Pattern of Malnutrition among Pregnant Women Attending Antenatal Care Service at Juba Teaching Hospital, South Sudan
Abstract
Malnutrition among pregnant women is a pressing public health concern in sub-Saharan Africa, including South Sudan. The prevalence of malnutrition is attributed to limited access to nutritious food, food insecurity, inadequate health care services, and the determinantal effects of armed conflicts and displacement. However, less or none is known about South Sudan. Therefore, this study was conducted to determine nutritional status and the related factors among pregnant women who attended antenatal care services in Juba Teaching Hospital, South Sudan. A cross-sectional study was conducted from September 01 to 30, 2023. Sociodemographic, socioeconomic, anthropometrics, and clinical-related information were collected using a prestructured interviewer-administered questionnaire. The mid-upper-arm circumference tape was used to define the nutritional status of pregnant women. Epi Data version 4.6 and SPSS version 26 were utilized for data entry and statistical analysis, respectively. A total of 280 pregnant women were included with the response rate stood at 97%. More than half of pregnant women were 25–45 years old. More than half (56.4%) had acquired primary education, and 54.6% were unemployed. The prevalence of malnutrition among pregnant women was 4.3%. Malnutrition was more in pregnant women with no formal education in the second trimester. However, this study indicated a statistically insignificant association between the prevalence of malnutrition in pregnant women and different factors of this study. Thus, the finding reveals the need of enhancing second-trimester nutritional status by the institute health programming. A total of 280 pregnant women were included, with a response rate of 97%. More than half of pregnant women were 25–45 years old. More than half (56.4%) had acquired primary education, and 54.6% were unemployed. The prevalence of malnutrition was 4.3%. The malnutrition was higher in second-trimester women with no formal education. However, the study found no statistically significant association between malnutrition prevalence and various factors. The finding highlights the importance of improving nutritional status during the second trimester through health programming at the institute.
1. Introduction
As defined by the World Health Organization (WHO), malnutrition is a cellular imbalance between the supply of nutrients and a person’s intake of energy and nutrients to meet body growth, maintenance, and its functions [1]. Globally, 6.9 million pregnant women (25%), especially in soared crisis countries, are malnourished [2, 3]. In Africa, 23.5% of pregnant women have malnutrition, and nearly 68% of rural pregnant women are malnourished in sub-Saharan Africa [4, 5]. Malnutrition is often grouped into undernutrition and overnutrition. Undernutrition consists of stunting, wasting, and underweight. This is caused by a lack of food intake to meet the nutritional body needs [6]. Overweight or overnutrition refers to excessive fats in the body because of an overdiet intake that is more than the body needs [7]. Pregnant women on quantity and quality of food a pregnant woman should take during pregnancy [8]. This, among other factors, such women during pregnancy have highly nutritional demands during pregnancy; ensuring they have balanced and adequate nutritional diets is fundamental for good pregnancy outcomes [9]. During pregnancy and breastfeeding, nutritional demands increase, and meeting this need is much critical throughout the time of pregnancy and lactation. Besides the increase in body needs during pregnancy, several factors contribute to causing malnutrition during pregnancy. Among these contributing factors are ignorance, lack of awareness, lack of food, illness, and infections [10]. Further studies within the region revealed that maternal educational level was associated with undernutrition in pregnancy, especially among women who lack education.
Malnutrition in pregnant women can lead to serious health adverse both in mother and infant. In the mother, undernutritional mothers are at high risk of developing spontaneous abortion, anemia in pregnancy as well as the risk of maternal death [11]. While in the fetus, malnutrition in pregnancy is at risk of intrauterine growth retardation, small for gestation age, premature birth, intrauterine fetal death, birth defects, and underdevelopment of fetal organs [12]. Improvement of nutritional diet among pregnant women is an essential component in maintaining pregnant women’s health and prevention of nutritional imbalances caused by pregnancy. A variety of healthy diets are recommended for pregnant women besides keeping women on supplementary iron and folic acid during the entire pregnancy period [13].
To achieve optimal maternal and perinatal outcomes, pregnant women’s dietary intake should be maintained [14]. Many studies revealed an association of inadequate food intake in pregnant women and intrauterine growth failure, especially among women with protein–energy malnutrition due to daily nutritional requirements shortage [15]; because of maternal nutritional demand during pregnancy, WHO indicated that an estimated average of 56% of pregnant women suffer from nutritional anemia beside other 82% pregnant women with zinc deficiency worldwide [16]. However, less or none is known about South Sudan.
Studies conducted in different sub-Saharan African countries indicated various factors which are associated with malnutrition in pregnancy. In a study done in the Morogoro region of Tanzania, women with stable employments were less likely to had malnutrition compared to nonemployed women [17]. Furthermore, single pregnant women were mostly found to be associated with undernutrition in pregnancy [18]. This is in agreement with another study conducted in the Gondor region of Ethiopia that revealed women with bad marital status to be two times at risk of having undernutrition [19]. Regarding maternal age, pregnant women with ages between 16 and 20 years old were found to have had malnutrition compared to those above 24 years old of age [20]. A woman’s educational level and her gestational age play a significant role in her health during pregnancy. Findings from the Eastern Ethiopian region disclosed that pregnant women with educational backgrounds, those in the second or third trimester, and also women with big family size members were among pregnant women with the possibilities of catching malnutrition during pregnancy [21].
As there was no similar research conducted before to determine pregnant women’s nutritional status nationwide and in Juba Teaching Hospital in particular. Conducting this study will determine the magnitude of malnutrition among pregnant women in South Sudan. The results shall guide health policymakers and other stakeholders in designing policy and planning related to maternal health.
2. Materials and Methods
2.1. Study Setting
Juba Teaching Hospital is in Juba, the capital city of the Republic of South Sudan. It has a bed capacity of 500 beds and serves a total of 12,444,018 South Sudan Population as the hospital is considered a main national referral facility [22]. The facility has different departments, among them is the maternal and child health department. The daily pregnant visiting Antenatal care (ANC) ranges from 50 to 60 women per day. The clinic is located within the Department of Obstetrics and Gynecology and provides ANC counseling, birth preparedness package, physical assessment, laboratory screening, and prevention of mother-to-child transmission (PMTCT). These besides the provision of malaria prevention services during pregnancy as well as prevention of anemia in pregnancy through folic and iron supplementation.
2.2. Study Design, Sample Size, and Technique
N = (1.96) 2 × 0.21(1 − 0.21)/(0.05) 2 = 254.9, convinced to 255.
About 10% for nonrespondents had been added to 280; the amount of 10% when calculated was 25.
Therefore, 255 + 25 = 280.
Therefore, N = 280, which was the expected sample size to this study.
Due to the study time limitation, a total enumerative (consecutive) sampling technique was used to enroll the participants in the study. This sampling procedure considers enrollment of the study subject meeting the criteria of inclusion consecutively until the required sample size is completed.
Due to the study time limitation, a total enumerative (consecutive) sampling technique was used to enroll the study population size. This sampling procedure considers enrollment of the study subject meeting the criteria of inclusion consecutively until the required sample size is completed.
2.3. Data Collection Tool and Procedures
Data were collected for a duration of 1 month from 1st to 30 September 2023. All pregnant who were eligible for the study were recruited through the ANC clinic. A tool for data collection contains three parts. The first part is for introduction and socioeconomic information, the second part is for reproductive and clinical information, and the third part is for anthropometric data such as weight, height, and mid-upper-arm circumference (MUAC).
A study was considered using MUAC tape to determine a pregnant woman with malnutrition [24]. A simple tool (tape) is used in a low-setting area to detect malnutrition among pregnant and lactating mothers as well as among children from 6 to 12 months [25]. The tool was validated by WHO and United Nations Children’s Funds (UNICEF) use in 2009 [26]. This is because using biochemical measurements is expensive and requires resources.
The adult MUAC tape ranged from 6 to 52 cm, and to measure the women’s arm, a tape was placed between the tip of the shoulder and elbow of the left arm, and the reading was taken at mid of the arm [27]. A MUAC measurement between 19 and 22 was considered having mild-to-moderate undernutrition; below 19 was severely malnourished, while the outpoint of more of 23 cm and above was considered normal [28, 29].
To allow women to be smoothly attended by the ANC providers, client recruitment was started at the reception point where women were registered, and vital signs and anthropometric measures were taken. During this point, the study purpose and its objectives were explained to clients. Those who consented to participate in the study and met the study criteria were given the consent form to sign and enrolled systematically into the study through one-after-one enrollment, followed by socioeconomic data, obstetrics, and anthropometric data collection. However, biochemical records were required after finalizing the meeting with the designed ANC provider.
2.4. Study Variables
Malnutrition in pregnant women was the dependent variable. It is measured using a MUAC measuring tape to the nearest 1 mm at the mid-point between the shoulder and elbow on the woman’s bare left arm. The cutoff value is dichotomized into normal if the reading is 23 cm or above (MUAC ≥ 23) or undernutrition if the measurement is below 23 cm (MUAC < 23).
In the study, women’s sociodemographic characteristics (age, education, income, size of the family and occupation, meal intake) and reproductive health-related characteristics (parity, gestational age of pregnancy, gravidity) were considered independent variables.
2.5. Data Entry and Analysis
All were checked for completeness, and each questionnaire was given a unique code. The complete questionnaire was entered into Epi Data Manager version 4.6 to control the data entry process and then exported into SPSS version 26 for analysis. The relationship between outcome variables and exposure variables was done using the chi-square test, and a (p) value of less than 0.05 would be considered significant.
Two-step logistics regression (bivariate and multivariate) was not used to analyze the association of the independent variables on the dependent variable by controlling confounders. This was because the Chi-square tests were statistically insignificant. The dependent variable was malnutrition in pregnancy. Indepedent variables were statistically evaluated at 95% level of significance, predictors variables which were insignificant at bivariate were not computed through multivariate logistic regression.
2.6. Ethical Consideration
The study was commenced after securing and obtaining the ethical clearance from the National Ministry of Health through the office of the Medical Director of Juba Teaching Hospital.
The purpose of the study was explained to the participants. Those who understood and agreed to participate in the study received the consent form to sign before being enrolled in the study. For minor participants (less than 18 years), consent for participating was also taken through their adult companions. An interview was conducted considering the privacy and confidentiality of the study subject. Names were not included in the study, and any participant had a right to drop the study at any time. For participants less than 18 years old were permitted to participate in the study through their guardians.
3. Results
3.1. Pregnant Women’s Sociodemographic Characteristics
In regard to descriptive analysis of sociodemographic characteristics of pregnant women attending ANC at JTH. A total of 280 pregnant women were interviewed with the response rate stood at 97%. More than half of pregnant women were 25–45 years old. In regard to Level of education, 142 of the mothers (56.4%) had acquired primary education, with only 8.21% having attained university qualifications. Unemployment accounted for more than half (54.6%) among these women, while a low proportion of them (27.5%) were revealed to have been self-employed. The size of the family members of 6 and above was the major: 168 (60%). Daily meal frequency of two meals per day was 68.6%, and adequate partner support was 50.4% (Table 1).
| Variable | n = 280 | % |
|---|---|---|
| Age | ||
| Less than 18 years | 12 | 4.3 |
| 18–24 years | 126 | 45 |
| 25–45 years | 142 | 50.7 |
| Marital status | ||
| Married | 270 | 96.4 |
| Single | 6 | 2.1 |
| Cohabiting | 4 | 1.4 |
| Education level | ||
| No educational formal | 71 | 25.4 |
| Primary–secondary | 158 | 56.4 |
| University and above | 51 | 18.2 |
| Occupation | ||
| Employed | 50 | 17.9 |
| Self-employed | 77 | 27.5 |
| Not employed | 153 | 54.6 |
| Partners support | ||
| No support | 85 | 30.4 |
| Not adequate | 54 | 19.3 |
| Adequate | 141 | 50.4 |
| Family size | ||
| 2 members or less | 26 | 9.3 |
| 3–5 members | 86 | 30.7 |
| 6 and above | 168 | 60 |
| Daily meal frequency | ||
| 0–1 meal/day | 71 | 25.4 |
| 2 meals/day | 192 | 68.6 |
| 3 meals and above/day | 17 | 6.1 |
| Alcohol intake | ||
| Yes | 13 | 4.6 |
| No | 267 | 95.4 |
| Gravidity | ||
| Gravida 1 | 66 | 23.6 |
| Gravida 2+ | 214 | 76.4 |
| Trimester | ||
| 2nd trimester | 66 | 23.6 |
| 3rd trimester | 214 | 76.4 |
| Maternal chronic physical sickness | ||
| Present | 17 | 6.1 |
| Not present | 263 | 93.9 |
Pregnant Women’s weight in kilos, height in centimeters, and MUAC in centimeters stood at a mean of 66.02, 163.18, and 27.15, respectively, as indicated in Table 2.
| Descriptive statistics | n | Min | Max | Mean | Std. dev |
|---|---|---|---|---|---|
| Weight by kg | 280 | 43 | 110 | 66.02 | 11.428 |
| Height by cm | 280 | 150 | 199 | 163.18 | 7.609 |
| MUAC by cm | 280 | 21 | 40 | 27.15 | 3.473 |
3.2. Prevalence of Malnutrition among Pregnant Women
The prevalence of malnutrition among pregnant women attending Juba Teaching Hospital staged at 4.3%. The malnutrition was more in pregnant women with 8 years or less, single marital status, no educational formal, unemployed, second trimester, and so on.
3.3. Pattern of Malnutrition among Pregnant Women Attended Antenatal Care at Juba Teaching Hospital
To the study identified factors associated with malnutrition among pregnant women attending antenatal care services at Juba Teaching Hospital. These factors include age, marital status, education level, occupation, partner support, family size, daily meal frequency, and alcohol intake, among others. The results of this research study revealed that these factors were statistically insignificant association (Table 3).
| Factors | Malnutrition | X2 | df | P-value | ||
|---|---|---|---|---|---|---|
| MUAC < 23: n (%) | MUAC > = 23: n (%) | Total | ||||
| Age | — | — | — | 1.721 | 2 | 0.423 |
| Less than 18 years | 1 (8.3) | 11 (91.7) | 12 (100) | — | — | — |
| 18–24 years | 7 (5.6) | 119 (94.4) | 126 (100) | — | — | — |
| 25–45 years | 4 (2.8) | 138 (97.2) | 142 (100) | — | — | — |
| Marital status | — | — | — | 2.451 | 2 | 0.294 |
| Married | 11 (4.1) | 259 (95.9) | 270 (100) | — | — | — |
| Single | 1 (16.7) | 5 (83.3) | 6 (100) | — | — | — |
| Cohabiting | 0 (0) | 4 (100) | 4 (100) | — | — | — |
| Education level | — | — | — | 0.995 | 2 | 0.608 |
| No educational formal | 4 (5.6) | 67 (94.4) | 71 (100) | — | — | — |
| Primary–secondary | 7 (4.4) | 151 (95.6) | 158 (100) | — | — | — |
| University and above | 1 (2.0) | 50 (98.0) | 51 (100) | — | — | — |
| Occupation | — | — | — | 0.070 | 2 | 0.966 |
| Employed | 2 (4.0) | 48 (96.0) | 50 (100) | — | — | — |
| Self-employed | 3 (3.9) | 74 (96.1) | 77 (100) | — | — | — |
| Not employed | 7 (4.6) | 146 (95.4) | 153 (100) | — | — | — |
| Partners support | — | — | — | 0.081 | 2 | 0.960 |
| No support | 4 (4.7) | 81 (95.3) | 85 (100) | — | — | — |
| Not adequate | 2 (3.7) | 52 (96.3) | 54 (100) | — | — | — |
| Adequate | 6 (4.3) | 135 (95.7) | 141 (100) | — | — | — |
| Family size | — | — | — | 4.064 | 2 | 0.131 |
| 2 members or less | 3 (11.5) | 23 (88.5) | 26 (100) | — | — | — |
| 3–5 members | 4 (4.7) | 82 (95.3) | 86 (100) | — | — | — |
| 6 and above | 5 (3.0) | 163 (97.0) | 168 (100) | — | — | — |
| Daily meal frequency | — | — | — | 1.937 | 2 | 0.380 |
| 0–1 meal/day | 1 (1.4) | 70 (98.6) | 71 (100) | — | — | — |
| 2 meals/day | 10 (5.2) | 182 (94.8) | 192 (100) | — | — | — |
| 3 meals and above/day | 1 (5.9) | 16 (94.1) | 17 (100) | — | — | — |
| Alcohol intake | — | — | — | 0.610 | 1 | 0.435 |
| Yes | 0 (0) | 13 (100) | 13 (100) | — | — | — |
| No | 12 (4.5) | 255 (95.5) | 267 (100) | — | — | — |
| Gravidity | — | — | — | 0.663 | 1 | 0.415 |
| Gravida 1 | 4 (6.1) | 62 (93.9) | 66 (100) | — | — | — |
| Gravida 2+ | 8 (3.7 | 206 (96.3) | 214 (100) | — | — | — |
| Trimester | — | — | — | 0.663 | 1 | 0.415 |
| 2nd trimester | 4 (6.1) | 62 (93.9) | 66 (100) | — | — | — |
| 3rd trimester | 8 (3.7) | 206 (96.3) | 214 (100) | — | — | — |
| Maternal chronic physical sickness | — | — | — | 0.810 | 1 | 0.368 |
| Present | 0 (0) | 17 (100) | 17 (100) | — | — | — |
| Not present | 12 (4.6) | 251 (95.4) | 263 (100) | — | — | — |
4. Discussion
In this study, the prevalence of malnutrition among pregnant women attending ANC at Juba Teaching Hospital was only 4.3%. This was mainly common among women with single marital status, women with no formal education, unemployed, and women in their second trimester of pregnancy. This study was much less than that found in a meta-analysis review done in many African countries to identify the burden and determinants of malnutrition among pregnant women in Africa, where prevalence exceeded 20% [4]. Such low prevalence might not necessarily represent the nutritional facts among the entire pregnant women population in South Sudan; this was because of the setting of the study, which included a limited sample size.
Despite the lack of significant association between the pregnancy and women’s sociodemographic and obstetrics factors, it is worthy to note that in this study, malnutrition was mainly common among single pregnant women and those with no educational background. These findings are in line with similar studies conducted in Tanzania and Kenya, respectively, where single mothers and those with no educational background were found to have malnutrition [30, 31]. These findings could be explained by the fact that those with no educational background are hardly getting challenges of being employed with the convenience jobs that have good income. Similarly, as for single mothers, this study indicated that malnutrition is also common among women who lack the support of their partners. These findings are in line with other studies done by Edem M, where it was found that women with less partner support are likely to develop malnutrition during their pregnancy [32]. Additionally, malnutrition prevalence was also common among young age pregnant women less than 18 years. These findings are supported by similar findings where young age pregnant women were found experiencing malnutrition compared to those with above 18 years old [33]. Despite the lack of clearly scientific explanation for this, a possible justification could be due to a lack of knowledge on nutrition in pregnancy among young age women with no information on nutritional demands during pregnancy.
5. Conclusion
Despite the fact that the malnutrition level among pregnant is reported by the study as low, malnutrition among pregnant women remains a major public health most disquiet matter as it complicates the pregnancy outcome. In this study, malnutrition was more in pregnant women with 18 years or less, single marital status, no educational formal, unemployed, second trimester, beside others. Prevention of malnutrition in pregnancy requires the development of multisectoral approaches by the government and its health partners. The study recommends institutional programing that reduces early marriage and enhances the educational level and self-reliant and productive community.
Abbreviations
-
- ANC:
-
- Antenatal care
-
- JTH:
-
- Juba Teaching Hospital
-
- MUAC:
-
- Mid-upper-arm circumference
-
- PMTCT:
-
- Prevention of mother-to-child transmission
-
- UNICEF:
-
- United Nations Children’s Fund
-
- WHO:
-
- World Health Organization.
Conflicts of Interest
The authors declare that there are no conflicts of interest.
Authors’ Contributions
Conceptualization was done by Zechariah J. Malel; Formal analysis was done by Zechariah J. Malel; Investigations were done by Madut Madut. J, Akech Akol Augustine, Nyang Deng Machok, Daniel Tong Tong, Michael Maluil, Madut, and Rose Juma Efrem; Methodology was done by Zechariah J. Malel. All authors contributed to data collection free of charge, as well as the corresponding author who developed the study design, analyzed, and wrote the manuscript for free.
Acknowledgments
The author is thankful to the Juba Teaching Hospital Administration, Department of Obstetrics and Gynecology and particularly the staff in the Maternity and Antenatal Care (ANC) Department for their collaboration with the research team throughout the data collection duration.
Open Research
Data Availability
The dataset for this manuscript is available on the SPSS database and can be shared if requested.
