Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia

Background Maternal undernutrition is one of the most common causes of maternal morbidity and mortality in developing countries. Severe undernutrition among mothers leads to reduced lactation performance which further contributes to an increased risk of infant mortality. However, data regarding nutritional status of lactating mothers at Dessie town and its surrounding areas is lacking. This study assessed dietary diversity, nutritional status and associated factors of lactating mothers visiting health facilities at Dessie town, Amhara region, Ethiopia. Methods Institutional based cross-sectional study was conducted from March to April, 2017 among 408 lactating mothers. Systematic random sampling technique was employed to select the study participants. Data on socio-demographic and economic characteristics, health related characteristics, dietary diversity and food security status of participants were collected using interviewer administered questionnaire. Data were entered into EPI-INFO and analyzed using SPSS Version 22. Bivariate and multivariate analyses were performed to identify factors associated with dietary diversity and nutritional status of lactating mothers. Results More than half (55.6%) of lactating mothers had inadequate dietary diversity (DDS<5.3) and about 21% were undernourished (BMI<18.5 kg/m2). Household monthly income [AOR = 2.0, 95% CI (1.15, 3.65)], type of house [AOR = 1.8, 95% CI (1.15, 2.94)], nutrition information [AOR = 1.6, 95% CI (1.05, 2.61)] and household food insecurity [AOR = 1.8, 95% CI (1.05, 3.06)] were factors associated with dietary diversity of lactating mothers. Being young in age 15–19 years [AOR = 10.3, 95% CI (2.89, 36.39)] & 20–29 years [AOR = 3.4, 95% CI (1.57, 7.36)], being divorced/separated [AOR = 10.1, 95% CI (1.42, 72.06)], inadequate dietary diversity [AOR = 3.8, 95% CI (2.08, 7.03)] and household food insecurity [AOR = 3.1, 95% CI (1.81, 5.32)] were factors associated with maternal undernutrition. Conclusion The dietary diversity of lactating mothers in the study area was sub optimal and the prevalence of undernutrition was relatively high. Public health nutrition interventions such as improving accessibility of affordable and diversified nutrient rich foods are important to improve the nutritional status of mothers and their children in the study area. Institutional based cross-sectional study was conducted in an urban setting at Dessie town from March to April 2017. Dessie is located about 401 km away from Addis Ababa, the capital city of Ethiopia and 480 kms away from the capital city of the Amhara Regional State, Bahir-Dar. Dessie is one of the three metropolitan towns in the Amhara region. According to Dessie town administration office report, in 2011, Dessie town had a total population of 154,513 of which 80,575 were females and 73,938 were males. The town has 5 governmental health facilities; 1 referral hospital and 4 health centers. Our study participants were lactating mothers/ breastfeeding mothers (15–49 years) with children under two years who visited Dessie town health facilities during the study period. Lactating mothers visited these health facilities to get various services such as family planning services and vaccination services for their children. Lactating mothers who were critically ill, had physical deformity (that causes difficulty for anthropometric measurements), and who were pregnant during the study period were excluded. Sample size was determined using single population proportion formula by considering the following assumptions: 56.4% proportion of lactating mothers with inadequate diet diversity score [14], 95% confidence interval and 5% margin of error. A sample size of 416 was taken after considering 10% non response rate. Systematic random sampling technique was employed to select mothers after the first eligible lactating woman was selected by lottery method. In this regard, every 2nd (K = 1.7) lactating woman visiting the health facilities was included in the study. This was determined by calculating the average monthly flow of lactating mothers for three months to each health facility (i.e. 163+175+214+50+110 = 712/416 = 1.71). Data were collected using pre-tested and interviewer-administered questionnaire adapted from different literatures. The questionnaire was used to collect socio-demographic and economic characteristics, health related characteristics, food security status and dietary diversity of participants. It was first prepared in English, translated into Amharic and translated back to English by another person to check its consistency. The translated Amharic version was pretested on 21 (5%) of similar subjects at Dessie Town Family Guidance Association model clinic to ensure appropriateness of the study tools and to acquire common understanding on the assessment tools. During data collection, four nurses were hired as data collectors and 2 health officers were involved as supervisors. Data collectors and supervisors were trained for two days on the study objectives, purpose and how to take anthropometric measurements based on the research instrument. Food insecurity was assessed using household food insecurity access scale (HFIAS) version 3 [17], a tool validated in Ethiopia [18] as well as other developing countries [19, 20]. The HFIAS tool has nine questions asking household’s last month experience about three domains of food insecurity: feeling uncertainty of food supply, insufficient quality of food, and insufficient food intake and its physical consequences. Study participants were categorized into two levels of food-security status (food-secured and food-insecured) [21] as follows; they were classified as food secure if the participants responded ‘no’ to all of the nine questions and insecure if the participants responded ‘yes’ to at least one of the 9 questions included on the HFIAS tool. Dietary diversity of lactating mothers was assessed using a 24-hour dietary recall method. Participants were asked to recall freely what they consumed the previous day, inside and outside their home. We then categorized the foods they consumed into the nine food groups (starchy staples, roots and tubers; dark green leafy vegetables; other vitamin A rich fruits and vegetables; other fruits and vegetables; fats and oils; meat and fish; eggs; legumes; nuts and seeds and milk and milk products) [22]. Dietary diversity score (DDS) was determined as the sum of the number of different food groups consumed by the mother in the 24 hours prior to the assessment. Mothers were categorized as having adequate or inadequate dietary diversity after calculating the mean DDS. Mothers who had consumed food groups below the mean DDS were considered as having inadequate DDS and those who consumed higher or equal to the mean DDS were considered as having adequate DDS. In our case, mothers who consumed < 5.3 mean food groups were considered as having inadequate dietary diversity and those who consumed ≥5.3 mean food groups were considered as having adequate dietary diversity. Anthropometric measurement (weight and height) of lactating mothers was taken using a weighing scale with an attached height meter (Charder HM200P Stadiometer, Taiwan). During anthropometric measurements, mothers removed their shoes and wore light clothing. The weighing scale was checked before and after each measurement for its accuracy by an object with a known weight. Body mass index (BMI) was then calculated by dividing the weight of mothers in kilogram to height in meter square (kg/m2). BMI was calculated using CDC’s online BMI calculator for adults and was also checked manually. For mothers with age below 18years, BMI for age was calculated. Data were cleaned, coded and entered into EPI-INFO version 3.5.4 software and transferred and analyzed using SPSS version 22. Descriptive statistics such as frequencies, proportions and chi-square (X2) were used to present the study results. In this study, there were two dependent variables; dietary diversity and nutritional status of lactating mothers. In the binary logistic regression analysis, the association between single explanatory variables and dependent variable was examined by computing odds ratio at 95% confidence level. Independent variables with p-value less than 0.2 were fitted in to a multivariate logistic regression model to identify factors associated with dependent variables. For all statistical significance tests between each independent and dependent variables, significance level was declared if p-value was < 0.05. The study protocol was approved by the Ethical Review Board of Faculty of Chemical and Food Engineering, Bahir Dar University. Permission to conduct the research was granted by Amhara Region Health Bureau, Dessie Referral Hospital and Dessie town health department. Informed consent was obtained from participants after explaining the study objectives. Participation was voluntary and mothers signed (or provided a thumb print if illiterate) a statement of an informed consent after which they were interviewed. For participants who were below 18 years old, written consent was secured from them and from their guardian as well.