Impact of Household Food Security and Anaemia on Pregnancy Outcomes Among Rural Women in Eastern Uganda

Abstract

Food security in Uganda is influenced by a combination of factors, including agricultural practices, climate conditions, economic stability, and social dynamics. According to the 1996 World Food Summit, food security exists “when all people at all times have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” (FAO, 1996; Summit 2007). This definition emphasizes not only the availability of food but also its quality, safety, and the ability of people to access it consistently. It is a complex and multi-dimensional issue influenced by various economic, social, environmental, and political factors (Mbow et al. 2020). According to the Global Hunger index 2023, Uganda scored 25.2, meaning that the level of hunger is serious. Anaemia is a medical condition characterized by a deficiency or a reduced amount of protein hemoglobin in the blood (Parbey et al. 2019; Nkurunziza et al. 2022). Globally, Iron deficiency anaemia (IDA) is one of the most prevalent types of anaemia, affecting a significant proportion of women, particularly during pregnancy, as well as young children and individuals in low-income settings. (Finkelstein et al. 2020; Udho et al. 2022). It occurs when the body lacks enough iron to produce adequate hemoglobin. Anaemia in pregnancy has been linked to adverse pregnancy outcomes for both the mother and the infant. Infant adverse outcomes may include preterm birth, low birth weight, Inter Uterine Growth Restriction (IUGR), still birth and low birth length. Household food security and anaemia prevalence are closely interconnected because the availability, accessibility, and quality of food at the household level play a significant role in determining the risk and prevalence of anaemia. Addressing these issues requires a holistic approach that combines food security initiatives with health and nutrition programs. The study aimed at determining the impact of household food security and anaemia on pregnancy outcomes among rural women in Eastern Uganda and specifically to (1) determine the prevalence and severity of anaemia among pregnant women (2) assess the level of household food security among pregnant women (3) examine the associations between household food security and maternal anaemia with adverse pregnancy outcomes, including low birth weight, preterm birth, and birth length (4) identify the factors influencing household food security, including socioeconomic, dietary, and health factors, in the study population as well as (5) to determine effect of postpartum maternal iron supplementation and food security on infant weight, length and maternal anaemia and provide evidence-based recommendations for culturally tailored interventions aimed at improving food security, preventing anaemia, and enhancing pregnancy outcomes among rural women in Eastern Uganda. This study was conducted in three stages, the first stage and second stage were carried out in health facilities and the third stage (intervention) was done in the community. The first stage of the study involved a descriptive cross-sectional design that was carried out in three healthcare facilities at different admission levels namely Jinja Regional Referral Hospital (JRRH) at the regional level, Buwenge General Hospital (BGH) at the district level, and Bugembe Health Centre IV (BHC) at sub-district level. The second stage involved an analytical case-control study design also carried out in the health care facilities. The third stage involved an interventional study design which was carried out in the community under a home visit approach. The first stage had a total of 263 participants who were recruited from the healthcare facilities using the simple random sampling method. The study employed a mixed method design using both primary data from the respondents and secondary data from the medical reports and history from the health facilities. The inclusion criteria included, (1) pregnant mothers in the third trimester and those booked to deliver from that health facility. (2) those who had delivered and had not been discharged yet within 72 hours. (3) mothers with complete medical records reflected in the hospital data. (4) mothers with a singleton or infant. (5) without other medical complications and chronic illnesses like Tuberculosis (TB) and HIV. (6) Mothers who consented to be part of the study. Mothers who were excluded from the study were those who had medical complications such as hypertension, diabetes, and sickle cell anaemia, TB, HIV. (2) mothers with multiple pregnancies or twins (3) mothers who didn’t live within the eastern Uganda. (4) mother without complete medical records. (5) those who didn’t consent to participate in the study. The second stage (case-control) included 50 mothers who had delivered from the above healthcare facilities. They were recruited using consecutive sampling method. This stage used a case- control method. Participants were allocated into two groups. (I) The case group included 25 mothers with infants who had Low birth weight, participated in the first stage of the study, lived within eastern Uganda, consented to be part of the second stage of the study (II) The control group included 25 mothers, who had infants with normal birth weight, participated in the first stage of the study living in eastern Uganda, those who consented to be part of the second stage of the study. The third stage was an interventional stage which included mothers with infants having adverse pregnant outcomes, participated in stage I and stage II, lived in eastern Uganda, consented to be part of the third stage and agreed to be visited in their homes. Through a face-to-face interview, variables that were measured included household food security which was measured using the Food Insecurity Experience Scale (FIES), dietary diversity measured by Household Dietary Diversity Score (HDDS), Minimum Dietary Diversity for Women (MDD-W), and the Food Frequency Questionnaire (FFQ). Anaemia was measured by taking maternal blood samples and comparing with the WHO cut offs. Pregnancy outcomes were measured including life of the infant, gestation age, birth weight, birth length and signs of anaemia and other parameters were measured by the study questionnaires. The third stage (intervention), included home visits which were carried out after every two weeks for a period of 2 months making a total of four visits for the intervention. The intervention group was offered (1) nutrition education and counselling about breast feeding, food security, hygiene and sanitation and backyard farming, (2) Iron and Folic Acid Supplementation (200mg Ferrous and 400mcg Folic acid), (3) supply of a food basket having 15 raw eggs, 1 kg iron rich beans, 2kg orange sweet potato, 2 bulbs of spinach and nutrition assessment of the baby on every visit. The home visits lasted for a maximum of one hour. The findings of the study showed that majority of the respondents, 42.6% were aged between 18-28 years. 52.9% of the respondents attained primary level of education and most of them were farmers which accounted for 61.6%. Majority of the households, 46.8% had more than five children. Many of the households had more than 7 members (53.6%). 62.7% of the mothers had limited land access. 68.0% of the respondents owned livestock. The majority of the mothers 82.0% had low income. Food insecurity was high with only 11% of the respondents being food secure and 89% being food insecure. Several socio-demographic factors, including maternal age, education level, occupation, number of children, land availability, and household income, were significantly associated with food security status. The study revealed that 4.8% of the respondents were severely food insecure. Risk factors that were significant with prevalence of food insecurity included food safety, access to safe water, waste management and involvement of households in sugarcane growing. The findings of this study indicated that 49.1% of the households had moderate household dietary diversity meaning that they consumed at least 6-7 food groups while 62.9% of the respondents had adequate individual minimum dietary diversity. (5 food groups). Cereals and tubers were highly consumed, 73% and 61% respectively. Animal protein including meat, fish, poultry were among the food groups least consumed. The study showed an association between food insecurity and higher rates of anaemia. 38.8% of the respondents were anaemic with 2% severely anaemic though majority 27.3% were mildly anaemic. Factors such as low dietary diversity (= 5 food groups), inadequate access to and compliance with iron and folic acid (IFA) supplements, and experiencing side effects from these supplements were significant contributors to anaemia. Conversely, anaemia was associated with adverse pregnancy outcomes. Anaemic mothers had higher odds of preterm birth at 2.95, low birth weight 2.74. and infants with anaemia indicating that food security and anaemia status profoundly affect pregnancy outcomes. Factors including time of 1st ANC visit, interpregnancy interval and gestation age were significant risk factors to low birth weight. The findings of the study intervention indicated that maternal anthropometric measurements improved except for height which doesn’t usually change in adults. Body weight, BMI and MUAC increased by 4.17kg, 2.29kg/m2, 3.72cm respectively. The Hb level showed the highest increment from 10.44g/dL to 12.48 g/dL with an increase of 2.05g/dL. The average infant weight also increased from 1.88 kg to 2.94 kg and the average length increased from 40.94 cm to 48.33 cm. There was increased knowledge and compliance for iron and folic acid supplementation. The side effects of the Supplements reduced. Nutrition education increased maternal awareness about breast feeding, food availability, backyard farming and hygiene and sanitation. Eggs were most consumed at 88%, orange sweet potato most shared at 28.8% and iron rich beans were most lost at 20.2%.