Original Research••

Dietary factors associated with anaemia among pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia: a facility-based cross-sectional study

Abstract

Background Anaemia is a major public health problem during pregnancy, especially in developing countries such as Ethiopia. Poor diet patterns are common contributors to anaemia. This study assessed the dietary factors associated with anaemia among pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia.

Methods A facility-based cross-sectional study was conducted from June to August 2021 among 367 pregnant women who were selected using systematic random sampling techniques. A structured questionnaire was used to collect sociodemographic, obstetric and dietary data. The nutritional status of pregnant women was assessed using a mid-upper arm circumference measuring tape, and haemoglobin levels were tested using the haematocrit centrifugation technique. The data were analysed using SPSS V.21. Bivariate and multivariate logistic regression analyses were performed to assess dietary factors associated with anaemia and p<0.05 was used to declare statistical significance.

Results Dietary pattern predictors such as meal frequency (adjusted OR (AOR)=0.27, 95% CI: 0.12, 0.59), meat consumption frequency (AOR=4.05, 95% CI: 2.46, 33.65), fruit and vegetable consumption frequency (AOR=2.88, 95% CI: 2.08, 26.81), Dietary Diversity Score (AOR=12.81, 95% CI: 3.93, 41.75), food aversion (AOR=0.12, 95% CI: 0.03, 0.47) and undernutrition (AOR=0.22, 95% CI: 0.07, 0.64) were significantly associated with anaemia.

Conclusion Predictors of dietary pattern, such as meal frequency, Dietary Diversity Score, food aversion, meat consumption frequency, fruit and vegetable consumption frequency, and undernutrition were significantly associated with anaemia among pregnant women in the study area. Therefore, healthcare providers, policymakers, researchers and other stakeholders should pay special attention to maternal dietary patterns to address the identified factors. Programmes should be developed and implemented to improve optimal dietary patterns and proper nutrition during pregnancy to overcome anaemia and other pregnancy complications.

What is already known on this topic

  • Anaemia is a public health problem in pregnancy, especially in developing countries such as Ethiopia.

  • An adequate diet for pregnant women plays an important role in the well-being of both the mother and the fetus.

  • Previous literature has shown that pregnant women in Ethiopia have a higher prevalence of anaemia and poor dietary habits.

What this study adds

  • Dietary habits have a significant association with the risk of anaemia in pregnancy.

  • Variables related to dietary pattern, such as meal frequency, Dietary Diversity Score, food aversion, frequency of meat consumption, frequency of fruit and vegetable consumption, and undernutrition were key significant factors for anaemia.

How this study might affect research, practice or policy

  • This study recommends that healthcare providers, policymakers, researchers and other stakeholders pay special attention to maternal dietary patterns.

  • Strategies and policies should focus on improving adequate dietary patterns and proper nutrition during pregnancy to overcome anaemia and other pregnancy complications.

Introduction

Anaemia is an illness in which the body haemoglobin levels are below normal, reducing the oxygen-carrying capacity of red blood cells in body tissues.1 2 Anaemia in pregnant women remains the most important health problem in developing countries due to various sociocultural and economic problems such as illiteracy, poverty, lack of awareness and poor dietary habits.3 4 It is mainly driven by nutrient deficiency, such as iron, folate and vitamin deficiencies, and poor maternal nutrition habits during pregnancy.5 6 Anaemia is related to a variety of terrible impacts for both mother and child, such as fatigue, impaired immune function and increased chronic diseases due to inadequate haemoglobin.7 8 In addition to this, it is associated with a higher possible risk of developing neural tubes, pre-eclampsia, fetal deformities and premature babies.9

Ethiopia ranks among the nations with the highest documented maternal and child mortality, possibly due to anaemia and other complications.10 11 The 2016 Ethiopian Demographic Health Survey report indicated that the prevalence of anaemia was 41%.12 Several variables impact reproductive performance, but it is commonly recognised that adequate diet in pregnant women plays an important role in the well-being of both mother and fetus.13 14 The primary causes of anaemia may include a low iron intake in the diet and poor absorption from diets.15 16 Throughout pregnancy, women need proper nutrition for a healthy outcome; they also need more food, a varied diet, increased calorie intake and micronutrient supplements.17 18

Poor maternal nutrition habits, such as inadequate diet, low meal frequency, excessive tea and coffee consumption during meals, and food aversion, are associated with anaemia and can result in a low intake of vital nutrients such as protein, vitamin C, vitamin A, iron and vitamins.19 20 Although Ethiopia has a diverse agricultural settings and grows a variety of cereal grains and vegetables, it has a severe lack of diversified diet plans, where diet and lifestyle are primarily starchy staples and dependent on single grain crops.21–24 Furthermore, extra meals, as well as frequent use of some essential iron-rich vegetables and types of food from animal sources, are not well practised among pregnant women.25 26

Poor dietary practices and nutritional deficiencies have been documented in previous studies among pregnant women in Ethiopia.27 28 However, the direct association between dietary patterns and nutritional status on the risk of anaemia and other health complications during pregnancy has not been identified. Although sociodemographic and health-related factors related to anaemia are assessed, the dietary habits associated with anaemia have not been addressed in previous studies.29–31 Unlike previous studies, this study focused specifically on dietary patterns and their association with anaemia prevalence and the impact of improved dietary habits and good nutrition on reducing the threat of anaemia and negative birth outcomes in the study area. The study is important to alert the direct contribution of dietary patterns to the health impacts of pregnant women, especially the risk of anaemia. It is critical to identify the contribution of poor dietary patterns to maternal anaemia to improve evidence-based recommendations and strategies on the problem of anaemia, as well as maternal dietary habits in Ethiopia. In spite of search efforts, there is no published evidence focusing specifically on the linkage of dietary habits with the risk of anaemia in pregnancy in the study area as well as the country. Therefore, the study aimed to assess dietary factors associated with anaemia among pregnant women in Sekota town, Northern Ethiopia.

Methodology

Study setting and period

The study was conducted in public health facilities found in Sekota town from June to August 2021 among pregnant women attending an antenatal care (ANC) clinic. Sekota is the administrative centre of the Wag Himra Zone in the Amhara National Regional State and is located about 870 km northwest of Addis Ababa, the capital of Ethiopia. The town is bordered to the north by the Tigray region. Farming, livestock, small-scale trade and employment are the main sources of income for the town residents. According to the 2007 national census, the total population of this town was 22 346, of whom 10 760 were men and 11 586 were women. Sekota Hospital and Sekota Health Center are the health facilities that provide ANC services for the community (figure 1).

Figure 1
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Figure 1

Map of the study area, Sekota town, Wag Himra Zone, Amhara Region, Northern Ethiopia.

Study design

A facility-based cross-sectional study design was implemented to identify dietary variables that contribute to anaemia among pregnant women attending ANC clinics.

Source population and study subjects

The source of the population for this study was pregnant women who attended the ANC clinic in public health facilities in Sekota town during the data collection period. The study subjects were systematically selected pregnant women who attended the ANC clinic in public health facilities during the data collection period. During data collection, the effect of ANC visits on the validity of the data was controlled by assessing the existing data from the health centre and asking the study subjects about their previous visits.

Inclusion and exclusion criteria

Pregnant women who came to public health centres for ANC services were included; however, pregnant women with infectious diseases (HIV/AIDS, tuberculosis), chronic diseases (hypertension, diabetes mellitus), haematological diseases and emergency cases were excluded. Similarly, pregnant women who were unable to hear and/or speak were excluded.

Sample size determination and procedures

The sample size of this study was calculated using a single population proportion formula considering the previous finding of 31.6% with 95% confidence and 5% margin error.32 Based on this assumption, the sample size is calculated using the following formula:

Display Formula

where p=prevalence of anaemia (31.6%) and d=the margin of error (the required precision), which we assume to be 5%; Z=the upper percentile of the normal distribution.

Display Formula

Upon considering the non-response rate of 10%, the final study sample size was 367. The calculated sample size was allocated proportionally to both the hospital and the health centre in the town based on the average client load of each health centre. The average number of pregnant women who visited the ANC clinic daily during the data collection period was estimated based on the daily client flow of the clinic from the previous 2 months which was obtained by referring to a client registration book/record before data collection in the centres. The sampling interval was calculated by dividing the monthly average attendance at follow-up of the ANC by the required sample size (k=N/n). The lottery method was used to pick out the first study participant and systematic sampling was used to get the rest. Therefore, 367 pregnant women visiting the ANC from June to August 2021 were selected for the study.

Data collection tools and procedures

A semistructured and validated questionnaire developed from previous literature33–35 was used to obtain sociodemographic, obstetric and dietary data. The 24-hour dietary recall method, adapted from the recommendation of the Food and Agriculture Organization and used to measure household and individual dietary diversity, was applied to assess dietary diversity.36 37 A 2-day non-consecutive multiple-pass 24-hour recall method was used to decrease bias. The nutritional status of pregnant women was assessed using mid-upper arm circumference (MUAC) measurements.38 39 MUAC is considered to be a much simpler anthropometric measure and correlation with body mass index to assess the nutritional status of the adult population, and researchers use it as a better indicator of maternal nutrition during pregnancy.40

The upper left arm was taken for right-handed pregnant women and the upper right arm for left-handed women with no clothing on them. The circumference of the mid-upper arm of a pregnant woman was measured at the middle point between the edge of the shoulder and the tip of the elbow on the arm. After ensuring that the tape was applied with the proper tension, measurements were performed using adult MUAC tape that was non-elastic and non-stretchable. Finally, the average of two measurements was taken on the same day. The MUAC of a pregnant mother was assessed and recorded to the nearest 0.1 cm using standard procedures. A pregnant woman with MUAC <23 cm was considered undernourished, while a pregnant woman with MUAC ≥23 cm was considered to have normal nutritional status. A blood sample was tested by laboratory staff and health professionals using the haematocrit centrifugation technique to assess the haemoglobin level of pregnant women.41 42 A haemoglobin level of less than 11 g/dL was considered anaemic, while those with a value greater than 11 g/dL were considered non-anemic.43 44

Data quality control

The questionnaire was developed in English, translated into local languages (Himtegne and Amharic) for simplicity, and then back-translated to English to verify consistency by two language experts who speak English and local languages fluently. Data were collected by four trained diploma holder and one bachelor’s degree supervisor after receiving training in the background, objectives, tools and ethical procedures of the study.

Data analysis

The data were coded before access to the software. The data were put in EPI Data V.3.1 software and then exported and analysed using IBM SPSS V.21 software. Descriptive data were presented using tables, graphs and figures. Bivariate and multivariate logistic regression analyses were used to analyse the association of dependent and independent variables. Variables with a p<0.2 in the bivariate logistic regression analysis were included in the multivariate logistic regression to identify dietary factors associated with anaemia. Hosmer-Lemeshow was used to test the model’s fitness. The level of significance was assessed at a 95% CI with a p<0.05.

Result

Sociodemographic and economic characteristics of the respondents

A total of 367 women were interviewed in our study, giving a 100% response rate. Most of the participants (346, 94.3%) were married, and 356 (97.0%) were followers of the Orthodox Christian Church. The 257 (70.0%) respondents were Agew, followed by Amhara (97, 26.4%) in ethnicity. More than half (54.2%) of the women were within the age range of 26–34 years (table 1).

Table 1
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Sociodemographic and economic characteristics of pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia, 2021 (n=367)

Obstetric-related characteristics of the respondents

The majority (209, 56.9%) of participants were in the second trimester of their gestational age. 312 (85.0%) of pregnant women completed ANC service in the second and above current pregnancy (table 2).

Table 2
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Obstetric-related characteristics of pregnant women attending antenatal care (ANC) clinic in Sekota town, Northern Ethiopia, 2021 (n=367)

Prevalence of anaemia among the respondents

Of the 367 pregnant women who participated in the study, 111 (30.3%) were anaemic, with 81 (72.9%) having mild anaemia and 30 (27.1%) having moderate anaemia (figure 2).

Figure 2
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Figure 2

Prevalence of anaemia among pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia, 2021 (n=367).

Dietary Diversity Score of the respondents

In this research, the percentage of pregnant women who achieved an optimal Dietary Diversity Score (≥5 food groups) was 29.7%, while 70.3% of pregnant women had inadequate dietary diversity. All pregnant women (100%) consumed food from the cereal food group. Pregnant women consumed 83.1% and 65.1% of pulses and other vegetables, respectively (figures 3 and 4).

Figure 3
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Figure 3

Dietary Diversity Score of pregnant women attending antenatal care clinics in Sekota town, Northern Ethiopia, 2021 (n=367).

Figure 4
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Figure 4

Food group consumption patterns of pregnant women attending antenatal care clinic in Sekota town, Northern Ethiopia, 2021 (n=367).

Dietary habits and food frequency patterns of pregnant women

The majority (224, 61.1%) of the respondents ate three or fewer times a day. Approximately 69 (18.8%) of respondents consume meat once a week, while 38 (10.4%) of the women never consume meat at all (table 3).

Table 3
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Dietary habits and food frequency of pregnant women attending antenatal care clinic in Sekota town, Northern Ethiopia, 2021 (n=367)

Nutritional status of the respondents

The result of this finding indicates that 23.2% of the respondents were undernourished and 76.8% of the respondents were well nourished (figure 5).

Figure 5
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Figure 5

Nutritional status of pregnant women attending antenatal care in Sekota town, Northern Ethiopia, 2021 (n=367).

Sociodemographic and obstetric factors associated with anaemia among women

In bivariate analysis, the educational and occupational status of women and husbands, monthly average income, pregnancy interval, parity and trimester were predicted to be associated with anaemia. However, in multivariable analysis, the occupational status of the husband, monthly average income and pregnancy interval were significantly associated with anaemia. Pregnant women and their husbands who were government employees were less likely to be anaemic than those with other occupations. Similarly, pregnant women with a monthly average income greater than 3000 Ethiopian birr and a birth interval greater than 2 years were less likely to be anaemic (table 4).

Table 4
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Sociodemographic and obstetric factors associated with anaemia among pregnant women attending antenatal care in Sekota town, Northern Ethiopia, 2021 (n=367)

Dietary-related factors of anaemia among pregnant women

In both bivariate and multivariate logistic regression analyses, dietary factors such as meal frequency, meat intake frequency, fruit and vegetable consumption frequency, food aversion, Dietary Diversity Score and undernutrition were significantly associated with anaemia (table 5).

Table 5
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Dietary factors of anaemia among pregnant women attending antenatal care in Sekota town, Northern Ethiopia, 2021 (n=367)

Discussion

The results of this study are very important for policy and implementation. Anaemia is a common health problem in developing countries such as Ethiopia, which is primarily caused by nutritional deficiencies that result from inadequate diet intake. It is critical to identify the factors that contribute to the risk of anaemia in pregnancy. Therefore, this study identified dietary factors that are associated with anaemia among pregnant women attending ANC in Sekota town, Northern Ethiopia. Dietary factors such as meal frequency, Dietary Diversity Score, food aversion, frequency of meat consumption, frequency of fruit and vegetable consumption, and undernutrition were significantly associated with anaemia among pregnant women in the study area.

In Ethiopia, poor dietary patterns and nutritional deficiencies are documented among women; this may be due to sociodemographic and economic factors. Dietary patterns, especially during pregnancy, have a significant impact on the health of women and children. The risk of nutritional deficiencies among pregnant women is not only for her; it has a negative and an intergenerational impact. Dietary patterns are dependent on a single crop with limited use of fruits, vegetables and animal-sourced products.45 The study conducted in Eastern Ethiopia indicated that only 15.2% of pregnant women had appropriate dietary practices. Similarly, only 29.4% of pregnant women had good dietary diversity, a 37.5% high food variety score and 24.7% consumed foods from animal sources.46 Another finding conducted in Dire Dawa, Ethiopia indicated that 52% of women had a habit of food aversion.47 According to the study conducted in Northwest Ethiopia, 19.9% pregnant women had a poor dietary pattern and only 33% eat fruits, due to accessibility problems of food varieties and culturally critical indicators of maternal dietary patterns.48

In the current study, pregnant women with an inadequate Dietary Diversity Score were 12.8 times more likely to have anaemia than those who had an adequate Dietary Diversity Score. This is supported by the findings conducted in Mekele town, Hosana and Southern Ethiopia.33 49 50 This may be due to inadequate dietary diversification, which could well result in a lack of micronutrients such as vitamins, minerals and other essential minerals that may significantly increase iron bioavailability.51–53 Similarly, pregnancy requires a physiological variety of nutrients; it is advisable to diversify the diet from the usual one.48 54 However, in this study, most pregnant women (70.3%) scored less than the expected Dietary Diversity Score. Furthermore, pregnant women with MUAC greater than 23 cm were 78% less likely to develop anaemia during pregnancy than those with MUAC less than 23 cm. This result was similar to studies done in Jijiga and Central Ethiopia.34 35 The observed association could be due to increased nutritional demands of pregnancy, which generally result in macronutrient and micronutrient deficiency, leading to undernutrition.55 56 Undernourished pregnant women are exposed to micronutrient deficiency, which leads to anaemia and other complications during pregnancy.57 In the present study, pregnant women who ate more than three times a day were 73% less likely to be anaemic than those whose meal frequency was less than three times each day. This result was supported by previous findings conducted in Mekele town and Central Ethiopia.35 49 This could be because pregnancy is a particularly nutrient-demanding time which can be met with increased meal frequency. Pregnant women should eat more frequently than usual.35 58

They also found that the pregnant women who eat meat once or less per week are four times more likely than those who eat meat once a week to develop anaemia. The results were similar to those of previous research in Ethiopia.34 49 50 The reason may be that red meat is a good source of haemoglobin.59 However, pregnant women in this setting do not frequently eat meat and other animal-sourced foods, which may be due to the lifestyle of the environment not being appreciated, especially pregnant women. This may also be due to the limitations of access to animal-sourced foods, as well as the lack of knowledge of pregnancy, which is a critical period of human lifecycle. Similarly, women who eat fruits and vegetables every day are less likely to develop anaemia. The result is similar to the results of a previous study in Jijiga and Mekele.34 49 This could be because fruits and vegetables enhance vitamin C, which improves iron absorption to resist the risk of anaemia.60 61 Another significant result from this research is that pregnant women who did not experience food aversion during their pregnancy were 98% less susceptible to developing anaemia than those who did. These are supported by studies carried out in other parts of Ethiopia.35 62 This may be because physiological changes during pregnancy expose women to food aversion.63 64 Consistent with studies in other parts of Ethiopia,30 34 50 sociodemographic characteristics and obstetric factors such as the occupational status of the husband, monthly average income and pregnancy interval were associated with anaemia. This is because sociodemographic and economic factors, as well as obstetric factors, have important implications for the individual’s health aspects of the community.65

Overall, the main strength of this study is that it identified the link between dietary patterns and maternal anaemia, which is important for recommendations and strategies on maternal diet and health. Additionally, the research included laboratory methods to assess iron status. Despite these strengths, the study exhibited limitations: a cross-sectional design that does not show temporal and causal effect relationships of variables with dependent variables and a facility-based design that is limited to pregnant women who do not attend ANC services. Participants’ responses to dietary habit questions might be subjected to some level of recall bias.

Conclusion and recommendation

This study identified dietary factors associated with anaemia among pregnant women receiving ANC in the town of Sekota in Northern Ethiopia. Key dietary factors such as meal frequency, Dietary Diversity Score, food aversion, meat consumption frequency, fruit and vegetable consumption frequency, and undernutrition were associated with the risk of anaemia. Therefore, healthcare professionals, policymakers and other stakeholders should put special emphasis on maternal dietary patterns to overcome anaemia and related problems associated with it. Furthermore, initiatives should be independently developed and implemented to improve proper nutrition throughout pregnancy.

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