Background to the Study
The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. However nutritional deficiencies are widely prevalent globally and contribute significantly to high rates of morbidity and mortality among mothers, infants and children in developing countries. More than one third of child deaths in some developing countries are thought to be attributable to maternal and child under nutrition (Black, Allen, Bhutta, Caulfield, de Onis, Ezzati, et al, 2008). The prevalence of maternal undernutrition – that is, a BMI of less than 18.5 kg/m2 – ranges from 10 to 19% in most countries with more than 20% of women in sub-Saharan Africa, South central and Southeastern Asia, and Yemen reported to have a BMI of less than 18.5 kg/m2 (Thirukkanesh & Zahara, 2010) . This scenario has adverse effects on pregnancy outcome and increases the risk of maternal and infant morbidity and mortality.
Maternal malnutrition occur more in pregnancy because nutrient needs including that of micronutrients are increased during the period of pregnancy relative to women who are not pregnant (Christian, 2010). The increased nutritional need is due to the physiologic changes of the woman and the metabolic demands of the fetus. Proper maternal nutrition during pregnancy is thus imperative for the health of both the woman and the offspring.
Nutritional deficiencies are common during pregnancy, especially in pregnant women from economically disadvantaged settings where diets with low density of minerals and vitamins are consumed. Malnutrition among pregnant women in these settings manifests itself at the macronutrient and/or the micronutrient level.
Maternal malnutrition is a modifiable risk factor of public health importance. Prevention of malnutrition including micronutrient deficiency therefore has been integrated into efforts to prevent adverse birth outcomes, particularly among economically developing/low-income populations (Kawai, Spiegelman, Shankar & Fawzi, 2011). Poor nutritional status of mothers during pregnancy has direct and indirect consequences on the health of mothers and that of their children. The nutritional status of a mother therefore is important, both as an indicator of her overall health and as a predictor of pregnancy outcome for both mother and child (Elshibly & Schmalisch, 2008; Khoushabi & Saraswathi, 2010). Beyond the period of pregnancy, adequate maternal nutrition is needed for breastfeeding, recovery following the stress of pregnancy and childbirth, coping with child rearing and care and preparation for future pregnancies.
Micronutrient deficiency is a form of malnutrition that can be found among pregnant women involving low levels of micronutrients. Multiple micronutrient deficiencies commonly co-exist in pregnant women, especially in less developed nations (Christian, 2010). Nigeria is one developing country where such deficiencies can exist. Though micronutrients are nutrients needed only in very small quantities, they are essential for normal physiological function, growth and development. According to Taddese & Henok, (2013), micronutrient deficiencies result from inadequate intake of meat, fruits and vegetables, but infections can also be a cause. These deficiencies as aforementioned can negatively impact the health of the mother, her pregnancy, as well as the health of the newborn baby. Micronutrients otherwise known as vitamins and minerals refer to those nutrients required in small amounts in the range of milligrams or micrograms (Berman, Snyder, Kozier & Erb, 2008). Micronutrients are needed to metabolize the energy-giving nutrients. Micronutrients include the water soluble vitamins, Vitamin C and the B-complex vitamins, the fat soluble vitamins A, D, E, and K and minerals.
Globally, approximately two billion people, the majority being women and young children, are affected, by micronutrient deficiencies, with even higher rates during pregnancy (IFPRI, 2014). This is especially so for adolescent pregnancies and women of lower economic or minority status in low and middle-income economic settings (Darnton-Hill, 2012). These micronutrient deficiency states exist in Nigeria and pose a public health problem (National Demographic Health Survey, 2013). Deficiencies in micronutrients such as folate, iron and zinc and vitamins A, B6, B12, C, E and riboflavin are highly prevalent and may occur concurrently among pregnant women (Black, Allen, Bhutta, Caulfield, de Onis, Ezzati M, et al, 2008). Although iron-deficiency anemia is recognized as an important risk factor for maternal and perinatal mortality globally, emerging evidence suggests that micronutrients such as vitamin B12, folic acid, vitamin D and selenium may also be important for maternal, infant and child outcomes (Darnton-Hill &Mkparu, 2015). Other micronutrients that are important for maintaining the mother and the foetus through the period of pregnancy include Vitamin C and Calcium. Their deficiencies also put the life of the mother and the foetus at risk.
The World Health Organization (WHO) and systematic reviews currently favour the supplementation of micronutrients to pregnant mothers (Black et al, 2008). Micronutrient supplementation in pregnant women therefore is a strategy for reducing adverse pregnancy outcomes through improved maternal nutritional and immune status (Allen, 2005; and Bhutta, Ahmed, Black, Cousens, Dewey, Giugliani, 2008). Although there are variations in policies and strategies across climes used in ensuring that adequate micronutrient nutrition is maintained in pregnancy, there are differences in knowledge, which could influence attitude may translate compliance to nutritional programs.
The use of micronutrient supplements have been correlated with knowledge and attitude likewise other health related behaviors. Consequently improved knowledge and positive attitude to health services may be instrumental to improving the use of such services. De Ver Dye (2015) asserts that micronutrient supplementation knowledge is associated with micronutrient supplement consumption in a dose-response manner over pregnancy with increasing knowledge associated with increased MNS consumption. Similarly Gebremedhin, Samuel, Mamo, Moges & Assefa (2014) observed that promoting the knowledge of women on anemia are essential strategies for improving the utilization of iron supplements for the prevention of anaemia. This strategy is considered effective in enhancing compliance to supplementation of other micronutrients other than iron. Improved knowledge may translate to a positive attitude further encouraging compliance to healthy behaviors such as micronutrient supplementation in pregnancy. This study is therefore aimed at assessing the knowledge, attitude and use of micronutrient supplementation among pregnant women utilizing health facilities in Enugu South Local Government of Enugu State.
Statement of problem
Good nutrition during pregnancy is one of the most significant contributors to optimal maternal and foetal health. However, poor maternal and newborn health and nutrition remain significant contributors to the burden of disease and mortality (WHO, 2013). Poor quality diets during pregnancy have been found to be associated with pre-eclampsia, pre-term birth, miscarriage, intra-uterine growth restriction, low birth weight and an increased risk of developing chronic diseases later in life. This is because young children’s nutrition depends critically on the nutritional status of their mothers during pregnancy and lactation (UNICEF, 2011). Furthermore, the period of foetal development especially the period of organogenesis and maintaining the pregnancy are biological processes that require the provision of an optimal nutritional status.
Micronutrient deficiency during pregnancy remains a problem in different settings despite the fact that routine provision of micronutrient supplements has been recommended and is the norm for pregnant women. Multiple micronutrient deficiencies commonly co-exist in pregnant women, especially in less developed nations such as Nigeria. According to the National Demographic Health Survey (2008), micronutrient deficiency was high among women, especially during pregnancy. Five years later, the National Demographic Health Survey (2013) also identified micronutrient deficiency during pregnancy as an existing public health problem. Findings by UNICEF show that diets of women often lack critical nutrients such as zinc, magnesium, iodine, copper, iron and folic acid among others that optimise pregnancy outcome that can be obtained from dietary supplements or sourced from balanced diets. These nutrient deficiencies are generally found in low-socio-economic populations, where they are more likely to involve multiple rather than single deficiencies (Allen; as cited in Ugwa, 2015); thereby predisposing pregnant women in these settings to micronutrient deficiency.
Studies of micro nutrient deficiencies outside and within Nigeria has revealed that considerable proportion of pregnant women still suffer deficiencies of micronutrient such as iron, folic acid, calcium and vitamin C. (Afam & Nkwam, 2012; Ogbodo, 2012; Oguizu, 2015). However, while most attention has been focused on a few micronutrients, for example iron and folate as mentioned above, multiple micronutrient deficiencies occur simultaneously especially when diets are poor (Allen, 2005). In some of these studies, isolated micronutrient deficiencies exist. For instance, in different studies carried out by Ugwuja, (2010), Adesina, (2011) & Ukibe et al (2013), 75- 77% of pregnant women were found to be anaemic as a result of deficiency of iron. In other cases combined micronutrient deficiencies exist. Also as much as 79.5% of women were deficient in Vitamin C according to Ugwa, Gwarzo & Ashimi (2014).
Interventions aimed at preventing micronutrient deficiency in pregnancy include supplementation, fortification of staple foods with micronutrients, health and nutrition education, control of parasitic infections, and improvement in sanitation. Supplementation with micronutrients is a well-established intervention but the coverage and impact has been poor despite clear WHO recommendations for both anaemic and non-anaemic pregnant women and by national bodies (Darnton-Hill, 2015).
Despite routine micronutrient supplementation being an integral aspect of antenatal care given to pregnant women in Nigeria, studies have shown pregnant women to be deficient in micronutrients as outlined. The researcher also has observed that for pregnant women and other individuals, mere prescription and in some cases direct provision of drugs does not translate to compliance to the use of these drugs. The researcher wonders if the pregnant women are knowledgeable about micronutrient supplementation and their benefits in pregnancy. What could be the attitude of women to micronutrient supplementation in pregnancy? How do they use these micronutrients. Are there factors that influence the use of micronutrients during pregnancy? This study is therefore designed to investigate the knowledge, attitude and the use of micronutrient supplements among pregnant women in selected health facilities in Enugu State, Nigeria.
Purpose of Study
The purpose of the study is to assess pregnant women’s knowledge, attitude and use of micronutrient supplements in selected health facilities in Enugu State.
The specific objectives are to:
- determine pregnant women’s knowledge of micronutrient supplementation during pregnancy in selected health facilities in Enugu.
- determine pregnant women’s knowledge of the benefits of micronutrient supplementation during pregnancy in selected health facilities in Enugu.
- determine pregnant women’s attitude toward micronutrient supplementation in selected health facilities in Enugu.
- determine the use of micronutrient supplements during pregnancy among pregnant women in selected health facilities in Enugu.
- determine the factors affecting the use of micronutrient supplements during pregnancy in selected health facilities in Enugu.
- There is no significant association between the pregnant women’s socio-demographic variables (age, parity, educational level, occupation, gestational age and time of antenatal registration) and their use of micronutrient supplements.
- There is no significant relationship between pregnant women’s knowledge of the benefit and their use of micronutrient supplements
- There is no significant association between pregnant women’s attitude and their use of micronutrient supplements.
- There is no significant relationship between the pregnant women’s knowledge of micronutrient supplementation and their use of micronutrient supplements
- There is no significant joint contribution of the predictor variables to use of micronutrient supplements.
Significance of the Study
Findings from this study will reveal pregnant women’s knowledge, attitude and use of micronutrient supplementation during pregnancy. The findings will provide data on the knowledge and attitude towards micronutrient supplementation. Communication of this information to nurses will provide information that can be used to assess the effectiveness and acceptance of nutritional education given to pregnant mothers during antenatal classes.
Assessment of effectiveness and acceptance of health education; which is an integral part of antenatal care is a priceless tool for planning and implementation of antenatal nutritional care.
Furthermore, results of the study will reveal the pattern of use, enabling and discouraging factors to the use of micronutrient supplements in pregnancy. This information will provide useful feedback to nurses, other health care providers, the government and other stakeholders such as non- governmental health organizations on pregnant women’s adherence to micronutrient supplementation which is evidence based strategy for improving pregnancy outcomes.
Finally based on the findings, the present study will provide baseline information to identify areas that need improvement and modification by stakeholders in the preparation and distribution of micronutrient supplements. This is because identification of enabling and discouraging factors will identify factors that need to be reinforced or modified to improve perceptions and use of micro nutrient supplements.
Scope of the Study
The study is delimited to the knowledge, attitude and use of micronutrient supplements. It is also delimited to pregnant women in Enugu State, Nigeria.
Operational definition of terms
Micronutrient supplements: micronutrient supplements for this work include iron (folate), folic acid, Vitamin C and Calcium.
Knowledge of micronutrient supplements: this include awareness of micronutrient supplementation in pregnancy, source of information concerning micronutrient supplementation, the content of the information received from those sources, definition of micronutrient supplements, identification of micronutrient supplements needed in pregnancy and where they can be obtained.
Knowledge of benefits of micronutrient supplements: this is the pregnant women’s knowledge of the benefits of using micronutrients in pregnancy such as the role of micronutrient supplements in formation and growth of the growing baby, maintaining the health of the mother and the baby, prevention of complication and malformation, prevention of death etc
Attitude towards micronutrient supplementation during pregnancy: this refers to the women’s opinion and feelings towards micronutrient supplementation in pregnancy
Use of micronutrient supplements: this refers to the type, frequenctime of commencement of micronutrient supplementation in pregnancy, estimated duration of use of micronutrient supplements during pregnancy, and usual source of micronutrients used by the pregnant women etc.
Factors determining use of micronutrient supplements in pregnancy: these include motivating factors such as free distribution and availability of drugs, previous positive experience from supplementation, maternal literacy level and educational level etc and discouraging factors such as gastrointestinal side effects, forgetfulness, lack of money etc