Minimum Dietary Diversity and Associated Factors Among Pregnant Women Attending Antenatal Care in Government Health Facilities of Soro District, Hadiya Zone, Southern Ethiopia


 Background: Dietary diversity is a good proxy indicator for micronutrient adequacy in pregnant women. Despite some improvements in dietary intake among pregnant mothers, achieving the minimum dietary diversity among them is still a great challenge in Ethiopia. There are no enough studies done on minimum dietary diversity among pregnant women and factors identified were more of local based. Therefore this study determined the prevalence of minimum dietary diversity and its associated factors among pregnant women attending antenatal care in government health facilities of Soro district, Hadiya Zone, Southern Ethiopia.Methods: This is the facility based study conducted in government health facilities of Soro district, Hadiya Zone from Oct. 2020-Jan 2021. Cross sectional study design was undertaken by using systematic sampling on 422 pregnant women attending antenatal care. Both bivariate and multivariable logistic regression analysis were used to assess the association of independent variables with outcome variable.Result: From the total of the 422 study subjects, 416 pregnant women attending antenatal care were participated in the study and making the response rate 98.6 percent. The overall prevalence of pregnant mothers who have met the minimum dietary diversity was only 7.9%. Maternal educational status being grade nine above, eating meal more than three times per day and women being currently not married were factors found to be significantly associated with minimum dietary diversity among pregnant mothers attending antenatal care in government health facilities.Conclusion: The prevalence of the minimum dietary diversity among pregnant women attending ANC in public health facilities of Soro district was very low and far from national and international recommendations to enhance the maternal food diversity. Inter sectoral collaboration is very important to enhance the minimum dietary diversity during pregnancy and should be worked intensively and in an integrated manner.


Introduction
Maternal nutrition is one of the greatest opportunities to improve the health across generations. WHO says good maternal nutrition as the best start in life [1]. Maternal nutrition is not only critical to reduce mortality and disability, but is the foundation for a child's growth and development. The most critical window of opportunity for impactful intervention is the rst 1,000 days of a child's life that includes pregnancy and the rst two years of life after birth. Pregnancy is a special period in human life with in uence on not only pregnant women, but also on the health and productivity of the next generation.
Interventions during this period of time support a broader lifecycle approach to nutrition. Appropriate nutrition is the most critical one to ensure optimum physical and cognitive development [2][3][4].
If a woman is malnourished during pregnancy, or if her child is malnourished during the rst two years of life, the child's physical and mental growth and development may be slowed. Hence how women eat and maternal nutritional status during pregnancy is very important for better health of the mother as well as for better and healthy growth and development of the child [4][5][6].
Dietary diversity is a good proxy indicator for micronutrient adequacy in pregnant women. The fetus is dependent on the range of micronutrients circulating in the mother's blood supply for optimal. It is essential for mothers, caregivers, family members, and communities to have accurate information on how women should eat during pregnancy and breastfeeding [1,5]. However, Pregnancy is the life threatening situation though it is a normal physiological event in life stage in Africa. Sub-Saharan Africa is a region known by highest maternal and child mortality in the world. In sub-Saharan Africa 32 million babies are born small for gestational age (SGA) annually representing 27% of all births in low and middle income countries. Furthermore fetal growth restriction causes more than 800000 deaths each year in the rst month of life and follows with substantially increased risk of being stunted among children [7].
The consequence of the maternal malnutrition is not limited on mother but it has also both short and long term implications for offspring. It sets a stage for poor pregnancy outcomes, affecting the survival and quality of the offspring. Studies show that poor quality of diet for women is the main factor for energy and micronutrient de ciencies among pregnant women [7].
Despite some improvement in nutritional status of mothers and children, maternal undernutrition is still a challenge in Ethiopia [4,8]. Intake of macro and micronutrients were below the recommendation among pregnant women in rural area, Southern Ethiopia. Nearly all (99.0%) of the pregnant women were de cient in niacin, folate and calcium. More over only quarter of women had succeeded adequate food intake during their pregnancy [9]. Fear of big fetuses, abortion, less blood, lack of strength during birth, miscarriages or stillbirths, and maternal deaths as well as child's colic and poor skin conditions after birth are identi ed reasons for mothers to be restricted to take healthy foods during pregnancy [10,11]. There is no recent study done on dietary diversity and its associated factors among pregnant women at the study area. Therefore this study determined the prevalence of minimum dietary diversity and its associated factors among pregnant women attending antenatal care (ANC) in government health facilities of Soro district, Hadiya Zone, Southern Ethiopia.

Study design and setting
This study was undertaken in government health facilities located in Soro district, Hadiya Zone which is located in 32 km from Zonal city, Hosanna and 262km from Addis Ababa. The district has thirty two rural kebeles. It hast ve health centers serving more than 125000 people [12]. Facility based cross sectional study was employed to assess the prevalence and factors associated with minimum dietary diversity among pregnant women attending antenatal care in public health centers.

Study population
All pregnant women who have been attending antenatal care in government health facilities at Soro district were source population of this study. The study population was those pregnant women who were randomly selected for the study within in the selected health facilities. Pregnant women who were severely ill, unable to hear and talk were excluded from the study.

Sample size determination and sampling technique
By considering an anticipated proportion of adequate dietary diversity among pregnant women 50%, 5% type I error, margin of error 5 % and 10% contingency for the non-response the nal sample size was 422. Systematic sampling was applied to select those study subjects by preparing the K-value and by randomly selecting the rst number to commence the study at each health facility.

Operational de nition
Minimum dietary diversity: The proportion of the pregnant women 15-49 years of age who have consumed at least ve out of ten de ned food groups in the previous day or night [13].

Data collection processes and tools
Quantitative data were collected through face to face interview by using standard pretested questionnaires which were extracted from recognized sources. Data collectors were trained for two days on purpose of the study, how to collect data and ethical considerations. Questionnaire was prepared in English and translated into Amharic and then translated back to English language by uent speakers of both languages. Data collection was undertaken from Oct. 2020-Jan 2021 by hiring ve data collectors and three supervisors who have experience on data collection.

Data processing, analysis and presentation
After eld work data were checked for completeness and consistence before data entry and cleaning. Then data were entered and analyzed by SPSS for windows version 20 (SPSS Inc. version 20, Chicago, Illinois). Descriptive summary was presented by using frequencies, proportions, means and tables. Both bivariate and multivariable logistic regression analysis were used to assess the association of independent variables with outcome variable and to control the possible confounding factors. Those independent variables with p-value less than or equal to 0.25 were candidates for multivariable logistic regression and nally variables with p-value less than 0.05 in multivariable logistic regression were selected as signi cantly associated with the outcome variable.

Result
Socio demographic characteristics of the study participants From the total of the 422 study subjects, 416 pregnant women attending antenatal care were participated in the study and making the response rate 98.6 percent. The mean age was 27.34 year (SD±4.34). More than two third 323(77.6%) of the respondents were protestants in their religion and most were married 391(94.0%). According to the ethnicity, majority 366(88.0%) were the Hadiya ethnic groups. Nearly half of the pregnant women had attended 1-8 class in their education and most of them were housewives in their occupation (Table 1). Majority of the households 265(63.7%) with pregnant women had more than or equal to ve household members. One hundred seventy nine (43.0%) of the pregnant women had a gravidity of either four up to ve likewise majority 179(43.0%) had a live birth of three up to four children. Nearly half of the respondents 198(47.6%) were in the second trimester of the pregnancy during the study. According to the health status, most of the pregnant women 356(85.6%) had no any illness within the last one month as they had reported orally. Typhoid fever was reported by more than one third of those experienced illness within one month prior to the date of the data collection (Table2).  Pregnant women who have attended grade 9 and above in their education had 8.5 times more odds of getting minimum dietary diversity than those who were unable to read and write. Those who consumed food four and more times were 6.1 times more likely to practice minimum dietary diversity than their counterparts who received three and less times in the previous day. Mothers were in the marriage at the time had 8 percent less odds of having minimum dietary diversity than those who were not in the marriage (Table 4).  10.6%). The nding of this study was lower than studies conducted in Ethiopia and other countries. It is lower than the ndings in studies undertaken in Bale Zone (43.8%), South East Ethiopia, Gojam (45%), Northern Ethiopia, Shashemane (25.4%), Ethiopia and Ghana (46.1%) [11,[14][15][16]. This might be due to the fact that the season when the study undertaken affected the study nding. Even though it is the harvesting season around the study area, most food products are starchy sources mainly barley, wheat, maize and teff. It might also be due to the new FAO 2016 guideline where the study tool was adapted, that recommends considering a pregnant woman achieved minimum dietary diversity if a pregnant woman consumes at least ve out of ten food groups in the previous 24 hours.
Starchy staples were the most common food group eaten by respondents (99.5%). This might be due to more production of starchy foods in the study area and low purchasing power to access fruits and animal products from the market. It might also be due to lack of awareness on diversifying diets with low cost and effort among pregnant women and within the community where the women from. The nding is in line with the study done in Eastern Ethiopia and Kenya [17]. However, the study conducted in Gojam, Northern Ethiopia [15] indicated that legumes, nuts, and seeds (85.5%) were the most commonly consumed food groups.
In this study maternal education was associated with achieving the minimum dietary diversity among pregnant mothers attending ante natal care. Women who have attended grade 9 and above in their education had 8.5 times more odds of getting minimum dietary diversity than those who were unable to read and write. The nding is similar with the study done in Shashemane, Ethiopia where pregnant women who had tertiary and secondary education had three times and two times more likely to achieve the adequate dietary diversity, respectively, as compared to those who had no formal education. It also agrees with studies conducted in Jille Tumuga, North eastern Ethiopia, East Gojam, North West Ethiopia and Kenya [11,15,17,18]. This indicates as the education status of women increases the likelihood getting diverse diet increases. This might be that fact that as the more mothers educated the chance to get the nutrition information either by reading, learning or watching from different sources might be extended.
The frequency of the diet in the previous day prior to study is found to be a factor associated with minimum dietary diversity among pregnant women. In this study those who consumed food four and more times were 6.1 times more likely to practice minimum dietary diversity than their counterparts who received three and less times in the previous day. This might be the fact that as the frequency of the diet increases it provides the pregnant women an opportunity to get a diet from different food groups. It is a common habit in the study area that the pattern of eating foods depends on the speci c time of the day.
It is culture to practice cereal and grain sources with coffee in the morning and kocho (product of false banana) or enjera( bread made of teff or wheat) with cabbage or wot (stew made of bean or pea) in the mid day or night. If pregnant women get snack, it may add an access to get additional meal from different food groups. The nding is consistent with the studies done in Alemata Hosiptal, Northern Ethiopia and Finote selam town, North West Ethiopia [19,20] where pregnant women those who got three and more meals per day had more odds of meeting minimum dietary diversity than their counterparts. This study reports the nding which is inconsistent with other studies that marital status was associated with minimum dietary diversity. Mothers were currently married had 8 percent less odds of having minimum dietary diversity than those who were not in the marriage. This might be the fact that culturally and religiously common to women should give priority for their husbands and gusts in the house and there is a belief that tasty and delicious foods should given for them to show the respect from wives.
Sample size may also affect the nding as most of the respondents were currently married and incomparable in proportion with those who were single, widowed or separated during the study.
This study has its own limitations. The nature of the study being a cross sectional study is di cult to ascertain the causation of the selected factors with minimum dietary diversity among pregnant women.
Recall bias and social desirability might affect the study as the study was based on twenty four hour recall and there might be reporting socially acceptable and common diet during the interview. Seasonality may also affect the study as the access for different foods depends on harvesting season in the study area. Factors related with husbands and household food security were not studied and need to be considered in the future studies.

Conclusion And Recommendation
The prevalence of the minimum dietary diversity among pregnant women attending ANC in public health facilities of Soro district was very low and far from national and international recommendations to enhance the maternal food diversity. The maternal education being grade 9 and above, meal frequency being four and above and being currently unmarried were the factors independently associated with meeting minimum dietary diversity among pregnant women.
Inter sectoral collaboration is very important to enhance and extend the formal and nutrition education for females and should be worked intensively and in integrated manner. Agricultural sector should work in nutrition sensitive food production which increases the access for pregnant women to receive locally prepared nutritious foods and to consume at least four times within one day. Health workers those who work in ANC clinic should focus on maternal nutrition counseling and advocacy that ensures pregnant mothers to get their meal from different food groups by using nutrition education and communication tools. Household and community based awareness creation activities should be done on improving the dietary diversity of the mothers currently in marriage.

Declarations
Ethical approval and consent to participate Ethical clearance was obtained from the Wachemo University, college of medicine and health sciences ethical committee. The letter of cooperation was written for Sorro District health o ce in order to proceed the study. The study was conducted based on voluntary participation by study subjects after explaining the purpose of study. Informed consent was obtained from each participant before starting the interview without any obligation or persuading. Anyone had right to withdraw from interview at any time without any harm. No name of participant has been written and code was used instead and con dentiality of data was assured for participants. Privacy and con dentiality of personal information of research subjects have been ensured during the study. The overall method was preformed according to the world medical association (WMA) regulations and principles on research involving human participants.