Gestational weight gain and its determinant factors among women attending at public health facilities, Northwest Ethiopia, 2023

Abstract

Background

Women who do not gain enough weight during pregnancy had increased risk of preterm delivery, low birth weight, prematurity, a longer hospital stay, and consequently, higher health-related costs. However, research on gestational weight gain and its determinants is scarce in developing countries, including Ethiopia. Therefore, this study aimed to assess adequate gestational weight gain and its determinant factors among pregnant women who had ANC follow-up visits at public health facilities in Debre Markos town, Northwest Ethiopia.

Methods

An institutional-based cross-sectional study was conducted from January 1, 2023 to June 30, 2023. The Ethiopian National Antenatal Guideline (ENAG) was used to define Gestational Weight Gain (GWG). A systematic random sampling technique was employed to select 532 study participants. Data was entered into Epidata Version 3.1 and exported into SPSS Version 25 for statistical analysis. Bivariable and multivariable binary logistic regression analyses were conducted to examine the association between the outcome variable and independent variables. An adjusted odds ratio with a 95% confidence interval was used to report the strength of the association.

Results

This study found that 30.9% (95% CI: 27.0, 34.7) of women gained adequate gestational weight. Number of ANC visits (AOR = 5.9, 95% CI: 3.02, 14.7), Meal frequency (AOR = 3.2, 95% CI: 1.56, 6.67), and consumption of animal source foods at least once per week (AOR = 2.7, 95% CI: 1.47, 4.90) were statistically associated with adequate weight gain.

Conclusion and recommendation

Nearly one-third of pregnant women gain adequate gestational weight. Women who had frequent ANC visits, meal frequency, and consumption of animal source foods at least once per week were significantly associated with adequate gestational weight gain. Women centered nutritional counseling and support is essential to improve weight gain during pregnancy.

Introduction

Gestational Weight Gain (GWG) is defined as the amount of weight gain from conception until the birth of the baby [1]. It is one of the important determinants of pregnancy outcome and has a significant influence on the birth-weight of the fetus [2]. Weight gain during pregnancy is also a good measure of intrauterine fetal nutrition and is associated with maternal and fetal health, which may influence gestational age at birth, mode of delivery, birth weight, and maternal weight retention after delivery [3, 4].

Gestational weight gain is substantially influenced by several factors, including maternal, physiological, and social characteristics, and the rate of weight gain is also variable throughout pregnancy and its timing during pregnancy [2].

Studies conducted across the globe, the proportion of women who gained the recommended amount of weight during their pregnancy period was ranged from 25.4 to 72.4% in developed countries [5–13], 3–34.4% in African countries [14–19], and 24–28% in Ethiopia [20, 21].

Excessive weight gain during pregnancy is common in developed countries and associated with an increased risk of pregnancy induced hypertension, macrosomia, cesarean delivery, and complications during the postpartum period, all of which can negatively impact both maternal and fetal outcomes [22, 23]. In contrast, the evidence indicates that inadequate weight gain during pregnancy increases the risk of preterm delivery, low birth weight, prematurity, a longer hospital stay, and consequently, higher health-related costs [23]. Nevertheless, a slower rate of gain during the later stages of of pregnancy may still play an important role in promoting healthy outcomes [24].

The recommended amount of GWG varies based on the pre pregnancy body mass index (BMI) of the women. According to the United State Institute of Medicine (IOM) recommendations, women with BMI ≤ 18.5 kg/m2 are recommended to gain 12.5–18 kg; women with BMI 18.6–24.9 kg/m2 are recommended to gain 11.5–16 kg; women with BMI 25.0 to 29.9 kg/m2 are recommended to gain 7–11.5 kg; and women with BMI ≥ 30.0 kg/m2 are recommended to gain 5–9 kg [1]. Furthermore, according to the Ethiopian National ANC Guideline (ENAG), the recommended GWG is 10–12.5 kg and 1.5–2 kg per month after 4 months of pregnancy [25].

Adequate weight gain during pregnancy is associated with better neonatal and maternal outcomes. It supports the growth and development of the fetus and reduces the likelihood of morbidity and mortality [21]. Nonetheless, in Sub-Saharan African (SSA) countries, limited information is available regarding gestational weight gain and its associated factors. This is probably because estimation of GWG requires women to be followed from pre-pregnancy to near childbirth, which is frequently infeasible in low-income settings where preconception care is low and births are largely happening at home. Therefore, this study aimed to assess adequate gestational weight gain and its associated factors among pregnant women who had ANC follow up in Debre Markos town public health facilities, Northwest Ethiopia.

Methods

Study design, period, and setting

An institutional-based cross-sectional study was conducted among pregnant women attending at public health facilities in Debre Markos town from January 1, 2023 to June 30, 2023. Debre Markos is the capital city of East Gojjam Zone, and it is 300 km and 265 km away from Addis Ababa, the capital city of Ethiopia, and Bihar Dar, the capital city of Amhara National Regional State, respectively. According to the population projection, it has a total population of 140,699; 69,620 (49.5%) were males and 71,079 (50.5%) were females. Debre Markos town has four primary-level health centers: Debre Markos, Hidassie, Wuseta, and Gozamin health centers. In addition, the town has one tertiary-level healthcare facility i.e., Debre Markos Comprehensive Specialized Hospital.

Population and eligibility criteria

All pregnant women who had ANC follow-up visits in public health facilities in Debre Markos town were the source population. All pregnant women who had ANC follow-up visits in public health facilities in Debre Markos town during the data collection period were the study population.

Based on the records in the ANC follow-up chart, pregnant women who had ANC visits more than two times (before 16 weeks of gestational age and after 36 weeks) in public health facilities in Debre Markos town were included in this study, whereas pregnant women with twin pregnancies and gestational diabetes were excluded.

Sample size determination

The sample size was calculated using the assumption of a single population proportion formula by considering the proportion of adequate weight gain from the previous study (28%) [21], 95% Confidence Interval (CI), and 4% margin of error (d = 0.04).

= (Zα₂)² p (1-P)/d²

= (1.96)² 0.28(1-0.28)/ (0.04)²

= 484

Thus, after adding 10% for a possible non-response rate, the final sample size was 532.

Moreover, the adequacy of the sample size was checked using significant variables that have been reported in the previous study [20] (Table 1).

Table 1.

Sample size calculation using significant variables associated with adequate GWG among women attending ANC

Variables	Power	Ratio	% outcome in unexposed group	% outcome in exposed group	COR	Sample Size
Occupational Status	80	1:1	55.5	38.7	2.64	285
Weight Status	80	1:1	75.0	76.1	3.52	245
Perinatal Depression	80	1;1	72.2	66.7	2.30	317

Therefore, the largest sample size was obtained from the single population proportion formula, which was 532.

Sampling technique and procedure

A total of 3,484 women attended ANC services, including 708 at Debre Markos Comprehensive Specialized Hospital and 2,776 at the health centers. From these, 532 women were selected to participate in the study; 106 from each health center and 108 from the comprehensive specialized hospital. The study participants were selected using a systematic random sampling technique after being proportionally allocated to each public health facility. The sampling interval (k) was calculated by dividing the total population to the sample size (3484/532), resulting in a sampling interval of 7. The starting number was selected by a lottery method. The list of women’s medical record number in the maternal registration book was used as a sample frame to draw a sample.

Operational definitions

Gestational weight gain (GWG)

In the current study, gestational weight gain (GWG) was calculated as the difference between the pregnant mother’s weight measured after 36 weeks of the gestational age and her weight recorded before 16 weeks of the gestational age, based on the records in the ANC follow-up chart. A weight gain of 10–12.5 kg was considered adequate, in accordance with ENAG [25].

Data collection tool, procedure, and quality assurance

A structured questionnaire adapted from previous similar studies was used to collect the data. The data were collected through face to face interviews and chart reviews. Two BSc midwives collected the data, and one MSc midwife supervised the overall data collection process.

The quality of the data was assured through careful design of the questionnaire, proper training of the data collectors and supervisor, close supervision of the data collection process. Furthermore, a pretest was done, and appropriate modifications were made accordingly. Finally, the completeness and consistency of the collected data were checked to ensure the quality of the data.

Data processing and analysis

Data were entered into Epi-data Version 3.1 and exported into SPSS Version 25 for analysis. Descriptive analysis was employed using numbers and percentages. Data were presented using tables, figures, and texts. A binary logistic regression model was fitted to assess the association between dependent and independent variables. Variables, such as age, religion, marital status, occupation, educational status, occupation, plan of pregnancy, gravidity, parity, number of ANC visits, physical exercise, meal frequency, nutritional counseling, consumption of animal source foods, consumption of fruits and vegetables, and wealth index were included in the model. A Hosmer-Lemeshow goodness of fit test was used to check the model’s fitness. The result of Hosmer-Lemeshow test was 0.86, indicating the model fitted the data well. Variables with a p-value < 0.25 were candidates for multivariate logistic regression. The strength of the association was reported using an Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI). A p-value < 0.05 was used to declare a statistically significant association between the outcome variable and predictor variables.

Results

Socio-demographic characteristics

A total of 517 pregnant mothers participated in this study, with a response rate of 97.2%. The mean age of the study participants was 27.1 ± 4.89 years. More than half (53.8%) of the study participants were attended college and above education program. The majority (97.1%) of pregnant women, were orthodox by religion, and about 220 (42.6%) women were, housewives (Table 2).

Table 2.

Socio-demographic characteristics of study participants (N = 517)

Variables	Categories	Frequency	Percent (%)
Age in years	< 20	36	7.0
	20–29	333	64.4
	30–39	137	26.5
	> 40	11	2.1
Marital status	Single	11	2.1
	Married	496	95.9
	Divorced	8	1.5
	Widowed	2	0.4
Educational status	No formal education	12	2.3
	Primary	31	6.0
	Secondary	196	37.9
	College and above	278	53.8
Religion	Orthodox	502	97.1
	Protestant	1	0.2
	Muslim	14	2.7
Occupation of the mother	House-wife	220	42.6
	Farmer	24	4.6
	Government worker	183	35.4
	Merchant	44	8.5
	Others	46	8.9
Occupation of father	Farmer	12	2.3
	Government worker	299	57.8
	Merchant	148	28.6
	Others	58	11.2
Wealth Index	Poor	151	29.2
	Medium	268	51.8
	Rich	98	19.0

Obstetrics- and medical-related characteristics of the study participants

Nearly two-thirds of the pregnant women (61.3%) were multigravida. Among the study participants, only 8 (1.5%) had a previous spontaneous abortion. A majority of pregnant women (91.3%) had intended pregnancies (Table 3).

Table 3.

Obstetrics- and medical-related characteristics of the study participants

Variable	Categories	Frequency	Percent (%)
Intention of pregnancy	Intended	472	91.3
	Unintended	45	8.7
Abortion	Yes	8	1.5
	No	509	98.5
Number of pregnancy	Primigravida	200	38.7
	Multigravida	317	61.3
Number of ANC visit	≤3 times	91	17.6
	>3 times	426	82.4

Nutrition-related characteristics of the study participants

Among the total study participants, 479 (92.6%) received nutritional counselling during ANC follow- up visits. Nearly all (98.8%) of the study participants did physical exercise at least once per week (Table 4).

Table 4.

Nutrition-related characteristics of the study participants

Variables	Categories	Frequency	Percent (%)
Nutritional counseling	Yes	479	92.6
	No	38	7.4
Meal frequency	< 3 times per-day	91	17.6
	4 times/one additional food per day	426	82.4
Fruit and vegetable consumption	Not at all	1	0.2
	At least once per week	516	99.8
Animal source foods	Not at all	98	19.0
	At least once per week	419	81.0
Physical exercise	Not at all	6	1.2
	At least once per day	511	98.8

Gestational weight gain

According to the current study, about 30.9% (95% CI: 27.0, 34.7) of pregnant women gained adequate gestational weight during their pregnancy, with a mean gestational weight gain of 8.4 kg (Fig. 1).

Fig. 1.

Gestational weight gain among women who had ANC follow-up in Northwest Ethiopia

Factors affecting gestation weight gain during pregnancy

Based on the bivariable binary logistic regression analyses, educational status, occupation, plan of pregnancy, number of ANC visits, meal frequency, consumption of animal source foods, and wealth index were included in the multivariable analysis. Finally, the number of ANC visits (AOR = 5.9, 95% CI: 2.02, 14.7), meal frequency (AOR = 3.2, 95% CI: 1.56, 6.67), and consumption of animal-source foods at least once per week (AOR = 2.7, 95% CI: 1.47, 4.90) were found to be statistically significant factors positively associated with adequate GWG (Table 5).

Table 5.

Factors associated with GWG during pregnancy among women who had ANC follow-up

Variable	Categories	Gestational weight gain				P-value
		Adequate	Inadequate	COR (95%CI)	AOR (95%CI)
Number of ANC visit	≤ 3 times	8	83	1	1
	> 3 times	152	274	5.75(2.71, 12.2)	5.9(3.02, 14.7)	< 0.001
Meal frequency	≤ 3 times/day	10	81	1	1
	> 3 times/day	150	276	4.40(2.21, 8.74)	3.22(1.56, 6.67)	0.002
Consumption of animal source foods	Not at all	16	82	1	1
	At least once per week	144	275	2.68(1.51, 4.75)	2.7(1.47, 4.90)	0.001

Discussion

According to the current study, the proportion of adequate gestational weight gain was 30.9%. Factors significantly associated with adequate gestational weight gain were the number of ANC follow-up visits > 3 times, the frequency of feeding > 3 times per day, and animal source food consumption at least once per week.

In this study, the mean gestational weight gain was 8.4 kg. This finding is consistent with the studies conducted in Addis Ababa (8.7 kg) and Hariri regional state (8.96 kg), Ethiopia [20, 21]. However, it is lower than the studies conducted in North America (13.9 kg) [6], Europe (14.7 kg) [26], Brazil (12.3 kg) [27], and Uganda (12.43 kg) [16]. The possible reason for this discrepancy might be due to the difference in socio-demographic status, socio-economic, such as access to food, community wealth index, nutritional status, dietary habits during pregnancy, and level of awareness among the pregnant mothers [28, 29]. Evidence showed that those women who had low level of awareness regarding the recommended weight gain during pregnancy had inadequate gestational weight gain [30].

The current study found that the proportion of women who gained adequate gestational weight was 30.9% (95% CI: 27.0, 34.7). This finding is lower than the studies conducted in Brazil [27]. Evidence showed that different high-income countries reported that a higher proportion of women gained excessive gestational weight during their pregnancy [6, 26]. A low proportion of women with adequate gestational weight gain in this study could be due to a wide range of nutritional problems, economic instability, poverty, food insecurity, and frequent infections, which are common in sub-Saharan African countries [23]. However, this finding is higher than similar studies conducted in African countries such as Ghana (8.8%) [31], Uganda, Kampala, and Tanzania [16, 17].

According to the current study, those women who had frequent ANC follow-up visits (> 3 times) were 5.9 times more likely to gain adequate gestational weight than their counterparts. This finding was supported by similar studies conducted in Ethiopia [20, 21]. This could be explained by the fact that during ANC visits, women are likely to receive advice on weight management, the importance of maintaining a balanced diet, and the need for proper nutrition during pregnancy [32]. In order to reduce perinatal mortality and improve the pregnancy experience of women, a minimum of eight contacts have been started in Ethiopia [33]. For those pregnant women with identified problems, additional contacts may be scheduled as necessary [34]. This schedule enables the ANC provider to early detect and treat potential maternal and fetal complications before advancing to a severe or irreversible stage [34, 35]. It also gives room for the pregnant woman to share her symptoms and worries with her care provider before become worsening.

Those women who fed more than three times per day were 3.2 times more likely to gain adequate gestational weight during their pregnancy period. This finding is supported by similar studies done in Ethiopia [20, 21].This might be due to promoting a healthy diet by increasing the frequency, quality, quantity, and diversity of food consumed as well as ensuring its safety [36]. Therefore, it is recommended to advice mothers to get at least one additional nutrient-dense, safe, and diverse meal per day during pregnancy to fulfill the extra energy and protein requirement.

The current study also found that those women who consumed animal source foods at least once per week were 2.7 times more likely to gain adequate gestational weight as compared to their counterparts. It is supported by another study conducted in Ethiopia [21]. This finding is supported by the scientific fact that maintaining diversified food and a healthy diet during pregnancy is essential for the mother´s and fetus´ health [32]. Moreover, in order to meet the needs of both the mother and the fetus, a healthy pregnancy diet must provide with an adequate intake of energy, protein, vitamins, and minerals [37, 38].

Strengths and limitations of the study

This is a multi-center study design with a larger sample size covering all public health facilities in the region, using systematic random sampling, and using nationally recognized guidelines for.

assessment. However, it has some limitations. Women’s last weight was measured at 36 weeks of gestation, but there may be a weight gain after 36 weeks of gestation. Moreover, a cross-sectional nature prevents establishing causal relationships, and potential for recall bias in dietary and lifestyle information.

Conclusions and recommendations

This study found that nearly one third of the study participants gained adequate gestational weight during their pregnancy period. Those women who had frequent ANC follow-up visits, who had a meal frequency greater than three times per day, and who consumed animal source foods at least once per week during pregnancy had a positive association with gestational weight gain. All childbearing women need to receive more nutrition-related counseling and consultations offered by health providers during prenatal visits and also it is better to advise pregnant mothers to have frequent ANC follow-up visits. Moreover, further prospective follow-up studies are needed to identify the causal relationship between determinant factors of weight gain during pregnancy.

Abbreviations

ANC

Antenatal care

AOR

Adjusted Odds Ratio

BMI

Body Mass Index

CI

Confidence Interval

COR

Crude Odds Ratio

ENAG

Ethiopian National Antenatal Guideline

FANC

Focused Antenatal Care

GDM

Gestational Diabetic Mellitus

GWG

Gestational Weight Gain

SBA

Small for Gestational Age

Author contributions

MA conceptualized the study and EA and MLE were involved in design, analysis, interpretation, report and manuscript writing. MA, EA, MLE, TA, HM, AA and MAM made substantial contribution to conception, analysis and interpretation of data, drafting the manuscript and critical revision for important intellectual content. All the authors read and approved the final manuscript.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained from Debre Markos University, College of Medicine and Health Sciences ethical review committee with the reference number HSC/R/C/Ser/PG/Co/03/11/15. A verbal informed consent was obtained from all pregnant women. All the information obtained from the charts and pregnant women were kept confidential. All the processes of the research were performed and secured in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.