Effect of nutrition education and counseling intervention on the dietary diversity practice of pregnant women in Ethiopia: a systematic review and meta-analysis

Abstract

Background

A diversified diet plays a crucial role in decisive pregnancy outcomes and the future health of the child. In Ethiopia, inadequate dietary diversity among pregnant women remains a significant public health concern, contributing to maternal undernutrition, low birth weight, and poor infant development. Nutritional education and counseling intervention during pregnancy are the best strategies to improve dietary diversity practice of pregnant women.

Objective

This systematic review and meta-analysis aimed to estimating the pooled effects of nutrition education and counseling intervention on the pregnant women dietary diversity practice in Ethiopia.

Methods

The relevant studies searched from distinct databases such as (PubMed, Google scholar, Scopus, web of science, Embase, Seince direct and the institutional repository of Ethiopian universities were used. Data were extracted using Microsoft Excel, and analysis was performed using STATA-17. A random-effects model was used to estimate the overall effect size of nutritional education and counseling intervention on the dietary diversity practice of pregnant women. The pooled effect size was expressed as a risk ratio (RR) with a 95% CI. -test statistics were used for assessing heterogeneity between included studies. Egger’s test and funnel plot were used for assessing publication bias.

Results

A total of nine peer-reviewed studies that met the inclusion criteria with a total of 3739 pregnant women were involved in this study. The pooled effect of nutritional education and counseling intervention was RR: 1.78 with 95% CI (1.44, 2.18). There was a high heterogeneity ( = 91.1%) observed between includes studies.

Conclusions

Nutrition education during pregnancy have a positive effect in improving dietary diversity practice of pregnant women. Therefore, we recommend that health care providers and stakeholders offer nutrition education and counseling alongside routine services for pregnant women, ensuring they are equipped with essential knowledge about healthy dietary behaviors during pregnancy.

Registered on the PROSPERO database (CRD42025106769).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08943-3.

Background

An unbalanced diet during pregnancy has a significant contribution for maternal morbidity and mortality, unfavorable birth outcomes, and an elevated risk of chronic disease later in life [1, 2].

According to a report by UNICEF, about 25% of pregnant women worldwide are undernourished, with the highest rates found in crisis countries such as those with conflicts or natural disasters [3]. In Africa, 23.5% of pregnant women are malnourished, and in sub-Saharan Africa, nearly 68% of rural pregnant women are malnourished [4]. In Ethiopia, 32% of pregnant women experienced the burden of under nutrition [5], and maternal undernutrition accounts for more than half of newborn and child fatalities [6].

Worldwide, 25% of pregnant women were exposed for malnutrition. The consumption of fruit and vegetables (FV) is recommended as part of a balanced diet. However, food intake during pregnancy is often below the recommended amounts worldwide [7].

Sustainable Development Goal (SDG) aims to eliminate all types of malnutrition and meet the nutritional requirements of pregnant women by the year 2030. The World Health Assembly has set a goal to reduce pregnancy-related anemia by 50% by 2025, which is linked to maternal nutritional diet [8]. Thus, evaluating the pooled effect of nutrition education and counseling intervention for the improvement of dietary diversity could help to generate comprehensive evidence for policy and decision-making processes.

Nutrition education and counseling interventions are effective strategies to improve dietary diversity practices for the better health outcomes of pregnant women [9]. Nutrition education is critical in nutritional behavior change attempts because it improves participants’ nutrition and food literacy. Food literacy encompasses both nutrition literacy and the capacity to apply that knowledge to make sound decisions, whereas nutritional literacy is the set of skills required to comprehend and analyze information about food and its nutrients [10].

WHO suggests that ANC providers offer adequate, specific, and acceptable nutrition education to pregnant women during each visit of healthcare facilities, aiming to enhance the dietary practices [11]. The Ethiopian government also recommends nutrition counseling throughout pregnancy [12]. However, the routine nutritional counseling service in providing quality nutrition education is ineffective in changing the behavior of pregnant women [13].

In Ethiopia, the dietary food consumption of pregnant women is inadequate in both quantity and quality, characterized by low energy and nutrient content, with percentages ranging from 12.8% to 74.5% [12, 13]. The primary cause of this inadequate nutritional food consumption is the lack of awareness among pregnant women regarding their dietary requirements [12].

Even though there are small-scale studies, there is no a comprehensive systematic review and meta-analysis investigating the overall effect of nutrition education intervention on the dietary diversity practice of pregnant women in Ethiopia. Therefore, this systematic review and meta analysis aimed to review the existing evidence to determine the pooled estimate of the effect of nutrition education intervention on the improvement of dietary diversity practice among pregnant women in Ethiopia. The results of this review and meta-analysis could help to provide comprehensive evidence for policy makers, planners, and program evaluators.

Methods

Protocol registration and reporting

This review was conducted according to the protocol that has been registered at PROSPERO. The results of this systematic review and meta-analysis were reported based on the PRISMA reporting guideline to ensure transparent and complete reporting in review processes [14]. During the review, a wide range of databases were searched using electronic databases, reference lists of included studies, and cross-referencing to minimize the omission of relevant studies.

Search strategy

This review uses relevant studies searched from international electronic databases such as PubMed, Scopus, Scopus, Web of Science, Google Scholar, Science Direct and Embase. Moreover, the reference lists of eligible articles were searched to get additional studies. Eligible primary studies were accessed using the following key words, searching terms, “effect” OR “impact” AND “nutrition education” OR “counseling” AND “Pregnant Women” AND “dietary diversity practice” AND “Randomized Controlled trial” AND “in Ethiopia”. The search was limited to the English language and publication year 2010 and later.

Eligibility criteria

The eligibility criteria of the included studies were defined based on the PICOS (participants, intervention, comparison, outcomes and study design) framework.

Participants

Pregnant women.

Intervention

Nutrition education and counseling.

Comparator

Routine healthcare, not involved in the nutrition education intervention program.

Outcomes

Dietary diversity practice measured using validated dietary diversity indicators or food group consumption scores.

Study design

Randomized controlled trials and quasi-experimental studies.

Two authors (GS and MB) were assigned to filter the studies based on their title, abstract, and full text. Arguments concerning the study of eligibility solved by discussion with team members.

Inclusion and exclusion criteria

The authors include studies conducted on the effects of nutritional education and counseling intervention on dietary diversity practice of pregnant women in Ethiopia. Studies conducted using randomized controlled trial and qusi-experimental studies were included in this review. Qualitative studies, case studies, crossectional studies and ongoing studies with insufficient PICOS information were excluded.

Risk of bias (quality) assessment

The risk of bias assessment for the included studied performed using the revised Joanna Briggs Institute (JBI) quality-assessment tool, specifically designed for randomized controlled trials (RCTs) and quasi-experimental studies [15]. The tool has 13 questions for RCTs and 9 questions for quasi-experimental studies. Two reviewers (GS and MB) assessed the methodological quality of the included studies independently. Any disagreements and issues relating to the evaluation and classification of the articles were resolved through team discussions. Finally, the studies were classed as low risk, medium risk, and high risk of bias based on the overall risk of bias evaluation.

Outcome variable

This systematic review and meta-analysis primarily assessed the pooled effect of nutrition education and counselling intervention on pregnant women’s dietary diversity practice. All included studies assessed dietary diversity practice of pregnant women using standardized food group based indicators based on the FAO/WHO guideline. The dietary diversity practice of pregnant women was evaluated by asking women whether they had consumed various food items in the past 24 h. Women who consumed five or more food groups in the previous day was categorized as having good dietary diversity practice, otherwise not.

Approaches of nutrition education

This review emphasizes the effect of nutrition education as an intervention aimed at enhancing the knowledge of pregnant women and promoting positive dietary behaviors among pregnant women. The contents of provided nutrition education include identifying locally available nutritious food groups and the importance of a diverse diet during pregnancy for maternal and fetal health. These strategies highlight the significance of dietary changes during pregnancy, including increasing meal variety and frequency, as well as enhancing the intake of iron-rich foods during pregnancy.

Based on the included studies nutrition education mainly involves group sessions at health posts or community gatherings, direct (face-to-face) or indirect (e.g., phone calls and video conferencing) teaching methods through interactive discussions with and without visual aids such as pictures, pamphlets, videos, etc., for certain periods. Nutrition education and counseling were given by experienced health education and nutrition experts and delivered to the intervention group.

Data extraction

Two reviewers (GS and MB) checked titles and abstracts of the studies based on the eligibility criteria. The first author’s name, publication year, study region, study setting, sample size, and events in intervention and control groups were extracted using Microsoft Excel format.

Statistical analysis

The extracted data were exported into STATA-17 for statistical analysis. The pooled estimate of nutritional education and counseling intervention on pregnant women’s dietary diversity practice were assessed by a random effects model and expressed as risk ratio (RR) with a 95% confidence interval. The heterogeneity between the included studies was assessed using the Cochrane statistics. The heterogeneity was handled by conducting subgroups and sensitivity analysis. The subgroup analysis was performed based on median sample size, study setting, and region. One-leave-out analysis was performed to identify small study effects on the pooled effect estimate. Publication bias was also assessed using the graphical (funnel plot) and statistical (Regression based egger’s) tests.

Results

The literature search results of the combined electronic databases yield a total of 310 articles. Of these, 256 duplicate articles were removed. 32 studies were excluded because of screening titles and abstracts. About 22 articles were screened for full text articles. Additionally, 13 studies were excluded since it is not conducted in Ethiopia, not randomized controlled trial and systemic review. Finally, nine studies were included for this review and meta-analysis (Fig. 1).

Fig. 1.

PRISMA 2020 flow diagram describing the selection of studies for systematic review and meta-analysis

Characteristics of included articles

In this systematic review and meta-analysis, nine primary studies with randomized controlled trial and quasi-experimental study designs were used to estimate pool effect of nutrition education and counseling intervention on dietary diversity practice of pregnant women. A total of 4127 study participants (intervention group = 2012, control group = 2074) were involved with the smallest sample size (138) from Amhara region and largest sample size (744) from Oromia region. Four studies were conducted from Oromia region, two studies from Amhara region, one study from southern Ethiopia and two studies were conducted in Adiss Ababa city administration (Table 1).

Table 1.

Shows a descriptive summary of the studies included in this systematic review and meta-analysis

Authors, publication year	Region	Study Setting	Study design	Sample size	Event in Intervention	Event in Control	Study Quality	Reported Outcomes
Beressa G., et al. 2024 [16]	Oromia	CB	RCT	447	101/224	69/223	High	The proportion of adequate DDP was 14.15% higher in the intervention compared to the control group (45.09% versus 30.94%).
Demilew Y., et al. 2020 [17]	Amhara	CB	RCT	645	175/313	66/332	High	In the intervention group, DD improved by 24.6%, whereas in the control group, it showed a 15.9% reduction, with an overall difference of 40.5%.
Diddana T.,2018 et al. 2014 [18]	Amhara	CB	RCT	138	58/69	50/69	High	The Intervention group had 84.1% good DDP versus 72.5% in the control group. this is statistically significance difference improvement (P < 0.001)
Gebremichael, M. et al. 2023[19]	Oromia	CB	RCT	744	233/372	144/372	Medium	The proportion of pregnant women with optimal dietary practices increased by 34.7% in the intervention group, and this is a significant difference (p < 0.001)
Mohammedsanni et al. 2018 [20]	AA	IB	RCT	683	135/347	15/336	Medium	Pregnant women of intervention arm were have a significant improvement on DD (consumption of > = 5 food groups) (39.0% vs. 4.5%).
Sisay et al., 2023 [21]	SE	IB	RCT	235	64/115	83/120	High	The intervention group showed significant improvements in DD.
Tesfaye A., et al. 2025 [22]	Oromia	CB	RCT	426	87/207	35/219	High	Pregnant adolescents who had NEC, the DD increased by 20.3%. However, pregnant adolescents in the control group, DDP decreased by 5.6%.
Tsegaye D., et al. 2022 [23]	Oromia	CB	QE	403	102/207	68/196	High	Pregnant women who received NEC had higher DDP compared with women in the control group.
Zelalem A., et al. 2017 [24]	AA	IB	QE	406	340/406	190/406	Medium	DDP of pregnant women after NEC increased from 46.8% to control group 83.7%. But The study didn’t show a significant effect on increased.

Abbreviations: AA Addis Ababa, CB Community based, DDP Dietary diversity practice, IB Institutional based, RCT Randomized controlled trial, RR Risk ratio, QE Quasi experimental, NEC Nutrition education and counseling

Risk of bias assessment

The risk of bias for included studies was assessed using revised Joanna Briggs Institute (JBI) quality-assessment tool, specifically designed for randomized controlled trials (RCTs) and quasi-experimental. Based on this tool, six studies were assessed as having a high quality and three studies had medium quality.

Pooled effect of guided nutritional education and counselling

Seven randomized control trials and two qusi-experimental studies were included to estimate the pooled effect of nutrition education and counseling intervention during pregnancy on the dietary diversity practice of pregnant women. Based on the random effects model, the pooled effect size was RR: 1.54: 95% CI (1.34, 1.76), P-value = 0.001 with a high heterogeneity ( = 80.7%) (Fig. 2). The result of the pooled estimate declared that there is a strong association between guided nutrition education and counseling intervention on women’s dietary diversity practice during pregnancy. Women who received nutrition education and counseling during pregnancy were 1.54 times more likely to practice dietary diversity than pregnant women in the control group.

Fig. 2.

Forest plot showing the pooled effect of NEC on dietary diversity practice of pregnant women in Ethiopia

Handling heterogeneity

To evaluate the observed heterogeneity, subgroup and sensitivity analysis were conducted to identify the source of heterogeneity for the pooled effect of nutritional education and counseling intervention on dietary diversity practice during pregnancy. Subgroup analyses were carried out by region, study setting, types of study design and median sample size. The effect of nutrition education and counseling intervention on dietary diversity practice were statistically significant (RR = 1.56 wth 95% CI (1.15, 2.12) for studies done from Oromia region of Ethiopia ( = 87.0%; p-value=0.001) and (RR= 1.63 with 95% CI (1.37, 1.95) for studies conducted from AA city administration ( = 81.2%; p-value=0.02). However, studies done from other regions did not indicate a significant difference in the intervention effect. Subgroup analysis based on the median sample size of studies showed that, dietary diversity of pregnant women in studies with sample size grouped 138–426 (RR= 1.56 with 95% CI (1.27, 2.09) were showed that significant difference on the intervention effect (= 90.1 and p-value = 0.001).

In the subgroup analysis pooled RR varied from 1.48 to 1.8, within a 95% CI between 1.19, and 2.477. The highest pooled RR was observed from study conducted in southern Ethiopia region (RR = 1.8; with 95% CI: 1.32, 2.47) and lowest was observed among studies conducted inamong in community based study setting (RR = 1.48 with 95% CI (1.19, 1.83). Subgroup analysis indicated that the effect of nutrition education on dietary diversity practice of women during pregnancy did not significantly difference based on place of region, study setting, study design and median sample size (Table 2).

Table 2.

Sub-group analysis for the pooled effect of nutrition education and counseling intervention on dietary diversity among pregnant mothers in Ethiopia

Variables	Subgroup	No. of included studies	RR with (95% CI)	Heterogeneity across studies		Heterogeneity between group (p-value)
				(%)	P-value
Region	AA	2	1.63(1.37, 1.95)	81.2	0.02	0.544
	Amhara	2	1.33(0.99, 1.79)	70.3	0.06
	Oromia	4	1.56(1.15, 2.12)	87.0	0.001
	S/Ethiopia	1	1.80(1.32, 2.47)	00	0.00
Study Setting	CB	6	1.48(1.19, 1.83)	83.0	0.001	0.379
	IB	3	1.66(1.44, 1.91)	65.2	0.057
Study design	RCT	7	1.57(1.36, 1.81)	71.0	0.002	0.638
	QE	2	1.38(0.82, 2.33)	95.1	0.001
Sample size	138–426	5	1.56 (1.17, 2.09)	90.1	0.001	0.880
	447–744	4	1.53(1.42, 1.65)	00.0	0.820

Publication bias

A leave-one-out sensitivity analysis was conducted and was declared that the absence of any influence of a single study on the overall effect estimate since the confidence intervals of all omitted studies contain the overall estimate effect size (Fig. 3).

Fig. 3.

Sensitivity analysis of the effect of nutrition education and counseling intervention and 95% confidence limits

There was a symmetrical funnel plot that showed the absences of publication bias (Fig. S1). And also, the egger regression test result (P-value: 0.0831) indicates no significant publication bias. Furthermore, the Galbraith plot showed that a favorable positive impact of nutrition education on the dietary diversity practice of pregnant women. Three studies fell outside the 95% CI of the standardized log RR, indicating presence of potential heterogeneity or outlier studies. Estimating the overall effect after removing these studies, a slight change in the overall RR was observed, and it reduced the heterogeneity by 12.81% (RR = 1.59; 95% CI: (1.61, 1.98); = 68.4%) (Fig. S2).

Discussion

Nutritional education and counseling interventions focused on maintaining diversified food diet and participating in physical activity have been recommended by the WHO for all pregnant women. Guided nutritional education and counseling interventions is a widely used approach to enhance the dietary diversity of women during pregnancy [25]. This systematic review and meta-analysis evaluated the effect of nutrition education and counseling intervention on the dietary diversity practice of pregnant women in Ethiopia. The finding of this review showed that pregnant women in the intervention group were 1.54 times more likely to practice dietary diversity (RR = 1.54: 95% CI (1.34, 1.76) as compared with women in the control group. This finding indicated that nutrition education and counseling intervention during pregnancy significantly improved the dietary diversity practice of pregnant women. This finding is in line with the study conducted in Pakistan [26], in Malawi [27], in Iran [28], and in Burkina Faso [29]. The possible justification for this might be that nutrition health education and counseling can help women in understanding the importance of a varied diet during pregnancy and inspire continuous efforts to keep-up on a wide diet [30].

Similarly, this review report is supported by study conducted in Kenya. This might be because nutritional education and counseling interventions are effective strategies to improve pregnant women’s dietary practice and calorie intake, which helps enhance their nutritional diet [31].

The UNICEF report also supported the findings of this meta-analysis, indicating that nutrition education and counseling interventions during pregnancy can improve the intake of diverse foods for women and their families, empowering them to make informed decisions and take action to enhance women’s dietary practice [8].

Ethiopian women often reduce their food intake during pregnancy, despite increasing nutritional needs with gestational age, due to the belief that increased nutrient consumption results in having a larger baby, which may lead to complications during delivery. Consequently, they tend to eat less while pregnant compared to their eating habits before pregnancy [32–35]. This is due to pregnant women’s difference in beliefs and understanding on the type and quantity of food groups required during pregnancy. The second possible justification might be the counseling practices of the routine health service provided during ANC follow-up and at the community level by health experts with a focus on the need for pregnant women to eat one additional meal from available foods. This usual counseling service fail to bring about behavioral change towards having good dietary practice during pregnancy [36].

The World Health Assembly had a target to reduce maternal under nutrition, especially anemia and low birth weight through nutritional education and training. Additionally, nutritional counseling is helping the pregnant women on focusing heathy diet eating that contain adequate energy, protein, mineral and vitamin [37]. All of this evidence was aligned with this systematic review and analysis report.

Limitation

This systematic review had moderate heterogeneity which may affect the interpretation of pooled estimates. Variations in intervention content, intensity, duration, baseline dietary diversity, study quality, and contextual factors may have influenced the pooled estimates.

Study implication

The result of this meta-analysis showed that nutritional education and counseling intervention had a significant effect on pregnant women’s dietary diversity practice than women got routine counselling service. This meta-analysis helps for policy makers and stakeholders to focus on guided and individual based nutrition education and counselling for pregnant women.

Conclusion and recommendations

This meta-analysis suggests that the pooled estimate of nutrition education and counseling intervention is important to improve the dietary diversity practice of pregnant women than the routine counselling service. Thus, nutrition education and counseling interventions would be provided to pregnant women starting from in the first visit for ANC service. Further, rigorously designed randomized controlled trials with standardized interventions are needed to strengthen causal inference and guide effective policy and program implementation.

Authors’ contributions

Author Contributions: GS: Conceptualization; formal analysis; methodology; validation; writing the original draft. MB: Conceptualization; methodology; validation; review & editing the manuscript. TM: Data curation; methodology; software; writing, review & editing the manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data availability

The datasets supporting the findings of this article are available in the manuscript or from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

Not applicable; since we did not use primary data that needs ethical approval and consent to participate.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.