of preconception care, revealing a significant awareness gap among women. These f indings emphasize the need to enhance women’s education, involve men in reproductive health, and for healthcare providers use cesarean delivery encounters as key opportunities to educate women about PCC. In addition, health facility readiness should be improved to enhance PCC awareness.

• Preconception Care • Knowledge • Health Belief Model • South Ethiopia

Elisso M, Lodebo M, Tessema, Beraku, Yohannes S, et al. (2026) Health Belief Model-Based Evaluation of Preconception Care Knowledge among Pregnant Women in Southern Ethiopia. JSM Women’s Health 6(1): 1016.

ANC: Antenatal Care; DM: Diabetes Mellitus; HBM: Health Belief Model; HIV: Human Immunodeficiency Virus; NEMMCS: Negist Eleni Mohamed Memorial Comprehensive Specialized; PCC: Preconception Care; PNC: Postnatal Care; SNNPRG: Southern Nation Nationality People of Region of Government; STI: Sexually Transmitted Infection; WHO: World Health Organization

Preconception care entails offering biological, behavioral, and social health interventions to women and couples prior to conception to improve their health and avoid behaviors and environmental factors that could harm the health of the mother and the unborn child [1]. Women’s and their partners’ health is the focus of preconception care (PCC) before becoming pregnant [2]. Every woman of reproductive age who is capable of becoming pregnant qualifies for preconception care, whether or not she plans to become pregnant. Risk assessment, health promotion, and medical and behavioral health interventions are important PCC components [3].

PCC can make a useful contribution to reducing maternal and childhood mortality and morbidity and to improving maternal and child health in both high and low-income countries by preventing anemia, unplanned pregnancy, sexually transmitted diseases, adolescent pregnancy, congenital anomalies, stillbirth, low birth weight, and preterm birth [4,5]. PCC was listed as one of the interventions that could avert 71% of neonatal deaths, 33% of stillbirths, and 54% of maternal deaths per year [6]. In addition, it will increase the seeking of antenatal care by 39% and positively influence the continuum of maternal care [7].

In order to enhance health and ensure adequate pregnancy preparation, the preconception period is the optimal time to start treatments linked to nutrition and other lifestyle factors [8]. Neural tube abnormalities can be avoided by taking daily supplements of 0.4 to 0.8 mg of folic acid during the pre-pregnancy and early stages of pregnancy. The crucial window for supplementation lasts for the first two to three months of pregnancy and begins at least one month before conception [9]. PCC has the potential to significantly impact 208 million pregnancies annually throughout the world [8]. Unfortunately, adolescents in low- and middle-income countries bear a disproportionately high burden of maternal and infant mortality [4].

Globally, pregnancy and childbirth problems such as hemorrhage, hypertensive disorders, sepsis, and abortion account for more than 70% of maternal mortality, and in 2017, there were approximately 295,000 maternal deaths worldwide secondary to pregnancy and childbirth. Of the estimated maternal deaths worldwide, over 86 percent (254,000) occurred in Sub-Saharan Africa and Southern Asia [10]. While 14,000 maternal deaths occurred in Ethiopia in 2017. Complications of preterm birth, asphyxia, intra-partum perinatal death, and neonatal infections account for more than 85% of newborn deaths [11]. PCC can make a useful contribution to reducing maternal and childhood mortality and morbidity and improving maternal and child health in both high- and low-income countries through prevention of anemia, unplanned pregnancy, STIs, adolescent pregnancy, congenital anomalies, stillbirth, low birth weight, and preterm birth [4]. Women who possess a strong understanding of preconception care are more likely to engage in preventive health behaviors, thereby reducing the risk of complications during pregnancy [2]. However, many women still lack adequate knowledge about the importance of preconception care, which can lead to adverse health outcomes for both mothers and their infants [12], despite the availability of recommended WHO PCC components.

Measuring only factual knowledge of specific PCC interventions (e.g., folic acid, STI screening, vaccination) does not explain why knowledge remains low or why women do not seek PCC services even when they are available. Thus, relying solely on WHO-defined PCC content fails to capture the psychological and contextual determinants that shape women’s health-seeking behaviors. In contrast, the Health Belief Model (HBM) offers a comprehensive behavioral framework that helps explain the motivations and barriers underlying women’s decisions to seek or avoid PCC. Previous studies have shown that socio-demographic factors such as age, marital status, residence, educational status, occupational status, family income, and media exposure, obstetrical factors like status of pregnancy, place of delivery, PNC utilization, history of modern contraceptive, and history of chronic illness were associated with PCC knowledge [13-17]. Although these factors are frequently cited, the specific influence of mode of delivery, particularly cesarean versus vaginal delivery, remains insufficiently explored. This gap is important because delivery-related healthcare encounters may serve as valuable opportunities to provide PCC education. Furthermore, unlike other maternal health services, preconception care is not yet well recognized or systematically integrated into the Ethiopian healthcare system. In addition, existing studies do not assess the readiness of health facilities to deliver PCC. These gaps highlight the need for further research in this area. This study aims to assess the level of knowledge about preconception care and identify associated factors among pregnant women who visited NEMMH for pregnancy care during the study period.

Study Design and Setting

An institution-based cross-sectional study was conducted from May to August 2022. The study was conducted at Wachemo University, Nigist Eleni Mohamed Memorial Comprehensive Specialized Hospital, Hosanna Town, Southern Ethiopia. It is the only Comprehensive Specialized Hospital found in the Hadiya zone. Hosanna town is situated 232 kilometers from Addis Ababa, the capital city of Ethiopia. The Hospital was established in 1976 E.C. and has been serving about 1,568,000 males and 1,632000 females.

Study Population

All pregnant women attending antenatal care (ANC) at Wachemo University Nigste Elieni Mohamed Memorial Comprehensive Specialized Hospital during the data collection period were included in the study. However, women who were severely ill were excluded from participation.

Sample Size and Sampling Procedure

The sample size for the study was calculated using the single population proportion formula, based on the following assumptions: a proportion (p) of 26.8% was obtained from the study conducted in West Shewa Oromia region, Ethiopia [12], a 95% confidence interval (CI), a critical value (Zα/2) of 1.96, and a margin of error (d) of 0.05. This calculation resulted in a required sample size of 332 pregnant women. A systematic random sampling technique was used to select study participants. The data collection period for this study was 3 months. A total of 747 pregnant women received ANC services in the 3 months preceding data collection. Based on this, the sampling interval was determined by dividing the total number of 747 by a calculated sample size of 332, resulting in a sampling interval of approximately 2. Finally, every other ANC patient was selected for an interview within 3 months. The first pregnant woman was randomly selected from among the first two based on the sequence of their charts.

Variables

Knowledge of PCC was a dependent variable: assessed using a structured questionnaire consisting of 34 items developed based on the Health Belief Model (HBM). Each item represented a knowledge indicator linked to one of the six HBM constructs. Perceived Susceptibility (6 items), Perceived Severity (5 items), Perceived Benefits (7 items, Perceived Barriers (5 items), Cues to Action (6 items), Self-Efficacy (5 items). An overall knowledge score was computed by summing all correct responses (range: 0–34). Participants who scored ≥50% (≥17 correct responses) were categorized as having good knowledge; those scoring <50% were categorized as having poor knowledge [14].

Mother’s socioeconomic and demographic, obstetric and medical-related, access to and readiness of health facility-related, were independent variables.

Data Collection Technique and Instrument

The data collection instrument for this study included sections on socio-demographic and economic characteristics, obstetric and medical history, and access to and readiness of health facilities, which were adapted from previously published studies [15-20]. In contrast, knowledge items were newly developed specifically for this study based on the six constructs of the Health Belief Model (HBM): Perceived Susceptibility (6 items), Perceived Severity (5 items), Perceived Benefits (7 items), Perceived Barriers (5 items), Cues to Action (6 items), and Self-Efficacy (5 items). The tool was initially prepared in English, translated into Amharic, and back-translated to ensure semantic consistency. Content validity was confirmed through expert review by maternal and public health professionals, with a scale-level Content Validity Index (S-CVI) of 0.92. Face validity was assessed during a pretest on 5% of participants at Worabe Comprehensive Specialized Hospital, leading to minor revisions for clarity. Reliability testing demonstrated acceptable internal consistency, with Cronbach’s alpha values ranging from 0.70 to 0.78 across HBM constructs and an overall alpha of 0.77. Data collection was carried out using structured, pretested, interviewer-administered questionnaires. A team of six midwives served as data collectors, with two supervisors overseeing the process. Two days of training were provided for data collectors and supervisors before data collection, on the objective of the study, the data collection tool, and the procedure. Data were collected after explanation of the objectives of the study, and participants had signed the informed consent using a consent form designed for the study.

Data Processing and Analysis

The completed survey was reviewed for accuracy and consistency. To reduce data entry mistakes, the collected data were entered using EpiData version 3.1. For statistical analysis, it was afterwards exported to SPSS version 23. Descriptive statistics, including frequency and percentage, were calculated to summarize the characteristics of the study variables. All explanatory variables associated in binary logistic regression with a p-value of 0.25 or less were considered for multivariable logistic regression analysis to control confounding factors. Odds ratio with a 95% confidence interval was computed to assess the strength of association in the adjusted model. Finally, p-value < 0.05 was used to declare the final statistical significance and the association between the participants’ knowledge and explanatory variables.

Ethics Approval and Consent to Participate

Ethical clearance was obtained from the Institutional Review Board (IRB) of the Hosanna College of Health Sciences, with Ref No: Code 1102/2014 E.C. Responsible Hospital managers were communicated, and permission letters were obtained. Before data collection, written informed consent was obtained from study participants. Confidentiality of the information was secured throughout the study process. Finally, the result of the study was used only for study purposes.

Socio-Demographic Characteristics

A total of 332 pregnant women participated, giving a response rate of 100%. The age of the participants ranged from 15 to 45 years, with a mean age of 25.7 years (SD ±4.3). The majority (84%) of the study participants were Hadiya in ethnicity, and nearly three-fourths (74.4%) of protestant religion followers. Nearly one-fifth (21.7%) of the respondents had no formal education, and one-half (50.3%) were housewives (Table 1).

Table 1: Socio-demographic characteristics of the study participants in Wachemo University Nigste Elieni Mohamed Memorial Comprehensive Specialized Hospital, Southern Ethiopia, 2022(n= 332).

Obstetrical and Pre-Existing Medical Illnesses of the Study Participants

Of the total study participants, 41.3% of women were experiencing their first pregnancy, and 52.3% were multiparous. 31.3% of participants reported a prior history of adverse pregnancy outcomes, including 49% with a history of abortion and 19.7% with a history of stillbirth. Among all participants, 5.1% had a pre-existing medical illness (Table 2).

Table 2: Obstetrical and medical related characteristics of the study participants in Wachemo University Nigste Elieni Mohamed Memorial Comprehensive Specialized Hospital Southern Ethiopia, 2022 (n= 332)

*Human immunodeficiency virus/ Acquired immunodeficiency syndrome, ** Diabetes Mellites, aAntenatal care, bPostnatal care

Access to and Readiness of Health Facilities-Related Characteristics

Among the total study participants, (72.3%) perceived distance to reach a nearby health facility on foot was less than 30 minutes. The majority, (84.6 %) of respondents had access to transportation, and nine in ten (90.9%) study participants said the availability of medication. Only 12% health workers at the facility discuss preconception care during pregnancy, family planning, and PNC visits. All participants reported that preconception care is not provided as part of the routine services offered to women of reproductive age at their health facility. The majority, (90%) of participants reported that health facility does not provide preconception care services like counseling, screening, and education. More than two-thirds, (68.3%) of study participants had husband support for health services, and (72.9%) had autonomy on maternal health services.

Level of Knowledge of Study Participants

The overall level of knowledge of preconception care (PCC) among the study participants, based on the Health Belief Model (HBM) constructs, was 158 (47.6%, 95% CI: 42.3, 53.0%), reflecting the proportion of participants who correctly identified at least half of the HBM-related knowledge items.

Knowledge of Perceived Susceptibility: The composite knowledge score for perceived susceptibility was 40%, highlighting limited awareness of the full spectrum of pre-pregnancy risks. Among the total participant 58.1% recognized that uncontrolled chronic diseases (e.g., diabetes or hypertension) could lead to complications. In addition, 51.8% were aware that being underweight or overweight increases pregnancy-related risks. About 50% identified the association between unplanned pregnancies and adverse outcomes. However, only 25% were aware that maternal age extremes, previous adverse pregnancy outcomes, and exposure to environmental toxins increase pregnancy risks.

Knowledge of Perceived Severity: The level of knowledge regarding the severity of pre-pregnancy health risks among pregnant women was 47.8%. From this, 61.4% of participants recognized that failure to take folic acid before conception increases the risk of neural tube defects, while 48.2% identified the importance of vaccination to prevent congenital infections. Awareness of untreated sexually transmitted infections (STIs) was higher at 79.5%. Besides this, 25% of participants recognized gestational diabetes and preconception hypertension as serious maternal and neonatal risks.

Knowledge of Perceived Benefits: Among the total study participants, 53.3% demonstrated good knowledge of beneficial preconception interventions. From this, 61.4% recognized folic acid supplementation, 79.5% acknowledged STI screening, 48.2% were aware of vaccination benefits, 81.3% identified regular exercise, and 51.8% understood the value of maintaining optimal body weight. However, 24.7% recognized the benefits of preconception mental health counseling, and 25% avoiding harmful substances such as alcohol, tobacco, or drugs.

Knowledge Perceived Barriers: The level of knowledge score for perceived barriers was 51.5%, demonstrating awareness of structural and social challenges that could hinder uptake of PCC services. Among this, 90% of participants were aware of the lack of PCC services at health facilities as a barrier, 27.7% cited cost and distance, and 88% noted limited provider awareness. However, only 25% recognized cultural beliefs and a lack of family or social support as potential obstacles.

Knowledge of Cues to Action: The total knowledge score for cues to action was 36.6%, indicating a significant gap in understanding external prompts to engage in preconception care. From this, only 12% identified counseling during ANC, PNC, or family planning visits as a source of PCC information. 68.3% recognized husband or partner support, 57.5% cited mass media and community health education, and 28.6% mentioned advice from friends or relatives. Furthermore, 25% participants reported reminders from community health workers and acknowledged participation in community health programs as motivating factors.

Knowledge of Self-Care and Self-Efficacy: The level of knowledge score for self-efficacy was 56%, reflecting some understanding of personal capacity to adopt healthy pre pregnancy behaviors. 52.4% recognized the importance of stopping alcohol and smoking, 58.1% understood the need for chronic disease management before conception, 81.3% acknowledged the role of lifestyle modifications (nutrition and exercise), and 68.3% recognized partner participation as supportive. In addition, 25% were aware of seeking preconception information via social media or written resources.

Factors Associated With Knowledge of Preconception Care

Based on the multivariable analysis, women’s educational status was significantly associated with their knowledge of preconception care (PCC). Specifically, women who attained college-level education and above were over four times more likely to have good knowledge about PCC compared to those with no formal education (AOR = 4.17; 95% CI: 1.56, 11.18).

Previous mode of delivery also showed a significant association with knowledge of PCC. Women who had previously delivered by cesarean section were more likely to have good knowledge compared to those who delivered vaginally (AOR = 3.31; 95% CI: 1.29, 8.46).

In addition, husband support emerged as a significant factor influencing women’s knowledge of PCC. Women who reported receiving support from their husbands were more than twice as likely to have good knowledge compared to those without such support (AOR = 2.54; 95% CI: 1.12, 5.81) (Table 3).

Table 3: Bivariable and multivariable logistic regression analysis of factors associated with the knowledge of preconception care among pregnant women in Wachemo University Nigste Elieni Mohamed Memorial Comprehensive Specialized Hospital Southern Ethiopia, 2022 (n= 332).

* Cesarean Section, **Preconception Care

Preconception care is a key to reducing and preventing maternal and child morbidity and mortality. In Sub-Saharan Africa, particularly in Ethiopia, where maternal and neonatal mortality rates remain alarmingly high,increasing awareness and understanding of PCC is vital [21]. This institution-based cross-sectional study aimed to assess the level of PCC knowledge among pregnant women and identify factors influencing that knowledge.

The current study showed that less than one-half 158 (47.6%, 95% CI: 42.3, 53.0%) participants had good knowledge of PCC. From an HBM perspective, this level of awareness reflects limited perceived susceptibility and perceived severity toward adverse pregnancy outcomes among many Ethiopian women. The lack of integration of PCC services into routine healthcare also reduces cues to action, the external triggers (such as counseling or health education) that motivate women to seek information or services before conception. The current finding is consistent with studies done in Wolkite (45.5%) [22], Zambia 47.4% [23], Jordan 48.6% [24], Malaysia (51.9%) [25], and Nepal (49%) [26]. However, this finding is higher than the study done in West Shewa zone in Oromia (26.8%) [16], Jimma (21.3%) [27], Debre Birhan (17.3%) [28], Adiet Amhara 27.5% [20], Hawassa (20%) [13], Ethiopia (30.9%) [12], Kenya (38.3%) [29], and Sudan (11%) [30]. A possible reason might be the difference in study setting; the previous studies were conducted in a community setting or in a primary health facility, whereas the current study was conducted in a facility. As result of the study setting difference, study participants in specialized hospitals might have a higher level of health care awareness, enabling them to understand the importance of preconception care, and women who had care in specialized hospitals might be more likely to have pre-existing health conditions, complications, and perceived risk in pregnancy, which encouraged them to be more to understand preconception services than general pregnant population.

Whereas it is lower than the study done in Hosanna 64.8% [31], Addis Ababa 58% [32]. Iran among reproductive-age women (68%) [33], Saudi 57.2% [34], and the study done in Nigeria (65%) [35]. The low awareness level in our study could have resulted from the differences in health sector infrastructure, socioeconomic factors, in the study population, preconception care services across the countries, and promotion of preconception care through mass media. A significant contributing factor to the lower level of awareness in our study could be the limited integration of PCC into routine healthcare services in Ethiopia. In many settings, PCC is still not systematically included in pre-pregnancy care, and there is a lack of structured programs to educate women about its importance before conception.

Most participants (90%) reported that PCC services were not available in their health facilities, and only 12% had ever been counseled about PCC during ANC, family planning, or postnatal visits. According to the HBM, such system-level limitations represent strong perceived barriers that hinder women’s awareness and engagement. Even when women recognize their susceptibility or the potential benefits of PCC, lack of access to services prevents them from translating knowledge into behavior. Strengthening service availability, provider counseling, and community-level information dissemination is therefore crucial to lowering these barriers.

Women who attended College and above had better knowledge about PCC than women with no formal education. This finding was similar to studies conducted in the West Shewa zone [19], Hawassa, South Ethiopia [17], Adet town, Northwest Ethiopia [36], Jimma, Southwest Ethiopia [15], and Nigeria [35]. This might be explained by the fact that higher educational attainment among women could have resulted in better capability to seek health information, like preconception care, among the participants. Educated women are more likely to understand and value the perceived benefits of preconception interventions such as folic acid supplementation, vaccination, and lifestyle modification, allowing women to recognize the positive impact of preventive actions on maternal and child health. Education also enhances self-efficacy, giving women confidence in their ability to seek, interpret, and apply health information. In addition, women with higher educational attainment often have better access to health communication channels (e.g., internet, social media, written materials), which reinforce knowledge and motivation for preventive actions.

The results of our study showed that women who delivered their last child by cesarean section were seven times more likely to have good knowledge of PCC than those women who gave birth through spontaneous vaginal delivery. This may be due to their increased exposure to healthcare providers and more intensive medical care during and after the surgical procedure, which creates additional opportunities for health education. Women undergoing cesarean delivery often receive counseling on birth spacing, recovery, and the importance of optimizing health before a subsequent pregnancy. Such repeated interactions with healthcare professionals serve as crucial cues to action within the Health Belief Model framework, reinforcing awareness of the benefits of PCC, including adequate nutritional preparation, management of prior pregnancy complications, and planning for healthier future pregnancies. In addition, prior obstetric complications increase perceived susceptibility to adverse pregnancy outcomes and enhance perceived severity of potential risks. Women who have experienced complex deliveries may be more attentive to health information and more motivated to adopt preventive practices, reflecting the HBM principle that perceived threat drives health-seeking behavior.

According to our study, study participants who had their husbands’ support about maternity care were three times more likely to have good knowledge about PCC than their counterparts. This finding is in line with studies done in Mekelle, Ethiopia [37], and Nigeria [35]. Male involvement helps reduce perceived barriers, such as lack of encouragement or financial support, and strengthens cues to action through discussions, joint decision-making, and emotional reinforcement. When husbands are involved in maternal health, women are more empowered to seek information and adopt preventive health behaviors before conception.

The findings of this study emphasize the urgent need to integrate PCC into routine maternal health services within Ethiopian healthcare settings. Given that less than half of pregnant women demonstrated adequate knowledge of PCC, targeted health education strategies must be implemented, particularly for women with lower educational attainment.

Healthcare encounters, such as antenatal care and cesarean section follow-up visits, provide valuable opportunities to deliver PCC messages, counseling, and essential services. Improving facility readiness by ensuring availability of PCC materials, protocols, and services such as screening for chronic conditions, counseling on nutrition and harmful exposures, and folic acid supplementation. Additionally, counseling during antenatal and post-cesarean follow-up visits should be used to enhance women’s understanding of their susceptibility to pregnancy-related complications and the severity of adverse outcomes that can be prevented through effective preconception care.

Male involvement in reproductive health should be strengthened to enhance partner support and shared decision-making, which serve as important cues to action in improving women’s awareness and engagement with PCC.

This study has some limitations. Its cross-sectional design prevents establishing causal relationships between factors and knowledge of preconception care. Being institution-based, findings may not be generalizable to women in rural areas or other health facilities. Knowledge was self-reported, which may introduce social desirability or recall bias. finally, the PCC knowledge items were newly developed and not previously validated, limiting comparability with other studies.

This study revealed that less than half of the pregnant women had good knowledge of preconception care (PCC), indicating a significant gap in awareness and preparedness for optimal maternal and child health outcomes. Within the framework of the Health Belief Model, educational status (self-efficacy and perceived benefits), mode of previous delivery (cues to action), and husband support (reducing barriers and enhancing cues) were the main factors influencing PCC knowledge.

Improving women’s knowledge requires strengthening health education that increases perceived susceptibility and benefits of PCC, removing structural barriers, and creating supportive social and institutional environments. The findings highlight the urgent need for targeted health education, greater male involvement, and the institutionalization of PCC services within routine maternal healthcare to improve awareness. Strengthening healthcare provider training and facility readiness is also crucial to ensure that PCC becomes a standard part of reproductive health services in Ethiopia.

Ethical clearance was obtained from the Institutional Review Board (IRB) of the Hossana College of Health Sciences, with Ref No: Code 1102/2014 E.C.

TG and ME developed the study’s conceptualization, data curation, and developed initial drafts. TG, ME, ML, TB, SY, and YT participated in the methodology, data analysis, interpretation, and draft review. TG and ME prepared the final draft. All authors read and approved the final manuscript.

We would like to express our sincere gratitude to Hosanna Health Science College for granting us the opportunity to conduct this research project. Next, we are grateful to give special thanks to Nigist Eleni Mohammed Memorial Comprehensive Specialized Referral Hospital for all its support during actual data collection and Hosanna Health Sciences College Institutional Review Board (IRB),tudy participants, data collectors, and supervisors for their unlimited support and contribution during the research work.

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