Tafasa et al.

BMC Nutrition (2023) 9:115 BMC Nutrition

https://doi.org/10.1186/s40795-023-00773-2

RESEARCH Open Access

Dietary diversity, undernutrition

and associated factors among pregnant
women in Gindeberet district, Oromia,
Ethiopia: a cross-sectional study
Segni Mulugeta Tafasa1*, Jiregna Darega2, Nagasa Dida2 and Feyisa Dudema Gemechu2

Abstract
Background Appropriate levels of dietary diversity are essential for proper physiology of human being and it is
crucial to consume healthy foods at every phase of life, especially during pregnancy. Inadequate dietary diversity
and malnutrition are risk factors for low birth weight, intrauterine growth reduction and small for gestational age.
This study was aimed to assess dietary diversity, undernutrition and associated factors among pregnant women in
Gindeberet district, Oromia, Ethiopia, 2020.
Method A community based cross-sectional study was conducted among 627 pregnant women in Gindeberet
district selected by systematic random sampling from October 10/2020– November 10/2020. Data were collected
through interviewer administered questionnaires. The collected data were coded and entered to Epi-info version
7.2.2.6 and analyzed by SPSS version 23. Logistic regression analysis was carried out to identify factor associated with
undernutrition and dietary diversity. Level of statistical significance was declared at p-value < 0.05.
Results overall prevalence of inadequate dietary diversity and undernutrition were 276 (44.4%) and 110 (17.7%)
respectively. Pregnant women who did not receive antenatal care (AOR = 2.32, [95% CI: 1.38, 3.90]), family size ≥ 5
(AOR: 2.93; [95%CI: 1.10, 7.79]), unprotected sources of water (AOR: 4.14; [95% CI: 1.63, 10.52]) were significantly
associated with undernutrition. Rural residence (AOR = 2.59, [95% CI: 1.66–4.04]), pregnant women who did not
received ANC (AOR = 2.52, [95% CI: 1.58–4.03]) and nutrition information (AOR = 1.43; [95% CI: 1.10, 2.10]) were
significantly associated with dietary diversity among pregnant women.
Conclusion undernutrition and inadequate dietary diversity among pregnant women were high in study area.
Source of drinking water, ANC visit and family size were significantly associated with pregnant women undernutrition.
Place of residence, ANC visit and nutrition information were significantly associated with inadequate dietary diversity.
Therefore, pregnant women, government, non-governmental organization and stakeholders should focus on
importance of ANC visit, clean source of drinking water and adequate dietary diversity to improve nutritional status of
pregnant women.

*Correspondence:
Segni Mulugeta Tafasa
[email protected]
Full list of author information is available at the end of the article

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Tafasa et al. BMC Nutrition (2023) 9:115 Page 2 of 12

Keywords Dietary diversity, Undernutrition, Pregnant women, Gindeberet district

Introduction amounts of nutrients during pregnancy will have stored

Undernutrition is an outcome of insufficient quantity enough fat to be used for herself and the fetus [10].
and quality of food and frequent episodes of infectious Maternal undernutrition is a worldwide public health
disease or consumption of inadequate energy, protein problems affecting higher proportion of women in devel-
and micronutrients to meet basic requirements for body oping countries [11]. It remains as persistent and destruc-
maintenance, growth, and development [1]. Dietary tive health problem in low and middle-income countries.
diversity is the consumption of a variety of food groups The global undernutrition among women in reproduc-
over a reference period which has been accepted as an tive age is significantly higher in Africa, particularly in
aspect of dietary quality and can show nutritional ade- sub-Saharan Africa, South central and Southeastern Asia
quacy [2]. due to chronic energy and/or micronutrient deficiencies
Appropriate levels of nutrients are essential for proper especially during pregnancy [12].
physiology of human being and it is crucial to consume According to a study done on the burden and determi-
healthy foods at every phase of life, beginning in the nants of malnutrition among pregnant women in Africa
womb. Good nutrition is vital for any pregnancy and not 23.5% of pregnant mothers are living with the undernu-
only helps for health of mother, but also influences the trition problem and they might have been suffering from
development of the fetus and ensures that the baby grow pregnancy complications and adverse birth outcomes
well in infancy and beyond [3, 4]. related to their nutritional problems. Many women in
Nutrition is a vital part of human life and its need dif- Africa suffer from chronic energy deficiency, inadequate
fers with age, gender and physiological changes such as weight gain during pregnancy, and low micronutrient sta-
pregnancy (changes in body composition, weight gain, tus [13]. Undernutrition is one of the most serious health
changes in blood composition, metabolic changes and problems affecting both mothers and their children in
adaptive responses) [4]. Over all energy needs increased Ethiopia [14]. As evidenced by 2016, EDHS, malnutrition
by 13% during pregnancy. Specifically, protein need among women is high with 22% of them is undernour-
increased by 54% and vitamin and mineral need by ished or thin, which is linked to a maternal mortality rate
0-50%. To meet these high demands most nutrients needs of 420/100,00live birthshs [15]. Similarly different study
are increased during pregnancy [5]. During the prenatal conducted in Ethiopia showed prevalence of undernutri-
period, the fetus obtains all of its nutrients through the tion ranges from 14.4 to 44.9% [16–22].
placenta and maternal tissues such as breast and uterus Inadequate dietary diversity is also worldwide prob-
need improved energy requirements for tissue synthesis. lems. The study done in Laikipia; Kenya found 39.2% of
So dietary consumption has to meet needs of mother as pregnant women had low dietary diversity score [23].
well as the products of conception and enable the mother Another study conducted in Nepal showed that 64.2%
to lay down stores of nutrients required for the develop- of pregnant women had low dietary diversity score [24].
ment of the fetus [6]. Pregnant women need one extra In Ethiopia inadequate dietary diversity among preg-
meal every day in order to maintain good health and nant women is high. Different studies conducted across
strength to maintain their health and the health of the the country reported inadequate dietary diversity among
baby. So, pregnant women should choose a high quality, pregnant women which ranges from 38.8 to 69.6% [2, 17,
diverse diet, consume fresh foods and prepare nutrient 25–27].
rich meals [3]. Maternal nutritional status during pregnancy has
Women with good nutritional status during pregnancy significant consequences for health of both pregnant
are better able to cope with the stress of pregnancy and women and newborn babies. Improper nutrition intake
have good pregnancy outcome. Nutritional intervention is risk factor for low birth weight (LBW), intra uterine
during pregnancy would prevent poor maternal weight growth restriction (IUGR), and small for gestational age
gain and decrease the incidence of low birth weight and (SGA), preterm birth, stillbirths, miscarriages, growth
preterm birth by using locally accessible and afford- failure, increased risk of maternal and neonatal mortality,
able diets [7]. Balanced energy and protein intake dur- impaired cognitive development, sub-optimal produc-
ing pregnancy improves fetal growth and can minimize tivity in adults and reduced economic growth and other
the risk of stillbirth and small-for-gestational-age infants adverse outcomes during pregnancy and births [28].
[8]. Well-nourished mothers have healthier babies and Undernutrition and inadequate dietary diversity
a lower risk of maternal mortality and morbidity [9]. A among pregnant women are commonly associated with
woman who was able to consume the recommended increased demands during pregnancy and lactation,
infections, socio-demographic related factors, obstetric
Tafasa et al. BMC Nutrition (2023) 9:115 Page 3 of 12

(zα/2 )2 × p(1 − p) (zα/2 )2 × pq (1.96)2 × 0.449 × (1 − 0.449)

related factors, dietary consumption related factors and n=
d2
=n=
d2
=n=
(0.05)2
= 380

environmental related factors [13, 16, 18, 20, 22, 25,

29–33]. Where: n = required sample size.
Due to the intergenerational effect of malnutrition Z = z -value corresponding to a 95% level of
government of Ethiopia have been proposed initiatives significance = 1.96.
such as National Nutrition Strategy (NNS) and National d = margin of error (5%).
Nutrition Program (NNP) to tackle this problem [34] By considering 1.5 design effect and 10% non-response
Despite this magnitude of undernutrition and inad- rate the final sample size for study were 627.
equate dietary diversity is remained high among preg-
nant women. Even though nutritional status of pregnant Sampling technique and sampling procedures
women is important in breaking intergenerational effect First, ‘kebeles (small administrative unit in Ethiopia)’ in
of undernutrition, little is known specifically in our study the district were stratified into urban and rural areas.
area. Therefore, this study was aimed to assess undernu- Then, 9 (nine) ‘kebeles’ from 31 rural and 1(one) ‘kebeles’
trition, dietary diversity and associated factors in Ginde- from two urban ‘kebeles’ were selected by lottery meth-
beret district, Oromia, Ethiopia. ods. Then, pregnant women were selected from each
‘kebele’ by systematic random sampling techniques using
Methods pregnant women registration book found in health post
Study setting and period by considering a list of them as a sampling frame. Then,
The study was conducted in Gindeberet district. Ginde- k was calculated as follows (K = N/n = 2400/627 = 3.8 ≈ 4;
beret district is found at 192 km far from Addis Ababa to Where N = pregnant women in the selected kebele and
the west and bounded by Horo Guduru Wollega Zone to n = total sample size required). Then, from 1 to 4 random
the west, by Chobi district to the south, by Abuna Ginde- start were selected by lottery methods. The random start
beret district to the east and by Amhara regional state to 2 were selected, then every 4th pregnant women were
the north. There are 31 rural and urban ‘kebeles’ in the selected from pregnant women registers until fulfilling
district. Total population of the district is estimated to the required sample size Fig. 1.
be 147256, of which 128696 were rural and 18560 were
urban. The reproductive age group women (15–49 years) Operational and term definitions
were 32588. Total pregnant women were 5110 [35]. Undernutrition: MUAC less than 23 cm was an indica-
Before study area selection health managers and other tor of undernutrition and MUAC ≥ 23 cm was for normal
non-governmental stake holder recommendation were nutritional status [36, 37].
assessed. Depending on the health planners, non-govern- Pregnant women: The women identified as pregnant
mental organization and expert recommendation study by health extension workers and registered on pregnant
area was selected. The study was conducted from Octo- women registration book.
ber 10/2020 – November 10/2020. Drinking water sources: ‘Protected’ if pipe/hand pump/
protected spring and not otherwise [22].
Study Design and Population Dietary diversity Score (DDS): sum of food groups
A community-based cross-sectional study was con- eaten by pregnant women over 24 h preceding data col-
ducted. All pregnant women residing in the district lection [38].
were source population and all pregnant women resid- Inadequate dietary diversity: when pregnant women
ing in randomly selected kebele were considered as study consume less than five food groups.
populations. All pregnant women who have lived for six Adequate dietary diversity: When pregnant women
months and above in the study ‘kebele’ were included in consume five or more food groups [39].
the study. Critically ill and pregnant women with both
arm deformities were excluded from the study. Data collection tool and procedure
Data were collected by using pre-tested structured inter-
Sample size determination and sampling technique viewer administered questionnaires through face-to-face
Sample size determination interview and MUAC measuring tape. The question-
The sample size was calculated using single population naires contain socio-demographic factors, obstetric char-
proportion formula with the following assumptions: The acteristics of pregnant women, pregnant women dietary
44.9% prevalence was taken from a study done on under diversity and environmental factors. The questionnaires
nutrition and associated factors among pregnant women were adapted by reviewing different related literatures
in Gumay district, Jimma Zone, South West Ethiopia [36, 37, 40, 41].
[22] with 95% confidence interval the, margin of error The pregnant women dietary diversity was measured
(d = 5%). by a qualitative recall of all foods consumed by each
Tafasa et al. BMC Nutrition (2023) 9:115 Page 4 of 12

Fig. 1 Schematic presentation of sampling procedure for the study on dietary diversity, under nutrition and associated factors among pregnant women
in Gindeberet district, Oromia, Ethiopia, 2020 Key: PW = pregnant women, Kach = Kachise, Ke/S = Kere Sole, D/F = Dire Faji, Ki/S = Kiltu Senbeta, B/F = Beke
Feyina, K/B = Kelo Bedasa, H/A/D = Hula Aba Dadi, K/D = Kere Dobi, W/R = Wine Roge

pregnant women during the previous 24 h, which were The data collectors and supervisors were trained on how
validated tools prepared by FAO. It is a dichotomous to approach pregnant women and collect data for two
indicator of whether or not to feed ≥ 5 of 10 food groups days. Language experts translate questionnaires to local
in the last 24 h. This was categorized as inadequate language Afan Oromo and back to English to check con-
dietary diversity score (< 5 food groups) and adequate sistency. MUAC was measured two times if there is varia-
dietary diversity score (≥ 5 food groups). The ten lists of tion between measurements average was accepted.
food groups were used to assess the 24 h recall [starchy
staples, pulses, nuts/seeds, dairy, meat/poultry/fishes, Data Processing and Analysis
eggs, dark green leafy vegetables, other vitamin-A rich After data collection all questionnaires were checked for
fruits/vegetables, other fruits and other vegetables] [38]. consistence and completeness before undergoing further
Anthropometric measurements: trained data collectors analysis. Then data were coded and entered into Epi-info
measured a Mid Upper Arm Circumference (MUAC) version 7.2.2.6 and exported to Statistical Package for
according to standard. The MUAC of pregnant woman Social Science (SPSS) version 23 for further data analy-
was measured at mid-point between the tip of the shoul- sis. Descriptive statistics such as frequency, proportion,
der (olecranon process) and tip of the elbow (acromion mean and standard deviation were used to describe char-
process) of left arm. An adult MUAC tape that was non- acteristics of study participants. The presence of multi-
elastic and non-stretchable was used to take measure- collinearity between independent variables was checked
ments, after checking that the tape was applied without by using the variance inflation factor (VIF). However,
any clothing and with correct tension (not too loose or there was no multicollinearity problems. Bi-variable and
not too tight) [36, 37]. Data were collected by ten diploma multivariable logistic regression analysis were carried
nurses. out to identify factor associated with undernutrition and
inadequate dietary diversity. The model fitness for the
Data quality control variables was assessed by the Hosmer-Lemeshow good-
Data were collected by structured and pretested ques- ness of fit test statistics at p > 0.05, which shows fitness of
tionnaires. pre-test was done on 5% of sample size in the model. Odds ratios with their 95% confidence inter-
Damota kebele of the district other than selected kebele. vals were used to see strength of association between
Tafasa et al. BMC Nutrition (2023) 9:115 Page 5 of 12

independent and dependent variables. Variables with Obstetrics related factors

P < 0.05 were considered as significantly associated with About 153 (24.6%) of participants had their first preg-
undernutrition and dietary diversity score. nancy at teenage (< 20 years). With regard to gravidity
515 (82.9%) of study participants had less than five preg-
Results nancies before current and 66 (10.6%) of study partici-
Socio-demographic factors pants had never been pregnant before current pregnancy.
Six-hundred twenty-one pregnant women were included 322 (51.9%) and 299 (48.1%) of study participants had
in the study with response rate of 99%. The mean age of birth interval of greater and less than three years respec-
pregnant women were 30 (± 5.4) years, while age of par- tively. With regard to trimester of pregnancy, 373 (60.1%)
ticipants ranges from 18 to 45 years. Considering educa- and 186 (30.0%) of study participants were in second and
tional and occupational status of women, 163 (26.2%) of third trimester of pregnancy respectively. Majority of the
participants were able to read and write and 505 (81.3%) pregnant women had first ANC visit and second ANC
of participants were housewife. 494 (79.5%) of the preg- visit which were 146(23.5%) and 242(39%) respectively.
nant women were rural resident. 336(54.1%) and 285 About 45(7.2%) of the women had history of one abor-
(45.9%) of study participant had family size of ≥ 5 and < 5 tion Table 2.
children respectively Table 1.

Table 1 Socio-demographic factors among pregnant women in Gindeberet district, Oromia, Ethiopia, 2020 (n = 621)
Variables Categories Frequency Percent (%)
Age of participants < 20 113 18.2
20–35 399 64.3
> 35 109 17.6
Place of Residence Urban 127 20.5
Rural 494 79.5
Religion Orthodox 154 24.8
Protestant 459 73.9
Wakefeta 8 1.3
Ethnicity Oromo 616 99.2
Other 5 0.8
Marital status Married 540 87.0
Others** 81 13.0
Occupational status of the mother Farmer 18 2.9
House wife 453 72.9
Private employee 51 8.2
Merchant 43 6.9
Government employee 56 9.0
Occupational status of the husband Farmer 422 68.0
Private employee 49 7.8
Merchant 63 10.1
Government employee 87 14.0
Educational status of mother Informal education 213 34.3
Only primary education (1–8 grade) 224 36.1
Secondary education (9–12 grade) 132 21.3
College Diploma and above 52 8.4
Educational status of husband Informal education 187 30.1
Only primary education (1–8 grade) 134 21.6
Secondary education (9–12 grade) 194 31.2
College Diploma and above 106 17.1
Number of family size <5 285 45.9
≥5 336 54.1
Number of family size < 15 years Number of family who have no < 15 years children 67 10.8
Number of family who have < 15 years children 554 89.2
Number of family size > 65 years Number of family who have no > 65 years 529 85.2
Number of family who have > 65 years 92 14.8
** Amhara, Tigre
Tafasa et al. BMC Nutrition (2023) 9:115 Page 6 of 12

Table 2 Obstetrics characteristics among pregnant women in Gindeberet district, Oromia, Ethiopia, 2020 (n = 621)
Variables Categories Frequency Percent (%)
Gestational week First trimester (1–12) weeks 62 10.0
s trimester (13–27) weeks 373 60.1
Third trimester (28–40) weeks 186 30.0
Ever been pregnant before No 66 10.6
Yes 555 89.4
Gravidity <5 515 82.9
≥5 106 17.1
Parity 0 75 12.1
1–3 228 36.7
≥4 318 51.2
Year of inter-pregnancy interval <3 299 48.1
≥3 322 51.9
Attending ANC clinic No 97 15.6
Yes 524 84.4
ANC Visit First visit 146 23.5
s visit 242 39.0
Third visit 103 16.6
Fourth and above visit 31 5.9
Using of modern contraceptive before No 148 23.8
Yes 473 76.2
Age at first pregnancy < 20 years 153 24.6
21–30 years 464 74.7
> 30 years 4 0.6
Numbers of abortions made 0 572 92.1
1 45 7.2
≥2 4 0.6
Intention of pregnancy Planned 532 85.7
Unplanned 89 14.3

Dietary consumption related factors MUAC measurement among pregnant women was
Majority of respondents 503 (81%) and 118 (19%) ate 23.99 cm (± 1.62 SD) Fig. 2.
meals less than four and greater or equal to four times
a day respectively. More than half of respondents 377 Prevalence of Dietary Diversity
(60.7%) took two cups of coffee per day. Almost all of The mean dietary diversity score of study participant
respondents 559 (90.0%) did not consume alcohol dur- were 4.98 (± 1.26SD). Among the participant 345 (55.4%)
ing their pregnancy. 440(70.9%) of pregnant women and 276 (44.6%) had adequate and inadequate dietary
did not change their feeding style during pregnancy diversity score respectively. Regarding the consumed
and 153(24.6%) had eating problem during pregnancy. food groups by pregnant women in the previous 24 h,
Around 181(29.1%) of study participant had nutritional nearly all women 615 (99%) consumed starchy staples,
information Table 3. 560 (90.2%) of women consumed pulses, and 325 (52.3%)
consumed nuts and seeds. Moreover, 169 (27.2%) flesh
Environmental related factors foods were minimally consumed and other vegetables
556 (89.5%) of respondents had latrine. The majority of 154 (24.8%) were the least consumed food groups Fig. 3.
respondents 570 (91.8%) used drinking water from pro-
tected sources and about 355 (57.2%) of respondents Factors associated with undernutrition
washed their hands after latrine. Regarding hand wash- Bivariable and multivariable logistic regression analysis
ing during critical time 97.6%, 68% and 57.2% of women were carried out to identify factor associated with under-
washed their hand before eating, before food preparation nutrition. On multivariable analysis ANC visit, family
and after toilet respectively Table 4. size and source of drinking water were significantly asso-
ciated with undernutrition.
Prevalence of undernutrition This study showed that pregnant mothers who did not
Over all prevalence of undernutrition were 110 (17.7%) received antenatal care (ANC) during their pregnancy
among pregnant women in study area. The mean of were two times more likely [AOR = 2.32, 95% CI: (1.38,
Tafasa et al. BMC Nutrition (2023) 9:115 Page 7 of 12

Table 3 Dietary consumption related factors among pregnant women in Gindeberet district, Oromia, Ethiopia, 2020 (n = 621)
Variables Categories Frequency Percent (%)
Alcohol consumption Yes 62 10
No 559 90.0
Frequency of Coffee consumption None (Don’t take coffee at all) 44 7.1
Rarely (once a week or less) 12 1.9
Seldom (once in a day) 188 30.3
Often ( > = two cups per day) 377 60.7
Changing feeding style after No 440 70.9
Yes 181 29.1
Frequency of meals Less than four times per day 503 81
Four and above times per day 118 19
Having Nutritional information No 181 29.1
Yes 440 70.9
Sources of nutritional information Health provider 365 58.8
Family 2 0.3
Media 69 11.1
Friends 3 0.5
Having eating problem No 468 75.4
Yes 153 24.6
Type of eating problem Loss of appetite 54 8.7
Vomiting 57 9.2
Nausea 57 9.2
Heart burn 23 3.7

Table 4 Environmental related factors among pregnant women in Gindeberet district, Oromia, Ethiopia, 2020 (n = 621)
Variables Categories Frequency Percent (%)
Source of drinking water Protected sources 570 91.8
unprotected sources 51 8.2
Latrine possession No 65 10.5
Yes 556 89.5
Critical times of hand washing practice After latrine 355 57.2
Before food preparation 422 68.0
Before eating 606 97.6
After clean child feces 383 61.7
After handling garbage 612 98.6

Fig. 3 Dietary diversity among pregnant women in Gindeberet district,

Fig. 2 Prevalence of undernutrition among pregnant women in Gindebe-
Oromia, Ethiopia, 2020 (n = 621)
ret district, Oromia, Ethiopia, 2020 (n = 621)

3.90)] to be undernourished when compared to their

counterpart. Pregnant women who had ≥ 5 family size
[AOR: 2.93; 95% CI: (1.10, 7.79)] were three times more
likely to develop undernutrition when compared to study
Tafasa et al. BMC Nutrition (2023) 9:115 Page 8 of 12

participant who had < 5 family size. The pregnant women Discussion
used unprotected sources of water [AOR: 4.14, 95% CI: This study assessed prevalence of undernutrition, dietary
(1.63, 10.52)] were four times more likely to develop diversity and associated factors among pregnant women
undernutrition when compared to those who use pro- in Gindeberet district, Oromia, Ethiopia. In the cur-
tected source of water Table 5. rent study prevalence of undernutrition and inadequate
dietary diversity were 110 (17.7%) and 276 (44.6%)
Factors Associated with inadequate Dietary Diversity respectively. ANC visit, family size and source of drink-
Multivariable logistic regression analysis showed that ing water were significantly associated with undernutri-
place of residence, ANC visit and nutrition informa- tion, where as place of residence, ANC visit and nutrition
tion were significantly associated with dietary diversity information were significantly associated with inade-
score. This study revealed that pregnant women who live quate dietary diversity score.
in rural area were [AOR = 2.59, 95% CI: (1.66, 4.04)] 2.59 The study found that 110 (17.7%) of pregnant women
times more likely to have inadequate dietary diversity were undernourished. This is in line with study done in
than those who live in urban area. Pregnant women who Dire Dawa city administration, Ethiopia (18.2%), Gon-
did not visit ANC [AOR = 2.52, 95% CI: (1.58, 4.03)] were dar Town Northern Ethiopia (14.4%) and Laikipia, Kenya
2.52 times more likely to have inadequate dietary diver- (19.3%) [16, 23, 39]. Our finding was lower than the study
sity than those who visit ANC during their pregnancy. conducted in Syrian, Jordan (49.2%) [42]. The difference
Pregnant women who had nutrition information [AOR could be related to difference in socio-demographic char-
1.43; 95% CI: (1.10, 2.10)] were 1.43 times more likely to acteristics of study participants, it is also lower than the
have inadequate dietary diversity, as compared to those finding from Addis Ababa (24.6%), Shashemene district
who did not have nutrition information Table 6. west Arsi zone (34%), Gumay district Jimma zone (44.4%)
[20, 22, 43]. These differences may be due to variations
in supply and access of dietary diversity and nutrition

Table 5 Bi-variable and multivariable logistic regression analysis of factors associated with undernutrition among pregnant women in
Gindeberet district, Oromia, Ethiopia, 2020 (n = 621)
Variables Undernutrition COR (95% CI) AOR (95% CI) P-value
Yes No
Education of mothers Informal education 41(20%) 156(80%) 0.25(0.06, 0.95) 0.526(0.07, 3.85) 0.527
Primary school 36(16.1%) 188(83.9%) 0.32(0.09, 1.08) 0.49(0.08, 3.21) 0.458
Secondary school 22(16.7%) 110(83.3%) 0.31(0.087, 1.07) 0.59(0.94, 3.68) 0.570
Diploma & above 11(16.18%) 57(83.82%) 1 1
Occupation of Farmer 11(50%) 11(50%) 4.60(1.56, 13.54) 1.45(0.11, 20.06) 0.781
mothers Housewife 67(14.9%) 382(85.1%) 0.81(0.39, 1.68) 2.21(0.26, 18.56) 0.465
Private employee 16(30.8%) 35(69.2%) 2.04(0.69, 6.00) 11.80(1.20, 53.84) 0.134
Merchant 6(14%) 37(86%) 0.75(0.25, 0.24) 1.63(0.17, 15.86) 0.676
Gov’t employee 10(17.9%) 46(82.1%) 1 1
Residence Urban 11(8.7%) 116 (91.3%) 1 1
Rural 99(20%) 395(80%) 2.64(1.371, 5.09) 1.30(0.421, 4.02) 0.648
Source of drinking Protected 95(16.7%) 475(83.3%) 1 1
water Unprotected 15(29.4%) 36(70.6%) 2.08(1.10, 3.96) 4.14(1.63, 10.52) 0.003*
ANC visit Yes 444(84.7%) 80(15.3%) 1 1
No 67(69.1%) 30(30.9%) 2.49(1.519, 4.07) 2.32(1.38, 3.90) 0.001*
Gravidity ≤5 45(15.5%) 245(84.5%) 1
>5 65(19.6%) 266(80.4%) 0.75(0.49, 1.14) 0.73(0.38, 1.43) 0.367
Gestational age First trimester 15(24.2%) 47(75.8%) 1 1
s trimester 65(17.4%) 308(82.6%) 0.66(0.35, 1.25) 0.633(0.32, 1.26) 0.193
Third trimester 30(16.1%) 156(83.9%) 0.60(0.30, 1.21) 0.67(0.32, 1.43) 0.305
Having nutrition Yes 66(15.0%) 374(85.0%) 1 1
information No 44(24.3%) 137(75.7%) 1.82(1.19, 2.79) 1.280(0.77, 2.13) 0.341
Family size >5 69(20.5%) 267(79.5%) 1.54(1.10, 2.35) 2.93(1.10, 7.79) 0.031*
≤5 41(14.5%) 244 (85.5%) 1
Alcohol consumption Yes 57(91.9%) 5(8.1%) 0.38(0.15, 0.97) 2.74(1.05, 7.17) 0.054
No 454(81.2%) 105(18.8%) 1 1
*Significant at p-value < 0.05, COR = Crude Odds Ratio, AOR = Adjusted odds ratio, C.I.=Confidence Interval
Tafasa et al. BMC Nutrition (2023) 9:115 Page 9 of 12

Table 6 Bi-variable and multivariable logistic regression analysis showing factors associated with dietary diversity among pregnant
women in Gindeberet district, Oromia, Ethiopia, 2020 (n = 621)
Variables Dietary diversity COR (95% CI) AOR (95% CI) P-value
Adequate Inadequate
Education of Informal education 115(56%) 98(44%) 3.30(1.36, 8.02) 0.56 (0.12, 2.55) 0.452
mothers Primary school 116(51.8%) 108(48.2%) 3.91(1.87, 8.18) 0.65 (0.16, 2.65) 0.543
Secondary school 72(54.5%) 60(45.5%) 3.50(1.62, 7.56) 0.70 (0.18, 2.73) 0.604
Diploma & above 42(80.8%) 10(19.2%) 1 1
Occupation of Farmer 9(40.9%) 13(59.1%) 3.61(1.29, 10.10) 2.87(0.75, 11.01) 0.125
mothers Housewife 244(54.3%) 205(45.7%) 2.10(1.14,3.86) 2.28(0.89, 5.83) 0.085
Private employee 29(61.5%) 22(38.5%) 1.56(0.59, 4.16) 0.79(0.13, 4.82) 0.804
Merchant 23(53.5%) 20(46.5%) 2.17(0.94, 5.00) 2.55(0.88, 7.40) 0.085
Gov’t employee 40(71.4%) 16(28.6%) 1 1
Place of Urban 94(74%) 33(26%) 1 1
residence Rural 251(50.8%) 243(49.2%) 2.76(1.79, 4.26) 2.59(1.66, 4.04) 0.001*
Source of drink- Protected sources 311(54.6%) 259(45.4%) 1 1
ing water Unprotected sources 34(66.7%) 17(33.3%) 0.60(0.33, 1.10) 0.44(0.24, 0.83) 0.125
ANC visit Yes 310(59.2%) 214(40.8%) 1 1
No 35(36.1%) (6263.9%) 2.57(1.64,4.02) 2.52(1.58, 4.03) 0.001*
Having nutrition Yes 267(60.7%) 173(39.3%) 1 1
information No 78(43.1%) 103(56.9%) 2.04(1.44, 2.89) 1.43(1.10, 2.10) 0.001*
Consumption of Yes 46(74.2%) 16(25.8%) 2.50(1.38, 4.52) 2.32(1.24, 4.33) 0.065
alcohol No 299(53.5%) 260(46.5%) 1
Vomiting 1. Yes 27(47.4%) 30(52.6%) 0.70(0.40, 1.20) 0.76(0.42, 1.38) 0.363
2. No 318(56.4%) 246(43.6%) 1 1
Gravidity 1. < 5 288(55.9%) 227(44.1%) 1 1 0.44
2. ≥ 5 57(53.8%) 49(46.2%) 0.84(0.53, 0.31)
*Significant at p-value < 0.05, COR = crude odds ratio, AOR = Adjusted odds ratio, C.I = Confidence Interval

information, sample size difference and study time zone to mothers who visit ANC. This finding was in line with
variation. study conducted in Shashemene district west Arsi zone
Our study found 276 (44.6%) of pregnant women had and Rayitu district Bale zone of Oromia, Ethiopia [20,
inadequate dietary diversity. This is higher than the study 26]. This might be due to the fact that pregnant women
done in Laikipia, Kenya (39.2%), Ghana (14.5%), Tigray, who visit ANC clinic have more information on proper
Ethiopia (38.8%), North East Ethiopia (31.4%), Shasha- consumption of diet during their pregnancy.
mane, Ethiopia (25.4%) [23, 25, 44–46]. The possible Pregnant women who had family size greater than five
difference might be related to difference in time zone were more likely to be undernourished than pregnant
variation of study and sample size difference. Further- women who had family size equal or less than five. This
more, this study contains 10 food groups with two cat- finding was supported by a study conducted in Madagas-
egories whereas study conducted in Ghana contained car and Ilu Aba Bor zone, southwest Ethiopia [29, 47].
eleven food groups. Additionally, geographical location, This might be due to the fact that women with large fam-
seasonal variability and socio-cultural factors may result ily sizes share meals (foods) with other family members,
in difference. thus, pregnant women might not get enough foods. As a
Our finding on inadequate dietary diversity was lower result, they prone to develop undernutrition.
than study done in Gojjam, Northwest Ethiopia (55%), Our finding also showed that pregnant women those
Dire Dawa town, Ethiopia (57%), Bale, Oromia, Ethiopia used unprotected sources of water were 4 times more
(54.5%) [17, 26, 27]. The difference might be due to study likely to be undernourished than those mothers who used
period, variation of the food group involved in assessing protected sources of water. The possible reason could be
dietary diversity, as study conducted in Bale, Oromia, explained as pregnant women use non-potable water,
Ethiopia contained nine food groups. Also, variation in they became susceptible to infectious diseases which may
geographical location and agricultural practice may be disturb digestive system and subsequently leads to mal-
making the difference. absorption. This leads to the fact that women with mal-
The study showed that, pregnant women who did not absorption may develop undernutrition.
visit antenatal care (ANC) during their pregnancy were 2 Pregnant women who lived in rural were two times
times more likely to be undernourished when compared more likely to have inadequate dietary diversity when
Tafasa et al. BMC Nutrition (2023) 9:115 Page 10 of 12

compared to their counterparts. This finding was con- •  To practice diversified meal from locally available
sistent with study conducted in Fitche, Oromia, Ethiopia source.
[48] this could be related to lifestyle difference between
Abbreviations
rural and urban resident and easy accessibility of differ- CI Confidence Interval
ent food groups by urban residents. DDS Dietary Diversity Score
Pregnant women who had not nutrition information EDHS Ethiopian Demographic and Health Survey
FAO Food and Agriculture Organization
during their pregnancy were 1.43 times more likely to IUGR Intra Uterine Growth Restriction
have inadequate dietary diversity when compared to MUAC Mid-Upper-Arm-Circumstance
those who had nutrition information. This is also sup- SD Standard Deviation
SGA Small for Gestation Age
ported by study conducted in North East Ethiopia, west SPSS Statistical Package for Social Science
Shoa, Oromia, Ethiopia and Addis Ababa, Ethiopia [2, 49, WHO World Health Organization
50]. This may be due to the fact that those who get infor-
Acknowledgements
mation about nutrition had better knowledge and under- Our appreciation goes to the Gindeberet district administration office and
standing to practice diversified diet than those who did selected kebele administrators for facilitating the process of data collection.
not have nutrition information. We are also thankful to the study participants, data collectors, and supervisors
for their contribution to this study.
Pregnant women who did not visit ANC clinic were
two times more likely to have inadequate dietary diver- Authors’ contributions
sity when compared to those who visited the clinic. This FDG: designed and participated in data collection, conducted the data
analysis and interpretation, SMT: writes the original manuscript, SMT, JD and
could be due to the fact that ANC visits offer a contact ND: advised on the data analysis, interpretation and report writing. All authors
point to get nutritional counsel for pregnant women as critically reviewed and approved the final version of the manuscript.
well as during ANC visit women may get information on
Funding
different locally available food source as well as advised No funding sources.
on importance of diversified meal during pregnancy.
Data Availability
The data and all supporting materials used in the preparation of this
Conclusions manuscript are freely available from the corresponding author at reasonable
Magnitude of undernutrition and inadequate dietary request.
diversity among pregnant women were high in study
area. Source of drinking water, ANC visit and family Declarations
size were significantly associated with pregnant women
Ethics approval and consent to participate
undernutrition and place of residence, ANC visit and All methods of this study were carried out under the Declaration of Helsinki’s
nutrition information were significantly associated with ethical principle for medical research involving human subjects. Ethical
inadequate dietary diversity. Therefore, pregnant women, approval to conduct this study was obtained from the ethical review
committee of Ambo University, College of Medicine and Health Science
government, non-governmental organization and other (Ref. No: PGC/07/2020). An official letter was sent to Gindeberet district
stake holders should focus on importance of ANC visit administration. Permission letter was delivered to selected kebele in the
and adequate dietary diversity to improve nutritional sta- district. Written informed consent were obtained from study participant.
Confidentiality and privacy of the information was maintained. The
tus of pregnant women. participants were informed that participation is fully voluntary.

Recommendations Consent for publication

Not applicable.
Based on the finding the following recommendation was
forwarded. Competing interests
The authors declare no competing interests.

For woreda health office and health extension workers Author details
•  To give health education on importance of ANC visit 1
Department of Public Health, Institute of Health Sciences, Wallaga
to improve nutritional status of women. University, Nekemte, Ethiopia
2
Department of Public Health, College of Medicine & Health Sciences,
•  To provide counselling on importance of child Ambo University, Ambo, Ethiopia
spacing to improve nutritional status of pregnant
women. Received: 17 September 2022 / Accepted: 29 September 2023
•  To educate pregnant women on diversified meal,
early initiation of ANC and clean source of water
during pregnant women conference.

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center, Addis Ababa, Ethiopia. 2020. Springer Nature remains neutral with regard to jurisdictional claims in
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