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. 2022 Feb 17;17(2):e0263957. doi: 10.1371/journal.pone.0263957

Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia

Awel Seid 1, Hirut Assaye Cherie 1,*
Editor: Mohammad Hossein Ebrahimi2
PMCID: PMC8853554  PMID: 35176095

Abstract

Background

Maternal undernutrition is one of the most common causes of maternal morbidity and mortality in developing countries. Severe undernutrition among mothers leads to reduced lactation performance which further contributes to an increased risk of infant mortality. However, data regarding nutritional status of lactating mothers at Dessie town and its surrounding areas is lacking. This study assessed dietary diversity, nutritional status and associated factors of lactating mothers visiting health facilities at Dessie town, Amhara region, Ethiopia.

Methods

Institutional based cross-sectional study was conducted from March to April, 2017 among 408 lactating mothers. Systematic random sampling technique was employed to select the study participants. Data on socio-demographic and economic characteristics, health related characteristics, dietary diversity and food security status of participants were collected using interviewer administered questionnaire. Data were entered into EPI-INFO and analyzed using SPSS Version 22. Bivariate and multivariate analyses were performed to identify factors associated with dietary diversity and nutritional status of lactating mothers.

Results

More than half (55.6%) of lactating mothers had inadequate dietary diversity (DDS<5.3) and about 21% were undernourished (BMI<18.5 kg/m2). Household monthly income [AOR = 2.0, 95% CI (1.15, 3.65)], type of house [AOR = 1.8, 95% CI (1.15, 2.94)], nutrition information [AOR = 1.6, 95% CI (1.05, 2.61)] and household food insecurity [AOR = 1.8, 95% CI (1.05, 3.06)] were factors associated with dietary diversity of lactating mothers. Being young in age 15–19 years [AOR = 10.3, 95% CI (2.89, 36.39)] & 20–29 years [AOR = 3.4, 95% CI (1.57, 7.36)], being divorced/separated [AOR = 10.1, 95% CI (1.42, 72.06)], inadequate dietary diversity [AOR = 3.8, 95% CI (2.08, 7.03)] and household food insecurity [AOR = 3.1, 95% CI (1.81, 5.32)] were factors associated with maternal undernutrition.

Conclusion

The dietary diversity of lactating mothers in the study area was sub optimal and the prevalence of undernutrition was relatively high. Public health nutrition interventions such as improving accessibility of affordable and diversified nutrient rich foods are important to improve the nutritional status of mothers and their children in the study area.

Background

Nutrient requirements increase considerably during lactation since breast milk has to supply an adequate amount of all the nutrients for an infant’s needs for growth and development [1]. Lactating women require approximately 500 additional kcal per day beyond what is recommended for non-pregnant women [2]. It is therefore important that lactating women eat sufficient quantity and quality of food during this period [3]. Nutritional inadequacy of lactating mothers not only affects milk composition and production but also the health of the mothers and their infants. If the mother is undernourished during lactation, the nutrients that are transferred to the baby will be of poor quality and quantity [4]. One of the proxy indicators for measuring dietary adequacy of lactating mothers is dietary diversity which refers to the number of different foods or food groups consumed over a given reference period [5].

According to the 2016 demographic and health survey, maternal mortality in Ethiopia is 412/100,000 live births [6]. Women of reproductive age are also vulnerable to undernutrition. The 2011 Ethiopian demographic and health survey revealed that the level of undernutrition among women is relatively high with 27% of women either thin or undernourished [7]. Studies conducted on lactating mothers from 2011 up to 2016 in different parts of Ethiopia also indicated their poor nutritional status [8–12] and poor dietary diversity [13, 14].

A number of factors were reported to be associated with mothers’ dietary diversity; maternal education [13], monthly income, home gardening, source of drinking water [14], food security, maternal health [13, 15] and season [15]. Factors such as size of farm land, length of years of marriage, maize cultivation, frequency of antenatal care visit, age of breastfeeding child [8], dietary diversity [9], family size, age at first pregnancy, home delivery, nutrition education [11] mothers’ level of education, sickness and production of staple crops [16] were associated with nutritional status of lactating women. However, these factors may vary from setting to setting. Besides, studies which assessed both dietary diversity and nutritional status of lactating mothers in Ethiopia are scant. In this study, we assessed dietary diversity, nutritional status and associated factors of lactating mothers who visited government health facilities at Dessie town, Amhara region, Ethiopia. The output of this study will be important for various stakeholders who are working in improving maternal and child nutrition in the study area.

Methods

Study setting and population

Institutional based cross-sectional study was conducted in an urban setting at Dessie town from March to April 2017. Dessie is located about 401 km away from Addis Ababa, the capital city of Ethiopia and 480 kms away from the capital city of the Amhara Regional State, Bahir-Dar. Dessie is one of the three metropolitan towns in the Amhara region. According to Dessie town administration office report, in 2011, Dessie town had a total population of 154,513 of which 80,575 were females and 73,938 were males. The town has 5 governmental health facilities; 1 referral hospital and 4 health centers. Our study participants were lactating mothers/ breastfeeding mothers (15–49 years) with children under two years who visited Dessie town health facilities during the study period. Lactating mothers visited these health facilities to get various services such as family planning services and vaccination services for their children. Lactating mothers who were critically ill, had physical deformity (that causes difficulty for anthropometric measurements), and who were pregnant during the study period were excluded.

Sample size and sampling procedures

Sample size was determined using single population proportion formula by considering the following assumptions: 56.4% proportion of lactating mothers with inadequate diet diversity score [14], 95% confidence interval and 5% margin of error. A sample size of 416 was taken after considering 10% non response rate. Systematic random sampling technique was employed to select mothers after the first eligible lactating woman was selected by lottery method. In this regard, every 2nd (K = 1.7) lactating woman visiting the health facilities was included in the study. This was determined by calculating the average monthly flow of lactating mothers for three months to each health facility (i.e. 163+175+214+50+110 = 712/416 = 1.71).

Data collection

Data were collected using pre-tested and interviewer-administered questionnaire adapted from different literatures. The questionnaire was used to collect socio-demographic and economic characteristics, health related characteristics, food security status and dietary diversity of participants. It was first prepared in English, translated into Amharic and translated back to English by another person to check its consistency. The translated Amharic version was pretested on 21 (5%) of similar subjects at Dessie Town Family Guidance Association model clinic to ensure appropriateness of the study tools and to acquire common understanding on the assessment tools. During data collection, four nurses were hired as data collectors and 2 health officers were involved as supervisors. Data collectors and supervisors were trained for two days on the study objectives, purpose and how to take anthropometric measurements based on the research instrument.

Food insecurity was assessed using household food insecurity access scale (HFIAS) version 3 [17], a tool validated in Ethiopia [18] as well as other developing countries [19, 20]. The HFIAS tool has nine questions asking household’s last month experience about three domains of food insecurity: feeling uncertainty of food supply, insufficient quality of food, and insufficient food intake and its physical consequences. Study participants were categorized into two levels of food-security status (food-secured and food-insecured) [21] as follows; they were classified as food secure if the participants responded ‘no’ to all of the nine questions and insecure if the participants responded ‘yes’ to at least one of the 9 questions included on the HFIAS tool.

Dietary diversity of lactating mothers was assessed using a 24-hour dietary recall method. Participants were asked to recall freely what they consumed the previous day, inside and outside their home. We then categorized the foods they consumed into the nine food groups (starchy staples, roots and tubers; dark green leafy vegetables; other vitamin A rich fruits and vegetables; other fruits and vegetables; fats and oils; meat and fish; eggs; legumes; nuts and seeds and milk and milk products) [22]. Dietary diversity score (DDS) was determined as the sum of the number of different food groups consumed by the mother in the 24 hours prior to the assessment. Mothers were categorized as having adequate or inadequate dietary diversity after calculating the mean DDS. Mothers who had consumed food groups below the mean DDS were considered as having inadequate DDS and those who consumed higher or equal to the mean DDS were considered as having adequate DDS. In our case, mothers who consumed < 5.3 mean food groups were considered as having inadequate dietary diversity and those who consumed ≥5.3 mean food groups were considered as having adequate dietary diversity.

Anthropometric measurement (weight and height) of lactating mothers was taken using a weighing scale with an attached height meter (Charder HM200P Stadiometer, Taiwan). During anthropometric measurements, mothers removed their shoes and wore light clothing. The weighing scale was checked before and after each measurement for its accuracy by an object with a known weight. Body mass index (BMI) was then calculated by dividing the weight of mothers in kilogram to height in meter square (kg/m2). BMI was calculated using CDC’s online BMI calculator for adults and was also checked manually. For mothers with age below 18years, BMI for age was calculated.

Data analysis

Data were cleaned, coded and entered into EPI-INFO version 3.5.4 software and transferred and analyzed using SPSS version 22. Descriptive statistics such as frequencies, proportions and chi-square (X2) were used to present the study results. In this study, there were two dependent variables; dietary diversity and nutritional status of lactating mothers. In the binary logistic regression analysis, the association between single explanatory variables and dependent variable was examined by computing odds ratio at 95% confidence level. Independent variables with p-value less than 0.2 were fitted in to a multivariate logistic regression model to identify factors associated with dependent variables. For all statistical significance tests between each independent and dependent variables, significance level was declared if p-value was < 0.05.

Ethics approval and consent to participate

The study protocol was approved by the Ethical Review Board of Faculty of Chemical and Food Engineering, Bahir Dar University. Permission to conduct the research was granted by Amhara Region Health Bureau, Dessie Referral Hospital and Dessie town health department. Informed consent was obtained from participants after explaining the study objectives. Participation was voluntary and mothers signed (or provided a thumb print if illiterate) a statement of an informed consent after which they were interviewed. For participants who were below 18 years old, written consent was secured from them and from their guardian as well.

Results

Socio-demographic characteristics

A total of 408 lactating mothers participated in this study making a response rate of 98.1%. The few non-response rates were due to refusal to participate in the study. The mean (± SD) age of lactating mothers was 26.1 (±4.5) years. About 81% of participants attended formal education and more than half (59.3%) of them had a monthly household income of more than 2000 Ethiopian Birr. The majority (79.4%) of study participants were housewives; married (98.5%) and live in male-headed households (64%) (Table 1).

Table 1. Socio-demographic and economic characteristics of lactating mothers (n = 408) visiting governmental health facilities of Dessie town, Ethiopia, March-April, 2017.

Characteristics Number Percent
Age groups (in years)
 15–19 17 4.2
 20–29 303 74.2
 30–40 88 21.6
Mean (±SD) maternal age in years 26.1 (± 4.5)
Maternal religion
 Muslim 241 59.1
 Orthodox 164 40.2
 Protestant 3 0.7
Residence
 Urban 392 96.1
  Rural 16 3.9
Maternal education
 No formal Education 76 18.6
 Primary Education (Grade 1–8) 131 32.1
 Secondary Education (Grade 9–12) 127 31.1
 College Diploma & above 74 18.1
Husband education
 No formal Education 46 11.3
 Primary Education (Grade 1–8) 98 24.0
 Secondary Education (Grade 9–12) 123 30.1
 College Diploma & above 141 34.6
Maternal occupation
 House wife 326 79.9
 Daily laborer 8 2.0
 Merchant 23 5.6
 Private Business 18 4.4
 Government Employee 31 7.6
 NGO Employee 2 0.5
Husband occupation
 No work 7 1.7
 Daily laborer 37 9.1
 Merchant 103 25.2
 Private Business 129 31.6
 Government Employee 123 30.1
 NGO Employee 9 2.2
Household monthly income (in ETB)
 ≤ 500 7 1.7
 501–1000 64 15.7
 1001–1500 42 10.3
 1501–2000 53 13.0
  ˃ 2000 242 59.3
Type of house
 Corrugated iron roof wall made with soil 287 70.3
 Corrugated iron roof wall made with cement 121 29.7
Head of household
 Husband 261 64.0
 Wife 17 4.2
  Both Husband & wife 130 31.9
Current marital status
 Married/Living together 402 98.5
 Single/ Never married 1 0.2
 Divorced/separated/Widowed 5 1.2
Family size
 1–3 persons 207 50.7
 4–6 persons 187 45.8
  ˃ 6 persons 14 3.4
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Eating habits, dietary diversity and food security

Table 2 presents eating habits, dietary diversity and food security status of lactating mothers. Lactating mothers were asked if there were any changes in their eating habits such as changes in meal frequency; in their food intake and avoidance of any kind of foods during their lactation period. In this regard, only 46.3% of lactating women consumed 4 or more times per day and the majority (65.7%) didn’t change their food intake during lactation.

Table 2. Eating habits, dietary diversity and food security status of lactating mothers (n = 408) visiting governmental health facilities, Dessie town, Ethiopia, March-April, 2017.

Characteristics Number Percent
Daily Meal Frequency
 2 times 24 5.9
 3 times 195 47.8
 4 & above times 189 46.3
Changes in food intake during lactation
 Yes 140 34.3
 No 268 65.7
Food intake changes
  Frequency of meal 36 8.8
 Amount of meal 49 12.0
 Both frequency & amount of meal 54 13.2
Avoidance of food during lactation
  Yes 31 7.6
  No 377 92.4
Got nutrition information
 Yes 262 64.2
 No 146 35.8
Source of nutrition information
 Health professionals 204 50.0
 Mass media 44 10.8
 Both health professionals and mass media 14 3.4
Food groups consumed by lactating mothers in previous 24 hours
 Starchy staples, roots and tubers 364 89.2
 Dark green leafy vegetables 265 65.0
 Other vitamin A rich fruits and vegetables 170 41.7
 Other fruits and vegetables 209 51.2
 Fats and oils 401 98.3
 Meat and fish 146 35.8
 Eggs 149 36.5
 Legumes, nuts and seeds 309 75.7
 Milk and milk products 159 39.0
Mean dietary diversity score 5.3±1.74
Food security status Food secured 289 70.8
Food insecured 119 29.2
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The mean (±SD) dietary diversity score of lactating mothers was 5.3 (±1.74) and more than half (55.6%) of them had inadequate dietary diversity (DDS less than 5.3). Food groups such as fats and oils (98.3%) and starchy staples, roots and tubers (89.2%) were the most consumed food groups by the mothers. About three fourth of the mothers had consumed legumes, nuts and seeds and 65% of mothers had consumed dark green leafy vegetables. Compared to other food groups, animal source foods such as meat, fish, eggs and milk were the least consumed food groups (consumed by less than 40% of the mothers). More than one fourth (29.2%) of lactating mothers participated in our study were food insecured.

Lactating mothers were also asked if they have got any information related to nutrition (such as feeding during pregnancy and lactation, consumption of diversified food items, inclusion of fruit and vegetables in the diet, micronutrient supplementation etc). In this regard, the majority (64.5%) of lactating mothers had nutrition information and half of these mothers have got this information from health professionals during their antenatal care visits (Table 2).

Nutritional status of lactating mothers

The mean BMI (±SD) of lactating mothers was 22.5(±3.5) kg/m2. About 21% of mothers were undernourished (BMI less than 18.5 kg/m2) and 3.68% mothers were obese (Fig 1).

Fig 1.

Fig 1

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Factors associated with dietary diversity of lactating mothers

In the bivariate analysis, maternal educational status, husband education, household monthly income, type of house, daily meal frequency, changes in food intake during lactation, nutrition information, and food security status of lactating mothers had association with dietary diversity (Table 3). However, in the multivariable logistic regression analysis, household monthly income, type of house, nutrition information, and food security status of lactating mothers were factors which showed association with dietary diversity of lactating mothers. Lactating mothers who had household monthly income of less than or equal to 1,500 ETB were 2 times more likely to have low dietary diversity than those who had household monthly income of more than 1,500 ETB [AOR = 2.0, 95% CI (1.15, 3.65)]. Similarly, lactating mothers who lived in corrugated iron roof and wall made of soil were 1.8 times more likely to have low dietary diversity than those who lived in a house with corrugated iron roof and wall made of cement [AOR = 1.8, 95% CI (1.15, 2.94)]. Nutrition information had also a significant association with dietary diversity of lactating mothers. Lactating mothers who did not get nutrition information were 1.6 times more likely to have low dietary diversity compared to those who have got nutrition information [AOR = 1.6, 95% CI (1.05, 2.61)]. Lactating mothers who lived in food insecured households were 1.8 times more likely to have low dietary diversity than those who lived in food secured households [AOR = 1.8, 95% CI (1.05, 3.06)] (Table 3).

Table 3. Association of variables with dietary diversity of lactating mothers (n = 408) visiting governmental health facilities of Dessie town, Ethiopia, March-April, 2017.

Dietary Diversity
Variables Inadequate Adequate COR AOR
n (%) n (%) (95% CI) (95% CI)
Maternal age (in years)
 15–19 12(2.96) 5 (1.24) 1 1
 20–29 156(38.2) 147(36.0) 0.5(0.32, 0.86) 0.5(0.15, 1.50)
 30–40 59(14.48) 29(7.12) 1.2(0.38, 3.67) 0.8(0.25, 2.84)
Current marital status
 Married/Living together 223(54.64) 179(43.86) 1 1
 Divorced/Separated/ 4(0.92) 2(0.48) 1.65(0.29, 8.87) 0.4(0.05, 3.33)
Maternal education
  No formal Education 54 (13.2%) 22 (5.4%) 2.3 (1.31, 3.87)** 1.5 (0.82, 2.83)
  Formal Education 173 (42.4%) 159 (39.0%) 1 1
Husband education
  No formal Education 34 (8.3%) 12 (3.0%) 2.5 (1.25, 4.95)** 0.8 (0.30, 1.85)
  Formal Education 193 (47.3%) 169 (41.4%) 1 1
Household monthly income
 ≤ 1500 ETB 85 (20.8%) 28 (6.9%) 3.3 (2.02, 5.31)** 2.0 (1.15, 3.65)**
 ˃ 1500 ETB 142 (34.8%) 153 (37.5%) 1 1
Type of house
Corrugated iron roof and wall made with soil 177 (43.4%) 110 (27.0%) 2.3 (1.48, 3.52)** 1.8 (1.15, 2.94)**
Corrugated iron roof and wall made with cement 50 (12.2%) 71 (17.4%) 1 1
Nutrition information
  Yes 132 (32.3%) 130 (31.9%) 1 1
  No 95 (23.3%) 51 (12.5%) 1.8 (1.21, 2.79)** 1.6 (1.05, 2.61)**
Daily meal frequency
 ≤ 3 Meals/day 136 (33.3%) 83 (20.4%) 1.8 (1.19, 2.62)** 1.3 (0.86, 2.02)
 ˃ 3 Meals/day 91 (22.3%) 98 (24.0%) 1
Changes in food intake
 Yes 67 (16.4%) 73 (17.9%) 1
  No 160 (39.2%) 108 (26.5%) 1.6 (1.07, 2.44)** 1.3 (0.80, 1.95)
Food security status
  Food Secured 142 (34.8%) 147 (36.1%) 1 1
  Food Insecured 85 (20.8%) 34 (8.3%) 2.6 (1.63, 4.10)** 1.8 (1.05, 3.06)**
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COR- Crude Odds Ratio, AOR- Adjusted Odds Ratio, ETB-Ethiopian birr N.B- *p- value significant at level of P <0.2,

**p-value significant at level of P<0.05.

Factors associated with nutritional status of lactating mothers

Both bivariate and multivariate analyses were done to identify factors associated with nutritional status of lactating mothers (Table 4). In the bivariate analysis, maternal age, marital status, husband education, household monthly income, daily meal frequency, nutrition information, household food security status and women dietary diversity had association with nutritional status of lactating mothers.

Table 4. Association of variables with nutritional status of lactating mothers (n = 408) visiting governmental health facilities of Dessie town, Ethiopia, March-April, 2017.

Nutritional status (BMI)
Variables Underweight Normal/Overweight/Obese COR AOR
n (%) n (%) (95% CI) (95% CI)
Maternal age (in years)
 15–19 8(2.0) 9(2.2) 6.2(1.98, 19.51) 10.3(2.89, 36.39)**
 20–29 66(16.2) 237(58.0) 1.9(0.98, 3.88) 3.4(1.59, 7.36)**
 30–40 11(2.7) 77(18.9) 1 1
Maternal marital Status
 Married/Living together 81(19.8) 321(78.7) 1 1
 Divorced/separated 4(0.9) 2(0.5) 7.9(1.43, 44.03) 10.1 (1.42, 72.06)**
Head of household
 Husband 61 (15.0) 200(49.0) 1.9(1.07, 3.37) 1.4(0.71, 2.66)
 Wife 6(1.5) 11(2.7) 3.4(1.15, 10.32) 0.8 (0.18, 3.79)
 Both husband & wife 18(4.4) 112(27.5) 1 1
Maternal education
 No formal education 19(4.7) 57(13.9) 1.3(0.75, 2.41) 0.5(0.24, 1.19)
 Formal education 66(16.2) 266(65.2) 1 1
Husband education
 No formal education 19 (4.6) 27 (6.6) 3.2 (1.66, 6.01)** 1.9(0.88, 3.98)
 Formal education 66 (16.2) 296 (72.6) 1 1
Household monthly income
≤ 1500 ETB 38 (9.3) 75 (18.4) 2.7(1.62, 4.41)** 1.1 (0.54, 2.34)
> 1500 ETB 47 (11.5) 248 (60.8) 1 1
Type of house
 Corrugated iron roof wall made with soil 67(16.4) 220(53.9) 1.7(0.96, 3.08) 1.4(0.73, 2.73)
 Corrugated iron roof wall made with cement 18(4.4) 103(25.3) 1 1
Daily meal frequency
≤ 3 meals/day 56 (13.7) 163 (40.0) 1.9 (1.15, 3.12)** 1.5 (0.84, 2.58)
˃ 3 meals/day 29 (7.1) 160 (39.2) 1 1
Avoidance of food during lactation
Yes 5(1.2) 26(6.4) 0.7 (0.27, 1.92) 1.1 (0.32, 3.22)
No 80(19.6) 297(72.8) 1 1
Family size
 1–3 persons 50(12.2) 157(38.5) 1 1
 4–6 persons 32(7.8) 155(38) 0.6(0.39, 1.07) 1.2 (0.52, 2.91)
  ˃ 6 persons 3(0.7) 11(2.7) 0.9(0.23, 3.19) 2.9 (0.52, 16.90)
Nutrition information
Yes 47 (11.5) 215 (52.7) 1 1
No 38 (9.3) 108 (26.5) 1.6 (0.99, 2.62)* 1.2 (0.66, 2.13)
Women dietary diversity
  Adequate 17 (4.2) 164 (40.2) 1 1
 Inadequate 68 (16.6) 159 (39.0) 4.1 (2.32, 7.33)** 3.8 (2.08, 7.03)**
Food security status
 Food secured 41 (10.0) 248 (60.8) 1 1
 Food insecured 44 (10.8) 75 (18.4) 3.5 (2.16, 5.84)** 3.1(1.81, 5.32)**
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COR- Crude Odds Ratio, AOR- Adjusted Odds Ratio, ETB-Ethiopian birr,

**p-value significant at level of P<0.05.

In the multivariable logistic regression analysis, maternal age, marital status, inadequate dietary diversity and household food insecurity showed association with nutritional status of lactating mothers. Lactating women in the age group of 15–19 years and 20–29 years were 10.3 times [AOR = 10.3, 95% CI (2.89, 36.39)] and 3.4 times [AOR = 3.4, 95% CI (1.57, 7.36)] more likely to be underweight than older mothers respectively. Maternal marital status was also one of the factors which showed association with mothers’ nutritional status. Lactating women who were divorced or separated were 10 times more likely to be undernourished than their counterparts [AOR = 10.1, 95% CI (1.42, 72.06)].

Lactating mothers who had inadequate dietary diversity score were 3.8 times more likely to be undernourished than those who had adequate dietary diversity score [AOR = 3.8, 95% CI (2.08, 7.03)]. Similarly, lactating mothers who lived in food insecured households were 3 times at risk of becoming undernourished compared to their counterparts [AOR = 3.1, 95% CI (1.81, 5.32)].

Discussion

The mean dietary diversity score (DDS) of lactating mothers in our study was 5.3 and this was slightly higher than studies reported from other parts of Ethiopia; Jimma zone (4.9) [9] and Aksum town (3.4) [14]. These differences might be due to differences in socio-demographic and economic situations of mothers.

The majority (98%) of lactating mothers in our study reported that they have consumed oils and fats in the previous 24 hours and this is related to the tradition of adding small amount of oil or fat (commonly butter) in the preparation of Ethiopian stews or dishes at least three times a day. Starchy staples, roots and tubers were also the most consumed food groups (nearly by 90% of the mothers) and this is in agreement with other studies reported from different parts of Ethiopia [8, 13, and 14].

The mean BMI of lactating mothers was 22.5 kg/m2. This figure was slightly higher than the mean BMI of lactating women reported from Womberma woreda of Amhara region (20 kg/m2) [11] and Jimma zone, Oromia region, Ethiopia (19.2 kg/m2) [9]. These differences might be due to differences in socio demographic and economic characteristics of study participants.

Nearly one fifth of our study participants (20.8%) were undernourished (BMI less than 18.5kg/m2). This prevalence was comparable with that reported for lactating women who attended Nekemtie town hospitals and health centers (20.5%) [10]. On the other hand, the prevalence of undernutrition in our study was lower than that reported from Samre woreda (31%) [8] and Alamata district of Tigray, Ethiopia (24.6%) [12]. It is recommended that lactating woman should take at least two additional meals per day during lactation [23]. However, in our study more than half of the mothers didn’t take any additional meal during lactation which may result in low dietary intakes. Dietary intakes below the recommended frequency might lead mothers to poor nutritional status. In general, poor nutritional status of lactating women is a developmental threat of a given country as children born from women who became malnourished during pregnancy and lactation are at higher risk of developing various health problems [24].

Lactating mothers who had household monthly income of less than or equal to 1,500 ETB were two times more likely to have low dietary diversity than those who had household monthly income of more than 1,500 ETB. This finding is in agreement with a study conducted in Aksum town, Ethiopia [14] and a study conducted in Bangladesh [25]. This might be due to the fact that having low monthly income hinders lactating mothers from purchasing diversified foods. Similarly, lactating mothers who lived in corrugated iron roof with wall made of soil were 1.8 times more likely to have low dietary diversity than those who lived in a house with corrugated iron roof wall made of cement. This might be associated with the economic status of the households’ as living in an improved house can be directly related to the economic status of lactating mothers and high probability of having a diversified food.

In our study, mothers who did not get nutrition information were 1.6 times more likely to have low dietary diversity than those mothers who got nutrition information. Unlike other studies which showed a positive association between education and dietary diversity [13, 26], education by itself didn’t have association with mothers’ dietary diversity in our study. This finding shows that rather than formal education, specific information about nutrition is the one which helps mothers to improve their dietary pattern or eat a diversified diet. In fact, Woldehawaria et al. [14] from Aksum town, Ethiopia also indicated absence of association between education and maternal dietary diversity.

Lactating mothers who lived in food insecured households were 1.8 times more likely to have low dietary diversity than those who lived in food secured households. A study done in Angecha district, Southern Ethiopia also reported that mothers from food-insecure households were 3.4 times more likely to have low dietary diversity [26] when compared with mothers from food secure households. Reports from other countries such as Vietnam, Bangladesh and Nepal [13, 25, 27] also support our finding. On the other hand, food insecurity had no association with dietary diversity in a study conducted in Aksum town, Ethiopia [14].

The covariates maternal age, marital status, women dietary diversity and household food security status had statistically significant association with mothers’ nutritional status. Young mothers and mothers who were divorced or separated had a higher chance of being undernourished than their counterparts. Similar finding was reported by Teller and Yimer [28] from Southern Ethiopia. This might be associated with the economic status of mothers as it could be endangered by a negative change in marital status. Lactating mothers with inadequate dietary diversity were 3.8 times more likely to be exposed to undernutrition compared to those who had adequate dietary diversity. This was supported by a study conducted in Dedo and Seqa-Chekorsa Districts of Jimma Zone, Ethiopia [9]. Similarly, lactating mothers from food insecure households were 3 times more likely to be undernourished when compared with those mothers from food secure households. Our finding was supported by one study from rural Kenya [29]. Different studies also indicated the association between household food insecurity with inadequate energy and nutrient intake and in turn malnutrition among household members [19, 30].

Our study had two major limitations due to its cross sectional nature; one it was not possible to assess seasonal variation of food availability which will have an effect on dietary diversity and two it was difficult to establish a cause and effect relationship between one of our dependent variables (nutritional status) and the independent variables although some associations were observed.

Conclusion

The dietary diversity of lactating mothers in the study area was sub optimal and prevalence of undernutrition was high. Household monthly income, type of house, nutrition information, and household food insecurity status were factors significantly associated with dietary diversity of lactating mothers. On the other hand, inadequate dietary diversity and food insecurity were factors strongly associated with the nutritional status of lactating mothers. Public health nutrition interventions such as improving accessibility of affordable and diversified nutrient rich foods are important to improve the nutritional status of mothers and their children in the study area.

Supporting information

S1 Data. Manuscript data.

(DOC)

Click here for additional data file. (240KB, doc)
S2 Data. Supplementary data.

(SAV)

Click here for additional data file. (70.5KB, sav)
S1 Questionnaire

(DOC)

Click here for additional data file. (94KB, doc)

Acknowledgments

We are grateful for Bahir Dar Institute of Technology, School of Research and Graduate Studies for supporting this study. We are also grateful to Amhara Region Health Bureau and Dessie town health department for facilitating this research by timely writing support letters. Finally, our special thanks go to data collectors and study participants who contributed to this study.

Abbreviations

AOR

Adjusted odds ratio

BMI

Body mass Index

CI

Confidence interval

COR

Crude odds ratio

CSA

Central Statistics Agency

DDS

Dietary Diversity Score

ETB

Ethiopian Birr

WHO

World Health Organization

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

The funding was in the form of financial support to help the researchers for their data collection. However, the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Besides, any of the authors did not receive salary from the funder for this specific study.

References

  • 1.Doran L, Evers S. Energy and Nutrient inadequacies in the diets of low income women who breastfeed. Journal of American Dietetic Association 1997; 97(11): 1283–1287. [DOI] [PubMed] [Google Scholar]
  • 2.Kominiarek MA, Rajan P. Nutrition Recommendations in Pregnancy and Lactation. Med Clin North Am.2016; 100(6):1199–1215. doi: 10.1016/j.mcna.2016.06.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.World Health Organization (WHO). World Health StatiStics. 2009.
  • 4.Sanusi R, Falana O. The Nutritional Status of Mothers Practicing Breast Feeding In Ibadan, Nigeria. Afr. J. Biomed. Res. 2007; 12(2): 107–112. [Google Scholar]
  • 5.Arimond M, Torheim L, Joseph M. Dietary Diversity as a Measure of the Micronutrient Adequacy of Women’s Diets: Results from Rural Bangladesh Site. 2009.
  • 6.CSA Ethiopia Demographic and Health Survey: Key indicators report. Central Statistical Agency, Addis Ababa, Ethiopia, 2016.
  • 7.Central Statistical Agency [Ethiopia] and ICF International Ethiopia Demographic and Health Survey, 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International. 2012.
  • 8.Haileslassie K, Mulugeta A, Girma M. Feeding practices, nutritional status and associated factors of lactating women in Samre Woreda, South Eastern Zone of Tigray, Ethiopia. Nutrition Journal.2013; 12: 28. doi: 10.1186/1475-2891-12-28 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Alemayehu M, Argaw A, G/Mariam A. Factors Associated with Malnutrition among Lactating Women in Subsistence Farming Households from Dedo and Seqa-Chekorsa Districts, Jimma Zone, 2014. Developing Country Studies. 2015; 5(21): 114–122. [Google Scholar]
  • 10.Hundera T, Gemede H, Wirtu D, Kenie D. Nutritional Status and Associated Factors among Lactating Mothers in Nekemte Referral Hospital and Health Centers, Ethiopia. Food Science and Quality Management.2015;International Journal of Nutrition and Food Sciences 4(2):216. [Google Scholar]
  • 11.Berihun S, Kassa G, Teshome M. Factors associated with underweight among lactating women in Womberma woreda, Northwest Ethiopia; a cross- sectional study. BMC Nutrition.2017; 3:46. doi: 10.1186/s40795-017-0165-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Sitotaw K, Hailesslasie K, Yohannes A. Comparison of nutritional status and associated factors of lactating women between lowland and highland communities of District Raya, Alamata. BMC Nutrition.2017; 3:61. doi: 10.1186/s40795-017-0179-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Nguyen P, Avula R, Ruel M, Saha K, Ali D, Tran L, et al. Maternal and Child Dietary Diversity Are Associated in Bangladesh, Vietnam, and Ethiopia. The Journal of Nutrition.2013; 143:1176–1183. doi: 10.3945/jn.112.172247 [DOI] [PubMed] [Google Scholar]
  • 14.Weldehaweria N, Misgina K, Weldu M, Gebregiorgis Y, Gebrezgi B, Zewdie S, et al. Dietary diversity and related factors among lactating women visiting public health facilities in Aksum town, Tigray, Northern Ethiopia. BMC Nutrition. 2016; 2(38): 1–9. [Google Scholar]
  • 15.Savy M, Martin-Prével Y, Traissac P, Eymard-Duvernay S, Delpeuch F. Dietary diversity scores and nutritional status of women change during the seasonal food shortage in rural Burkina Faso. J Nutr.2006; 136(10):2625–32. doi: 10.1093/jn/136.10.2625 [DOI] [PubMed] [Google Scholar]
  • 16.Demissie T, Mekonen Y, Haider J. Agro-ecological comparison levels and correlate of nutritional status of women. Ethiop J Health Dev.2003; 17:189–196. [Google Scholar]
  • 17.Coates J, Swindale A, Bilinsky P. Household Food Insecurity Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide (v. 3). Washington, DC: Food and Nutrition Technical Assistance Project, Academy for Educational Development, 2007. [Google Scholar]
  • 18.Gebreyesus SH, Lunde T, H Mariam D, Woldehanna T, Lindtjørn B. Is the adapted Household Food Insecurity Access Scale (HFIAS) developed internationally to measure food insecurity valid in urban and rural households of Ethiopia? BMC Nutrition 2015, 1:2. [Google Scholar]
  • 19.Knueppel D, Demment M, Kaiser L. Validation of the Household Food Insecurity Access Scale in rural Tanzania. Public Health Nutr. 2010; 13(3):360–7. doi: 10.1017/S1368980009991121 [DOI] [PubMed] [Google Scholar]
  • 20.Mohammadi F, Omidvar N, Houshiar-Rad A, Khoshfetrat MR, Abdollahi M, Mehrabi Y. Validity of an adapted Household Food Insecurity Access Scale in urban households in Iran. Public Health Nutr. 2012; 15(1):149–57. doi: 10.1017/S1368980011001376 [DOI] [PubMed] [Google Scholar]
  • 21.Becquey E, Martin-prevel Y, Traissac P, Dembele B, Bambara A, Delpeuch F. The Household Food Insecurity Access Scale and an Index-Member Dietary Diversity Score Contribute Valid and Complementary Information on Household Food Insecurity in an urban West-African setting. Journal of Nutrition.2010; 140(12): 2233–40. [DOI] [PubMed] [Google Scholar]
  • 22.FAO. Guidelines for measuring household and individual dietary diversity. 2013.
  • 23.ENA Counselor’s guide: Key behaviors for optimal breast feeding, complementary feeding and maternal nutrition at critical stages in the life cycle of women and children_ draft for discussion_ linkages project.
  • 24.Bain LE, Awah PK, Geraldine N, Kindong NP, Sigal Y, Bernard N, et al. Malnutrition in sub-Saharan Africa: burden, causes and prospects. Pan Afr Med J. 2013; 15:120. doi: 10.11604/pamj.2013.15.120.2535 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Thorne-Lyman AL, Valpiani N, Sun K, Semba RD, Klotz CL, Kraemer K. Household dietary diversity and food expenditures are closely linked in rural Bangladesh, increasing the risk of malnutrition due to the financial crisis. J Nutr. 2009;140:182S. doi: 10.3945/jn.109.110809 [DOI] [PubMed] [Google Scholar]
  • 26.Moges MB, Alehegn BG. Low dietary diversity and associated factors among lactating mothers in Angecha districts, Southern Ethiopia: community based cross-sectional study. BMC Res Notes.2018; 11:892. doi: 10.1186/s13104-018-4001-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Singh DR, Ghimire S, Upadhayay SR, Singh S, Ghimire U. Food insecurity and dietary diversity among lactating mothers in the urban municipality in the mountains of Nepal. PLoS ONE. 2020; 15(1): e0227873. doi: 10.1371/journal.pone.0227873 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Teller H, Yimer G. Levels and determinants of malnutrition in adolescent and adult women in southern Ethiopia. Ethiopian Journal of Health Development 2000; 14(1):57–66. [Google Scholar]
  • 29.Gewa C, Oguttu M., Yandell N. Maternal nutrition in rural Kenya: health and socio-demographic determinants and its association with child nutrition. Matern Child Nutr. 2012; 8(3): 275–286. doi: 10.1111/j.1740-8709.2011.00322.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Oldewage-Theron WH, Dicks EG, Napier CE. Poverty, household food insecurity and nutrition: coping strategies in an informal settlement in the Vaal Triangle, South Africa. Public Health. 2006; 120: 795–804. doi: 10.1016/j.puhe.2006.02.009 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Miquel Vall-llosera Camps

9 Jun 2021

PONE-D-20-31562

Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia

PLOS ONE

Dear Dr. Cherie,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Senior Editor

PLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: No

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: No

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Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Comments:

1. It is important that this study highlights the important issues faced by lactating mothers, especially in resource poor context. The manuscript will therefore be of interest to those who are working in the related fields, and I hope can be published in the PLOS ONE after a revision.

2. Background: The authors have attempted to highlight the importance of food security and dietary diversity. However, I could not find a clear rationale why the authors wanted to focus on both the outcomes at the same time in this manuscript. In addition, it would be helpful if the authors state the scientific gaps and how this study is going to fill the gaps. Why do the authors think that this study is beneficial for researchers and the public in other regions within and outside the country? Further, the authors have mentioned “lactating mothers” often, but did not explain what they mean by “lactating mothers” in this study.

3. Line 56-57- reference is missing?

4. Line 67-69, when these study were conducted?

5. Provide theoretical basis for selecting independent variables in the study? What theories underpin your study?

6. The HFIAS tools was validated in Tanzania and Iran, how would you justify the use of this tool in Ethiopia?

7. What are the possible bias in the study and how it was attempted to minimize it?

8. Why study participants were categorized only into two levels of food-security 123 status (food-secured and food-insecure)? Why not the cumulative HFIAS score was categorized into four levels of household food insecurity: food secured, and mild, moderate, and severe food insecurity, following HFIAS guideline.

9. What does nutrition information refers to?

10. What happen after pretesting of tools?

11. Line 136-38, what is your reference to take this cut of value for low and high DDS.

12. “For mothers with age below 18years, BMI for age was calculated” what reference you used for this measurement?

13. Why all independent variables were fitted in to a multivariate logistic regression model to identify factors associated with dependent variables? Why not only significant variables?

14. In table 1, need to mention what does” P” “a” “b” stands for , and where does it come from?

15. Also, the p-value 0.00 need to be presented in standard form for writing p-value.

16. P-value in all tables need to be presented in standard format.

17. Digit after decimal need to be uniform though out the manuscript.

18. Discussion need to focus on major findings of the study and also please revise this section thoroughly and provide sufficient discussion of relevant studies.

19. Please also check this study: “Food insecurity and dietary diversity among lactating mothers in the urban municipality in the mountains of Nepal”. https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0227873

20. Language correction is required. I suggest author to have proof read of the manuscript from native English language speaker.

21. Could you please also provide your data set for review purpose?

Reviewer #2: The effort in this paper is good at providing an overview of the problems with diet and nutritional status during lactation. This information is also essential due to the lack of such data in developing countries. However, several things need to be clarified in this manuscript, including:

Characteristics of participant:

The author can explain the activities carried out by lactating women when visiting health facilities, whether the health facility provides education and counselling services during breastfeeding (so we can assume participants are healthy people) or treated for an illness. However, if the participant is sick, the conclusions in the text need to be explained more specifically that the importance of this paper is (for example) to improve the quality of services and education in health facilities, not to the public.

Research purposes: In line 77-79: “However, these factors may not be consistent in all settings and thus call for the need for context-specific information to design and implement appropriate nutrition interventions”, this statement looks inconsistent and hard to follow. The author can explain the urgency of this paper when compared with other existing data. If it is said that the factors related to dietary diversity and nutritional status are not consistent across all settings, the authors are expected to explain why this study was carried out in a more specific context, not in general.

Dietary diversity:

• Authors need to review how to interpret DDS. For example, is DDS data normally distributed or is it necessary to use distribution data.

• Further insights for analyzing DDS can be found in the FAO Guideline (on REF #24, page 26-27). There are no established cut-off points in terms of the number of food groups to indicate adequate or inadequate (or low/high in this text) dietary diversity for the DDS. The author can analyze using the score data from each participant to see the correlation with other variables.

• If the mean DDS used as the cut-off, this would result in a low/high proportion of around 50 per cent. However, the authors need to reconsider the results and discussions regarding the prevalence of low DDS since it cannot be compared with other populations (in line 268-273).

• In line 260-266 Discussion, the authors compare DDS in studies with different maximum DDS values. Please compare something equivalent.

• In line 278-282: oil and fat consumption were high (98%), it mentions due to adding a small amount of oil/fat in meal preparation. The author needs to explain whether there is a restriction of food quantities to at least 15 grams to include the food group in daily consumption. For women aged 15-49 years, dietary diversity scores were more strongly correlated with micronutrient adequacy of the diet when food quantities of approximately one tablespoon or less (<15g) were not included in the score (Arimond et al., 2010).

Nutritional status:

• The author needs to review whether the BMI data is normally distributed to be presented as a mean.

• On line 193-194, it says there are 21% underweight and 12% overweight. This needs to be clarified because, in Table 2 and Table 4, all participants are categorized as underweight and normal.

• The author can also mention whether there are participants who fall into the obese category.

• In addition, similar to DDS, the authors need to consider analyzing the correlation using the continuous variable (BMI itself) compared to the analysis after being categorized.

Dietary assessment method:

• Based on the level of the objective of dietary assessment, the authors need to explain whether the data were collected by single or replicated in non-consecutive days.

• In addition, it is necessary to clarify the method mentioned (24h dietary recall) to record all food consumed by the mother for 24 hours or recall the specific consumption of 9 food groups.

Data analysis:

• It is recommended that the authors present the results of the correlation analysis (r and p values) for each of the tested independent variables, as stated in lines 213-215. (This might be attached in an supplementary table).

• The variables included in the regression analysis also need to be discussed regarding aspects of biological plausibility. For example, if specific variables are tested (such as maternal religion, family size, and head of household), these variables need to be discussed in the introduction/discussion.

Writing suggestions

• In the second paragraph of the Background, the author can select only information related to the topics discussed in this paper. The author needs to reconsider the relationship between urbanization, primary-secondary-tertiary level of health care with the topic.

• Authors can use more recent DHS data (is there a 2016 edition?) to describe nutritional problems in the study area.

• Paternal or parental education?

• Tables 1 & 2, contents and headings in tables are inconsistent. The author needs to review whether the DD & nutritional status data in table 1 is needed. The same data has shown in tables 3 & 4

• Authors need to add information to the superscript “a” and “b” in data tables 1 and 2.

• Eating habits: this data appears in the result, but there is no explanation regarding the meaning of habits.

• Dietary diversity categories: low/high or adequate/inadequate?

• Discussion: In the first paragraph, the author can explain the most interesting findings or the ones that answer the main problem in the research

**********

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Reviewer #1: No

Reviewer #2: No

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Attachment

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PLoS One. 2022 Feb 17;17(2):e0263957. doi: 10.1371/journal.pone.0263957.r002

Author response to Decision Letter 0

19 Sep 2021

Dear Sir/Madam,

We have revised our manuscript based on each reviewer's comments. We have tried to address each of the reviewer's comments and submitted it is as Responses to reviewers' together with our manuscript. Thanks

Sincerely,

Attachment

Submitted filename: Response to reviewers.doc

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Decision Letter 1

Mohammad Hossein Ebrahimi

19 Jan 2022

PONE-D-20-31562R1

Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia

PLOS ONE

Dear Dr. Cherie,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 05 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

********** 

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

********** 

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #2: The author has made considerable improvements in this paper. Data and supplementary tables are also presented as needed.

Reviewer #3: It is clear that the authors have corrected and improved the manuscript. They also provided responses to all the reviewer's comments. The manuscript is relevant and provides important data to Public Health System of Ethiopia and other developing countries.

Reviewer #4: Based on table 1, one person was single/never married! How was she lactating then?

In table 2, please put SD for mean of dietary diversity score.

For tables 3 and 4, please spelll out AOR and COR at foot of the tables.

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Reviewer #2: Yes: Sofa Rahmannia

Reviewer #3: No

Reviewer #4: No

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Decision Letter 2

Mohammad Hossein Ebrahimi

2 Feb 2022

Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia

PONE-D-20-31562R2

Dear Dr. Cherie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Mohammad Hossein Ebrahimi

8 Feb 2022

PONE-D-20-31562R2

Dietary diversity, nutritional status and associated factors among lactating mothers visiting government health facilities at Dessie town, Amhara region, Ethiopia

Dear Dr. Cherie:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Data. Manuscript data.

    (DOC)

    Click here for additional data file. (240KB, doc)
    S2 Data. Supplementary data.

    (SAV)

    Click here for additional data file. (70.5KB, sav)
    S1 Questionnaire

    (DOC)

    Click here for additional data file. (94KB, doc)
    Attachment

    Submitted filename: Comments.docx

    Click here for additional data file. (14.7KB, docx)
    Attachment

    Submitted filename: Response to reviewers.doc

    Click here for additional data file. (77KB, doc)
    Attachment

    Submitted filename: Authors response.doc

    Click here for additional data file. (29KB, doc)

    Data Availability Statement

    All relevant data are within the paper and its Supporting information files.

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