The Effect of Flipchart-Based Health Education on Knowledge and Self-Efficacy Regarding High-Risk Pregnancy among Pregnant Women
Abstract
Maternal mortality remains a major public health challenge in Indonesia, and limited knowledge of high-risk pregnancy is one of the factors that may delay appropriate decision-making and reduce women’s confidence in managing pregnancy-related complications. This study aimed to examine the effect of flipchart-based health education on the knowledge and self-efficacy of pregnant women regarding high-risk pregnancy. A pre-experimental study with a one-group pretest-posttest design was conducted at the Kapas Health Center, Bojonegoro Regency. The population consisted of 302 pregnant women, and a sample of 51 participants was selected using the Lemeshow formula. The independent variable was health education delivered through flipchart media, while the dependent variables were knowledge and self-efficacy regarding high-risk pregnancy. Data were collected using structured questionnaires and analyzed using the Wilcoxon signed-rank test with a significance level of 0.05. The results showed a statistically significant improvement in knowledge after the intervention (p = 0.008). Before the intervention, 27 participants (53%) had poor knowledge, 20 (39.2%) had adequate knowledge, and 4 (7.8%) had good knowledge. After the intervention, the proportion with poor knowledge decreased to 16 participants (31.4%), while 24 (47%) had adequate knowledge and 11 (21.6%) had good knowledge, indicating that 68.6% achieved adequate-to-good knowledge after the intervention. A significant improvement was also observed in self-efficacy (p = 0.000). Prior to the intervention, 12 participants (23.5%) had low self-efficacy and 39 (76.5%) had high self-efficacy; after the intervention, all participants (100%) demonstrated high self-efficacy. In conclusion, flipchart-based health education was effective in improving both knowledge and self-efficacy among pregnant women regarding high-risk pregnancy. This approach may serve as a practical, low-cost, and accessible educational strategy for use in community health centers to support better maternal awareness, confidence, and decision-making.
Full text article
References
World Health Organization, “Maternal mortality,” Fact sheet, Apr. 7, 2025.
[2] World Health Organization, UNICEF, UNFPA, World Bank Group, and UNDESA/Population Division, Trends in Maternal Mortality 2000 to 2023: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: WHO, 2025.
[3] Ministry of Health Republic of Indonesia, Indonesia Health Profile 2024. Jakarta: Ministry of Health Republic of Indonesia, 2025.
[4] M. Syairaji, D. S. Nurdiati, B. S. Wiratama, Z. D. Prüst, K. W. M. Bloemenkamp, and K. J. C. Verschueren, “Trends and causes of maternal mortality in Indonesia: a systematic review,” BMC Pregnancy and Childbirth, vol. 24, 2024, doi: 10.1186/s12884-024-06687-6.
[5] M. A. Ratnaningtyas and F. Indrawati, “Characteristics of pregnant women with high-risk pregnancies,” HIGEIA: Journal of Public Health Research and Development, vol. 7, no. 3, pp. 334–344, 2023, doi: 10.15294/higeia.v7i3.64147.
[6] L. D. Prafitri, Suparni, and N. I. Kusuma, “Factors Affecting Early Detection of High Risk of Pregnancy,” Jurnal Proteksi Kesehatan, vol. 14, no. 2, pp. 64–73, 2025.
[7] A. P. Putri and Y. Y. Lu, “Maternal Health Literacy in Pregnant Women: A Concept Analysis,” Maternal and Child Health Journal, vol. 28, pp. 1272–1282, 2024, doi: 10.1007/s10995-024-03945-z.
[8] M. Meldgaard, M. Gamborg, and H. T. Maindal, “Health literacy levels among women in the prenatal period: A systematic review,” Sexual & Reproductive Healthcare, vol. 34, art. 100796, 2022, doi: 10.1016/j.srhc.2022.100796.
[9] T. Singh, B. Tripathy, A. K. Pandey, D. Gautam, and S. S. Mishra, “Examining birth preparedness and complication readiness: a systematic review and meta-analysis of pregnant and recently delivered women in India,” BMC Women’s Health, vol. 24, art. 119, 2024, doi: 10.1186/s12905-024-02932-4.
[10] A. Zaman et al., “The role of antenatal education on maternal self-efficacy, fear of childbirth, and birth outcomes: A systematic review and meta-analysis,” European Journal of Midwifery, vol. 9, art. 13, 2025, doi: 10.18332/ejm/200747.
[11] Y. Xu, Y. Han, L. Wang, H. Xue, Y. Liu, Y. Men, Y. Chen, X. Zhou, and Q. Li, “Effect of antenatal education and midwifery-led care on maternal anxiety, depression, and birth outcomes: A meta-analysis of clinical trials,” Women and Birth, vol. 39, no. 1, art. 102138, 2026, doi: 10.1016/j.wombi.2025.102138.
[12] H. H. Mohammed, A. A. Abd El Hamed, N. A. Abd El-Fadil Afefy, N. A. Sherif, and S. M. Ibrahim, “The effectiveness of nurse-led antenatal education on maternal self-efficacy: an evidence-based approach,” BMC Nursing, vol. 24, art. 895, 2025, doi: 10.1186/s12912-025-03471-5.
[13] H. H. Mohammed, A. A. Abd El Hamed, N. A. Sherif, N. A. Abd-El Fadeel Afefy, and S. M. Ibrahim, “Nursing-led childbirth preparedness sessions: enhancing self-efficacy and maternal outcomes among primiparous women,” BMC Nursing, vol. 25, art. 323, 2026, doi: 10.1186/s12912-026-04404-6.
[14] N. K. Youssef, M. F. Mostafa, and W. H. Ibrahim, “Effect of Implementing Childbirth Preparation Classes on Women’s Self-efficacy and Pregnancy Outcomes,” The Malaysian Journal of Nursing, vol. 16, no. 3, pp. 98–108, 2025, doi: 10.31674/mjn.2025.v16i03.010.
[15] T. S. Hadaro, K. Fikadu, B. Afework, H. Alemu, B. Kussia, and A. S. Ozgu-Erdinc, “Childbirth Self-Efficacy and Its Associated Factors among Pregnant Women in Arba Minch Town, Southern Ethiopia, 2023: A Cross-Sectional Study,” Journal of Pregnancy, vol. 2024, art. 6478172, 2024, doi: 10.1155/2024/6478172.
[16] S. M. Sholikah, F. Nurwulansari, E. N. Aini, S. Wardoyo, and J. J. Pramudita, “The role of continuity of care in high-risk pregnant women in Indonesia,” European Journal of Midwifery, vol. 9, art. 2, 2025, doi: 10.18332/ejm/195831.
[17] I. R. Kusuma, R. Damayanti, S. Prasetyo, and H. Andriani, “Continuity of care and socio-demographic predictors of postpartum family planning utilization among women with a high-risk pregnancy in Indonesia: case-control study,” Bali Medical Journal, vol. 13, no. 3, 2024, doi: 10.15562/bmj.v13i3.5221.
[18] H. Rosiana, M. Ruspita, and S. Isharyanti, “The Effect of Website-Based Information on Pregnant Women’s Knowledge of High-Risk Conditions and Birth Preparedness,” Indonesian Health Issue, vol. 5, no. 1, pp. 162–168, 2026, doi: 10.47134/inhis.v5i1.168.
[19] A. Yolanda, Wijayanti, and R. Wulandari, “The Influence of Health Education with Flip Sheets Media about Fe Tablets on the Level of Knowledge of Pregnant Women at the Sungai Raya Public Health Center in Kubu Raya,” Journal of Advanced Nursing and Health Sciences, vol. 6, no. 1, pp. 1–7, 2025, doi: 10.34035/kn.v6i1.1506.
[20] D. P. Khairunnisa, Y. Herawati, T. Nurlatifah, H. Wijayanegara, A. Suardi, and H. Garna, “Effectiveness of Triple Elimination Flipchart (LeB3E) in Improving Pregnant Women’s Knowledge, Attitudes, and Preventive Actions,” Jurnal Riset Kesehatan Poltekkes Depkes Bandung, vol. 17, no. 2, pp. 433–441, 2025, doi: 10.34011/juriskesbdg.v17i2.2761.
[21] B. Capili and J. K. Anastasi, “An Introduction to the Quasi-Experimental Design (Nonrandomized Design),” American Journal of Nursing, vol. 125, no. 1, pp. 47–52, 2025, doi: 10.1097/01.NAJ.0001081740.74815.20.
[22] A. Althubaiti, “Sample size determination: A practical guide for health researchers,” Journal of General and Family Medicine, vol. 24, no. 2, pp. 72–78, 2023, doi: 10.1002/jgf2.600.
[23] M. A. Ratnaningtyas and F. Indrawati, “Karakteristik Ibu Hamil dengan Kejadian Kehamilan Risiko Tinggi,” HIGEIA (Journal of Public Health Research and Development), vol. 7, no. 3, pp. 334–344, 2023, doi: 10.15294/higeia.v7i3.64147.
[24] G. Kostania, E. K. Mas’udah, and S. Suprapti, “Development of flipchart media for assisting pregnant women by community health cadres,” Indonesian Journal of Midwifery, vol. 14, no. 1, pp. 71–81, 2022, doi: 10.36419/jki.v14i1.764.
[25] S. G. Windari, J. Ernawaty, and Y. Artati, “The effect of health education on knowledge and self-efficacy among high-risk pregnant women,” Jurnal Kesehatan Tambusai, vol. 5, no. 4, pp. 12136–12144, 2024, doi: 10.31004/jkt.v5i4.37125.
[26] N. M. Ningrum, “Early detection of high-risk pregnancies through antenatal care examinations,” Abdi Medika: Journal of Community Service, vol. 4, no. 1, pp. 16–23, 2024.
[27] Ministry of Health Republic of Indonesia, Basic Health Research (Riskesdas). Jakarta, Indonesia: National Institute of Health Research and Development, 2022.
[28] K. Okoye and S. Hosseini, “Wilcoxon Statistics in R: Signed-Rank Test and Rank-Sum Test,” in R Programming. Singapore: Springer, 2024, pp. 279–303.
[29] M. O. Akinwaare and O. A. Oluwatosin, “Effect of goal-oriented prenatal education on birth preparedness, complication readiness and institutional delivery among semi-urban pregnant women in Nigeria: A quasi-experimental study,” PLOS One, vol. 18, no. 7, e0289414, 2023.
[30] A. Yoseph, W. Teklesilasie, F. Guillen-Grima, and A. Astatkie, “Effect of community health education on mothers’ knowledge of obstetric danger signs and birth preparedness and complication readiness practices in southern Ethiopia: A cluster randomized controlled trial,” PLOS One, vol. 19, no. 11, e0312267, 2024.
[31] E. H. El-shrqawy, A. Elnemer, and H. M. Elsayed, “Effect of antenatal education on pregnant women’s knowledge, attitude and preferences of delivery mode,” BMC Pregnancy and Childbirth, vol. 24, art. no. 740, 2024, doi: 10.1186/s12884-024-06922-0.
[32] M. Khan, A. Dave, M. Benton, N. Moss, and M. K. Kaler, “Health literacy interventions for pregnant women with limited language proficiency in the country they live in: A systematic review,” BMC Public Health, vol. 24, art. no. 3287, 2024, doi: 10.1186/s12889-024-20747-8.
[33] S. Li, H.-J. Chen, J. Zhou, Y.-B. Zhouchen, R. Wang, J. Guo, S. R. Redding, and Y.-Q. Ouyang, “Effectiveness of a Web-Based Medication Education Course on Pregnant Women’s Medication Information Literacy and Decision Self-Efficacy: Randomized Controlled Trial,” J. Med. Internet Res., vol. 27, e54148, 2025, doi: 10.2196/54148.
[34] M. Liu, Y. Fang, M. Liu, et al., “The dyadic associations among self-efficacy, dyadic coping, and health-related quality of life between high-risk pregnant women and spouses: A cross-sectional study,” Quality of Life Research, vol. 33, pp. 2235–2245, 2024, doi: 10.1007/s11136-024-03692-2.
[35] A. Zaman, H. A. Fadlalmola, S. E. Ibrahem, et al., “The role of antenatal education on maternal self-efficacy, fear of childbirth, and birth outcomes: A systematic review and meta-analysis,” European Journal of Midwifery, vol. 9, art. no. 13, 2025, doi: 10.18332/ejm/200747.
[36] World Health Organization, WHO recommendations on maternal health: guidelines approved by the WHO Guidelines Review Committee, 2nd ed. Geneva, Switzerland: World Health Organization, 2025.
Authors
Copyright (c) 2026 Sri Hardi Wuryaningsih, Adin Mu’afiro, Miadi, Nimas Dhalita Audria Hanun
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution-ShareAlikel 4.0 International (CC BY-SA 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).