Study setting and period

The study was conducted from 20 September to 5 October 2020 at public health facilities in Samara-Logia city administrative and Dubti district, Afar Regional State, northeast Ethiopia, that is located 588 km away from the capital city, Addis Ababa. The study settings are bordered on the south by the Afambo district, on the southwest by Mille, on the west by Chifra, on the northwest by the administrative zone 4, on the north by Kori, on the northeast by Elidar, and on the east by Aysaita district. The area has a 1200-m altitude above sea level, and the main source of income in this area is trade and pastoralism.

As of 2007, Ethiopia’s population has been growing at a rate of 2.6% per annum. At this rate, the total population of the study settings will number 99,889 by 2019 (CSA 2007). Of these, 3097 are pregnant women. The area has a 1200-m altitude above sea level, and the main source of income in this area is trade and pastoralism.

The pastoral community is completely rain-fed. In normal years, the region receives annual rainfall in the range of 425–1300 mm. The area is marginal for agricultural production and suffers a food deficit every year. The main source of income is livestock production and trading. The main types of livestock are cattle, sheep, goats, and camels. Seasonal livestock migration to the major rivers to seek pasture and water is common during the long dry season (Bona).

Study settings have six functional public health facilities and 16 health posts with various private clinics, pharmacies, drug stores, and rural drug vendors. These health facilities are serving more than 250,000 population since the regional referral hospital is found in this area. According to the health office report of the year 2019, the health facilities give antenatal care services to nearly 5000 pregnant women.

Study design

A health facility-based cross-sectional study design was employed.

Source and study population

The source population is all pregnant women who were attending ANC follow-ups at selected public health facilities.

The study population is all pregnant women who were attending ANC follow-ups at selected public health facilities during the data collection period.

Eligibility criteria

Inclusion criteria

All pregnant women who were presented to health facilities for ANC follow-up during the data collection period at the selected public health facilities were included in this study.

Exclusion criteria

Pregnant women who were critically sick and came to the selected health facilities other than ANC check-ups during the data collection period were excluded from this study.

Sample size determination

The required sample size for this study was determined for both objectives (prevalence and associated factors), and the objective that provides the maximum sample size was considered as the final sample size for this study.

Thus, for the first objective, the sample size was calculated using single population proportion formula; the prevalence of undernutrition among pregnant women (P = 35.5%) was taken from a study conducted in Sidama zone, Ethiopia (Loha 2013), with assumptions of 95% confidence interval, 5% margin of error, and 10% to compensate non-responses.

$$n=frac{{(Zalpha /2)}^{2}(P)(1-P)}{{d}^{2}}$$

where n is the sample size, /2 is the critical value for normal distribution at 95% confidence level (1.96), P is the prevalence of malnutrition among pregnant women, and d is the marginal error. Then, the calculated sample size becomes 387. Here, the maximum sample size was obtained for the first objective compared to the second objective (387 and 372, respectively).

Sampling techniques

In this study, from the six public health facilities found in Samara-Logia town and Dubti district, three health facilities were selected using a simple random sampling technique. Dubti Hospital was selected from the three health facilities in Dubti district. Similarly, Logia and Samara Health Centers were selected from the Samara-Logia city administration health facilities. Then, the calculated sample size was proportionally allocated for each randomly selected health facility based on the case flows they had reported in the previous 1 year. Similarly, the arrival of each pregnant woman for the first time to get antenatal care was considered at random. Thus, study participants were recruited based on their random arrival as per the inclusion criteria. The data was collected until the calculated sample size is satisfied.

Study variables

Dependent variable

Independent variables

  • Socio-economic and socio-demographic factors: maternal age (in years), a maternal education level (illiterate, primary level, secondary level, tertiary level), religion (Muslim, Orthodox Christianity, Protestant, and others), ethnicity (Amhara, Afar, Oromia, Tigray, and others), marital status (single, married, divorced, and widowed), mother’s main occupation (housewife, farmer, civil servant, merchant, daily labourer, student, and others), average monthly household income (in Ethiopian birr), and family size-related (in number) information

  • Knowledge of taking an extra meal during pregnancy

  • Obstetric- and medical problem-related factors: ANC, pregnancy status, parity, HIV/AIDS, infections within 4 weeks, and so on

  • Behavioural factors, such as alcohol, khat, and cigarette use during the pregnancy period

Data collection tools and techniques

Data collection instrument

The questionnaire was adapted and modified from the national nutrition programme guideline (FMOH 2013) and the Ethiopian demographic and health survey CSA (2016). Mid-upper arm circumference (MUAC) anthropometric measurement was used to measure the nutritional status of pregnant women participating in this study which is a commonly used approach in the diagnosis of acute malnutrition among pregnant women. The measurement was taken at the middle of the upper arm, and it was measured using adult size MUAC. Finally, the measurement of MUAC was rounded to the nearest 0.1 cm.

Data collection techniques

Face-to-face interviews were employed using a standardized, structured, and field-tested questionnaire to collect the data. Experienced data collectors who had conducted similar interviews in the previous years were recruited. The principal investigators and supervisors have checked the activities of each team daily.

Three supervisors including principal investigators coordinated the overall data collection process. Six trained health professionals collected the data. The nutritional status of pregnant women was determined through anthropometric measurement using mid-upper arm circumference (MUAC), which is a commonly used approach in the diagnosis of acute malnutrition among pregnant women. MUAC of each woman was measured at the mid-point between the tips of the shoulder and elbow of the left arm using non-elastic, non-stretchable MUAC tapes, and measurements were recorded to the nearest 0.1 cm.

Data quality assurance

The questionnaire was standardized and contextualized. It was originally developed in English and translated into local language (Afar-aaf). It was back-translated into English version to keep its consistency. A pretest of the questionnaire was done on 5% (i.e. 20 participants) of the samples at a non-selected health facility (i.e. mille health centre), and an amendment was made based on the findings.

Two days of training were provided to the data collectors and supervisors focused on data collection procedures, quality, interviewing techniques, and related issues. Apart from the 2-day training, supervisors and the principal investigator reviewed the collected data daily to identify errors, omissions, and inconsistencies. Data were checked for completeness, accuracy, and clarity by the study core team and supervisors.

Data management and analysis

Data entry and coding were done using Epi-data 3.1. Data cleaning and analysis were carried out using Stata version 14.0. Descriptive statistics were done, and the results were presented using texts, frequency tables, and median with interquartile range. The median was used for continuous variables, which were not normally distributed.

Independent variables were explored in assessing maternal undernutrition using (1) socio-demographic characteristics (maternal age, educational status, marital status, ethnicity, religion, occupation, and average monthly household income); (2) access to and utilization of available health services (antenatal care checkup, distance to health facilities, using available health services and a household visit by community health workers); and (3) knowledge of extra meal taking during pregnancy-related variables was examined.

Correlation between independent variables was assessed using the variance inflation factor. Model fitness was checked using the Hosmer and Lemeshow fitness of test. Both crude odds ratio and adjusted odds ratio (AOR) with corresponding 95% confidence interval was reported to show the nature of associations observed. In multivariable analysis, a statistically significant level was declared using AOR with its corresponding 95% confidence interval.

Operational definitions

Undernutrition

Maternal undernutrition was assessed using a mid-upper arm circumference (MUAC) and categorized as undernutrition (MUAC < 22) and normal (MUAC ≥ 22) (Dadi and Desyibelew 2019; Haji 2016).

Good knowledge on an extra meal during pregnancy

Knowledge of the benefits of taking an extra meal during pregnancy is computed from five yes/no questions: (1) Do you know extra meal during pregnancy help the foetus to develop well? (2) Do you know the foetus competes for nutrients during pregnancy? (3) Do you know extra meal taking will help for the health of the foetus and yourself? (4) Do you know extra meal taking will help to prevent infections during pregnancy? (5) Do you know taking extra meal help to prevent anaemia during pregnancy? (EPHI 2015). Therefore, women who answered above the mean score were considered knowledgeable on extra meal taking, and those who answered below the mean score were considered as not knowledgeable on extra meal taking during pregnancy.

Substance use during pregnancy

If pregnant women use either alcohol, cigarette, or khat at least once during this index pregnancy, they were considered substance users.

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