Food Security of the Pregnant Population Cared for in Bosques De María in Barranquilla, Colombia in 2020

Background: According to observations of maternal and child health and nutritional indicators and the levels of food insecurity in the Atlantic region, the need to characterize the components of food access, intake and nutritional status of the population of interest in the city of Barranquilla was identied. The aim of this research was to characterize the food and nutritional security of the pregnant population served in Camino Bosques de María Health Service in Barranquilla during their last trimester in 2020. Methods: This was a cross-sectional descriptive study that assessed the dimensions of food security situation to determine the approximation of access to food, consumption practices, health knowledge, and nutritional status of pregnant women who were cared for by the Camino Bosques de Maria Health Service, located in southwestern Barranquilla, one of the most vulnerable zones in the city. Results: With regard to household members, information was collected from 331 households, which consisted of an average of 4.6 members; only 10.1% of pregnant women were in the contributory scheme, while 54.9% were in the subsidised scheme, and 35.1% did not have any type of aliation. The foods with the highest weekly average reported intake were cereals such as rice and pasta (6.3 days per week). In relation to their nutritional status according to anthropometry, 41.4% had an adequate body mass index, 23% were overweight, 19.3% were underweight, and 13.9% were obese for gestational age. A total of 2.4% did not have gestational age information for this calculation. Conclusions: Improving food security and nutrition during pregnancy is vitally important, as it promotes maternal and child health. In a territory such as Barranquilla, this characterization allows health decision-makers to link programs that promote not only health at the intrahospital level but also at the community level, as described in resolution 3280 of 2018, the ten-year public health plan—currently under evaluation and construction—and the ten-year breastfeeding plan. self-produced). Food consumption was assessed according to meal times, usual intake, and diary intake. Health and nutritional status were assessed according to health aliation, which is the subsidised regime intended for vulnerable populations that paid for by the state, and workers who contribute to the health system; prenatal check-up attendance; body mass index (BMI) for gestational age established in the resolution 2465 of 2016 based on the Atalah classication criteria 1997 [18]; micronutrient intakes; knowledge about health and nutrition; and knowledge about the practice of breastfeeding.

aim of this research was to characterize the food and nutritional security of the pregnant population served by the Camino Bosques de María Health Service in Barranquilla during their last trimester in 2020.

Study design
This was a cross-sectional descriptive study that assessed the dimensions of food security situation to determine the approximation of access to food, consumption practices, health knowledge, and nutritional status of pregnant women who were cared for by the Camino Bosques de Maria Health Service, located in southwestern Barranquilla, one of the most vulnerable zones in the city.

Source of Information for Analysis
A secondary analysis of the information collected in the rst step of the project called "the effectiveness of a public health intervention for the prevention of stunting in the population under one year of age in an urban area of the Special District of Barranquilla" was approved and conanced by the Ministerio de Ciencia, Tecnología e Innovación in Colombia.
The sampling frame consisted of surveys performed with pregnant women who attended Camino Bosques de María between October and December 2020, a period impacted by the COVID-19 pandemic. Women voluntarily participated.
The research team, with the support of nutrition and nursing professionals with experience in prenatal care, completed a survey about food, nutrition and health in the context of food security. The survey was modi ed after a pilot test according to the ndings of the test, such as the mother's level of understanding, ease of completion and time e ciency.
The eld collection team carried out a weekly data critique to improve the instrument over time. It should be noted that the survey data were collected digitally through an Excel matrix constructed by the research team. Anthropometric measurements were taken with a weighing machine (Seca 876) and stadiometer (Seca 876) using the Frankfort plan. Measurements were repeated three times (for each woman) to ensure the precision and accuracy of the data.

Variables
Sociodemographic variables included location of residence; type of housing; age of members of household (years); education (last school approved), according to the International Standard Classi cation of Education [17]; and occupation. Food access was assessed according to food decisions, purchase of food, and purchased food (bought, given away, taken from the shop or self-produced). Food consumption was assessed according to meal times, usual intake, and diary intake. Health and nutritional status were assessed according to health a liation, which is the subsidised regime intended for vulnerable populations that paid for by the state, and workers who contribute to the health system; prenatal check-up attendance; body mass index (BMI) for gestational age established in the resolution 2465 of 2016 based on the Atalah classi cation criteria 1997 [18]; micronutrient intakes; knowledge about health and nutrition; and knowledge about the practice of breastfeeding.

Statistical analysis
A descriptive analysis was carried out for all variables. The data are described according to the means, medians, and ranges.
The statistical package used in the analysis was R.

Ethical considerations
The study complies with the principles in the Declaration of Helsinki regarding the development of research that involves human participants. All participants agreed to participate. The databases created for the study were anonymized for statistical analysis and reporting of the results and conclusions. The study was authorized by the ethics committee of Fundación Santa Fe de Bogotá (record number CCEI-10734-2019).

Sociodemographics
Three hundred thirty-one pregnant women were screened, of whom 25.1% lived in the Bosque neighbourhood, 16.6% in the Gardenias neighbourhood, 5.1% in the Villa Caracas neighbourhood, 4.2% in the Sourdi neighbourhood, 4.5% in the Villa San Pablo and/or Florez neighbourhood, and 44.5% in other neighbourhoods did not reach a frequency of 0.30%.
The types of housing mentioned by respondents were mostly ats and houses (48.3% and 41.7%, respectively). To a lesser extent, rooms in tenements or other types of structures were identi ed (10.3%). Additionally, the predominant type of housing was that which was fully paid for (57.4%) and rented or sublet (38.4%); only 1.5% said they were paying for their own house, and 2.7% said they were in pawn, usufruct and/or de facto occupancy (2.7%).
With regard to household members, information was collected from 331 households, which consisted of an average of 4.6 members. From these 331 households, sociodemographic information was collected for approximately 1,512 persons, a gure that varied by variable. This variability was because the survey was answered entirely by the pregnant woman, and in some cases, they did not remember all the information about their families.
On average, the age of the respondents was 23.5 years, while the minimum and maximum ages were 13 years and 48 years, respectively. regarding the educational level, 30.6% of the household members had level 1 education, i.e., primary education, while 24.5% had level 2 or 3 education, i.e., secondary education. Regarding activity, 34.7% were found to be working, and when asked about the type of work, 22.1% reported that they were unquali ed employees and 17.2% reported that they were labourers (Table 1).
It is important to mention that 36.6% of the families were composed of a migrant population from Venezuela, a country located in northeastern Colombia. Total 524* 100 *The totals change according to the answers given by the pregnant women interviewed.

Food access
The decision to buy food was made by 66.8% of the pregnant women who responded to the survey. Similarly, 92.1% of women made the largest proportion of household food purchasing decisions. Of the food purchases, 78.0% were made by women.
The purchased food (bought, given away, taken from the shop or self-produced) is described in Table 2. Rice is a food that some families bought and gave away simultaneously.
** It is a pre-cooked food based on a mixture of cereals, legumes and whole milk powder, with vitamins and minerals and essential fatty acids and easy to prepare. It contains amino-chelated micronutrients that improve absorption in the target population and has an adequate balance of essential amino acids. Contains no preservatives or colouring agents [19].
***NA: does not apply In terms of the frequency of acquisition, 37.6% of food was acquired daily (especially foods such as rice, meat and eggs), 16.2% weekly, 23.5% fortnightly, 19.8% monthly and 2.9% every other day or two or three times a week. In turn, the most frequent type of acquisition was purchasing (87.8%), followed by given as a gift, taken from the shop and bought-given as a gift (10.6%, 1.2% and 0.4%, respectively). Among the foodstuffs given as gifts were milk, eggs, oil, rice, grains and pasta.
In addition, the most frequent places of purchase were shops (

Usual intake
The foods with the highest weekly average reported intakes were cereals such as rice and pasta (6.3 days per week); sweeteners such as honey, panela and sugar (5.1 days per week); liquid milk (4.1 days per week); and sweets such as candy (4 days per week). In contrast, high-protein foods such as meat, poultry and sh were consumed only 2.5 days per week, 2.3 days per week and 1.6 days per week, respectively, and the consumption of fruit and vegetables did not exceed 3.5 days per week.

Diary intake
It was identi ed that fruit in the form of juice (1.9 times a day), sweeteners such as sugar or honey (1.7 times a day), vegetable mixtures (1.7 times a day), sweets such as candies (1.6 times a day) and cereals such as rice or pasta (1.4 times a day) had the highest average daily consumption. However, high-protein foods such as eggs did not exceed the daily frequency of 1.2 times, and beef, veal, chigüiro, rabbit, goat or curi did not exceed the daily frequency of 1.1 times (Table 3).

Micronutrient intakes
A total of 67.4% of the pregnant women indicated that they were prescribed iron, 54.4% were given iron, and 61.3% consumed iron. A total of 66.9% of the pregnant women mentioned that they were prescribed calcium, 53% were given calcium, and 61.8% consumed calcium. Seventytwo percent of the pregnant women reported that they were prescribed folic acid, 57.7% were given folic acid and 68% consumed folic acid.
knowledge about health and nutrition.
Awareness of warning signs showed that pregnant women most frequently recognized headache and discharge of uid or blood from the vagina (31.4% and 28.7%, respectively). Pregnant women also reported other signs to a lesser extent, e.g., 11.9% swelling of the face and feet in the morning, 11.6% wheezing, 10.4% contractions, and 8.2% seeing lights.
In terms of knowledge about the practice of breastfeeding, 98.2% of the respondents considered breastfeeding their babies. A total of 53.3% of pregnant women were recommended to breastfeed exclusively for an average of 6.3 months, and 40.1% were recommended to breastfeed continuously with the introduction of food for an average of 15 months.

Discussion
This study shows that food security is an important component in the analysis of maternal and child health and nutrition. Regarding access to food, it was found that the decision to purchase food was predominantly made by women. In terms of food purchased by households in the month prior to the survey, oil, rice, spaghetti and high-protein foods such as meat and eggs were most frequently reported. However, regarding the frequency of food consumption in pregnant women, the consumption of meat and eggs only reached a frequency of 1.2 times a day. With regard to the nutritional status of the pregnant women, 36.9% were overweight, and 19.3% were underweight. Micronutrient prescription did not exceed 72%, and intake did not exceed 68%. Similarly, knowledge of warning signs in general did not exceed 18.4%, with the exception of headache and vaginal discharge, which reached 31.4% and 28.7%, respectively. Finally, knowledge of breastfeeding practices was scarce.
Recent evidence shows that food purchasing decisions in households are made by women. One of the results obtained in this research shows that 92.1% of women make the decision to purchase food to be included in the family food basket; in Soracá Boyacá, a similar level was reported (82.11%) [20]. Different studies support the fact that women ful l the role of housewives, which empowers them to make decisions regarding household nutrition [21,22,23]. Looking at the food purchased by households, it is evident that is the foods chosen are mostly calorie-dense, while access to healthy food is limited. Similar situations have been observed in other territories, such as San Andrés and Magdalena Medio, where the priority of households has been to access food sources of carbohydrates and sugars [13,14].
In terms of food intake, two key aspects were identi ed, the rst related to meal times and the second to the source of food consumed on a daily basis. Regarding the rst aspect, slightly less than 55% of participants reported eating snacks between main meals, which is not in line with the Colombian dietary guidelines (Guías Alimentarias Basadas en Alimentos, in Spanish) that recommend three snacks between main meals, i.e., one in the morning, one in the afternoon and one in the evening. This situation is similar to that evidenced in the Survey of nutritional status in Colombia ENSIN 2015, which shows that the daily frequency of meal times in pregnant women is lower for intermediate meal times such as snacks and night snacks; the Atlantic region is the one with the lowest number of meal times per day compared to other regions (8). The second aspect indicates that there is a preference for fruit juices instead of whole fruits (1.9 vs. 1.4 times a day); a high intake of sugars and sweets was also reported (1.7 times a day), contrary to the GABA suggestion, which recommends the intake of whole fruits, encourages limited consumption of sugars and encourages the consumption of water [24].
In relation to micronutrient intake, low prescription rates were identi ed. These prescription levels are not in line with the Ministry of Health's recommendation and its provision for the rst prenatal consultation before 10 weeks, including the prescription of calcium, iron and folic acid [25]. Previous studies have reported higher prescription levels close to 80%. Similarly, low adherence to micronutrient supplementation was a nding in this study. These ndings are in line with the literature, which reports an inadequate intake of folic acid [26]. In addition to folic acid, studies also link calcium and iron with low intake adherence among pregnant women (<50%) [27]. Similarly, other studies also report moderate intakes of the three recommended micronutrients in pregnancy [28].  [30], while in Peru, a study reported that more than 80% of pregnant women indicated vaginal bleeding as a warning sign [31]. In relation to breastfeeding knowledge, the intention to breastfeed was high; however, knowledge was low, as reported in the literature informing prenatal education strategies [32]. A systematic review on food education in pregnant women led to the conclusion that successful experiences stimulate the inclusion of education in prenatal care, with personalized nutritional counselling and the use of ICTs being the alternatives of choice [33]. The results showed an improvement in the level of knowledge achieved; among the learning activities used to achieve the observed changes were the use of individual sessions or small groups [34,35,36], the use of video debate, the preparation of recipes and the delivery of brochures and shopping cards [37,38]. These ndings revealed favourable results for improving the level of knowledge, stimulating changes in dietary patterns and preventing de ciencies through supplementation.
It should be noted that these results were obtained from a population reporting 65% food insecurity in 2015 (Atlantic region), which may have been further exacerbated by the emergence of the COVID-19/SARS-CoV-2 pandemic.

Limitations
The sampling for this study did not allow us extrapolate the results to the entire population of Barranquilla because it refers a speci c population.

Conclusion
Strengthening food security during pregnancy is vitally important, as it promotes maternal and child health. Food security not only involves the consumption of healthy foods but also relates to strategies to improve access to healthy foods and prenatal education strategies that promote appropriate practices, knowledge and attitudes in pregnant women and their support network. In a territory such as Barranquilla, this characterization allows health decision-makers to link programs that promote not only health at the intrahospital level but also at the community level, as described in resolution 3280 of 2018 [25], the ten-year public health plan (currently under evaluation and construction) [39] and the ten- GABA: Food guidelines (Guías Alimentarias basadas en Alimentos para mujeres gestantes, madres en período de lactancia y niños y niñas menores de 2 años para Colombia).