Nutritional knowledge , attitude and practices among pregnant women who attend antenatal care at public hospitals of Addis Ababa , Ethiopia

During pregnancy, maternal nutrition requires considerable attention; however, pregnant women’s nutritional knowledge, attitudes, and practices are less understood. The objective of this study was to assess nutritional knowledge, attitude, and practices among pregnant women who attend antenatal care at public hospitals of Addis Ababa, Ethiopia. An institution based cross-sectional study was conducted to collect relevant data of 322 pregnant women, who attended antenatal care service in selected public hospitals in Addis Ababa, Ethiopia from April to May, 2015. Simple random sampling procedure was used to select the public hospitals and systematic sampling techniques were used to select pregnant mothers by using hospitals’ registration lists. Data were coded and entered to computer using Epi data version 3.1 and exported to statistical package for social sciences (SPSS) program version 21.0 for further analysis. Multivariable logistic regression analyses were used to identify independent predictors of knowledge, attitude, and practices of pregnant women regarding nutrition. The study revealed that of the 322 pregnant women surveyed, 87(27%), 156(48.4%), and 111(34.5%) of them had knowledge, favorable attitude, and good practices of nutrition during pregnancy, respectively. There was a positive significant association between educational status of women (AOR=3.047, 95%CI (1.046 to 8.873)), family income (AOR=3.093, 95%CI (1.076 to 8.890)), attitude (AOR=4.4, 95%CI (2.315 to 8.299)), number of pregnancies (AOR=2.175, 95%CI (1.034 to 4.573)) and nutrition knowledge during pregnancy. Whereas knowledge, family income, husband education and occupation had a positive association with good practices of nutrition during pregnancy. Knowledge, attitude and practices of pregnant mothers regarding nutrition during pregnancy were low in the study area.


INTRODUCTION
All human beings need a balanced amount of nutrients for proper functioning of the body system.Nutrition is a fundamental pillar of human life, health and development throughout the entire lifespan (Daba et al., 2013).There are approximately 40 different nutrients that are essential for health.If any one of these is deficient in the diet, the person will not be fully healthy and able to resist the agents of disease (Collins, 2007).
Malnutrition is an umbrella term for poor nutrition, whether that is excess consumption of nutrients (overnutrition) or inadequate consumption or absorption of one or more nutrients undernutrition) while undernutrition includes being underweight for one's age, too short for one's age (stunted), dangerously thin (wasted) and deficient in vitamins and minerals (micronutrient malnutrition).Malnutrition is now a problem in both poor and rich countries.In developing countries, while widespread under nutrition and micronutrient deficiencies persist, obesity is also fast emerging as a problem (Shekar et al., 2006).
In Ethiopia, nutritional disorders are among the main causes of morbidity and mortality.The major problems are protein-energy malnutrition and micronutrient deficiencies such as vitamin A, iron, and iodine (Federal Democratic Republic of Ethiopia MoH. Health Sector Development Programme, 2010).27% of women in Ethiopia are undernourished with a body mass index (BMI) of less than the 18.5 cutoff points; only 4% are obese with a BMI of more than 25.0.These figures put Ethiopia among sub-Saharan countries with the highest proportion of malnourished women (IYCN, 2011).
Pregnancy is a time of increased energy and nutrient needs for a woman in order to meet the needs of the growing fetus and of maternal tissues associated with pregnancy, proper dietary balance is necessary to ensure sufficient energy intake for adequate growth of fetus without drawing on mother's own tissues to maintain her pregnancy (Subarnalata and Panda, 2006).
The poor health and nutrition of women and the lack of care that contributes to their death in pregnancy and child birth also compromises the health and survival of the infants and children (Abdella, 2010).Undernutrition has the most damaging effect on the fetus during pregnancy and in the first two years of life, and the effects of this early damage on health, brain development, intelligence, educability, and productivity are largely irreversible (Shekare et al., 2006).
The pregnant and lactating woman's diet should include a substantial increase in calories, protein, calcium, folic acid, iodine and iron.Pregnant women at particular risk for nutritional deficiencies are adolescents, underweight women, obese women, women with chronic nutritional problems, women who smoke or ingest alcohol or drugs, low income women, and women with chronic illnesses such as diabetes or anemia (Edris et al., 2005).Knowledgeable about nutrition during pregnancy was low in previous studies conducted in 2013 in East Wollega, Ethiopia (64.4%) and in 2012 in Malaysia (70%) (Daba et al., 2013;Mitra et al., 2012).
Practices of eating fresh vegetables and daily milk consumption, is low in the previous studies conducted in America (58.9 and 42.7%) respectively (Federal Democratic Republic of Ethiopia, 2013).While many studies and projects focus on maternal health in Addis Ababa, less attention is given to maternal nutrition in this study area (Berg et al., 2011).It is clear that maternal nutrition is crucial in reducing maternal and infant morbidity and mortality, but no study has been conducted to assess nutritional knowledge, attitude and practices of pregnant mothers in the study area.Therefore, the aim of this study was to assess nutritional knowledge, attitude, and practices among pregnant women who attend antenatal care at public hospitals of Addis Ababa, Ethiopia.

MATERIALS AND METHODS
The study was conducted in Addis Ababa, the capital city of Ethiopia.Established in 1887, by Emperor Menilik II, the city is divided into ten sub-cities.In 2014, Addis Ababa had a projected population of 3,194,999 million of whom 1,679,998 (53%) were females and 1,515,001 (47%) were males (Marías and Glasauer, 2014).According to the information from Ministry of Health, in Addis Ababa there are eight hospitals that provide antenatal services to the public.Based on the information provided from each of these hospitals, the average number of pregnant mothers attending antenatal clinics antenatal care (ANC) is estimated at 2527 per month.The study was conducted from April to May, 2015.
The study population included randomly selected pregnant women who had visited public hospitals in Addis Ababa during the month of April 2015 for antenatal care.The sample size was determined using single population proportion formula at 95% of confidence interval with assumption of prevalence of knowledge of pregnant mothers towards nutrition 64.4% (Daba et al., 2013) with (α=0.05) 5% marginal error (d=0.05).Since the total study population in the study area is below 10,000, reduction formulas were employed.By factoring in a 10% non-response rate, the final sample size was 340.
The calculated sample size was proportionally allocated to randomly select four public hospitals in Addis Ababa based on the number of clients attending antenatal care (ANC).To select study subjects from each antenatal care unit systematic random sampling technique was applied by using client's registration order to get ANC care during the data collection period.Then every 7th person, as they registered, was included in the study at each antenatal care unit until the desired sample size was attained.
An unstructured, semi-structured and structured questionnaire was prepared in English.The questionnaire was translated to Amharic and after data collection it was translated back to English to check for consistency by experts.Data were coded and entered to computer using Epi data version 3.1 and exported to SPSS program version 21.0 for further analysis.The result was presented using frequency tables and percentage.Bivariate analysis was done to determine association between factors and knowledge, attitude and practice among pregnant mothers.Multivariate logistic regressions were performed to identify the independent predictors of knowledge, attitude and practice among pregnant mothers.
Data were supervised by BSc midwives who were trained on the objective of the study, methods of data collection, and content of questionnaire in order to avoid any ambiguity raised during data collection.Data was checked for completeness, accuracy, and consistency by supervisors and principal investigator after the data collection on daily base.The prepared questionnaire was pre-tested on 5 % of pregnant mothers who were not being included in the study to identify the clarity and sequence of question.

Knowledge
This refers to an individual's knowledge of nutrition, including the ability to remember and recall food and nutrition related terminology.

Knowledgeable
If respondents score ≥ 70% (out of 100%) on the knowledge questions.

Not knowledgeable
If respondents score < 70% (out of 100%) on the knowledge questions.

Attitudes
Pregnant women's feeding or eating behavior which is influenced by her emotions, motivations, perceptions and thoughts.

Favorable attitude
The respondents attitude score > median

Unfavorable attitude
The respondents 'attitude score less than or equal to the median.

Practice
This is the observable action of the mothers that could affect her nutrition such as eating, feeding, cooking and selecting of foods.

Good practices
This is when the pregnant mothers include fruits, vegetables, meat, milk and milk products in their diet at least once per day, and for frequency of four or more meals per day.

Poor practices
This is when the pregnant mothers did not practice food recommendation for pregnant women and for frequencies, less than once per day regarding fruits, vegetables, meat, milk, and milk products and meal frequency less than three times per day.

Ethical consideration
Ethical clearance was obtained from the Institutional Review Board Tenaw et al. 83 of Addis Ababa University.Communication with different hospital administrators were made through formal letter obtained from Addis Ababa University.After the purpose and objective of the study have been informed, written and verbal consent was obtained from each study participant.Participants were informed that participation was on voluntary basis and they can withdraw from the study at any time if they were not comfortable about the questionnaire.In order to keep confidentiality, the information was maintained throughout by excluding names as identification in the questionnaire and kept their privacy during the observation by observing them alone.

RESULTS
A total of 322 pregnant mothers participated in the study, with 94.7% response rate.The mean age (0±SD) of the participants was 28.44 (0±4.199)years, while age range was 18 to 42.About 75% of the respondents were in the age range of 25 to 34 years (Table 1).From the participants, 27% had good knowledge about maternal nutrition during pregnancy (Figure 1).Regarding attitude of mothers about nutrition during pregnancy, 156 (48.4%) had favorable attitude.The highest positive attitude score were for preparing meals with iron-rich foods (91%) followed by preparing meals with iodized salt (90.7%) (Figure 2).Concerning micronutrient supply, 204 (63.4%) of women had iron tablets and took them correctly, but only 25 (7.8%) of women had folic acid supplies at three months before pregnancy and within three months after conception.In general, 34.5% of the pregnant mothers reported good practices regarding antenatal nutrition (Figure 3).

Factors associated with maternal nutrition knowledge during pregnancy in Addis Ababa public hospitals
The factors associated with nutritional knowledge during pregnancy include educational status of the women, family income, attitude and number of pregnancies (Table 2).

Factors associated with maternal nutrition attitude during pregnancy in Addis Ababa public hospitals
Knowledge was another factor associated with favorable nutritional attitudes during pregnancy (Table 3).

Factors associated maternal nutrition practice during pregnancy in Addis Ababa public hospitals
The husband's education, occupation, monthly income and knowledge were additional factors associated with nutrition practice during pregnancy (Table 4).

DISCUSSION
This study was conducted to investigate the level of  pregnancy is good for their pregnancy.This study also revealed that 87 (27%) and 101(31.4%) of pregnant mothers reported practices of eating fresh vegetables and daily milk consumption respectively.The practice is lower than the study conducted in America (58.9 and 42.7%) respectively (Federal Democratic Republic of Ethiopia, 2013).Therefore, Addis Ababa pregnant mothers needs to improve utilization of fresh vegetables and milk consumption.The difference might be due to cultural, socio economic differences and access to nutritious food.Of the mothers surveyed, 209 (65%) reported having four or more meals per day.More than 219 (68%) of the respondents reported eating snacks between meals.This means the remaining 32% of the mothers do not have good meal practice based on the recommended meal practice.204 (63.4%) reported eating more carbohydrates between meals during their pregnancy, which was higher than the study conducted in East Wollega (33.9%) (Berg et al., 2011).This study uncovered that, 303(94.1%) of the pregnant mothers had the habit of eating either plant or animal protein daily.This finding was greater than the study conducted in Ethiopia at district level (42.7%) (Federal Democratic Republic of Ethiopia, 2013).The difference may be accessibility of variety of foods in cities than districts.Majority of the mothers in this study, 204 (63.4%) had a good iron supply during pregnancy, which is similar with the study conducted in Western Kenya (62%) (Perumal et al., 2013).This study revealed that, 111(34.5%) of the pregnant mothers had good nutritional practices, which is similar to the study conducted in the East Wollega (Berg et al., 2011).

Conclusion
Most pregnant women in this study reported poor level of knowledge and practices about nutrition and balanced diet during pregnancy.Monthly income, educational level and attitude were the significant factors affecting nutritional knowledge of mothers during pregnancy.Monthly income, husband education and occupation were significant predicting factors for nutritional practices during pregnancy.Good knowledge about maternal nutrition usually affects nutritional attitudes during pregnancy.

RECOMMENDATION
Since pregnant women in this study reported poor knowledge and nutritional practices during pregnancy, health care providers should introduce strategies for providing health education about proper and balanced maternal nutrition during ANC visits.
(Daba et al., 2013)Mitra et al., 2012) on this study, 27% of the mothers had knowledge about nutrition during pregnancy, which is lower than previous studies conducted in 2013 in East Wollega, Ethiopia which is 64.4%, and in 2012 in Malaysia it was 70%(Daba et al., 2013;Mitra et al., 2012).As the result showed there is a knowledge gap about nutrition during pregnancy among respectively.Which is lower than the study conducted in Ethiopia at district level(78.2,68.5, 57.3, 62.9, 71.8%and61.3%respectively)(FederalDemocratic Republic of Ethiopia, 2013).The difference might be due to residence differences and giving attention for other milk substituting products, since they have different options.This study also revealed 147(45.7%)and114(35.4%) of pregnant mothers had knowledge about the danger of malnutrition on the mother and her fetus, respectively.This is similar with the study in East Wollega, which is 34.8%(Daba et al., 2013).Most of the pregnant mothers (280 (87%)) thought that eating more protein or beans during Figure 3. Nutrition practice level of pregnant mothers in Addis Ababa, public hospitals, 2015

Table 2 .
Factors associated with nutritional knowledge of pregnant mothers (N=322).

Table 3 .
Factors associated with nutritional practices of pregnant mothers (N=322).

Table 4 .
Factors associated with nutritional practices of pregnant mothers (N=322).