Study design, period, and setting
Institution-based cross-sectional study was conducted to assess the prevalence and associated factors of undernutrition among pregnant women visiting ANC follow up clinics of health facilities. It was conducted from July to January 2019 in Silte Zone. It is one of fourteen Zones of the southern region of Ethiopia and found 172 km away from Addis Ababa (the capital city of Ethiopia). The administrative center of the zone is Werabe town. This zone consists of 3 administration towns, and 10 rural weredas. Based on the last Census conducted by the central statistical agency of Ethiopia, in 2018 the Zone has an estimated population of 1,017,557 of whom 34510 were expected pregnant women. About 13% of the total population is urban inhabitants. Also there are 4 Hospitals and 33 Health centers.
Study Subjects
Sample size determination and sampling technique
The sample size (n) required for the study was calculated using a single population proportion formula. Considering the absence similar study conducted in similar context as per our search effort, we took p-value of 50%, 5% marginal error, and 95% confidence interval were used to obtain the maximum sample size. With the addition of 10% non-response rate, the initial sample size was increased from 384 to 422. In the study area, the antenatal care service is provided in all health care facilities. To increase the generalizability of the results, health facilities were stratified based on the type of the health facility, 1 hospital from the four hospitals and 10 health centers from the 33 health centers were selected randomly. The calculated sample size was allocated proportionately to each stratum. According to the health facilities report, on average, 15–30 pregnant women visit the ANC daily and 2066 pregnant women have been enrolled in ANC of selected health facilities. Forty two from Tora primary hospital and 380 from 10 health centers were selected using a systematic random sampling technique at interval of k = 5. Of the first five pregnant women, the 3rd woman was randomly selected by using a lottery method. Accordingly, every 5th pregnant women were chosen based on their visiting order until the sample size was met. Participants were approached after receiving service.
Measurements and data collection tools
An interviewer-administered questionnaire was used to collect the data. Socio-demographic factors (such as Age, Marital status, Residence, Occupation, maternal educational status, religion, and husband educational status), Obstetric history of respondents, nutrition knowledge, dietary practice, and anthropometric data were collected. Sociodemographic questions were adapted from the Ethiopian demographic and health survey (EDHS 2016)(31). Knowledge questions were adopted from the Food and Agricultural Organization of the United Nation (FAO) knowledge, attitude, and practice survey guideline(32). Nutritional knowledge consists of women’s nutrition during pregnancy and breastfeeding, micronutrient supplements for pregnant women, recommendation of folic acid supplements, health risks for low–birth–weight babies, and family planning. There 5-items measuring nutritional knowledge were rated on a dichotomous scale (0 = “does not know” response, 1 = “knows”). For each question, a correct response was coded as 1 and an incorrect response as 0. The total score was calculated from all the correct responses, with a maximum of 5. Mean is used as a cut off value for nutritional status. Dietary change as a result of current pregnancy was assessed by a single item “Do you change a diet as a result of current pregnancy?”(33)
Measurement of middle upper arm circumference (MUAC) was used to determine the nutritional status of pregnant women. MUAC of the left arm was measured triplicate using a non-stretchable standard MUAC tape to the nearest 0.1 cm with no clothing on the arm. The mean of triplicate measurement was taken. Pregnant women having MUAC< 23 cm were considered undernourished and ≥ 23 cm well-nourished (23, 34, 35). Meal frequency was considered to be recommended (adequate) when respondents take an additional meal (>3 meals per day) as a result of the current pregnancy(36).
Data Quality Control
Data collectors and supervisors were trained before data collection. The instrument was pretested in 5% of the sample size. It was conducted on individuals with similar characteristics of the study population who were not a part of the actual study. Based on the pretest results, the instrument was modified and changed into local contexts. Trained supervisors supervise the data collection and check the completeness of the questionnaire on a daily base. In addition, principal investigators carefully cleaned and entered collected data into a computer. During the entry of data, double-entry verification using Epidata 3.1 was applied.
Data processing and analysis:
Data were entered into a computer using Epi data 3.1, and edited, cleaned, and analyzed using SPSS version 20. Bivariable and multivariable logistic regression was used to determine the degree of association between independent and dependent variables. Variables with p-value of < 0.25 in Bivariable logistic regression analysis were candidates for multivariable logistic regression analysis. In multivariable logistic regression analysis, those variables with a p-value ≤ 0.05 with adjusted odds ratio interval exclude one was considered as statistically significant.