Pp t Presentation 3

Nutrition of pregnant women and its associations with maternal
and perinatal outcomes in rural central Ethiopia:

A focus on dietary diversity, nutrient density and food composition
By :
Taddese Alemu Zerfu
Supervisors :
Melaku Umeta (PhD)
Kaleab Baye (PhD)
Center for Food Science and Nutrition

Addis Ababa University
June 27, 2016
Introductio Objective Methods Results & Discussions Conclusions &
s Recommendations
n Part I Part II Part III Part Iv
Costs $ 3.5 trillion to global

Economy
7% of the global disease

795 million burden
(1: 9) people
No Enough Food 20% of maternal
(45%) of U5 deaths
 3.1 million each Year
Sub-Saharan
Africa (%)
Asia (#)
2
s Recommendations
n Part I Part II Part III Part Iv
Birth
(LBW)
Pregnant woman
(low weight gain) Childhood
(Stunted)
Adolescence
(Stunted)
Pregnancy Birth 0 – 24 months
4
s Recommandations
n Part I Part II Part III Part IV
Presentation Outline
200
150
Fe ( 50% - 4 folds)
Percent (%)
100
Protein (55%)
Zinc (40%)
50
Energy by 12%
5
s Recommandations
Maternal poor nutrition during pregnancy was associated with :
 PTB
(Christian et al. 2009)
 Reproductive loss (still births)

(Abu-saad & Fraser 2010; Mori et al. 2012)
 Low birth weight infants & IUGR

(Potdar Ramesh D et al. 2014; Muthayya 2009
On the other hand,

 Nutrition interventions(e.g. supplementation) were associated with
reduced risks
 Supplementation with PE (Imdad & Bhutta 2011)
 Supplementation with MMN (Zerfu & Ayele 2013; )
6
Introductio Objective Methods Results & Discussion Conclusions &
s Recommendations
High level of Malnutrition (Macro & MMN) :
Thinness (underweight) of mothers,
 Paucity ofChildhood
evidence on &maternal
stunting wasting, nutrition
27.4% & among WRA &  MMN deficiencies E.g. Anemia
(G/Medhin, 2014 )  Few localized cross-sectional
23% Pregnant mothers  Periodic (5yrs) national surveys

High burden of APO :
(Alemu & Umeta 2015)
LBW/
 Very Few SGA (11%, EDHS 2011)
Longitudinal
(Dynamic
Alemu, T. and Umeta, M., 2015. Reproductive
PTB period of pregnancy)
and Obstetric
(14.3%) Factors
Still birth (26/1000/yr)
Are Key Predictors of Maternal Anemia
 Thereduring Pregnancy
is little/no study usinginmethod
Ethiopia:
methods
Evidence from Demographic and Health Survey (2011). Anemia, 2015
Unacceptably High rate of :
•PMR & NMR (46 & 28/1000)
•IMR (41/1000)
•MMR (420/105)
(UN IGMIE, 2015 & WHO, 2013).

7
Introductio Specific Methods Results & Discussion Conclusions &
n Recommendation
Objectives Part I Part II Part III Part IV
Presentation Outline s
I - To identify, characterize, and evaluate the nutrient composition &

density of most commonly consumed foods during pregnancy
II - To determine the association of maternal dietary diversity during

pregnancy with maternal anemia and key prenatal outcomes in rural
and resource limited settings of Ethiopia
III - To investigate the association of the consumption of specific

food groups with the risk of adverse pregnancy outcomes & Maternal
Anemia during pregnancy
IV - To explore maternal food taboos, dietary habits and cultural

beliefs of weight gain during pregnancy in rural Ethiopia
9
s Recommendations
n Part I
Part II Part III Part IV
Study Area & Subjects Dietary assessment Intake estimation Nutrient Analysis
Study
Study Area
Area
 Located
Located in
in Central
Central Ethiopia,
Ethiopia, Oromia
Oromia
Regional
Regional State
State
•• Over
Over 3,202,689
3,202,689 population)
population)
•• Rural
Rural (86.6%)
(86.6%)
(CSA,
(CSA, 2013)
2013)
M
Major
ajor food
food crops
crops include:
include:
 Cereals
Cereals ,, pulses,
pulses, oil
oil seeds
seeds
 Vegetables,
Vegetables, fruits,
fruits, root
root crops
crops
10
s Recommendations
n Part I
assessment Intake estimation Nutrient Analysis

DietaryDietary
Study Area & Subjects assessment Nutrient intake est. Nutrient Aanalyses
Study
Study Subjects
Subjects
 Pregnant
Pregnant women
women (n
(n == 55)
55)
 Selected
Selected from
from rural
rural HH
HH in
in four
four district
district
The
The inclusion
inclusion criteria
criteria
 Lived
Lived in
in the
the study
study area
area for
for at
at least
least
6months,
6months,
 Singleton
Singleton pregnancy
pregnancy
 Apparently
Apparently healthy
healthy
11
s Recommendations
n Part I
Study Area & Subjects Dietary assessment Intake

Nutrient intakeestimation
est. NutrientNutrient Analysis
Aanalyses
Food
Food Sample
Sample Collection
Collection
 A
A two-day
two-day weighed
weighed dietary
dietary record
record of
of foods
foods (n
(n == 55).
55).
 Trained
Trained local
local HEW
HEW &
& AEW
AEW collected
collected food
food samples.
samples.
 Feeding
Feeding cups
cups and
and plates
plates were
were distributed
distributed to
to the
the pregnant
pregnant mothers
mothers
two
two days
days before
before intake
intake was
was assessed.
assessed.
 All
All days
days of
of the
the week
week were
were equally
equally represented
represented in
in the
the sample
sample
12
s Recommendations
n Part I
Study Area &Subjects Dietary assessment Intake estimation

NutrientNutrient Analysis
Aanalyses
 Food
Food intakes
intakes were
were converted
converted to
to nutrient
nutrient intakes
intakes
 The
The mean
mean ±± SD
SD // Median
Median and
and 1st
1st and
and 3rd
3rd quartiles
quartiles (Q1,
(Q1, Q3)
Q3)
were
were calculated
calculated
 The
The critical
critical nutrient
nutrient densities
densities
 RNI
RNI // energy
energy requirements
requirements for
for each
each trimester
trimester of
of pregnancy
pregnancy
13
s Recommendations
n Part I
Study Area &Subjects Dietary assessment NutrientNutrient Analysis

Aanalyses
Intake estimation
•• AOAC,
AOAC, 2000
2000
 Moisture
Moisture by
by weight
weight difference
difference
 Crude
Crude protein
protein determined
determined as
as 'N‘
'N‘ Kjeldahl
Kjeldahl
 CHO
CHO by
by difference,
difference,
 Gross
Gross energy,
energy, Atwater's
Atwater's conversion
conversion factors
factors
 Mineral
Mineral content
content AAS
AAS
14
s Recommendations
n Part I
Commonly
Commonly Consumed
Consumed Foods
Foods
 Starchy
Starchy staples
staples
 Hot
Hot drinks
drinks
 ASF
ASF
Ra
r
 Fruits &
e
Fruits &
vegetables
vegetables
15
s Recommendations
n Part I
Table 1.1 : Macronutrient content of common ''ready to eat'' foods of pregnant mothers in
rural Arsi, Ethiopia.
Carbohydrate Protein Fat Energy
Food Item
(mg/100g) (mg/100g) (mg/100g) (kcal)
Enjera
Teff enjera, red, fermented 22.1 3.4 0.9 140
Teff enjera, white, fermented 17.7 6.48 0.7 155
Teff enjera, sergegna, fermented 29.93 3.00 1.5 140
Barely enjera, white, fermented 16.57 2.6 0.2 138
Barely enjera, black, fermented 17.9 3.6 0.9 158
Mixed grain enjera, fermented 17.2 4.8 1.3 150
Stew (eaten with enjera)
 Bean or pea 7.8 2.3 6.3 143.8
 Lentils 13.5 3.1 7.2 355
 Pea, split 8.5 3.2 6.9 353.1
 Kale 4.3 1.1 0.1 22.5
 Potato 20.2 1.2 0.1 199.7
 Bean/pea with curd/tofu 8.5 2.4 5.7 143.9 16
s Recommendations
n Part I
Table 1.1 : Macronutrient content of common ''ready to eat'' foods of pregnant

mothers in rural Arsi, Ethiopia.
Carbohydrate Protein Fat Energy

Food Item
(mg/100g) (mg/100g) (mg/100g) (kcal)
Other foods/drinks
10.78 8.93 8.01 147.62
 Porridge with butter
34.19 22.75 0.7 205.24
 Roasted bean ('ashuk')
18.9 5 2.8 169.2
 Coffee drinks
17
s Recommendations
n Part I
Table 1.3 : Key micronutrients (Iron, Zinc and Calcium) content of common ''ready to eat''
foods consumed by pregnant women, rural Arsi Ethiopia
Food Item Zinc Iron Calcium
(mg/100 g) (mg/100 g) (mg/100 g)
Stew (eaten with Injera)
Injera
 Teff
Stew, fromred,
bean or pea 1.2
1 14.7
1.6 50
18
enjera, fermented
 Stew from lentils 0.60
1.2 4.2
7 19.0
55
 Teff enjera, white, fermented
 Stew from pea, split 0.72 5.5 28.5
1.23 7 100
 Teff enjera, sergegna, fermented
 Stew from kale 0.4 0.7 43
1.2 2.1 5
 Barely enjera,
Stew from white, fermented
potato 0.9 1.5 9
1.8 3.6 34
 Barely
Stew from bean/pea
enjera, black, fermented 2.1 5.4 49
Beverages/drinks
0.88 4.4 21
 Wheat enjera, white, unfermented
 Coffee drinks 2.5 4 84
1.2 2.9 13
 Mixed
Tea grain enjera, fermented 0.8 6.1 168
20
s Recommendations
n Part I
Table 1.4 : Nutrient density (mg per 1000 kcal) of key micronutrients (Iron, Zinc and
calcium) from major ''ready to eat'' foods of pregnant mothers, rural Arsi Ethiopia
Food Items Zinc Iron Calcium
(mg/100 kcal) (mg/100 kcal) (mg/100 kcal)
Enjera
Other foods/drinks
Stew (eaten with enjera) 4.5 55.4 188.5
Teff enjera, red, fermented
·· Coffee
Stew, from bean or pea 9.4
3.8
4.5 15.1
6
26.4
316.7
67.9
207.4
Teff enjera, white, fermented
·· Stew
Teafrom lentils 2.3
4.6
15.8 71.6
377.1
Teff enjera, sergegna, fermented
· Stew from pea, split 3
2.7 23
26.4
20.7 633.5
107.5
4.5 7.9 18.9
Barely enjera, white, fermented 1.5 2.6 162.1
· Stew from kale
6.8
3.4 13.6 128.2
33.9
Barely
· enjera,
Stew black,
from fermented
potato 5.7
7.9
3.3 20.4
16.6
184.8
79
Mixed
· grainfrom
Stew enjera, fermented
bean with curd/tofu
21
s Recommendations
n Part I
Conclusion Part - I
 Laboratory based data for pregnancy (NFCS, WRG)
 Main food sources were plant based starchy staples

 Limited intake of ASF, fruits & vegetables.
 Low nutrient content of macronutrients
 Low densities of key micronutrients like Fe, Zn & Ca.
23
s Recommandations
Maternal poor nutrition during pregnancy was associated with :
 PTB
(Christian et al. 2009)
 Reproductive loss (still births)

(Abu-saad & Fraser 2010; Mori et al. 2012)
 Low birth weight infants & IUGR

(Potdar Ramesh D et al. 2014; Muthayya 2009
On the other hand,

Nutrition interventions (e.g. supplementation) were associated with
lower risk of adverse outcomes
 Supplementation with PE (Imdad & Bhutta 2011)
 Supplementation with MMN (Zerfu & Ayele 2013; )
24
Introductio Objectives Methods Results & Discussion Conclusions &
n Recommendation
Part I Part II Part III Part IV
I - To identify, characterize, and evaluate the nutrient composition &

density of most commonly consumed foods during pregnancy
II - To determine the association of maternal dietary diversity during

pregnancy with maternal anemia and key prenatal outcomes in rural
and resource limited settings of Ethiopia
III - To investigate the association of the consumption of specific food

groups with the risk of adverse pregnancy outcomes & Maternal
Anemia during pregnancy

25
s Recommendations
n Part I
Dietary diversity during pregnancy is associated with reduced risk of

maternal anemia, preterm delivery, and low birth weight in a
prospective cohort study in rural Ethiopia.
Am J Clin Nutr 2016;103:1482–8.
26
s Recommendations
n Part I
Study design Sampling Data Collection Outcome Ass’t

Study
Study Design
Design
 Longitudinal,
Longitudinal, prospective
prospective cohort
cohort
 WDDS
WDDS
 Adequate
Adequate (unexposed)
(unexposed)
 Inadequate
Inadequate (exposed)
(exposed)
1st 2nd 3rd 4th

27
s Recommendations
n Part I
432 Enrolled Participants
216 inadequate
216 Adequate
(WDDS < 4)
(WDDS ≥ 4)
30 lost to follow-up 28 lost to follow-up

- 14 lost in the 3rd & 4th ANC - 14 lost in the 3rd & 4th ANC
- 6 incomplete data - 6 incomplete data
- 10 delivered at home - 8 delivered at home
186 Completed 188 Completed
28
s Recommendations
n Part I

Sample
Sample Size
Size
 Open Assumptions
Assumptions
Open Epi
Epi Kelsey
Kelsey statistical
statistical
software
software  95
95 %
% significance
significance level
level
 80%
80% power,
power, and
and
 A
A total
total of
of 168
168 subjects
subjects per
per arm,
arm,  27
27 %
% anemia
anemia prevalence
prevalence among
among
exposed
exposed
 20%  Anticipated
Anticipated 10%
10% lower
lower
20% attrition
attrition
prevalence
prevalence ofof anemia
anemia among
among
 432
 432 was
was required
required unexposed
unexposed
29
Introductio Objective Methods Results & Discision Conclusions &
s Recommandations
n Part I
 Pre-tested
Pre-tested questionnaire
questionnaire (EDHS,
(EDHS, FAO)
FAO)
 MWN
MWN in
in 88 HC
HC
 Weight
Weight (nearest
(nearest 100g)
100g)
 Height
Height (nearest
(nearest mm)
mm)
 MUAC
MUAC (Non-stretch
(Non-stretch measuring
measuring
tape)
tape)
 Hgb
Hgb (A
(A portable
portable HemoCue
HemoCue (AB
(AB Leo
Leo
Diagnostics)
Diagnostics)
30
s Recommendations
n Part I
Study design Outcome Ass’t

Sampling Data Collection
 Hgb
Hgb (Twice)
(Twice)
 At
At enrollment
enrollment &
& Term
Term
 GA
GA was
was documented
documented by
by MW
MW Last
Last Menustrail
Menustrail Period
Period &
& Palpation
Palpation
 BWg
BWg MWN
MWN immediately
immediately after
after delivery.
delivery.
 Stillbirth
Stillbirth (no
(no signs
signs of
of life
life at
at birth
birth after
after 28
28 completed
completed weeks
weeks of
of
gestation)
gestation)
 PTB,
PTB, (<37
(<37 wks),
wks), by
by MWN
MWN at
at birth
birth
31
s Recommendations
n Part I
Table 2.1 : Baseline socio-demographic, anthropometric, and biochemical

characteristics of a cohort of pregnant women in rural Arsi, Ethiopia
Women Dietary Diversity Score (WDDS)
P- values
Characteristics Inadequate (< 4) Adequate ( ≥ 4)
(n = 186) (n = 188)
Maternal age (y) 25.54 ± 0.347 24.44 ± 0.30 0.017

Educational status (Completed y) 3.9 ± 0.288 5.7 ± 0.355 < 0.001
Proportion of nulliparous women (%) 21.7% 23% 0.663
Previous deliveries or parity (n) 2.34 ± 0.09 2.14 ± 0.08 0.147
Previous abortions (n) 0.11 ± 0.02 0.08 ± 0.02 0.369
Monthly income (ETB) 1507 ± 212 1566 ± 264 0.767
Land size, hectare 1.62 ± 0.12 1.36 ± 0.08 0.079
MUAC, 5cm 22.43 ± 0.12 22.97 ± 0.14 0.001
Height, 5cm 158 ± 0.11 159.24 ± 0.39 0.039
Weight, 6Kg 51.95 ± 0.43 52.59 ± 0.52 0.358
Gestational age, wk 26.59 ± 0.22 25.32 ± 0.26 < 0.001
Hemoglobin, g/dl 10.95 ± 0.12 11.73 ± 0.12 < 0.001
32
s Recommendations
n Part I
*
* Inadequate
*
*
*
*
Figure 2 : Food groups consumed by category of women dietary diversity

score (WDDS) 33
s Recommendations
n Part I
Table 2. 2 : Pregnancy and birth outcomes of pregnant women by dietary diversity

group at end line (Term)
Women Dietary Diversity Score (WDDS)
P - Values
Inadequate (< 4) Adequate ( ≥ 4)
Outcome variable (n = 186) (n = 188)
Birth weight, g 2690.9 ± 20.65 3192.3 ± 33.3 < 0.001

Weight, Kg 61.32 ± 0.51 62.65 ± 0.53 0.072
Changes from baseline 9.42 ± 0.16 10.02 ± 0.18 0.01
Gestational age, wk 36.86 ± 0.07 37.39 ± 0.08 < 0.001

Duration of follow up, wk 10.76 ± 0.25 12.05 ± 0.27 < 0.001
Hemoglobin, g/dl3 10.96 ± 0.14 12.19 ± 0.13 < 0.001

Changes from baseline 0.00 ± 0.11a 0.46 ± 0.13b 0.009
Number of IFA tabs taken 35.39 ± 4.38 41.72 ± 3.25 0.345

IFA, proportion taking 4,5
23.7a 33.7a 0.659
34
s Recommendations
n Part I
Baseline
Term
Figure 3 : Incidence of anemia by WDDS category at

baseline and end line
35
s Recommendations
n Part I
Table 3 : Risk of maternal anemia and adverse pregnancy outcomes

by dietary diversity group
Assessment Exposure Status Outcomes Total RR (95% CI)
Anemic Non-Anemic
Inadequate 70 116 186 2.29 (1.62 , 3.24) 
Anemia
Adequate 37 151 188 1
Total 107 267 374
LBW Normal weight Total
Birth weight Inadequate 23 163 186 2.06 (1.03, 4.11) 
Adequate 11 177 188
Total 34 340 374 1
PTB Term birth Total
Pre-Term delivery Inadequate 42 144 186

9 179 188 4.61 (2.31, 9.19) 
Adequate
323 374 1
Total 51
Stillbirth Live birth Total
Still Birth Inadequate 13 173 186 2.71 (0.88, 8.36)
Adequate 4 184 188 1
Total 17 357 374
36
s Recommendations
n Part I
Inadequate
Adequate
Figure 4 : Incidence of adverse pregnancy outcomes by WDDS

category at the end of follow-up
37
s Recommendations
n Part I
Conclusion Part II
 Compared to their counterparts, Pregnant women in the inadequate WDDS

group :
 Had a higher risk of anemia, LBW, PTB, but not of stillbirth
 The FAO WDDS could be used as a simple tool to assess the dietary
quality of pregnant women,
 Further defining recommendations of a “balanced diet” for pregnancy
 Population based RCT of various options to improve DD are needed before

conclusive recommendations can be made.
Paper Published on
38
Introductio Objectives Methods Results & Discussion Conclusions &
n Recommendation
Part 1 Part 2 Part 3 Part 4
I - To identify, characterize, and evaluate the adequacy of most

commonly consumed foods during pregnancy
II - To determine the association of maternal dietary diversity during pregnancy

with maternal anemia and key prenatal outcomes in rural and resource limited
settings of Ethiopia
Part - III A :
Food groups associated with risk of adverse pregnancy outcomes
III - To investigate the association of the consumption of specific food groups

Part - III B :
with
Foodthe risk associated
groups of adversewith
pregnancy outcomes
risk of anemia during&third
Maternal Anemia
trimester (term) during
of
pregnancy pregnancy

39
s Recommendations
n Part I
Part - III A :
Consumption of dairy, fruits and dark green leafy vegetables is associated with
lower risk of adverse pregnancy outcomes in a prospective cohort study in rural
Ethiopia
40
s Recommendations
n Part I
432 enrolled participants
Drop out (n= 58)

Discontinuation of ANC visits (n= 28)
Incomplete data (n= 12)
Did not deliver in a health facility (n= 12)
374 completed
LBW Preterm Stillbirth ≥ 1 APO

(N= 34) (N= 51) (N=17) (N= 74)
(9.1%) (13.6%) (4.5%) (19.8%)
Figure 3.1: Study participant flowchart– prospective cohort of pregnant

mothers, in rural Arsi, Central Ethiopia 41
s Recommendations
n Part I
Table 3.1: Association between specific food groups consumption with adverse
pregnancy outcomes in Central Arsi, rural Ethiopia (n = 374).
Adverse Pregnancy Outcome (APO)
Number
COR (95% CI) AOR (95% CI)
Food groups consumed (%)
Starchy staples
Yes 374 (100) - -
No 0 (0) - -
Meat & fish
Yes 17 (4.5) 1 1
No 357 (95.5) 1.89 (0.42, 8.47) 0.50 (0.07, 3.84)
Organ meat
Yes 23 (6.1) 1 1
No 351 (93.9) 2.71 (0.62, 11.82) 1.21 (0.20, 7.27)
Dark green leafy vegetables
Yes 146 (39) 1 1
No 228 (61) 2.31 (1.29, 4.31) 2.01 (1.04 , 3.87)
Vitamin A rich foods
Yes 103 (27.5) 1 1
No 271 (72.5) 2.01 (1.05, 3.84) 1.23 (0.57, 2.65)
42
s Recommendations
n Part I
Adverse Pregnancy Outcome (APO)

Food groups Number
consumed (%) COR (95% CI) AOR (95% CI)
Other fruits & vegetables

Yes 83 (22.2) 1 1
No 291 (77.8) 2.75 (1.26, 5.99) 1.48 (0.57, 3.84)
Legumes
Yes 333 (89) 1 1
No 41 (11) 1.16 (0.53, 2.55) 1.39 (0.56, 3.49)
Eggs
Yes 71 (19) 1 1
No 303 (81) 1.88 (0.89, 3.99) 0.59 (0.21, 1.66)
Milk & Products
Yes 113 (30.2) 1 1
No 261 (69.8) 3.35 (1.65, 6.79) 2.64 (1.11, 6.30)
Animal Source foods
Yes 141 (37.7) 1 1
No 233 (62.3) 2.85 (1.54, 5.25) 1.46 (0.69, 3.06)
All types of fruits &
vegetables. 212 (56.7) 1 1
Yes 162 (43.3) 3.24 (1.89 , 5.54) 2.92 (1.49, 5.67) 
No
s Recommendations
n Part I
Table 3. 2 : Logistic regression analysis of pregnant mothers' anthropometric &

nutritional characteristics with adverse pregnancy outcomes, rural Ethiopia
Nutritional Number Adverse Pregnancy Outcome (APO)

Characteristics (%) COR(95% CI) AOR (95% CI)
Weight gained (kg)

<6 33 (8.8) 1 1
6-9 155 (41.4) 0.98 (0.41, 2.37) 1.23 (0.46, 3.32)
9.1 - 12.5 147 (39.3) 1.64 (0.66, 4.07) 1.78 (0.64, 4.99)
> 12.5 39 (10.4) 2.80 (0.76, 10.37) 2.60 (0.63, 10.78)
MUAC (cm)
<21 90 (24.1) 1 1
21 - 23 171 (45.7) 0.31 (0.15, 0.64) 1.39 (0.72, 2.70)
23+ 113 (30.2) 0.61 (0.31 , 1.21) 1.72 (0.76, 3.86)
Hgb (g/dl) - at baseline
107 (28.6) 1 1
<11 267 (71.4) 0.26 (0.15, 0.45) 0.73 ( 0,36, 1.48)
11+
Hgb (g/dl) - at term
<11 121 (32.4) 1 1
≥ 11 253 (67.6) 0.17 (0.10, 0.30) 0.23 (0.11, 0.45) 44
s Recommendations
n Part I
Conclusion Part - III A
 The incidence of APO: LBW, PTB still birth is comparable to national

prevalence estimates,
 But, still above other regions (including East Africa).
 Consistent and adequate intake of ASF (diary), fruits and vegetables

(dark green leafy vegetables) were independently associated with
APO
 Anemia during pregnancy was also associated with risk of APO

Paper ready for submission
45
s Recommendations
n Part I
Part - III B :
Food groups associated with lower risk of anemia
during third trimester (term) of pregnancy
46
s Recommendations
n Part I
Figure 1 : Maternal dietary diversity groups vis-à-vis anemia

status during pregnancy in rural Ethiopia, 2015
47
s Recommendations
n Part I
Table 3.3: Logistic regression analysis of pregnant mothers' key food diversity groups &
maternal anemia, rural Ethiopia (n = 374).
Maternal anemia
Food groups Number COR AoR
(%) (95% CI) (95% CI)
1. Consumed Animal Source foods (ASF)

 Yes 141 (37.7) 1 1
 No 233 (62.3) 3.25 (1.96, 5.38) 2.36 (1.35, 4.14)
2. Consumed meat & meat products

 Yes 32 (8.6) 1 1
 No 242 (91.4) 16.75 (2.26, 124.27) 7.70 (0.97, 61.03)
3. Consumed fruits and vegetables.

 Yes 212 (56.7) 1 1
 No 162 (43.3) 1.60 (1.04, 2.48) 0.74 (0.38, 1.40)
4. Consumed Fruits
 Yes 83 (22.2) 1 1
 No 291 (77.8) 2.87 (1.54, 5.34) 1.97 (0.99, 4.13)
5. Consumed legumes
 Yes 333 (89.5) 1 1
 No 39 (10.5) 1.91 (0.98, 3.74) 1.32 (0.56, 3.11)
6. Dietary Diversity Adequacy

Adequate (WIDDS ≥ 4) 186 (49.7) 1 1
Inadequate (WIDDS < 4) 188 (50.3) 3.18 (2.01, 5.03) 2.22 (1.09, 4.52)
s Recommendations
n Part I
Table 3.43 : Logistic regression analysis of pregnant mothers' selected HH and individual
nutrition sensitive characteristics & maternal anemia, rural Ethiopia
Maternal anemia
Maternal HH & individual Number
characteristics (%) COR AoR
(95% CI) (95% CI)
1. Land size (Hectare)

 No Land 133 (35.6) 1 1
 <1 136 (36.4) 0.57 (0.34 , 0.96) 0.60 (0.33, 1.09)
 1-2 70 (18.7) 0.66 (0.35, 1.23) 0.77 (0.38, 1.54)
 2+ 35 (9.4) 0.66 (0.29, 1.46) 1.02 (0.42, 2.47)
2. Radio in the HH
 Yes 270 (72.6) 1 1
 No 102 (27.4) 1.48 (0.89, 2.46) 1.93 (1.12, 3.39)
3. Mobile phone in the HH
 Yes 286 (76.5) 1 1
 No 88 (23.5) 2.55 (1.56, 4.17)  3.14 (1.75, 5.62)
4. AV (TV, DVD...etc) in HH
 Yes 119 (31.8) 1 1
 No 255 (68.2) 1.37 (0.85, 2.21) 1.01 (0.57, 1.80)
49
s Recommendations
n Part I
Table 3: Logistic regression analysis of pregnant mothers' key food diversity

groups & maternal anemia
Number Maternal anemia

Maternal HH & individual (%) COR AoR
characteristics (95% CI) (95% CI)
1.5.Land size (Hectare)

Maternal Educational status
 NoNoLand
formal Education
133 (35.6) 120 (32.1) 1 1 11
 <1 136 (36.4) 95 (25.4) 0.570.75
(0.34(0.43
, 0.96) 
, 1.31) 0.60
0.47(0.33,
(0.25,1.09)
0.88)
 Primary
 1-2 70 (18.7) 159 (42.5) 0.661.35
(0.35, 1.23)2.26)
(0.80, 0.77
0.85(0.38,
(0.46,1.54)
1.57)
 2+Primary+ 35 (9.4) 0.66 (0.29, 1.46) 1.02 (0.42, 2.47)
2. Presence of Radio in the HH
6. MUAC Yes(Cm) 270 (72.6) 1 1
 No< 21 (SAM) 102 (27.4) 90 (24.1) 1.481(0.89, 2.46) 1
1.93 (1.12, 3.39)
3. Presence 171 (45.7) 1.86 (1.10, 3.15)  1.52 (0.75 , 3.11)
 of21mobile
- 23phone
(MAM)in the HH
 Yes23+ (Normal)
286 (76.5) 113 (30.2) 1 2.66 (1.46, 4.85)  11.03 (0.43, 2.34)
 No 88 (23.5) 2.55 (1.56, 4.17)  3.14 (1.75, 5.62)
4. Presence of AV (TV, DVD...etc)
7. Hemoglobin
 Yes (g/dl) at baseline 119 (31.8) 1 1
107 (28.6) 1 1
<11 (anemic)
No 255 (68.2) 1.37 (0.85, 2.21) 1.01 (0.57, 1.80)
267 (71.4) 17.68 (10.14, 30.80) 28.56 (14.33, 56.79)
11+ (Non-Anemic)
50
s Recommendations
n Part I
Conclusion Part - III B
 Anemia is a moderate public health problem in the study area.
Dietary diversity and nutrition related factors were important factors

determining risk of anemia at term of pregnancy.
 Integrated efforts responding to each are required to

improve current status and associated adverse outcomes
51
s Recommendations
n Part I
Dietary habits, food taboos and perceptions towards weight

gain during pregnancy in Arsi, rural central Ethiopia: qualitative
cross-sectional study.
(Paper under consideration for publication on BMC Journal of Health, Population and Nutrition)
52
s Recommandations
n Part I
Study design Results Conclusion

Results
Study
Study Participants
Participants Dietary Habits Food taboos & perceptions
Qualitative,
Qualitative, cross-sectional
cross-sectional
 38
38 KII
KII
 88 FGD
FGD
Purposefully
Purposefully selected
selected
Pregnant
Pregnant women
women
Husbands,
Husbands,
Elderly,
Elderly,
Community
Community leaders,
leaders,
Health
Health && agriculture experts..
agriculture experts
Thematic
Thematic framework
framework data
data analysis
analysis
53
s Recommendations
n Part I
Results
Results
Study design Dietary Habits Food taboos & perceptions Conclusion
Food
Food types
types consumed
consumed
 Cereals
Cereals and
and legumes,
legumes, mainly
mainly in
in the
the form
form of
of
Injera
Injera with
with ‘Shiro’
‘Shiro’ stew
stew
 Meat
Meat && poultry
poultry was
was limited
limited to
to annual
annual festivities
festivities
&& occasions
occasions
 Food
Food consumption
consumption and
and production
production were
were
related
related
‘’‘’ …my
…my pregnant
pregnant wife
wife needs
needs varieties
varieties of
of
foods
foods including
including fruits
fruits and
and vegetables
vegetables …… but
but
as we do not produce these…
as we do not produce these… she rarely she rarely
consumes
consumes fruits
fruits ….’’
….’’
Husband
Husband of
of aa pregnant
pregnant woman,
woman, 42
42 years,
years,
FGD discussant
FGD discussant
54
s Recommendations
n Part I
Results
Results
Quantity
Quantity of
of Food
Food consumed
consumed
Most
Most reported
reported to
to reduce
reduce food
food intake
intake
 Gastric
Gastric irritation
irritation
 Low
Low compliance
compliance to
to IFA
IFA
‘….
‘…. The
The nurse
nurse in
in the
the nearby
nearby health
health center
center gave
gave
me 90 tablets in three rounds, but I
me 90 tablets in three rounds, but I couldn’t couldn’t
take
take more
more than
than ten…
ten… II suffered
suffered from
from gastric
gastric
irritation….
irritation…. ….’
….’
Pregnant
Pregnant mother,
mother, 35
35 years,
years, diagnosed
diagnosed with
with
anemia
anemia
55
s Recommandations
n Part I
Results
Results
Study design Conclusion
Dietary Habits Food taboos & perceptions
Taboos
Taboos && perceptions
perceptions related
related toto weight
weight gain
gain “.. If not for few mothers who are illiterates and
live deep to the rural area, who still believe that
Divergent
Divergent opinions
opinions some foods needs to be avoided during
pregnancy, I don't think that peri-urban and

Food
Food taboos
taboos are
are now
now an
an old
old story
story educated mothers believe so …”

Health
Health workers
workers && other
other KI
KI Nurse, female, 34years

 Some
Some foods
foods should
should be
be avoided
avoided
during “…..mothers should be careful not to eat some
during pregnancy
pregnancy
(e.g.
(e.g. cheese,
cheese, vegetable
vegetable && sugarcane)
sugarcane) foods during pregnancy, particularly during late
 Elderly,
Elderly, pregnant
pregnant women
women && periods, our community strongly believes that
their
their husbands
husbands what a mother eats directly go to the womb to
feed the baby and can harm it ….’’
Pregnant mother, 34years, FGD discussant

56
s Recommandations
n Part I
Results
Results
Study design Conclusion
Dietary Habits Food taboos & perceptions
Perceptions
Perceptions related
related to
to weight
weight gain
gain
 Almost
Almost all
all participants
participants disfavored
disfavored weight
weight gain
gain during
during
pregnancy
pregnancy
 Fear
Fear of
of having
having big
big babies
babies
 Believe
Believe that
that delivering
delivering big
big babies
babies complicates
complicates labor
labor and
and is
is
dangerous
dangerous
57
s Recommendations
n Part I

 Dietary
Dietary intake
intake &
& quality
quality of
of the
the pregnant
pregnant women
women remains
remains as
as low
low or
or same
same
as
as the
the pre-pregnancy
pre-pregnancy state:
state:

 Limited
Limited production
production and
and market
market accessibility
accessibility of
of fruits
fruits and
and vegetables,
vegetables,

 Low
Low consumption
consumption of
of animal
animal source
source foods.
foods.

 Taboos
Taboos and
and misconceptions
misconceptions towards
towards some
some foods
foods

 Misconceptions
Misconceptions about
about weight
weight gain
gain during
during pregnancy
pregnancy
58
s
n Recommendation
Part I
Part II Part III Part
IV s
General Conclusion

 Plant-based
Plant-based starchy
starchy staples
staples &
& hot
hot drinks
drinks
 Limited
 Limited consumption
consumption of
of ASFs,
ASFs, fruits,
fruits, and
and vegetables.
vegetables.
 Poor
 Poor macronutrient
macronutrient contents
contents
 Low
 Low in
in zinc
zinc &
& calcium
calcium density
density (g/100
(g/100 kcal),
kcal),
 But
 But met
met the
the desired
desired density
density for
for iron  Unlikely
iron  Unlikely to
to meet
meet the
the
requirement
requirement
59
s
n Recommendation
Part I
IV s
General Conclusion
 WDDS
 WDDS ≥
≥ 44 was
was associated
associated with
with reduced
reduced maternal
maternal anemia,
anemia,
LBW
LBW &
& PTB
PTB
 Dairy,
 Dairy, fruits
fruits and
and vegetables
vegetables were
were associated
associated with
with lower
lower risk
risk
of
of APO.
APO.
 DD
 DD &
& nutritional
nutritional factors
factors were
were associated
associated with
with aa lower
lower risk
risk of
of
maternal
maternal anemia
anemia & & APO
APO
 Several
 Several misconceptions
misconceptions and
and taboos
taboos towards
towards these
these foods
foods
were
were identified.
identified.
 Food
 Food restriction
restriction for
for fear
fear of
of complications
complications in
in delivering
delivering aa
bigger
bigger healthier
healthier baby
baby
60
s
n Recommendation
Part I
IV s
General Recommendations

 Culturally-adapted
Culturally-adapted IEC/BCC
IEC/BCC

 To
To improve
improve intake
intake of
of nutrient-dense
nutrient-dense foods
foods

 Compliance
Compliance toto supplements
supplements like
like IFA
IFA

 Discourage
Discourage the
the consumption
consumption of of beverages
beverages like
like coffee
coffee and
and tea
tea
during
during pregnancy
pregnancy

 Efforts
Efforts to
to improve
improve DD
DD through
through the
the promotion
promotion of
of both
both the
the production
production and
and
consumption
consumption of
of ASFs,
ASFs, fruits
fruits && vegetables
vegetables

 Combating
Combating HTP HTP like
like :: taboos,
taboos, dietary
dietary restrictions
restrictions and
and misconceptions
misconceptions
related
related to
to the
the intake
intake ofof adequate
adequate and
and quality
quality foods
foods during
during pregnancy
pregnancy

 An
An overall
overall guideline
guideline that
that aims
aims to
to improve
improve the
the diets
diets of
of pregnant
pregnant women
women

 For
For economically
economically insecure
insecure mothers,
mothers, Pregnant
Pregnant women
women could
could benefit
benefit from
from
balanced
balanced protein
protein energy
energy supplementation.
supplementation.
61
s
n Recommendation
Part I
IV s
Recommended
Recommended Future
Future Studies
Studies
•• Additional
Additional observational
observational and
and ethnographic
ethnographic studies
studies are
are needed
needed to
to
understand
understand what
what governs
governs food
food choices
choices during
during pregnancy
pregnancy in
in order
order to
to
help
help design
design effective
effective food-based
food-based strategies
strategies
•• Population
Population based
based trials
trials are
are needed
needed to
to confirm
confirm the
the association
association of
of WDDS,
WDDS,
maternal
maternal anemia
anemia and
and adverse
adverse pregnancy
pregnancy outcomes.
outcomes.
•• Modeling
Modeling integrated
integrated prevention
prevention &
& control
control strategies
strategies for
for predicting
predicting
maternal
maternal anemia
anemia &
& APO
APO
62
Publications/Manuscripts
II –– Published
Published Articles
Articles
1.Zerfu
1.Zerfu TA,
TA, Umeta Baye K.K. Dietary
Umeta M,M, Baye Dietary diversity
diversity during
during pregnancy
pregnancy isis associated
associated with
with reduced
reduced risk risk of
of maternal
maternal anemia,
anemia,
preterm
preterm delivery,
delivery, andand low
low birth
birth weight
weight in
in aa prospective
prospective cohort
cohort study
study in
in rural
rural Ethiopia
Ethiopia. . The
The American
American journal
journal ofof clinical
clinical
nutrition
nutrition 2016
2016 103:
103: 1482-1488.
1482-1488.
2.Zerfu
2.Zerfu and Ayele: Micronutrients
and Ayele: Micronutrients and and pregnancy;
pregnancy; effect
effect of
of supplementation
supplementation on on pregnancy
pregnancy and and pregnancy
pregnancy outcomes:
outcomes: aa
systematic
systematic review
review,, Nutrition
Nutrition Journal
Journal 2013,
2013, 12:20
12:20
3.Taddese
3.Taddese Alemu
Alemu and
and Melaku Umeta, ““Reproductive
Melaku Umeta, Reproductive and and Obstetric
Obstetric Factors
Factors Are
Are Key
Key Predictors
Predictors of of Maternal
Maternal Anemia
Anemia duringduring
Pregnancy
Pregnancy in in Ethiopia:
Ethiopia: Evidence
Evidence fromfrom Demographic
Demographic and and Health
Health Survey
Survey (2011),”
(2011),” Anemia
Anemia,, vol.
vol. 2015,
2015, Article
Article IDID 649815,
649815, 88
pages,
pages, 2015.
2015. doi:10.1155/2015/649815
doi:10.1155/2015/649815
IIII –– Manuscript
Manuscript under
under considration
considration for
for Publication
Publication
1.Zerfu
1.Zerfu TA,
TA, Umeta
Umeta MM and
and Baye
Baye K:K: Maternal
Maternal Food
Food Taboos,
Taboos, Dietary
Dietary Habits
Habits and
and Cultural
Cultural Beliefs
Beliefs ofof weight
weight gain
gain during
during pregnancy
pregnancy in
in
Rural
RuralCentral
CentralEthiopia;
Ethiopia;Community
CommunityBased
BasedQualitative Study.. BMC
QualitativeStudy BMC Population,
Population, Health
Health and
and Nutrition.
Nutrition.
IIIIII –– Manuscripts
Manuscripts prepared
prepared for
for Submision
Submision
1.Maternal
1.Maternal dietary
dietary and
and nutrition
nutrition sensitive
sensitive characteristics
characteristics associated
associated with
with risk
risk of
of anemia
anemia atat term,
term, in
in aa prospective
prospective
cohort study, in rural Ethiopia
cohort study, in rural Ethiopia
2.Nutrient
2.Nutrient composition
composition andand micronutrient
micronutrient densities
densities of
of commonly
commonly consumed
consumed foods
foods by
by pregnant
pregnant women
women in in rural
rural Arsi,
Arsi,
central
central Ethiopia
Ethiopia
3.Consumption
3.Consumption of of diary,
diary, fruits
fruits and
and dark
dark green
green leafy
leafy vegetables
vegetables isis associated
associated with
with lower
lower risk
risk of
of adverse
adverse pregnancy
pregnancy
outcomes in a prospective cohort study in rural Ethiopia
outcomes in a prospective cohort study in rural Ethiopia
63
Acknowledgement

 Almighty
Almighty God,
God, his
his Mother
Mother and
and the
the Saints
Saints

 Supervisors
Supervisors (Dr.
(Dr. Melaku
Melaku U
U&& Dr.
Dr. Kaleab
Kaleab B)
B)

 Wife
Wife (Asefash
(Asefash M.
M. &
& Family)
Family)

 PhD
PhD Fellows
Fellows &
& Other
Other Collegues
Collegues

 APHRC,
APHRC, AAU
AAU &
& DU
DU

 Oromia
Oromia RHB,
RHB, Arzi
Arzi Zonal
Zonal Health
Health Office,
Office,

 District
District &
& HF
HF managers
managers &
& Experts
Experts

 Study
Study particiapnts
particiapnts &
& Data
Data Collectors
Collectors
64
Feeding the pregnant mother is
Feeding the generation !!!
Together ! Integrated!
Diversified!
65

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Nutrition of pregnant women and its associations with maternal

and perinatal outcomes in rural central Ethiopia:

Center for Food Science and Nutrition

Costs $ 3.5 trillion to global

7% of the global disease

Pregnancy Birth 0 – 24 months

 Reproductive loss (still births)

 Low birth weight infants & IUGR

On the other hand,

27.4% & among WRA &  MMN deficiencies E.g. Anemia

(G/Medhin, 2014 )  Few localized cross-sectional

23% Pregnant mothers  Periodic (5yrs) national surveys

(UN IGMIE, 2015 & WHO, 2013).

I - To identify, characterize, and evaluate the nutrient composition &

II - To determine the association of maternal dietary diversity during

III - To investigate the association of the consumption of specific

IV - To explore maternal food taboos, dietary habits and cultural

assessment Intake estimation Nutrient Analysis

Study Area & Subjects Dietary assessment Intake

Study Area &Subjects Dietary assessment Intake estimation

Study Area &Subjects Dietary assessment NutrientNutrient Analysis

Table 1.1 : Macronutrient content of common ''ready to eat'' foods of pregnant

Carbohydrate Protein Fat Energy

 Main food sources were plant based starchy staples

 Reproductive loss (still births)

 Low birth weight infants & IUGR

On the other hand,

I - To identify, characterize, and evaluate the nutrient composition &

II - To determine the association of maternal dietary diversity during

III - To investigate the association of the consumption of specific food

IV - To explore maternal food taboos, dietary habits and cultural

Dietary diversity during pregnancy is associated with reduced risk of

prospective cohort study in rural Ethiopia.

Am J Clin Nutr 2016;103:1482–8.

Study design Sampling Data Collection Outcome Ass’t

1st 2nd 3rd 4th

432 Enrolled Participants

30 lost to follow-up 28 lost to follow-up

186 Completed 188 Completed

Study design Sampling Data Collection Outcome Ass’t

Study design Sampling Data Collection Outcome Ass’t

Study design Outcome Ass’t

Table 2.1 : Baseline socio-demographic, anthropometric, and biochemical

Maternal age (y) 25.54 ± 0.347 24.44 ± 0.30 0.017

Figure 2 : Food groups consumed by category of women dietary diversity

Table 2. 2 : Pregnancy and birth outcomes of pregnant women by dietary diversity

Birth weight, g 2690.9 ± 20.65 3192.3 ± 33.3 < 0.001

Gestational age, wk 36.86 ± 0.07 37.39 ± 0.08 < 0.001

Hemoglobin, g/dl3 10.96 ± 0.14 12.19 ± 0.13 < 0.001

Number of IFA tabs taken 35.39 ± 4.38 41.72 ± 3.25 0.345

Figure 3 : Incidence of anemia by WDDS category at

Table 3 : Risk of maternal anemia and adverse pregnancy outcomes

Pre-Term delivery Inadequate 42 144 186

Figure 4 : Incidence of adverse pregnancy outcomes by WDDS

 Compared to their counterparts, Pregnant women in the inadequate WDDS

 Population based RCT of various options to improve DD are needed before

I - To identify, characterize, and evaluate the adequacy of most

II - To determine the association of maternal dietary diversity during pregnancy

III - To investigate the association of the consumption of specific food groups