Diversified dietary intake and associated factors among pregnant mothers attending antenatal care follow-up in public health facilities of Dire Dawa, Eastern Ethiopia

Poor diversity dietary intake has great significance to women, pregnancy outcome and on her fetus or the growing and development of their baby collectively. Uncertainty of studies to examine whether pregnant women have been utilizing diversity dietary in their frequent intake and this has changed nutritional status. Therefore, this study aims to assess diversified dietary intake and associated factors among pregnant mothers attending antenatal care follow-up in public health facilities of Dire Dawa, Eastern Ethiopia. A facility-based cross-sectional study was conducted among 453 pregnant mothers randomly selected from the antenatal care unit at public health facilities from November 1-30/2020. Study subjects were selected with a systematic random sampling method from randomly selected antenatal care unity of health facilities in Dire Dawa Administration. A structured questionnaire and anthropometric measurements were used to collect data. Data were entered with kobo software and exported to Statistical Package for Social Science statistical software version 20 for analysis. Binary and multiple logistic regression models were used to declare the significance of independent variables at P<0.05. This study shows 55% (95% CI = (50–59.5) were inadequate diversified dietary intake. Having lower monthly income (Adjusted Odds Raito [AOR] = 4.4, Confident interval [95%CI] = 1.3–14.6), elementary educational status of mothers (AOR = 3.8, 95%CI = 1.5–9.9), consumption of two meals per day (AOR = 16.6, 95% CI = 2.04–135.8), didn’t get antenatal care counseling (AOR = 2.2, 95% CI = 1.1–2.8) were significantly associated with diversified dietary. The result revealed that around 55% of respondents had inadequate dietary diversity. low household income, had less maternal education level and, consuming two meals per day, and no information about dietary diversity has contributed to inadequate dietary diversity. Accordingly, go forward in the right side of those variables were the core recommendation of this study.

problem of maternal malnutrition due to diversified diets are mostly based on starchy foods with slight or no animal products and few fresh fruits and vegetables [24]. Studies were done in different parts of the Africa region, Kenya and Ghana shows that 43.9% and 74.5% of women get minimum dietary diversity score (MDDS) respectively, and also mean dietary iron intake from 3.8 to 97.8 mg/d and 34-100% of the women's reproductive age (WRA) in Kenya, Nigeria, and South Africa had inadequate intakes) [25][26][27].
In Ethiopia, Iron consumption is described to be high (47-97.8 mg/d) and only 8-12% of the women's reproductive age (WRA) had inadequate intake. Mean dietary vitamin A intake reached from 71 to 2477 μg/d, and 3-100% had inadequate intake. Mean dietary zinc intake from 3.8-16.2 mg/d and 23-96% had inadequate intake in Ethiopia [27]. Organs are being designed, and the fetus develops at an enormously rapid rate, this all leads to improved nutrient needs that want the pregnant women to grow both the diversity and the total of foods consumed [28]. Ethiopia's administration launched the National Nutrition Program and prioritized interventions like, Stimulate maternal nutrition containing adequate intake of diversified foods to develop the nutritional status of women. The application of the above strategy, thinness, and different micronutrient deficiencies are common problems during pregnancy [23,29].
A cross-sectional study was done in Dire Dawa 2017, Dietary diversity and nutritional status of pregnant women attending a public hospital, high undernourished and low diversified dietary of pregnant women were found [30]. However, there is little known about the relationship between dietary diversity and associated factors among pregnant mothers in Eastern Ethiopia, particularly this study assesses the impact of health service utilization, maternal illness, and meal frequency on diversified dietary intake of pregnant mothers. Therefore, this study aims to assess dietary diversity and associated factors among pregnant mothers both in urban and rural public health facilities in Dire Dawa.

Study setting, design, and population
The facility-based cross-sectional study design was conducted in Dire Dawa city administration from November 1-30/2020. Dire Dawa is one the administrative city, which is 515 km far from Addis Ababa, a capital city. Dire Dawa's 2020 population is now estimated at 408,096 and the annual growth of the population was 4.37%. There are two governmental hospitals, four private hospitals, five higher clinics, twelve medium clinics (Private), fifteen health centers, and thirty-four health posts with 100% health service coverage. All public health facilities give Antenatal care. The total number of pregnant mothers come to public health on ANC Follow up in a single month 1256.

The population of the study
All pregnant mothers attending antenatal care at public health facilities of Dire Dawa from 12 weeks gestational age, were the source population and those pregnant mothers who were selected among Antenatal care follow-up from selected public health facilities during the data collection time were the study population.
All pregnant mothers attending antenatal care at the selected facility were included in this study.
During the collecting time, the pregnant mother's ill and/or difficulty communicating was excluded.

Sample size determination
The required sample size was determined by using a single population proportion formula with the following assumptions: n ¼ z 2 pq d 2 With a 95% confidence interval (CI) reported prevalence from a similar study had been conducted in the study area 57%) (31) With 5% precision and 10% non-response rate was used. The final sample size for the study was the final sample size with a single population proportion formula is 453. For factors associated with diversified dietary intake the sample size using Epi-info software imperial statistics like odd ration, the proportion of exposed and unexposed with diversified dietary intake and power of 80%, with the ratio of exposed to unexposed 1:1 and 5% level of significance. Finally, the sample size for the second objective, which is calculated for the associated factors For Diversified Dietary intake, is less than the first objective. Therefore, the sample size of the first objective is taken as the final sample size, which is 453.

Sampling techniques
From seventeen public health facilities in the Dire Dawa administration stratified by urban and rural strata, by using simple random technique 8 public health facilities (i.e. 4 from urban and 4 from rural) were selected.
The calculated sample size (453) is proportionally allocated to the selected public health facility based on their average number of client flows (client load). Participants in each facility were selected by using a systematic sampling technique after calculating the sampling interval (K) for each facility. To determine whom to be included in our sample we use systematic random sampling then calculate for constant 'K' by dividing the total client flow of required public health facilities in 15 days by our required sample size in that facility and the first sample was selected by lottery method between 1 and K, then every K interval value was selected to get required sample size from each public health facility during the required period.

Data collection tools, techniques, and personnel
Data were collected by interview administered methods using a Structured and pre-tested questionnaires and anthropometric measurement. The quantitative data collection questionnaire has four components: socio-demographic characteristics, Health service factors, and maternal factors. Parts of the questionnaire on the Individual Dietary Diversity Scale (IDDS) were assessed by using a standard questioner developed by Food and Nutrition Technical Assistant (FANTA) [2]. Eight clinical nurses experienced in data collection were recruited as data collectors. The training was given by (PI) to data collectors and supervisors for three days about the objective and methodology of the research on basic skills of anthropometric, interview techniques, data recording, ways of obtaining consent, and on how to maintain confidentiality of information.

Precautions made to limit exposer to COVID-19 during data collocation
The data collectors were a trend and updated on the current situation of COVID-19 along with precautions that must be implemented during the data collection. The data collectors were provided with personal protective tools (face mask, glove, and sanitizer hand rub) and a proper time and calendar were developed to limit crowding during data collection with other data collectors at the site.

Operational definitions and measurements
Dietary diversity. Number of individual food groups consumed over 24 hours, inadequate dietary diversity:-When individuals consume less than five food groups, Adequate dietary diversity:-When individuals consume greater than five food groups [2].
Meal frequency. Pregnant mothers eating a meal more than 3times per day had adequate meal frequency and less than 3 times inadequate meal frequency [31].

Data processing and data analysis
Data were cleaned and checked by Kobo tool data and it was exported to SPSS version 20 for analysis. Frequency distribution and percentages were computed to describe socio-demographic and other characteristics of respondents and presented in tables and figures. To identify factors associated with Diversified Dietary Intake, binary logistic regression analysis was carried out at two levels, first bivariate logistic regression was performed on each independent variable with the outcome variable, and those variables with a p-value < 0.25 were included in the final model (multivariate analysis). The strength of association was measured using the odds ratio, and 95% confidence intervals. Statistical significance was declared at P-value <0.05. Hosmer and Lemeshow goodness of fit (p-value above) was used to show model fitness in stepwise backward regression analysis. For qualitative data, the narrative data was interpreted and described.
In this analysis, dietary diversity scores were calculated by summing up the number of food groups consumed over 24 hours by the women. The scores greater than or equal to 5 were coded as adequate dietary diversity scores and inadequate dietary diversity otherwise (FHI/ FAO/FANTA, 2016) [2]. The women with Mid Upper Arm Circumference (MUAC) less than 23cm were categorized as wasted, based on previous studies.

Data quality assurance
To maintain consistency, the questionnaire was first translated from English to the local language (Afan-Oromo, somaligna, and Amharic) the native language of the study area, and was back-translated to the English language by professional translators. To evaluate the acceptability and applicability of the procedures and tools a pre-test was administered on 5% of the sample in Gende Gerada health center. Finally, unclear questions were modified before the data collection. To keep completeness and consistency, data collectors were closely supervised before and during the data collection process by the supervisor.

Ethical considerations
Ethical clearance was obtained from Research Ethical Review Committee of Dire Dawa University, college of medicine and health science. Then, to get the required support, a formal letter was written from the college of medicine and health science to the Dire Dawa administrative health bureau. An informed voluntary, written, and signed consent was obtained from all subjects for their participation after the nature of the study is fully explained to them in their local languages. A thumbprint or signature was used on the consent form. Those who are signed written consent were only participants in the study and confidentiality of response was maintained throughout the research process by giving code for the participant. The entire study participants were informed that data was kept private and confidential and used only for research purposes. The participants were also assured that they have the right to refuse or withdraw if they are not comfortable at any time. Personal privacy and cultural norms were respected.

Socio-demographic characteristics
Out of 453 pregnant mothers, 448 of them provided a complete response to the questionnaire marking the response rate of 98.9%. The mean age with a standard deviation of study participants was 27.7 ± 5.01SD and above half of them, 282 (62.9%) were within the age group of 20-29 years. The majority of the participant were urban 289 (64.5%) and educational status, most respondents 124(27.7%) had High and preparatory school. Concerning the respondent's occupation, 273(60.9%) were housewives. Of the total, 150(33.5%) of husbands education had college and above. Out of the total, 178(39.7%) pregnant mothers monthly income had greater than 3000ETB, 145(32.4%) between 2100-3000ETB (Table 1).

Maternal and health service factors
Out of 448 participants three fourth 346 (77.2%) of them were no illness in the past four weeks, 160 (35.7%) of respondents there is no counseling about diversified dietary intake, and a majority of 259 (57.8%) of participants reported that they consumed three times meals per day ( Table 2).

Nutritional status among pregnant mothers
The mean and standard deviation MUAC of the respondent was 25.4cm ±3.5SD cm. Out of the pregnant mothers, 133(29.7%) of them were under nutritional and 315(70.3%) were having normal nutritional status.

Factors associated with diversified dietary intake pregnant mother
The association of outcome variable (Diversified Dietary Intake) and independent variables was assessed using both bivariate and multivariate logistic regression. Accordingly; bivariate analysis revealed that out of fourteen explanatory variables only nine variables such as-educational status, maternal occupation, husband education and occupation, family size, monthly income, meal frequency, information about dietary diversity and MUAC had a statistical association with pregnant mother diversified dietary intake (P-value <0.25) whereas residence,

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Diversified dietary intake and associated factors among pregnant mothers attending ANC religion, age, past illness of mothers and ANC visit were not significantly associated and excluded from further analysis ( Table 3).
After bivariate analysis; those variables showing significant association were entered into multivariate logistic regression in order to rule out the effect of confounding variables. As a result four of contributing factors such as, Household monthly income, maternal education, information about dietary diversity, and meal frequency were the variables that were significantly associated with diversified dietary intake (P-value <0.05).
In this study, pregnant Mothers who had elementary education were almost 3.8 times more likely to have inadequate dietary diversity as compared to those who had college and above education (AOR = 3.8, 95% CI:1.5, 9.9). Concerning family monthly income; those who had an estimated monthly income of less than 1000ETB had 4.4 times more likely an increase the

Discussion
This study found that about 55% of a pregnant mothers were inadequate dietary diversity (< 5 food groups) while 45% of them were adequate dietary diversity (> = 5 food groups). The finding of this study was lower as compared to the inadequate dietary diversity in which pregnant mothers should consume 57% study done in Dire Dawa 2016, [30], 59.6% in Gambela [33], 73% in Mekele [34], and 56.4% in Axum Northern Ethiopia [35]. And also this finding was higher as compared to inadequate dietary diversity in which pregnant mothers should consume study conducted in Pakistan 2014, 11% [22], 25.6% in Nepal 2016 [36], 37% in Bangladesh 2015 [37], 22.7% in Malaysia 2015 [38], 39% in Laikipia, Kenya 2016 [39], 25.4% in Shashemene 2017 [40] and 38.8% in Alamata 2017 [31]. The possible reason for this great discrepancy may be due to differences with respect to socio-demographic, socio-economic health characteristics of the population, and sample size variation. Many studies also used the nine or fourteen food groups, and those consumed four or more food groups of the fourteen food groups were considered as they achieved diversified dietary intake which result from high proportion of diet diversity.
When comparing individual food group consumption patterns, grain, other vegetables, and dark green leafy vegetables are the commonest consumption in the study area due to being easily available and cheapest for other food groups. In the particular conception of the animal sources of food such as dairy products, egg, meat, and fish were observed among some number of participants. This is also because of seasonal variability since a dairy products like milk and milk products are accessible in the study area and the practice of eating meat and fish was mostly oriented towards the celebration of religious holidays, marriage ceremony and other social welfares.   Maternal education, Monthly income, Meal frequency, and information about dietary diversity are significantly associated with dietary diversity intake.

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Pregnant mothers who had elementary education were almost 4 times more likely to have inadequate dietary diversity as compared to those who had college and above education. This is in line with a study done in rural Bangladesh 2015 [37], southwest Bangladesh 2016 [41], Bangladesh 2013 [42], Kenya 2016 [39], Alamata [31], and Hossana, Ethiopia, [43], Tigray Ethiopia [44]. The reason behind here is because the most educated pregnant mother had good food choices due to knowledge about the importance of food and were more likely to understand educational messages transfer through different media channels and also a pregnant mothers who had education have greater awareness about how to utilize available resources for the improvement of their diet quality.
Family income was significantly associated with pregnant mother dietary diversity. As a result, the study revealed those who had a monthly income of less than 1000ETB had 4.4 times more likely an increase in the chance of inadequate dietary diversity as compared to those who had a monthly income of greater than 3000 ETB. This result is supported by different studies conducted in India [45], Ahvaz-Iran [7], Shashemene 2017 [40]. As income levels decreased, the chance of pregnant mothers being inadequate in dietary diversity was high [46]. The possible reason behind here is income and the prices of foods determine food access. Mothers with higher income have the purchase power to afford foods from the market even not available at home.
In this study, pregnant mothers who had two meals per day was 16.6 times more likely to have inadequate dietary diversity as compared to those who had greater than four meals per day. This finding is in line with the other studies conducted in Hossana [43], Alamata [31], and Bale, Ethiopia, [47]. This might be related to their opportunity of having greater than two meals may have the chance of consuming different categories of food group.
This study also showed that pregnant mothers who had not the exposure of dietary diversity information were 2.2 times more likely to have inadequate dietary diversity as compared to those who were the exposure to dietary diversity information. This finding is in line with studies carried out Hossana town south Ethiopia [48], in Jijiga town [49], in Guto Gida Woreda, East Wollega, and Central Gonder [50,51]. This is since those who had exposure to dietary diversity have better knowledge about the importance of a diversified diets to maintain proper health and pregnancy outcomes.
This study may have certain limitations like due to the cross-sectional design this study cannot make the cause and effect relationship between different factors with the outcome variable. Besides, this study might not give the exact figure of the dietary diversity practice due to recall bias so the 24-hour dietary recall may not truly represent the usual intake and is also unable to generalize to the population because of the health-facility nature of this study.

Conclusions
This study suggested that around 55% of respondents had inadequate dietary diversity mainly defined by the inclusion of ten food groups. The study showed that pregnant mothers' educational status, family income, meal frequency, and information about dietary diversity have contributed to low diversified dietary intake. There is a need for enhancing dietary diversity or food groups and promotion of awareness on nutritional benefits especially consumption of at least five food groups for pregnant women. Increase meal frequency and health service utilization. And also support health facilities to train their health professionals especially, health extension workers should provide regular advice to women about the nutritional value of consuming different food groups.