Prevalence and predictors of khat chewing among pregnant women in Ethiopia: Insights from a national health survey

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Despite these known risks, national estimates of prevalence, patterns, and factors associated with khat use among pregnant women in Ethiopia remain poorly understood. This study aimed to address this gap by examining the prevalence and predictors of khat chewing among pregnant women using nationally representative data. Methods We analyzed data from the 2016 Ethiopian Demographic and Health Survey (EDHS), focusing on the couples’ recode file. A total of 727 pregnant women with complete data on khat use and partner information were included. Khat chewing status was defined as ever having chewed khat. Descriptive statistics and chi-square tests were used to examine bivariate associations. Multivariable logistic regression was performed to identify independent predictors. Results The prevalence of khat chewing among pregnant women was 12.5%. It was higher among women aged 25–34 years, Muslims (89.0%), and those whose partners chewed khat (87.9%). In adjusted analysis, women aged 25–34 had twice the odds of khat chewing compared to those aged 15–24 (AOR = 2.02; 95% CI: 1.10–3.81; p = 0.025). Women in the middle wealth category had higher odds than those in the poor category (AOR = 2.31; 95% CI: 1.11–4.80; p = 0.025). Partner khat chewing was strongly associated with maternal use (AOR = 15.55; 95% CI: 6.54–43.11; p < 0.001). Maternal smoking showed a large but statistically non-significant positive association (AOR = 5.40; 95% CI: 0.78–35.82; p = 0.078). Conclusion Khat chewing during pregnancy is influenced by maternal age, middle household wealth, and particularly partner behavior. These findings highlight the need for targeted, culturally sensitive interventions integrated into maternal health programs that engage couples, address relationship dynamics, and consider socioeconomic and age-specific risk factors to reduce khat use and improve maternal and fetal outcomes. Health Policy Catha edulis khat pregnancy maternal khat chewing Ethiopia 1. Introduction Khat (Catha edulis Forskal), known locally as “ chat ” in Ethiopia, is a stimulant plant widely chewed in East Africa and the Arabian Peninsula for its euphoric and appetite-suppressing effects ( 1 ). The primary psychoactive compound, cathinone, acts as a natural amphetamine, increasing dopamine and serotonin release in the central nervous system ( 2 ). Fresh khat leaves are typically chewed slowly over several hours, with users ingesting 100–500 grams per session; the plant material is retained in the cheek and gradually swallowed, with the orally absorbed amount equating to 5 mg of amphetamine and 0.05 mg/kg of cathinone ( 3 – 5 ). The adverse effects of khat chewing during pregnancy appear to intensify in proportion to the frequency and duration of use ( 6 , 7 ). Various studies have reported that chewing khat during pregnancy has a negative health consequences such as low birth weight (LBW), fetal hypoxia ( 8 ); fetal growth restriction (FGR), small for gestational age (SGA) ( 9 ); prelabor rupture of membranes (PROM) ( 10 ); congenital malformations, preterm birth, stillbirth ( 8 , 11 , 12 ); maternal anemia and broader obstetric complications ( 10 , 12 ); increased risk of anemia ( 13 ); cognitive and behavioral impact on the mother ( 14 ). Despite these risks, khat chewing remains deeply embedded in social and cultural practices in Ethiopia, where it is the second-largest export crop after coffee ( 15 ). Khat use among pregnant women in Ethiopia varies from 11% in the south ( 16 ) to 66.9% in the east ( 17 ). A recent systematic review and meta-analysis found the pooled prevalence of khat use during pregnancy in Ethiopia to be 26.6% (95% CI: 17.8–35.5) ( 18 ), indicating a substantial public health burden. However, to the best of our knowledge, no previous study has utilized nationally representative data to investigate the practice of khat chewing among pregnant women and their partners. This study fills the gap by analyzing the Ethiopian Demographic and Health Survey (EDHS) 2016 to estimate national prevalence and identify individual and partner-level predictors of khat chewing among pregnant women using nationally representative data. 2. Materials and Methods 2.1. Study population and sampling This study used data from the 2016 EDHS, the most recent nationally representative DHS conducted in Ethiopia at the time of analysis ( 19 ). The EDHS employed a two-stage stratified cluster sampling design across 645 clusters (202 urban, 443 rural). A total of 16,650 households were selected, with a 94.6% response rate, yielding data from 15,683 women aged 15–49. We analyzed the couples’ recode dataset, which includes linked data for married or cohabiting women and their partners who both completed individual interviews. The unit of analysis was the couple. From this dataset, we identified 727 couples who had complete data on khat use. 2.2. Data collection Data were collected using standardized questionnaires administered through face-to-face interviews. Five questionnaires were used to collect the EDHS data. We utilized the couples’ recode dataset, which contains one record for each interviewed woman and her partner. Participants were asked two questions regarding khat use: “Have you ever chewed khat?” and “In the last 30 days, how many days did you chew khat” ( 19 ). 2.3. Outcome and predictor variables The outcome variable in this study was the khat chewing status of pregnant women. The predictor variables were maternal age, residence, religion, educational level, wealth index, employment status, maternal cigarette and alcohol use, partner’s educational level, partner’s khat chewing status, partner’s alcohol drinking status, and whether the partner helps in household chores. 2.4. Data analysis Data analysis was performed using R software (version 4.4). Descriptive statistics were summarized using frequency tables. Bivariate associations were examined using chi-square tests, and multivariable logistic regression was used to identify factors associated with khat chewing status. As a sensitivity analysis, we also fitted a structural equation model (SEM) using the weighted least squares mean and variance adjusted (WLSMV) estimator to account for the binary nature of the outcome. The model included all significant predictors from the logistic regression and estimated their adjusted associations with khat chewing using probit coefficients. Variables with p < 0.05 were considered statistically significant, and the strength of the association was also measured with adjusted odds ratio at a corresponding 95% confidence interval. 3. Results Among the 727 pregnant women included in the analysis, 12.5% reported chewing khat. Prevalence within each group differed significantly by age, with the highest proportion observed among women aged 25–34 years (61.5% of khat chewers) compared to 25.3% among those aged 15–24 (p = 0.035). Khat chewing was also markedly more common among Muslim women (89.0%) than among those of other religions (11.0%) (p < 0.001). Maternal education and household wealth index showed no significant associations in unadjusted analyses (p = 0.068 and p = 0.112, respectively). Partner characteristics showed strong associations with women’s khat chewing. A large majority of khat-chewing women had partners who also chewed khat (87.9% vs. 7.7% among non-chewers, p < 0.001). Notably, maternal alcohol use was strongly associated with khat chewing. The vast majority of khat chewers did not drink alcohol (94.5%) compared to 74.2% of non-chewers (p < 0.001) (Table 1 ). Table 1 Sociodemographic characteristics of pregnant Ethiopian women aged 15–49, Ethiopian Demographic and Health Survey 2016 (n = 727) Categories Yes No P-value* Maternal Age 15–24 23 (25.3) 241 (37.9) 0.035 25–34 56 (61.5) 303 (47.6) 35–49 12 (13.2) 92 (14.5) Residence Urban 19 (20.9) 122 (19.2) 0.809 Rural 72 (79.1) 514 (80.8) Religion Muslim 81 (89.0) 301 (47.3) < 0.001 Others 10 (11.0) 335 (52.7) Maternal Education No education 59 (64.8) 340 (53.5) 0.068 Primary 26 (28.6) 210 (33.0) Secondary+ 6 (6.6) 86 (13.5) Wealth Index Poor 42 (46.2) 320 (50.3) 0.112 Middle 20 (22.0) 87 (13.7) Rich 29 (31.9) 229 (36.0) Maternal Working Status No 68 (74.7) 463 (72.8) 0.794 Yes 23 (25.3) 173 (27.2) Maternal smoking status No 88 (96.7) 629 (98.9) 0.23 Yes 3 (3.3) 7 (1.1) Mother drinks alcohol No 86 (94.5) 472 (74.2) < 0.001 Yes 5 (5.5) 164 (25.8) Partner Educational Level No education 49 (53.8) 243 (38.2) 0.009 Primary 31 (34.1) 250 (39.3) Secondary+ 11 (12.1) 143 (22.5) Partner Helps with Chores No 62 (68.1) 369 (58.0) 0.085 Yes 29 (31.9) 267 (42.0) Partner Drinks Alcohol No 74 (85.1) 384 (61.8) < 0.001 Yes 13 (14.9) 237 (38.2) Partner Chews Khat No 7 (8.0) 404 (65.1) < 0.001 Yes 80 (92.0) 217 (34.9) *P-values are from Chi-square tests Multivariable logistic regression analysis identified several significant predictors of khat chewing among pregnant women (Table 2 ). Women aged 25–34 years had twice the odds of khat chewing compared to those aged 15–24 years (AOR = 2.02; 95% CI: 1.10–3.81; p = 0.025), while the association for women aged 35–49 years was not statistically significant (AOR = 2.00; 95% CI: 0.81–4.84; p = 0.126). Compared with women from poor households, those in the middle wealth category had more than twice the odds of khat chewing (AOR = 2.31; 95% CI: 1.11–4.80; p = 0.025). Maternal smoking status showed a non-significant positive association (AOR = 5.40; 95% CI: 0.78–35.82; p = 0.078). Partner khat chewing was identified as a significant predictor: women whose partners chewed khat were over 15 times more likely to chew khat themselves (AOR = 15.55; 95% CI: 6.54–43.11; p < 0.001). The SEM results were directionally consistent with the logistic regression findings (Supplementary Table 1). In particular, partner khat chewing remained the strongest predictor (probit coefficient = 1.34, p < 0.001), followed by maternal age 25–34 years (probit coefficient = 0.40, p = 0.040) and middle wealth status (probit coefficient = 0.45, p = 0.038). Table 2 Logistic regression of current khat chewing among pregnant Ethiopian women aged 15–49, Ethiopia (n = 727) Categories AOR 95% CI p-value Maternal Age 15–24 Ref 25–34 2.02 1.10 ; 3.81 0.025 35–49 2.00 0.81 ; 4.84 0.126 Residence Urban Ref Rural 0.48 0.20 ; 1.13 0.095 Religion Muslim Ref Other 0.41 0.13 ; 1.18 0.113 Maternal Education None Ref Primary 0.95 0.49 ; 1.81 0.879 Secondary+ 0.60 0.16 ; 1.99 0.417 Wealth Index Poor Ref Middle 2.31 1.11 ; 4.80 0.025 Rich 1.08 0.48 ; 2.33 0.856 Maternal Working Status No Ref Yes 0.98 0.52 ; 1.78 0.938 Maternal smoking status No Ref Yes 5.40 0.78 ; 35.82 0.078 Mother drinks alcohol No Ref Yes 1.05 0.27 ; 3.82 0.939 Partner Educational Level None Ref Primary 0.70 0.38 ; 1.30 0.268 Secondary+ 0.43 0.15 ; 1.14 0.097 Partner Helps with Chores No Ref Yes 1.10 0.62 ; 1.96 0.736 Partner Drinks Alcohol No Ref Yes 1.26 0.48 ; 3.23 0.632 Partner Chews Khat No Ref Yes 15.55 6.54 ; 43.11 < 0.001 AOR: Adjusted Odds Ratio; CI: Confidence Interval; Ref: Reference category 4. Discussion This study provides the first national estimate of khat chewing among pregnant women in Ethiopia using linked couple data from the 2016 EDHS. The prevalence of khat chewing was 12.5%, comparable to the 11% reported in Southern Ethiopia ( 16 ), lower than the 15.5% reported in Eastern Ethiopia ( 20 ), and substantially below the national estimate reported prevalence of current khat use among women of reproductive age (65.9%, 95% CI: 63.5–68.2%) ( 18 ). These discrepancies likely reflect differences in study design, regional variation, and measurement. Our analysis assessed lifetime use (ever chewed), whereas others focused on current or recent use. Furthermore, our findings are based on a nationally representative sample, while most prior studies were facility- or community-based, often in high-prevalence regions such as Eastern Ethiopia, where khat cultivation is widespread and constitutes a major source of income and cash crop ( 17 , 20 ). We found women aged 25–34 had twice the odds of khat chewing compared with those aged 15–24 (AOR = 2.02; 95% CI: 1.10–3.81; p = 0.025). This finding is consistent with evidence suggesting that khat use increases with social independence and marital responsibilities, which are more common in this age group. Similarly, a study from Eastern Ethiopia showed that women aged 25–35 and those ≥ 35 years were more than twice as likely to chew khat as younger women ( 20 ). Previous research in Ethiopia and other East African settings similarly suggests that khat chewing rises during early adulthood and stabilizes or declines in later years ( 21 – 23 ). The higher prevalence among women aged 25–34 may reflect cultural acceptance, marital status, and greater autonomy. Household wealth showed a non-linear association with khat use. Women in the middle wealth quintile were more than twice as likely to chew khat compared with those in the poorest group (AOR = 2.31; 95% CI: 1.11–4.80; p = 0.025). This suggests khat use is not limited to poverty-driven behavior but reflects sociocultural dynamics and affordability patterns. Similar non-linear relationships have been observed elsewhere, where middle-income groups both have the financial means to purchase substances and live in environments that normalize their use ( 16 , 24 ). Women in the poorest households may be unable to afford khat, while those in the wealthiest groups may benefit from higher education and greater exposure to health promotion ( 25 , 26 ). As noted in prior studies, khat use represents both a public health concern and a socio-economic challenge, with broad implications for households and communities ( 27 ). The strong association between maternal alcohol use and khat chewing observed in the bivariate analysis was not sustained in the adjusted model, suggesting that its effect is mediated or confounded by other factors, most notably partners’ substance use behaviors and religious affiliation. Another significant factor influencing khat chewing among pregnant women is whether their partners also engage in the practice. The analysis revealed that the most influential individual-level predictor of women’s khat chewing behavior was the khat use of their male partners. Specifically, pregnant women whose partners reported chewing khat were found to be more than 15 times as likely to engage in the same practice themselves (AOR = 15.55; 95% CI: 6.54–43.11; p < 0.001). A systematic review and meta-analysis study found that pregnant women whose partners chewed khat were over six times more likely to chew khat themselves compared to those whose partners did not chew ( 23 ). This striking association underscores the powerful role of intimate partner influence in shaping women’s substance use behaviors. Women whose partners chew khat are more likely to adopt the same behavior, highlighting the strong role of partner influence in shaping maternal health choices. Similar findings have been documented in prior studies, where spousal or household khat use significantly increased the likelihood of women’s initiation and continuation of chewing ( 21 , 28 ). Such results are consistent with social learning theory, which emphasizes the role of close interpersonal relationships in reinforcing health-related behaviors and emphasizes the importance of observing, modeling, and imitating the behaviors, attitudes, and emotional reactions of others ( 29 ). In contexts where khat chewing is normalized within family settings, partner behavior not only provides direct exposure and accessibility but also legitimizes the practice, thereby amplifying women’s risk of khat consumption. This study utilized nationally representative data from pregnant women and their partners. However, the relatively small sample size of 727 pregnant women, with only 91 khat chewers, may limit statistical power and contribute to wide confidence intervals. In addition, the cross-sectional design limits the ability to draw causal conclusions between khat chewing and health outcomes. The reliance on self-reported data also poses challenges, as recall bias or underreporting may occur, particularly given the sensitive nature of khat use during pregnancy. The survey instruments do not always capture detailed information on the frequency, intensity, or context of khat use, which restricts the depth of interpretation. Furthermore, cultural stigma and social desirability bias may cause some respondents to conceal their practices, leading to an underestimation of true prevalence. The couples’ recode dataset also excludes single mothers and polygamous unions, which reduces the generalizability of findings to non-traditional family structures. Future research with larger sample sizes, more qualitative and longitudinal studies is needed to comprehensively assess the factors associated with khat chewing in Ethiopia. Studies should also consider community-level influences such as peer norms, local availability, and economic stressors. 5. Conclusion This study demonstrates that khat chewing during pregnancy is a public health concern in Ethiopia, with a national prevalence of 12.5%. The behavior was most common among women aged 25–34, those in the middle wealth quintile, and women whose partners also chewed khat. Multivariable analysis identified maternal age and partner behavior as the strongest predictors: women aged 25–34 had approximately twice the odds of khat use compared with younger women, while having a partner who chewed khat increased maternal use more than fifteenfold. These findings highlight the need for targeted, culturally sensitive interventions that consider the social and familial contexts of substance use. Given the dominant influence of partner behavior, prevention strategies should engage couples and address relationship dynamics, rather than focusing solely on women. Routine screening for khat use during antenatal care, supported by standardized referral pathways and evidence-based counseling services, could facilitate early identification and management. Beyond clinical care, public awareness campaigns and community-based engagement are critical to reduce stigma, challenge misconceptions, and promote healthier norms. Embedding prevention and support within maternal health programs, while addressing broader socioeconomic and cultural determinants, represents a practical pathway to reduce khat use in pregnancy and improve maternal and child health outcomes in Ethiopia. Abbreviations AOR Adjusted Odds Ratio CI Confidence Interval EDHS Ethiopian Demographic and Health Survey LBW Low Birth Weight SGA Small for Gestational Age PROM Prelabor Rupture Of Membranes WLSMV Weighted Least Squares Mean and Variance Declarations Competing interests The authors declare that they do not have any conflict of interest. Ethical approval and consent to participate Not applicable. Consent for publication Not applicable. Funding The authors did not receive any funding for this work. Authors’ Contributions NA conceived the study and analyzed the data. NA and EA wrote the first draft. NA, EA and SB reviewed and edited the final version. All authors approved the manuscript for publication. Availability of data and materials The dataset used in this study is available from DHS Program (https://dhsprogram.com) for legitimate reasons. The R code used in the analysis of the dataset is available at (https://github.com/NebyuDanielAmaha/Khat_EDHS) Acknowledgment The authors would like to thank the DHS Program for providing the survey dataset free of any cost. References Al-Hebshi N, Skaug N (2005) Khat (Catha edulis)—an updated review. Addict Biol 10(4):299–307 Engidawork E (2017) Pharmacological and toxicological effects of Catha edulis F.(Khat). Phytother Res 31(7):1019–1028 Aronson JK (2014) Plant poisons and traditional medicines. Manson's tropical infectious diseases. Elsevier, pp 1128–1150 Haroz R, Greenberg MI (2005) Emerging drugs of abuse. Med Clin 89(6):1259–1276 Kelly JP (2011) Cathinone derivatives: a review of their chemistry, pharmacology and toxicology. Drug Test Anal 3(7–8):439–453 Nakajima M, Jebena MG, Taha M, Tesfaye M, Gudina E, Lemieux A et al (2017) Correlates of khat use during pregnancy: a cross-sectional study. Addict Behav 73:178–184 Emebet Dendir ED, Negussie Deyessa ND (2017) Substance use and birth weight among mothers attending public hospitals: a case control study Bayih WA, Belay DM, Ayalew MY, Tassew MA, Chanie ES, Feleke DG et al (2021) The effect of substance use during pregnancy on neonatal outcomes in Ethiopia: A systematic review and meta-analysis. Heliyon. ;7(4) Wondemagegn AT, Bekana M, Bekuretsion Y, Afework M (2024) The effect of possible mediators on the association between chewing khat during pregnancy and fetal growth and newborn size at birth in Eastern Ethiopia. BMC Pregnancy Childbirth 24(1):63 Yadeta TA, Egata G, Seyoum B, Marami D (2020) Khat chewing in pregnant women associated with prelabor rupture of membranes, evidence from eastern Ethiopia. Pan Afr Med J. ;36(1) Roble AK, Gundappa R, Sheik Abdirahman F, Abdi AM (2023) Determinants of adverse birth outcomes in public hospitals of the Somali region, Eastern Ethiopia: a multicenter unmatched case-control study. Clin Med Insights: Pediatr 17:11795565231195253 Alzahrani MA, Alsahli MA, Alarifi FF, Hakami BO, Alkeraithe FW, Alhuqbani M et al (2023) A narrative review of the toxic effects on male reproductive and sexual health of chewing the psychostimulant, Catha edulis (Khat). Med Sci Monitor: Int Med J Experimental Clin Res 29:e939455–e939451 Kedir H, Berhane Y, Worku A (2013) Khat chewing and restrictive dietary behaviors are associated with anemia among pregnant women in high prevalence rural communities in eastern Ethiopia. PLoS ONE 8(11):e78601 Manzar MD, Salahuddin M, Sony P, Maru TT, Pandi-Perumal SR, Moscovitch A et al (2017) Sleep disturbances and memory impairment among pregnant women consuming khat: an under-recognized problem. Annals Thorac Med 12(4):247–251 FMHACA. Ethiopian National Drug Control Master Plan (2017) 2017–2022. Addis Ababa: Ethiopian Food. Medicines and Health Care Administration and Control Authority Mekuriaw B, Belayneh Z, Yitayih Y (2020) Magnitude of Khat use and associated factors among women attending antenatal care in Gedeo zone health centers, southern Ethiopia: a facility based cross sectional study. BMC Public Health 20(1):110 Wood EA, Stark H, Case SJ, Sousa B, Moreno M, Motuma A et al (2024) Khat use and related determinants among pregnant women within Haramaya, Ethiopia: a mixed methods study. Front Global Women's Health 5:1359689 Wogayehu B, Demissie T, Wolka E, Alemayehu M, Daka K (2023) The epidemiology of khat (Catha edulis) chewing and alcohol consumption among pregnant women in Ethiopia: a systematic review and meta-analysis. PLOS Global Public Health 3(9):e0002248 Demographic E (2016) Addis Ababa, Ethiopia, and Rockville. CSA and ICF, Maryland, MA, USA Misgana T, Tesfaye D, Alemu D, Gebremichael B, Tamiru D, Tariku M et al (2022) Khat use and associated factors during pregnancy in eastern Ethiopia: A community-based cross-sectional study. Front Global Women's Health 3:941300 Alem A, Kebede D, Kullgren G (1999) The prevalence and socio-demographic correlates of khat chewing in Butajira, Ethiopia. Acta psychiatrica Scandinavica 100:84–91 Kassim S, Croucher R, Al'Absi M (2013) Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers. J Ethnopharmacol 146(3):835–841 Haile D, Lakew Y (2015) Khat chewing practice and associated factors among adults in Ethiopia: further analysis using the 2011 demographic and health survey. PLoS ONE 10(6):e0130460 Reda AA, Moges A, Biadgilign S, Wondmagegn BY (2012) Prevalence and determinants of khat (Catha edulis) chewing among high school students in eastern Ethiopia: a cross-sectional study. PLoS ONE 7(3):e33946 Khawaja M, Al-Nsour M, Saad G (2008) Khat (Catha edulis) chewing during pregnancy in Yemen: findings from a national population survey. Matern Child Health J 12(3):308–312 Wondemagegn AT, Cheme MC, Kibret KT (2017) Perceived psychological, economic, and social impact of khat chewing among adolescents and adults in Nekemte Town, East Welega Zone, West Ethiopia. Biomed Res Int 2017(1):7427892 Onaolapo OJ, Olofinnade AT, Ojo FO, Adeleye O, Falade J, Onaolapo AY (2022) Substance use and substance use disorders in Africa: An epidemiological approach to the review of existing literature. World J psychiatry 12(10):1268 Damena T, Mossie A, Tesfaye M (2011) Khat chewing and mental distress: a community based study, in jimma city, southwestern ethiopia. Ethiop J health Sci 21(1):37–46 Bandura A, Walters RH (1977) Social learning theory. Prentice hall Englewood Cliffs, NJ Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryTables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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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-9040410","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":601257867,"identity":"e0b48b40-810c-4cdc-bd0d-70edd1f29da0","order_by":0,"name":"Nebyu Daniel Amaha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYFACHiBmY2DgB7ETCkjRItkA0mJAihaDAyAOMVrM2XuPSfOU2eUZn1+d+OGBAYM8v9gB/Fose86lSfOcSy42u/F2swTQYYYzZyfg12JwI8dMmreNOXHbjbMbQFoSDG4T0nL/DUhLfeLmGWc3/yBOyw0ekJbDiRv4e7cRacuZvGTLOeeOJ864wbvNIsFAggi/HD978MabsurE/v6zm2/+qLCR55cmoAUIWCTAlARYpQRB5SDA/AFM8R8gSvUoGAWjYBSMQAAAem1FFx6lFM8AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-5900-5939","institution":"Mekelle University","correspondingAuthor":true,"prefix":"","firstName":"Nebyu","middleName":"Daniel","lastName":"Amaha","suffix":""},{"id":601263552,"identity":"b54734ed-18e0-412d-8867-a0b56f1acde6","order_by":1,"name":"Eleni Mekonnen Abrha","email":"","orcid":"https://orcid.org/0009-0000-6973-2830","institution":"Woreda Nutrition Officer","correspondingAuthor":false,"prefix":"","firstName":"Eleni","middleName":"Mekonnen","lastName":"Abrha","suffix":""},{"id":601263553,"identity":"1b3c919d-a811-4807-ba01-00ba3d72c0f9","order_by":2,"name":"Sibhatu Biadgilign","email":"","orcid":"https://orcid.org/0000-0002-7582-5977","institution":"Independent Researcher","correspondingAuthor":false,"prefix":"","firstName":"Sibhatu","middleName":"","lastName":"Biadgilign","suffix":""}],"badges":[],"createdAt":"2026-03-05 13:21:03","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9040410/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9040410/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104403058,"identity":"4cb0da92-05a1-419e-827f-95aef95c9e91","added_by":"auto","created_at":"2026-03-11 12:17:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":599754,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9040410/v1/1451a282-f55a-44f7-ad58-e2d60cae5981.pdf"},{"id":104040789,"identity":"9c6b1eda-dbc4-4e39-82de-eada641625d3","added_by":"auto","created_at":"2026-03-06 04:33:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21116,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9040410/v1/fa90dd4b5864188be031131d.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003ePrevalence and predictors of khat chewing among pregnant women in Ethiopia: Insights from a national health survey\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eKhat (Catha edulis Forskal), known locally as \u0026ldquo;\u003cem\u003echat\u003c/em\u003e\u0026rdquo; in Ethiopia, is a stimulant plant widely chewed in East Africa and the Arabian Peninsula for its euphoric and appetite-suppressing effects (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The primary psychoactive compound, cathinone, acts as a natural amphetamine, increasing dopamine and serotonin release in the central nervous system (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Fresh khat leaves are typically chewed slowly over several hours, with users ingesting 100\u0026ndash;500 grams per session; the plant material is retained in the cheek and gradually swallowed, with the orally absorbed amount equating to 5 mg of amphetamine and 0.05 mg/kg of cathinone (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe adverse effects of khat chewing during pregnancy appear to intensify in proportion to the frequency and duration of use (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Various studies have reported that chewing khat during pregnancy has a negative health consequences such as low birth weight (LBW), fetal hypoxia (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e); fetal growth restriction (FGR), small for gestational age (SGA) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e); prelabor rupture of membranes (PROM) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e); congenital malformations, preterm birth, stillbirth (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e); maternal anemia and broader obstetric complications (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e); increased risk of anemia (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e); cognitive and behavioral impact on the mother (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Despite these risks, khat chewing remains deeply embedded in social and cultural practices in Ethiopia, where it is the second-largest export crop after coffee (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKhat use among pregnant women in Ethiopia varies from 11% in the south (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) to 66.9% in the east (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A recent systematic review and meta-analysis found the pooled prevalence of khat use during pregnancy in Ethiopia to be 26.6% (95% CI: 17.8\u0026ndash;35.5) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), indicating a substantial public health burden. However, to the best of our knowledge, no previous study has utilized nationally representative data to investigate the practice of khat chewing among pregnant women and their partners. This study fills the gap by analyzing the Ethiopian Demographic and Health Survey (EDHS) 2016 to estimate national prevalence and identify individual and partner-level predictors of khat chewing among pregnant women using nationally representative data.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study population and sampling\u003c/h2\u003e \u003cp\u003eThis study used data from the 2016 EDHS, the most recent nationally representative DHS conducted in Ethiopia at the time of analysis (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The EDHS employed a two-stage stratified cluster sampling design across 645 clusters (202 urban, 443 rural). A total of 16,650 households were selected, with a 94.6% response rate, yielding data from 15,683 women aged 15\u0026ndash;49. We analyzed the couples\u0026rsquo; recode dataset, which includes linked data for married or cohabiting women and their partners who both completed individual interviews. The unit of analysis was the couple. From this dataset, we identified 727 couples who had complete data on khat use.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Data collection\u003c/h2\u003e \u003cp\u003eData were collected using standardized questionnaires administered through face-to-face interviews. Five questionnaires were used to collect the EDHS data. We utilized the couples\u0026rsquo; recode dataset, which contains one record for each interviewed woman and her partner. Participants were asked two questions regarding khat use: \u0026ldquo;Have you ever chewed khat?\u0026rdquo; and \u0026ldquo;In the last 30 days, how many days did you chew khat\u0026rdquo; (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Outcome and predictor variables\u003c/h2\u003e \u003cp\u003eThe outcome variable in this study was the khat chewing status of pregnant women. The predictor variables were maternal age, residence, religion, educational level, wealth index, employment status, maternal cigarette and alcohol use, partner\u0026rsquo;s educational level, partner\u0026rsquo;s khat chewing status, partner\u0026rsquo;s alcohol drinking status, and whether the partner helps in household chores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using R software (version 4.4). Descriptive statistics were summarized using frequency tables. Bivariate associations were examined using chi-square tests, and multivariable logistic regression was used to identify factors associated with khat chewing status. As a sensitivity analysis, we also fitted a structural equation model (SEM) using the weighted least squares mean and variance adjusted (WLSMV) estimator to account for the binary nature of the outcome. The model included all significant predictors from the logistic regression and estimated their adjusted associations with khat chewing using probit coefficients. Variables with \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant, and the strength of the association was also measured with adjusted odds ratio at a corresponding 95% confidence interval.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eAmong the 727 pregnant women included in the analysis, 12.5% reported chewing khat. Prevalence within each group differed significantly by age, with the highest proportion observed among women aged 25\u0026ndash;34 years (61.5% of khat chewers) compared to 25.3% among those aged 15\u0026ndash;24 (p\u0026thinsp;=\u0026thinsp;0.035). Khat chewing was also markedly more common among Muslim women (89.0%) than among those of other religions (11.0%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Maternal education and household wealth index showed no significant associations in unadjusted analyses (p\u0026thinsp;=\u0026thinsp;0.068 and p\u0026thinsp;=\u0026thinsp;0.112, respectively). Partner characteristics showed strong associations with women\u0026rsquo;s khat chewing. A large majority of khat-chewing women had partners who also chewed khat (87.9% vs. 7.7% among non-chewers, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Notably, maternal alcohol use was strongly associated with khat chewing. The vast majority of khat chewers did not drink alcohol (94.5%) compared to 74.2% of non-chewers (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of pregnant Ethiopian women aged 15\u0026ndash;49, Ethiopian Demographic and Health Survey 2016 (n\u0026thinsp;=\u0026thinsp;727)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMaternal Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e241 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e303 (47.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92 (14.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (79.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e514 (80.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (89.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e301 (47.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e335 (52.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMaternal Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e340 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e210 (33.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86 (13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWealth Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e320 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87 (13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRich\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e229 (36.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMaternal Working Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (74.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e463 (72.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (25.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e173 (27.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMaternal smoking status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e629 (98.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMother drinks alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (94.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e472 (74.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e164 (25.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePartner Educational Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e243 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e250 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e143 (22.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartner Helps with Chores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (68.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e369 (58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e267 (42.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartner Drinks Alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (85.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e384 (61.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e237 (38.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartner Chews Khat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e404 (65.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (92.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e217 (34.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*P-values are from Chi-square tests\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariable logistic regression analysis identified several significant predictors of khat chewing among pregnant women (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Women aged 25\u0026ndash;34 years had twice the odds of khat chewing compared to those aged 15\u0026ndash;24 years (AOR\u0026thinsp;=\u0026thinsp;2.02; 95% CI: 1.10\u0026ndash;3.81; p\u0026thinsp;=\u0026thinsp;0.025), while the association for women aged 35\u0026ndash;49 years was not statistically significant (AOR\u0026thinsp;=\u0026thinsp;2.00; 95% CI: 0.81\u0026ndash;4.84; p\u0026thinsp;=\u0026thinsp;0.126). Compared with women from poor households, those in the middle wealth category had more than twice the odds of khat chewing (AOR\u0026thinsp;=\u0026thinsp;2.31; 95% CI: 1.11\u0026ndash;4.80; p\u0026thinsp;=\u0026thinsp;0.025). Maternal smoking status showed a non-significant positive association (AOR\u0026thinsp;=\u0026thinsp;5.40; 95% CI: 0.78\u0026ndash;35.82; p\u0026thinsp;=\u0026thinsp;0.078). Partner khat chewing was identified as a significant predictor: women whose partners chewed khat were over 15 times more likely to chew khat themselves (AOR\u0026thinsp;=\u0026thinsp;15.55; 95% CI: 6.54\u0026ndash;43.11; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The SEM results were directionally consistent with the logistic regression findings (Supplementary Table\u0026nbsp;1). In particular, partner khat chewing remained the strongest predictor (probit coefficient\u0026thinsp;=\u0026thinsp;1.34, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), followed by maternal age 25\u0026ndash;34 years (probit coefficient\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;=\u0026thinsp;0.040) and middle wealth status (probit coefficient\u0026thinsp;=\u0026thinsp;0.45, p\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression of current khat chewing among pregnant Ethiopian women aged 15\u0026ndash;49, Ethiopia (n\u0026thinsp;=\u0026thinsp;727)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMaternal Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.10 ; 3.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81 ; 4.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.20 ; 1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13 ; 1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMaternal Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.49 ; 1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16 ; 1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.417\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWealth Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.11 ; 4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRich\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48 ; 2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMaternal Working Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52 ; 1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMaternal smoking status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78 ; 35.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMother drinks alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27 ; 3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePartner Educational Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38 ; 1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15 ; 1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartner Helps with Chores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62 ; 1.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartner Drinks Alcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48 ; 3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePartner Chews Khat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.54 ; 43.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAOR: Adjusted Odds Ratio; CI: Confidence Interval; Ref: Reference category\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study provides the first national estimate of khat chewing among pregnant women in Ethiopia using linked couple data from the 2016 EDHS. The prevalence of khat chewing was 12.5%, comparable to the 11% reported in Southern Ethiopia (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), lower than the 15.5% reported in Eastern Ethiopia (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and substantially below the national estimate reported prevalence of current khat use among women of reproductive age (65.9%, 95% CI: 63.5\u0026ndash;68.2%) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These discrepancies likely reflect differences in study design, regional variation, and measurement. Our analysis assessed lifetime use (ever chewed), whereas others focused on current or recent use. Furthermore, our findings are based on a nationally representative sample, while most prior studies were facility- or community-based, often in high-prevalence regions such as Eastern Ethiopia, where khat cultivation is widespread and constitutes a major source of income and cash crop (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe found women aged 25\u0026ndash;34 had twice the odds of khat chewing compared with those aged 15\u0026ndash;24 (AOR\u0026thinsp;=\u0026thinsp;2.02; 95% CI: 1.10\u0026ndash;3.81; p\u0026thinsp;=\u0026thinsp;0.025). This finding is consistent with evidence suggesting that khat use increases with social independence and marital responsibilities, which are more common in this age group. Similarly, a study from Eastern Ethiopia showed that women aged 25\u0026ndash;35 and those\u0026thinsp;\u0026ge;\u0026thinsp;35 years were more than twice as likely to chew khat as younger women (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Previous research in Ethiopia and other East African settings similarly suggests that khat chewing rises during early adulthood and stabilizes or declines in later years (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The higher prevalence among women aged 25\u0026ndash;34 may reflect cultural acceptance, marital status, and greater autonomy.\u003c/p\u003e \u003cp\u003eHousehold wealth showed a non-linear association with khat use. Women in the middle wealth quintile were more than twice as likely to chew khat compared with those in the poorest group (AOR\u0026thinsp;=\u0026thinsp;2.31; 95% CI: 1.11\u0026ndash;4.80; p\u0026thinsp;=\u0026thinsp;0.025). This suggests khat use is not limited to poverty-driven behavior but reflects sociocultural dynamics and affordability patterns. Similar non-linear relationships have been observed elsewhere, where middle-income groups both have the financial means to purchase substances and live in environments that normalize their use (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Women in the poorest households may be unable to afford khat, while those in the wealthiest groups may benefit from higher education and greater exposure to health promotion (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). As noted in prior studies, khat use represents both a public health concern and a socio-economic challenge, with broad implications for households and communities (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The strong association between maternal alcohol use and khat chewing observed in the bivariate analysis was not sustained in the adjusted model, suggesting that its effect is mediated or confounded by other factors, most notably partners\u0026rsquo; substance use behaviors and religious affiliation.\u003c/p\u003e \u003cp\u003eAnother significant factor influencing khat chewing among pregnant women is whether their partners also engage in the practice. The analysis revealed that the most influential individual-level predictor of women\u0026rsquo;s khat chewing behavior was the khat use of their male partners. Specifically, pregnant women whose partners reported chewing khat were found to be more than 15 times as likely to engage in the same practice themselves (AOR\u0026thinsp;=\u0026thinsp;15.55; 95% CI: 6.54\u0026ndash;43.11; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A systematic review and meta-analysis study found that pregnant women whose partners chewed khat were over six times more likely to chew khat themselves compared to those whose partners did not chew (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This striking association underscores the powerful role of intimate partner influence in shaping women\u0026rsquo;s substance use behaviors. Women whose partners chew khat are more likely to adopt the same behavior, highlighting the strong role of partner influence in shaping maternal health choices. Similar findings have been documented in prior studies, where spousal or household khat use significantly increased the likelihood of women\u0026rsquo;s initiation and continuation of chewing (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Such results are consistent with social learning theory, which emphasizes the role of close interpersonal relationships in reinforcing health-related behaviors and emphasizes the importance of observing, modeling, and imitating the behaviors, attitudes, and emotional reactions of others (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In contexts where khat chewing is normalized within family settings, partner behavior not only provides direct exposure and accessibility but also legitimizes the practice, thereby amplifying women\u0026rsquo;s risk of khat consumption.\u003c/p\u003e \u003cp\u003eThis study utilized nationally representative data from pregnant women and their partners. However, the relatively small sample size of 727 pregnant women, with only 91 khat chewers, may limit statistical power and contribute to wide confidence intervals. In addition, the cross-sectional design limits the ability to draw causal conclusions between khat chewing and health outcomes. The reliance on self-reported data also poses challenges, as recall bias or underreporting may occur, particularly given the sensitive nature of khat use during pregnancy. The survey instruments do not always capture detailed information on the frequency, intensity, or context of khat use, which restricts the depth of interpretation. Furthermore, cultural stigma and social desirability bias may cause some respondents to conceal their practices, leading to an underestimation of true prevalence. The couples\u0026rsquo; recode dataset also excludes single mothers and polygamous unions, which reduces the generalizability of findings to non-traditional family structures. Future research with larger sample sizes, more qualitative and longitudinal studies is needed to comprehensively assess the factors associated with khat chewing in Ethiopia. Studies should also consider community-level influences such as peer norms, local availability, and economic stressors.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study demonstrates that khat chewing during pregnancy is a public health concern in Ethiopia, with a national prevalence of 12.5%. The behavior was most common among women aged 25\u0026ndash;34, those in the middle wealth quintile, and women whose partners also chewed khat. Multivariable analysis identified maternal age and partner behavior as the strongest predictors: women aged 25\u0026ndash;34 had approximately twice the odds of khat use compared with younger women, while having a partner who chewed khat increased maternal use more than fifteenfold. These findings highlight the need for targeted, culturally sensitive interventions that consider the social and familial contexts of substance use. Given the dominant influence of partner behavior, prevention strategies should engage couples and address relationship dynamics, rather than focusing solely on women. Routine screening for khat use during antenatal care, supported by standardized referral pathways and evidence-based counseling services, could facilitate early identification and management. Beyond clinical care, public awareness campaigns and community-based engagement are critical to reduce stigma, challenge misconceptions, and promote healthier norms. Embedding prevention and support within maternal health programs, while addressing broader socioeconomic and cultural determinants, represents a practical pathway to reduce khat use in pregnancy and improve maternal and child health outcomes in Ethiopia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEDHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEthiopian Demographic and Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLBW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow Birth Weight\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSGA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSmall for Gestational Age\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrelabor Rupture Of Membranes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWLSMV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWeighted Least Squares Mean and Variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have any conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors did not receive any funding for this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNA conceived the study and analyzed the data. NA and EA wrote the first draft. NA, EA and SB reviewed and edited the final version. All authors approved the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used in this study is available from DHS Program (https://dhsprogram.com) for legitimate reasons. The R code used in the analysis of the dataset is available at (https://github.com/NebyuDanielAmaha/Khat_EDHS)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the DHS Program for providing the survey dataset free of any cost.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Hebshi N, Skaug N (2005) Khat (Catha edulis)\u0026mdash;an updated review. Addict Biol 10(4):299\u0026ndash;307\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEngidawork E (2017) Pharmacological and toxicological effects of Catha edulis F.(Khat). Phytother Res 31(7):1019\u0026ndash;1028\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAronson JK (2014) Plant poisons and traditional medicines. Manson's tropical infectious diseases. Elsevier, pp 1128\u0026ndash;1150\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaroz R, Greenberg MI (2005) Emerging drugs of abuse. Med Clin 89(6):1259\u0026ndash;1276\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly JP (2011) Cathinone derivatives: a review of their chemistry, pharmacology and toxicology. Drug Test Anal 3(7\u0026ndash;8):439\u0026ndash;453\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakajima M, Jebena MG, Taha M, Tesfaye M, Gudina E, Lemieux A et al (2017) Correlates of khat use during pregnancy: a cross-sectional study. Addict Behav 73:178\u0026ndash;184\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmebet Dendir ED, Negussie Deyessa ND (2017) Substance use and birth weight among mothers attending public hospitals: a case control study\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBayih WA, Belay DM, Ayalew MY, Tassew MA, Chanie ES, Feleke DG et al (2021) The effect of substance use during pregnancy on neonatal outcomes in Ethiopia: A systematic review and meta-analysis. Heliyon. ;7(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWondemagegn AT, Bekana M, Bekuretsion Y, Afework M (2024) The effect of possible mediators on the association between chewing khat during pregnancy and fetal growth and newborn size at birth in Eastern Ethiopia. BMC Pregnancy Childbirth 24(1):63\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYadeta TA, Egata G, Seyoum B, Marami D (2020) Khat chewing in pregnant women associated with prelabor rupture of membranes, evidence from eastern Ethiopia. Pan Afr Med J. ;36(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoble AK, Gundappa R, Sheik Abdirahman F, Abdi AM (2023) Determinants of adverse birth outcomes in public hospitals of the Somali region, Eastern Ethiopia: a multicenter unmatched case-control study. Clin Med Insights: Pediatr 17:11795565231195253\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlzahrani MA, Alsahli MA, Alarifi FF, Hakami BO, Alkeraithe FW, Alhuqbani M et al (2023) A narrative review of the toxic effects on male reproductive and sexual health of chewing the psychostimulant, Catha edulis (Khat). Med Sci Monitor: Int Med J Experimental Clin Res 29:e939455\u0026ndash;e939451\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKedir H, Berhane Y, Worku A (2013) Khat chewing and restrictive dietary behaviors are associated with anemia among pregnant women in high prevalence rural communities in eastern Ethiopia. PLoS ONE 8(11):e78601\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzar MD, Salahuddin M, Sony P, Maru TT, Pandi-Perumal SR, Moscovitch A et al (2017) Sleep disturbances and memory impairment among pregnant women consuming khat: an under-recognized problem. Annals Thorac Med 12(4):247\u0026ndash;251\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFMHACA. Ethiopian National Drug Control Master Plan (2017) 2017\u0026ndash;2022. Addis Ababa: Ethiopian Food. Medicines and Health Care Administration and Control Authority\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMekuriaw B, Belayneh Z, Yitayih Y (2020) Magnitude of Khat use and associated factors among women attending antenatal care in Gedeo zone health centers, southern Ethiopia: a facility based cross sectional study. BMC Public Health 20(1):110\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWood EA, Stark H, Case SJ, Sousa B, Moreno M, Motuma A et al (2024) Khat use and related determinants among pregnant women within Haramaya, Ethiopia: a mixed methods study. Front Global Women's Health 5:1359689\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWogayehu B, Demissie T, Wolka E, Alemayehu M, Daka K (2023) The epidemiology of khat (Catha edulis) chewing and alcohol consumption among pregnant women in Ethiopia: a systematic review and meta-analysis. PLOS Global Public Health 3(9):e0002248\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemographic E (2016) Addis Ababa, Ethiopia, and Rockville. CSA and ICF, Maryland, MA, USA\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisgana T, Tesfaye D, Alemu D, Gebremichael B, Tamiru D, Tariku M et al (2022) Khat use and associated factors during pregnancy in eastern Ethiopia: A community-based cross-sectional study. Front Global Women's Health 3:941300\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlem A, Kebede D, Kullgren G (1999) The prevalence and socio-demographic correlates of khat chewing in Butajira, Ethiopia. Acta psychiatrica Scandinavica 100:84\u0026ndash;91\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKassim S, Croucher R, Al'Absi M (2013) Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers. J Ethnopharmacol 146(3):835\u0026ndash;841\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaile D, Lakew Y (2015) Khat chewing practice and associated factors among adults in Ethiopia: further analysis using the 2011 demographic and health survey. PLoS ONE 10(6):e0130460\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReda AA, Moges A, Biadgilign S, Wondmagegn BY (2012) Prevalence and determinants of khat (Catha edulis) chewing among high school students in eastern Ethiopia: a cross-sectional study. PLoS ONE 7(3):e33946\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhawaja M, Al-Nsour M, Saad G (2008) Khat (Catha edulis) chewing during pregnancy in Yemen: findings from a national population survey. Matern Child Health J 12(3):308\u0026ndash;312\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWondemagegn AT, Cheme MC, Kibret KT (2017) Perceived psychological, economic, and social impact of khat chewing among adolescents and adults in Nekemte Town, East Welega Zone, West Ethiopia. Biomed Res Int 2017(1):7427892\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnaolapo OJ, Olofinnade AT, Ojo FO, Adeleye O, Falade J, Onaolapo AY (2022) Substance use and substance use disorders in Africa: An epidemiological approach to the review of existing literature. World J psychiatry 12(10):1268\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamena T, Mossie A, Tesfaye M (2011) Khat chewing and mental distress: a community based study, in jimma city, southwestern ethiopia. Ethiop J health Sci 21(1):37\u0026ndash;46\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura A, Walters RH (1977) Social learning theory. Prentice hall Englewood Cliffs, NJ\u003c/span\u003e\u003c/li\u003e\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":true,"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":"Catha edulis, khat, pregnancy, maternal khat chewing, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-9040410/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9040410/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eKhat (Catha edulis) consumption has been associated with a range of biological, social, and psychological complications. Despite these known risks, national estimates of prevalence, patterns, and factors associated with khat use among pregnant women in Ethiopia remain poorly understood. This study aimed to address this gap by examining the prevalence and predictors of khat chewing among pregnant women using nationally representative data.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analyzed data from the 2016 Ethiopian Demographic and Health Survey (EDHS), focusing on the couples\u0026rsquo; recode file. A total of 727 pregnant women with complete data on khat use and partner information were included. Khat chewing status was defined as ever having chewed khat. Descriptive statistics and chi-square tests were used to examine bivariate associations. Multivariable logistic regression was performed to identify independent predictors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe prevalence of khat chewing among pregnant women was 12.5%. It was higher among women aged 25\u0026ndash;34 years, Muslims (89.0%), and those whose partners chewed khat (87.9%). In adjusted analysis, women aged 25\u0026ndash;34 had twice the odds of khat chewing compared to those aged 15\u0026ndash;24 (AOR\u0026thinsp;=\u0026thinsp;2.02; 95% CI: 1.10\u0026ndash;3.81; p\u0026thinsp;=\u0026thinsp;0.025). Women in the middle wealth category had higher odds than those in the poor category (AOR\u0026thinsp;=\u0026thinsp;2.31; 95% CI: 1.11\u0026ndash;4.80; p\u0026thinsp;=\u0026thinsp;0.025). Partner khat chewing was strongly associated with maternal use (AOR\u0026thinsp;=\u0026thinsp;15.55; 95% CI: 6.54\u0026ndash;43.11; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Maternal smoking showed a large but statistically non-significant positive association (AOR\u0026thinsp;=\u0026thinsp;5.40; 95% CI: 0.78\u0026ndash;35.82; p\u0026thinsp;=\u0026thinsp;0.078).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eKhat chewing during pregnancy is influenced by maternal age, middle household wealth, and particularly partner behavior. These findings highlight the need for targeted, culturally sensitive interventions integrated into maternal health programs that engage couples, address relationship dynamics, and consider socioeconomic and age-specific risk factors to reduce khat use and improve maternal and fetal outcomes.\u003c/p\u003e","manuscriptTitle":"Prevalence and predictors of khat chewing among pregnant women in Ethiopia: Insights from a national health survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-06 04:33:10","doi":"10.21203/rs.3.rs-9040410/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":"4c99d753-fcf3-4525-84ec-8443d75fa469","owner":[],"postedDate":"March 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":63990081,"name":"Health Policy"}],"tags":[],"updatedAt":"2026-03-06T04:33:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-06 04:33:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9040410","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9040410","identity":"rs-9040410","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}