Demographic and socio-economic characteristics
A total of 415 early third trimester pregnant mothers were recruited. Of these, 203 were in the intervention group and another 212 in the control group with 100 % response rate. The mean ages (±SD) of the mothers were 39(±15) years. Out of the total mothers interviewed, three fourth 305 (73.5%) belongs to the age group of 20-34 years. Most of the mothers 393(94.7%) were currently in marital union and 395(95.2) them were orthodox religion believer. Six out of ten 254 (61.2%) of the mothers were rural residence, greater than three-fourth of them had less 5 family members 320(77.1%). More than one third 320 (41.9%) of the mothers and almost half of the husbands 196 (47.2%) were illiterate. Majority of the maternal occupational 333(80.2%) were housewife and more than half paternal occupation 234 (56.4%) were farmers. One fifth of the mothers 86(20.72%) had middle wealth quintile [Table 1].
Table 1: Demographic and socio-economic characteristics of pregnant mother, Tigray Region, Northern Ethiopia, 2019 (N=415)
Characteristics
|
Number
|
Percent
|
Maternal Age
|
< 20 years
|
68
|
16.39
|
20-34 years
|
305
|
73.49
|
35-49 years
|
42
|
10.12
|
Marital status
|
Marred
|
393
|
94.70
|
Single
|
15
|
3.61
|
Divorced
|
7
|
1.69
|
Religion
|
Orthodox
|
395
|
95.18
|
Muslim
|
20
|
4.82
|
Place of Residence
|
Rural
|
254
|
61.20
|
Urban
|
161
|
38.80
|
Family members
|
< 5 members
|
320
|
77.11
|
>5 members
|
95
|
22.89
|
Maternal highest Grade
|
No formal education
|
174
|
41.93
|
Elementary School
|
134
|
32.29
|
Above Secondary School
|
107
|
25.8
|
Paternal highest grade
|
No formal education
|
196
|
47.23
|
Elementary School completed
|
107
|
25.78
|
Above secondary School
|
112
|
27.0
|
Maternal occupation
|
Housewife
|
333
|
80.24
|
Daily-laborer
|
25
|
6.0
|
Employed
|
57
|
13.7
|
Husband occupation
|
Farmer
|
234
|
56.39
|
Employed government
|
56
|
13.49
|
Employed non-government
|
25
|
6.0
|
Daily-laborer
|
47
|
11.33
|
Self-employed non farming
|
53
|
12.77
|
Wealth Quantiles
|
Lowest
|
82
|
19.76
|
Second
|
84
|
20.24
|
Middle
|
86
|
20.72
|
Fourth
|
91
|
21.93
|
Highest
|
72
|
17.35
|
Environmental characteristics
Around four out of ten 182(43.9%) households did not possess toilet and out of the owners of toilet 112(48.1%) were pit latrine without slab [Table 2].
Table 2: Environmental characteristics of pregnant mothers, Tigray Region, Northern Ethiopia, 2019 (N=415)
Characteristics
|
Number
|
Percent
|
Have toilet
|
Yes
|
233
|
56.1
|
No
|
182
|
43.9
|
Kind of toilet
|
Pit latrine without slab
|
112
|
48.1
|
Pit latrine with slab cover
|
86
|
36.9
|
Ventilated improved pit latrine
|
20
|
8.6
|
Flush toilet
|
15
|
6.4
|
Obstetric and reproductive health characteristics
Three-fourth 326 (78.5%) of the mothers were willing to get pregnant and two third of the mothers 278 (66.99%) were multi gravid and 150 (36.1%) of them had 1-2 parity. Majority of 409(98.5%) of mothers did not have history gestational diabetes, gestational hypertension or postpartum depression previously. Sixty one percent (n=257) of mothers had received antenatal care during their last pregnancy. Around four percent (n=15), 246(59.3%) and 27(6.5%) were examined for ANC by Doctor/IEOS, Nurse/midwifery and Health extension workers respectively. Majority of the mothers 216(52%) receive ANC for their last delivery in public health centers. Ninety-five percent (n=395) of the mothers receive ANC for their current pregnancy and 313(75.4%) of mothers receive ANC in public health center. Most of them 382(92%) took supplements (Iron/folic acid Iodine, or other) during the current pregnancy [Table 3].
Table 3: Obstetric and reproductive health characteristics of pregnant mother, Tigray Region, Northern Ethiopia, 2019 (N=415)
Characteristics
|
Number
|
Percent
|
When you got pregnant, did you want to get pregnant
|
Yes
|
326
|
78.55
|
No
|
89
|
21.45
|
Gravidity
|
Primi-gravida
|
137
|
33.01
|
Multi gravid
|
278
|
66.99
|
Parity
|
1-2
|
150
|
36.1
|
3-4
|
82
|
19.8
|
>5
|
46
|
11.1
|
Gestational diabetes, high blood pressure, depression, or postpartum depression in your last pregnancy
|
No history of the mentioned
|
409
|
98.55
|
History Gestational Diabetes
|
2
|
0.48
|
History of Gestational Hypertension
|
2
|
0.48
|
History postpartum depression
|
2
|
0.48
|
Receive antenatal care during you last pregnancy
|
Yes
|
257
|
61.93
|
No
|
158
|
38.07
|
Examined by Doctor/IEOS during ANC
|
Yes
|
15
|
3.6
|
No
|
400
|
96.4
|
Examined by Nurse/midwife during ANC
|
Yes
|
246
|
59.3
|
No
|
169
|
40.7
|
Examined by Health extension worker during ANC
|
Yes
|
27
|
6.5
|
No
|
388
|
93.5
|
Receive antenatal care for your last child in Governmental Hospital
|
Yes
|
15
|
3.6
|
No
|
400
|
96.4
|
Receive antenatal care for your last child in public hospital
|
Yes
|
84
|
20.2
|
No
|
331
|
79.8
|
Receive antenatal care for your last child in public health center
|
Yes
|
216
|
52.0
|
No
|
199
|
48.0
|
Receive antenatal care for your last child in Health post
|
Yes
|
23
|
5.5
|
No
|
392
|
94.5
|
Did you see anyone for antenatal care for this pregnancy
|
Yes
|
395
|
95.2
|
No
|
20
|
4.8
|
Place receive antenatal care for current pregnancy
|
Government hospital
|
30
|
7.2
|
Public hospital
|
72
|
17.3
|
Public health center
|
313
|
75.4
|
Did you take any supplements (Iron/folic acid Iodine, or other) during this pregnancy
|
Yes
|
382
|
92.0
|
No
|
33
|
8.0
|
Dietary and nutritional characteristics
Most of the pregnant mothers 392 (94%) were supplemented iron folic acid less than 90 days. More than one third 138(33.3) of the household resources were managed by husband and 145(34.9%) of the participants feel little weight gain since they become pregnant. Around quarter 61(14.7) of the mothers were physically threatened by their husband and 34(8.2%) of them felt down depressed or hopeless. Almost nine out of ten mothers 366(88.5%) had no food taboos during this pregnancy and 359(86.5%) of them had no food cravings during this pregnancy. Average calcium level at base line was mean (±SD) 410±208 gm [Table 4].
Table 4: Dietary and nutritional characteristics of pregnant mothers, Tigray Region, Northern Ethiopia, 2019 (N=415)
Characteristics
|
Number
|
Percent
|
Days Iron/folic acid supplemented
|
< 90 days
|
392
|
94
|
>90 days
|
23
|
5.5
|
In the past month, have there been days when you did not have enough food or money to buy food?
|
Yes
|
81
|
19.5
|
No
|
334
|
80.5
|
Household resources are managed by whom?
|
Partner
|
138
|
33.3
|
Mother
|
54
|
13.0
|
Both of them
|
223
|
53.7
|
How do you feel about your weight change since you became pregnant?
|
Gaining too much
|
95
|
22.9
|
Gaining too little
|
145
|
34.9
|
It’s okay
|
116
|
28.0
|
Not sure
|
37
|
8.9
|
Weight has not changed
|
22
|
5.3
|
In the last month, has your partner physically threatened or tried to hurt you
|
Yes
|
61
|
14.7
|
No
|
354
|
85.3
|
In the last month, have you felt down, depressed, or hopeless
|
Yes
|
34
|
8.2
|
No
|
381
|
91.8
|
Any change in feeding habit
|
Yes
|
64
|
15.4
|
No
|
351
|
84.6
|
Food taboos during this pregnancy
|
Yes
|
49
|
11.8
|
No
|
366
|
88.2
|
Food cravings during this pregnancy
|
Yes
|
56
|
13.5
|
No
|
359
|
86.5
|
Food averted during this pregnancy
|
Yes
|
54
|
13.0
|
No
|
361
|
87.0
|
Average calcium intake
|
410±208 gm
|
Communication related characteristics
Majority of the mothers did not read a newspaper or magazine 275(66.3%) and More than half 249(59.8%) of the mothers did not listen radio and more than one third 284(68.4%) did not watch television [Table 5].
Table 5: Communication related characteristics of pregnant mothers, Tigray Region, Northern Ethiopia, 2019(N=415)
Characteristics
|
Number
|
Percent
|
Read a newspaper or magazine
|
At least once a week
|
49
|
11.8
|
Less than once a week
|
91
|
21.9
|
Not at all
|
275
|
66.3
|
Do you listen Radio
|
At least once a week
|
102
|
24.6
|
Less than once a week
|
65
|
15.7
|
Not at all
|
248
|
59.8
|
Watch television
|
At least once a week
|
82
|
19.8
|
Less than once a week
|
49
|
11.8
|
Not at all
|
284
|
68.4
|
Factors affecting Blood pressure variability among groups
Table 6 shows the results of mixed effect logistic regression analyses examining the effect of calcium nutrition education among pregnant women’s individual characteristics and community-level factors in pregnant women in blood pressure fluctuation. Model 1, the empty model, includes only random intercept to capture between-cluster variability. In this model, 16% of the total variance in the odds of in blood pressure fluctuation was accounted for by between-cluster variation (ICC=0.12, The ICC was computed in each successive model to understand the relative effects of individual-level and community level factors on women in blood pressure fluctuation. Similarly, the ICC was computed in each successive model to understand the relative effects of individual-level and community level factors on calcium nutrition education to in blood pressure fluctuation. The between-cluster variability over successive models, from 12% in the empty model, to 9.7% in the individual-level only model, 8.9% in the community-level only model, and 8.3% in the combined model [Table 6]. Showing that variation in the blood pressure variability was explained best by the inclusion of both individual level characteristics.
The proportional of change in model in variance indicated the addition of predicators to the empty model better explained pregnant women calcium nutrition education change in blood pressure fluctuation.
Individual level effect
Model 2 contained only the individual level variables. Results showed that nutrition education on calcium for pregnant mothers was significantly associated with blood pressure variability, those mothers who got education had 62% lower blood pressure variability when compared with the control groups [AOR=0.38; 95% CI: 0.19, 0.5]. Concerning maternal highest grade, Pregnant mothers who attained secondary school had 79% less likely blood pressure variability than mothers who were with no formal education [AOR=0.21, 95%CI: 0.20,0.70]. Employed pregnant women [AOR=9.05; 95% CI: 1.95, 14.02] had higher likelihood of blood pressure variability when compared to the reference category. Pregnant mothers who did not visit health facility for ANC had higher likely of blood pressure variability than those visited for ANC [AOR=1.82; 95% CI: 1.01, 2.22]. Women supplemented iron/folic acid less than 90 days had 6 times greater odds of blood pressure variability than women supplemented iron/folic greater than 90 days. Women who were not craving were 22 % less likely blood pressure variability than those who were craving [AOR=0.78; 95% CI: 0.20, 0.98]. The odds of blood pressure variability among women who read newspaper less than a week was 99.3% less likely than mother who did not read at all [AOR=9.05; 95% CI: 1.95, 14.02]. As the average calcium intake increased by 1 unit the blood pressure variability decreases by 0.99 unit [AOR= -0.99; 95% CI:0.993-0.998].Compared to the empty model, the variation in health facility delivery was significant across communities (τ = 0.81, p<0.001). The intra-community correlation was 9.7% indicating the variability in the outcome variable.
Community level effect
We examined the effects of community level factors on the likelihood of blood pressure variability in model 3. As shown in the model, women living in urban area had 2.11 times higher odds of blood pressure variability than rural residents [AOR=2.11; 95% CI: 1.36, 3.26]. The intra individual correlation in the model increased, whereas that of the community decreased further suggesting that the proportional change in variance of odds of blood pressure across individuals and communities was explained by individual level characteristics. In other words this indicates that the differences in the likelihood of blood pressure variability were partly as a result of composition of communities by community level characteristics.
Finally we included both the individual and community variables in model 4. For the individual level variables, the relationship was consistent with that observed in model 1. Nutrition education on calcium for pregnant mothers was significantly associated with blood pressure variability, those mothers who got education had 71% lower blood pressure variability when compared with the control groups [AOR=0.29; 95% CI: 0.19, 0.50]. Concerning maternal highest grade, Pregnant mothers who attained secondary school had 80% less likely blood pressure variability than mothers who were with no formal education [AOR=0.20, 95%CI: 0.04,0.97]. Employed pregnant women [AOR=10.17; 95% CI: 1.96, 15.28] had 9 times higher likelihood of blood pressure variability when compared to the reference category. Pregnant mothers who did not visit health facility for ANC had 1.4 times higher likely of blood pressure variability than those visited for ANC [AOR=1.39; 95% CI: 1.05, 1.83]. Women supplemented iron/folic acid less than 90 days had 6 times greater odds of blood pressure variability than women supplemented iron/folic greater than 90 days. Women who were not craving were 23 % less likely blood pressure variability than those who were craving [AOR=0.77; 95% CI: 0.18, 0.0.93]. The odds of blood pressure variability among women who read newspaper less than a week was 99.3% less likely than mother who did not read at all [AOR=0.07; 95% CI: 0.01,0.40]. As the average calcium intake increased by 1 unit the blood pressure variability decreases by 0.99 units [AOR= -0.99; 95% CI: 0.993-0.998]. However there are no significant community factors on the combined model 4. The community level variance was significant (τ =0.12, p<0.001). The intra-community correlation decreased to 8.3% suggesting that the inclusion of the community variables improved the overall explained variance in the use of delivery care compared with model 3. Moreover, the smaller values of AIC and BIC indicated that model 4 was a better explanatory model.
Table 6: Two level mixed effect logistic regression of individual and community factors on Blood Pressure variability during pregnancy, Tigray Region, 2019
Characteristics
|
Model I
Empty model
|
Model II
Individual factors
OR (95%CI)
|
Model III
Community/HH factors
OR (95%CI)
|
Model IV
Individual and community factors OR (95%CI)
|
Fixed effect (individual factors)
|
|
|
|
|
Study arm (Calcium nutrition education)
|
Intervention arm
|
-
|
0.38* (0.20-0.70)
|
|
0.29*(0.19-0.50)
|
Control arm
|
-
|
1.00
|
|
1
|
Maternal Age
|
-
|
|
|
|
< 20 years
|
-
|
1.00
|
|
1
|
20-34 years
|
-
|
0.33(0.51-2.19)
|
|
0.43(0.12-1.48)
|
35-49 years
|
-
|
0.35(0.12-1.18)
|
|
0.42(0.06-2.90)
|
Family members
|
--
|
|
|
|
< 5 members
|
-
|
0.35(0.12-1.09)
|
|
0.32(0.10-0.9)
|
>5 members
|
-
|
1.00
|
|
1.00
|
Maternal highest Grade
|
-
|
|
|
|
No formal education
|
-
|
1
|
|
1
|
Elementary School
|
-
|
0.75(0.23-2.42)
|
|
0.77(0.24-2.53)
|
Above Secondary School
|
-
|
0.21*(0.05-0.95)
|
|
0.20*(0.04-0.97)
|
Paternal highest grade
|
-
|
|
|
|
No formal education
|
-
|
1
|
|
1
|
Elementary School completed
|
-
|
1.68(0.41-6.82)
|
|
2.02(0.66-6.17)
|
Above secondary School
|
-
|
2.45(0.84-7.15)
|
|
1.73(0.41-7.31)
|
Maternal occupation
|
-
|
|
|
|
Housewife
|
-
|
1
|
|
1
|
Daily-laborer
|
-
|
0.35(0.06-1.96)
|
|
|
Employed
|
-
|
9.05*(1.95-14.02)
|
|
10.17*(1.96-15.28)
|
Husband occupation
|
-
|
|
|
|
Farmer
|
-
|
1
|
|
1
|
Employed government
|
-
|
1.06(0.20-5.56)
|
|
0.90(0.16-5.20)
|
Employed non-government
|
-
|
1.67(0.32-8.79)
|
|
1.52(0.27-8.57)
|
Daily-laborer
|
-
|
2.01(0.41-9.86)
|
|
1.89()0.36-9.82
|
Self-employed non farming
|
-
|
1.55(0.38-6.18)
|
|
1.38(0.31-6.15)
|
Wealth Quantilles
|
-
|
|
|
|
Lowest
|
-
|
1
|
|
1
|
Second
|
-
|
1.44(0.41-5.12)
|
|
1.38(0.38-5.04)
|
Middle
|
-
|
2.01(0.41-9.78)
|
|
1.93(0.36-10.24)
|
Fourth
|
-
|
0.27(0.06-1.26)
|
|
0.27(0.06-1.27)
|
Highest
|
-
|
0.86(0.17-4.35)
|
|
0.98(0.18-5.44)
|
Have toilet
|
-
|
|
|
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
0.59(0.23-1.52)
|
|
0.63(0.23-1.69)
|
When you got pregnant, did you want to get pregnant
|
Yes
|
-
|
1.00
|
|
1
|
No
|
-
|
1.36(0.45-4.13)
|
|
1.56(0.49-4.94)
|
Gravidity
|
-
|
|
|
|
Primi gravid
|
-
|
1.00
|
|
1
|
Multi gravid
|
-
|
0.65(0.24-1.73)
|
|
0.67(0.25-1.82)
|
Receive antenatal care during you last pregnancy
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
1.82*(1.01-2.22)
|
|
1.39*(1.05-1.83)
|
Did you see anyone for antenatal care for this pregnancy
|
Yes
|
-
|
1.00
|
|
1
|
No
|
-
|
1.65*(1.24-1.73)
|
|
1.78*(0.33-0.99)
|
Place receive antenatal care for current pregnancy
|
Government hospital
|
-
|
1
|
|
1
|
Public hospital
|
-
|
6.51 (057-73.97)
|
|
2.26(0.16-30.93)
|
Public health center
|
-
|
2.09 (0.17-25.98)
|
|
8.66(0.57-13.10)
|
Did you take any supplements (Iron/folic acid Iodine, or other) during this pregnancy
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
2.16(0.52-8.97)
|
|
1.69(0.39-7.33)
|
Days Iron/folic acid supplemented
|
|
|
|
|
> 90 days
|
-
|
1
|
|
1
|
< 90 days
|
-
|
6.32*(1.09-36.59)
|
|
7.88*(1.29- 48.08)
|
In the past month, have there been days when you did not have enough food or money to buy food
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
0.67(0.25-1.86)
|
|
0.61(0.21-1.76)
|
Household resources are managed
|
|
|
|
|
Partner
|
-
|
1
|
|
1
|
Mother
|
-
|
0.77(0.20-2.99)
|
|
0.94(0.22-3.98)
|
Both of them
|
-
|
1.21(0.44-3.34)
|
|
1.37(1.08-3.86)
|
How do you feel about your weight change since you became pregnant
|
Gaining too much
|
-
|
1
|
|
1
|
Gaining too little
|
-
|
0.87(0.29-2.60)
|
|
0.89(0.29-2.71)
|
It’s okay
|
-
|
0.57(0.16-2.06)
|
|
0.62(0.16-2.38)
|
Not sure
|
-
|
0.19(0.02-1.73)
|
|
0.15(0.01-1.65)
|
Weight has not changed
|
-
|
3.96(0.64-24.43)
|
|
3.39(0.49-23.67)
|
In the last month, has your partner physically threatened or tried to hurt you
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
0.63(0.11-3.52)
|
|
0.88(0.14-5.40)
|
In the last month, have you felt down, depressed, or hopeless
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
0.81(0.07-9.36)
|
|
0.67(0.05-8.45)
|
Any change in feeding habit
|
|
|
|
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
1.25(0.35-4.50)
|
|
1.27(0.34-4.75)
|
Food taboos during this pregnancy
|
|
|
|
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
0.86 (0.21-3.59)
|
|
0.96(0.22-4.26)
|
Food cravings during this pregnancy
|
|
|
|
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
0.78*(0.20-0.98)
|
|
0.77*(0.18-0.93)
|
Food averted during this pregnancy
|
|
|
|
|
Yes
|
-
|
1
|
|
1
|
No
|
-
|
3.45(0.88-13.57)
|
|
3.27(0.78-13.59)
|
Average calcium intake
|
-
|
0.996*(0.993-0.998)
|
|
0.996*(0.993-0.998)
|
Read a newspaper or magazine
|
|
|
|
|
Not at all
|
-
|
1
|
|
1
|
Less than once a week
|
-
|
0.07*(0.01-0.43)
|
|
0.07*(0.01-0.40)
|
At least once a week
|
-
|
0.35(0.09-1.40)
|
|
0.29 (0.07-1.28)
|
Do you listen radio
|
|
|
|
|
Not at all
|
-
|
1
|
|
1
|
Less than once a week
|
-
|
0.86(0.20-3.68)
|
|
1.03(0.23-4.56)
|
At least once a week
|
-
|
0.79(0.25-2.48)
|
|
0.86(0.26-2.82)
|
Watch television
|
|
|
|
|
Not at all
|
-
|
1
|
|
1
|
Less than once a week
|
-
|
0.64(0.10-3.96)
|
|
0.55(0.08-3.58)
|
At least once a week
|
-
|
0.74(0.17-3.10)
|
|
0.99(0.22-4.53)
|
Fixed effect (Community/facility factors)
|
Place of Residence
|
-
|
|
|
|
Rural
|
-
|
|
1
|
1
|
Urban
|
-
|
|
2.11*(1.36-3.26)
|
1.39(0.44-4.44)
|
Examined by Doctor/IEOS during ANC
|
|
|
|
|
Yes
|
-
|
|
1
|
1
|
No
|
-
|
|
0.53(0.17-1.64)
|
0.68(0.11-3.99)
|
Examined by Nurse/midwife during ANC
|
|
|
|
|
Yes
|
-
|
|
1
|
1
|
No
|
-
|
|
1.09(0.71-1.67)
|
2.96(0.49-17.80)
|
Examined by Health extension worker during ANC
|
|
|
|
|
Yes
|
-
|
|
1
|
1
|
No
|
-
|
|
0.71(0.29-1.72)
|
0.63(0.08-4.69)
|
Random effects
|
Empty
|
Individual
|
Community/facility
|
Individual and community
|
Variance (SE)
|
0.16*(0.609)
|
0.81*(0.5)
|
0.36*(0.07)
|
0.12*(0.53)
|
(VPC)= ICC (%)
|
12%
|
9.7%
|
8.9%
|
8.3%
|
PCV
|
Reference
|
35
|
22
|
12
|
Log-likelihood
|
-276.68484
|
-117.81133
|
-269.68537
|
-116.30423
|
Model fit statistics
|
|
|
|
|
AIC
|
557.3697
|
291.6227
|
551.3707
|
296.6085
|
BIC
|
565.4262
|
384.2542
|
575.5404
|
402.473
|
NB: * indicates significant variable in its respective model, the empty model contains no variables, SE = Standard error, VPC= Partition variance coefficient AIC=Akaike Information Criteria. PCV was calculated for successive models with reference to null model to look at relative contribution of each model to explain BP variability