Fresh Moringa Leaf Consumption during Pregnancy and Its Association with Maternal Hemoglobin Level and Newborn Nutritional Status in Southern Ethiopia

Abstract

Background: Moringa stenopetala, commonly known as the "miracle tree," is rich in essential nutrients and holds promise for addressing maternal undernutrition and anemia, particularly in resource-limited settings. In Ethiopia, maternal anemia and low birth weight remain critical public health concerns. Although efforts such as antenatal nutrition counseling, iron and folic acid supplementation, and community education through health extension workers have contributed to some progress, challenges persist. Poor adherence to iron and folic acid supplementation, rising food prices, and the increased burden of malnutrition continue to hinder sustained improvements. Despite Moringa‘s wide availability, affordability, and well-documented nutritional value, there is a lack of empirical evidence in Ethiopia regarding its association on maternal and newborn health outcomes during pregnancy. This study aims to assess the association between fresh Moringa leaf consumption during pregnancy with maternal hemoglobin level, fetal nutritional status, and newborn birth weight in Southern Ethiopia. Methods: This study employed a mixed design, incorporating community-based cross-sectional, comparative cross-sectional and prospective cohort approaches. Sample sizes were determined using single and double population proportion formulas via Epi Info version 7.2 and G\*Power version 3.1, respectively. Data were collected from 623 participants to assess fresh moringa leaf consumption and its associated factors. Of these, 460 pregnant women (230 consumers and 230 non-consumers) were included to examine associations with maternal hemoglobin levels, neonatal birth weight, and newborn nutritional status. Participants were recruited from May to June 2022, at 20–26 weeks of gestation, from 20 randomly selected kebeles across two districts, with proportional allocation based on population size. Follow-up continued up to delivery to track moringa consumption status in both groups. Data collection included structured interviews, hemoglobin measurements, maternal mid-upper arm circumference, and newborn birth weights. Newborn nutritional status was assessed using standard clinical tools. The data collection team consisted of ten nurses, three lab technologists, viii and two supervisors with public health master‘s degrees. Data were collected digitally via Kobo Collect, supported by standard tools, and analyzed using STATA version 14.0. Descriptive statistics were presented through frequencies, tables, and graphs. Principal component analysis was used to assess household wealth status and knowledge of moringa‘s benefits. Bivariable analyses (p < 0.25) identified candidate variables for multivariable modeling for each outcome variables. Associations with outcome variables were tested using multivariable regression model at a 95% confidence level (p < 0.05). Binary Logistic regression analyzed factors influencing moringa consumption. Independent t tests compared mean maternal hemoglobin, newborn birth weight, and nutritional status between consumer and non-consumer groups. Additionally, multilevel mixed-effects linear regression, modified Poisson regression, and structural equation modeling were applied, as appropriate, to assess outcomes related to hemoglobin levels, newborn nutrition, and birth weight respectively by considering assumption for each model. Result: Fresh Moringa stenopetala leaf consumption was reported by 49.6% of pregnant women (95% CI: 45.67%–53.52%). Significant associated factors were age under 24 years, rural residence, ANC attendance, and good knowledge of moringa‘s nutritional benefits. Multilevel analysis revealed that moringa consumption was associated with a 0.90 g/dl increase in maternal hemoglobin levels (β = 0.90; 95% CI: 0.54–1.27), with an overall mean of 11.76 ± 1.47 g/dl. Other contributing factors included number of children under five, bleeding during pregnancy, male-headed households, ANC attendance, rural residence, and distance to the nearest health facilities. Fetal malnutrition affected 9.79% of newborns—8.4% among moringa consumers and 11.21% among non-consumers. While the mean Clinical Assessment of Nutritional (CAN) score was significantly higher among consumers (mean difference = 1.48; p = 0.002), the incidence of malnutrition did not differ significantly. Risk factors included adolescent maternal age, low educational status, absence of dietary counseling, and low dietary diversity (<5 food groups). In the cohort analysis, infants of moringa consumers had a significantly higher mean birth weight (3334.42 g) than non-consumers (3196.73 g; p = 0.008). Moringa intake was associated with a 115.77 g increase in birth weight (β = 115.77; SE = 43.03; p = 0.007). Additional determinants ix included maternal hemoglobin, maternal and newborn nutritional status, residence, history of pica, current pregnancy bleeding encountered, parity, and distance to the nearest health facility, and also gestational age at delivery. Conclusion: This study found that 49.6% of pregnant women consumed fresh Moringa stenopetala leaves. Consumption was significantly associated with younger maternal age, rural residence, antenatal care attendance, and good knowledge of moringa‘s nutritional benefits. After adjusting for confounders, moringa intake was linked to higher maternal hemoglobin levels and birth weight of newborn. Although the incidence of fetal malnutrition did not differ significantly in both group,while newborns of moringa consumers had better Clinical Assessment of Nutritional scores, indicating improved fetal nutrition. These findings highlight the potential of Moringa stenopetala as a locally accessible and affordable dietary supplement to improve maternal and neonatal health. Its positive effects on hemoglobin and birth weight suggest it could help address maternal anemia and low birth weight ongoing public health concerns in Ethiopia and similar contexts. Recommendations: To improve maternal and newborn health outcomes, the Ministry of Health and stakeholders should incorporate Moringa stenopetala into maternal nutrition and antenatal care programs. This can be achieved by strengthening community-based education for women of reproductive age, training health professionals in evidence-based dietary counseling that includes moringa, and promoting large-scale roundemized clinical trial, longitudinal research to further validate its nutritional benefits and long-term effects.