Key element missed in nutrition policy: why does undernutrition not decline among pregnant women in Ethiopia? | Health Research Policy and Systems

Undernutrition is a global problem that is linked either directly or indirectly with tremendous causes of death and disability. Over the past decades, the number of people affected has increased from 780 million in 1992 to 828 million in 2022 [1, 2]. Sub-Saharan Africa is disproportionately affected by the burden of undernutrition, with the highest percentage of malnutrition among nutritionally vulnerable groups (women and children) [3].

Inadequate nutritional status during pregnancy puts the health of the mother and foetus at risk [4]. Undernutrition raises the risk of low birth weight, foetal intrauterine growth retardation, miscarriages, preterm delivery and gestational anaemia and negatively affects the newborn’s immune system development [4,5,6]. A study conducted in Addis Ababa revealed that women who practiced food taboos were two times more likely to experience anaemia those than who did not practice food taboos [7].

Ethiopia is known for its undernutrition problem among pregnant women, in which 32% of women are underweight [8]. To fulfil the increased needs of both mother and foetus during pregnancy, a better diet that includes enough calories, protein, vitamins and minerals is required [9]. Moreover, food taboo is a common practice during pregnancy for pregnant women in Ethiopia, and at least one type of food is restricted throughout the course of pregnancy by several women [10].

The prevalence of food taboo during pregnancy among pregnant women in Addis Ababa was 18.2% [7], in Mekele City 12% [11], Oromiya region, Haramaya District 48% [12], Amahara region, Bahir Dar City 27.5% [13], Southern Ethiopia, Hadiya zone 27% [14] and Somali Region 67.4% [15]. The evidence indicates that food taboos are caused by the interplay of multiple factors, such as cultural beliefs, socioeconomic factors, and service-related factors [16] As a result, appropriate nutrition policies are crucial to diminish it negative consequences (Table 1).

Ethiopian nutrition policy and its impact on maternal nutritional problems

Historically, health policy in Ethiopia started toward the end of the imperial period. However, the broader health policy developed in 1993 during the transitional government focused on controlling infectious diseases, epidemics, diseases related to malnutrition and improving the health needs of women and children [17]. Nutrition was one of the priority areas in a 20-year health sector development program (HSDP) and a health sector transformation plan strategy (HSTP) [18, 19]. To overcome problems related to malnutrition, particularly to reduce maternal undernutrition, childhood stunting, wasting and underweight in children under 5 years of age, the Ethiopian government developed national nutrition strategies and programs through collaborative work. Even though the policy brought some improvement in decreasing nutritional problems over the past years (Table 2), millions of women in Ethiopia still suffer from chronic and acute forms of malnutrition at the time of pregnancy [20, 21]. Therefore, another key component with the new strategies must be incorporated into national nutritional plans and programs.

Missed key element in Ethiopian national nutrition policy

Ethiopia is home to diverse cultural malpractices such as food taboos during pregnancy that lead to anaemia, macro and micronutrient deficiency illnesses, low resistance to infection and poor foetal physical and mental growth [22]. The evidence indicates that there is a considerable magnitude of food taboo practices during pregnancy among pregnant women in Ethiopia [7, 10,11,12, 14, 15].

A systematic review and meta-analysis carried out in Ethiopia revealed that the pooled prevalence of food taboos among pregnant women in Ethiopia was 34.22% (with 95% confidence interval [CI] 25.47–42.96), and significant heterogeneity was observed among studies (I² = 98.6%, P value < 0.0001). The highest prevalence of food taboo was found in the Somali region 67.38% (63.66–71.10), and the lowest prevalence was reported from a study conducted in the Tigray region 11.45% (8.02–14.87) [10].

Policy recommendations

First and foremost, food taboos should be incorporated into national nutrition policies and strategies.

Next, nutrition education regarding food taboos should be integrated into a basic antenatal care program that includes the assessment and identification of evidence of restricted food at the time of pregnancy, the reasons behind tabooed food, advice about essential foods commonly consumed and foods minimized during pregnancy.

Delivery of education on the impact of food taboos on mothers and their foetuses during antenatal care (ANC) follow-up at ANC clinics to all pregnant women in all regions of Ethiopia.