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Abstract

Background:

Undernutrition is a major issue among pregnant women, leading to substantial morbidity and mortality. However, the evidence revealed that there is limited evidence in Ethiopia, particularly in the study setting. Therefore, this study aimed to determine the magnitude of undernutrition and associated factors among pregnant mothers attending antenatal care in Northwest Ethiopia.

Methods:

A facility-based cross-sectional study was employed among 401 systematically selected pregnant mothers who attended antenatal care from January to February 2021. A pretested, structured questionnaire, laboratory investigations, and anthropometric measurements were used for data collection. Data were entered into EpiData 3.1 and exported into SPSS version 26 software for analysis. Both bi-variable and multivariable logistic regressions were performed. Variables with a P-value <.05 at a 95% confidence interval were considered statistically significant.

Results:

In this study, the magnitude of undernutrition among pregnant women was 17.71% (95%CI: 14.0, 21.7). Lowest dietary diversity (AOR = 2.96; 95%CI: 1.20, 7.30), medical illness (AOR = 4.79; 95%CI: 1.20, 19.03), household food insecurity (AOR = 6.71; 95%CI: 2.80, 16.07), and intestinal parasite (AOR = 10.36, 95%CI: 4.37, 24.56) were factors associated with undernutrition.

Conclusion:

The study highlights that undernutrition among pregnant women remains a significant public health concern, emphasizing the need for targeted nutritional interventions during antenatal care. Thus, strengthening and enhancing early intervening modifiable factors of maternal undernutrition may help to improve both maternal health and pregnancy outcomes.

Keywords

antenatal care undernutrition pregnant women Ethiopia

Introduction

Undernutrition is defined as a lack of proper nutrition and micronutrients that are essential for healthy growth and development, which is the outcome of insufficient food intake, inadequate care, infectious disease, and deficiencies in vitamins and minerals (micronutrient deficiencies).¹ It is caused by a poor dietary intake, intestinal parasites, poor appetite, recurrent attacks of malaria, and common infectious diseases, such as diarrhea.^2,3 Cultural practices, heavy workloads, domestic responsibilities, inadequate access to safe drinking water, and poor sanitation further increased the risk of illness and malnutrition.⁴ Situations like baseline undernutrition, young maternal age, multiple pregnancy, short interpregnancy interval, and parasitic infestations increase the requirement for nutrients during pregnancy.⁵ Maternal undernutrition during pregnancy has effects on survival, increasing the incidence of acute and chronic diseases, leading to intrauterine growth retardation, preterm birth, abortion, perinatal mortality, impaired immunity, stunting, and poor maternal health outcomes.⁶

Globally, 821 million people were undernourished, out of which 257 million were in Africa, of whom 237 million were in sub-Saharan Africa and 20 million in Northern Africa.⁷ In developing countries, 3.5 million mothers and children under 5 die each year due to the underlying cause of undernutrition, and millions more are permanently disabled by the physical and mental effects of a poor dietary intake.³

In resource-poor countries like sub-Saharan Africa and south-central and Southeast Asia, maternal undernutrition was highly prevalent and recognized as a key determinant of poor perinatal outcomes.⁸ In Malawi, approximately around 6.5 million people are undernourished, exposing millions of mothers and children to undernutrition.⁹ The Nigeria demographic health survey reported that 11% of pregnant mothers attending antenatal care were undernourished.⁵ Ethiopian food security reported that around 14 800 pregnant and lactating women were moderately acutely undernourished, and 3.2% were severely acutely undernourished, and 25% of these required inpatient care.¹⁰ A study conducted in Ziway district, Oromia region, showed that about 48.6% women of reproductive age were undernourished.¹¹ Further Study employed at Gondar University Hospital among pregnant women of antenatal care showed that 16.2% pregnant women were undernourished.¹²

In Ethiopia, several efforts have been made to reduce maternal undernutrition. The national nutrition program launched in 2008 targeted pregnant and lactating women through nutritional support, deworming, early treatment of underlying causes,¹³ routine nutritional assessment during ANC visits, and continued micronutrient supplementation.⁸ Nutrition was also incorporated into the Millenium Development Goal strategies to eradicate extreme poverty and hunger, which was achieved.¹⁴ Despite all measures, in Ethiopia, maternal undernutrition was (22%) and its consequences, like maternal anemia (24%) and poor pregnancy outcome (low birth weight, preterm birth, and stunting), are still the main challenges.¹⁵

Even though there have been improvements in health indicators, the burden of maternal undernutrition and its consequences remain alarmingly high.¹⁶ Pregnancy requires adequate energy, protein, vitamins, and minerals to meet maternal and fetal needs. However, many women, especially in low-income countries like Ethiopia, consume insufficient vegetables, meat, dairy, and fruit, leading to multiple nutritional deficiencies.⁸ Nutrition remains a low priority in many countries, despite its clear short- and long-term consequences. Chronically undernourished women are more likely to give birth to undernourished children, perpetuating a cycle of intrauterine growth restriction, preterm birth, and low birth weight that must be broken.^1,15 Despite the high prevalence of maternal undernutrition and its impacts on maternal and pregnancy outcomes reported in Ethiopia, there is limited evidence regarding the magnitude and factors associated with undernutrition in our study setting. In addition, identifying the determinants of maternal undernutrition is important in the early detection and targeted interventions. Therefore, the objective of this study was to assess the magnitude and factors associated with undernutrition among pregnant women attending antenatal care in Northwest Ethiopia.

Methods and Materials

Study Design, Period, and Setting

A facility-based cross-sectional study design was conducted from February 15 to March 15, 2021. The study was conducted at Motta Hospital, which was located in Motta town in the Amhara National Regional State, East Gojam Zone, Ethiopia. It was bordered in all dimensions by the Hulet Ejju Enesse woreda. It was 371 km away from the capital city of Addis Ababa and 120 km from Bahir Dar city. The community in the study setting relies on mixed farming, cultivating cereals, pulses, and root crops as staple foods, with occasional animal-source foods supplementing the diet.¹⁷ However, intake of nutrient-rich foods such as meat, dairy products, vegetables, and fruits remains limited.¹⁸ Livelihoods of households in the study area depend largely on subsistence agriculture with small-scale trade and seasonal labor.¹⁹ The town had a total of 6 kebeles, 1 hospital, 1 health center, 1 medium clinic, and 6 pharmacies. The hospital had an inpatient room, a laboratory room, a drugstore, 2 outpatient department pharmacies, a delivery room, and an antenatal care clinic (ANC). The ANC clinic provides services to approximately 9768 pregnant women per year.²⁰

Study Population and Their Eligibility Criteria

All pregnant women attending antenatal care services at the hospital served as the source population, whereas all pregnant women attending antenatal care services during the study period were taken as the study population. All systematically selected pregnant women attending antenatal care services and willing to participate were included in the study. The pregnant women who were seriously ill or mentally incapable were excluded from the study.

Sample Size Determination and Sampling Technique

The sample size was determined for the first objective by using a single population proportion formula with assumptions of frequency (prevalence of undernutrition among pregnant women attended ANC at Gondar University Hospital) of 16.2%,¹² 95%CI, 5% margin of error, and 10% non-response rate, which yielded 359. Sample size determination for the second objective; the factors for maternal undernutrition obtained from the same study and calculated by Epi Info 7 menu statically, with assumptions of, 95%CI, 80% power and exposed to unexposed ratio of 1:1. Since sample size for single population proportion (359) was smaller than sample for associated factors (187, 227, 381 and 401) so, we used a final sample size of 401.

Sampling Procedures

A systematic random sampling technique was used to select the study participants. According to the 3-month hospital report, 35 to 39 pregnant women visited ANC daily, and on average, 37 women attended ANC daily. Therefore, 814 pregnant women were enrolled in ANC in 1 month of the study period. Since the sample size was determined as 401, 814/401 gave a sampling interval of 2, which was used to select the study participants. The pregnant women were assigned unique numbers (1, 2), and the numbers were put on pieces of paper. The pieces of paper were thoroughly mixed, and then number 1 was randomly picked. The first woman selected was 1, then 3, 5, 7, 9 [. . .] accordingly. Pregnant women were selected to participate in the study until the required sample size of 401 pregnant women was obtained.

Study Variables

The dependent variable of interest was maternal undernutrition, which was diagnosed in pregnant women with a MUAC below 23 cm.^21
-23 Pregnant women who consumed 5 or more food groups out of 10 (Starchy staples, pulses, nuts and seeds, dark green leafy vegetables, other vitamin A-rich fruits and vegetables, other vegetables, other fruits, eggs, milk and milk products, and meat, poultry and fish) were considered to have a high dietary diversity score.²⁴ Food taboos: Is the food that is strictly forbidden for health due to cultural or spiritual reasons, and known from virtually all human societies that are found in various forms all over the world.^24
-26 Factors considered as potential confounders included: age, residence, educational level of mother, occupation of husband, family income, family size, dietary diversity, household food insecurity, medical illness, and intestinal parasitic infection.

Data Collection Tools and Procedures

A pretested structured questionnaire was adapted by reviewing relevant literature and making certain modifications.^2,12,27,28 The questionnaire was prepared in English and then translated into the local language. The questionnaires contain sociodemographic characteristics, Obstetric and reproductive-related factors, medical and infection-related factors, dietary and behavior-related factors, and household food insecurity. Data was collected through face-to-face interviews of the pregnant women, laboratory investigation, and anthropometry measurement (MUAC) was taken from each woman.

Anthropometric measurement to determine the nutritional status of pregnant women, 2 MUAC measurements were taken from the non-dominant arm using a non-stretchable standard MUAC tape with no clothing on the arm. The measurements were recorded to the nearest 0.1 cm, and the average of the 2 measurements was used for analysis. Women with an average MUAC below 23 cm were considered as having ‘undernutrition’, whereas those with MUAC measurement 23 cm or above were considered as having ‘normal nutritional status’.^21
-23,29 The dietary diversity of pregnant women was assessed using the updated FAO Minimum Dietary Diversity for Women (MDD-W) assessment tool.²⁴ A 24-hour dietary recall was conducted in which each participant was asked to report all foods and beverages consumed during the previous day. The reported items were then grouped into the 10 standard FAO food groups. A dietary diversity score was calculated by counting the number of food groups consumed. Pregnant women who consumed 5 or more food groups were categorized as achieving minimum dietary diversity, whereas those consuming fewer than 5 were classified as having low dietary diversity according to the FAO MDD-W guidelines.^24,30

Household food insecurity was measured using the Household Food Insecurity Access Scale (HFIAS), developed by FANTA. The tool includes 9 questions on changes in diet or food consumption over the previous 30 days due to limited food access. Responses were scored from 0 to 27, with higher scores indicating greater food insecurity. A higher HFIAS score indicates more inadequate access to food and greater household food insecurity, whereas a score of 0 indicates secure access to food.^31,32 The stool examination was undertaken by 3 laboratory technologists. A stool sample was collected from each participant using a stool specimen container with an applicator stick. Direct wet mount and formaldehyde-ether sedimentation methods were performed to effectively detect intestinal parasites (IP). The World Health Organization (WHO) standard operating procedures for the diagnosis of IP were used as a reference for identification.³³

Data Quality Control

Questionnaires were translated into the local language and back translated in to English to check their consistency. Two days of training were given for the data collectors and supervisors before data collection. A 5% pretest was conducted at Motta Health Center, so that the questionnaire was then assessed for its clarity, length, and completeness. Some skip patterns were then corrected; questions difficult to ask were rephrased. MUAC was measured by a midwife according to standard procedures, and laboratory investigations were performed by a laboratory technician following the World Health Organization’s standard operating procedures for the diagnosis of intestinal parasites, which were used as a reference for identification. The quality of the collected data was checked daily by the principal investigator and supervisors.

Statistical Analysis

After ensuring the completeness of the questionnaire, the data were checked, coded, and entered into EpiData 3.1 statistical packages and analyzed using SPSS version 26 software. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to describe the study population with respect to relevant variables. Binary and multivariate logistic regressions were employed to identify the relationships between the predictors and the outcome variable, and variables with p-values less than 0.25 at a 95% confidence interval were taken as candidates for multivariable logistic regression analysis. The association between dependent and independent variables was determined using odds ratios with 95% confidence intervals, and P-values <.05 were considered significant. The Hosmer–Lemeshow goodness-of-fit test (P = .493) was used to assess model fitness. Multicollinearity among independent variables was assessed using variance inflation factors (VIF) and tolerance tests, indicating no multicollinearity issues. Finally, the results were presented in narrations, tables, and figures.

Ethical Considerations and Consent to Participate

The data collection was carried out after taking ethical approval from the Institutional Review Board (IRB) of Bahir Dar University College of Medicine and Health Science, with (Ref no M/S/963/2021). A formal letter was written to the Motta Hospital. Official permission was secured from Motta Hospital. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki. The purpose of the study and participants’ right to refuse were explained to the study participants, and informed written consent was obtained. Moreover, consent from participants with no formal education was obtained after the information sheet was read aloud in the local language and documented by thumb impression with a witness. Additionally, written informed consent was obtained from the legally authorized representatives of all participants under 18 years old before enrollment. Participants who had intestinal parasites, urinary tract infection, and anemia were treated accordingly, and nutrition education was given to all study participants by the health care provider of the ANC unit. Those women identified as severely undernourished were transferred to the Ready Use Therapeutic Food room in the hospital. Coding was implemented to remove respondents’ names and other personal identifiers throughout the study to ensure participant confidentiality.

Results

Socio-Demographic Characteristics of the Study Participants

A total of 401 pregnant women volunteered to take part in the study, with a response rate of 100%. More than one-third (35.2%) of the participants were in the age group of 25 to 29 years, with a mean age of 29 (±2.59 SD) years. The majority of the respondents, 344 (86%), were Amhara in ethnicity, and two-fifths (60.8%) of respondents were Orthodox religion followers. More than three-fifths, 249 (62.1%), of the respondents were housewives, and 327 (81.5%) of the participants were from urban areas. Regarding women’s educational status, 134 (34.2%) attended diploma and above, followed by 163 (40.6%) whose partners attended diploma and above. A total of 329 (82.5%) of respondents had >54.5 U.S Dollars monthly income. The average household size was 3.7 (±1.67). The majority of the source of drinking water, 384 (95.8%) of participants, was tap water, and 356 (88.8%) had a media device for information (Table 1).

Table 1.

Socio-Demographic and Environmental Characteristics of Pregnant Women Attending Antenatal Care at Motta Hospital, Northwest, Ethiopia, 2021 (n = 401).

Study variables	Frequency	Percentage (%)
Age (years)
15-19	29	7.2
20-24	117	29.2
25-29	141	35.2
30-34	75	18.7
35-49	39	9.7
Residence
Urban	327	81.5
Rural	74	18.5
Marital status
Single	3	0.7
Married	390	97.3
Divorced	3	0.7
Widowed	5	1.2
Ethnicity
Amhara	345	86.0
Tigre	12	3.0
Agew	44	11.0
Religion
Orthodox	244	60.8
Muslim	157	39.2
Women’s educational status
Unable to read and write	38	9.5
Read and write	33	8.2
Primary school	137	34.2
Secondary school	56	14.0
Diploma and above	137	34.2
Women’s occupation
Government employee	131	32.7
Private worker	10	2.5
Merchant	8	2.0
Housewife	249	62.1
Others	3	0.7
Husband’s educational status
Unable to read and write	14	3.5
Read and write	14	3.5
Primary school	109	27.2
Secondary school	90	22.4
Diploma and above	163	40.6
Occupation of husband
Government employee	172	42.9
Private employee	90	22.4
Merchant	110	27.4
Daily laborer	18	4.5
Family income (Birr)
<36.4 USD	14	3.5
36.4-54.5 USD	56	14.0
>54.5 USD	329	82.5
Family size
1-3	242	60.3
4-6	119	29.7
>6	40	10.0
Source of drinking water
Tap water	384	95.8
Running/river	7	1.7
Pound/well	10	2.5
Having latrine
Yes	401	100.0
Having television/radio
Yes	356	88.8
No	45	11.2

USD ≈ 55 Ethiopian birr.

Obstetric and Reproductive Characteristics of Respondents

More than one-half, 213(53.1%) of respondents were in the third trimester, almost one-half 188(46.9%) of the respondents were in the second trimester, and 125(31.5%) were on second antenatal care, 163(40.6%) were pregnant for first time at the time and 2 (0.5%) had birth interval of below 1 year. The majority of pregnancy 398 (99.3%) were wanted pregnancies (Table 2).

Table 2.

Obstetric and Reproductive Characteristics of Pregnant Women Attending Antenatal Care at Motta Hospital, Northwest, Ethiopia, 2021 (n = 401).

Study variables	Frequency	Percentage (%)
Trimester of pregnancy
Second	188	46.9
Third	213	53.1
Number of ANC visits
First	64	16.0
Second	125	31.2
Third	112	27.9
Fourth and above	100	24.9
Birth interval
No previous birth	163	40.6
<1 y	2	0.5
1-2 y	140	34.9
>2 y	96	23.9
Wanted pregnancy
Yes	398	99.3
No	3	0.7

Abbreviation: ANC, antenatal care.

Medical, Infection, and Nutritional Characteristics of Study Participants

Among the study participants, 26 (6.5%) had a previously known medical illness; of these, 13 (3.2%) had malaria, 7 (1.7%) had diarrhea, and 6 (1.5%) were known antiretroviral therapy patients. Regarding laboratory investigation reports, 65 (16.2%) of the study participants had intestinal parasites, the most prevalent being hookworm at 24 (6.0%), followed by amebiasis at 16 (4.0%). Additionally, 16 (4.0%) had a urinary tract infection, 3 (0.7%) had a new retroviral infection, and 11 (2.7%) were anemic. In this study, the mean (±SD) MUAC was 24.3 cm (±4.7). “Among the study participants, 16.46% were moderately undernourished, while 1.25% were severely undernourished. Slightly more than half (50.1%) of the participants had 3 meals per day. The common food for nearly all participants, 399 (99.5%), was ‘injera wot’. A total of 295 (73.6%) drank coffee, and most of them consumed it within 30 minutes after a meal. The majority, 265 (66.1%), had the lowest dietary diversity score. According to the Household Food Insecurity Access Scale, 214 (53.4%) of the participants were food secure, while 187 (46.6%) were food insecure. Among the study participants, 10.5% had the habit of avoiding certain foods due to food taboos, and 9.7% consumed alcohol during pregnancy (Table 3).

Table 3.

Medical and Nutritional Characteristics of Pregnant Women Attending Antenatal Care at Motta Hospital, Northwest, Ethiopia, 2021 (n = 401).

Study variables	Category	Number(n)	Percentage
Medical illness	Yes	26	6.5
Medical illness	No	375	95.5
Types of medical illness	Malaria	13	3.2
	Diarrhea	7	1.7
	HIV/AIDS(Known)	6	1.5
Problem with eating	Yes	46	11.5
Problem with eating	No	355	88.5
Laboratory investigation
Sexually transmitted disease	HIV/AIDS(New)	3	0.7
	Hepatitis B virus	12	3.0
	Hepatitis C virus	2	0.5
	Venereal disease research laboratory	5	1.2
Urinary tract infection	Yes	16	4.0
	No	385	96.0
Intestinal parasites	Present	65	16.2
	Absent	336	82.8
Type of intestinal parasites	Gardia Lamblia	15	3.7
	Ameobioses	16	4.0
	Hook worm	24	6.0
	H. Pylori	7	1.7
	Ascariasis	3	0.7
Anemia	Yes	11	2.7
	No	390	97.3
Number of meals per day
Two times	85	21.2
Three times	201	50.1
Four or more times	115	28.7
Common food
Injera-wot	399	99.5
Fruit	1	0.2
Vegetables	1	0.2
Drinking coffee
Yes	295	73.6
No	106	26.4
Time of drinking coffee
30 min before meal	16	4.0
During meal	21	5.2
Within 30 min after meal	258	64.4
The habit of avoiding food
Yes	42	10.5
No	359	89.5
Alcohol consumption
Yes	39	9.7
No	362	90.3
WDDS
Lowest dietary diversity	265	66.1
Minimum dietary diversity	136	33.9
HFIAS
Household food secured	214	53.4
Household food insecure	187	46.6

Abbreviations: AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; HFIAS, household food insecurity access scale; WDDS, woman dietary diversity score.

The Magnitude of Maternal Undernutrition

Overall, the magnitude of maternal undernutrition was 17.71% with (95%CI: 14.0, 21.7; Figure 1).

Figure 1.

The overall magnitude of maternal undernutrition at Motta hospital, northwest Ethiopia, 2021 (n = 401).

Factors Associated With Maternal Undernutrition

Using a bivariable logistic regression model, age, residence, women’s educational status, occupation of husband, family income, family size, dietary diversity, household food insecurity, medical illness, and intestinal parasitic infection were found to be candidate variables for multivariable analysis at P-value < .25. In multivariable logistic regression analysis, dietary diversity, medical illness, household food insecurity, and intestinal parasitic infection were found to be statistically significant at a P-value < .05 level. In this study, mothers with the lowest dietary diversity had 2.96 times higher odds of being undernourished as compared with those mothers with minimum dietary diversity (AOR = 2.96; 95%CI:1.20,7.30). Women who had 1 or more medical illnesses were 4.8 times more likely to be undernourished as compared with those who had no medical illness (AOR = 4.79; 95%CI:1.20,19.03). Household food-insecure mothers were 6.72 times more likely to be undernourished as compared to household food-secure mothers (AOR = 6.71; 95%CI: 2.80, 16.07). Again, mothers who had 1 or more intestinal parasitic infection were10.4 times more likely to be undernourished as compared with those who had no intestinal parasitic infection (AOR = 10.36; 95%CI: 4.37, 24.56; Table 4).

Table 4.

Bivariable and Multivariate Logistic Regression Analysis Among Pregnant Mothers Attending Antenatal Care, at Motta Hospital, Northwest, Ethiopia, 2021(n = 401).

Study variables	Undernutrition		COR (95%CI)	AOR (95%CI)	P-value
Study variables	Yes	No	COR (95%CI)	AOR (95%CI)	P-value
Age (in years)
15-19	5	24	0.33 (0.10,1.06)	0.20 (0.11, 5.90)	.83
20-24	11	106	0.16 (0.06, 0.40)	2.92 (0.49, 7.28)	.236
25-29	18	123	0.23 (0.104, 0.52)	1.81 (0.42, 3.80)	.421
30-34	22	53	0.66 (0.29, 1.50)	0.61 (0.21, 2.37)	.588
35-49	15	24	1	1
Residency
Urban	52	275	1	1
Rural	19	55	1.82 (1.0, 3.32)	0.55 (0.20, 1.49)	.243
Women’s educational status
Unable read and write	18	20	11.43 (4.62, 28.27)	0.50 (0.08,3.17)	.469
Read and write	8	25	4.06 (1.46,11.31)	1.43 (0.20,10.0)	.718
Primary school	23	114	2.56 (1.17,5.61)	1.49 (0.32,6.96)	.609
Secondary school	12	44	3.46 (1.39,8.57)	0.29 (0.06,1.26)	.099
College/above	10	127	1	1
Occupation of husband
Government employee	15	157	1	1
Private employee	25	68	3.37 (1.66,6.73)	2.37 (0.30, 18.42)	.407
Merchant	22	91	2.43 (1.21, 4.88)	1.65 (0.27, 9.82)	.579
Daily laborer	7	13	3.75 (1.18,11.87)	1.37 (0.22, 8.31)	.726
Family income in birr
<2000	7	7	6.31 (2.11,18.84)	0.59 (0.08, 4.09)	.599
2000-3000	18	38	2.98 (1.57,5.68)	0.55 (0.18,1.67)	.295
>3000	45	284	1	1
Family size
1-3	32	210	1	1
4-6	21	98	1.40 (0.77,2.56)	1.96 (0.42,9.02)	.385
>6	18	22	5.36 (2.59, 11.09)	1.96 (0.59, 6.46)	.265
Dietary diversity
Lowest	61	204	3.76 (1.86, 7.62)	2.96 (1.20, 7.30)**	.018
Minimum	10	126	1	1
Medical illness
Yes	16	10	9.31 (4.01, 21.57)	4.79 (1.21, 19.03)**	.026
No	55	320	1	1
Household food security
Secured	11	203	1	1
Insecure	60	127	8.71 (4.41, 17.21)	6.71 (2.80, 16.08)**	.001
Intestinal parasite
Present	37	28	12.1 (6.58,22.22)	10.36 (4.37, 24.56)**	.001
Absent	33	302	1	1

1: reference category.

Abbreviations: COR, crude odds ratio; AOR, adjusted odds ratio; CI: confidence interval.

Statistically significant at P-value < .05.

Discussion

Maternal undernutrition is critical for maternal and pregnancy outcomes. Thus, undernutrition is the root cause of major pregnancy complications, which are associated with maternal morbidity and mortality. This facility-based cross-sectional study identifies factors associated with maternal undernutrition in the study settings. Dietary diversity, medical illness, household food insecurity, and intestinal parasitic infection were all associated with undernutrition in this study.

In the present study, the magnitude of undernutrition (MUAC<23 cm) among pregnant mothers attending antenatal care at Motta Hospital was 17.71% (95%CI: 14.0, 21.7). This finding is in line with the study conducted at Gondar university hospital 16.2%¹² and the study conducted in Gondar town 14.4%29. The similarity may be due to comparable sociodemographic, economic, and dietary conditions, where pregnant women often share similar living standards, cultural dietary patterns, health service utilization patterns, and food insecurity levels that lead to maternal undernutrition. However, this finding is lower than studies conducted in the Oromia region, Rayitu district, 24%²⁷; Gambella, 28.6%,³⁴ Sidama Zone,31.4%³⁵; Shashemene town, 34%³⁶; Bangladesh, 34%,³⁷ and Iran,51.3%.³⁸ The difference might be due to variation in sociodemographic characteristics, study interval, cultural dietary practices, and measurement of the MUAC cut-off point, which readily increases the chance of many women being considered undernourished. This study is higher than the study conducted in Nigeria, 11%⁵ and Wando Genet 9.2%.²⁸ This difference might be due to the smaller sample size, different socio-demographic status, and different anthropometric measurements.

The present study indicated that household food insecure were significantly associated with undernutrition. Household food-insecure mothers were 6.72 times more likely to be undernourished than household food-secure mothers. This finding is consistent with the studies conducted in Gambella,³⁴ Sidama Zone,³⁴ and Jimma district.³⁹ This similarity might be due to the fact that food insecurity involves reductions in food consumption, compromised diet quality and diversity, and deprivation of calories or essential nutrients that can affect both physical and mental health, leading to undernutrition, and also due to the use of similar measurements designed by the Food and Agriculture Organization.⁴⁰

In this study, pregnant mothers who had intestinal parasitic infection were 10.4 times more likely undernourished as compared to mothers who had no intestinal parasitic infection. This finding is supported by studies conducted at Gondar University Hospital¹² and Butajira hospital.⁴¹ This is because intestinal parasitic infections affect the nutritional status of pregnant mothers by increasing nutrient losses, reducing appetite, decreasing dietary intake, causing vomiting, diarrhea, bleeding of the gastrointestinal tract, poor digestion, and impaired absorption.²¹

This study also showed that mothers who had the lowest dietary diversity were 2.96 times more likely to be undernourished than mothers with medium dietary diversity. This finding is similar to the Studies conducted in Gambella³⁴ and Jimma district³⁹ revealed that low dietary diversity was associated with undernutrition. This is because dietary intake reflects the micronutrient adequacy of the diet, which plays a major role in reducing the risk of undernutrition and micronutrient deficiency, increasing individual immunity against infection, and contributing greatly to the healthy growth and development of the fetus.²⁴

The current study identified the significant association between medical illness and maternal undernutrition. Mothers who had a medical illness were 4.8 times more likely undernourished as compared to those mothers who had no medical illness. A possible justification might be due to nutrient loss from medical illness like diarrhea, malaria, HIV, and the like, which leads pregnant mothers to poor appetite, vomiting, impaired digestion and nutrient absorption, and increases the risk of developing undernutrition.^41,21 Therefore, these findings highlight important gaps in maternal nutritional status among pregnant women in northwest Ethiopia. The results suggest that improving nutritional health education during antenatal care is essential. Enhancing antenatal care nutrition counseling, ensuring early infection control, and strengthening household food security interventions could significantly improve maternal nutritional status, which has the potential to reduce pregnancy complications, maternal morbidity, and mortality in the study area.

Limitation of the Study

Even though efforts were made to minimize limitations, the study was based on self-reported survey data, which may be influenced by recall bias and social desirability bias, as women may report more acceptable responses. Recall bias may have occurred because some questions about household food insecurity referred to events that occurred 4 weeks prior, and the 24-hour dietary diversity score; this was minimized by probing respondents about the events. Residual confounding from unmeasured variables may also have affected the results. Additionally, since a cross-sectional design was used, cause-and-effect relationships could not be established.

Conclusion

In the present study, the magnitude of undernutrition among pregnant women was 17.71%. Lowest dietary diversity, medical illness, household food insecurity, and intestinal parasite were factors associated with maternal undernutrition. Hence, strengthening counseling on diversified foods during pregnancy, providing deworming supplements to all pregnant mothers, detecting and treating medical conditions during pregnancy, offering joint nutrition counseling for pregnant women and their partners, and enhancing preconception care for early detection and treatment of diseases may help improve both maternal health and pregnancy outcomes. Therefore, the present study concludes that, by intervening in modifiable factors, maternal undernutrition can be decreased.

Footnotes

Acknowledgements

We would like to thank Bahir-Dar University for granting ethical approval. We extend our gratitude to study participants, data collectors, the supervisor, and Motta Hospital staff.

ORCID iDs

Mebratu Demissie

Aberash Beyene Derribow

Mangistu Abera

Author Contributions

MDS and MA wrote the proposal, participated in data collection supervision, analyzed the data, and drafted the paper. MA, ABD, GBJ, and BW approved the proposal with some revisions, participated in data analysis, and revised subsequent paper drafts. AA and AM supervised the manuscript. MA, ABD, and MDS commented on the final paper and manuscript. All authors read and approved the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data that support the findings are available from the corresponding author upon a reasonable request.*

List of Abbreviations

ANC: antenatal care; BMI: body mass index; FAO: food and agriculture organization; FANTA: food and nutrition technical assistance; HFIAS: household food insecurity access scale; MUAC: measurement of upper arm circumference; SSA: sub-saharan Africa; WMDDS: women minimum dietary diversity score; WHO: World health organization.

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