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Objective: To assess the magnitude of under nutrition and associated factors
among pregnant women.
Methods: Hospital based cross-sectional study was conducted from March, 1 to
April 30, 2015, at ante natal care, Nigist Eleni Mohammed Memorial General
Hospital. A total of 211 pregnant women who visited ante natal care services
were selected using systematic sampling methods. Data was collected using a
structured interviewer administered questionnaire. Mid upper arm circumference
was measured using adult mid upper arm circumference tape. The data was edited,
coded manually and entered into EPI data version 3.2.1 and analyzed using SPSS
version 20.0 software. Predictors of under nutrition were identified using
multi variable logistic regression models. P values<0.05 were considered for
statistical significance.
Results: A total of 211 participants were interviewed giving response rate
of 100% and 24.6% of the pregnant women were undernourished. Frequency of meal
consumption less than three times per day (AOR=2.60 (95% CI: 1.04-6.54)),
earning monthly income of greater than two thousand Birr (AOR=0.319 (95% CI:
0.11-0.90)) and having dietary diversity scores of less than five (AOR=12.39
(95% CI: 2.61-58.92)) were predictors of under nutrition.
Conclusion: Large proportions of women were undernourished in the study area.
Enhancing intervention of maternal nutrition during pregnancy, focusing on
diversification of diet and importance of having additional meal during
pregnancy through health extension workers and women’s development army is
essential to curb the problem of maternal malnutrition.
Keywords: Under nutrition, Hosanna, Pregnant woman
INTRODUCTION
Appropriate levels of nutrients are essential for proper physiology of
human being. Nutrition is a vital part of human life and its need differs with
age, gender and physiological changes such as pregnancy [1].
Under nutrition is when the body contains below normal level of one or
more nutrients, i.e., shortages in macro nutrients and/or micro nutrients.
‘Under nutrition includes stunting, wasting and lack of essential vitamins and
minerals (collectively referred to as micro nutrients) [2-4].
The incidence of dietary inefficiencies as a consequence of dietary
habits and patterns in pregnancy is higher during pregnancy than at any other
stage of the life cycles [1].
Insel and Wardlaw defines good nutrition is critical during child
bearing years and the health and nutritional habit of woman in the years before
pregnancy and while she is planning to be pregnant or has the potential of
becoming pregnant is particularly important [5].
Maternal under nutrition may dispose mothers to poor well-being
including infection, preeclampsia/eclampsia and adverse pregnancy consequences
such us preterm birth and intrauterine growth retardation [6]. Pregnant women
are mainly susceptible to nutritional inefficiencies because of
Although pregnancy is considered to be normal physiological incident
for most African women, it is a serious situation because of reduced quality of
diet ads to the extensive energy and micro nutrient shortages [7]. Pregnancy
places extra demand on the body systems of pregnant women, necessitating
optimal intake of essential nutrients. Maternal diets during pregnancy have
gained a lot of attention over the years. This is due to the increased
physiologic, metabolic and nutritional demand placed on pregnant women by her
gravidity. The dietary intake of pregnant woman requests to provide energy and
nutrient for the mother [8].
Pregnancy increases energy needs by 13%, protein by 54% and vitamin and
mineral by 0-50%. Research has also proven that, 30,000 kcal (336 MJ) are
essential to produce a baby, increase placenta size and reproductive organs,
yield energy for newly formed tissues
and produce extra fat stores in the mother [5,9].
Inappropriate dietary practices characterized by reduced dietary
intakes, reduced consumption of meals and insufficient intake of fruits and
vegetables among pregnant women yielded to under nutrition [10]. Pregnant women
need beneficial food for the fetus to mature well if not, the result will lead
to underweight [11]. For healthy pregnancy, continuous supply of micro
nutrients is essential for both mother and growing baby.
Majority of recent research has proven that from beginning, having
right balance of key micro nutrient is appropriate to insure long term health
of mothers and their infants [11,12].
Study on magnitude of under nutrition, factors independently associated
with under nutrition is scarce in Ethiopia. There is no study done in Nigist
Eleni Mohammed Memorial general Hospital regarding magnitude of under
nutrition, factors significantly associated with under nutrition.
Therefore, our study aimed to show rate of magnitude of under nutrition
as well as factors associated with under nutrition at ANC clinic of NEMMGH.
Although there are studies on maternal under nutrition, they have not included factors like household food security status, meal pattern and dietary diversity. This study will fill the knowledge gap concerning maternal under nutrition to some extent and will serve as base line information for researchers, policymakers and planners to design appropriates interventions related to maternal under nutrition in the study area.
METHODS AND MATERIALS
Study area
It was conducted in Nigist Eleni Mohammed Memorial General Hospital ANC
clinic, it is government funded hospital located at 230 and 194 km away from
the capital city in Ethiopia (Addis Ababa) and SNNPR (Hawassa), respectively.
The Hospital currently is in transition period to be Wachemo university
hospital which is serving in four majors clinical fields, i.e., Internal
medicine, pediatrics, surgery and gynecology. There are also some minor
specialized field like dental care service, ophthalmology, dermatology
services. This hospital also renders MCH related services including EPI, PNC,
FP and ANC services in separate room. Currently the hospital is serving more
than one million people.
Study design and period
Hospital based cross-sectional study was conducted from March, 1 to
April 30, 2015.
Sample size determination and sampling
technique
Sample size determination: Sample size was determined using a formula for estimation of single
population proportion with the following assumptions:
Where, n=sample size
Z=standard normal variable value corresponding to 95% level of
significance=1.96
P=expected proportion of under nutrition during pregnancy=19.8%=0.198
Q = (1-p) = (1-0.198) = 0.802
d=Margin of sampling error tolerated (absolute precision) (5%)
None response rate=10%
Therefore, n=244
N=920
Since my target population is less than 10,000, correction formula was employed
to calculate the final sample size.
NC=n/1+n/N=244/1+244/1975=192
When 10% contingency is added to the total sample size, the final
sample size becomes 211.
Assumption: P=19.8% [13].
Sampling technique: A systematic sampling technique was implemented to select pregnant
women and to be included in the study. By dividing the potential number of ANC
attendants during the study period (N=920) by the sample size (n=211) a
sampling interval K of 4 was obtained. Therefore, every k women coming to ANC
service was included in the study.
Study population
Sampled pregnant women who visited Nigist Eleni Mohamed Memorial
General Hospital during data collection period.
Data collection
Trained nurses/public health professionals whom can speak native
language collect data from the mothers using a structured questionnaire. The
principal investigator supervised the data collection procedure. The structured
questionnaire generated information on the socio-demographic and economic
factors, dietary and reproductive factors.
Anthropometric measurements: Maternal anthropometric measurements were done according to the
standards. MUAC of pregnant woman was measured at mid-point between the tip of
the shoulder (olecranon process) and tip of the elbow (acromion process) of
left arm. An adult MUAC tape that was non-elastic and non-stretchable was used
to take measurements, after checking that the tape was applied with correct
tension (not too loose or not too tight). The MUAC of woman was read and
documented to nearest 0.1cm. MUAC measurement was performed by clinical
nurse/public health professional following standard instructions and steps. A
range below 22 cm was an indicator of under nutrition and a range of >22 cm
was for normal nutritional status.
Methods for assessing food consumption of
individual:
24 h recall method: The
purpose of assessing dietary intake was to evaluate nutritional quality of the
diet. 24 h recall dietary method provides quantitative information on food
intake. Nine lists of food groups were used to assess the 24 h recall [14]. A
score of 1 was given for those who responded ‘yes’ and a score of zero was
given for those who responded ‘no’ for food groups listed. Finally, those who
got DDS score of less than 5/9 were classified as having less diversified diet
and those who got score of >5/9 were classified as having well diversified
food.
Household food security status: The household food insecurity statuses
of the respondents were assessed with HFIAS using nine questions adapted from
FANTA guideline. The HFIAS contains two types of related questions. The first
question type was called an occurrence questions. There were nine occurrence
questions that ask whether a specific condition associated with experience of
food insecurity ever occurred during the previous four weeks (30 days). Each
severity question was followed by frequency of occurrence question, which asks
how often a reported condition occurred during the previous four weeks. Each
occurrence question consists of time frame for recall, body of question, and
two response options (0=no, 1=yes). There is also a ‘skip code’ next to each
“no” response option. This code instructs the enumerator to skip the related
frequency-of-occurrence follow-up question whenever the respondent answers “no”
to an occurrence questions. Each HFIAS frequency of occurrence question asked
respondent how often the condition reported in the previous occurrence question
happened in the previous four weeks. There are three response options
representing a range of frequencies (1=rarely, 2=sometimes, 3=often). Finally,
those respondents who were coded as (1) and (0) were categorized as food
insecurity and food security, respectively [15].
STATISTICAL ANALYSIS
Data were coded and cleaned with Epi-Data version 3.1 and were analyzed
by SPSS for window version 20.0. Descriptive statistics like frequency, mean
and standard deviation were implemented. Inferential statistical test like bi
variable and multi variable logistic regression analyses were performed.
Bi variable and multi variable backward logistic regression were done
to identify factors associated with under nutrition. Before running multi
variable logistic regression, multi-collinearity between independent variables
was checked in linear regression by variance inflation factors (VIF). Variables
which had significant association at p-value <0.25 in the bi variable
logistic regression models were candidate for multi variable logistic
regression. The model fitness for the variables was assessed by the
Hosmer-Lemeshow goodness of fit test. P-value of less than 0.05 was considered
as independently associated in the multivariable analysis.
ETHICAL APPROVAL
Ethical clearance was obtained from Jimma University Ethical Review
Committee and official permission letter to conduct study was obtained from
Nigist Eleni Mohamed Memorial General Hospital administrators. Verbal informed
consent was taken from each studying subject after clear orientation of study
objective. Confidentiality of the information was also assured and collected
anonymously.
RESULTS
Socio-demographic and economic factors
Out of 211 sampled pregnant women to be included in the study, all of
them responded to questionnaire making response rate of 100%. The mean age (±
SD) of participants were 28 (± 1.98) years, while age of participants range
from 24 to 34 years.
Considering educational and occupational status of women, 15 (7.1%) of
participants were illiterate and 113 (53.6%) of participants were housewife,
respectively.
98 (46.4%) of respondents earn income from formal employment, 89 (42.2%)
engaged in business, 18 (8.5%) from farming and 6 (2.8%) from other sources.
Regarding monthly income of women, 86 (40.8%) of participants were with
an estimated monthly income of less than one thousand Ethiopian Birr (Table 1).
Reproductive and dietary factors
14 (6.6%) of study participants had four and above pregnancies before
current one and 77 (36.5%) of study participants had never been pregnant.
174 (82.5%) of study participants never experienced birth interval of
less than two years and only 37 (17.5%) experienced birth interval of less than
two years.
With regard to trimester of pregnancy, 99 (46.9%) of study participants
were in second trimester of pregnancy. Majority of respondents, 180 (85.3%)
normally consumed greater than three meals per day. 181 (85.8%) of study
participants were food secured. 144 (68.2%) of study participants scored DDS of
less than five (Table 2).
Magnitude of under nutrition
The overall prevalence of under nutrition in this study was 52 (24.6%).
Predictors of under nutrition
The bivariate logistic analysis showed that educational status, family
size, source of income, monthly income, frequency of meal consumption per day,
previous pregnancy, food secure and DDS were associated with under nutrition.
However, other factors like age, marital status, occupational status of husband
and women, religion, birth interval, trimester of pregnancy, prenatal dietary
advice, history of nausea and vomiting did not show any significant association
with under nutrition (Table 3).
Variables with p-value<0.25 like source of income, previous
pregnancy, number of meals per day, monthly income, house hold, food security
and DDS entered multi variable logistic analysis.
Frequency of meal consumption less than three times per day,
earning monthly income of greater than
two thousand Ethiopian birr (ETB), and having dietary diversity scores (DDS) of
less than five were factors independently associated in multivariate logistic
regression analysis.
The result of multi variable logistic regression showed that pregnant women
who had frequency of meal consumption less than three times per day were 2.60
times more likely to develop under
nutrition as compared to pregnant women who had meal consumption greater than
three times per day, (AOR=2.60 (95% CI (1.04-6.54)). Moreover, pregnant women
who earned monthly income greater than 2000 ETB decreased risk of under
nutrition by 0.68 times as compared to
those who earned monthly income less than 1000 ETB (AOR=0.32 (95% (0.11-0.90)).
Participants who had DDS less than five were 12.39 times more likely to
increase under nutrition as compared to those who had DDS greater than 5 (AOR=12.39
(95% CI (2.61-58.92)) (Table 3).
DISCUSSION
In this study MUAC, 24 h dietary recall method and household food
insecurity access scale were used to measure the magnitude of malnutrition and
as indicator of nutritional status, to assess the quality/diversity of food, to
assess household food insecurity among pregnant women.
Our result revealed that 24.6%
of pregnant women were undernourished. The magnitude of under nutrition
observed in this study was greater than study conducted in eastern Ethiopia
(19.8%) [13] and southern Ethiopia (9.2%) [9]. This difference might be due to
sample size difference, geographical and feeding style differences between
populations in the studies. But it is consistent with finding from study
conducted in Zimbabwe where significant number of respondents (76%) had MUAC
equal or greater than 22 cm and only 24% had MUAC less than 22 cm [5].
Pregnant women who consumed meal less than three times per day were two
times more likely malnourished than
those who consumed meal for greater than or equal to three times. This is in
line with World Health Organization [16] recommendation that pregnant women
consume at least three meals per day with two snacks to meet increased caloric
demands during pregnancy. Having less frequent meals could lead to inadequate
intake of essential nutrients which finally, causes under nutrition.
The income status was an indicator of access to adequate food supplies
which is main determinant of maternal nutritional status. Lower risk of under
nutrition was observed among women who had monthly income of greater than two
thousand Ethiopian birr in present study. This is not in line with study done
in East Wollega zone, Ethiopia in which respondent’s monthly income greater
than two thousand Ethiopian birr was risk factors for under nutrition [1]. This
discrepancy might be due to difference in control of income within household.
As this study was done in the cash crops area where most of income might be
controlled by men as opposed to the study area where there are no cash crops
and usually men tend to spend cash mostly on non-food items.
Low dietary diversity among pregnant women was one of the factors
contributing to under nutrition. In this study women who had dietary diversity
scores less than five was twelve times more likely be malnourished than those
women who had dietary diversity scores greater than five. This finding is in
line with reports of a study conducted in Pakistan [17] among pregnant women.
It was assumed that for an increase of dietary diversity by one, pregnant women
gained 0.24 kg in second trimester and 0.71 kg gain in third trimester. For an
increase of one dietary diversity scores, they will gain 0.02 Kg/week. This
could be due to the fact that as pregnant woman get diversified diet, they will
be well nourished that will directly have beneficial role in breaking
inter-generational cycle of malnutrition.
Although national nutrition program, millennium development goals and
national nutrition strategy considers maternal nutrition during pregnancy to be
a key factors in preventing inter-generational cycle of malnutrition, maternal
and infant mortality, large proportion of pregnant women are still having under
nutrition. The implication of under nutrition during the first 1000 days is
far-reaching. Therefore, the findings called for strengthening the existing
initiatives to combat the rate of under nutrition among pregnant women in the
study area.
CONCLUSION
Large proportions of women were undernourished in the study area.
Frequency of meal consumption less than three times per day, earning monthly income of greater than two thousand
Ethiopian birr (ETB) and having dietary diversity scores (DDS) of less than
five were factors independently associated with under nutrition of pregnant
women. Different nutritional assessments methods such as 24 h dietary recall
and household food security status among pregnant women were assessed according
to the standard. Enhancing intervention of maternal nutrition during pregnancy,
focusing on diversification of diet and importance of having additional meal
during pregnancy through health extension workers and women’s development army
is essential to curb the problem of maternal malnutrition.
ACKNOWLEDGMENT
We wish to thank Jimma University for funding this research. Authors
also wish to acknowledge Nigist Eleni Mohammed Memorial General Hospital staff
for their support in facilitating the data collection process.
1.
Daba G, Beyene F, Fekadu H,
Garoma W (2013) Assessment of knowledge of pregnant mothers on maternal
nutrition and associated factors in Guto Gida Woreda, East Wollega Zone,
Ethiopia. J Nutr Food Sci 3: 1.
2.
Horton R (2008) Maternal
and child under nutrition: An urgent opportunity. Lancet 371: 179.
3.
Black RE, Victora CG,
Walker SP, Bhutta ZQA, Christian P, et al. (2013) Maternal and child under
nutrition and overweight in low-income and middle-income countries. Lancet 382:
427-451.
4.
Dewan M (2008) Malnutrition
in women. Studies on Home and Community Science 2: 7-10.
5.
Man’ombe S (2012) Pregnant
women as beneficiaries of the vulnerable group feeding (VGF) programme in Mbire
district Zimbabwe: An assessment of nutritional vulnerability. Master’s Degree
Thesis, University of the Free State.
6.
Jiang T, Christian P,
Khatry SK, Wu L, West Jr KP (2005) Micronutrient deficiencies in early
pregnancy are common, concurrent and vary by season among rural Nepali pregnant
women. J Nutr 135: 1106-1112.
7.
Lartey A (2008) Maternal
and child nutrition in sub-Saharan Africa: Challenges and interventions. Proc
Nutr Soc 67: 105-108.
8.
Sholeye OO, Badejo CA,
Jeminusi OA (2014) Dietary habits of pregnant women in Ogun-East Senatorial
Zone, Ogun State, Nigeria: A comparative study. Int J Nutr Metab 6: 42-49.
9.
Kuche D (2011) Factors
associated with dietary practices and nutritional status among pregnant women
in Wondo Genet district. Ethiopian Public Health Institute.
10.
Othoo DA, Waudo J, Kuria EN
(2014) Dietary assessment of vitamin A and Iron among pregnant women at Ndhiwa
sub district Hospital, Kenya. Afr J Food Agric Nutr Dev 14: 2114-2128.
11.
Opara JA, Adebola HE,
Oguzor NS, Abere SA (2011) Malnutrition during pregnancy among child bearing
mothers in Mbaitolu of south-eastern Nigeria. Adv Biol Res 5: 111-115.
12.
Muthayya S (2009). Maternal
nutrition and low birth weight-what is really important. Indian J Med Res 130: 600-608.
13.
Kedir H, Berhane Y, Worku A
(2016) Magnitude and determinants of malnutrition among pregnant women in
eastern Ethiopia: Evidence from rural, community-based setting. Matern Child
Nutr 12: 51-63.
14.
Food and Agriculture
Organization (2014) Guidelines for measuring household and individual dietary
diversity.
15.
Coates J, Swindale A,
Bilinsky P (2007) Household Food Insecurity Access Scale (HFIAS) for
measurement of food access: Indicator guide. Washington, DC: Food and Nutrition
Technical Assistance Project, Academy for Educational Development.
16.
WHO (2012) Guideline: Daily
iron and folic acid supplementation in pregnant women. World Health
Organization.
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