Undernutrition and Associated Factors Among Lactating Women in Dire Dawa Health Facilities, Ethiopia

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However, there was limited information on maternal nutrition status in low-income countries like Ethiopia, especially in the study area. Objectives: Determine magnitude of undernutrition and associated factors among lactating women Methods: Institutional based cross-sectional study was conducted among 422 lactating women in Dire Dawa town health facilities from February 10/02/2019 – March 30/ 03/2019. Result: Prevalence of undernutrition was 22 %. Women who age 15-25 years were four times more likely undernourished than older [AOR=4.04(CI: (1.74, 9.40)]. Unable to read and write Women were almost five times more likely to be undernourished than formal education [AOR=4.76 CI: (2.31, 9.81)]. Women who have family size >7 were six times more likely to be undernourished than family size < 3 [AOR=5.53 CI :( 1.15, 26.53)]. Women not take additional food during lactating were 4.5 times more likely undernourished than take additional food [AOR=4.56 CI (1.50, 13.9)]. DD score = 5) DD [AOR= 4 CI: (2.02, 7.90)]. Conclusion: Prevalence of undernutrition in the study area was high: Factors associated with underweight were: Age of lactating women, Education status, Family size, Additional food during lactation and DD score. Thus, multi-sectoral collaboration targeted at improving women’s educational status and increasing food during lactation need to be emphasized. Nutrition & Dietetics Undernutrition lactating Dire Dawa Ethiopia Figures Figure 1 Figure 2 Background Undernutrition and its associated disease conditions can be caused by eating too little, or eating an unbalanced diet that lacks necessary nutrients. Undernutrition, defined as failure to consume adequate energy, protein, and micronutrients to meet basic requirements for body maintenance, growth, and development (UNICEF, 2011). Undernutrition is one of the most devastating problems worldwide and is inextricably linked with poverty (IYCF, 2011). Women are more likely to suffer from nutritional deficiency than men including their reproductive biology, low social status, poverty and lack of education. Physiologically, women are more likely to be undernourished, especially if they are menstruating, pregnant, or lactating (Black.RE et al., 2013). In addition, socio-cultural traditions and disparities in household work patterns can also increase women’s chance of being undernourished (Ransom IE and KL, 2013). Nutrition throughout life has a major effect on health. This is true for lactating women as adequate maternal nutrition is one of the best ways to ensure maternal and fetal wellbeing in developed and developing countries (IYCF,2011).Diet quality in the first 1000 days of life, is fundamental for physical and mental development as well as maintaining good health in later life. Large segment of worlds’ population being undernourished or have low mineral and vitamin status due to lack of availability or inability to access to food of quality of diet. So providing a nourishing diet for pregnant and lactating mother results in significantly better infant health outcomes (WHO, 2014). Lactating women produce between 700 to 800 ml of milk per day. This needs an extra 500 kilocalories energy provision per day in additional to normal 2200 kilocalories (Patricia, 2014). Breast milk is rich in the vitamins and minerals needed to protect an infant’s health and promote growth and development. If the mother’s diet is poorly diversified, the levels of micronutrients in breast milk may be reduced or the mother’s own health may be affected (Allen, 2000). Adequate nutrition during lactation is not only important for optimum growth, maturation, mental development, physical wellbeing and disease resistance, but also breaks the intergenerational link of malnutrition and the transmission of its harmful effect to the succeeding generation through women and their children (Gala.U.M et al., 2016, Gemeda et al., 2013). In Sub-Saharan Africa (SSA), undernutrition during pregnancy and lactation is a widespread problem due to monotonous, plant based diet which does not meet the requirement. (Imamura et al. 2015). Even when enough food is available, the majority of women do not receive adequate nutrients during pregnancy and lactation attributable to poor knowledge on what constitutes an adequate diet (Ahmed et al., 2012). Methods Study Area and Period The study was conducted in Dire Dawa city administration which is located in the Eastern part of the Ethiopia. According to the Ethiopian central statistics authority’s 2008 report, Dire Dawa administrative region has total population of 453,000 of whom almost one to one male to female ratio. It is situated 515Kms from Addis Ababa. Dire Dawa city administration is one of the two City Administration and majority of its population lives in urban area with 233,224 or around 68.22% of the population are urban inhabitants.The public health organizations which are involved in health care delivery include 1public referral hospital, 1 public district hospital and 8 public health centers. All health institutions provide maternal health service in addition to other service. The study was conducted from February 10/02/2019 – March 30/ 03/2019. Study Design Institutional based cross sectional study design was used. Population Source population All lactating mothers living in Dire dawa City who were visiting Dire Dawa Health facilities for postnatal care and EPI program was considered as the source of population. Study population Selected lactating mothers who visiting Dire dawa Hospitals and Health Centers for postnatal care and EPI program during data collection period were considered as study population. Inclusion and exclusion criteria Inclusion Criteria Those lactating mothers living in Dire Dawa City and who was visiting at Dire dawa Hospitals and Health centers for post-natal care and EPI program during the study period. Exclusion Criteria Lactating women who were critical ill, pregnant and physical deformity will be excluded from the study to improve quality of anthropometric measurements. Data collection instrument Data on socio demographic, dietary diversity and food security variables were collected by using structured pretested Amharic version questionnaires adapted from different literature review (Eshetu et al., 2017, Kiday et al., 2013a, Mihiretu et al., 2015, Temesgen et al., 2015). The adapted data collection tools prepared in English will be translated to Amharic language and again back to English to check consistency. Food security was assessed using Household Food Insecurity Access Scale (HFIAS), it validated tool use in the Ethiopian context (Seifu et al., 2015). The HFIAS 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. (Coates et al., 2007). The mother’s dietary intake pattern will be measured by a qualitative recall of all foods consumed by each woman during the previous 24 hours. Thus, certain food groups was aggregated to calculate Individual (women) dietary diversity score (WDDS) and the mean DDS will be used to classify mothers food intake as adequate or not (Kennedy et al., 2013). To measure the outcome variable, anthropometric measurement (weight) of lactating women were measured to the nearest 100 g using portable electronic digital scale (Seca, Germany model) and height will be measured to the nearest 0.1 cm using a portable wooden height measuring board with sliding head bar through standard anthropometric measuring technique. Data collectors and data collection procedures The data will be collected by 8 nurses’ work in the post-natal and EPI service and the data was collect at exit. Data collectors were trained for two days by principal investigator. Two BSC holders in Nursing or health officer will be recruited and trained for supervising data collectors. Training was given about methods of anthropometric measurement, interviewing technique and filling questionnaires. To measure weight of mother requested to remove shoe, wear light close and other supportive materials and data collectors were weigh the study participant on calibrated portable digital scale and value will be recorded to the nearest 100 gram or 0.1 kg. To measure height the study participant was requested to stand erect with their shoulder level, hands was at the side, head, scapulae, buttock and heel were in contact with vertical measuring board with sliding head bar and height value will be recorded to the nearest 0.1 cm. (WHO 2012) Data quality control To assure the quality of the data, structured and pretested questionnaire was used. Pretest of the questionnaire was employed prior to actual data collection period among 5% of the study sample on one health center not included in this study. The final version of the questionnaire which was prepared in English translated into the local language of the respondents (Amharic language) and again translated back to English. The data collectors and supervisors were given two day intensive training by principal investigator (PI) on the instruments, method of data collection, how to take anthropometric measurements and ethical issues. Relative Technical error Measurement (%TEM) was done to minimize the random anthropometric measurement errors and relative TEMs for intra and inter examiners for weight and height was acceptable if relative technical error Measurement less than 1.5% and 2% respectively (Perini. et al., 2005). Functionality of digital weight scales will be checked using known weight every morning before data collection begin and before every weight measurement the data collectors were assure the scale reading exactly at zero (NHANES, 2007). Intensive supervision were done by principal investigator and supervisor and they were check the collected data for completeness, accuracy, and consistency throughout the data collection period. The overall supervision was done by the principal investigator. Data double entry was used to make comparisons of two data cells and resolve if there is some difference. Data processing and analysis Data was coded and entered on to Epi-data version 3.0 and exported to SPSS Version 22 for analysis. Missing values checked by conducting simple frequency analysis. Exploratory data analysis was done to check missing values, potential outliers and the normality distribution for those continuous variables. Body mass index of the mother was calculated through weight in kilogram divided by square of height in meters and based on the result mother was categorized in to underweight with BMI less than 18.5 kg/m2, normal those having BMI 18.5-24.99 kg/m2, overweight with BMI 25-29.99 kg/m2 and obese those having BMI greater than or equal to 30 kg/m2 (WHO 2012). Since the interest was identifying lactating women at risk of undernutrition, the dependent variables are coded as 1 lactating women were undernourished (BMI 2 was removed from analysis and those variables have no collinear effect was included in binary logistic regression model to see the possible relationships with the outcome variables. Covariates with a p-value less than 0.25 in the bivariable logistic regression analysis was candidate for a multivariable logistic regression analysis to control potential confounders and to identify associated factors of undernutrition. The fitness of the model was tested by Hosmer- Lemeshow goodness of fit test (p-value=0.83). Odd Ratios along with 95% Confidence interval was estimated measure the strength of the association. Level of statistical significance was declared at p-value less 0.05. Results were presented using frequencies, summary measures, tables, and figures. Results Socio-demographic characteristics of study participants A total of 401 lactating women aged 15-49 were interviewed, with a response rate of 95 %. Almost half, 329 (49.4%) of the respondents were in the age group of 26–35 years. The mean (±SD) age of respondents were 28.7 (±6.2) years. Majority, 569 (93.1%) of study participants were married. one hundred eighty-nine (47.1%) lactating women were orthodox religion followers. Regarding to education status, 59 (14.7%) women and 48 (12 %) husband, were not able to read and write. From the total study participant, 162 (40.4%) lactating women were housewife. Majority, 323 (80.5%) of the study participants lived in male-headed households. More than one fourth, 119 (29.6%) study participants have family size seven and more than seven. (Table 1) Table 1: Socio-demographic characteristics of lactating women whose age is 15-49 years in in Dire Dawa town, Eastern Ethiopia, 2019/20 (n=401) Variables Category Frequency Percent Age of lactating women 15-25 year 149 37.2 26-35 year 176 43.9 36-49 year 75 18.7 Current marital status of women Married 368 91.8 Other* 33 8.2 Religion of women Orthodox 189 47.1 Muslim 134 33.4 Protestant 78 19.5 Education of women Unable to read and right 59 14.7 Able to read and write 103 25.7 Only primary 91 22.7 Secondary 107 26.7 College diploma and above 41 10.2 Education of husband Unable to read and right 48 12.0 Able to read and write 64 16.0 Only primary 85 21.2 Secondary 147 36.6 College diploma and above 57 14.2 Occupation of women Housewife 162 40.4 Daily labor 51 12.7 Private employee 67 16.7 Government employee 121 30.2 Occupation of husband Daily labor 146 36.4 Private employee 78 19.5 Government employee 177 44.1 Head of the house hold Male 323 80.5 Female 78 19.5 Family size 1-3 76 19.0 4-6 206 51.4 >=7 119 29.6 Household Food Security : 107 (26.7 %) 95% CI (22.4, 30.9) of the households were food insecure while the remaining 294 (73.3 %) 95% CI (69.1, 77.6) were food secured period (Figure 1). 4.3. Maternal Health Care and Feeding Practices Majority, 245 (61.1 %), lactating women received antenatal care (ANC) at least once during their last pregnancy. But 39 (9.7%) lactating women were not taken ANC follow up during their pregnancy and also only 117 (29.2 %) of study subject had ANC visits of greater than or equal to 4 times (which is recommended). 176 (43.9%) of the study participants had 3-6 previous pregnancies. Only one third (28.4 %) of the respondent had birth interval > 2 years for their last delivery. From the total study participants, 96 (23.9%) got their first pregnancy in less than 18 year. More than three fourth (78.8%) study subject have got nutrition education. Majority, 360(89.8%) of the study participant did not avoid any food because of cultural/traditional reasons, whereas, only 83 (20.7%) of them were eating additional foods during their lactation period. The mean ± SD of women dietary diversity score of lactating mothers in the study area was 5 ±1.5, majority of them, 258 (64.3 %) had DDS of >= 5 and 143 (35.7%) lactating women had <5 DDS. From the total participant, 102 (25.4%) of respondents had experienced illness in the past two weeks preceding the study time. Concerning latrine availability, only 33 (8.2%) of households included in this study had no their own latrine (Table 2). Table 2: Maternal health care and feeding Practices women in Dire Dawa town, Eastern Ethiopia, 2019/20 (n=401) Variables Category Frequency Percent Breastfeed child age 6-11 month 170 42.4 12-18 month 158 39.4 19-24 month 73 18.2 Number of ANC visits No visit 39 9.7 =4 visit 117 29.2 Number of pregnancy 6 Child 15 3.7 Age at first pregnancy =18 years 305 76.1 Birth interval First birth 85 21.2 1-2 year 202 50.4 >2 year 114 28.4 Place of delivery Health facility 333 83.0 Home 68 17.0 Nutritional education Yes 316 78.8 No 85 21.2 Number of feeding =3 feed 294 73.3 Avoiding food during lactation Yes 41 10.2 No 360 89.8 Additionally food consumption Yes 83 20.7 No 318 79.3 Women dietary diversity =5 DD 258 64.3 History of illness Yes 299 74.6 No 102 25.4 Availability of toilet Yes 33 8.2 No 368 91.8 4.4. Maternal nutritional status The nutritional status of lactating women was measured by Body Mass Index (BMI). Accordingly, the mean (+SD) BMI was 21 (+2.4) Kg/m2. From the total study participants, 88 (22 %); 95% CI (18, 25.9) had BMI of <18.5 Kg/m2 and 288 (71.8 %); 95% CI (67.6, 76.1) were in normal range (Figure 2). 4.5. Factors associated with undernutrition among lactating women To determine the association between undernutrition and explanatory variables, bivariate analysis was performed using logistic regression. The result indicates that there is association between nutritional status of lactating women and some of the explanatory variables under the study such as age of lactating women, educational status of women, Age at first pregnancy family size, frequency of ANC visit, birth interval for the index child, additional food during lactation, Number of feeding, women dietary diversity and levels of household food insecurity, and (Table 4). Lactating women who had =4 ANC visit [AOR= 1.77, 95% CI: (0.86, 3.59)]. Those lactating women who had 1-2 years birth interval from index child had 1.24 times more likely undernutrition than those women who had > 2-year birth interval from index child [AOR=1.23 95% CI: (0.60, 2.50)]. Those women found in food insecure households had 3 times more likely to be undernourished than women in food secured households [OR= 2.86, 95% CI: (1.74, 4.72)]. Even if all these factor (described above) are not significantly associated with outcome variable in the multivariable logistic regression. In multivariable logistic regression analysis, the covariates: age of lactating women, educational status of women , family size, additional food during lactation and women dietary diversity score were statistically significant at 5% level of significance and were found to be the predictors of undernutrition among lactating women in the study. Those women who age are 15-25 years four times more likely undernourished than those women age 36 to 49 age during lactating [AOR=4.04(CI: (1.74, 9.40)].Lactating women unable to read and write were almost five times more likely to be undernourished than women who had formal education [AOR=4.76 CI: (2.31, 9.81)].Lactating women who have family size >7 were six times more likely to be undernourished than women who have family size less than 3 [AOR=5.53 CI :( 1.15, 26.53)].those women not take additional food during lactating were 4.5 times more likely undernourished than women take additional food during lactating. [AOR=4.56 CI (1.50, 13.9)]. Regarding women dietary diversity score, those with dietary diversity score below the mean (= 5 [AOR= 4 CI: (2.02 ,7.90) ](Table 3). Table 3: Factors associated with undernutrition among lactating women in Dire Dawa town, Eastern Ethiopia, 2019/2020 (n=401) Covariant Category BMI COR (95% CI) AOR (95%CI) =18.5 kg/m2 normal Age of lactating Women 15-25 year 55 (36.9%) 94 (63.1%) 2.59 (1.33, 5.05) 4.04 (1.74, 9.40) ** 26-35 year 19 (10.8%) 157 (89.2%) 0.54 (0.25,1.13) 0.71 (0.29, 1.61) 36-49 year 14 (18.4%) 62 (81.6%) 1 1 Education status of women Unable to read and write 28 (47.5%) 31 (52.5%) 5.26 (2.82, 9.82) 4.76 (2.31, 9.81) ** Able to read and write 25 (24.3%) 78 (75.7%) 1.86 (1.05, 3.32) 1.77 (0.88, 3.53) Have formal education 35 (14.6%) 204 (85.4%) 1 1 Age at first pregnancy =18 years 61 (20%) 244 (80%) 1 1 Family size 1-3 12 (15.8%) 64 (84.2%) 1 1 4-6 33 (16.1%) 173 (83.9%) 1.02 (0.49, 2.09) 3.56(0.78, 16.24) >=7 43 (36.2%) 76 (63.8%) 3.02 (1.47, 6.21) 5.53 (1.15, 26.53) ** Number of ANC visit = 4 visit 18 (15.4%) 99 (84.6%) 1 1 Birth interval first birth 18 (21.2%) 67 (78.8%) 1.34 (0.65, 2.75) 2.73 (0.67, 11.22) 1-2 year 51 (25.2%) 151 (74.8%) 1.68 (0.94, 3.03) 1.24 (0.60, 2.50) >2 year 19 (16.7%) 95 (83.7%) 1 1 additional food during lactation No 83 (26.1%) 235 (73.9%) 5.51 (2.15, 14.1) 4.56 (1.50, 13.9) ** Yes 5 (6.1%) 78 (93.9%) 1 1 Number of feeding =3 feed 51 (17.3%) 243 (82.7%) 1 1 Women dietary Diversity score =5 30 (11.6%) 228 (88.4%) 1 1 Household food security Food in secure 39 (41.6%) 68(58.4%) 2.86(1.74, 4.72) 1.1 (0.53, 2.11) Food secure 49 (16.9%) 245 (83.1%) 1 1 AOR= Adjusted Odd Ratio; CI= Confidence Interval, COR= Crude Odd Ratio; **= p-value < 0.05. Discussion The prevalence of undernutrition was 22 %. Age of lactating women, Education status of lactating women (those unable to read and write), Family size, additional food during lactation and women dietary diversity score were significantly associated with undernutrition. The prevalence of undernutrition (BMI < 18.5 kg/m2) among lactating women in this study was 22 %. This prevalence was much closer to the study documented in Ambo district 21.5% (Eshetu et al., 2017) and Nekemte 20.5% (Temesgen et al., 2015). It also similar to studies Adama 19.5% (Biru et al., 2017), Tigray, 24.6 % (Kiday et al., 2013) and also in Amhara region of Wombera district 25.6% (Sileshi et al., 2017). When this figure is compared with the result of Jimma 40.6% (Mihiretu et al., 2015) and Bible 41.7% (Kedir et al., 2015), it is much lower. This discrepancy could probably be attributed to 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 and time difference in which the current study was conducted recently after several community-based interventions were undertaken and also due to sample size difference between the studies. On the contrary, the prevalence is much higher than studies in Indonesia 9%, (Madanijah.et al., 2016) Tibet 10.3% (Wang et al., 2010), Myanmar 11.9% ( Zhao et al., 2014) and Nigeria 5% (Sanusi and Falana, 2009). The difference in the prevalence might be due to socio-demographic factors like education status of women and economic differences between the studies areas. The present study has affirmed that age of lactating women was significantly associated with their nutritional status. Mothers within the age group of 15-25 had four times more likely to be undernourished when compared with those mothers in the age group of 36-49. This is in line with a result from study done in Ambo district indicate that lactating women in age group of 17-25 more exposed to undernutrition than older women (Eshetu et al., 2017). Similarly in Bangladesh and Nepal, younger women in the age group 15–24 were more likely to be undernourished than older women (Rahman et al., 2015) (Bhandari S, et al 2016). Educational status of lactating women was a factor that predicted their nutritional status in this study. Lactating women who were unable to read and write were five times more likely to be undernourished than those mothers who had formal education. Similar studies from India (Maheshwari1.S et al.2015) and also in Ethiopia Ambo district (Eshetu et al., 2017) also reported that undernourished women were more common among those with no formal education. This might be related with an increased awareness of self-care, health service utilization and recognizing the importance of increasing meal frequency during lactation among educated women. In this study, statistically significant association was found between the covariate family size index and nutritional status of lactating women. Women from > 7 family size were 5.53 times more likely to be undernourished than women in the 1-3 family size. This had been also supported by the study from Wombera woreda, Northwest Ethiopia and Nekemte 25.6% (Sileshi et al., 2017) (Temesgen et al., 2015). This association could be due to the fact that women from family size higher were in difficulties of meeting their dietary requirement, engaged in strenuous works like daily laborer and have minimal health care practice and also food security issue in women with higher family size and related underweight and nutritional depletion of the mother due to successive pregnancies. Additional food during lactation was another factor associated with undernutrition. Accordingly, women who not got additional food during lactation were 4.56 times more likely to be undernourished compared to those who’s got additional food during lactation. This had been also supported by a study done in Tigray (Ismael et al., 2017). This could be because during lactation more energy were required than from normal time even more than from pregnancy time, so if the lactating women did not get adequate food during lactation were more exposed to undernutrition. Dietary diversity score of studied women was also another factor that affects their nutritional status in this study. Those women whose dietary diversity score below the mean (= 5), implying that eating diverse food groups as a protective to undernutrition. This finding agrees with a study done in Dedo and Seqa-Chekorsa districts, Jimma Zone (Mihiretu et al., 2015). This might be because women with low dietary diversity may not get enough balanced diet which is essential for the human body to be immune and perform metabolic activities and also diversified food reflects dietary quality, improves daily nutrient and energy intake. Lactating women who do not get enough energy and nutrients in their diets risk maternal depletion and exacerbates women undernutrition (Allen LH. 2012). The current study has the following limitations. An anthropometric measurement error was one of the limitations of this study: To minimize this; data collectors were well trained, standardization of anthropometric measures was done and the instrument was calibrated. Since some of the questions are asking the event that occurs 4 weeks back, there is a possibility that some of the responses might suffer from recall bias and this may affect prevalence estimates. This was minimized by probing the respondents about the event. The strength of this study, it has 96.5% response rate. Conclusion And Recommendations Conclusion The result of this study indicated that prevalence of undernutrition (BMI <18.5 Kg/m2) among lactating women in the study area was high. The predictors of undernutrition among lactating women in the study area were: Education status of lactating women (those unable to read and write), Age of lactating women, Family size, additional food during lactation and women dietary diversity score. Recommendations Based on the finding of this study, the following recommendations were made: Should strength sustained health and nutrition education to the women, their families and communities regarding increased food intake, proper dietary practices, and dietary diversification during their lactation time. Should closely work with health extension workers to increase awareness of lactating women on how to improve their own nutritional status. They should create strong multisector collaboration targeted at improving women educational status and increasing household food security status. Should work with beneficiary programs like safety net complemented with nutritional intervention to food insecure households. For further studies: Furthermore, longitudinal studies should also be conducted for a better understanding of the maternal dietary intake with relating to the nutritional status of lactating women. Declarations Acknowledgement First of all, I would like to thanks Dire Dawa University for giving me opportunity to develop this research. I extend my appreciation for staffs of Sabian hospitals, and Gende kore, Goro and Legehare Health centers providing important information and for their unlimited co-operation and also I thank the data collectors, supervisors, study participants, and questionnaire translators; without whom the research would not be done. Ethical considerations Before starting of the data collection process, Dire dawa University School of medicine and college of health sciences Institutional Health Research Ethics Review Committee (IHRERC) was secured by ethical clearance and Dire dawa University was write Official letter to hospital and health centers. Informed voluntary written and signed consent was obtained from each participant after explaining the purpose and benefits of the study. The data collector were trained to respect the culture of the people in these communities throughout the data collection process. Confidentiality of the study participants’ information also ensure. Consent for publication Not applicable Availability of data and material “Availability of Data and Materials” Funding All sources of funding for the research was Dire Dawa Univerisity. Authors' contributions Performed the thematic analysis and wrote the first draft of the manuscript as part of her master’s project. LR supervised the analysis and the master’s project. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Abbreviations AOR Adjusted Odds Ratio ANC Ante Natal Care BMI Body Mass Index CED Chronic Energy Deficiency CSA Central Statistical Agency DDS Dietary Diversity Score EDHS Ethiopian Demographic and Health Survey FAO Food and Agriculture Organization FMoH Federal Minster of Health HFIAS Household Food Insecurity Access Scale TEM Technical Error Measurement NGOs Non-Governmental Organizations NHANE National Health And Nutrition Examination Survey UNICEF United Nation Children’s Fund WHO World Health Organization References Abebe Ferede, Firaol Lemessa, Mesfin Tafa and Solomon Sisay 2017. The prevalence of malnutrition and its associated risk factors among women of reproductive age in Ziway Dugda district, Arsi Zone, Oromia Regional State, Ethiopia, Journal of public health 52(13), pp. 1 -8. 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Maternal and child undernutrition and overweight in low-income and middle-income countries, Lancet 382(98) pp. 427-451.Coates.J, Anne .S and Paula.B 2007. Household Food Insecurity Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide VERSION 3, August 2007. From https://www.fantaproject.org/monitoring.../HH-food-insecurity retrieved on October /9/2018 CSA 2016.Ethiopia Demographic and Health Survey Addis Ababa, Ethiopia.From; https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf retrieved on October /9/2018 Eshetu Zerihun, Gudina Egata, Frehiwot Mesfin. 2016 Under Nutrition and its Associated Factors among Lactating Mothers in Rural Ambo District, West Shewa Zone, Oromia Region, Ethiopia. East African Journal of Health and Biomedical Sciences, Volume 1 (1): pp. 39-48. FAO (Food and Agriculture Organization). 2008. Guidelines for measuring household and individual dietary diversity. (version 4), Rome, Italy. 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Maternal and Child Nutrition, 8: 275-286. Ismael Kalayu, Kiday Hailesslasie and Yohannes Adama 2017. Comparison of nutritional status and associated factors of lactating women between lowland and highland communities of District Raya, Alamata, Southern Tigray, Ethiopia, BMC Nutrition, 3(61), pp. 1-12. IYCN 2011. Infant & Young Child Nutrition Project Literature Review Prepared for the Message and Materials Development Workshop produced through support provided by the United States Agency for International Development, Addis Ababa, Ethiopia. From; iycn.org/files/IYCN-Ethiopia-Literature-review- retrieved on November 14/2018 P 2014. underlying causes of child and maternal malnutrition in the estate sector of Sri Lanka, Journal of South Asian studies, 02(03), pp. 241-255. Kedir Teji Roba, Thomas Connor, Tefera Belachew and Nora Brien 2015. Seasonal variation in nutritional status and anemia among lactating mothers in two agro-ecological zones of rural Ethiopia: A longitudinal study. Nutrition pp 1-6. S, Borne.D and Guy Plasqui 2014. Body composition, water turnover and physical activity among women in Narok County, Kenya, BMC Public Health 14(12), pp. 1-8. G, Tellier.B. and Claude .M 2010. Guidelines for Measuring Household and Individual Dietary Diversity', From; www.fao.org/3/a-i1983e.pdf retrieved on November 14/2018 Kidney Hailesslasie, Afework Mulugeta and Meron Girma., 2013. Feeding practices, nutritional status and associated factors of lactating women in Samre Woreda, South Eastern Zone of Tigray, Ethiopia, S, Rimbawan.R, Dodik.B, Zulaikhah.Z, Nuri.A, Lilis.N, Tonny.S, Laksmi.M and Jacques.B 2016. Nutritional status of lactating women in Bogor district, Indonesia: cross-sectional dietary intake in three economic quintiles and comparison with pre-pregnant women, British Journal of Nutrition S, Brijesh P, Singh.O, Singh and Gupta, P. 2015. Variation in body mass index and their determinants among married women in Uttar Pradesh, International Journal of Health,3 (2), pp. 52-55. R, Balakrishna.N, Arlappa.N, Laxmaiah.2010. Diet and Nutritional Status of Women in India, J.Hum Ecol, 29(3), pp. 165-170. Mesfin Tafa and Jemal Haider; 2013 Effect of modern family planning methods use on the nutritional status of women of reproductive age group at Tena district, Arsi Zone, Ethiopia, an international conference on family planning, A.A, Ethiopia,pp.1-8. Mihiretu Alemayehu, Alemayehu Arga and Abele G.Mariam 2015. Factors Associated with Malnutrition among Lactating Women in Subsistence Farming Households from Dedo and Seqa-Chekorsa Districts, Jimma Zone, 2014, iiste 5 (21), pp. 1-9. Negassie Berhe, Kebede Haile, Meresa Gebremedhin, Yosef Sibhatu, 2016. Dietary diversity and related factors among lactating women visiting public health facilities in Aksum town, Tigray, Northern Ethiopia, BMC Nutrition 2(38 ), pp. 2-9. NHANES (National Health and Nutrition Examination Survey). 2007. Anthropometry procedures manual. From; https://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/manual_ retrieved on November Nikolaos KM, Charilaos D, Sci MM, Meropi K, Evangelia M, 2010 Clinical nutrition in practice. Blackwell Publishing Ltd, UK. NNP-II 2013. National Nutrition Programme June 2013 - June 2015 From; fao.org/fileadmin/.../Ethiopia_National_Nutrition_Strategy_ . retrieved on October /21/2018 U 2014. A study of the nutritional status and dietary intake of lactating women in Umuahia, Nigeria, American Journal of Health Research 2(1), pp. 20-26. A, Glauber.L, Oliveira.D and Ornellas.J 2005. Technical error of measurement in anthropometry. Rev Bras Med Esporte , 11(7), pp 86-90 Rahman, S, Mondal.N, Islam.R, Ahmed.K, Karim, R. and Alam.S 2015. Under Weightiness among Ever-married Non-pregnant Women in Bangladesh: A Population-Based Study, Universal Journal of Food and Nutrition Science, 3(2), pp. 29-36. E and Kanbaro.L, 2003. Nutrition of women and Adolescent girls: Why it matters? Population Reference Bureau. www.prb.org/.../2003/NutritionofWomenandAdolescentGirlsWhyItMatters.asp N, Balakrishna.N, Arlappa.A, Laxmaiah.S and Brahmam.G 2010. Diet and nutritional status of women in India, J Hum Ecol 29(3), pp. 165-170. Saba Abraham, Gebremeskel Miruts and Ashenafi Shumye 2015. The magnitude of chronic energy deficiency and its associated factors among women of reproductive age in the Kunama population, Tigray, Ethiopia, in 2014." BMC Nutrition 1(12), pp1-9. A and Falana.M 2009. The Nutritional Status of Mothers Practicing Breast Feeding In Ibadan, Nigeria, African Journal of Biomedical Research, 12(2), pp. 1-7. Seifu Hagos, Torlief Lunde, Damen H.Mariam and Tassew Woldehanna 2015. 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, 1(2), pp. 1-10. Sileshi Berihun, Getachew Mullu Kassa and Muluken Teshome 2017. Factors associated with underweight among lactating women in Womberma woreda, Northwest Ethiopia; a cross-sectional Temesgen Jessica, Habtamu Fkadu, Desalege Wirtu and Duncan Kenya Nutritional Status and Associated Factors among Lactating Mothers in Nekemte Referral Hospital and Health Centers, Ethiopia, Food Science and Quality Management 35(24), pp.1-11. UNICEF 2009. Tracking progress on child and maternal nutrition a survival and development priority From; https://www.unicef.org/.../Tracking_Progress_on_Child_and_Maternal_Nutrition UNICEF 2011. United Nations Children’s Fund. Programming Guide: Infant and Young Child Feeding. https://www.unicef.org/nutrition/files/Final_IYCF_programming_guide_2011.pdf Z, Dang, S., and Yan, H 2010. Nutrient intakes of rural Tibetan mothers: a cross-sectional survey, BMC Public Health , 10(801), pp. 1-8. WHO 1995. Physical status: The use and interpretation of anthropometry, report of WHO expert committee. WHO technical report series, Geneva. from www.who.int /iris/handle/10665/37003 . WHO 2005. Quantifying the health impact at national and local levels, WHO environmental burden of disease series, Geneva. From; who.int/outgrowth/publications/quantifying_health_impact/e . retrieved on October 28/2018 WHO 2012. Global Database on Body Mass Index. From; who.int/nutrition/databases/bmi/ retrieved on on November /02/2018 WHO 2014. Comprehensive implementation plan on maternal, infant and young child nutrition. From; who.int/nutrition/publications/CIP_document/en. retrieved on October /19/2018 A, Zhang.Y, Li.B, Wang.P, Li.J, Xue.Y, and Gao.H 2014. Prevalence of Anemia and Its Risk Factors Among Lactating Mothers in Myanmar, American Journal of Tropical Medicine and Hygiene. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-88070","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":3102846,"identity":"c93562dd-6b5e-4b08-96ba-2d05a4d60b40","order_by":0,"name":"Zerihun Tariku ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIie2QsUrDUBSGz+VCspzS9RZp8wotWYt9lZRCnF2yNlA4LrFdDeg72DfI5YJdNK6BdmiWTBUsji7eaIMuNzo63G/6h/Px/xwAi+WfopogYxizONMJ/6LglxJ+K20abxQWg/pd8a6uS3VJO5i4T6VM6bm/LAK2fyEYTAwKSzZDlVIFiBdDuaatnxYBH90R+KYWLkJQHVJ6RgiypO30vgicsw7BNDEojledlG5VK3mtuO9amZsUFM5J0XV6WPbZwrUSmIYJ1MMwV4iFbrnJZ376WC56t7kYJZnpYw/8DSM1cFchPybReX+5mcnXQzT23NhQ0wz8kVl9K9rvLRaLxdLKB9J5XOdBBAgHAAAAAElFTkSuQmCC","orcid":"","institution":"Dire Dawa university","correspondingAuthor":true,"prefix":"","firstName":"Zerihun","middleName":"","lastName":"Tariku","suffix":""},{"id":3102847,"identity":"ef3887a3-bb5d-47cb-8108-f21cc28f2803","order_by":1,"name":"Bereket Tefera ","email":"","orcid":"","institution":"Dire Dawa university","correspondingAuthor":false,"prefix":"","firstName":"Bereket","middleName":"","lastName":"Tefera","suffix":""},{"id":3102848,"identity":"b341aa63-e5da-4704-b44d-5c74f1398cfe","order_by":2,"name":"Serawit Samuel","email":"","orcid":"","institution":"Dire Dawa university","correspondingAuthor":false,"prefix":"","firstName":"Serawit","middleName":"","lastName":"Samuel","suffix":""},{"id":3102849,"identity":"125c3849-7f9d-4ca2-89e5-641790de2646","order_by":3,"name":" Tariku Derese ","email":"","orcid":"","institution":"Dire Dawa university","correspondingAuthor":false,"prefix":"","firstName":"Tariku","middleName":"","lastName":"Derese","suffix":""},{"id":3102850,"identity":"0b0b12b1-f15e-43e2-b702-74f1bf734df7","order_by":4,"name":"Melese Markos ","email":"","orcid":"","institution":"Dire Dawa university ","correspondingAuthor":false,"prefix":"","firstName":"Melese","middleName":"","lastName":"Markos","suffix":""},{"id":3102851,"identity":"3c4daecf-6d09-41b7-a051-cc5a82640fd8","order_by":5,"name":"Samuel Dessu ","email":"","orcid":"","institution":"Dire Dawa university","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Dessu","suffix":""}],"badges":[],"createdAt":"2020-10-05 14:15:22","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-88070/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-88070/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":2816824,"identity":"82ba3644-f085-48e1-814c-9113c0b5dffc","added_by":"auto","created_at":"2020-10-06 21:30:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32970,"visible":true,"origin":"","legend":"Household food security levels among the study participants in Dire Dawa town, Eastern Ethiopia, 2019/20 (n=401)\n\n","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-88070/v1/a8385e326ee75a1064ebf819.png"},{"id":2816825,"identity":"46ae6283-d3b4-4f6e-8aca-1c8e1f5be1ce","added_by":"auto","created_at":"2020-10-06 21:30:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13195,"visible":true,"origin":"","legend":"Nutritional status of study participants Using BMI in Dire Dawa town, Eastern Ethiopia, 2019/20 (n=401)","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-88070/v1/4723603689a5a26ee2531cc4.png"},{"id":13600920,"identity":"7e064067-a316-4d03-a920-500624ab0b96","added_by":"auto","created_at":"2021-09-17 05:45:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":480625,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-88070/v1/2ca80ed3-0a22-44c4-880e-1ffd52546063.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eUndernutrition and Associated Factors Among Lactating Women in Dire Dawa Health Facilities, Ethiopia\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eUndernutrition and its associated disease conditions can be caused by eating too little, or eating an unbalanced diet that lacks necessary nutrients. Undernutrition, defined as failure to consume adequate energy, protein, and micronutrients to meet basic requirements for body maintenance, growth, and development (UNICEF, 2011). Undernutrition is one of the most devastating problems worldwide and is inextricably linked with poverty (IYCF, 2011).\u003c/p\u003e\n\u003cp\u003eWomen are more likely to suffer from nutritional deficiency than men including their reproductive biology, low social status, poverty and lack of education. Physiologically, women are more likely to be undernourished, especially if they are menstruating, pregnant, or lactating (Black.RE\u0026nbsp; et al., 2013). In addition, socio-cultural traditions and disparities in household work patterns can also increase women\u0026rsquo;s chance of being undernourished (Ransom IE and KL, 2013).\u003c/p\u003e\n\u003cp\u003eNutrition throughout life has a major effect on health. This is true for lactating women as adequate maternal nutrition is one of the best ways to ensure maternal and fetal wellbeing in developed and developing countries (IYCF,2011).Diet quality in the first 1000 days of life, is fundamental for physical and mental development as well as maintaining good health in later life. Large segment of worlds\u0026rsquo; population being undernourished or have low mineral and vitamin status due to lack of availability or inability to access to food of quality of diet. So providing a nourishing diet for pregnant and lactating mother results in significantly better infant health outcomes (WHO, 2014).\u003c/p\u003e\n\u003cp\u003eLactating women produce between 700 to 800 ml of milk per day. This needs an extra 500 kilocalories energy provision per day in additional to normal 2200 kilocalories (Patricia, 2014). Breast milk is rich in the vitamins and minerals needed to protect an infant\u0026rsquo;s health and promote growth and development. If the mother\u0026rsquo;s diet is poorly diversified, the levels of micronutrients in breast milk may be reduced or the mother\u0026rsquo;s own health may be affected (Allen, 2000).\u003c/p\u003e\n\u003cp\u003eAdequate nutrition during lactation is not only important for optimum growth, maturation, mental development, physical wellbeing and disease resistance, but also breaks the intergenerational link of malnutrition and the transmission of its harmful effect to the succeeding generation through women and their children (Gala.U.M et al., 2016, Gemeda et al., 2013).\u003c/p\u003e\n\u003cp\u003eIn Sub-Saharan Africa (SSA), undernutrition during pregnancy and lactation is a widespread problem due to monotonous, plant based diet which does not meet the requirement. (Imamura et al. 2015). Even when enough food is available, the majority of women do not receive adequate nutrients during pregnancy and lactation attributable to poor knowledge on what constitutes an adequate diet (Ahmed et al., 2012).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Area and Period\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Dire Dawa city administration which is located in the Eastern part of the Ethiopia. According to the Ethiopian central statistics authority\u0026rsquo;s 2008 report, Dire Dawa administrative region has total population of 453,000 of whom almost one to one male to female ratio. It is situated 515Kms from Addis Ababa. Dire Dawa city administration is one of the two City Administration and majority of its population lives in urban area with 233,224 or around 68.22% of the population are urban inhabitants.The public health organizations which are involved in health care delivery include 1public referral hospital, 1 public district hospital and 8 public health centers. All health institutions provide maternal health service in addition to other service. The study was conducted from February 10/02/2019 \u0026ndash; March 30/ 03/2019.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInstitutional based cross sectional study design was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll lactating mothers living in Dire dawa City who were visiting Dire Dawa Health facilities for postnatal care and EPI program was considered as the source of population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelected lactating mothers who visiting Dire dawa Hospitals and Health Centers for postnatal care and EPI program during data collection period were considered as study population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and exclusion criteria\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThose lactating mothers living in Dire Dawa City and who was visiting at Dire dawa Hospitals and Health centers for post-natal care and EPI program during the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLactating women who were critical ill, pregnant and physical deformity will be excluded from the study to improve quality of anthropometric measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection instrument\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData on socio demographic, dietary diversity and food security variables were collected by using structured pretested Amharic version questionnaires adapted from different literature review (Eshetu et al., 2017, Kiday et al., 2013a, Mihiretu et al., 2015, Temesgen\u0026nbsp; et al., 2015). The adapted data collection tools prepared in English will be translated to Amharic language and again back to English to check consistency.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Food security was assessed using Household Food Insecurity Access Scale (HFIAS), it validated tool use in the Ethiopian context (Seifu et al., 2015). The HFIAS has nine questions asking household\u0026rsquo;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. (Coates et al., 2007).\u003c/p\u003e\n\u003cp\u003eThe mother\u0026rsquo;s dietary intake pattern will be measured by a qualitative recall of all foods consumed by each woman during the previous 24 hours. Thus, certain food groups was aggregated to calculate Individual (women) dietary diversity score (WDDS) and the mean DDS will be used to classify mothers food intake as adequate or not (Kennedy et al., 2013).\u003c/p\u003e\n\u003cp\u003eTo measure the outcome variable, anthropometric measurement (weight) of lactating women were \u0026nbsp;measured to the nearest 100 g using portable electronic digital scale (Seca, Germany model) and height will be measured to the nearest 0.1 cm using a portable wooden height measuring board with sliding head bar through standard anthropometric measuring technique.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collectors and data collection procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data will be collected by 8 nurses\u0026rsquo; work in the post-natal and EPI service and the data was collect at exit. Data collectors were trained for two days by principal investigator. Two BSC holders in Nursing or health officer will be recruited and trained for supervising data collectors. Training was given about methods of anthropometric measurement, interviewing technique and filling questionnaires.\u003c/p\u003e\n\u003cp\u003eTo measure weight of mother requested to remove shoe, wear light close and other supportive materials and data collectors were weigh the study participant on calibrated portable digital scale and value will be recorded to the nearest 100 gram or 0.1 kg.\u003c/p\u003e\n\u003cp\u003eTo measure height the study participant was requested to stand erect with their shoulder level, hands was at the side, head, scapulae, buttock and heel were in contact with vertical measuring board with sliding head bar and height value will be recorded to the nearest 0.1 cm. (WHO 2012)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData quality control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo assure the quality of the data, structured and pretested questionnaire was used. Pretest of the questionnaire was employed prior to actual data collection period among 5% of the study sample on one health center not included in this study. The final version of the questionnaire which was prepared in English translated into the local language of the respondents (Amharic language) and again translated back to English. The data collectors and supervisors were given two day intensive training by principal investigator (PI) on the instruments, method of data collection, how to take anthropometric measurements and ethical issues.\u003c/p\u003e\n\u003cp\u003eRelative Technical error Measurement (%TEM) was done to minimize the random anthropometric measurement errors and relative TEMs for intra and inter examiners for weight and height was acceptable if relative technical error Measurement less than 1.5% and 2% respectively (Perini. et al., 2005). Functionality of digital weight scales will be checked using known weight every morning before data collection begin and before every weight measurement the data collectors were\u0026nbsp; assure the scale reading exactly at zero (NHANES, 2007).\u003c/p\u003e\n\u003cp\u003eIntensive supervision were done by principal investigator and supervisor and they were check the collected data for completeness, accuracy, and consistency throughout the data collection period. The overall supervision was done by the principal investigator. Data double entry was used to make comparisons of two data cells and resolve if there is some difference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData processing and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was coded and entered on to Epi-data version 3.0 and exported to SPSS Version 22 for analysis. Missing values checked by conducting simple frequency analysis. Exploratory data analysis was done to check missing values, potential outliers and the normality distribution for those continuous variables.\u003c/p\u003e\n\u003cp\u003eBody mass index of the mother was calculated through weight in kilogram divided by square of height in meters and based on the result mother was categorized in to underweight with BMI less than 18.5 kg/m2, normal those having BMI 18.5-24.99 kg/m2, overweight with BMI 25-29.99 kg/m2 and obese those having BMI greater than or equal to 30 kg/m2 (WHO 2012). Since the interest was identifying lactating women at risk of undernutrition, the dependent variables are coded as 1 lactating women were undernourished (BMI \u0026lt;18.5 kg/m2) and coded as 0 if not.\u003c/p\u003e\n\u003cp\u003eMulti-Collinearity effect was checked and variables with SE \u0026gt;2 was removed from analysis and those variables have no collinear effect was included in binary logistic regression model to see the possible relationships with the outcome variables. Covariates with a p-value less than 0.25 in the bivariable logistic regression analysis was candidate for a multivariable logistic regression analysis to control potential confounders and to identify associated factors of undernutrition. The fitness of the model was tested by Hosmer- Lemeshow goodness of fit test (p-value=0.83).\u0026nbsp; Odd Ratios along with 95% Confidence interval was estimated measure the strength of the association. Level of statistical significance was declared at p-value less 0.05. Results were presented using frequencies, summary measures, tables, and figures.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSocio-demographic characteristics of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 401 lactating women aged 15-49 were interviewed, with a response rate of 95 %. Almost half, 329 (49.4%) of the respondents were in the age group of 26\u0026ndash;35 years. The mean (\u0026plusmn;SD) age of respondents were 28.7 (\u0026plusmn;6.2) years. Majority, 569 (93.1%) of study participants were married. one hundred eighty-nine (47.1%) lactating women were orthodox religion followers. Regarding to education status, 59 (14.7%) women and 48 (12 %) husband, were not able to read and write. From the total study participant, 162 (40.4%) lactating women were housewife. Majority, 323 (80.5%) of the study participants lived in male-headed households. More than one fourth, 119 (29.6%) study participants have family size seven and more than seven. (Table 1)\u003c/p\u003e\n\u003cp\u003eTable 1: Socio-demographic characteristics of lactating women whose age is 15-49 years in in Dire Dawa town, Eastern Ethiopia, 2019/20 (n=401)\u003c/p\u003e\n\u003ctable border=\"1\" width=\"651\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"237\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eVariables \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e\u003cstrong\u003eCategory \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"237\"\u003e\n\u003cp\u003eAge of lactating women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e15-25 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e149\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e37.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e26-35 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e176\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e43.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e36-49 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e18.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"237\"\u003e\n\u003cp\u003eCurrent marital status\u0026nbsp; of women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e368\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e91.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eOther*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e8.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"237\"\u003e\n\u003cp\u003eReligion of women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eOrthodox\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e189\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e47.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eMuslim\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e134\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e33.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eProtestant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e19.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" width=\"237\"\u003e\n\u003cp\u003eEducation\u0026nbsp; of women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eUnable to read and right\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e14.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eAble to read and write\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e103\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e25.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eOnly\u0026nbsp; primary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e22.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eSecondary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e107\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e26.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eCollege diploma and above\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e10.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" width=\"237\"\u003e\n\u003cp\u003eEducation\u0026nbsp; of\u0026nbsp; husband\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eUnable\u0026nbsp; to read and right\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e12.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eAble\u0026nbsp; to read and write\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e16.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eOnly primary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e21.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eSecondary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e147\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e36.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eCollege diploma and above\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e14.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" width=\"237\"\u003e\n\u003cp\u003eOccupation\u0026nbsp; of women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eHousewife\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e162\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e40.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eDaily labor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e12.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003ePrivate employee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e16.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eGovernment employee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e121\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e30.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"237\"\u003e\n\u003cp\u003eOccupation\u0026nbsp; of\u0026nbsp; husband\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eDaily labor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e146\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e36.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003ePrivate employee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e19.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eGovernment employee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e177\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e44.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"237\"\u003e\n\u003cp\u003eHead of the house hold\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e323\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e80.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e19.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"237\"\u003e\n\u003cp\u003eFamily size\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e1-3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e19.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e4-6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e206\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e51.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"222\"\u003e\n\u003cp\u003e\u0026gt;=7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e119\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"81\"\u003e\n\u003cp\u003e29.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eHousehold Food Security\u003c/strong\u003e: 107 (26.7 %) 95% CI (22.4, 30.9) of the households were food insecure while the remaining 294 (73.3 %) 95% CI (69.1, 77.6) were food secured period (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3. Maternal Health Care and Feeding Practices\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajority, 245 (61.1 %), lactating women received antenatal care (ANC) at least once during their last pregnancy. But 39 (9.7%) lactating women were not taken ANC follow up during their pregnancy and also only 117 (29.2 %) of study subject had ANC visits of greater than or equal to 4 times (which is recommended). 176 (43.9%) of the study participants had 3-6 previous pregnancies. Only one third (28.4 %) of the respondent had birth interval \u0026gt; 2 years for their last delivery. From the total study participants, 96 (23.9%) got their first pregnancy in less than 18 year. More than three fourth (78.8%) study subject have got nutrition education. Majority, 360(89.8%) of the study participant did not avoid any food because of cultural/traditional reasons, whereas, only 83 (20.7%) of them were eating additional foods during their lactation period. The mean \u0026plusmn; SD of women dietary diversity score of lactating mothers in the study area was 5 \u0026plusmn;1.5,\u0026nbsp; majority of them, 258 (64.3\u0026nbsp; %) had DDS of \u0026gt;= 5 and 143 (35.7%) lactating women had \u0026lt;5 DDS. From the total participant, 102 (25.4%) of respondents had experienced illness in the past two weeks preceding the study time. Concerning latrine availability, only 33 (8.2%) of households included in this study had no their own latrine (Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2: Maternal health care and feeding Practices women in Dire Dawa town, Eastern Ethiopia, 2019/20 (n=401)\u003c/p\u003e\n\u003ctable border=\"1\" width=\"622\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"243\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariables \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u003cstrong\u003eCategory \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrequency \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u003cstrong\u003ePercent \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"243\"\u003e\n\u003cp\u003eBreastfeed child age\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e6-11 month\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e170\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e42.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e12-18 month\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e158\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e39.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e19-24 month\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e18.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"243\"\u003e\n\u003cp\u003eNumber of ANC visits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eNo visit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e9.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026lt;4\u0026nbsp; visit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e245\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e61.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026gt;=4 visit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e117\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e29.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" width=\"243\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNumber of pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u003cu\u003e\u0026lt;\u003c/u\u003e 2 Child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e210\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e52.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e3-4 Child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e124\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e30.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e5-6 Child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e13.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026gt;6 Child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e3.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eAge at first pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026lt;18 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e23.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026gt;=18 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e305\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e76.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"243\"\u003e\n\u003cp\u003eBirth interval\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eFirst\u0026nbsp; birth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e21.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e1-2 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e202\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e50.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026gt;2 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e114\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e28.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003ePlace of delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eHealth\u0026nbsp; facility\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e333\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e83.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eHome\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e17.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eNutritional education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e316\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e78.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e21.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eNumber of feeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026lt;3 feed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e107\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e26.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026gt;=3 feed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e294\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e73.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eAvoiding food during lactation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e10.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e89.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eAdditionally\u0026nbsp; food\u0026nbsp; consumption\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e20.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e318\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e79.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eWomen dietary diversity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026lt;5 DD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e143\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e35.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003e\u0026gt;=5 DD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e258\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e64.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eHistory of illness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e299\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e74.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e102\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e25.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"243\"\u003e\n\u003cp\u003eAvailability of toilet\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e8.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"185\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e368\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e91.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e4.4. Maternal nutritional status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe nutritional status of lactating women was measured by Body Mass Index (BMI). Accordingly, the mean (+SD) BMI was 21 (+2.4) Kg/m2. From the total study participants, 88 (22 %); 95% CI (18, 25.9) had BMI of \u0026lt;18.5 Kg/m2 and 288 (71.8 %); 95% CI (67.6, 76.1) were in normal range (Figure 2). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5. Factors associated with undernutrition among lactating women\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the association between undernutrition and explanatory variables, bivariate analysis was performed using logistic regression. The result indicates that there is association between nutritional status of lactating women and some of the explanatory variables under the study such as age of lactating women, educational status of women, Age at first pregnancy family size, frequency of ANC visit, birth interval for the index child, additional food during lactation, Number of feeding, women dietary diversity and levels of household food insecurity, and (Table 4).\u003c/p\u003e\n\u003cp\u003eLactating women\u0026nbsp; who had \u0026lt; 4 ANC visit were 1.7 times more likely to be undernourished than those women who had \u0026gt;=4 ANC visit [AOR= 1.77, 95% CI: (0.86, 3.59)]. Those lactating women who had 1-2 years birth interval from index child had 1.24 times more likely undernutrition than those women who had \u0026gt; 2-year birth interval from index child [AOR=1.23 95% CI: (0.60, 2.50)]. Those women found in food insecure households had 3 times more likely to be undernourished than women in food secured households [OR= 2.86, 95% CI: (1.74, 4.72)]. Even if all these factor (described above) are not significantly associated with outcome variable in the multivariable logistic regression.\u003c/p\u003e\n\u003cp\u003eIn multivariable logistic regression analysis, the covariates: age of lactating women, educational status of women , family size, additional food during lactation and women dietary diversity score were statistically significant at 5% level of significance and were found to be the predictors of undernutrition among lactating women in the study. Those women who age\u0026nbsp; are 15-25 years four times more likely undernourished than those women age 36 to 49 age during lactating [AOR=4.04(CI: (1.74, 9.40)].Lactating women unable to read and write were almost five times more likely to be undernourished than women who had formal education [AOR=4.76 CI: (2.31, 9.81)].Lactating women who have family size \u0026gt;7 were six times more likely to be undernourished than women who have family size less than 3 [AOR=5.53 CI :( 1.15, 26.53)].those women not take additional food during lactating were 4.5 times more likely undernourished than women take additional food during lactating. [AOR=4.56 CI (1.50, 13.9)]. Regarding women dietary diversity score, those with dietary diversity score below the mean (\u0026lt; 5) were 4 more likely to be undernourished than women with score \u0026nbsp;\u0026gt;= 5 [AOR= 4 CI: (2.02 ,7.90) ](Table 3).\u003c/p\u003e\n\u003cp\u003eTable 3: Factors associated with undernutrition among lactating women in Dire Dawa town, Eastern Ethiopia, 2019/2020 (n=401)\u003c/p\u003e\n\u003ctable border=\"1\" width=\"726\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003e\u003cstrong\u003eCovariant \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"148\"\u003e\n\u003cp\u003e\u003cstrong\u003eCategory \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"228\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;18.5 kg/m2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUndernutrition\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026gt;=18.5 kg/m2 \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003enormal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"121\"\u003e\n\u003cp\u003eAge of lactating\u003c/p\u003e\n\u003cp\u003eWomen\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e15-25 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e55 (36.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e94 (63.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2.59 (1.33, 5.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e4.04\u0026nbsp; (1.74, 9.40)\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e26-35 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e19 (10.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e157 (89.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0.54 (0.25,1.13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e0.71 (0.29, 1.61)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e36-49 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e14 (18.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e62 (81.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"121\"\u003e\n\u003cp\u003eEducation\u003c/p\u003e\n\u003cp\u003estatus of women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eUnable to read and write\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e28 (47.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e31 (52.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5.26 (2.82, 9.82)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e4.76 (2.31, 9.81)\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eAble to read and write\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e25 (24.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e78 (75.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.86 (1.05, 3.32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1.77 (0.88, 3.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eHave formal\u0026nbsp; education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e35 (14.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e204 (85.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003eAge at first\u003c/p\u003e\n\u003cp\u003epregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026lt; 18 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e27 (28.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e69 (71.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.56 (1.03, 2.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e0.92 (0.48,\u0026nbsp; 1.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026gt;=18 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e61 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e244 (80%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"121\"\u003e\n\u003cp\u003eFamily size\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e1-3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e12 (15.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e64 (84.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e4-6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e33 (16.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e173 (83.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.02 (0.49, 2.09)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e3.56(0.78, 16.24)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026gt;=7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e43 (36.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e76 (63.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e3.02 (1.47, 6.21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e5.53 (1.15, 26.53)\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003eNumber of\u003c/p\u003e\n\u003cp\u003eANC visit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026lt; 4 visit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e70 (24.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e214 (75.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.79 (1.2, 3.18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1.76 (0.86, 3.59)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026gt;= 4 visit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e18 (15.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e99 (84.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" width=\"121\"\u003e\n\u003cp\u003eBirth interval\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003efirst birth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e18 (21.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e67 (78.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.34 (0.65, 2.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e2.73 (0.67, 11.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e1-2 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e51 (25.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e151 (74.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.68 (0.94, 3.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1.24 (0.60, 2.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026gt;2 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e19 (16.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e95 (83.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003eadditional food during lactation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e83 (26.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e235 (73.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5.51 (2.15, 14.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e4.56 (1.50, 13.9)\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e5 (6.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e78 (93.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003eNumber\u003c/p\u003e\n\u003cp\u003eof feeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026lt; 3 feed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e37 (34.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e70 (65.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2.52 (1.53, 4.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e0.67 (0.32, 1.64)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026gt;=3 feed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e51 (17.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e243 (82.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003eWomen\u0026nbsp; dietary\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiversity score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026lt; 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e58 (40.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e85 (59.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e5.19 (3.12, 8.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e4 (2.02 ,7.90)\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003e\u0026gt;=5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e30 (11.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e228 (88.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"121\"\u003e\n\u003cp\u003eHousehold\u003c/p\u003e\n\u003cp\u003efood security\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eFood in secure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e39 (41.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e68(58.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e2.86(1.74, 4.72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1.1 (0.53, 2.11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"148\"\u003e\n\u003cp\u003eFood secure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"128\"\u003e\n\u003cp\u003e49 (16.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e245 (83.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"726\"\u003e\n\u003cp\u003e\u003cstrong\u003eAOR= Adjusted Odd Ratio; CI= Confidence Interval, COR= Crude Odd Ratio; **= p-value \u0026lt; 0.05.\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe prevalence of undernutrition was 22 %.\u0026nbsp; Age of lactating women, Education status of lactating women (those unable to read and write), Family size, additional food during lactation and women dietary diversity score were significantly associated with undernutrition.\u003c/p\u003e\n\u003cp\u003eThe prevalence of undernutrition (BMI \u0026lt; 18.5 kg/m2) among lactating women in this study was 22 %. This prevalence was much closer to the study documented in Ambo district 21.5% (Eshetu et al., 2017) and Nekemte 20.5% (Temesgen et al., 2015). It also similar to studies Adama 19.5% (Biru et al., 2017), Tigray, 24.6 % (Kiday et al., 2013) and also in Amhara region of Wombera district 25.6% (Sileshi et al., 2017). When this figure is compared with the result of Jimma 40.6% (Mihiretu et al., 2015) and Bible 41.7% (Kedir et al., 2015), it is much lower. This discrepancy could probably be attributed to 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 and time difference in which the current study was conducted recently after several community-based interventions were undertaken and also due to sample size difference between the studies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;On the contrary, the prevalence is much higher than studies in Indonesia 9%, (Madanijah.et al., 2016) Tibet 10.3% (Wang et al., 2010), Myanmar 11.9% ( Zhao et al., 2014) and Nigeria 5% (Sanusi and Falana, 2009). The difference in the prevalence might be due to socio-demographic factors like education status of women and economic differences between the studies areas.\u003c/p\u003e\n\u003cp\u003eThe present study has affirmed that age of lactating women was significantly associated with their nutritional status. Mothers within the age group of 15-25 had four times more likely to be undernourished when compared with those mothers in the age group of 36-49. This is in line with a result from study done in Ambo district indicate that lactating women in age group of 17-25 more exposed to undernutrition than older women (Eshetu et al., 2017). Similarly in Bangladesh and Nepal, younger women in the age group 15\u0026ndash;24 were more likely to be undernourished than older women (Rahman et al., 2015) (Bhandari S, et al 2016).\u003c/p\u003e\n\u003cp\u003eEducational status of lactating women was a factor that predicted their nutritional status in this study. Lactating women who were unable to read and write were five times more likely to be undernourished than those mothers who had formal education. Similar studies from India (Maheshwari1.S et al.2015) and also in Ethiopia Ambo district (Eshetu et al., 2017) also reported that undernourished women were more common among those with no formal education. This might be related with an increased awareness of self-care, health service utilization and recognizing the importance of increasing meal frequency during lactation among educated women.\u003c/p\u003e\n\u003cp\u003eIn this study, statistically significant association was found between the covariate family size index and nutritional status of lactating women. Women from \u0026gt; 7 family size were 5.53 times more likely to be undernourished than women in the 1-3 family size. This had been also supported by the study from Wombera woreda, Northwest Ethiopia and Nekemte 25.6% (Sileshi et al., 2017) (Temesgen et al., 2015). This association could be due to the fact that women from family size higher were in difficulties of meeting their dietary requirement, engaged in strenuous works like daily laborer and have minimal health care practice and also food security issue in women with higher family size and related underweight and nutritional depletion of the mother due to successive pregnancies.\u003c/p\u003e\n\u003cp\u003eAdditional food during lactation was another factor associated with undernutrition. Accordingly, women who not got additional food during lactation were 4.56 times more likely to be undernourished compared to those who\u0026rsquo;s got additional food during lactation. This had been also supported by a study done in Tigray (Ismael et al., 2017). This could be because during lactation more energy were required than from normal time even more than from pregnancy time, so if the lactating women did not get adequate food during lactation were more exposed to undernutrition.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Dietary diversity score of studied women was also another factor that affects their nutritional status in this study. Those women whose dietary diversity score below the mean (\u0026lt; 5) were four times more likely to be undernourished than women with the score a greater than or equal the mean (\u0026gt;= 5), implying that eating diverse food groups as a protective to undernutrition. This finding agrees with a study done in Dedo and Seqa-Chekorsa districts, Jimma Zone (Mihiretu et al., 2015). This might be because women with low dietary diversity may not get enough balanced diet which is essential for the human body to be immune and perform metabolic activities and also diversified food reflects dietary quality, improves daily nutrient and energy intake. Lactating women who do not get enough energy and nutrients in their diets risk maternal depletion and exacerbates women undernutrition (Allen LH. 2012).\u003c/p\u003e\n\u003cp\u003eThe current study has the following limitations. An anthropometric measurement error was one of the limitations of this study: To minimize this; data collectors were well trained, standardization of anthropometric measures was done and the instrument was calibrated. Since some of the questions are asking the event that occurs 4 weeks back, there is a possibility that some of the responses might suffer from recall bias and this may affect prevalence estimates. This was minimized by probing the respondents about the event. The strength of this study, it has 96.5% response rate.\u003c/p\u003e"},{"header":"Conclusion And Recommendations","content":"\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe result of this study indicated that prevalence of undernutrition (BMI \u0026lt;18.5 Kg/m2) among lactating women in the study area was high. The predictors of undernutrition among lactating women in the study area were:\u0026nbsp; Education status of lactating women (those unable to read and write), Age of lactating women, Family size, additional food during lactation and women dietary diversity score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the finding of this study, the following recommendations were made:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eShould strength sustained health and nutrition education to the women, their families and communities regarding increased food intake, proper dietary practices, and dietary diversification during their lactation time. Should closely work with health extension workers to increase awareness of lactating women on how to improve their own nutritional status.\u003c/li\u003e\n\u003cli\u003eThey should create strong multisector collaboration targeted at improving women educational status and increasing household food security status.\u003c/li\u003e\n\u003cli\u003eShould work with beneficiary programs like safety net complemented with nutritional\u003cbr /\u003e intervention to food insecure households.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor further studies:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eFurthermore, longitudinal studies should also be conducted for a better understanding of the maternal dietary intake with relating to the nutritional status of lactating women.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst of all, I would like to thanks Dire Dawa University for giving me opportunity to develop this research. I extend my appreciation for staffs of Sabian hospitals, and Gende kore, Goro and Legehare Health centers providing important information and for their unlimited co-operation and also I thank the data collectors, supervisors, study participants, and questionnaire translators; without whom the research would not be done.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore starting of the data collection process, Dire dawa University School of medicine and college of health sciences Institutional Health Research Ethics Review Committee (IHRERC) was secured by ethical clearance and Dire dawa University was write Official letter to hospital and health centers. Informed voluntary written and signed consent was obtained from each participant after explaining the purpose and benefits of the study. The data collector were trained to respect the culture of the people in these communities throughout the data collection process. Confidentiality of the study participants\u0026rsquo; information also ensure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eNot applicable\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u0026ldquo;Availability of Data and Materials\u0026rdquo;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eAll sources of funding for the research was Dire Dawa Univerisity.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003ePerformed the thematic analysis and wrote the first draft of the manuscript as part of her master\u0026rsquo;s project. LR supervised the analysis and the master\u0026rsquo;s project. All authors read and approved the final manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp; \u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eThe authors declare that they have no competing interests.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAOR\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Adjusted Odds Ratio\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eANC\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Ante Natal Care\u003c/p\u003e\n\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Body Mass Index\u003c/p\u003e\n\u003cp\u003eCED\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Chronic Energy Deficiency\u003c/p\u003e\n\u003cp\u003eCSA\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Central Statistical Agency\u003c/p\u003e\n\u003cp\u003eDDS\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Dietary Diversity Score\u003c/p\u003e\n\u003cp\u003eEDHS \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Ethiopian Demographic and Health Survey\u003c/p\u003e\n\u003cp\u003eFAO\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Food and Agriculture Organization\u003c/p\u003e\n\u003cp\u003eFMoH \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Federal Minster of Health\u003c/p\u003e\n\u003cp\u003eHFIAS \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Household Food Insecurity Access Scale\u003c/p\u003e\n\u003cp\u003eTEM\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Technical Error Measurement\u003c/p\u003e\n\u003cp\u003eNGOs \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Non-Governmental Organizations\u003c/p\u003e\n\u003cp\u003eNHANE \u0026nbsp;\u0026nbsp;\u0026nbsp;National Health And Nutrition Examination Survey\u003c/p\u003e\n\u003cp\u003eUNICEF\u0026nbsp;\u0026nbsp;\u0026nbsp; United Nation Children\u0026rsquo;s Fund\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbebe Ferede, Firaol Lemessa, Mesfin Tafa and Solomon Sisay 2017. 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Body composition, water turnover and physical activity among women in Narok County, Kenya, BMC Public Health 14(12), pp. 1-8.\u003c/li\u003e\n\u003cli\u003eG, Tellier.B. and Claude .M 2010. Guidelines for Measuring Household and Individual Dietary Diversity', From; \u003ca href=\"http://www.fao.org/3/a-i1983e.pdf\"\u003ewww.fao.org/3/a-i1983e.pdf\u003c/a\u003e retrieved on November 14/2018\u003c/li\u003e\n\u003cli\u003eKidney Hailesslasie, Afework Mulugeta and Meron Girma., 2013. Feeding practices, nutritional status and associated factors of lactating women in Samre Woreda, South Eastern Zone of Tigray, Ethiopia,\u003c/li\u003e\n\u003cli\u003eS, Rimbawan.R, Dodik.B, Zulaikhah.Z, Nuri.A, Lilis.N, Tonny.S, Laksmi.M and Jacques.B 2016. Nutritional status of lactating women in Bogor district, Indonesia: cross-sectional dietary intake in three economic quintiles and comparison with pre-pregnant women, British Journal of Nutrition\u003c/li\u003e\n\u003cli\u003eS, Brijesh P, Singh.O, Singh and Gupta, P. 2015. Variation in body mass index and their determinants among married women in Uttar Pradesh, International Journal of Health,3 (2), pp. 52-55.\u003c/li\u003e\n\u003cli\u003eR, Balakrishna.N, Arlappa.N, Laxmaiah.2010. Diet and Nutritional Status of Women in India, J.Hum Ecol, 29(3), pp. 165-170.\u003c/li\u003e\n\u003cli\u003eMesfin Tafa and Jemal Haider; 2013 Effect of modern family planning methods use on the nutritional status of women of reproductive age group at Tena district, Arsi Zone, Ethiopia, an international conference on family planning, A.A, Ethiopia,pp.1-8.\u003c/li\u003e\n\u003cli\u003eMihiretu Alemayehu, Alemayehu Arga and Abele G.Mariam 2015. Factors Associated with Malnutrition among Lactating Women in Subsistence Farming Households from Dedo and Seqa-Chekorsa Districts, Jimma Zone, 2014, iiste 5 (21), pp. 1-9.\u003c/li\u003e\n\u003cli\u003eNegassie Berhe, Kebede Haile, Meresa Gebremedhin, Yosef Sibhatu, 2016. Dietary diversity and related factors among lactating women visiting public health facilities in Aksum town, Tigray, Northern Ethiopia, BMC Nutrition 2(38 ), pp. 2-9.\u003c/li\u003e\n\u003cli\u003eNHANES (National Health and Nutrition Examination Survey). 2007. Anthropometry procedures manual. From;\u003ca href=\"https://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/manual_an.pdf\"\u003ehttps://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/manual_\u003c/a\u003e retrieved on November\u003c/li\u003e\n\u003cli\u003eNikolaos KM, Charilaos D, Sci MM, Meropi K, Evangelia M, 2010 Clinical nutrition in practice. Blackwell Publishing Ltd, UK.\u003c/li\u003e\n\u003cli\u003eNNP-II 2013. National Nutrition Programme June 2013 - June 2015 From; \u003cu\u003efao.org/fileadmin/.../Ethiopia_National_Nutrition_Strategy_\u003c/u\u003e. retrieved on October /21/2018\u003c/li\u003e\n\u003cli\u003eU 2014. A study of the nutritional status and dietary intake of lactating women in Umuahia, Nigeria, American Journal of Health Research 2(1), pp. 20-26.\u003c/li\u003e\n\u003cli\u003eA, Glauber.L, Oliveira.D and Ornellas.J 2005. Technical error of measurement in anthropometry. Rev Bras Med Esporte\u003cem\u003e, \u003c/em\u003e11(7), pp 86-90\u003c/li\u003e\n\u003cli\u003eRahman, S, Mondal.N, Islam.R, Ahmed.K, Karim, R. and Alam.S 2015. Under Weightiness among Ever-married Non-pregnant Women in Bangladesh: A Population-Based Study, Universal Journal of Food and Nutrition Science, 3(2), pp. 29-36.\u003c/li\u003e\n\u003cli\u003eE and Kanbaro.L, 2003. Nutrition of women and Adolescent girls: Why it matters? Population Reference Bureau. \u003ca href=\"http://www.prb.org/.../2003/NutritionofWomenandAdolescentGirlsWhyItMatters.asp\"\u003ewww.prb.org/.../2003/NutritionofWomenandAdolescentGirlsWhyItMatters.asp\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eN, Balakrishna.N, Arlappa.A, Laxmaiah.S and Brahmam.G 2010. Diet and nutritional status of women in India, J Hum Ecol 29(3), pp. 165-170.\u003c/li\u003e\n\u003cli\u003eSaba Abraham, Gebremeskel Miruts and Ashenafi Shumye 2015. The magnitude of chronic energy deficiency and its associated factors among women of reproductive age in the Kunama population, Tigray, Ethiopia, in 2014.\" BMC Nutrition 1(12), pp1-9.\u003c/li\u003e\n\u003cli\u003eA and Falana.M 2009. The Nutritional Status of Mothers Practicing Breast Feeding In Ibadan, Nigeria, African Journal of Biomedical Research, 12(2), pp. 1-7.\u003c/li\u003e\n\u003cli\u003eSeifu Hagos, Torlief Lunde, Damen H.Mariam and Tassew Woldehanna 2015. 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, 1(2), pp. 1-10.\u003c/li\u003e\n\u003cli\u003eSileshi Berihun, Getachew Mullu Kassa and Muluken Teshome 2017. Factors associated with underweight among lactating women in Womberma woreda, Northwest Ethiopia; a cross-sectional\u003c/li\u003e\n\u003cli\u003eTemesgen Jessica, Habtamu Fkadu, Desalege Wirtu and Duncan Kenya Nutritional Status and Associated Factors among Lactating Mothers in Nekemte Referral Hospital and Health Centers, Ethiopia, Food Science and Quality Management 35(24), pp.1-11.\u003c/li\u003e\n\u003cli\u003eUNICEF 2009. Tracking progress on child and maternal nutrition a survival and development priority From;\u003ca href=\"https://www.unicef.org/.../Tracking_Progress_on_Child_and_Maternal_Nutrition\"\u003ehttps://www.unicef.org/.../Tracking_Progress_on_Child_and_Maternal_Nutrition\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eUNICEF 2011. United Nations Children\u0026rsquo;s Fund. Programming Guide: Infant and Young Child Feeding. \u003ca href=\"https://www.unicef.org/nutrition/files/Final_IYCF_programming_guide_2011.pdf\"\u003ehttps://www.unicef.org/nutrition/files/Final_IYCF_programming_guide_2011.pdf\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eZ, Dang, S., and Yan, H 2010. Nutrient intakes of rural Tibetan mothers: a cross-sectional survey, BMC Public Health\u003cem\u003e,\u003c/em\u003e 10(801), pp. 1-8.\u003c/li\u003e\n\u003cli\u003eWHO 1995. Physical status: The use and interpretation of anthropometry, report of WHO expert committee. WHO technical report series, Geneva. from www.who.int\u003cu\u003e/iris/handle/10665/37003 . \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eWHO 2005. Quantifying the health impact at national and local levels, WHO environmental burden of disease series, Geneva. From; \u003cu\u003ewho.int/outgrowth/publications/quantifying_health_impact/e . retrieved on October 28/2018\u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eWHO 2012. Global Database on Body Mass Index. From; \u003ca href=\"http://www.who.int/nutrition/databases/bmi/\"\u003ewho.int/nutrition/databases/bmi/\u003c/a\u003e retrieved on on November /02/2018\u003c/li\u003e\n\u003cli\u003eWHO 2014. Comprehensive implementation plan on maternal, infant and young child nutrition. From;\u003cu\u003ewho.int/nutrition/publications/CIP_document/en. retrieved on October\u0026nbsp; /19/2018 \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eA, Zhang.Y, Li.B, Wang.P, Li.J, Xue.Y, and Gao.H 2014. Prevalence of Anemia and Its Risk Factors Among Lactating Mothers in Myanmar, American Journal of Tropical Medicine and Hygiene.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Undernutrition, lactating, Dire Dawa, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-88070/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-88070/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u0026nbsp;The nutritional status of lactating women is very important since it also affects the health of their children. However, there was limited information on maternal nutrition status in low-income countries like Ethiopia, especially in the study area.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e Determine magnitude of undernutrition and associated factors among lactating women\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Institutional based cross-sectional study was conducted among 422 lactating women in Dire Dawa town health facilities from February 10/02/2019 – March 30/ 03/2019.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResult:\u003c/strong\u003e Prevalence of undernutrition was 22 %. Women who age 15-25 years were four times more likely undernourished than older [AOR=4.04(CI: (1.74, 9.40)]. Unable to read and write Women were almost five times more likely to be undernourished than formal education [AOR=4.76 CI: (2.31, 9.81)]. Women who have family size \u0026gt;7 were six times more likely to be undernourished than family size \u0026lt; 3 [AOR=5.53 CI :( 1.15, 26.53)]. Women not take additional food during lactating were 4.5 times more likely undernourished than take additional food [AOR=4.56 CI (1.50, 13.9)]. DD score \u0026lt; 5 were four times more likely to be undernourished than (\u0026gt;= 5) DD [AOR= 4 CI: (2.02, 7.90)].\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Prevalence of undernutrition in the study area was high:\u0026nbsp;Factors associated with underweight were: Age of lactating women, Education status, Family size, Additional food during lactation and DD score. Thus, multi-sectoral collaboration targeted at improving women’s educational status and increasing food during lactation need to be emphasized.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Undernutrition and Associated Factors Among Lactating Women in Dire Dawa Health Facilities, Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-06 21:30:10","doi":"10.21203/rs.3.rs-88070/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3879ac7-6022-4581-90fb-75c18eed4a50","owner":[],"postedDate":"October 6th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":708213,"name":"Nutrition \u0026 Dietetics"}],"tags":[],"updatedAt":"2020-10-06T21:30:10+00:00","versionOfRecord":[],"versionCreatedAt":"2020-10-06 21:30:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-88070","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-88070","identity":"rs-88070","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}