Effect of Nutrition Education Integrating Behavioral Model and Theory during Pregnancy on Maternal Nutrition and Birth Weight in Bale Zone, Southeast Ethiopia

Abstract

Maternal malnutrition, anemia, inadequate or excessive gestational weight gain (GWG), miscarriage, low birth weight (LBW), preterm birth (PTB), intrauterine growth restriction (IUGR), prenatal and infant mortality, morbidity, and the risk of chronic disease later in life are all increased by a lack of dietary diversity (DD) during pregnancy. However, evidence for the effect of nutrition education during pregnancy on the maternal nutritional status and birth weight (BW) among was sparse and inconclusive in Ethiopia. This study aimed to assess the effect of nutrition education during pregnancy on the maternal nutritional status and birth weight in urban settings in Southeast Ethiopia. Chapter 2 A community-based two-arm parallel cluster randomized controlled trial was conducted among 454 randomly selected pregnant women attending antenatal care (227 intervention group and 227 control group) at health facilities from February to December 2021. A multistage cluster sampling technique, followed by systematic sampling, was used to select the pregnant women. Pregnant women who participated in the intervention arm received six nutrition education sessions. Women in the control group received standard care. We used a pre tested, interviewer-administered, structured questionnaire to collect the data. A 24-hour qualitative dietary recall was used to calculate the dietary diversity score (DDS). A nonstretchable mid-upper arm circumference (MUAC) tape was used to measure the MUAC. The haemoglobin (Hgb) level of pregnant women was measured by collecting a finger-prick venous blood sample using a HemoCue Hb 301. GWG was the difference between the last recorded weight before delivery and the weight recorded during the first trimester. BW was measured within the first hour of delivery. A multivariable generalized estimating equation (GEE) and linear mixed model (LMM) were used to evaluate the effect of the intervention on DDS, MUAC, and Hgb levels, accounting for the clustering. The generalized structural equations model (GSEM) and structural equations model (SEM) were used to examine the direct, indirect, and total effects of nutrition education on GWG and BW via the DDS, food security (FS), and nutrition knowledge. Adjusted odds ratio (AOR), an estimate (β), and beta coefficients (β), along with a 95% confidence interval (CI), were used for interpretations. viii Chapter 3 presents the results of the effect of nutrition education on DDS of pregnant women. After the intervention, the proportion of adequate DD was 14.15% higher in the intervention group (IG) compared to the control group (CG) (45.09% versus 30.94%, P = 0.002). The overall difference in adequate DD between the two groups was 8.5%. After adjusting for background characteristics, the multivariable GEE binary logistic model revealed that having received intervention [(AOR = 1.89, 95% CI: 1.27, 2.79)], being literate [(AOR = 3.41, 95% CI: 1.13, 10.23)], and having high wealth [(AOR = 1.60, 95% CI: 1.09, 2.35)] significantly improved adequate DD. Chapter 4 presents the results of the effect of nutrition education on nutrition status of pregnant women. The multivariable LMM indicated that having received nutrition education interventions (β = 0.85, 95% CI: 0.60, 1.12, P < 0.0001) improved the MUAC measurement of pregnant women. Chapter 5 presents the analysis of the effect of nutrition education on Hgb level of pregnant women. In a multivariable GEE linear model, having received nutrition education interventions improved Hgb levels among pregnant women (β = 0.36, 95% CI: 0.30, 0.43). An increase in the consumption of a cup of coffee or tea decreased Hgb levels by 0.14 g/dL (β = -0.14, 95% CI: -0.23, -0.06). Chapter 6 presents the results of the effect of nutrition education on GWG and BW. The GSEM revealed that receiving intervention during pregnancy had a total effect on GWG [(AOR = 2.056, 95% CI: 1.705, 2.695)]. Having DD had direct and total effects on GWG [(AOR = 1.105, 95% CI: 1.022, 1.196)]. Having food security had a total effect on GWG [(AOR = 1.928, 95% CI: 1.817, 2.052)]. Having fruit and vegetable knowledge had a total effect on GWG [(AOR = 1.971, 95% CI: 1.856, 2.105)]. The SEM revealed that receiving intervention during pregnancy had a direct effect on BW (unstandardized β = 0.144, 95% CI: 0.034, 0.252). Similarly, it revealed that receiving intervention during pregnancy had a direct effect on DDS (β = 0.580, 95% CI: 0.024, 1.038). Likewise, it indicated that receiving intervention during pregnancy had a total effect on increasing BW (β = 0.137, 95% CI: 0.029, 0.243). Nevertheless, there was no statistically observed indirect effect of nutrition education during pregnancy on GWG and BW via mediators. Chapter 7 presents the results of the systemtic review and meta-analysis on association between anaemia during pregnancy and LBW and PTB in Ethiopia. There were 35 and 8 studies, with 14,319 and 3,265 respondents included in the meta-analysis for LBW and PTB, respectively. Neonates born to women who had normal Hgb levels were less likely to be LBW [pooled odds ratio (POR) = 0.22, 95% CI: (0.17, 0.28); I2 = 80%] (low-quality evidence). Neonates born to ix women with normal Hgb levels had a lower risk of PTB [POR = 0.22, 95% CI: 0.18, 0.28; I2 = 19%] (very low-quality evidence). The effect size estimate remained significant after sub-group analysis based on study design and province, except in two retrospective cohort studies for LBW. In conclusion, the PhD study provides evidence on the importance of nutrition education during pregnancy for maternal nutritional status and BW. Chapter 8 presents the general discussion, implications of the findings, conclusion, and recommendations for further studies. Clinicaltrials.gov (PACTR202201731802989, Retrospectively registered on 24 January 2022)