Dietary diversity practice and associated factors among pregnant women in North East Ethiopia

Objective Diversified food during pregnancy is the very important since it is known to affect pregnancy and birth outcomes. The aim of this study was to assess dietary diversity practice and associated factors among rural pregnant women in North East Ethiopia. Result A total of 647 pregnant women were participated with a response rate of 97.4%. The adequate dietary diversity practice of pregnant women was found to be 31.4% [95% confidence interval (CI) 27.8–35.2]. Cereals were the most commonly consumed food groups. Dietary diversity practice of pregnant women was associated with maternal education [Adjusted Odds Ratio (AOR) = 2.36, 95% CI 1.29, 4.32], wealth index (AOR = 1.85, 95% CI 1.21, 2.82), nutrition information (AOR = 2.51, 95% CI 1.05, 6.02) and Productive safety net program beneficiary (PSNP) (AOR = 1.7, 95% CI 1.16, 2.50). The dietary diversity practice of pregnant women was found to be low in the study area. Maternal education, wealth status, having nutrition information and PSNP beneficiary were the determinant factors.


Introduction
Pregnancy is a critical period in the lifecycle during which additional nutrients are required to meet the metabolic and physiological demands as well as the increased requirements of the growing fetus [1]. So diversified dietary intake has to meet the needs of the mother as well as the products of conception [2]. Dietary diversity is the consumption of a variety of food groups over a reference period which has been accepted as an aspect of dietary quality and can indicate nutritional adequacy [3].
Diversified food during pregnancy is the most important since it is known to affect pregnancy and birth outcomes [4,5]. The effect of inadequate intake of nutrients during pregnancy leads to irreversible damage to the fetus that can compromise the future work capacity and survival [6][7][8].
Diets of pregnant women in low and middle-income countries (LMICs) are monotonous, low quality and predominantly plant-based with little consumption of micronutrient-dense animal-source foods, fruits, and vegetables [9,10]. The government of Ethiopia has launched National Nutrition Program and prioritized interventions like Promote maternal nutrition including adequate intake of diversified foods to improve the nutritional status of women. Even though the implementation of the above strategy, thinness and different micronutrient deficiencies are common problems during pregnancy [11,12]. There is limited data regarding the dietary diversity practice and factors associated during pregnancy in Ethiopia in general and specifically in rural areas. Therefore, the purpose of this study was to determine the dietary diversity practice and associated factors among rural pregnant women in Jille Tumuga district, Oromia Special Zone, Amhara region, Northeast Ethiopia. Aliwo et al. BMC Res Notes (2019) 12:123 Main text Method A community based cross-sectional study was conducted at Jille Tumuga district from March to April 2017. Jille Tumuga is a rural district found 265 kms far from Addis Ababa, the capital of Ethiopia, 616 kms away from Bahirdar (the capital city of the region).. The district is divided into 18 rural kebeles (smallest administrative unit in Ethiopia) and there are four governmental health centers and 21 health posts. It has a predominantly kola (Tropical Zone) agro-ecology and the altitude of the district ranges from 1000 to 2000 m above the sea level. Cereals, such as maize, sorghum, wheat, and barley are the main staple crops cultivated in the district. The main livestock reared are cattle and goats.
All pregnant women who lived in Jille Tumuga district for at least 6 months were eligible for the study. Sample size was estimated using the single population proportion formula [13] by considering adequate dietary diversity as 50% (since there was no similar study in the study area), 1.5 design effect and 10% non response rate the required sample size was 634. Since cluster sampling technique was used, all pregnant mothers in the selected cluster were included and the final sample size was 664. Clusters were Kebeles and from total kebeles, 7 were selected by simple random sampling.
An interviewer administered structured and pre-tested questionnaire was used to collect socio-demographic, maternal and health related factors, feeding & dietary diversity practice, wealth index and food security status of pregnant women. It was first prepared in English and then translated to oromifa and translated back to English to maintain its consistency. To ensure the quality of data, pre-test was done and modifications were made accordingly. Six health extension workers and two diploma nurses were involved in data collection supervision respectively.
Tools for measuring dietary diversity was adopted from FAO guidelines for measuring minimum dietary diversity women, 2016. It was assessed by asking respondents to list all food items they consumed in the last 24 h preceding the survey day. A total of ten food groups were used and respondents who consumed < 5 food groups were classified as having inadequate dietary diversity whereas those consumed ≥ 5 food groups were classified as having adequate dietary diversity practice [14].
Household's wealth index measuring tool was adopted from EDHS 2011 [15]. It was analyzed using Principal Component Analysis (PCA) by considering the household assets, such as livestock, type of house, durable assets, productive assets and agricultural land ownership. First, variables were coded between 0 and 1. Then variables entered and analyzed using PCA, and those variables having a communality value of greater than 0.5 were used to produce factor scores. Finally, the factor scores were summed and ranked into tertiles as poor, medium and rich.
Food insecurity was measured using FANTA household food insecurity access scale (HFIAS) tool. It is consisted of nine occurrence questions that represent a generally increasing level of severity of food insecurity (access), and nine "frequency-of-occurrence" questions. The frequency-of-occurrence question is skipped if the respondent reports that the condition described in the corresponding occurrence question was not experienced in the previous 4 weeks (30 days). Finally individuals were considered as food secure if they respond "no" to all of items or just experience worry but rarely; mildly food insecure if household worries about not having enough food sometimes or often/or unable to eat preferred foods; moderately food insecure if household scarifies quality more frequently, by eating a monotonous diet or undesirable foods sometimes or often and severely food insecure if household experience forced cutting back on meal size or number of meals often, and/or experiences any of the three most severe conditions [16].
The data was cheeked, coded and entered using EPI data 3.1 software and exported to SPSS version 20 statistical packages for further analysis. Data cleaning was performed. Frequencies and graphs were used to explore the data. Binary logistic regression was used to identify the confounders. Variables having p-value < 0.2 in the binary logistic regression was fitted into the multiple logistic regression models. Adjusted odds ratio (AOR) with 95% confidence interval (C.I) was computed to assess the presence and strength of association. Variables having p-value less than 0.05 in multiple logistic regressions were considered as significantly associated with the dependent variables. Hosmer-lemshow goodness of fit test was used for model adequacy checking and it was 0.52.

Socio-demographic characteristics
A total of 647 pregnant women were participated in this study with a response rate of 97.4%. The mean age of the participants was 26.21 (± 4.61) years. Most of the participants were married 643 (99.4%). Majority (68.3%) of the respondents were not educated. More than one third (33.2%) of the respondents were poor (Table 1).

Meal frequency and feeding practice
Less than half, 284 (43.9%) of respondents had meal frequency of four and above per day. Two hundred eighty six (44.7%) of respondents had the habits of taking snacks. One fifth of the respondents had habit of skipping meal and 158 (24.4%) of respondents had avoided some kind of food during pregnancy.

Dietary diversity practice of pregnant women
The overall prevalence of adequate dietary diversity practice among pregnant women were found to be 31.4% with (95% CI 27.8-35.2%) (Fig. 1).

Factors associated with dietary diversity practice of pregnant
In the adjusted analysis mother's educational status, wealth index, PSNP beneficiary and nutrition information were significantly associated with dietary diversity practices of pregnant women.
The odds of dietary diversity practice was 2.36 times (AOR = 2.36, 95% CI 1.29, 4.32) higher among pregnant women who can read and write than those who had no formal education. While the odds of dietary diversity practice was 94% (AOR = 1.94, 95% CI 1.24, 3.01) higher among pregnant women who had primary education and above than those having no formal education. With regard to wealth index, the odds of dietary diversity practice was 85% (AOR = 1.85, CI 1.21, 2.82) higher in rich pregnant women than the poor pregnant women. On the other hand, the odds of dietary diversity practice was 2.58 (AOR = 2.58, CI 1.05, 6.02) times higher among pregnant women who had nutrition information than their counterparts. While the odds of dietary diversity practice was 71% higher among pregnant women who are not beneficiary of productive safety net program than their counterparts (Table 2).

Discussion
Recognizing the dietary diversity practice of pregnant women is vital since it affects the health and long term productivity of the mother and the fetus. This study  [19]. This difference may be due to socio demographic factors. In this study most of the participants had lower educational level compared with aforementioned studies, which could affect mother's knowledge and practice of dietary diversity. Moreover, the study subjects of the current study had larger family size in which food sharing habit of large sized families is high and so that pregnant women may not get diversified foods as required. Most of the study participants of this study were also house wives whom could not generate money by themselves so it might affect their food purchasing power and further affect their dietary diversity practice. This study showed that the odds of adequate dietary diversity practice was two and more times higher in pregnant women who can read and write than those having  [17,[20][21][22][23]. This might be due to the contribution of education in giving information about the importance of diversified diet consumption. On the other hand educated women can have better employment opportunity and income which can further improve their household food security status and consumption of diversified food. According to this study dietary diversity was associated with wealth status of the household. There is increased odds of dietary diversity practice by 85% in rich pregnant women than the poor. This finding is in line with study conducted in Bangladesh, Ghana and Kenya [20,23,24]. This could be due to the fact that rich households will have access to a variety of food and the dietary practice of pregnant women in this household will be improved.
In addition, those who are not beneficiary of productive safety net program were 71% more likely to practice adequate dietary diversity than their counter parts. This might be due to PSNP is aimed for chronically food insecure households and these households food purchasing power and access to a variety of food is limited and cereal based monotonous diet is common.
This study revealed that having information about nutrition is significantly associated with the dietary diversity practice of pregnant women. The odds of dietary practice were 51% increased in those who got nutrition information than their counter parts. This is also supported by study conducted in East Wollega Zone, Ethiopia [25] and Gondar [26] in which nutrition information was important for good nutritional practices. This may be due to the fact that those who get information about nutrition will have better knowledge and understanding to practice diversified diet than those who do not.
Over all dietary diversity practice was low in the study area. Educational status of mothers, wealth status and nutrition information and PSNP beneficence were factors associated with adequate dietary diversity practice of pregnant mothers.
Multi-sectoral collaboration is needed to enhance the dietary diversity of pregnant women by promoting women's education, strengthening sustainable income generating activities and saving strategies to improve the wealth status of pregnant women. In addition, it is better to advocate nutrition education regarding dietary diversity during pregnancy.

Limitation
We didn't consider the amount of food consumed that may not accurately reflect their past feeding experience. In addition, there might be social desirability bias during answering wealth index questions.