Determinants of nutritional status among pregnant women in East Shoa zone, Central Ethiopia

Background: Undernutrition is an insufficient intake of energy and nutrients to meet an individual’s needs to maintain good health. Undernutrition during pregnancy severely affects the health of mothers and her baby. Globally it contributes directly or indirectly to 3.5 million maternal deaths annually. This study aimed to determine the level of undernutrition and identify factors associated with undernutrition among pregnant women attending public health facilities in the East Shoa Zone, Central Ethiopia. Methods: Institution-based cross-sectional study was conducted among 472 randomly selected pregnant women from June to August 2021. Sociodemographic, obstetrics, and knowledge related data were collected using a structured interviewer-administered questionnaire, and maternal nutritional status was measured using the Mid Upper Arm Circumference (MUAC). The collected data were entered to EPI-info version 3.5.4 and then exported to SPSS for windows version 26.0 software for analysis. Multivariable regression analysis was fitted to identify determinants of undernutrition. An adjusted odds ratio with 95% confidence intervals and a p-value < 0.05 was considered a statistically significant. Results: The prevalence of undernutrition among pregnant women was 13.9% [95% CI: 11.0–17.4]. On multivariable logistic regression model after adjusting background variables, wealth (AOR: 4.9, 95% CI 1.34–18.20), women's decision making power (AOR: 3.31, 95% CI 1.18–7.79), and nutritional counseling (AOR: 3.53, 95% CI 1.29–9.60) were independently associated with nutritional status of pregnant women. Conclusion: Findings indicated that significant number of pregnant women in the study were undernourished. Higher wealth index, nutritional counseling, and women's decision-making power were inversely associated with undernutrition. The findings imply the need for economic empowerment of women, enhancing decision-making ability of women and routine and consistent nutritional counseling to decrease undernutrition among pregnant women. According to the East Shoa zone health office, the health service delivery is organized under 3 hospitals, 59 health centers, and 290 health posts. All the facilities are expected to provide maternal and neonatal health care services based on the National Essential Health Services Packages (EHSP) for different levels of health care. According to the zonal report of 2020, the facilities in the zone provided antenatal care service (ANC) for more than 54,408 pregnant women. The food production system in the district is characterized by mixed crop-livestock farming, with predominant crop production. The community is also known for cultivating different fruits and vegetables, which are considered cash crops. Teff is the principal crop produced in the area. This study was conducted from June to August 2021. Institution-based cross-sectional study design was used. All pregnant women who came for ANC service at selected health institutions in Eastern Shoa Zone during the study period were considered the study population. Pregnant women living in Eastern Shoa Zone and attending ANC service at the selected health center during the study period were given a chance to be included in the study. Severely sick women were not eligible. The sample size was calculated by using OpenEpi version 3.01 software (OpenSource.org/licenses). The minimum sample size was calculated using a single population proportion formula. Assuming standard error corresponding to a 95% confidence level (Z) = 1.96, the proportion of undernourished pregnant women from the previous study (p = 19.1), (17), margin of error (d) = 5% and design effect 2, the estimated sample size was 475. Multistage stratified sampling techniques was used to select study participants. Of a total of health centers in the east Shoa zone, six health centers from urban and eight health centers were included from rural kebele by using the lottery method. The total sample size was allocated to each health center based on the number of women who visited the health center in the preceding year in the same month. Finally, a systematic random sampling technique was used to select participants by following the Kth value. The Kth value was calculated by taking the total number of pregnant women on ANC during the study period and dividing it by the sample size, and it was found to be three. Then, lottery methods was used to choose the first case within the interval, which turned out to be 1.The first comer was considered as the first participants, and participants who came at the third interval were interviewed until the determined sample size was achieved. A structured and pretested questionnaire was used to collect information on sociodemographic and obstetrics characteristics, women autonomy, Household Food Insecurity Access Scale (HHFIAS), and knowledge of women. The data collectors were trained nurses and midwives recruited for this study. Participants were invited to the survey when they came to receive ANC service at the selected health institution. All the participants completed the survey questions. Mid upper arm circumference of pregnant women was measured by using inelastic MUAC tape. The midpoint of the left upper arm was located by flexing the women's elbows to 900 with the palm facing upwards and the midpoint between acromion to olecranon processes was marked. After this, measuring tape was placed around the arm at the midpoint. Two measurements was taken and reported to the nearest 0.1 cm. Women with MUAC < 22 cm were considered undernourished, and ≥ 22 cm were considered well-nourished (7). The household food security status in the past 4 weeks before data collection was assessed by using the Food Insecurity Access Scale (HFIAS) measurement tool. The score was calculated for each household by summing up the nine food insecurity-related conditions' frequency of occurrence. A household that obtained < 2 scores were considered food secured and those that obtained ≥ 2 scores were considered food insecure (18). Women's decision-making power was assessed using six questions adapted from previous literature (19). For each question, three options were presented, and one score was given when a decision was made by the woman alone or jointly with her husband, or zero was given if the decision did not involve women. Gravidity is number of times that a women get pregnant. Parity is the number of times that a woman had given birth to a fetus with a gestational age of 24 weeks or more, regardless of the child was born alive or was stillbirth. A total of 16 questions focusing on nutrition knowledge were presented to participants of this study. For knowledge questions, respondents with an average score greater than or equal to mean score were categorized as having adequate knowledge about nutrition during pregnancy and respondents with average score less than mean value were classified as having inadequate knowledge (20). To ensure the quality of the data, local languages were used for understanding of the questions. In addition, pre-test of research instruments and thorough training of data collectors and supervisors were done before the actual data collection. The supervisors provided on-site support to data collectors daily. All completed questionnaires were collected by respective supervisors and checked overnight to ensure completeness and consistencies. Regular meetings were held to provide feedback on issues of concern identified from data collected the next day. The data were entered to EPI-info version 3.5.4 and then exported to SPSS version 26.0 software for analysis. Binary logistic regression was used to check the association between explanotory variables and undernutrition. All variables with a p-value < 0.25 in bivariate analyses remained in the model as potential confounders for multivariable analysis. Hosmer and Lemeshow's goodness-of-fit test was performed to assess whether the required assumption was fulfilled, and variance inflation factors were checked to assess for multi-collinearity. The strength of association was expressed as adjusted odds ratio with 95% confidence intervals. A p-value < 0.05 was considered a statistically significant association with undernutrition. Multicolliniarity was checked using standard error of >2.