SANTE MEDICAL COLLEGE DEPARTMENT OF

PUBLIC HEALTH NUTRITION

ASSESSMENT OF NUTRITIONAL
PRACTICES AND ASSOCIATED
FACTORS AMONG PREGNANT WOMEN
IN ALERT HOSPIATAL , ADDIS ABABA,
ETHIOPIA, 2023

A RESEARCH PROPOSAL TO BE SUBMITTED TO SANTE MEDICAL

COLLEGE DEPARTMENT OF PUBLIC HEALTH NUTRITION AS
PARTIAL FULLFILMENT FOR THE REQUIMENT OF MASTERS OF
PUBLIC HEALTH IN NUTRITION

JUNE, 2023 ADDIS ABABA, ETHIOPIA

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 ASSESSMENT OF NUTRITIONAL PRACTICES AND
ASSOCIATED FACTORS AMONG PREGNANT WOMEN

BY: YIGREMACHEW YIRGA SAHLE (BSc)

ADVISOR: TIRHAS TADESSE (PHD)

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 Name of principal investigator
Name of primary advisor
Full tittle of thesis research
Duration of thesis research
Study area
Total cost of the project
Address of the investigator
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Yigremachew Yirga Sahle(BSc)
Tirhas Tadesse(PhD)
Assessment of nutritional practice and
associated factors among pregnant women in
Alert Hospital , Addis Ababa, Ethiopia
Eight months
Kolfe Keranio sub city ,Addis Ababa
Ethiopia,
30,000.00 birr
Pushkin street sarbet, Addis Ababa.
yigruyirga@gmail.com
+251911198569
 I. Acknowledgement

I would like to express my sincere gratitude to all those who have supported me throughout this
research proposal work. First and foremost, I would like to thank my supervisor, Dr. Tirhas
Tadesse, for her guidance, encouragement, and constructive feedback. I am also grateful to the
staff and management of Alert Hospital Addis Ababa for their cooperation and assistance in
originating the research idea. I would also like to acknowledge the support of my family and
friends who have motivated me and helped me in various ways during this research proposal
preparation. This research would not have been possible without the help of all these people and
organizations.

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Contents
I. Acknowledgement ................................................................................ Error! Bookmark not defined.
1. CHAPTER ONE: INTRODUCTION ............................................................................................... 1
1.1. Background ..................................................................................................................................... 1
1.2. Statement of The problem .............................................................................................................. 1
1.3. Objective of the study ..................................................................................................................... 2
1.3.1. General objective ........................................................................................................................ 2
1.3.2. Specific objectives ....................................................................................................................... 2
1.4. Research questions .......................................................................................................................... 2
1.5. Significance of the study ................................................................................................................. 3
1.6. Scope and limitation of the study................................................................................................... 3
1.7. Organization of the paper .............................................................................................................. 4
1.8. The definition of terms ................................................................................................................... 4
2. CHAPTER TWO: REVIEW OF RELATED LITERATURE ....................................................... 5
2.1. The dietary practice of pregnant women and its determinants .................................................. 5
2.2. The knowledge and awareness of nutrition among pregnant women and its sources .............. 6
2.3. The nutritional status of pregnant women and its consequences ............................................... 7
2.4. Conclusion ....................................................................................................................................... 8
3. Methods and Materials ..................................................................................................................... 10
3.1. STUDY AREA ............................................................................................................................... 10
3.2. Source of population: .................................................................................................................... 10
3.3. Study population: .......................................................................................................................... 10
3.3.1. Inclusions criteria...................................................................................................................... 10
3.3.2. Exclusion criteria ...................................................................................................................... 10
3.3.3. Study design............................................................................................................................... 10
3.3.4. Sample size calculation ............................................................................................................. 11
3.3.5. Sampling technique ................................................................................................................... 11
3.3.6. The data collection method ...................................................................................................... 11
3.3.7. The data analysis method ......................................................................................................... 12
3.3.8. The ethical considerations ........................................................................................................ 12
4. Expected Result ................................................................................................................................. 13
5. Budget and Timeline ......................................................................................................................... 14
6. References .......................................................................................................................................... 15

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1. CHAPTER ONE: INTRODUCTION

1.1. Background

Nutritional assessment data of pregnant woman should take into consideration both macro and
micro nutrients along with maternal health, fatal growth, physical activity levels and gestational
states weight at conception is unimportant factor in pregnancy[1, 2]. Evidences show that nutrition
education during pregnancy has significant impact on dietary habit of pregnant woman on maternal
and birth outcome of pregnancy [3]. WHO recommends that healthcare providers need to give
adequate specific and acceptable nutrition related advices to pregnant woman during every visit of
ANC[16]. During pregnancy needs folic acid, iron, calcium, vitamin D, choline, omega-three fatty
acid, vitamin B and vitamin c fortified cereals enriched bread and pasta, peanuts, dark green leafy
vegetables, orange juice and beans[3,4].

Assessment of nutritional practices among pregnant women is important for identifying the gaps
and needs in maternal nutrition and designing effective interventions to improve it. However, there
is limited evidence on the nutritional practices and their determinants among pregnant women in
different settings and contexts. Therefore, this research aims to assess the nutritional practices and
their associated factors among pregnant women in Alert Hospital. This research will contribute to
the existing knowledge on maternal nutrition and provide recommendations for policy and practice
to enhance maternal and child health.

1.2. Statement of The problem

Nutrition during pregnancy is important for the health and well-being of both the mother and the
baby. Adequate nutrition can prevent complications such as anemia, preterm birth, low birth
weight, and preeclampsia [1,5]. Pregnant women need to consume a balanced diet that provides
enough calories, protein, vitamins, minerals, and fluids [6, 7]. However, many pregnant women
may face challenges in meeting their nutritional needs due to factors such as food availability,
affordability, accessibility, preferences, knowledge, beliefs, and practices [7,8,9]. In Ethiopia,
where malnutrition is a major public health problem, pregnant women are particularly vulnerable
to poor nutrition and its consequences[7,8,9,10]. Therefore, it is essential to assess the nutritional
practices and associated factors of pregnant women in alert hospital Addis Ababa, which is one of

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the largest referral hospitals in the country. This study will provide valuable information for
designing and implementing effective interventions to improve the nutritional status and outcomes
of pregnant women and their babies.

1.3. Objective of the study

1.3.1. General objective

The general objective of this study is to assess the dietary practices and associated factors of
pregnant women in alert hospital Addis Ababa.

1.3.2. Specific objectives

The specific objectives are:

• To assess the dietary intake and nutritional status of pregnant women in alert hospital Addis
Ababa
• To identify the factors associated with nutritional practices of pregnant women in alert
hospital Addis Ababa
• To evaluate the impact of nutritional practices on maternal and fetal outcomes in alert
hospital Addis Ababa
• To provide recommendations for improving the nutritional care of pregnant women in alert
hospital Addis Ababa

1.4. Research questions

• What are the dietary intake and nutritional status of pregnant women in alert hospital Addis
Ababa?
• What are the factors associated with dietary practices of pregnant women in alert hospital
Addis Ababa?
• What is the impact of dietary practices on maternal and fetal outcomes in alert hospital
Addis Ababa?

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1.5. Significance of the study

This research is important because it will provide evidence on the nutritional status and associated
factors of pregnant women in alert hospital Addis Ababa, Ethiopia, where malnutrition is a public
health problem and maternal mortality is high Nutrition is a vital factor for the health and well-
being of pregnant women and their unborn babies. Poor nutrition during pregnancy can lead to
adverse outcomes such as low birth weight, preterm delivery, anemia, and birth defects. However,
many pregnant women in low- and middle-income countries face multiple challenges in meeting
their nutritional needs, such as food insecurity, poverty, and lack of education, cultural beliefs, and
inadequate health services. This research will help to identify the gaps and barriers in providing
adequate nutrition to pregnant women and to inform interventions to improve maternal and child
health outcomes in this setting. This research will also contribute to the global knowledge on
nutrition in pregnancy and lactation and its lifelong consequences for both the mother and the
child.

1.6. Scope and limitation of the study

The scope of this research is to assess the nutritional status and associated factors of pregnant
women in alert hospital Addis Ababa, Ethiopia. The research will use a cross-sectional design and
collect data from a sample of pregnant women who attend antenatal care at the hospital. The
research will measure the anthropometric indicators, dietary intake, biochemical markers, and
sociodemographic characteristics of the pregnant women. The research will also explore the
perceptions and practices of the pregnant women and the health care providers regarding nutrition
in pregnancy. The research will analyze the data using descriptive and inferential statistics.

The limitation of this research is that it will only include pregnant women who attend antenatal
care at one hospital in Addis Ababa, which may not be representative of the general population of
pregnant women in Ethiopia. The research will also rely on self-reported data for dietary intake,
which may be subject to recall bias and social desirability bias. The research will not be able to
establish causal relationships between the nutritional status and associated factors of the pregnant
women and their pregnancy outcomes, as it will use a cross-sectional design. The research will

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also not be able to assess the long-term effects of nutrition in pregnancy and lactation on the health
and development of the mother and the child.

1.7. Organization of the paper

• Introduction. This section provides the background, statement of the problem, research objectives,
research questions, significance of the study, scope and limitation of the study, and definition of
terms.
• Literature Review. This section reviews the relevant literature on nutrition in pregnancy and
lactation, nutritional status and associated factors of pregnant women, and nutrition interventions
and policies in Ethiopia.
• Research Methodology. This section describes the research design, study area, study population,
sample size and sampling technique, data collection methods and instruments, data quality
assurance, data analysis methods, ethical considerations, and dissemination plan.
• Expected Results. This section outlines the expected results of the data analysis, according to the
research objectives and questions.
• Budget and Timeline. This section provides the estimated budget and timeline for the research
project.
• References. This section lists the sources cited in the paper.

1.8. The definition of terms

• Nutritional status: The condition of the body in relation to the intake and utilization of nutrients.
• Associated factors: The variables that influence or are related to the nutritional status of pregnant
women, such as sociodemographic characteristics, dietary intake, biochemical markers, and health
services.
• Pregnant women: Women who are carrying a developing fetus in their uterus.
• Alert hospital: A public hospital in Addis Ababa, Ethiopia, that provides maternal and child health
services, among others.
• Addis Ababa: The capital city and largest urban center of Ethiopia, located in the central highlands
of the country.

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2. CHAPTER TWO: REVIEW OF RELATED LITERATURE

Nutrition is a vital factor for the health and well-being of pregnant women and their unborn
children. Adequate nutrition during pregnancy can prevent maternal and fetal complications such
as anemia, preterm birth, low birth weight, birth defects, and childhood obesity [1, 2, 22, 23].
However, many pregnant women in developing countries face challenges in meeting their
nutritional needs due to socio-economic, cultural, and environmental factors [4, 5, 22]. The aim of
this literature review is to assess the nutritional practices and associated factors of pregnant women
in alert hospital Addis Ababa, Ethiopia. The review will focus on the following aspects:

• The dietary practice of pregnant women and its determinants

• The knowledge and awareness of nutrition among pregnant women and its sources
• The nutritional status of pregnant women and its consequences
• Dietary practice of pregnant women and its determinants

2.1. The dietary practice of pregnant women and its determinants

Dietary practice refers to the frequency, quantity, quality, and diversity of food intake by pregnant
women [23]. It is influenced by various factors such as socio-demographic characteristics,
economic status, cultural beliefs, food availability and accessibility, health service utilization, and
nutrition information [24]. A recent study conducted in Southwest Ethiopia found that only 23.7%
of the pregnant women had a good dietary practice, which was defined as consuming at least four
food groups per day [12,16,24]. The study also identified the following factors as determinants of
good dietary practice:

• Urban residency (AOR = 2.64; 95% CI: 1.18, 5.92)

• Monthly income > 2000 ETB (AOR = 2.47; 95% CI: 1.31, 4.65)

• Having nutrition information (AOR = 2.5; 95% CI: 1.14, 5.52)

• Good dietary knowledge (AOR = 2.79; 95% CI: 1.48, 5.27)

• Mothers occupation of employer (AOR = 1.88; 95% CI: 1.04, 3.42)

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• Family size < 5 (AOR = 3.37; 95% CI: 1.32, 8.65)

The study recommended that health professionals should provide health and nutrition education
and counseling for pregnant women, especially those who live in rural areas, have low income,
lack nutrition information, have poor dietary knowledge, are unemployed or have large family
sizes [22].

2.2. The knowledge and awareness of nutrition among pregnant women and its

sources

Knowledge and awareness of nutrition refer to the understanding and recognition of the importance
of nutrition for maternal and fetal health [ 3,12, 22, 24]. It can be acquired from various sources
such as health professionals, media, family, friends, books, or internet .A study conducted in New
York found that pregnant women gained awareness of the importance of nutrition when they were
pregnant, but faced barriers to making positive changes such as lack of time, money, motivation,
or support [3, 12, 22, 24].The study also evaluated the effectiveness of an educational intervention
based on My Plate and current evidence-based guidelines to improve nutrition education for
pregnant women [3,12,22,24]. The intervention consisted of a one-hour session that included a
PowerPoint presentation, handouts, food models, and interactive activities [3,12,,22,24]. The study
found that the intervention increased the knowledge and awareness of nutrition among pregnant
women significantly (p < 0.001) [3,12,22,24]. The study also identified six themes that represented
the perceptions of pregnant women regarding nutrition:

• Importance of healthy nutritional habits

• Knowledge

• Prevention of harm to baby

• Hurdles experienced throughout pregnancy

• Support

• Motivation The study concluded that nutritional counseling during pregnancy is an effective
intervention to improve pregnant women's knowledge and awareness of nutrition and suggested
that it should be incorporated into routine antenatal care [3,12,22,24].

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2.3. The nutritional status of pregnant women and its consequences

Nutritional status refers to the physical condition of pregnant women as determined by their dietary
intake and nutrient utilization [4, 5, 9,15,23]. It can be assessed by various indicators such as body
mass index (BMI), weight gain, hemoglobin level, serum micronutrient level, and dietary diversity
score [4, 5, 9,15,23]. It can have significant impacts on the health outcomes of both the mother
and the child [4, 5, 9,15,23,25]. A study conducted in Malaysia found that 38.5% of the pregnant
women had poor nutritional status, which was defined as having either underweight (BMI < 18.5
kg/m2), overweight (BMI > 25 kg/m2), anemia (hemoglobin < 11 g/dl), or low dietary diversity
score (< 5) [4, 5, 9,15,23,25]. The study also found that poor nutritional status was associated with
the following factors:

• Age < 20 years or > 35 years (p < 0.001)

• Education level < secondary school (p < 0.001)

• Occupation of housewife (p < 0.001)

• Parity > 3 (p < 0.001)

• Gestational age > 28 weeks (p < 0.001)

• Lack of knowledge of nutrition (p < 0.001) The study also reported that poor nutritional status
increased the risk of adverse maternal and fetal outcomes such as preterm delivery, low birth
weight, intrauterine growth restriction, and congenital anomalies [4, 5, 9,15,23,25]. The study
recommended that pregnant women should be screened for their nutritional status and receive
appropriate interventions to improve their dietary intake and nutrient supplementation [4, 5,
9,15,23,25].

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2.4. Conclusion

The literature review has examined the existing evidence on the impact of nutrition education on
pregnancy specific nutrition knowledge and healthy dietary practice among pregnant women. The
review has identified several gaps and challenges in the current research, such as:

• The lack of standardized and validated tools to measure nutrition knowledge and dietary practice
among pregnant women

• The heterogeneity of nutrition education interventions in terms of content, delivery, duration,

frequency, and intensity

• The limited number of randomized controlled trials and systematic reviews on the effectiveness
of nutrition education interventions

• The scarcity of data on the cost-effectiveness and sustainability of nutrition education

interventions

• The variation in the cultural and contextual factors that influence the acceptability and feasibility
of nutrition education interventions

The review has also highlighted some promising directions for future research, such as:

• Developing and testing culturally appropriate and context-specific nutrition education

interventions that address the needs and preferences of pregnant women

• Evaluating the impact of nutrition education interventions on maternal and birth outcomes, such
as gestational weight gain, anaemia, preterm birth, low birth weight, and congenital anomalies

• Exploring the mechanisms and mediators of behaviour change among pregnant women who
receive nutrition education interventions

• Assessing the potential of digital health technologies, such as mobile phones, apps, and social
media, to enhance the delivery and reach of nutrition education interventions

• Conducting cost-effectiveness and cost-benefit analyses of nutrition education interventions to

inform policy and practice decisions

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The literature review has demonstrated that nutrition education during pregnancy is a vital
component of maternal and child health care. It has also shown that there is a need for more
rigorous and comprehensive research to establish the best practices and strategies for improving
nutrition knowledge and dietary practice among pregnant women. By addressing the gaps and
challenges identified in this review, future research can contribute to the advancement of evidence-
based nutrition education interventions that can optimize maternal and child health outcomes.

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3. Methods and Materials

3.1. STUDY AREA

The study will be undertaken in Alert hospital, which exists in Kolfe Keranio Sub city. Since its
establishment it has been serving as referral hospital and provides different kinds of medical
treatments for patients coming from the hospital allotted catchment area. The catchment area of
the hospital is the pie share of the total population of the country dispensed among all referral
hospitals.

3.2. Source of population:

Pregnant women who came to seek ANC service in ALERT hospital.

3.3. Study population:

The study population will consist of pregnant women who attend antenatal care services at the
hospital during the study period.

3.3.1. Inclusions criteria

Pregnant women age 18 - 49 who came to attend antenatal follow up at ALERT Hospital.

3.3.2. Exclusion criteria

People who was not mentally competent to give consent due to mental illness, known diabetic,
hypertensive patient or other severe general medical conditions and minors under 18 years since
they do not have the right to make autonomous decision to consent were not enrolled in the study.

3.3.3. Study design

The study will be a cross-sectional survey conducted in alert hospital Addis Ababa, which is one
of the largest referral hospitals in Ethiopia.

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 3.3.4. Sample size calculation

The sample size will be calculated using a formula for estimating a single population proportion
with the following assumptions: prevalence of malnutrition among pregnant women = 20%,
margin of error = 5%, confidence level = 95%, and design effect = 2. The sample size will be
adjusted for non-response rate of 10%.

3.3.5. Sampling technique

The sampling technique will be a systematic random sampling, where every nth pregnant woman
who attends antenatal care services will be selected until the required sample size is reached.

3.3.6. The data collection method

The data collection tools will include a structured questionnaire, a 24-hour dietary recall, and
anthropometric measurements. The questionnaire will collect information on socio-demographic
characteristics, obstetric history, nutritional knowledge, beliefs, and practices of the pregnant
women. The 24-hour dietary recall will estimate the energy and protein intake of the pregnant
women using food composition tables and standard portion sizes. The anthropometric
measurements will include weight, height, mid-upper arm circumference, and triceps skinfold
thickness of the pregnant women using standardized procedures and equipment. The body mass
index, arm muscle area, and arm fat area will be calculated from these measurements.

The data quality will be ensured by pre-testing the questionnaire, training the data collectors and
supervisors, conducting regular field supervision and spot-checks, and performing data cleaning
and validation before analysis.

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 3.3.7. The data analysis method

The data analysis will be done using SPSS software. Descriptive statistics will be used to
summarize the socio-demographic characteristics, dietary intake, and nutritional status of the
pregnant women. Bivariate and multivariate logistic regression will be used to identify the factors
associated with nutritional practices and outcomes of the pregnant women. The level of
significance will be set at p < 0.05.

3.3.8. The ethical considerations

The ethical considerations for this research include obtaining informed consent from the
participants, protecting their confidentiality and anonymity, ensuring their voluntary participation
and withdrawal, respecting their dignity and rights, avoiding harm or discomfort, and reporting the
findings honestly and accurately. The limitations of this research include the possibility of recall
bias, social desirability bias, measurement error, sampling error, and generalizability issues.

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4. Expected Result

The expected result of this research is to assess the nutritional practices and associated factors of
pregnant women in Alert Hospital Addis Ababa. The research aims to answer the following
questions:

• What are the nutritional practices of pregnant women in Alert Hospital Addis Ababa?

• What are the factors that influence the nutritional practices of pregnant women in Alert Hospital
Addis Ababa?

• What are the implications of the nutritional practices of pregnant women in Alert Hospital Addis
Ababa for maternal and child health outcomes?

The research expects to find that:

• The nutritional practices of pregnant women in Alert Hospital Addis Ababa are suboptimal and
vary according to socio-demographic, economic, and environmental factors.

• The factors that influence the nutritional practices of pregnant women in Alert Hospital Addis
Ababa include knowledge, attitude, beliefs, culture, access, availability, affordability, and quality
of food and nutrition services.

• The nutritional practices of pregnant women in Alert Hospital Addis Ababa have significant
implications for maternal and child health outcomes, such as gestational weight gain, anaemia,
preterm birth, low birth weight, and congenital anomalies.

The research expects to contribute to the existing literature on nutrition practice and factors
affecting pregnant women. It also expects to provide evidence-based recommendations for
improving nutrition education and counselling, food and nutrition security, and maternal and child
health care in Alert Hospital Addis Ababa.

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5. Budget and Timeline

Activity Description Cost (BIRR) Duration

Literature review Searching and reviewing relevant literature on 1,500 1 month

nutrition practice and factors affecting pregnant
women
Research design Developing research questions, objectives, 5,000 1 months
hypotheses, methodology, and data collection
tools
Ethical clearance Obtaining ethical approval from the relevant 1,500 10 days
authorities and informed consent from the
participants
Data collection Recruiting and training data collectors, 10,000 3 months
conducting interviews and surveys with pregnant
women at Alert Hospital
Data analysis Cleaning, coding, and analyzing the data using 5,000 1 month
appropriate statistical software and techniques
Report writing Writing and editing the research report, including 5,000 40 days
findings, discussion, conclusion, and
recommendations
Submission research Submitting research report 2,000 10 days
report
Total 30,000 8 months

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