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Dietary practice during pregnancy and associated factors among pregnant women in Farta district, South Gondar Zone, Northwest Ethiopia, 2021

Open AccessPublished:February 02, 2022DOI:https://doi.org/10.1016/j.cegh.2022.100968

      Abstract

      Introduction

      Maternal undernutrition in low and middle-income countries is an underlining cause for more than 3.5 million deaths and disabilities. Maternal malnutrition during pregnancy increases the risk of gestational anemia, hypertension, miscarriages, and fetal deaths during pregnancy, preterm delivery, and maternal mortality.

      Method

      A community-based cross-sectional study was conducted from March 1 to April 1, 2021. A total of 615 pregnant women participated in the study. All eligible pregnant women were identified through a house-to-house visit with the help of health extension workers. The cluster sampling method was used to select the study participant. A pre-tested structured interviewer administered questioner was used. Filled questionnaires were checked, coded, and entered into EPI data version 4.6 and exported to SPSS version 23 software. A bivariate and multivariable logistic regression model was fitted to identify associated factors. An adjusted odds ratio with a 95% confidence interval was computed to determine the level of significance.

      Result

      This study has shown that only 27.2% of pregnant mothers had good dietary practices. In multivariable logistic regression analysis; average monthly income (≥3500 ETB) [AOR: 12.03 (95% CI: 2.83,51.17)], family size (1–3) [AOR: 5.66 (95% CI: 2.03,15.83)] & (4–6) [AOR: 2.84 (95% CI: 1.05, 7.67)], educational status (formal education) [AOR:7.61 (95% CI: 3.64,15.91)] and dietary knowledge [AOR: 1.99 (95% CI: 1.27, 3.12)] were the factors significantly associated with good dietary practices.

      Conclusion

      In this study, more than a quarter of pregnant mothers had good dietary practice. Educational status of the participant, dietary knowledge, monthly income, and family size was significantly associated with dietary practices of pregnant women. To improve dietary practice of pregnant women; enhance knowledge on nutrition through nutrition education and decrease family size by regular family planning counseling in the continuum of maternal care.

      Keywords

      Abbreviations:

      ANC (antenatal care), AOR (adjusted odds ratio), CI (confidence interval), BSC (Bachelor of Science), COR (Crud Odds Ratio), EDHS (Ethiopian Demographic Health Survey), ETB (Ethiopian Birr), SDGs (Sustainable Development Goals), SPSS (Statistical Package for Social Science)

      1. Introduction

      Pregnancy is a period when nutrient intake is extremely important to meet the mother's usual requirements, needs of the growing fetus, and to store nutrients required for fetal development and lactations.
      • Williamson C.
      Nutrition in pregnancy.
      So, better nutrition is related to improved infant, child, and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases (such as diabetes and cardiovascular disease), and longevity.
      • WHO
      Nutrition.
      Malnutrition in every form presents a significant and complex problem across the world.
      • Triunfo S.
      • Lanzone A.
      Impact of maternal under nutrition on obstetric outcomes.
      ,
      • Dukhi N.
      Global Prevalence of Malnutrition: Evidence from Literature.
      Today the world faces a double burden of malnutrition that includes both undernutrition and overweight, especially in low-and middle-income countries.
      • WHO
      Nutrition.
      Maternal undernutrition in low and middle-income countries causes more than 3.5 million maternal and under-five children to death and permanently disabled by the physical and mental effects of a poor dietary intake in the earliest months of life.
      • Black R.
      • Hopkins Bloomberg J.
      The lancet series on maternal and child Undernutrition, executive summary.
      It also contributes to 800,000 neonatal deaths annually and stunting, wasting, and micronutrient deficiencies are estimated to cause nearly 3.1 million child deaths annually.
      • Bhutta Z.A.
      • Das J.K.
      • Rizvi A.
      • et al.
      Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?.
      Maintaining good nutrition and a healthy diet during pregnancy is essential for the health of both the mother and her child.
      • Anyasor Chiamaka Ogechi1* O.O.H.
      Factors influencing the nutritional practice of pregnant women living in a semi-urban region of ogun state, Nigeria.
      Maternal malnutrition during pregnancy increases the risk of gestational anemia, obstructed labor, postpartum hemorrhage, preeclampsia, miscarriages, and fetal deaths during pregnancy, preterm delivery, and maternal mortality.
      • Williamson C.
      Nutrition in pregnancy.
      ,
      • I K
      Determinants of Adverse Maternal and Feotal Outcomes Among Women in Kamwenge District, South Western Uganda.
      For the newborn, it can cause low birth weight, stillbirth, birth asphyxia, preterm birth, neonatal death, and fetal intrauterine growth retardation that may have long-life consequences on newborn development.
      • Triunfo S.
      • Lanzone A.
      Impact of maternal under nutrition on obstetric outcomes.
      ,
      • I K
      Determinants of Adverse Maternal and Feotal Outcomes Among Women in Kamwenge District, South Western Uganda.
      Good maternal nutrition before, during, and between pregnancies could avoid health problems like: risk of fetal and infant mortality, intrauterine growth retardation, low birth weight, premature births, birth defects, cretinism, poor brain development, and risk of infection.
      • Nnam N.M.
      Improving maternal nutrition for better pregnancy outcomes.
      Ethiopia is one of the developing nations with a high burden of maternal and child undernutrition. A systemic review and meta-analysis which was done from 2008 up to 2018, from African pregnant women 23.5% were malnourished, the pooled prevalence of malnutrition was higher in Ethiopia that was 26%.
      • Desyibelew H.D.
      • Dadi A.F.
      Burden and determinants of malnutrition among pregnant women in Africa: a systematic review and meta-analysis.
      The 2018 Ethiopian demographic and health survey (EDHS) report indicates that 22% of women's reproductive ages were undernourished, while 8% are overweight or obese and 29% were anemic in addition to the prevalence of undernutrition in the Amhara region is 22.9%.
      • International ICCSAEaI
      Ethiopia Demographic and Health Survey.
      A study in the rural parts of Ethiopia showed that; poor dietary practice during pregnancy increases the risk of maternal anemia by twofold, low birth weight by 4–7 fold, and preterm delivery by 2 fold when compared with good dietary practice.
      • Taddese A.
      • Zerfu M.U.
      • Baye Kaleab
      Dietary Diversity during Pregnancy Is Associated with Reduced Risk of Maternal Anemia, Preterm Delivery, and Low Birth Weight in a Prospective Cohort Study in Rural Ethiopia.
      To relieve the burden of undernutrition; the government of Ethiopia has placed programs and initiatives with set targets and the national nutrition program was also launched in 2008.
      • GotFDR E.
      National Nutrition Programme June 2013-June 2015. Addis Ababa: Government of Federal Democratic Republic of Ethiopia.
      However, maternal undernutrition remains a major public health concern.
      Evidences might be important to support the progress of interventions being taken by the country.
      Moreover, as far as our knowledge there are limited studies regarding dietary practice and associated factors during pregnancy in a rural part of Ethiopia, especially in the Amhara region. So, this study tries to provide directions for both governmental and non-governmental bodies about dietary practices during pregnancy.

      2. Methods and materials

      2.1 Study design, setting, and period

      A community-based cross-sectional study design was conducted from March 1 to April 1, 2021, in Farta district, Northwest Ethiopia. Farta district is found in the South Gondar Zone. It is bordered on the South by Misrak Este, on the West by Fogera, on the North by Ebenat, and on the East by Lay Gayint. The district has 33 kebeles (small administrative units in Ethiopia), 7 health centers, and 54 health posts. A total of 56,579 reproductive-age women are found in the area.

      2.2 Study population

      All pregnant women who live in the Farta district were the source population. All pregnant women who live in the Farta district in selected clusters were the study population.

      2.3 Inclusion and exclusion criteria

      All pregnant women who lived for at least six months in the study area and were healthy (self-reported) were included. Pregnant women with confirmed diabetes mellitus at the time of data collection were excluded.

      2.4 Sample size and sampling techniques

      The sample size was calculated using the single population proportion formula. Based on previous research findings on the prevalence of good dietary practice during pregnancy 39.3%,
      • Nana A.
      • Zema T.
      Dietary practices and associated factors during pregnancy in northwestern Ethiopia.
      using a margin of error (0.05), at 95% confidence level (Z ᾳ/2 = 1.96);
      n=(Za2)2*P(1P)d2


      n=(1.96)2*0.39(10.39)(0.05)2


      n=360


      By considering 10% non-response rate and 1.5 designing effect the final sample size was 609.
      Among thirty-three kebeles (small administrative units in Ethiopia); six kebeles (Mahider-Mariam, Gena-Mechawecha, Gassay, Qusquam, Debre-Eyesus, and Hiruy–Abaregay) were selected as a cluster by simple random sampling method. All pregnant mothers in the selected clusters were included in the study.

      2.5 Operational definition

      Good dietary practice: There are fifteen dietary assessing questions. A woman has good dietary practice if she scored at least 75% of dietary practice assessing questions.
      • Demilew Y.M.
      • Alene G.D.
      • Belachew T.
      Effect of guided counseling on dietary practices of pregnant women in West Gojjam Zone, Ethiopia.
      Poor dietary practice: There are fifteen dietary assessing questions A woman has poor dietary practice if she scored less than 75% of dietary practice assessing questions.
      • Demilew Y.M.
      • Alene G.D.
      • Belachew T.
      Effect of guided counseling on dietary practices of pregnant women in West Gojjam Zone, Ethiopia.
      Good knowledge: A woman has good nutritional knowledge if she scored at least 75% of nutritional knowledge assessing questions.
      • Daba G.
      • Beyene F.
      • Garoma W.
      • Fekadu H.
      Assessment of nutritional practices of pregnant mothers on maternal nutrition and associated factors in Guto Gida Woreda, east Wollega zone, Ethiopia.
      Poor knowledge: A woman has poor nutritional knowledge if she scored less than 75% of nutritional knowledge assessing questions.
      • Daba G.
      • Beyene F.
      • Garoma W.
      • Fekadu H.
      Assessment of nutritional practices of pregnant mothers on maternal nutrition and associated factors in Guto Gida Woreda, east Wollega zone, Ethiopia.

      2.6 Data collection tools and procedures

      The data was collected using a structured and interviewer-administered questionnaire. The questionnaire had four parts. These were socio-demographic, pregnancy and obstetrics, knowledge of nutrition, and nutritional practice. The questionnaires were adapted from different literatures. The data collection tool was prepared in English and then translated into the local language (Amharic) and then re-translated back to English to keep consistency. Data collection was done by three BSc Midwives as collectors and two MSc Midwives as a supervisor. All responses to closed and open questions were written down manually by the interviewers. The supervisors assessed the consistency and completeness of data on daily basis.

      2.7 Data quality assurance

      One-day training was given for data collectors and supervisors about the purpose of the study, data collection tools, collection techniques, and ethical issues during the selection of participants and collection of the data. The tool was pretested on 5% of the actual sample size at Fogera district. During data collection, each data collector was supervised for any difficulties and direction and the necessary correction was provided. The collected data was cheeked for its completeness every day before the following day of data collection by supervisors and the principal investigator and corrective measures were taken according to the finding during supervision.

      2.8 Data processing and analysis

      Data were entered into EPI data version 4.6 and exported to SPSS version 23 for analysis. Variables that have an independent association with the dietary practice were identified based on AOR, with 95% CI and p-value less than 0.05. Descriptive statistics like percentage, mean and standard deviation were used for the presentation of data.

      3. Results

      3.1 Socio-demographic characteristics of study participants

      In this study, a total of 615 pregnant mothers have participated. The mean age with SD of pregnant mothers was 28.05 ± 5.23 and the range of 18–42. Ninety-eight percent of the participants were married. The majority (98.7%) were orthodox Christian. Six hundred seven (99.5%) were in the Amhara ethnic groups. More than half (66.7%) of the participants were unable to read and write. A majority (92.2%) of the study participants were housewives. Concerning monthly income, about 32.7% of the participants earn less than 2000 Ethiopian birr. Sixty-nine percent of the participants have a family size greater than four. Most (91.9%) of the participants' residence was rural (Table 1).
      Table 1Socio-demographic characteristics of pregnant mothers in Farta district, South Gondar Zone, Northwest Ethiopia, 2021 (n = 615).
      VariablesFrequencyPercent (%)
      Age≤19142.3
      20–2939664.4
      ≥3020533.3
      Marital statusSingle91.5
      Married60297.8
      Separated40.7
      ReligionOrthodox60798.7
      Muslim81.3
      EthnicityAmhara61299.5
      Oromo30.5
      Educational statusunable to read and write41066.7
      able to read and write13922.6
      formal education6610.7
      Husband's educational statusunable to read and write39664.4
      able to read and write14623.7
      Formal education7311.9
      OccupationHouse wife56992.5
      Farmer315.0
      Government employee71.1
      Other
      Laborer and student.
      81.4
      Husband's occupationFarmer56491.7
      Government employee152.4
      Other
      Self-employed and laborer.
      365.9
      ResidenceUrban508.1
      Rural56591.9
      Monthly income<200020132.7
      2000-350039363.9
      ≥3500213.4
      Family size1–318530.1
      4–636258.9
      ≥76811.1
      a Laborer and student.
      b Self-employed and laborer.

      3.2 Obstetric and pregnancy-related characteristics of pregnant mothers

      Concerning obstetric and pregnancy-related characteristics, more than half (51.5%) of the pregnant mothers were in the third trimester, followed by 38% of pregnant mothers were at the second trimester. Concerning women's previous pregnancies, 65.5% of pregnant mothers had 3-5 previous pregnancies. A 66.6% of the participants had a party of three to five. Eighty-seven percent of women had 3–5 years inter-pregnancy interval. Regarding history of child death, 4.8% of pregnant mothers had child death history and from this 25.9% was neonatal death. Regarding the place of delivery of the last baby, 89.8% of participants gave birth at health institutions (Table 2).
      Table 2Obstetric and pregnancy related characteristics of pregnant mothers in Farta district, South Gondar Zone, Northwest Ethiopia, 2021 (n = 615).
      VariablesfrequencyPercent (%)
      GravidityYes55790.6
      No589.4
      Number of gravidity0–216629.8
      3–536665.7
      ≥5254.5
      ParityYes55790.6
      No589.4
      Number of parity<216429.4
      3–537166.6
      ≥5223.9
      Pregnancy interval<2417.4
      3–548587.1
      ≥5315.6
      Child deathYes274.8
      No53095.2
      Time of child deathWith in1 month725.9
      1 month-1 year1763.0
      >1 year311.1
      Place of deliveryHome5710.2
      Health institution50089.8
      Number of live birth<434762.3
      ≥421037.7
      AbortionYes356.3
      No52293.7
      Number of abortion≤23497.1
      ≥312.9
      History of illnessYes487.8
      No56792.2
      ANCYes58394.8
      No325.2
      Number of ANC17212.3
      222438.4
      320835.7
      47913.6
      Initiation time of ANCFirst trimester7512.9
      Second trimester50486.4
      Third trimester40.7
      Stage of pregnancyFirst trimester6410.5
      Second trimester23438.0
      Third trimester31751.5

      3.3 Dietary knowledge of the pregnant mothers

      In this study, 188 (30.6%) of the study participants had good dietary knowledge and 427 (69.4%) had poor dietary knowledge. Except, for the knowledge about carbohydrates source foods (56.1%), iodine source foods (27.8%), vitamin A source foods (51.4%), and iron source foods (49.6%), other knowledge variables scored ≥75% indicating good dietary knowledge (Table 3).
      Table 3Dietary knowledge of pregnant mothers in Farta district, South Gondar Zone, Northwest Ethiopia, 2021 (n = 615).
      VariablesFrequencyPercent (%)
      Have you heard about nutrition?Yes60498.2
      No111.8
      Where do you heard?Mass media91.5
      School619.9
      Health institution51784.1
      Others172.8
      Is a balanced diet important during pregnancy?Yes152.4
      No60097.6
      Do you know food is important for body's heat and energy of the body?Yes142.3
      No60197.7
      Do you know food is important for proper functioning of the body?Yes132.1
      No60297.9
      Do you know food is important for infection fighting?Yes52284.9
      No9315.1
      Do you know about the main food groups of balanced diet?Yes101.6
      No60598.4
      Do you know about the main food source of protein?Yes8513.8
      No53086.2
      Do you know the main food source of carbohydrates?Yes22937.2
      No38662.8
      Do you know the main food source of vitamin A?Yes31651.4
      No29948.6
      Do you know about the main food source of iodineYes17127.8
      No44472.2
      Do you know the main food source of iron?Yes30549.6
      No31050.4

      3.4 Dietary practices of the pregnant mothers

      In this study 86% of pregnant mother avoid certain foods, of which 90.6% avoids food due to personal dislike. The majority (77.2%) of the participants skips their usual meal and the most commonly skipped meal was breakfast. Of all 104 (16.9%) who took an additional meal; 67 (77.4%) of them took one additional meal. Concerning consumption of macro and micronutrient source foods 77.4% and 35.1% were consuming, protein and vitamin-rich foods like fresh vegetables respectively. Most (90.4%) of pregnant mothers were using non-iodized salt. Ninety-seven percent of pregnant mothers are supplemented with iron. Generally, the majority (72.8%) of the study participants had poor dietary practices and the remaining 27.2% of the study participants had good dietary practices (Table 4).
      Table 4Dietary practice of pregnant mothers in Farta district, South Gondar Zone, Northwest Ethiopia, 2021 (n = 615).
      VariablesFrequencyPercent (%)
      Do you crave food not normally consumed?No9415.3
      Yes52184.7
      Do you avoid any food items during current pregnancy?No52986.0
      Yes8614.0
      Reason to avoid food during pregnancyPersonal dislike7790.6
      Religion11.2
      Makes fetus big78.2
      Do you Follow specific dietary regimen?No14523.6
      Yes47076.4
      How many times you eat per day?≤2254
      3–454688.8
      ≥5447.2
      Do you have a habit of eating snack?No41767.8
      Yes19832.2
      Do you skip any meal during current pregnancy?No14022.8
      Yes47577.2
      Which meal do you skip?break fast7854.2
      Lunch5638.9
      Dinner106.9
      Do you eat additional food?No51183.1
      Yes10416.9
      Number of additional foods16577.4
      21922.6
      Do you eat protein rich foods during current pregnancy?No42869.6
      Yes18730.4
      Do you have a habit of eating fresh fruits and vegetable?No34556.1
      Yes27043.9
      Which type of salt you use in your food?Iodized salt55490.1
      Not iodized salt619.9
      When you add salt in cooking food?At the end of cooking437.0
      At the middle of cooking56692.0
      At the beginning of cooking50.8
      Cook without any salt10.2
      Do you drink adequate amount of fluid per day?No243.9
      Yes59196.1
      Do you drink coffee or tea?No22336.3
      Yes39263.7
      How much do you drink coffee or tea per day?<3 cups7118.1
      ≥3 cups32281.9
      Do you have iron supplement during current pregnancy?No193.1
      Yes59696.9
      Did you drink alcohol?No487.8
      Yes56792.2

      3.5 Factors associated with dietary practices of pregnant women

      On bivariate analysis, the factors found to be significantly associated with good dietary practice were: educational status of mothers, husband's educational status, average monthly income, family size, residence, and nutritional knowledge.
      From the variables found to be significant in the bivariate analysis; average monthly income (≥3500 ETB) [AOR: 12.03 (95% CI: I2.83,51.17)], family size (1–3) [AOR: 5.66 (95% CI: 2.03,15.83)] & (4–6) [AOR: 2.84 (95% CI: 1.05, 7.67)], educational status (formal education) [AOR:7.61 (95% CI: 3.64, 15.91)] and dietary knowledge [AOR: 1.99 (95% CI: 1.27, 3.12)] were found to be significantly associated with good dietary practices in multivariable logistic regression analysis (Table 5).
      Table 5Bivariate and multivariable logistic regression analysis of factors associated with dietary practice of pregnant mothers in Farta district, South Gondar Zone, Northwest Ethiopia, 2021 (n = 615).
      VariablesDietary practiceCOR with 95%CIAOR with 95%CI
      GoodPoor
      EducationUnable to read and write7333711
      Able to read and write41981.93 (1.24, 3.01)**1.31 (0.8,2.15)
      Formal education531318.82 (9.75, 36.32)**7.61 (3.64,15.91)**
      Husband's educationUnable to read and write6832711
      Able to read and write461062.09 (1.35, 3.22)**2.11 (0.79, 5.67)
      Formal education531516.99 (9.05, 31.9)**2.05 (0.33, 12.86)
      Monthly income<20005914211
      2000–3500913020.73 (0.49,1.06)*0.7 (0.45,1.11)
      ≥350017410.23 (3.30, 31.69)**12.03 (2.83, 51.17)**
      ResidenceRural12843711
      Urban391112.1 (6.03, 24.32)**1.53 (0.59, 3.99)
      Family size1–387987.74 (3.36, 17,81)**5.66 (2.03,15.83)**
      4–6732892.2 (0.97, 5.01)2.84 (1.05, 7.67)*
      ≥776111
      Nutritional knowledgePoor7033911
      Good971094.310 (2.960–6.274)**1.99 (1.27, 3.12)**
      *Significant at p < 0.05, **Significant at p < 0.01.

      4. Discussion

      Maternal undernutrition remains a critical public health problem; which causes a burden of underweight, anemia, and micronutrient deficiencies across the globe. So this community-based cross-sectional study had tried to determine the prevalence of dietary practice among pregnant mothers who live in Farta district.
      The study revealed that only 27.2% with 95% CI (23.8, 30.7) of pregnant mothers had good dietary practices. This figure was in-line with a study conducted in, Ambo district, West Shoa Zone, Oromia, Ethiopia,
      • Tolera B.
      • Mideksa S.
      • Dida N.
      Assessment of dietary practice and associated factors among pregnant mother in Ambo District, West Shoa, Oromia, Ethiopia, 2018.
      However, the current study is higher than the study conducted in West Gojjam Zone, Northwest Ethiopia 19.9%.
      • Demilew Y.M.
      • Alene G.D.
      • Belachew T.
      Dietary practices and associated factors among pregnant women in West Gojjam Zone, Northwest Ethiopia.
      The discrepancy might be attributable to differences in the study period. In addition in this study majority (94.8%) of the respondents had at least one antenatal care visit; this may create a chance for pregnant mothers to gain information about nutritional practice.
      The current study is lower than the study findings in Gondar Town North West, Ethiopia, 40.1%,
      • Alemayehu M.S.
      • Tesema E.M.
      Dietary practice and associated factors among pregnant women in Gondar town north west, Ethiopia, 2014.
      Bahir Dar city Northwestern Ethiopia 39.3%,
      • Nana A.
      • Zema T.
      Dietary practices and associated factors during pregnancy in northwestern Ethiopia.
      and Dessie town which found 45.2%
      • Diddana T.Z.
      • Kelkay G.N.
      • Dola A.N.
      • Sadore A.A.
      Effect of nutrition education based on health belief model on nutritional knowledge and dietary practice of pregnant women in Dessie Town, Northeast Ethiopia: a cluster randomized control trial.
      of good dietary practice among pregnant mothers. The discrepancy between the studies might be due to differences in the study settings since the current study was conducted among rural residents with little access to nutrition education and health services. Moreover, respondents in this study had a low level of education. Their literacy level has been a barrier to access information related to good nutrition practices.
      The finding of this study identified that the educational status of pregnant mothers had a strong association with good dietary practices. Which is supported by the study conducted in Egypt in which women with a high level of education had a high level of nutritional knowledge and practice compared to low and moderate educational levels.
      • Alkalash S.H.
      • Hegazy N.N.
      • ELnady R.T.
      • Khalil N.A.
      Dietary practice and nutritional status among pregnant women.
      The current study showed that there was a strong negative association between family size of pregnant mothers and their dietary practice. The pregnant mothers whose family size ranges from 1 to 3 were 5.66 times more likely to have good dietary practice than those who have a family size of ≥7. And mothers who had family sizes 4–6 were 2.84 times more likely to have good dietary practice than those who had ≥7. This finding is supported by the study conducted in Illu Aba Bora Zone, Southwest Ethiopia.
      • Tsegaye D.
      • Tamiru D.
      • Belachew T.
      Factors associated with dietary practice and nutritional status of pregnant women in rural communities of Illu Aba bor zone, southwest Ethiopia.
      Increased family size may adversely affect the nutritional status of every member of the household, including pregnant mothers. Because the larger the family size the lesser food availability to each person within the household which affects nutritional practice.
      The finding of this study revealed that average monthly income has a strong statistical association with good dietary practices of mothers during pregnancy. Pregnant mothers who had an average monthly income greater than or equal to 3500 ETB were 12 times more likely to have good dietary practice than those earning less than 2000 ETB. Similar findings had also been reported from a study in Wondo Genet, Southern Ethiopia that identified average monthly income had a significant association with the dietary practice of pregnant mothers.
      • Kuche D.
      • Singh P.
      • Moges D.
      Dietary practices and associated factors among pregnant women in Wondo Genet District, southern Ethiopia.
      The possible reason might be families with low income may eat a less nutritious diet than those with a higher income, either because they cannot afford enough food or they eat nutritionally poor foods.
      In this study; nutritional knowledge during pregnancy had a significant association with the participant's dietary practice. Pregnant mothers who were knowledgeable about nutrition were two times more likely to have good dietary practice during pregnancy than their counterparts. This finding was similar to a study that was conducted in Gedeo Zone, Southern Ethiopia.
      • Yalewdeg M.
      • Birhane M.
      • Adissu Y.
      Dietary practices and their determinants among pregnant women in Gedeo zone, southern Ethiopia: a community-based cross-sectional study.
      The reason might be due to more exposure of pregnant women to dietary information; they become informed about the consequences of undernutrition on themselves and their fetus which will be enforced to practice adequate diet.

      5. Limitations of the study

      This study acknowledged some important possible limitations that should be considered when interpreting the results. First, the study was cross-sectional, a design that does not permit to establish cause-effect relationships. Second, recall bias might be introduced.

      6. Conclusion

      In this study, more than a quarter of pregnant mothers had good dietary practice. Educational status of the participants, dietary knowledge, monthly income, and family size were significantly associated with dietary practices of pregnant women. To improve dietary practice of pregnant women; enhance knowledge on nutrition through nutrition education and decrease family size by regular family planning counseling in the continuum of maternal care.

      Ethics approval and consent to participate

      This study was conducted under the declaration of Helsinki. Ethical clearance was obtained from the School of Midwifery (SMIDW/18/2013 ዓ.ም) under the delegation from the Ethical Review Board of the University of Gondar. A formal letter of cooperation was written for the Farta district health office and permission was obtained. Informed written consent was taken from each study participant. Any involvement in the study was after complete consent was obtained. All data was kept confidentially by using codes.

      Consent for publication

      Not applicable.

      Data sharing statements

      The datasets collected and analyzed for this study are available from the principal investigator and can be attained on a reasonable request.

      Funding statement

      The funding source of this research was the University of Gondar and the University has no role in design, data collection, analysis, decision to publish as well as preparation of the manuscript.

      Authors’ contributions

      All the authors had significant involvement in the conception and designing the study, acquisition of data, analysis, and interpretation of data, took part in drafting the article, revising the article, gave final approval of the version to be published, have agreed on the journal to which the article has been submitted and agree to be accountable for all aspects of the work.

      Declaration of competing interest

      The authors declare that they have no competing interests.

      Acknowledgments

      We would like to thank the University of Gondar for its financial support. We deeply appreciate the data collectors and the study participants.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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