Dietary Calcium Intake and Associated Factors Among Pregnant Women in Loma District, South West Ethiopia, 2020

Introduction

Inadequate intakes of calcium are one of the most serious public health problem affecting mothers and their children in the world. WHO estimates that at least one woman dies every seven min- utes from complications of hypertensive disorders of pregnancy this is may be because of low intakes of dietary calcium [1]. Inadequate intakes of calcium during pregnancy cause hyperten- sive disorder which is a major health problem leading maternal and perinatal morbidity and mortality. However, an adequate calcium intake during pregnancy might prevent pregnancy in- duced hypertension, preterm birth, FGR, increasing maternal bone mass, and reduce fracture risks [2-3].

In resource-poor environments across the globe, low quality monotonous diets are the norm. When grain- or tuber-based staple foods dominate and diets lack vegetables, fruits and ani- mal-source foods, risk for a range of micronutrient (calcium) de- ficiencies is high. Mainly pregnant women is vulnerable group , but there is no sufficient information on micronutrient (calcium) deficiencies on such global public health problem among preg- nant women [4].

There is less evidence from developing countries generally and specifically where monotonous diets, relying mostly on a typical few plant-based staple foods confirm this association specifical- ly among pregnant women [5]. Maternal diets during pregnan- cy need to provide nutrients for the mother as well as for fetal growth and development. Prevention of Hypertensive disorders and preeclampsia are the advantages of dietary calcium intakes during pregnancy[6].Ensuring that appropriate dietary calcium is consumed is important for preventing pregnancy induced hy- pertension and helping to reduce the risk of osteoporosis with advancing age [7-8]. So evaluation of dietary calcium intake and associated factors among pregnant women in Loma Woreda, Dawuro, South West Ethiopia is very important.

Materials and Methods

Study Settings and study period

The study was conducted in Loma Woreda from May to July 2019 which is located 512 km away from Addis Ababa, the cap- ital city of Ethiopia, 292 km from Hawassa, the regional town SNNPR. The district structured in to 24 rural and 3 urban kebe- les. According to the report of CSA the estimated population of Loma Woreda was 108,965 out of which 53,502 were male & 55,463were female[9]. Maize, enset (false banana), and root crops are majorly consumed food items [10].

Study Design: Community based cross sectional study design was used.

Source Population: All pregnant women who are living at least for six months in Loma Woreda

Study Population: Randomly selected pregnant women were participated during the study period.

Inclusion criteria: - Pregnant women who are living at least for 6 months in Loma Woreda.

Exclusion criteria: Seriously ill pregnant women during the in- terview were not considered in study.

Sample size determination

The sample size was determined by using single proportion for- mula by taking assumptions of the prevalence of dietary calcium intake as 50% , 5% marginal error, 95% CI, a non-response rate of 10%. Therefore, sample size is: n= (zα/2)2 p (1-p)/d2 = (P = 50%) (1.96)2*0.5(1-0.5)/ (0.05)2n = 384 When adding 10% none response rate, the maximum sample size were (384*10%) = 422.

Sampling procedures

From the total of 27 kebeles of Loma Woreda, 9 kebeles was selected by simple random sampling method. A sample frame from selected kebeles was taken from kebele health posts. Sam- ple size for each selected kebeles was allocated proportionally. Study participants were selected by using simple random sam- pling technique. List of participating households from the se- lected kebeles was obtained from HEW. After obtaining a list of participant households, we have selected the required sam- ple size by using lottery methods. A pregnant woman in each 9 kebeles and the first household was selected by simple random sampling method.

Figure 1: Schematic presentation of sampling procedure for the dietary calcium intakes and associated factors among pregnant women in Loma Woreda.

Operational definitions

Above RDA: The amount calcium intake is above1000 mg per day.

Below RDA: The amount of calcium intake is less than 1000 mg per day.

Adequate Intake: The amount of calcium intake is equals to 1000 mg per day.

Positive Attitude: Pregnant women’s score is ≥ the mean score 25 in likert scale

Negative Attitude: Pregnant women’s score is< 25 in likert scale.

Adequate Knowledge: Pregnant women score is ≥ the average score 7 Poor knowledge: Pregnant women score is < average score 7

Data collection tool and procedure

Recruitment of data collectors

Eight diploma nurses were recruited to collect the data and one BSC nurse and one Health officer were supervising data collec- tion. The data collector and supervisor were trained for two con- secutive days on the objective, ethics, method and contents of question.

Quantified multiple pass 24 hr. Recall

The 24 hour dietary recall includes the type of food and bever- ages consumed inside and outside of the house along with the quantity of the foods. The 24-hour period starts with the first food eaten by the pregnant women in the morning until the last food item consumed before going to bed. The Quantified 24 hr recall was used for at least three different days which covers at least one week day and one weekend day so as to adequately represent the habitual intake .The FAO (2018) Quick guide to use 24 hr recall was followed.

Dietary Recall: Each interview involved, a stepwise series of questions, normal household utensils, food substitutes (play dough, flour, lentils, water) and pictures of most commonly con- sumed foods in the specific regions to improve the memory of the respondents and assist in completing the questionnaires. 24hr dietary recall was conducted using the multiple-pass tech- nique which include,

First pass:-Quick list of all foods, drinks, snacks consumed from midnight of one day until midnight the following day.

Second pass:-Detailed and more specific descriptions of all the foods and drinks consumed, including cooking methods and brand names (where possible). The interviewer also asked if the respondent has remembered any additional items that were con- sumed but which were forgotten in the first pass.

Third pass:-Estimating portion sizes

In order to accurately estimate the portion size of foods and drinks consumed, Calibrated locally available labeled cup, bowl, spoon, serving spoons, food weighing scale. Moreover, the data collectors carried different sizes of locally consumed fruits and vegetables such as bananas, avocado, shallot, tomato, potato, yum to facilitate the recall [21].

Pass four:-The interviewer reviewed the recall to ensure that all the items have been recorded correctly. Every respondent were probed for snacks, drinks and outdoor consumption of any kind of food after they complete recall. The interviews were conducted on all seven days of the week to capture changes in intakes across various days of the week. The dietary recall was repeated in randomly selected of the house- holds by interviewer and in a different nonconsecutive day than the first. The recall was repeated to adjust for the day to day variation we were include week day and weekends and to adjust within person variation of nutrient intakes of the study partici- pants we were increased days. All recall days were arranged on non-special occasion days like holidays or feasts.

The calcium intake was calculated by using food composition table of Ethiopia[22]. After calculating the intake of dietary Cal- cium per day the values was compared with WHO Recommend- ed Dietary Allowances of Calcium for pregnant women as there is a lack of national standards.

The standard Questionnaire

Data was collected by using structured questionnaire which is adopted after reviewing literatures of similar studies based on the objective of this study. An interactive, multiple-pass 24hr di- etary recall questionnaire adapted and validated for use in devel- oping countries [30] was used to collect data on dietary intake. The knowledge and attitude of pregnant was categorized on two and five-level which includes the responses for given negative and positive statement as correct and incorrect and strongly dis- agree, disagree, neither agree nor disagree ,strongly agree, agree and (1,2,3,4,5) of likert scale. Data quality assurance Before data collection, the study questionnaire was checked us- ing a pretest of 5% of invited pregnant women from households. Before estimating portion size we were standardizes measuring tools, and we were observed locally available measuring tools in study area then measure the common foods from 10(ten) house- hold by digital food scale used to measure the gram amount of food consumed and of ingredients used in food preparation and finally took the average amount. Drinking cups glasses, spoons and ladles were labeled in to three categories based on their size (large, medium and small).

The questionnaire was prepared initially in English and then translated into Amharic Language, then retranslated back to English by another person who has good command of English, Amharic language to check for its consistency. The data collec- tors and supervisors were trained two days particularly in the proper filling of multiple pass 24 hour recalls. Information on 24-hour recall is collected using an open-ended format. Quan- titative information on food intake, as described using portion size, allows for the calculation of calcium intakes of a 24-hour recall form. Estimation of portion size is facilitated by the use of measurement aids such as standard household measurement tools [11]. To calculate calcium intakes, the estimated portion size or the amount of food intake was multiplied by the values of nutrient content in foods as found in the Ethiopian food com- position tables[22].

Data management and analysis plan

Data was checked for completeness and consistency, edited manually, coded and then entered in to Epi Data version 3.02 for data clearance and exported into SPSS version 20 for analysis. Descriptive statistics was used to calculate frequencies and per- centages of study participants with regard to different variables. Variables with a p-value less than 0.25 in the bi variable logistic regression analysis were candidate for multivariable analysis. AOR with 95% C.I. of p<0.05 in multivariable logistic regres- sion was considered as statistically significant.

Ethical clearance was obtained from Ethical Review Committee (ERC) of Wolaita Sodo University, department of Human Nutri- tion and support letter was to Loma Woreda Health office.

Results

Socio-demographic and Economic Characteristics of Participants

Three hundred and ninety eight (398) subjects were participat- ed in the study with response rate of 94%. The median age of study subjects was 30 years. Concerning educational level, 176 (44.2%) of the respondents were illiterate and 365(91.7%) of pregnant women’s earned less than 1000 ETB per month month- ly income. Two hundred twenty seven (57%) of the respondents had nutritional information during their pregnancy.

Table 1: Socio-demographic and economic factors among pregnant women in Loma woreda, south west, Ethiopia (n= 398)

Calcium Intakes

Out of 398 study participants responded for the questions to assess their dietary calcium intakes, 66.6% of them had inad- equate calcium intakes in which, greater than half 249 (62.6%) respondents had practiced avoiding calcium rich food during their pregnancy. Out of those who avoided food during their pregnancy, due to it makes the baby big, culture and it makes delivery difficult. About 44.7% pregnant women of this study were agreed on satisfactory birth out comes can be achieved through nutrition knowledge and practice of pregnant women. The median intake was 543 mg/day. The Proportion of pregnant women with low calcium intakes (less than 1000 mg per day) was 265(66.6%).

Figure 2: Distribution of dietary calcium intakes among pregnant women in Loma woreda, South west Ethiopia, 2019 (n=398).

Meal consumption pattern of pregnant women

Three hundred eighty three (96.2%) of the respondents had not practiced the habit of eating snacks between meals during their pregnancy. Majority of the pregnant mothers do not consume their snacks.

Figure 3: Meal pattern of pregnant women of Loma, south west Ethiopia, 2019(n=398)

Group of Foods consumed by pregnant women

Plant based foods such as cereal, roots and tubers and also green leafy vegetables were the most consumed. Flesh foods and milk products were the least consumed food groups.

In multivariate logistic regression, occupation AOR=0.052(0.01- 0.269), family size, AOR=0.285 (0.111- 0.733), attitude towards calcium intakes AOR= 0.003 (0.001-0.016), nutritional coun- seling AOR=2.432 (1.072-5.517), knowledge on calcium AOR 3.256 (1.241-8.547), regular consumption of milk AOR=2.806 (1.124-7.005) and age of respondents AOR = 0.126 (0.027- 0.581) are associated factors with dietary calcium intakes among pregnant women.

Discussion

The study was inspected the dietary calcium intakes and associ- ated factors among pregnant women. Low dietary Calcium in- take was widespread among pregnant women. Findings of this cross-sectional study indicate that a high proportion of pregnant women in study area do not consume enough calcium as well as calcium-rich food products; and meeting adequate intake of this nutrient is not possible through the current dietary patterns in the majority of the studied population. Dietary calcium intake was associated with age, occupation of respondents, family size, nutritional counseling, attitude towards dietary calcium intake and knowledge on calcium importance and regular consumption of milk.

Dietary Calcium Intake

The study presented that the average calcium intake in pregnant women in our study area was low (543mg/day) compared to WHO recommendation. This result clearly reflects the low con- sumption of calcium-rich products and culture of the communi- ty. The finding was correlated with survey conducted in china and Iran mean intakes were 633.2 ± 492.4 and 644 ± 255 respec- tively in 2015[13]. Likewise, low calcium intakes (561mg/day) were observed in Benin 2014 [14].Researcher’s also reported similar finding on the pregnant women in the study conducted in Sidama Zone, Southern Ethiopia. As it was observed with the other micronutrients, calcium intake was also lower than the rec- ommendation in both of the study groups. Its intake was much lower (below half of the requirement) during their pregnancy [15].

In differently, higher dietary calcium intakes 1,256.9 mg/day were observed in Thailand 2018[16]. Consequently to low av- erage calcium intakes, the occurrence of adequate calcium in- take in pregnant women in the current study is low. 33.4% of pregnant women have adequate calcium intake. This result is comparable in Nigeria the prevalence of calcium intake is 40% [10]. In contrast, higher prevalence of adequate calcium intake in America and Canada, and Europe, with their mean daily cal- cium intake as 1176, and 1141 mg/day respectively [6, 17].The discrepancy of the two studies may be due to the fact that the differences between the study participants, in that the present study was conducted on rural communities ( pregnant mothers) which can be lower than rural mothers in terms of educational, economic status and more access to nutrition information during pregnancy.

The different results underlined differences in dietary consump- tions. In developing country especially in our study area dietary calcium intakes among pregnant women are very low for the reason that diets are mainly on cereal and legumes based [18, 8, 19]. In addition the culture of community were prohibited to consume calcium rich food products for pregnant women mainly milk and milk products because of this food groups fattening the fetus and difficulty happen during delivery time. Whereas, in developed country, calcium intake is high due to production and usual consumption of dairy products. Definitely, consumption of calcium-rich foods is low in the study population [19].

Meaningful that hypertensive conditions and its difficulties during gestation are prevalent in developing countries and the positive role of adequate calcium intake in reducing the risk of hypertensive disorders, the common inadequate calcium intake through pregnancy in developing countries requires adequate in- terventions [7].

Factors Associated with Dietary Calcium Intake in Pregnant Women

Women who were being civil servants (AOR 0.052 95% CI 0.01-0.269) were less likely to have calcium intakes than farm- ers. This result is supported by the study conducted in Kenya in which employee was associated with dietary calcium intakes (AOR= 1.08 95% CI 0.88 - 2.45). Also in this study women’s dietary attitude had shown negative relationship with dietary calcium intake of mothers during pregnancy (AOR=0.003 95% CI 0.001-0.016). This finding is also in agreement with the study conducted in America in which the most significant predictor for good dietary practice was women’s attitude towards dietary intake of calcium (AOR=2.32, 1.56-3.43). The present study also demonstrated that there was strong statistical association between regular consumption of milk and milk products and dietary calcium intake during pregnancy (AOR=3.256 95% CI 1.241-8.547). This result is supported by the study conducted in Thailand in which consumption of milk products was signifi- cantly associated with dietary calcium intakes (3.9 95% CI: 2.0- 5.9)[16].

The finding of this study identified that nutritional counseling have strong statistical association with dietary calcium intake of mothers during pregnancy AOR=2.432 95% CI: 1.072-5.517).

This result is supported by the study conducted in Thailand in which nutrition information was the predictor factor for dietary calcium intakes in the study area (AOR= 0.985, 95% CI: 0.775 - 1.250). Pregnant women in urban areas, women with those whose household size is less than four were significantly less likely to have higher calcium intakes compared to rural wom- en, with those whose household’s size was four or less(AOR 0.285 95% CI 0.111- 0.733). This result is supported by the study conducted in Benin in which house hold size was signifi- cantly associated with dietary calcium intakes (AOR 1.330 95% CI 1.092 - 1.618)[19].

Conclusion

From the present study, it can be concluded that, majority of pregnant mothers (66.6%) had a poor dietary calcium intakes during pregnancy. They lacked the basic and the essential foods to consume vegetables, fruits, egg, milk and others which are the basic sources of most of calcium. Moreover, unhealthy dietary intake was observed among them. The current study also showed that, the most significant predicting factors for dietary calcium intakes in this study were women’s nutrition knowledge, regu- lar consumption of milk, importance of calcium, age and family size. Study results show that dietary calcium intakes of pregnant women in the study area were not adequate. The results suggest that pregnant women need nutrition counseling regarding calci- um rich food intake practices during pregnancy.

List Of Abbreviations

AI = Adequate Intake 

AOR=Adjusted Odd Ratio

Ca = Calcium

COR= Crude Odd Ratio

CSA=Central Statics Agency

FAO= Food and Agriculture Organization

FNB=Food and Nutrition Book

RDA= Recommended Daily Allowance

SNNPR= Southern Nation Nationalities Peoples Region

WHO= World Health Organization

Declaration

By my signature below, I declare and confirm that this manu- script of research is our work. We have followed all ethical prin- ciples of research in the preparation, data collection, processing, analysis and completion of this thesis. All scholar materials that are included have been given recognition through citation. We affirm that we have cited and referenced all sources used in this document. Every serious effort has been made to avoid any pla- giarism in the preparation of this manuscript. I really declare that this thesis is not submitted to any other institution anywhere for the publication.

Consent form

I Adisu Hailu Tofu give my consent for information about myself/my relative to be published in Nutrition & Metabolism of BMC with manuscript ID- number - NUAM-D-20-00426,co- authors - Yibeltal Kassa and Damene Darota, I understand that the information will be published without my /my relative’s as the name attached, but that full anonymity cannot be guaranteed.

I understand that the text and any pictures or videos published in the article will be freely available on the internet and may be seen by the general public. The pictures, videos and text may also appear on other websites or in print, may be translated into other languages or used for commercial purposes. I have been offered the opportunity to read the manuscript.

Competing interets

The authors declare that they have no competing interest.

Acknowledgement

We would like to acknowledge Wolaita Sodo University; Col- lege of Medicine and Health Science for the approval of the ethical clearance. Our gratitude goes high school leaders, data collectors and students who participated in this study.

Data Availability

Data are available with the corresponding author in SPSS based.

Ethical concerns

Ethical clearance was taken from Ethical Review Committee of College of Medicine and health sciences of Wolaita Sodo Uni- versity. Furthermore, letter of permission was obtained from Dawuro zone Health department. Consent was obtained from the study subjects whose age was 15 and above years after they were informed about objectives and procedures of the study and their right to refuse participation any time they want shall as- sured. No data will be shared to anyone to secure confidentiality.

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