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Background: Maternal Nutrition contributes
significantly to the long term health of mothers and their children. Despite
this importance, globally, about 795 million people are undernourished and
women and their children are the most vulnerable groups.
Objective: The main aim of this study was to assess under nutrition and associated factors among
lactating mothers in Arba Minch zuria district, Southern Ethiopia.
Methods: Institution based cross-sectional
study was used. Data was collected using interview administered questionnaire
from a total of 441 lactating mothers. To get the required respondents, first
health centers in Arba Minch Zuria district were selected by using lottery
method and probability to population size was performed for each health center.
Finally, eligible respondents were selected using systematic sampling method.
The questionnaire was pretested and close supervision was undertaken during
data collection to assure the quality of data. The collected data was entered
using Epidata version 3.02 and exported to SPSS version 20.0 for analysis.
Binary and multivariable logistic regression were conducted, and finally
variables with p-value of <0.05 were considered as statistically significant
predictors.
Results: Prevalence of under nutrition in
this study was 26.1%. Under nutrition is higher among mothers who are unable to
read and write (AOR (95% CI)=3.931
(1.700, 9.091)), mothers who experienced more than five numbers of pregnancies
(AOR (95% CI)=2.453 (1.051,
5.728)), those with more than four members of family size (AOR (95% CI)=2.289 (1.171, 4.4720), those
who live in the household with no toilet (AOR (95% CI)=6.407 (3.556, 11.545)) and those who have less than 4
antenatal care visits (AOR (95% CI)=2.053 ([1.185, 3.559)).
Conclusion
and recommendations: In this study, the magnitude of under nutrition among lactating women
was high. So, nutrition based health information, education and communication
is needed for mothers especially during pregnancy and lactation in the study
area.
Keywords: Nutritional status, Arba Minch,
Health center, Lactating mother
Abbreviations:
ANC: Antenatal
Care; AOR: Adjusted Odds Ratio; BMI: Body Mass Index; CI: Confidence Interval; COR:
Crude Odds Ratio; EDHS: Ethiopian Demographic and Health Survey; FAO: Food and
Agricultural Organization; MDG: Millennium Development Goal; MNCH: Maternal,
Neonatal and Child Health; SNNPR: Southern Nation and Nationalities and Peoples
Region; USAID: United States Agency for International Development
SUMMARY
Maternal
nutrition during lactation plays a great role for the health of mother and
newborn. Despite this importance, about 20% of lactating mothers in Ethiopia
are under weigh and different factors are associated with the nutritional
status of lactating mothers. However, those factors were not well accessed in
the country. So, the main aim of this study was to assess nutritional status of
lactating mothers and its associated factors in Arba Minch Zuria district of
Ethiopia. The data was collected from lactating mothers who visited health
centers of the district for reasons like post natal care,
Body mass index of the lactating mothers was
measured and mothers were classified as under-weight
if their body mass index is ≤ 18.5 kg/m2, normal if their body mass
index is from 18.5-24.9 kg/m2, over weight if their body mass index
is from 25-29.9 kg/m2 and obese if their body mass index is >
30 kg/m2. Of the total 441 respondents in this study, 26.1% of
lactating mothers were underweight. In this study, under nutrition is
associated with educational level, numbers of pregnancies, family size, and
presence of toilet and antenatal care visits. In conclusion, the magnitude of
under nutrition among lactating women in this study was high. So, nutrition
based health information, education and communication by health extension
workers and other concerned bodies are needed for mothers especially during
pregnancy and lactation in the study area to decrease the problem.
BACKGROUND
Nutrition is a fundamental pillar of human
life, health and development [1]. Maternal nutrition during pregnancy and
lactation influences the growth and development of the fetus. As a result,
adequate nutrition for the mothers during lactation is important for the health
of mothers and their children [2]. Lactating mothers from low-income countries
are nutritionally vulnerable group. The maternal nutrition requirement varies
with respect to age, income and physiological changes like pregnancy and
lactation [1,3].
Inadequate quality and quantity diet is one of the major reasons for
high levels of malnutrition in pregnant and lactating women [4]. Due to the
nursing process, mothers are subjected to nutritional stresses and pregnancy
followed by lactation increase the health risk of mothers resulting in a high
maternal mortality [3]. Lack of sufficient calories, of macro- and micro-nutrients
by the mothers during critical times like pregnancy and lactation can lead to
deficiencies in building materials for the development and growth of the new
born [5].
Household food insecurity, hunger and under-nutrition remain critical
issues in different developing countries including Ethiopia [6]. In Ethiopia,
although there are maternal nutrition interventions that are efficacious and
effective in improving Maternal, Neonatal and Child Health (MNCH) outcomes,
implementations have been limited [7,8].
Malnutrition has been identified as a key underlying cause for maternal
deaths. It pre-disposes pregnant and lactating women to an increased risk of
infection, anemia, visual impairment, goiter among others. Environmental and
economic conditions have huge impacts on the nutritional status of women in
Sub-Saharan Africa. In this population, poverty limits food choices, thus
affecting their quality of diet [9].
Ethiopia has reached Millennium Development Goal (MDG) 1, halving the
number of undernourished people (from 75% to 35% over two decades). Despite
these positive advances, Ethiopia remains one of the world’s most food-insecure
countries, where approximately one in three people live below the poverty line
and about 27% of women age 15-49 were undernourished (BMI of less than 18.5
kg/m2) [10].
To solve the problem of maternal malnutrition, micronutrient
supplementation and food-based strategies such as diet diversity and food
fortification have been reported in many studies in Sub-Saharan Africa [9,11].
Despite these efforts, the proportion of children and mothers affected by
malnutrition is still high [2,3,12]. In addition, few studies in Ethiopia
highlighted the issue of nutritional status among lactating mothers. So, the
main aim of this study was to assess under nutrition and associated factors of
lactating mothers in Arba Minch Zuria district, Southern Ethiopia. The findings
of this study is vital for policy makers, health care providers and any
concerned bodies to design appropriate intervention strategies to tackle the
problem.
MATERIALS AND METHODS
Quantitative institution based
cross-sectional study was conducted on lactating women who visited Arba Minch Zuria district health centers from June 5-20, 2018. All
lactating mothers visited public health centers of the area were the source
population and all lactating mothers visited selected public health centers of
the area during data collection period were the study population. Lactating
mothers who lived in the area for more than six month and visited the public
health centers of the area were included into the study. Lactating mothers who
were critically ill, have hearing impairment and physical deformity that can
alter anthropometric measurements were excluded from the study.
Sample size
determination and sampling procedures
Sample size was calculated using single
population proportion formula by considering the following assumptions: P=20% (prevalence of underweight among
lactating mothers from the study conducted in Nekemte town [2], significance
level of 5% (α=0.05) and Z α/2=1.96, Margin of error of 4% (d=0.04) and 10% non-response rate, the final sample size
becomes 441 lactating mothers.
To get the eligible respondents, first, out
of the seven health centers in Arba Minch Zuria district, four of them were
selected by using lottery method. Then, the calculated sample size was
proportionally allocated to the health centers based on their population size
according to the average number of clients registered prior to the study period
in the respective health center. Finally the eligible respondents were selected
by using systematic sampling method.
Measurements
In this study,
lactating mother is a
mother who is feeding breast milk for her infant/child during the study period.
Body mass index is defined as the weight in kilograms
divided by the square of the height in meters (kg/m2). Under-nutrition is defined as,
lactating mothers with BMI of ≤ 18.5 kg/m2. Individual Dietary
Diversity Score is defined as, the
sum of food groups eaten in a specified reference period.
Food secure
households are those
who were not experienced none of the food insecurity (access) conditions or
just experienced worry, but rarely in the past 4 weeks. Food insecure households is inability
of households to access sufficient food at all time to lead active and healthy
life (includes all stages of food insecurity; mild, moderate and severe). Mildly food insecure households are households
that worried about not having enough food sometimes or often, and/or are unable
to eat preferred foods, and/or eat a more monotonous diet than desired and/or
some foods considered undesirable, but only rarely. Moderately food insecure households are household’s sacrifices
quality more frequently, by eating a monotonous diet or undesirable foods
sometimes or often, and/or have started to cut back on quantity by reducing the
size of meals or number of meals, rarely or sometimes. But it does not
experience any of the three most severe conditions. Severely food insecure households are those household who
has graduated to cutting back on meal size or number of meals often, and/or
experienced any of the three most severe conditions (running out of food, going
to bed hungry or going a whole day and night without eating), even as
infrequently as rarely.
Data collection
procedure
Data was collected
using structured interview administered questionnaire adopted from similar
studies and modified based on the study variables and local context. The questionnaire first prepared
in English and translated to Amharic and then translated back to English by
bilingual expert, to
check its consistency. Twelve female diploma nurse data collectors and three
MPH supervisors were recruited and trained for data collection.
Data quality assurance
To ensure the quality of data, training was
given for data collectors and supervisors. Pre-test was conducted on 5% of the
total sample to assess its clarity, length, completeness and consistency. The
questionnaire was also translated to Amharic and close supervision was
undertaken.
Data
processing and analysis
Data was coded,
entered into Epidata version 3.02 and exported to SPSS version 20.0 for
analysis. Descriptive statistics was computed to determine the frequency and
percentages. Binary logistic regression was conducted and COR with 95% CI was
estimated to select the candidate variables for the final model. Then,
variables with p-value of <0.25 at binary logistic regression were taken
into multivariable logistic regression to control confounding. Hosmer-Lemeshow
goodness-of-fit with stepwise (backward elimination) logistic regression was
used to test for model fitness. AOR with 95% CI was estimated to assess the
presence of association at multivariable logistic regression. Finally,
variables with p-value of <0.05 were considered as statistically significant
predictors of the outcome variable.
RESULTS
Socio-demographic
characteristics of the study respondents
Out of the total 445 sample size calculated
for the study, 441 respondents responded making a response rate of 99.1%. The
age of the respondents ranges from 15 to 46 with mean and standard deviation of
26.98 + 5.67. About 211 (47.8%) respondents were in the age group of
17-25 years, 291 (66%) were protestant and 438 (99.3%) were married. About 124
(28.1%) of mothers and 159 (36.1%) of husbands were unable to read and write.
Regarding their family size, 224 (50.8 %) of the respondents have 4-6 family
members (Table 1).
Maternal health care
and feeding practices
Household food
security level of the study participants
Household food security of the study
respondents was assessed and classified as; food secured, mildly food in
secured, moderately food in secured and severely food in secured. Accordingly,
majority, 377 (85.5%) of households were food secured and only 11 (2.5%) of the
respondents household were severely food in secured (Figure 1).
Under nutrition among
lactating mothers
The overall prevalence of under nutrition
(BMI<18.5 kg/m2) among lactating mothers in this study was 26.1% (Figure 2).
Factors associated with under nutrition among lactating mothers
Binary logistic regression analysis: In binary logistic regression analysis, maternal education (COR (95% CI)=4.478
(2.164, 9.269)), husband education (COR (95% CI)=4.65 (2.237, 9.672)), having
experienced >3 pregnancies (COR (95% CI)=2.704 (1.582, 4.623), having >4
family size (COR (95% CI)]=2.473 (1.461, 4.186)), absence of toilet (COR
(95% CI)=5.121 (3.242, 8.089)),
<4 ANC visits for the last pregnancy (COR (95% CI)=2.99 (1.965, 4.692)), presence of maternal diarrhea (COR (95% CI)=1.824 (1.120, 2.970)),
absence of nutritional education (COR (95%
CI)=1.870 (1.205, 2.902)) and being severely food insecure (COR (95% CI)=5.176 (1.483, 18.073)) shows
significant association with under nutrition (Table 3).
Multivariable logistic regression
analysis: In
multivariable logistic regression analysis, variables like maternal education,
number of pregnancy, family size, presence of toilet and number of antenatal
care visits shows significant association with under nutrition.
Mothers who are
unable to read and write were almost four times more likely to be
undernourished compared to those with secondary and above educational levels
(AOR (95% CI)=3.93 (1.700,
9.091)). Respondents who experienced 5-6 number of pregnancies were 2.45 times
more likely to be undernourished compared to those who experienced 1-2
pregnancies (AOR (95% CI)=2.453
(1.051, 5.728)). Similarly, respondents who have family size of 4-6 members
were 2.3 times more likely to be under nourished compared to those who have
family size of 1-3 members (AOR (95% CI)=2.289
(1.171, 4.472)).
Respondents who live in the household with no
toilet were 6.4 times more likely to be undernourished compared to their
counterparts (AOR (95% CI)=6.407
(3.556, 11.545)). Respondents who visited <4 ANC were 2 times more likely to
be under nourished compared to those who visited greater than or equal to four
(AOR (95% CI)=2.053 (1.185,
3.559)) (Table 4).
DISCUSSION
In this study, about 26.1% of lactating
mothers were undernourished. Under nutrition was more common among mothers who
are unable to read and write those who experienced high number of pregnancies,
those with high family size, those who reside in the household with no toilet,
and those who have less than four ANC visits for their last pregnancy.
The prevalence of under nutrition in this
study was comparable with findings of study conducted in Rayitu district of
Ethiopia (24%) [13], Alamata, Tigiray (24.6) [14] and Womberma district of
North West Ethiopia (25.4%) [15]. However, the prevalence is lower than study
conducted in Samre district of Tigray (31%) [3] and Dedo and Seka chekors’s of
Jimma district (40.6%) [16]. The difference might be as a result of improvement
in nutritional education, improvement in socio-economy and difference in
geographical setting. But, the finding of this study is higher than study
conducted in Tanzania (11%) [17], Nigeria (5%) [18], Nekemte town (20%) [2],
Ambo districts (21.5%) [19] and Offa district of Wolayta zone (15.8%) [20]. The
reason for this discrepancy may be due to difference in socio-economy,
geographical settings and seasonal variation.
Mothers who are unable to read and write were
almost four times more likely to be under nourished compared to those who have
secondary and above educational level. This finding is consistent with studies
conducted in Bangladesh [21], Ambo district [19], Adama district [22] and Offa
district [20]. The possible reason may be since those who are able to read and
write can get nutritional information through reading books, posters and
magazines than those who are unable to read and write.
Respondents who experienced 5-6 pregnancies
were 2.5 times more likely to be under nourished compared to those who
experienced 1-2 pregnancies. The finding of this study was inconsistent with
study conducted in Alamat highland of Tigray in which respondents who have
higher pregnancies were 44% less likely to be undernourished compared to those
who lower pregnancies [14]. However, this finding is supported by study
conducted in Babile, Ethiopia, which shows, as parity increased by one unit, the BMI of the lactating mothers
decreased [23]. The possible reason may be, because of the fact that, as
the number of pregnancy increases, exposure to different health problems
including under nutrition may occur. In addition, the mother herself may be
biologically depleted from too frequent births, which could also negatively
affect the nutritional status of herself and her newborn.
Respondents whose family size is greater than
four members were 2.29 times more likely to be under nourished compared to
those who have less family size. This finding is supported by the study
conducted in Womberma district of North West Ethiopia [15] and Nekemte town
[2]. This may be due shortages of food in the household with high family size
and culturally mothers always eat least food (some time leftover) at the last
which leads to under nutrition.
Respondents who have toilet were 6.4 times more
likely to be undernourished compared to their counterparts. This is supported
by study conducted in Adama district [22]. The reason might be due to the fact
that, open defecation, because of lack of toilet results in an increased risk
of diarrheal disease, which might contributes to under nutrition. In addition,
poor handling and disposal of household wastes including human excreta are
major causes of environmental pollution, which creates breeding grounds for
pathogenic microorganism that causes under nutrition.
Respondents who visited ANC <4 times were
two times more likely to be undernourished compared to those who visited >
4 times. This finding is consistent with the study conducted in Samre district of Tigray [3] and Rayitu
districts of Ethiopia [13]. This may be because of the fact that, ANC
time is a time when nutritional information and other support for healthy
behaviors is widely provided and might contribute to the lower probability of
getting under nutrition.
LIMITATIONS OF THE
STUDY
·
Since some question asks about past events, recall bias may occur.
·
An anthropometric measurement error may also occur.
CONCLUSION AND
RECOMMENDATION
Conclusion
The result of this study shows slightly high
proportion of under nutrition among lactating mothers. Predictors of under
nutrition among lactating mothers in this study includes: maternal educational
level, number of pregnancy, family size, presence of toilet and number of ante
natal care visits.
Recommendations
Based on the finding of this study, the following
recommendations were made:
Arba Minch woreda
health office:
·
Should strengthen health education programs on proper maternal and child
dietary practices and the need of adequate dietary intake during pregnancy and
lactation in order to improve health and nutrition outcomes of lactating
mothers and their children.
·
Since health extension workers are more close to the community, woreda
health office should work with health extension workers to increase awareness
of lactating mothers on how to improve their own nutritional status.
·
Woreda health office should have to work with different sectors like;
educational and agricultural sectors to improve women educational level and
then, their nutritional status.
Health extension
workers:
·
Health extension
workers should have to closely work with the community and provide health
information like; importance of adequate nutrition during lactation, importance
of having few children based on their capacity, importance of having toilet and
proper use of it and importance of antenatal and post natal visits for the
community.
Researchers:
·
Further research that uses advanced design is needed to identify more
variables that determine the nutritional status of lactating mothers.
DECLARATION
Ethical approval and
consent to participate
Ethical clearance was obtained from Arba Minch
University Research Ethic review committee to conduct the study. In addition
permission was obtained from Gamo Gofa Zone Health Department, managers of
health centers. Confidentiality was secured by informing and giving awareness
to the data collectors not to record identifiers of the client and disseminate
any information obtained from client.
Consent for
publication
Not applicable
Availability of data
and materials
The data collected for this study can be
obtained from the corresponding author based on a reasonable request.
Funding
The data collection process of this study was
funded by Arba Minch University for the support of data collection. The funding
body only followed the process to check whether the fund allocated was used for
the proposed research.
Authors’ contribution
GK wrote the proposal, participated in data
collection, analyzed the data and drafted the paper. FG and HH approved the
proposal with great revisions and revised subsequent drafts of the paper. MS
and MD contributed in the designing of the methodology and write-up. All
authors and read and approved the final manuscript.
Conflict of interest
The authors declare that they have no conflict
of interest regarding the publication of the paper.
Acknowledgement
Authors would like to thank Arba Minch
University, College of Medicine and Health Sciences for initiating them to
conduct this study and financial support. Deep appreciations have gone to
managers of the health centers. Also, special thanks to data collectors,
supervisors and all peoples who involved in the study directly or indirectly.
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Table 8
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