Background <p>Malaria remains a significant public health concern, particularly among pregnant women in malaria-endemic regions such as Nigeria. This study examined knowledge and attitude as a predictor of malaria prevention practices among pregnant women attending the State Hospital in Osun State, Nigeria.</p> Methods <p>A cross-sectional design was employed, using a systematic sampling method. Data were elicited using structured and validated questionnaire with Cronbach Alpha coefficient of 0.82. Data were analyzed using descriptive and inferential statistical techniques, including Pearson’s correlation and regression analysis and the significance level was set at p-value less than 0.05.</p> Results <p>The findings revealed that while 65.2% of respondents demonstrated high level of knowledge of malaria prevention, adherence to preventive practices varied; 63.3% reported consistently taking prescribed antimalarial medication, yet only 17.5% always slept under insecticide-treated nets (ITNs). Similarly, 75.4% of the respondents had a positive attitude towards malaria prevention practices. There was a significant relationship between respondents attitude and malaria prevention practice (<i>p</i> &lt; 0.000). In addition, the number of previous pregnancies was significantly related to attitude (<i>p</i> = 0.035). With three to four previous pregnancies, the majority (93.7%) exhibited a positive attitude, while those with one to two pregnancies (82.9%) and those with five or more pregnancies (81.9%) had a lower proportion of positive attitudes. Though according to the regression model, attitude significantly influenced behaviour, and the relationship was statistically significant (<i>p</i> = 0.010). However, the R² value of 0.021 indicates that attitude explains only about 2.1% of the variation in behaviour. In other words, while attitude is a significant predictor, most of the differences in behaviour are explained by other factors not included in the model.</p> Conclusion/recommendation <p>The study concluded that while participants demonstrated good knowledge of malaria prevention, their attitudes were largely negative. Behavioural gaps persisted, influenced by external barriers such as limited healthcare access, low socioeconomic status, and discomfort associated with ITN use. The study recommends implementing targeted health education programs that focus on sustaining positive behaviours, strengthening ANC service delivery, and providing practical solutions to address ITN-related discomfort, thereby improving malaria prevention among pregnant women.</p>