Pregnant mothers have limited knowledge and poor dietary diversity practices, but favorable attitude towards nutritional recommendations in rural Ethiopia: evidence from community-based study

Adequate and quality maternal nutrition is important for the health and reproductive performance of women as well as the health, survival, and development of children [1, 2]. Particularly, the first 1000 days of life, from conception to age two, is often considered as “the window of opportunity to prevent chronic malnutrition, childhood obesity and medical complications arising later in life” [3, 4]. Improvements in maternal and child nutrition can reduce multiple risks of Adverse Pregnancy Outcomes (APO) such as: fetal growth restriction, low birth weight babies and small-for-gestational age births. It also helps to prevent micronutrient deficiencies [5, 6]. As the high nutritional cost of pregnancy and lactation contributes significantly to their poor nutritional status, healthy nutrition intake during pregnancy is critical for pregnant women [7].

In Ethiopia, even if the right to adequate nutrition is enshrined and tremendous nutrition interventions have been undertaken, nutritional problems and infectious diseases are still amongst the major health problems of the country [8, 9]. Cognizant to this, evidences from the country and other similar settings shows that high under nutrition rates prevail, even among regions and households where food is plenty [9]. Nutritional knowledge and attitude are important factors of dietary practices and are, thus, potential targets for appropriate planning of nutrition interventions for vulnerable population groups like those lactating and women that are pregnant [10, 11]. Nutrition education enhances nutritional knowledge, thereby influencing attitude and practices towards good nutrition [12, 13]. Mother’s knowledge of nutrition is a very important nexus in good pregnancy outcomes and a crucial skill in improving children’s nutritional status [11].

Evidence on maternal knowledge and attitudes towards nutrition during pregnancy, and its association with their dietary diversity practices is hardly available. Existing studies [11, 14] reported maternal awareness levels or association with some pregnancy outcomes but lacked explanations of how awareness levels relate to attitudes and dietary diversity practices during pregnancy. Therefore, in this study, we aimed to assess the level of maternal knowledge and attitude towards nutrition during pregnancy and their relations with dietary diversity and nutritional practices of pregnant mothers in rural central Ethiopia.

Using data from an existing cohort study, the present study aimed to assess the level of awareness and maternal attitudes towards nutritional recommendations and dietary diversity practices during pregnancy. Pregnant mothers from rural villages were interviewed in private and separate settings according to preference, either at a nearby health facility or home, giving responses of their experience and knowledge about nutrition during pregnancy. Findings of the analysis revealed that the overall awareness of mothers about food sources and benefits of key micronutrients during pregnancy (iron and vitamin A) and dietary diversity or a balanced diet was limited. Mothers had poor dietary diversity and nutritional care practices, however attitudes were favorable towards both.

Assessing their knowledge about the food sources of vitamin A and iron, a sizable proportion of the mothers reported to know some food items that are available to their vicinity in both cases. Vegetables being mentioned frequently as major sources of both iron and vitamin A.

Scientifically; even if vegetables are rich in vitamin A, they contain the inactive carotenoids (Provitamin), which the body must convert to the active retinoid which are obtained solely from animal source foods like meat and milk. Unless people consume the active retinol forms of vitamin A, mere consumption of provitamins can’t guarantee availability of the nutrient [17]. This could be the main reason for high levels of vitamin A deficiency rates in the country, putting it among serious public health problems [18]. Despite in the study area where plant-based food sources are staple diets, the prevalence of vitamin A deficiency is very high, as people mainly rely on cereal grains, and other plant-based food sources which contain non-active forms of some of the micronutrients including vitamin A rich foods [19]. In related context, vegetables are also not as such iron sources. This rather could indicate a widespread misconception about the sources of iron in the community. On the other hand, about 13–16% of respondents mentioned that fruits; grains like wheat, barley, teff; and some animal source foods like egg and milk are the main sources of iron. This continue to show lack of clear and proper understanding or confusions about the food sources of iron in the community. Evidence suggests consuming red meat, such as beef, is particularly recommended as an important source of iron.

In both cases, it seems there is a widespread misconception and poor knowledge about the food sources of major nutrients during pregnancy. This low level of awareness and misperception about the food sources of iron is consistent with findings of previous and similar studies in Ethiopia [14, 20–22] and elsewhere [23, 24]. One of the studies in Ethiopia indicated that close to three-fourths (74.0%) of respondents were not aware of the main food groups or having a balanced diet. The same study indicated that an increasing awareness and knowledge provides information which may stimulate changing of attitude and subsequently result in the enhancement of healthy dietary practices [14]. Studies from other high-income countries also indicate that nutritional knowledge of mothers during pregnancy is sub-optimal. According to a Malayan study, only (65.7%) of the participants were able to give correct responses to questions related to nutritional knowledge [25].

Misconceptions and lack of awareness about nutrition in general and maternal nutrition in particular could be a main reason for low dietary diversity and proper nutritional care during pregnancy leading to high nutritional problems and their adverse consequences. Studies from other similar low-income settings also showed that pregnant women have inadequate intake of iron, folate, fruits, and vegetables, related to poor knowledge [26].

Promisingly and unconditional to existing facts that knowledge is a structural property of attitudes or a function of the number of beliefs and experiences linked to the attitude in memory and the strength of the associative links, we found a much higher favorable attitude towards the practice of balanced diets and dietary diversity food groups. In the current analysis, half (47%) of the mothers were unaware of what to eat during pregnancy and the meaning of a balanced diet and dietary diversity, however, attitudes and opinions of a balanced diet were promising.

Within high income settings, nutritional knowledge was found to be positively associated with education, household income, vitamin/mineral supplementation and regular physical activity [27]. Other studies have also indicated that, above-average nutritional knowledge was independently associated with the use of iron-folic acid and multivitamins [11]. In a Kenyan study, (46%) of the women in the study had a moderate level of nutrition knowledge, (44.6%) had a moderate health knowledge level, and (80.7%) had a moderate DDS level [28]. Similarly, a study from South Western Ethiopia, indicated that between half to three-fourths of mothers were aware of foods and food groups during pregnancy [14].

In our present analyses, unlike the low level of awareness about nutrition and dietary sources of iron and vitamin A, a considerable proportion of mothers had favorable attitudes towards dietary diversity (73.8%) and early initiation of antenatal care (66.8%) for better pregnancy and outcomes. This is contrary to theoretical behavioral models [29] and several study findings [30, 31]. Likewise, studies demonstrated that women with a higher level of education and had more than 10 prenatal visits were more likely to use iron supplements during pregnancy.

Analysis of association between maternal knowledge of food sources of selected micronutrients (vitamin A and iron) with dietary diversity practices of mothers showed that mothers who diversified their diets mentioned vegetables and fish as key food sources. On the other hand, wheat was more frequently mentioned as key food source of vitamin A. This shows that the former group is not only diversifying, but also more knowledge about the correct food sources of vitamin A. Mothers with less diversified group; on the other hand, were mentioning non-correct food items as well as unknowledgeable about food sources. This was also reflected in their attitude towards nutritive value of foods.

The present study had some limitations that need to be taken into consideration when interpreting the findings. Although it is recognized that both pre- and early-pregnancy nutrition are associated with pregnancy outcomes, we were only able to enroll women in their second trimester, mainly because of the late start of ANC visits. Furthermore, in spite of our efforts to collect data from all women during pregnancy, we didn’t collect data from those who were not visiting health facilities for antenatal care, which could potentially mask the views and awareness levels of those not attending. Our study was a health-facility based study and hence might have favored those with better access to health facilities.

Notwithstanding the above limitations, our study highlights the fact that the overall awareness level of pregnant mothers on nutrition during pregnancy, particularly their knowledge about sources of key micronutrients (iron and vitamin A) and a balanced or diversified diet was limited. Cognizant to this, the practices related to proper and diversified nutrition during pregnancy were also found to be poor. Nonetheless, a promising and favorable attitude towards dietary diversity and nutritional care practices were observed. This indicates that there is a conducive and great potential to ensure maternal dietary diversity and proper nutritional practices during pregnancy, even with modest, but targeted awareness raising activities along with economic empowerment of women to ensure access to necessary food items.