Background

Dietary Diversity is the feeding of an adequate variety of food groups. Sufficient maternal nutrition throughout the “first 1,000 days” window is mostly critical throughout a woman’s pregnancy through to the child’s second birthday. Improving the nutritional status of the woman before and during pregnancy can reduce the risk of adverse birth outcomes, such as low birth weight and pre-term birth [1–3].

A Diversified Dietary is one of the greatest strategies extremely suggested among pregnant women, which is associated with enriched diet competence through improved food groups in daily diet. Dietary diversity takes been defined as the number of diverse food groups that are consumed over a definite reference period [4–6]. Good maternal nutrition is significant to health and growth. Nutrition throughout pregnancy is different from the non-pregnant state; sufficient dietary feeding during pregnancy is needed to suitable birth outcomes and good health for the mother [7–10].

Pregnancy requests a good diet that contains a sufficient intake of energy, protein, vitamins, and minerals to meet maternal and fetal desires. In Poor countries in sub-Saharan Africa, south-central, and Southeast Asia, maternal undernutrition is highly prevalent and has poor perinatal outcomes [11].

A pregnant woman with advanced dietary diversity makes definite the adequacy of dietary diversity for their children and families. Inadequate dietary diversity at the individual, household, and community levels, or any combination of these, may be influence factors to poor nutrition status which is an intergenerational cycle of malnutrition [12]. Day-to-day calorie consumption among pregnant women is made-up to be about 1,800 calories per day during the first trimester, 2,200 calories per day during the second trimester, and 2,400 calories per day during the third trimester [13].

Globally, around 2 billion people, most women and young children, are affected, by micronutrient deficiencies, with even higher rates during pregnancy [14]. Nearly all (99%) of maternal deaths annually occur in developing countries [15].

About 870 million people are probable to be underweight around the world. Out of these, 852 million were in developing countries [16]. In further, 3.5 million women and children aged under five in developing countries die each year due to the underlying cause of undernutrition. Around 800 pregnant women die every day during pregnancy and childbirth and 8,000 newborn babes die within the first month of life in developing countries [12]. Inadequate dietary intake may lead to low birth weight, stillbirth, the premature rupture of membrane, intrauterine growth restriction, intrauterine fetal death, and congenital anomalies and affect later on sudden infant death syndrome, developmental impairment, malnutrition, and threat for chronic disease [17–19]. Universally, mortality and morbidity due to undernourishment have not meaningfully changed over the last 30 years, to advance it, the dietary diversification status of pregnant women needs to sustainably improve through addressing evidence and reduction of obstacles of obedience [20].

Poor diversified dietary consumption during pregnancy is an important contributor to international maternal malnutrition in less developed countries. A previous review showed that pregnant women in developing countries suffer from energy insufficiencies due to relatively insufficient energy intake. Besides, 42% of pregnant mothers globally and more than 50% of pregnant mothers in developing countries are anemic, mainly due to iron deficiency [21, 22].

In Africa alone, 20% of women are underweight, Even however dietary diversification is significant for the health of the mother and the fetus in Ethiopia, 22% of women are thin due to inadequate diet diversity (vegetables and fruits), and fluctuating regimes [23]. Still, a high 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) [25–27].

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.

Methods and materials

Result

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).

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Table 1. Socio-demographic characteristics of pregnant mothers attending antenatal care at public health facilities in Dire Dawa, Eastern Ethiopia, 2020.

https://doi.org/10.1371/journal.pgph.0000002.t001

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).

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Table 2. Maternal and health service factors of a pregnant mother attending antenatal care at public health facilities in Dire Dawa, Eastern Ethiopia, 2020.

https://doi.org/10.1371/journal.pgph.0000002.t002

While concerning antenatal care practice, 51(11.4%) of a pregnant mother had one ANC visit, 162 (36.2%) had two visits, 175(39.1%) had three visits and 60 (13.4%) of pregnant women had four visit. (Fig 1)

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Fig 1. Number of ANC Visit illness for dietary y diversity among pregnant mother attending antenatal care in public health facilities in Dire Dawa, 2020.

https://doi.org/10.1371/journal.pgph.0000002.g001

Dietary intake among pregnant mother

In this study about 245 (55%); 95%CI: (50, 59.6) pregnant mothers had Inadequate Dietary Diversity and 203(45%); 95%CI: (40.4, 50) pregnant mothers had Adequate Dietary Diversity practice which is recommended by FAO 2016 (> = five food groups) (Fig 2). The most commonly consumed food groups were other vegetables 440(98%) followed by grains 381(85%) and dark green leafy vegetables 222(50%) (Fig 3).

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Fig 2. Diversified dietary score of pregnant mother in public health facilities in Dire Dawa, 2020.

https://doi.org/10.1371/journal.pgph.0000002.g002

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Fig 3. Food groups consumption patterns of pregnant mother in public health facilities in Dire Dawa, 2020.

https://doi.org/10.1371/journal.pgph.0000002.g003

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, religion, age, past illness of mothers and ANC visit were not significantly associated and excluded from further analysis (Table 3).

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Table 3. Bivariate analysis of factors associated with diversified dietary intake of a pregnant mother attending antenatal care in public health facilities in Dire Dawa, Eastern Ethiopia, 2020.

https://doi.org/10.1371/journal.pgph.0000002.t003

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 chance of inadequate dietary diversity as compared to those who had an estimated monthly income of greater than 3000ETB (AOR = 4.4, 95% CI: 1.3, 14.6) and also those who had an estimated monthly income of 1100-2000ETTB increase the likelihood of attaining inadequate dietary diversity by 2.7 times as compared to those who had an estimated monthly income greater than 3000ETB (AOR = 2.7, 95% CI:1.3, 5.5).

This study also showed that pregnant mothers who had not exposure of dietary diversity information were 2.2 times more likely having inadequate dietary diversity as compared to those who were the exposure of dietary diversity information (AOR = 2.2, 95% CI:1.1, 2.8). Furthermore; those pregnant mothers who had two meals per day were 16.6 times more likely to have inadequate dietary diversity as compared to those who had greater than four meals per day (AOR = 16.6, 95% CI:2.04,135.8) (Table 4).

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Table 4. Multivariate analysis of factors associated with diversified dietary intake of a pregnant mother attending antenatal care in public health facilities in Dire Dawa, Eastern Ethiopia, 2020.

https://doi.org/10.1371/journal.pgph.0000002.t004

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.

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.

Supporting information

Acknowledgments

We would like to thank Dire Dawa University. Furthermore, I would like to thank the Administrative bodies of Dire Dawa Health bureau for giving information and their full cooperation, and, the study participants for their commitment to respond to questions by Sacrificing their time, data collectors, translators, and data supervisors for their commuted activities.