This study assessed the feeding practices, nutritional status and associated factors among lactating women from Samre woreda, South Eastern Zone of Tigray, Ethiopia. According to the essential nutrition action (ENA), taking at least two additional meals per day during lactation is recommended for all lactating women . Nevertheless, slightly below three fourth’s 285 (71.3%) of the study participants do not take any additional meal during their lactation time. The median dietary diversity score of the study participants was 5.0, which was lower than half of the food groups on FAO food grouping i.e. 14 food groups .
The prevalence of chronic energy deficiency (BMI <18.5 Kg/m2) among the lactating mothers was 25%, a prevalence which was very much lower than that of the Tigray region finding in the EDHS report of 2005 (37.5%) . The probable reason for this discrepancy could be the interventions on maternal health, nutrition and other women empowering programs by the government as well as other non-governmental organizations in the study area.
But, this finding was comparable with the finding of the Ethiopian Health and Nutrition Research Institute nutrition baseline survey report (28.8%) . On the contrary, our results were much lower than that of the prevalence in lactating mothers from the Southern region of Ethiopia (37%) . The proportion of lactating mothers with a MUAC of less than 21 cm was 13%. This figure was lower than the finding of the survey report on the situation analysis of women in Tigray in 2011 (18.1%) .
The dietary assessment from one day weighed food record showed that the energy and almost all nutrient intakes of the lactating women in the study area were below the recommended nutrient intakes of FAO/WHO/UNU . This finding was consistent with the finding of Huffman and his colleagues . According to this study, many women in Africa suffered from chronic energy deficiency, inadequate weight gain during pregnancy and poor nutritional status. The additional energy needed for lactation is 20-25% of energy needs in the non-pregnant non-lactating state . But, in the current study these energy needs were not met or were below the requirement of the lactating mothers. This might be due to their involvement in energy demanding workloads during the whole course of lactation and taking no additional meals from available foods in the household during this time.
The protein intake of the study participants was close to the recommended intake of FAO/WHO/UNU . The quality of the dietary protein can be improved by combining protein sources (grains and legumes) with different limiting amino acids . Thus, mixtures of plant proteins can serve as complete and well balanced source of amino acids for the lactating women from the study communities. In agreement with our findings, inadequate protein intake in lactating women was reported from Southern region of Ethiopia  and Malawi , where lactating women were predicted to be at risk of inadequate intakes of dietary protein.
The current study also revealed that micronutrient intakes especially zinc and calcium of the lactating women were below the recommended levels. However, iron intake (118 mg) was above the recommended intake of the FAO/WHO/UNU . This was comparable to a study done in Tigray by Adish and his colleagues . This may be due to the high content of iron in the Ethiopian diets as has been emphasized by Gebremedhin and his colleagues . According to this study, the consumption of the indigenous cereal teff (E.teff), oleaginous seeds and Ethiopian kale (B. carinatabraun), and all foods that appear to contain relatively high levels of iron enhance increased iron intake.
In the present study, it was also found that dietary zinc intake of the lactating women was lower than the recommended intakes of FAO/WHO/UNU . This might also be related to the much lower intake of animal source foods that contain highly bio-available zinc than the foods of plant origin. Yewelsew and her colleagues also reported low dietary zinc intake in pregnant women from Sidama Zone, Southern Ethiopia . As it was observed with the other micronutrients, the calcium intake was also lower than the recommended nutrient intake in the study participants. Inadequate intake of calcium among pregnant women from Sidama Zone, Southern Ethiopia was also reported by Yewelsew and her colleagues . The majority of the study subjects were consuming cereal based foods (99.2%) and legumes (74.2%), which are known to contain significant amount of phytate that reduces the bioavailability of the zinc, iron and calcium absorption .
Women of reproductive age are thought to be vulnerable to vitamin A deficiency during pregnancy and lactation [31, 32]. In the current study, it was found that the lactating women’s dietary intake of vitamin A (194 micro grams) was very much lower than the recommended intake (850 micro grams). The much lower intake of animal source foods (for vitamin A) as well as vitamins A and C rich fruits and vegetables might explain the lower intake of vitamin A in the lactating women.
Socio-economic and demographic factors affecting the nutritional status of the participants were size of farm land, length of years of marriage, maize cultivation, frequency of ANC visit and age of breastfeeding child. Those who had a land size of 0.26-0.75 hectares were 5.1 times more likely to be malnourished (MUAC < 21 cm) than those who had a land size of greater than 0.75 hectares. The strong association between land size and nutritional status might be explained by the fact that those who had a larger land size had an increased and diversified crop production as compared to those who had a smaller land size. Similarly, those whose years of marriage was between 11-20 years were 71% less likely to be malnourished (MUAC < 21 cm) than those whose years of marriage was less than or equal to 10 years. By the same token, the association between length of years of marriage and nutritional status could be explained by early marriage, i.e. those who were in a marriage for less than or equal to 10 years were mostly adolescents. A study by Teller and Gugsa conducted in Ethiopia reported similar finding, i.e., adolescent women were more likely to be malnourished compared to the other groups . Furthermore, growing of maize was also associated with the nutritional status (using MUAC) of the study participants, i.e., those who were not growing maize were 3 times more likely to be malnourished (MUAC < 21 cm) as compared to those who were growing maize. The probable reason could be because of the diversified cultivation of crops as those who were growing maize had better land size than those who were not growing maize.
Study conducted in Hadiya Zone showed that religion, ethnicity, household size, age and parity, land and livestock holding were not associated with malnutrition, as measured by BMI and MUAC. Instead, level of education, sickness and estimated production of staple crops were found to be significantly associated with malnutrition . In this study, nutritional status classified as MAUC < 21 cm or ≥ 21 cm did not reveal any statistical association with regard to family size, farm animal ownership, maternal educational status, number of meals per day, length of breast feeding, number of parity and eating additional food during lactation.
On the other hand, women who had ANC visit of less than or equal to 3 times were 2.9 times more likely to be malnourished (BMI < 18.5 kg/m2) than those who had more than 3 ANC visits per pregnancy. This might be because those who frequently visit the health institutions were getting health and nutrition educations as well as advice by the respective health professionals. Similarly, those women who had children aged greater than 12 months were 2.8 times more likely to be malnourished (BMI < 18.5 kg/m2) than those who had children aged less than or equal to 12 months. This could also be because of the increased nutritional requirement of the growing child but not increased food intake by the mother. Other probable reasons could also be giving less attention/care to the mother, work load and closely spaced pregnancies.
But, nutritional status of study participants according to BMI classification had no significant association on maternal educational status, household asset (radio) ownership, family size, maternal age, number of meals per day, number of parity, farm animal ownership and residence of the lactating mothers. This was in contrary to the study conducted on women’s nutritional status which had significant association on marital status, household assets, age of women and maternal education .
Major strengths of this study were the community based approach and random selection of the study households. This may made generalization possible to the study communities as an attempt was made to identify randomized households and lactating women from the study communities. Though weighed food record method is considered as a “gold” standard method for dietary assessment, the presence of data collectors in women’s homes for collecting weighed food records might alter the feeding behavior of the mothers, which may be considered as one of the limitations of this study. The seasonal variation of food availability that will have an effect on dietary intake and diversity was not considered due to the cross sectional nature of the study. Furthermore, it was difficult to establish a cause-effect relationship between the dependent variable (nutritional status) and the independent variables though association was observed.