The nutritional status of pregnant women has a role in determining maternal and fetal health outcomes. During pregnancy, which is a period of increased physiological demand, where adequate nutrition is essential for supporting the mother's well-being and the growth and development of the fetus [1], women require adequate nutrition, especially before and during pregnancy and while breastfeeding. The nutritional status of pregnant women indicates their overall health, and this is directly influenced by their dietary intake and the ability of their body to utilize nutrients effectively to meet metabolic demands during pregnancy [2]. Considers it one’s body condition or of a population in relation to their nourishment [3]. This largely depends on the consumption and effective utilization of nutrients to meet metabolic needs. The ability of pregnant women to receive appropriate amount of nutrients in proportion to the needs of their body determine their state of a good nutrition and status [4].

Studies in developing countries, including anthropometric, biochemical, and dietary assessments have shown that essential nutrients in the nutrition of most pregnant women had resulted in the occurrence of anemia among the low- and middle-income countries [5]. Deficiency in iron among these women has slightly risen in recent times by approximately 36.5% in these countries. Given the significant influence of anemia on the overall health, especially among vulnerable populations such as pregnant women. Nutrition of a mother during pregnancy can have a lasting impact on the health of her child, heighten the risk of hypertension in adulthood and stunted growth in infants with low birth weight [6]. Inadequate nutrients intake impacts a significant number of pregnant women globally, given that it is preventable [5].

Malnutrition remains a pervasive challenge to global health, manifesting in two distinct yet equally concerning forms that affect populations worldwide [7]. The condition encompasses both under nutrition, characterized by inadequate caloric and nutrient consumption, and over nutrition, which occurs when individuals consume excessive calories while receiving insufficient essential nutrients [8]. This dual nature of malnutrition reflects the complex nutritional landscape facing contemporary society, where food insecurity and poor dietary quality often coexist within the same communities.

The consequences of severe malnutrition are particularly devastating in low- and middle-income countries, where it serves as a major contributor to morbidity and mortality rates. These regions face the compounded challenge of limited access to nutritious foods while simultaneously dealing with the health implications of nutrient-poor, calorie-dense alternatives. The situation becomes even more critical during pregnancy, when women's bodies require substantially increased energy and nutrient intake to support both their own physiological needs and the developing fetus. This heightened nutritional demand during gestation underscores the importance of addressing malnutrition as a priority for maternal and child health outcomes, particularly in vulnerable populations where nutritional deficiencies can have long-lasting intergenerational effects.

When expectant mothers experience nutrient deficiencies, their developing fetuses are exposed to suboptimal levels of crucial macro and micronutrients, creating a cascade of adverse outcomes that can affect both immediate pregnancy success and long-term child development [9]. These nutritional inadequacies during the critical period of fetal development can manifest as restricted intrauterine growth, structural birth defects, premature delivery, and a spectrum of pregnancy-related complications that threaten both maternal and fetal wellbeing. The profound impact of maternal nutrition on pregnancy outcomes emphasizes the critical importance of promoting appropriate dietary practices and ensuring sufficient nutrient consumption throughout the gestational period, as these factors are fundamental to achieving optimal health outcomes for both mothers and their newborns [10]. Despite numerous intervention efforts and public health initiatives, Nigeria continues to grapple with persistently elevated rates of maternal and child malnutrition, highlighting the complex and multifaceted nature of this public health challenge that requires sustained, comprehensive approaches to address effectively [11].

The scope of malnutrition among pregnant women in Nigeria is particularly concerning, as documented by the National Health Survey, which found that approximately 7% of expectant mothers suffer from malnutrition, with significant variations observed across different regions of the country [12]. This nutritional crisis intersects with broader maternal health challenges, as pregnancy and childbirth represent uniquely vulnerable periods for women that contribute substantially to maternal morbidity and mortality worldwide [13]. The global scale of maternal mortality is staggering, with an estimated 275,000 women losing their lives annually due to complications arising during pregnancy and the birthing process [14]. Sub-Saharan Africa bears a disproportionate burden of this tragedy, recording a maternal mortality ratio of approximately 500 deaths per 100,000 live births, with Nigeria alone accounting for 14% of all global maternal deaths . The persistent nature of this crisis in Nigeria is evidenced by the 2018 National Demographic and Health Survey, which documented a maternal mortality ratio of 615 deaths per 100,000 live births, representing only marginal improvement from the 2008 figure of 545 deaths [13].

The devastating impact of elevated maternal mortality extends far beyond individual tragedy, creating profound consequences for child health outcomes and survival. Birth weight emerges as a crucial predictor of newborn health prospects, with infants weighing less than 2.5 kilograms at birth or those born prematurely facing significantly heightened risks of early childhood mortality [12,15]. This challenge reaches global proportions, with more than 20 million babies annually classified as low birth weight, representing 15.5% of all births worldwide, and over 95% of these cases occurring in developing nations. Low birth weight serves as a critical determinant not only of immediate neonatal survival but also of long-term developmental trajectories, influencing cognitive development, physical growth, and disease susceptibility throughout the individual's lifetime [16]. The interconnected nature of these challenges is particularly evident in Nigeria, where statistical evidence indicates that complications directly attributable to maternal malnutrition contribute significantly to the country's persistently high maternal mortality rates [17].

Within Nigeria's complex healthcare landscape, sociocultural dynamics play a pivotal role in shaping the nutritional status of pregnant women who seek care at healthcare facilities. The persistence of elevated malnutrition rates among this vulnerable population, despite enhanced awareness campaigns and targeted health interventions, underscores the profound influence of deeply embedded cultural practices and social structures on maternal nutrition [18]. This challenge manifests distinctly at the regional level, as exemplified by Oyo State, where approximately 10% of pregnant women experience malnutrition, revealing the presence of localized socioeconomic and cultural determinants that significantly impact nutritional outcomes within specific geographical contexts [19].

The global maternal healthcare landscape presents a paradox where, despite considerable progress in service delivery and health system strengthening, nutritional challenges among pregnant women in developing nations such as Nigeria continue to pose significant public health concerns. The complexity of maternal nutrition extends beyond simple dietary adequacy, encompassing a multifaceted web of social determinants that require comprehensive understanding to develop effective interventions. Contemporary research reveals a critical knowledge gap in the literature regarding the intricate ways in which various social factors interact and collectively influence nutritional practices and outcomes. While existing studies have predominantly examined individual variables such as social support systems, occupational factors, and peer influence in isolation, there remains limited exploration of their synergistic effects and combined impact on maternal nutrition. This research limitation is particularly pronounced in the context of pregnant women accessing specialized healthcare facilities, where the intersection of institutional care and community-based social influences creates unique dynamics that warrant comprehensive investigation.

Theoretical Framework: Socio-Ecological Model

The socio-ecological model provides a comprehensive lens to examine the multiple factors influencing nutritional status during pregnancy. Rather than narrowing maternal nutrition solely to individual responsibility, this framework considers the broader environmental and societal influences on nutritional behaviours [20,21].

What shape a pregnant woman’s diet at the individual level are personal health history, metabolic changes, food preferences, cultural beliefs, and the knowledge of nutrition [22,23]. Preconceived nutrition significantly affects maternal and fetal health [24]. The encouragement of interpersonal environment, including family, partners, friends, and healthcare professionals, also plays an integral role, coupled with the assistance from these networks can lead to healthier eating habits [25,26].

So many factors like access to food, transportation, community health programs, and neighbourhood support networks at the community level can promote or hinder healthy dietary practices during pregnancy [27-29].

On a wider scale, policies and cultural norms validate the broader context in which nutrition decisions are made. These include government nutrition guidelines (both federal and local), public health initiatives and programmes, agricultural subsidies and interventions, workplace health related policies, and culturally held beliefs around pregnancy [30-32].

Multi-level interventions such as personalized prenatal counselling should be supported by education for families and communities, improved food environments, and supportive policy frameworks. These emphasize the importance of the socio-ecological approach [33,34]. These accelerated efforts proved to be more successful in improving nutritional outcomes than isolated interventions [35,36]. Essentially, these holistic approaches often lead to healthier pregnancies and better long-term results for mothers and their children [30,37].

Study Design

This study employed a descriptive correlational research design to investigate the social predictors of nutritional status among pregnant women through a socio-ecological lens. This methodological approach was proffered for its ability to systematically examine how factors at multiple ecological levels including individual characteristics, interpersonal relationships, community resources, and societal policies collectively influence maternal nutrition outcomes without manipulating these naturally occurring relationships. The appropriateness of this design is the key reason it was utilized for identifying key social determinants such as maternal social support networks, peer influence, and occupation which predict nutritional adequacy during pregnancy. This approach enabled a holistic analysis of how social predictors at different ecological levels interact to shape nutritional vulnerability or resilience among pregnant women, generating evidence to inform contextually appropriate interventions that address the complex social determinants of maternal nutrition.

Study Settings

The study was conducted in Adeoyo Maternity Teaching Hospital. These institutions are referral centers and offer a wide range of healthcare services, including family medicine, diagnostic imaging, cancer care, emergency services, dialysis, physiotherapy, nursing education, rehabilitation, and pediatric intensive care.

Study Population

All the pregnant women who attended Adeoyo Maternity Teaching Hospital, Oyo state, Nigeria during the study period were used as the study population. Hospital records showed that approximately 233 pregnant women registered for the antenatal care while the study was on-going

Sample Size and Sampling Technique

A purposive sampling technique was employed to select the government owned hospitals as referral centers for family medicine, delivery and other health-related services within the locality. This approach ensured that the sample included pregnant women attending this hospital. The study recruited 233 pregnant women, of whom 208 provided complete and usable questionnaires, representing an 89.3% response rate.

Instrument for Data Collection

The instrument used for collecting data was constructed by the researcher based on a comprehensive review of relevant literature. The questionnaire underwent translation from English to Yoruba (the predominant language in the study setting) and back-translation to English to ensure linguistic equivalence and conceptual consistency. The instrument comprised three parts: Section A contained demographic profiles; Section B assessed nutritional knowledge using a 4-point Likert scale; and Section C examined social variables related to the study objectives.

Procedure for Data Collection

The researchers were assisted by assistants who were health attendants in distributing the questionnaire to the respondents to guarantee accurate data. Before starting data collection, needed approvals were secured from the facility head who supervises doctors, nurses and health attendants. At the beginning, the research team and assistants came together for a briefing to look over the study goals, ethics and how to give out the questionnaires. This allowed all members of the team to address participants’ questions and explain things clearly before the questionnaire.

All questionnaires were given to participants privately so they would feel comfortable answering honestly. Each researcher or assistant understood the research aim, what kinds of questions would be asked and that the respondents had the liberty to leave the study anytime they wished. To help more people take part, the forms were self-filled, and research assistants helped those who needed help. Immediately after finishing the questionnaires, they were collected to increase the likelihood of getting them back. During the collection process, researchers carefully monitored everything to solve any problems and to be sure ethical rules were always followed.

Ethical Considerations

The study used strict ethical guidelines, based on the Declaration of Helsinki, which deals with study participants. Before starting this research, ethical approval was granted by the Oyo State Ministry of Health’s ethical review committee with the protocol number (Reference No: AD13/479/723), so that all the participants’ rights and welfare were safeguarded. All the participants gave written and oral consent, so fully informed consent was obtained before they became involved. Because of how wholeheartedly the study was explained, participants fully understood its purpose, the process involved, the dangers and that they could pull out anytime without risks.

Data Analysis

All questionnaires were now received, coded and studied using both descriptive and inferential statistics of regression analysis. We described demographic variables using frequencies, percentages and frequency tables and regression analysis was used to examine each hypothesis at a statistical significance level of 0.05 (p < 0.05). The analysis of data was carried out using SPSS version 25.0.

Table 1 displays that 98 representing 47.1% are within the age of 20-29 years, 67 representing 32.1% are within the age of 30-39 years 41, representing 19.5% are within the age of 40-49 years, 3 representing 1.3% are within the age of 50-59 years.

Table 4.1 also shows 104 representing 50% are Christians, 91 representing 43.7% are Muslims, 7 representing 3.4% are traditional and 6 representing 2.9% belong to others. It was also found that 119, representing 57.2%, are Yoruba, 50, representing 24.0%, are Igbo and 22, representing 10.6%, and are Hausa/Fulani, while 17, representing 8.2%, belong to others. 69 representing 33.2 % have post-secondary school education, 47 representing 22.2% have Junior Secondary School, 62 representing 29.8% have Primary School and 30 representing 14.2% have no formal education.

Additionally, 4 representing 1.9% are single, 201 representing 96.6% are married, 2 representing 1.0% are divorced, and 1 representing 0.5% is a widow. Lastly, Table 4.1 reveals that 24, representing 11.5%, are unemployed, 66, representing 31.8%, are artisans, 97, representing 46.6%, are traders and 21, representing 10.1%, are civil servants

Demographic Characteristics of the Respondents

Table 1: Displays that 98 Representing 47.1% are within the Age of 20-29 Years, 67 Representing 32.1% are within the Age of 30-39 Years 41, Representing 19.5% are within the Age of 40-49 Years, 3 Representing 1.3% are within the Age of 50-59 Years.

The descriptive analysis of nutritional awareness of pregnant women is displayed in Table 2. The table shows that the weighted average (2.75) is greater than the average criterion (2.50). This indicates that pregnant women have adequate nutritional knowledge. Also, out of the 6 items used in measuring nutritional knowledge of pregnant women, only 3 items contribute to nutritional knowledge of pregnant women and rated as follows in order of magnitude; respondents with knowledge of a balanced diet during pregnancy (2.92>2.75) ranked highest among the mean score rating followed by I know which foods are rich in folic acid (2.81>2.75) followed by I am aware of the source of iron and its benefits for me and my unborn baby (2.79>2.75).while the other 3 items are lower than the weighted mean and ranked as follows; Vegetables and fruits are sources of vitamin (2.56<2.75) followed by Alcohol is good for pregnant women (2.62<2.75) and I understand the importance of calcium and how to include it in my diet (2.73<2.75).

Table 2: Descriptive Analysis of Nutritional Knowledge among Pregnant Women Attending Adeoyo Maternity Teaching Hospital Ibadan, Oyo State.

It is shown in table 3 that social factors (occupation, social support and peer influence) have a significant linear effect on the nutrition of pregnant women who visit the Adeoyo Maternity Teaching Hospital in Ibadan (F (3,204) = 205.929, p<0.05). The outcome was a coefficient of multiple regression of R=0.867 and a multiple R-squared of 0.752. According to the result, adjusted R2 has a value of 0. 748; thus, about 75% of the variance was explained by the independent variables. Thus, social support, job, and peer group play a role in shaping the nutritional status of pregnant women at Adeoyo Maternity Teaching Hospital Ibadan.

Regression Analysis of the Joint Contribution of Social Variables (Social Support, Occupation, and Peer Influence) on Nutritional Status

Table 3: Social Factors (Occupation, Social Support and Peer Influence) Have A Significant Linear Effect on The Nutrition of Pregnant Women.

Table 4 provides the unstandardized regression weight (β), the standardized error of estimate (SE), the standardized coefficient, the t-ratio and a statement about the significance level for social support, occupation and peer influence. According to the table, social support was measured with a significant beta weight of -0.833 (β=-0.833, t=-21.424, p<0.05), whilst peer influence (β=0.663, t=16.736, p<0.05) and work (β=-0.125, t=-3.177, p<0.05) also turned out to be significant. So, it means that social support, job status and friends influencers matter somewhat in predicting the nutritional status of pregnant women in Adeoyo Maternity Teaching Hospital, Ibadan.

Regression Analysis of the Relative Contribution of Social Variables Social Support, Occupation, and Peer Influence) on Nutritional Status

Table 4: Provides the Unstandardized Regression Weight (Β), The Standardized Error of Estimate (SE).

This study found that pregnant women attending Adeoyo Maternity Teaching Hospital demonstrated relatively high levels of nutritional knowledge, with an obtained weighted mean value of 2.75, exceeding the criterion mean value of 2.50. This finding aligns with Adeleye et al., who reported that women with higher nutritional knowledge exhibited better dietary diversity and reduced likelihood of underweight status or anemia. However, while nutritional knowledge represents an important foundation, the socio-ecological framework employed in this study reveals that knowledge alone operates within a complex web of multi-level influences that ultimately determine nutritional outcomes.

The socio-ecological model [20,21] posits that individual health behaviors emerge from dynamic interactions between personal characteristics and environmental contexts across multiple nested levels. This study's findings provide compelling empirical support for this theoretical framework, demonstrating how factors at the individual, interpersonal, organizational, and community levels collectively shape nutritional status among pregnant women. At the individual level, the relatively high nutritional knowledge observed among participants (weighted mean = 2.75) reflects personal factors including health literacy, dietary awareness, and understanding of pregnancy-specific nutritional requirements. The socio-ecological model emphasizes that individual-level factors such as personal health history, metabolic changes, food preferences, cultural beliefs, and nutritional knowledge fundamentally shape a pregnant woman's dietary behaviors [22,23]. This knowledge base serves as the cognitive foundation upon which women make dietary decisions, yet our findings reveal that this individual-level factor alone is insufficient to ensure optimal nutritional status.

Specifically, participants demonstrated strong knowledge regarding the importance of balanced diets during pregnancy (mean = 2.92), identification of folic acid-rich foods (mean = 2.81), and awareness of iron sources and benefits (mean = 2.79). This nutritional literacy represents a critical individual-level resource that enables women to recognize appropriate dietary choices. However, consistent with socio-ecological theory, the translation of this knowledge into actual nutritional status requires supportive conditions at higher ecological levels. Langley-Evans and Moran [24] emphasized that preconception nutrition significantly affects maternal and fetal health, suggesting that individual knowledge must be cultivated and sustained through ongoing interpersonal and community-level support systems.

The significant predictive power of social support (β = 0.833, t = 21.424, p < 0.05) represents the strongest effect among all variables examined, powerfully illustrating the interpersonal level of the socio-ecological model. This finding aligns with the theoretical assertion that encouragement from family, partners, friends, and healthcare professionals plays an integral role in promoting healthier eating habits during pregnancy [25,26].

Azene et al [38] demonstrated that social networks comprising family, friends, and community members profoundly influence food choices, health-seeking behaviors, and healthcare access. Our findings extend this understanding by quantifying the magnitude of social support's influence on nutritional status. The interpersonal environment functions as a bridge between individual knowledge and actual dietary behavior, providing emotional encouragement, practical assistance with meal preparation, financial resources for food procurement, and reinforcement of healthy nutritional practices.

Furthermore, Johnson et al. [39] established that social support independently influenced postpartum depression among nursing mothers (β = 0.403, p < 0.05), highlighting the interconnectedness between mental health and nutritional outcomes within supportive social environments. This suggests that the interpersonal level operates through multiple pathways: directly influencing food access and dietary choices, and indirectly through psychological well-being that affects appetite, motivation, and self-care behaviors. The socio-ecological framework helps explain how these interpersonal dynamics create a supportive or constraining context within which individual nutritional knowledge is either actualized or remains dormant.

The significant negative relationship between occupation and nutritional status (β = -0.125, t = -3.177, p < 0.05) reflects organizational-level determinants within the socio-ecological model. Specifically, the study revealed that 46.6% of participants were traders, 31.8% were artisans, 11.5% were unemployed, and only 10.1% were civil servants [40,41]. These occupational categories represent different organizational contexts that shape women's daily routines, energy expenditure, time availability for meal preparation, and access to workplace resources.

Smith et al. established that physically demanding occupations negatively impact dietary intake during pregnancy, with work hours and stress levels emerging as significant factors influencing pregnant women's nutritional status. The physically intensive nature of trading and artisanal work is often characterized by long hours, limited break time, inadequate rest facilities, and high energy demands create organizational constraints that interfere with optimal nutritional practices despite individual knowledge and interpersonal support.

The socio-ecological framework illuminates how workplace policies, organizational cultures, and occupational demands represent structural factors that operate beyond individual control yet profoundly affect health behaviors. Women engaged in informal sector occupations (traders and artisans) may face additional organizational barriers including lack of formal maternity leave policies, absence of workplace health programs, limited access to nutritious meals during work hours, and economic pressures that prioritize income generation over self-care. These organizational-level factors interact with individual knowledge and interpersonal support to constrain nutritional outcomes, demonstrating the necessity of multi-level interventions that address structural workplace conditions [42].

The significant positive effect of peer influence (β = 0.663, t = 16.736, p < 0.05) represents community-level determinants within the socio-ecological framework. As Oyeyemi et al. observed, pregnant women frequently rely on peer advice and recommendations when making food choices [43]. This illustrates how community norms, shared beliefs, and collective practices shape individual nutritional decisions through mechanisms of social learning, normative influence, and collective efficacy.

At the community level, the socio-ecological model emphasizes factors such as access to food, transportation, community health programs, and neighborhood support networks that can promote or hinder healthy dietary practices during pregnancy [27-29].Peer influence operates as a transmission mechanism through which community-level food norms, dietary practices, and nutritional beliefs are communicated and reinforced. When peers within a woman's community demonstrate positive nutritional behaviors, share information about food sources, and collectively value maternal nutrition, these community-level dynamics create an enabling environment that supports individual knowledge and interpersonal efforts.

However, peer influence can also transmit misinformation, perpetuate cultural food taboos that restrict nutritional diversity, and normalize inadequate dietary practices. The socio-ecological perspective recognizes that communities function as complex social systems where both health-promoting and health-constraining norms circulate simultaneously. Understanding peer influence within this framework reveals the importance of community-based interventions that leverage existing social networks while critically examining and transforming harmful collective practices.

Although not directly measured in this study, the socio-ecological framework emphasizes that broader policy and cultural contexts validate the environment in which nutrition decisions are made. These include government nutrition guidelines, public health initiatives and programs, agricultural subsidies and interventions, workplace health-related policies, and culturally held beliefs around pregnancy [30-32].

The findings regarding occupational constraints point to gaps in policy-level support, particularly the absence of protective labor policies for pregnant women in informal sector occupations. Nigeria's policy environment, including agricultural pricing, food subsidy programs, health insurance coverage, and maternal health policies, creates structural conditions that enable or constrain nutritional adequacy at all lower ecological levels. Golden and Earp and Perez-Escamilla et al. [33,34] emphasized that multi-level interventions including personalized prenatal counseling supported by education for families and communities, improved food environments, and supportive policy frameworks represent the socio-ecological approach's most effective application.

Collectively, these findings support Nweze's assertion that nutritional status during pregnancy is influenced by a complex interplay of physiological, sociocultural, and economic factors. This perspective aligns perfectly with the socio-ecological model's core principle that health outcomes result from interactions across multiple levels of influence [35]. The study demonstrates that individual nutritional knowledge (individual level) interacts reciprocally with social support systems (interpersonal level), occupational contexts (organizational level), peer networks (community level), and broader policy environments (societal level) to ultimately determine maternal nutritional status.

The adjusted R² value of 0.748 indicates that approximately 75% of variance in nutritional status is explained by the combined effect of social support, occupation, and peer influence, providing strong empirical validation for the socio-ecological framework's multi-level approach. This finding suggests that effective interventions must address factors at multiple ecological levels simultaneously rather than targeting isolated determinants. Bhutta et al. and Victora et al. [30,37] demonstrated that holistic approaches often lead to healthier pregnancies and better long-term outcomes for mothers and their children.

Furthermore, the socio-ecological perspective reveals that these levels are not independent but rather function as nested, interactive systems where changes at one level create ripple effects throughout the entire ecological structure. For instance, improving occupational policies (organizational level) may enhance women's capacity to utilize social support (interpersonal level) and actualize their nutritional knowledge (individual level). Similarly, strengthening community-level peer networks may compensate for limitations in organizational support while simultaneously advocating for policy-level reforms [44].

Implications for Multi-Level Interventions

The socio-ecological framework guiding this study offers clear implications for intervention design. Rather than focusing exclusively on nutrition education (individual level), effective programs must simultaneously strengthen social support networks, transform occupational conditions, leverage positive peer influence, and advocate for supportive policies. As Richard et al. [35] noted, interventions addressing multiple ecological levels prove more successful in improving nutritional outcomes than isolated approaches. This comprehensive perspective offers a roadmap for developing contextually appropriate interventions that recognize and address the complex social determinants of maternal nutrition within the specific ecological context of pregnant women attending maternity teaching hospitals in Nigeria.

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