This study assessed whether nutritional status and dietary pattern of lactating mothers were different between Ethiopian Orthodox lent fasting and non-fasting periods. It also determined factors associated with maternal underweight in rural Tigray, Northern Ethiopia.
4.1. Nutritional Status of Lactating Mothers
Adult stature is the collective outcome of the interaction between environment and inheritances, over the critical growing period of a person [39
]. Prior evidence has demonstrated that short maternal height was associated with increased offspring mortality, underweight, and stunting in infancy, childhood, and later in an adult age [39
]. In our study, prevalence of maternal stunting was 1.4%, which was less than previous findings in Ethiopia [5
]. Shorter women are believed to have reduced protein and energy stores, smaller size of their reproductive organs, and smaller pelvis diameter. This may limit fetal development in the uterus, increases risk for mother and child complication during delivery, and later infant growth through reduced breast milk quantity and quality, resulting in stunted children. Thus, appropriate feeding behavior is important for pregnant women health, and later for bearing healthier and well grown new born babies. This finding suggests that health extension agents working in the rural communities should advise mothers on appropriate feeding behavior during the pregnancy period.
The overall prevalence of maternal underweight in this study was between 32.6 and 33.6%. The prevalence was lower than previous findings in Tigray region (34–55%), and Dedo and Seqa-Chekorsa districts (41%), in South-west Ethiopia [9
]. Conversely, the prevalence was higher than in other studies in the Tigray and Oromia regions of Ethiopia [5
]. The latter could be related to climate phenomenon ‘El Nino’, which caused the strongest famine in Ethiopia, where the impact seriously affected Tigray region. It could also be related to differences in feeding practices, study population, and period [45
Shockingly, prevalence of underweight was 51% in fasting mothers compared with non-fasting mothers (25%). The result was consistent with studies conducted on lactating mothers living in the midland agro-ecology of Tigray region, which was 57% [12
]. Similarly, the BMI was significantly lower among fasting adults than non-fasting adults in Greek Orthodox Christians [28
]. This could be related to the almost 317 kcal difference between fasting and non-fasting adults, in end-holy days of fasting periods [46
In the present study, prevalence of overweight was between 1.1% and 3.8%, respectively, which was relatively comparable with the Ethiopian Demographic and Health Survey (EDHS) 2011 report (2.9%) in Tigray, and elsewhere (1.3–1.8%) in the region [5
], but lower than the EDHS (2016) report at national level (6%) and Tigray region (4.9%). In urban women, it was reported (6.2–25.3%) in Ethiopia, Bengal district in India (5.4%), and Nepal (6.3–24.8%) [44
]. This might be because we attributed this finding to rural people [10
], where most could engage in heavy physical activities and walking over long distances to access services due to the mountainous topography [53
Mothers thirty years of age and younger were 1.7 times more likely to be underweight than those above thirty. That conforms with other studies conducted in Ethiopia and Nepal, resulting in higher prevalence of underweight in younger women [10
]. In the current study, more than 27% of mothers fasted during their pregnancy period, and these mothers had 1.7 times more odds to be underweight than not fasting during the same period. In a previous study, more than one-third of mothers were fasting during their pregnancy period in Oromia region, Ethiopia [15
]. Similarly, those mothers fasting during lactation period were 2.9 times more exposed to underweight, than those who did not practice.
Mothers who had children between the age of 13 and 18 months, were twice more likely to be underweight compared to those who had a child aged 6–12 months. Similar result was observed in a study conducted by Haileslassie and his colleagues in Northern Ethiopia [5
]. This might be due to increased nutritional requirements of the growing child, effort for child care in connection with food intake by the mother that is not increased or even decreased.
Disease is one of the immediate causes of maternal and child undernutrition [1
]. Mothers who had any illness in the last four weeks preceding the survey were 3.6 times more frequently underweight than healthy mothers. In a study conducted in the Limu area of Southern Ethiopia, maternal sickness was positively associated with maternal underweight [55
]. This could be related to decreased food intake and absorption, alteration of metabolism, and increment in nutritional requirements. Marital status of lactating mothers was not significantly associated with maternal underweight. Prior evidence has also demonstrated that marital status was not associated with Ethiopian women [56
]. Otherwise, birth spacing has important implications for the health and nutritional status of mothers and their children [57
]. In our study, family planning use was not associated with maternal underweight, which is inconsistent with the study conducted in the Tena district of Oromia region, Ethiopia. In the latter, the prevalence of family planning utilization was higher (65%) than our finding, which was 52% [58
Good care during pregnancy is important for the health of the mother and development of the unborn baby. The findings of this study indicated that a major proportion (91%) of mothers had at least four ANC services during their pregnancy period, and were not significantly associated with maternal underweight. This result was equal with the regional coverage of Tigray (91%), but higher than the national prevalence (62%) [10
]. The postnatal period is a critical phase in the lives of a mother and the newborn baby. In this period, major changes occur, but it is the most neglected time for the provision of quality services. As a result, the rates of provision of skilled care are lower after childbirth when compared to rates before and during childbirth [59
]. In this study, prevalence of PNC coverage was 42.5%, which is comparable with previous findings in Tigray region (45.4%); however, PNC attendance was not significantly associated with maternal undernutrition.
Household size was not significantly associated with maternal underweight in the study. This coincides with studies in Southern Ethiopia and Tigray region [5
]. However, it was inconsistent with one study conducted in Nekemte town, Oromia region in Ethiopia [44
]. The difference might be a higher proportion of lactating mothers who lived in rural households with many family members, in our case. Grandfathers as a decision maker for the household were associated with maternal underweight. This could be related to sharing the household income to more family members or to the loss (death, departure) of the husband resulting in lower working capacity and income, or due to most lactating mothers in grandfather headed households being younger, which is associated with maternal underweight in our case. It has also been reported that mothers who had more children, decreases the resources allocated including food, resulting in underweight [60
Access to safe drinking water, sanitation and hygiene (WASH) services is a fundamental element of healthy communities and has an important positive impact on child and maternal nutrition [61
]. One-third of households included in this study, had non-improved water sources for household consumption. The odds of being underweight for mothers from non-improved water sources were 1.6 higher than those from households with improved water sources. This may be due to the fact of frequent illness related to water borne diseases and contamination.
Accordingly, child undernutrition was associated with source of drinking water in Iraq and sub-Saharan Africa [63
]. In contrast, toilet presence in the household was not associated with maternal underweight. This might apply to the majority of households included in the study, one of the successes of the health extension program in Ethiopia.
In our study, households not owning chickens were 1.8 times more likely to have underweight mothers, than those who owned chickens. Similarly, the proportion of mothers who ate more diversified foods were higher in households which owned chicken, than those from households not owning chicken. Prior research in Ethiopia, indicated that owning livestock in the household was associated with a higher diet diversity score [65
]. Studies in three East African countries also evidenced that, in households owning livestock, the prevalence of child stunting was low [66
]. Thus, promoting chicken husbandry may also improve the low consumption of animal source foods, and the diversity of food to be eaten at large. Among households involved in the study, more than a quarter (32.5%) were at the lowest wealth tertile. According to the EDHS report, a lower proportion of households (23%) was at the lowest wealth quantile [10
]. Of thirty-four woredas in Tigray region, thirty-one were food insecure, including our study district [33
]. The results from the present study showed that more than two-thirds (71%) of households were food insecure. Comparably, the prevalence of food insecurity was 76% in East Bedawacho district of Southern Ethiopia [67
]. However, the prevalence was lower than in a study conducted in two agro-climatic zones in Sidama, Southern Ethiopia, which was 82% [68
4.2. Dietary Patterns of Lactating Mothers
According to the essential nutrition action (ENA), mothers are recommended to take at least two additional meals during their lactation period [69
]. In the present study, nearly two-thirds of the mothers (65.4%) did not change the food intake during their lactation period. This result is lower than a study conducted in Samre district which reported (71%), but higher than findings in Raya area (59%) of Tigray region. This could be related to the interval in the study periods and study area [5
]. Lactating mothers who ate more than three times a day were 9–12%. This result agreed with findings in the Tigray, Oromia, and Southern regions in Ethiopia [11
]. One-third of lactating mothers ate less than three times on average of the two days preceding the survey during fasting period, which is lower than the expected three meals to have in a day of a normal adult in real context. Prior research in Samre district of Northern Ethiopia, showed that the proportion of lactating mothers who had less than three meals in the last 24-h preceding their survey was 27% [5
], which is comparable with our findings. However, this prevalence reduced to 8.4% in the non-fasting period, which is comparable with the prevalence (7.5%) of pregnant women in Gambela town, Western Ethiopia [70
]. Similarly, the number of meals eaten both by fasting and non-fasting mothers were significantly increased after two months of fasting period. The latter should be further studied for explanation.
Diet diversity is one important dimension of diet quality, and a proxy indicator for higher micronutrient adequacy [36
]. Majority of mothers had a diet diversity score of three and less in the fasting period (92%) and non-fasting period (87%). This could indicate that dietary micronutrient inadequacy is high in the study population. The median diet diversity score for both sub-groups of fasting and non-fasting mothers, increased significantly in non-fasting period. This was associated with higher consumption of ASFs and a higher frequency of meals in our and related studies [65
]. Thus, in the Ethiopian Orthodox fasting period, the feeding practice of lactating mothers is sub-optimal. This finding suggests that nutrition education, which will improve feeding practices should involve religious leaders in a sustainable manner. The number of mothers who had consumed more cups of coffee was higher in the fasting than non-fasting period, in the whole study population. Likewise, non-fasting mothers took significantly more coffee in the fasting period than non-fasting. However, consuming more coffee during the fasting period, where plant-based foods are the sole source of minerals, could reduce their bioavailability, leading to increased risk for micronutrient deficiencies, especially of iron, calcium, and zinc [73
]. However, many fasting mothers consumed more cups of coffee in the non-fasting than fasting period. This could be referred to some Ethiopian Orthodox religion monarchist, who preached to followers not to consume coffee during fasting periods.
In this study, cereals, pulses, and other vegetables were the main food groups commonly consumed by lactating mothers. This result agrees with previous studies in Ethiopia [65
]. These plant foods usually contain dietary components that compromise digestion and inhibit absorption of vital nutrients. For example, phytic acid chelates multivalent ions such as zinc, calcium, and iron; therefore, their bioavailability reduced [75
]. This finding suggests that traditional processing techniques which can improve the bioavailability of minerals should be promoted in the community. Dark green, leafy vegetables are important plant sources of micronutrients like iron, calcium, and vitamin A [76
]. However, their consumption was very low in the non-fasting period, both in fasting (5.6%) and non-fasting (2.8%) mothers. However, the result was lower than that previously reported for Axum town (19%) in Northern Ethiopia. The discrepancy between these two findings could be related to better market access, which is less in this study due to the rural area. However, the number of non-fasting mothers who consumed dark green, leafy vegetables was significantly higher in the fasting period than non-fasting period. This could be related to a potential to choose and consume more diversified food, especially ASFs which were less consumed in fasting period. Furthermore, almost all lactating mothers did not consume nuts and seeds, fruits, and vitamin A rich fruits and vegetables food groups at all in both study periods, because of a lack of cultivation on local farms and unavailability in the market [77
]. Thus, activities which can improve the dietary diversity including nuts and seeds, dark green leafy vegetables, and vitamin A and C rich fruits consumption, as well as meal frequency are inevitable. Moreover, the consumption of fruits which are rich in vitamin C should be taught to improve the mineral bioavailability of plant foods, which are the predominate source of most nutrients for a given community.
The proportion of lactating mothers who consumed ASFs was significantly lower in the fasting than non-fasting period. In Northern Ethiopia, particularly in rural Tigray, most strict Ethiopian Orthodox Christians abstain from eating animal source foods during the lent and other fasting periods or days, including Wednesday and Friday. During these fasting periods, the demand for cattle meat was observed to be low, resulting in closure of abattoirs or minimizing the service provided [78
]. A previous study, reported that more than 85% of butcher houses were closed in Addis Ababa during Wednesday and Friday, which are Orthodox Christians fasting days of the week [79
This study has much strength and some limitations. It is the first study in Ethiopia, which assessed the effect of religious fasting on maternal nutrition, particularly lactating mothers, who need more nutrients than pregnant women. Moreover, the study was done in an area, where almost all people were Ethiopian Orthodox Christians to minimize research bias. In addition, the study had a longitudinal nature, which considered a large sample size, and two 24-h dietary recall data for each study period. On top of these, this study also determined the differences in dietary and nutritional status during fasting and non-fasting periods, for both fasting and non-fasting mothers’ sub-groups, separately. However, the study only considered the long Ethiopian Orthodox lent fasting period out of the seven official fasting periods. This study did not measure micronutrient levels or bio-markers in the blood, to assess micronutrient deficiencies reflecting the consequences of qualitative malnutrition. Underweight only indicates energetic malnutrition, representing the tip of the iceberg.