Utilization Of Nutrition Services Provided At Health Facilities For Pregnant Women In Moshi – Urban, Kilimanjaro, Tanzania. A Cross Sectional Study

Nutritional status in pregnancy is a key determinant of birth outcomes. Under nutrition among pregnant women is clearly linked to negative maternal health outcomes, including the risk of maternal mortality and negative pregnancy outcomes ¹³. Research indicates the outcomes associated with under nutrition during pregnancy include low birth weight, preterm birth, micronutrient deficiencies, low nutrient stores in infants, fetal growth restriction, perinatal mortality, child stunting, later adulthood chronic diseases, and maternal mortality. Furthermore, one quarter of all newborn deaths related to under nutrition may be linked to poor maternal nutrition during pregnancy and fetal under nutrition. Moreover, anemia during pregnancy has also been identified as an underlying cause in approximately 20% of maternal deaths and is a key contributor to short stature (stunting), a consequence of chronic under nutrition during early childhood. Thus, malnutrition during pregnancy has far-reaching consequences as it can serve as a fertile ground for the intergenerational cycle of malnutrition in women and their newborn children ⁴.

In pregnancy, requirements of energy, protein, and essential micronutrients (vitamins and minerals) are increased not only to maintain the mother’s own health, but to also support optimal physical and brain development in the fetus. To sustain the production of adequate quantity and nutritional quality of breast milk, lactating women have higher requirements of energy, protein, and other micronutrients. Poor maternal nutrition over this period risks depletion of the mother’s own nutrient stores and health, and harms the nutrition and health of the growing child. Deficiencies of energy, protein, iron, calcium, iodine, vitamin A and folic acid during pregnancy predispose mothers to maternal complications and even mortality. These also contribute to fetal birth defects, low birth weight, restricted physical and mental potential, and fetal or newborn mortality ²³.

Pregnancy requires an increased intake of macronutrients and micronutrients for maternal and fetal needs, and malnourishment or inadequate dietary intake during pregnancy can lead to adverse perinatal outcomes. Observational study that was done by Rush ¹⁸, have indicated that both gestational weight gain and energy intake are strongly and positively associated with fetal growth, and possibly associated with a reduced risk of preterm birth. Moreover, these associations are stronger in undernourished women, i.e. those with low prepregnancy body mass index (BMI) ¹⁶.

During pregnancy, a baby developing inside the womb receives all its nutrition from its mother. Inadequate dietary intake during pregnancy can lead to malnutrition and poor outcomes for the baby. Therefore, advising women on their diet and providing food supplements during pregnancy may help babies to grow well and improve pregnancy outcomes. The 2016 WHO recommendations on routine antenatal care (ANC) for pregnant women and adolescent girls provide comprehensive guidance on the practice, organization and delivery of ANC and priorities woman-centred care to facilitate a positive pregnancy experience. Recognizing that ANC provides a strategic platform for important healthcare functions including health promotion and disease prevention, 14 out of the 49 recommendations in the WHO ANC guideline relate to nutrition. Antenatal micronutrient interventions recommended in this guideline for pregnant women and adolescent girls include daily elemental iron (30–60 mg) and folic acid (0.4 mg) to prevent maternal anemia; calcium supplementation (1.5–2 g daily) in populations with low dietary intake of calcium to prevent pre-eclampsia; and vitamin A supplementation (up to 10 000 IU vitamin A daily or up to 25 000 IU vitamin A weekly) in populations with a high prevalence of night blindness. Calcium supplementation is also recommended prior to pregnancy for the prevention of pre-eclampsia and its complications ^{28, 29}

The aim of this study is to assess the utilization of nutritional services as provided to pregnant women in health facilities and explore the nutritional knowledge of both providers and pregnant women attending reproductive and child health clinic.

Maternal and child health care services is essential component to promote family health. Despite of being provided free of cost, adequate utilization on of services is still the issue affecting health of both mother and child. Low utilization of health and nutrition services is a major setback to the attainment of ultimate health of many populations in developing countries.

Globally 52% of maternal deaths are attributable to hemorrhage, sepsis, and hypertensive disorders; 28% to non-obstetric causes; 8% to unsafe abortion. Anemia, which results from deficiencies of nutrients such as iron and folic acid is an important risk factor for hemorrhage; a leading cause of maternal mortality. Calcium deficiency during pregnancy also increases the risk of pre-eclampsia, another cause of maternal mortality. Improving nutrition alongside good antenatal care can reduce these numbers significantly. Maternal nutritional status before and during pregnancy is an important contributor to pregnancy outcomes and early child health.

In a review by Siekmans and colleages ²⁰, iron and folic acid (IFA) supplementation programmes in seven countries (Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria and Senegal) suggests that much remains to be done to improve uptake and adherence of essential nutritional supplements in pregnancy. Barriers to coverage include supply chain issues, lack of quality control and coordination, and inadequate staff training and patient counselling.

Maternal nutrition plays an important role in placental-fetal growth and development. Maternal under nutrition during pregnancy results in intrauterine growth restriction (IUGR) which is associated with increased perinatal morbidity and mortality. These children have an increased risk for development of metabolic syndrome in adult life. Evidence shows that the animal embryo comprises two group of cells in the early embryonic stage. The inner cell mass which develops as the fetus and the outer cell mass become the placenta. These developmental process is influenced by nutrition and hormones ²

Conception triggers thousands of complex and sequenced biological changes that transform two united cells into a member of the next generation of human beings. The rapidity with which structures and functions develop in mother and fetus and the time-critical nature of energy and nutrient needs make maternal nutritional status a key element of successful reproduction ⁵. Physiological changes in pregnancy can be divided into two basic groups: those occurring in the first half of pregnancy and those in the second half. Changes in the first half are considered “maternal anabolic “changes because they build the capacity of the mother’s body to deliver relatively large quantities of blood, oxygen, and nutrients to the fetus in the second half of pregnancy. The second half is “maternal catabolic” changes in which energy and nutrient stores, and the heightened capacity to deliver stored energy and nutrients to the fetus, predominate. Approximately 10% of fetal growth is accomplished in the first half of pregnancy, and the remaining 90% occurs in the second half.

The importance of perinatal nutrition and its role in offspring health, is recognized. Nutrition during pregnancy is an important factor associated with both maternal and infant health outcomes. Very little is known about the diet and nutritional status of pregnant women in South Africa, specifically residing in urban areas ²². Furthermore, understanding the associations of maternal diet and nutritional status during pregnancy with birth outcomes, as well as offspring health and development in the South African population will form the basis for the development of context-specific nutrition interventions that may improve birth outcomes and long-term quality of life of the mother and her offspring.

Maternal under nutrition at the time of conception have shown fewer cells in the inner cell mass in experimental animal studies, which is associated with reduced birth weight and postnatal growth, altered organ/body weight ratios and the development of chronic diseases as type 2 diabetes, hypertension (HTN), coronary artery disease (CAD) (12). Evidence has also suggested that disturbances during critical periods of fetal development alter the structure or function of distinct cells, organ systems or omoeostatic pathways. Therefore, the subjects will have an increased risk of developing cardiovascular disease and type 2 diabetes in later life. In a study by Eriksson and colleages ⁸ found the association between maternal malnutrition in early pregnancy and the occurrence of Coronary artery disease in the offspring. They have shown that exposure to malnutrition, especially in late gestation, is linked to impaired glucose tolerance, while exposure in early gestation is linked to atherogenic lipid disorders and obesity.

On the other hand, maternal under nutrition prior and during pregnancy has serious consequences on infant’s health and survival. It causes intrauterine growth retardation (IUGR), can initiate and perpetuate an intergenerational cycle of under nutrition and is a leading cause of low birth weight babies ²¹. Low birth weight (weight less than 2500g at birth) is a leading cause of increased neonatal and infant mortality rates, impaired immune function, and increased risk of cognitive and neurological impairment ⁵.

In a study conducted Tuncalp by and colleagues ²⁵, the most common micronutrient deficiency in pregnancy known to impact maternal health is iron deficiency due to increased iron demands. Iron deficiency is a common cause of anemia, which is estimated to affect 40% of pregnancies globally, highest in South-East Asia (49%), Africa (46%) and the Eastern Mediterranean (41%) and lower prevalence in Western Pacific (33%), the Americas (26%) and Europe (27%).

Maternal and child under nutrition contributes greatly to mortality and morbidity of women and children in Pakistan, and is also one of the most important contributing factors to intergenerational poverty ¹⁹. Around 51% of Pakistani women of reproductive age are anemic. In pregnancy, requirements of energy, protein, and essential micronutrients (vitamins and minerals) are increased not only to maintain the mother’s own health, but to also support optimal physical and brain development in the fetus. Furthermore, nutrition reserves are built over pregnancy to produce breast milk for the post-child birth phase. The impact of poor nutrition on maternal health and survival is indisputable. Anemia, which results from deficiencies of nutrients such as iron and folic acid is an important risk factor for hemorrhage; a leading cause of maternal mortality. Calcium deficiency during pregnancy also increases the risk of pre-eclampsia, another cause of maternal mortality. Improving nutrition alongside good antenatal care can reduce these numbers significantly. Globally 52% of maternal deaths are attributable to hemorrhage, sepsis, and hypertensive disorders; 28% to non-obstetric causes; 8% to unsafe abortion.

Very little is known about the diet and nutritional status of pregnant women in South Africa, specifically those residing in urban areas ²². Furthermore, understanding the associations of maternal diet and nutritional status during pregnancy with birth outcomes, as well as offspring health and development in the South African population will form the basis for the development of context-specific nutrition interventions that may improve birth outcomes and long-term quality of life of the mother and her offspring. Consequently, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to investigate nutritional status during pregnancy and assess early nutritionrelated exposures predictive of early childhood development in urban South Africa.

Nutrition for women in pre-pregnancy, pregnancy, and over the first two years of the child’s life is of utmost importance for the survival, health and development of mothers and their children. Maternal diet during pregnancy is thought to be one of the most influential factors on child health and development ¹⁸. However, dietary interventions during this period may miss a critical window to improve health during childhood, as well as adult life. Maternal over nutrition as well as under nutrition have been known to adversely affect metabolic regulation in offspring and increase the risk for metabolic disease development.

When adolescence is confronted with pregnancy, the nutrition requirements further becomes more demanding ¹⁵. Pregnancy presents another special stage in life that has the potential to positively impact on maternal health and that of the preceding generation. Adequate nutrition is imperative to meet the added demands of nutrients for the mother’s body, that of the growing fetus and instills a strong biological basis for the present and coming health, productivity and wellbeing of the mother. Other investigators further demonstrate that devastating effects of poor nutrition status at adolescent into motherhood, maternal body conformation, altered metabolism and supply of nutrients to the placenta can enhance positively or negatively the fetal development, growth and is interrelated to pregnancy outcome. Moreover, the relationship between nutrition status and pregnancy at adolescent is complex and attributed to different biological, economic, demographic and social factors which vary widely depending on the population in the interplay.

Food taboos and beliefs during pregnancy deprive women of necessary nutrients and foods available. Studies done in southern Tanzania showed that, pregnant women are discouraged from consuming fish and meat based on the belief that, these foods are linked with anemia during pregnancy ²⁶. In other areas of Tanzania, pregnant women are advised to eat low portions of food because of the local belief that eating more during pregnancy would result into a big baby that would be difficult to deliver.

Moshi is a municipality and the capital of Kilimanjaro region in the north eastern Tanzania. As of 2017, the municipality has an estimated population of 201,150 and a population density of 3,409 persons per km2 . In the last official census of 2012, the municipality had a population of 184,292. The municipality is situated on the lower slopes of Mount Kilimanjaro, a dormant volcano that is the highest mountain in Africa. The name Moshi has been reported to refer to the smoke that emanates from the nearby mountain. The municipality covers about 59 square kilometers (23 sq mi) and is the smallest municipality in Tanzania by area.

Moshi Urban is one of the seven districts of the Kilimanjaro Region of Tanzania. The regional capital of Moshi is located in the Moshi Urban District. The district is bordered to the north by the Moshi Rural District, to the east by the Mwanga District and to the south and west by the Manyara Region. According to the 2002 Tanzania National Census, the population of the Moshi Urban District is 144,336. According to the 2012 Tanzania National Census, the population of Moshi Urban District was 184,292.

Moshi is administratively divided into 21 wards and then subdivided into 60 hamlet .

Moshi urban has lower altitude and drier climate mean that the main crops grown on the higher slopes of Mt Kilimanjaro, are coffee and bananas, do not thrive there. The surrounding areas in Moshi urban district are known for extensive farms of maize and beans, grown once per year during the long rainy season (known as "masika" in Kiswahili). In addition, the Tanganyika Planting Company operates a very large sugar cane plantation and company town 20 kilometers (12 mi) south of Moshi.

The study design used was cross sectional study in which primary data was collected from pregnant women and service providers at reproductive and child health clinic. A cross sectional study is an observational study. It is relatively cheap and can be conducted in a very short period of time, also can be used for public health planning as well as hypothesis formulation (10). This study design was chosen because it is time and cost effective since it was one time survey and fit within the allocated time and resources available.

The study involved pregnant women attending health facilities, reproductive and child health workers, and reproductive and child health in charge. The health workers of RCH were involved because they are the one providing the nutrition services to pregnant women so they can give the needed information on the extent of utilization of nutrition services. The RCH in charge involved because the general information about the schedule of provision of nutrition services to pregnant women. The inclusion criteria’s for this study were pregnant women at the reproductive and child health clinic as well as the service providers.

The total of 105 pregnant women were involved in the study. Their mean age was 27.6 ± 5.61 (range: 18-38) years. Majority of pregnant women ranged between 18 -30 years with 71.4%. Additionally 22.9% of pregnant women were ranging between 31 – 35 years. And those pregnant women who were above 36 years were 5.7% who are termed as high risk women during pregnancy according to the ANC guidelines. Also, in terms of parity 35.2% of all pregnant women were having their first pregnancy, where 29.5% had one child, 21.9% and 13.3% they had more two or more children. On the other hand more than a half of the respondents started the ANC visits in their first trimester 63% as compared to 43% who started their visit during second trimester. Other demographic information includes marital status, education level, as well as occupation are presented in the Table 1.

Four variables were assessed during the study to identify nutritional related services that are available and provided in health facilities. The results shows that most pregnant women attending RCH clinic are being monitored their weight and height (100%), while 83.8% of the respondents reported about the availability of education sessions which includes nutrition education during their antenatal visit, with more than a half 72.4% on ferrous folic supplementation which is the lowest of all services provided because of inadequate supply of these supplements to the clinics by government which makes pregnant women to go and buy them from pharmacies outside the clinic. Lastly, hemoglobin test was readily available to pregnant women by 77.1%.

The study reveals that the timing and delivery of the nutritional education to pregnant women was perfect due to the fact that more than a half of all women surveyed started their ANC clinic during their first trimester of the pregnancy which is the period of rapid development of the child within the uterus and also the essential equipment’s to provide the needed services was available. This has been supported by Billah et al., ³ in a study that was conducted in Bangladesh it showed that in order for the nutrition services to be properly provided to the to pregnant women at RCH clinic there are things that should be put under control that is; presence of essential equipment and guidelines for service delivery, provision of basic nutrition training to all service providers and also proper arrangement of areas for services delivery so that all people get services without interference from other groups.

However, health care providers face some challenges in giving timely nutrition education and services to all pregnant women due to their inability to manage time despite the clinic being started at not as early as 7am but majority of the health workers reported women being late coming for their scheduled visits where they are found mostly kind of being tiresome due to high workload and inadequate number of providers at the RCH clinic.

The study also assessed the availability and accessibility of services at the clinics. The study reveal that there are four nutrition services commonly provided to pregnant women at antenatal clinics from the surveyed facilities were nutrition education, iron and folic acid supplementation, weight and height measurements, and hemoglobin level monitoring. The services are being provided daily to all women in their routine clinic and there is constant documentation of the services that they receive in every visit which is being documented on their ANC cards as well as the MTUHA books for health information management in hospitals.

Among the services provided at the facilities, weight and height measurements was the most provided service to all women in all facilities as this is the important parameter in the prevention of pregnancy complications during pregnancy and delivery such as gestational diabetes and pre-eclamsia, which was followed by nutrition education to help pregnant mothers eat well and balanced diet to assist in the health development of the fetus, ferrous folic supplementation and lastly, was hemoglobin test to all women in every visit, all these are there to assist women in the prevention of anemia during pregnancy and reduce maternal mortality.

Furthermore, service providers identified some of the challenges which makes their work a little more difficult such as inadequate visual aids during education sessions for providers, inadequate nutrition reading materials and less emphasis given to nutrition by other RCH providers and the government.

In a study by conducted Dolatian et al., ⁷ on weight gain during pregnancy outlined the adverse effects of excessive weight gain during pregnancy in quoting “Gestational weight gains above and below recommendations have been shown to be associated with prenatal adverse outcomes, So that excessive weight gain during pregnancy is associated with poor neonatal outcomes like early asphyxia, birth injury and hypoglycemia, large-for-gestationalage infants, while inadequate weight gain is a major risk factor for adverse fetal/neonatal outcomes such as intrauterine growth restriction, preterm birth and low birth weight. In addition, according to the study of Davis, Stange and Horwitz ⁶, chronic stress leads to change biological behaviors, which is followed by an imbalance diet, excessive weight gain during pregnancy and postpartum obesity.

Therefore, understanding the relative contribution of each group of factors to the risk of excessive and inadequate gestational weight gain is important in identifying at-risk pregnant women and designing effective interventions.

In addition, in Tanzania a case study of Temeke district in Dar es Salaam revealed that about 54% of pregnant women were not satisfied with antenatal services provided at the surveyed clinics ²⁶. Reasons mentioned included, spending long hours at clinic, high costs of some services and inadequate number of service providers. This also was seen in this study where there was no enough RCH staff to attend to all pregnant women in a short time, hence, lead them to stay for long time at the clinic waiting for service especially in the clinic where there was high heavy flow of clients.

Maternal knowledge assessed in the study also shows that majority of women are aware of the relationship between nutrition and health pregnancy outcomes. This is a result of being constantly informed on nutritional issues at the health facilities during pregnancy although there is slight variations on the massages delivered o pregnant women at the clinics by various providers. Also the source of nutrition information that they most used was hospitals despite occasional nutrition education provision at these clinics unlike other sources like friends and relatives, reading books and journals related to nutrition during pregnancy as well as the use of mass media. The main topics identified were balanced diet, exclusive breast feeding, increase consumption of green vegetables and fruits, increasing frequency of meals and effects of under nutrition.

In previous study by Mosha, ²⁴ the study done in Morogoro, Tanzania. Shows that inadequacy of nutrition knowledge of the surveyed pregnant women might be contributed by several factors reported in the study. These included occasional provision of nutrition education during ANC visits, inadequate use of visual aids during education sessions by providers, inadequacy of nutrition reading materials and less emphasis given to nutrition by RCH providers and the government. Women also reported that, increased consumption of green vegetables and fruits, which were aimed at increasing maternal blood, were among the most emphasized topics as opposed to other topics.

The study shows that dietary consumption of pregnant women 24 hours prior to the survey mainly were grains, plantains, white roots and tubers (bananas, cassava, potatoes, and rice), followed by meat, poultry and fish where the least consumed food groups are nuts and seeds as well as the eggs. Vitamin A-rich vegetables and tubers such as carrots and tomatoes were consumed daily as were mostly added in other dishes such as meat/fish or any other stew prepared as a family meal. Fruits and green vegetables were frequently consumed by majority of women. High consumption of fruits and green vegetables could have been influenced by the nutrition education delivered to these women during ANC visits. Also, the Tanzania focused antenatal care guidelines put more emphasize on the increased consumption of fruits and vegetables by pregnant women ⁹

Also, the study found that all women involved in the study were not consuming tea/coffee/Pepsi/coke drinks with food. This is because they have been discouraged during the nutrition sessions where they were told about the effects on absorption of some minerals such as Iron, whereby some of them were associated poor pregnancy outcomes like miscarriage and abortion. Despite nutrition sessions being occasionally provided by the health provider’s women seems to have mastered what they have been taught as evidenced by the high consumption of fruits and vegetables.

According to Symonds & Ramsay ²³ Women’s nutrient needs increase during pregnancy and lactation. Some of the increased nutrient requirements protect maternal health while others affect birth outcome and infant health. If the requirements are not met, the consequences can be serious for women and their infants. During pregnancy all women need more food, a varied diet, and micronutrient supplements. When energy and other nutrient intake does not increase, the body’s own reserves are used, leaving a pregnant woman weakened. Energy needs increase in the second and particularly the third trimester of pregnancy. Pregnant women also require more protein, iron, iodine, vitamin A, folate, and other nutrients. Deficiencies of certain nutrients are associated with maternal complications and death, fetal and newborn death, birth defects, and decreased physical and mental potential of the child.

SPSS-Statistical Product for Service Solutions

ANC-Antenatal Care

PNC-Postnatal Care

WHO-World Health Organization

BMI-Body Mass Index

FEFO-Ferrous Sulphate and Folic Acid

IFA-Iron and Folic Acid

RCH-Reproductive and Child Health Clinic

IUGR-Intra-Uterine Growth Retardation

CAD-Coronary Artery Disease

HTN-Hypertension

NuPED-Nutrition during Pregnancy and Early Development

IU-International Unity

UK-United Kingdom

SUA-Sokoine University of Agriculture

FANC-Focused Ante Natal Care

RUTF-Ready to Use Food

HIV-Human Immunodeficiency Virus

AIDS-Acquire Immunodeficiency Syndrome

URT-United Republic of Tanzania

My name is ALEX GASPER MEELA, a BSc student in Human Nutrition from Sokoine University of Agriculture. I am conducting a research titled UTILIZATION OF NUTRITIONAL SERVICES FOR PREGNANT WOMEN AT HEALTH FACILITIES, IN

MOSHI URBAN TANZANIA. The purpose of this study is “To assess the extent of utilization of nutrition services provided in health facilities among pregnant women in Moshi- Urban Tanzania”.

I kindly request your cooperation and assistance in obtaining your responses to questions that I will ask you. All information that will be collected about you will be kept confidential and any information that will have your name, your name will be removed and replaced with a number so that you cannot be identified.

SECTION A. Demographic Information

AgeYears.

Marital status?

1. Single2. Married3. Divorced/separated

Educational level

1. Primary2. Secondary 3. Certificate 4. Diploma5. Graduate/ degree

Occupation category.

1. Nurse Officer2. Assistant Nurse Officer3. Nurse Midwife4.Public Health Nurse

SECTION B. Timing and Delivery of Nutritional Services

How long have you been providing RCH services?Years.

Have you received any basic training on focused ANC?

Yes2. No.

What is the main source of information for your nutrition knowledge?

1. Mass media (radio, television)2. Nursing school syllabus3.Nutrition trainings in work4. Others specify………………………..

In past five years, have you attended any nutrition training/seminar/short course?

Yes 2. No

Which nutritional services are being provided or given to pregnant women at this facility?

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What nutrition problems are common among pregnant women attending this facility?

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When do the majority of pregnant women start attending ANC for the first time (indicate the month after each response).

1. First trimester2. Second trimester3. Third trimester

Do you use specific guideline in the delivery of nutrition education?

Yes 2. No

If YES, which one of these?

1. Job aids2. Counselling cards 3. Leaflets and brochures4. Others,

specify……..….....................

If NO, how do you deliver the nutrition education to pregnant women?

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What techniques do you use to deliver nutrition information to mothers?

1. Group education2. One to one counseling3. Both.

Do information about the risks of using tobacco, alcohol, illicit drugs provided to pregnant women?

Yes 2. No

How do you assess nutrition status of pregnant women?

1. Dietary assessment 2. Biochemical assessment3. Anthropometric assessment 4. Clinical assessment

What advice most common given pregnant women on their overall nutrition status?

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Do you think providing adequate, correct and timely nutrition education to pregnant women will reduce the problem of maternal malnutrition?

Yes 2. No

Is there a service which is given more emphasis? 1. Yes2. No

If YES, which one(s) and why

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In your opinion, do you think the government gives priority to nutrition services at the RCH clinics?

Yes 2. No

If YES, how?

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If NOT, what do think could be the main reasons?

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My name is ALEX GASPER MEELA, a BSc student in Human Nutrition from Sokoine University of Agriculture. I am conducting a research titled UTILIZATION OF NUTRITIONALSERVICESFORPREGNANTWOMENATHEALTHFACILITIES,

IN MOSHI URBAN TANZANIA. The purpose of this study is “To assess the extent of utilization of nutrition services provided in health facilities among pregnant women in Moshi- Urban Tanzania”.

I kindly request your cooperation and assistance in obtaining your responses to questions that I will ask you. All information that will be collected about you will be kept confidential and any information that will have your name, your name will be removed and replaced with a number so that you cannot be identified.

SECTION A: Demographic Information

Ward.............................

Number of the respondent…………………

Age of mother(yrs.)

Marital status? 1. Married 2. Single 3. Divorced 4. Cohabit

Education level.

1. Some primary 2. Primary 3. Secondary4. University/college

Occupation of the mother?

1. Employed 2. Self-employed 3. Business 4. None

Parity....................................

Age of the youngest child..............................

Family size (including yourself)…………… Children................Adult..............

How old is your pregnancy?Months.

At what trimester did you start ANC visit? 1. First trimester (1 to 3months) 2. Second trimester (4 to 6months) 3. Third trimester (7 to 9months)

What services have you received up to today for this pregnancy from the clinic? 1. Fefo supplements 1=Yes 2=No 2. Nutrition Education 1=Yes 2=No 3. Weight and height measurements 1=Yes 2=No 4. Hemoglobin test 1=Yes 2=No

Do you think ANC services are important to pregnant women? 1=Yes 2=No

SECTION B: MATERNAL KNOWLEDGE AND ATTITUDE ON NUTRITION DURING PREGNANCY

What do you know about the diet of a pregnant woman?

1. Meal frequency per day2. Amount of fluids per day3. Nutrients required

Do you know the relationship between diet, maternal nutrition and birth outcomes? 1=Yes 2=No

What is your major source of nutrition information?

1. Hospital 2. Relatives and Friends 3. Mass media including social media 4. Journals and books

Is there any food/drink which is restricted to be used during pregnancy? 1=Yes 2=No

If YES, please mention them.

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On your opinion, why do you think these foods/ drinks are restricted to be used during pregnancy?

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Do you think nutrition requirements are the same or differ throughout pregnancy?

1. Same 2. Different3. Don’t know

Do you think the nutrition knowledge you are receiving from RCH clinics is enough for you to improve your nutrition status? 1. Yes2. No

SECTION C: AVAILABILITY, ACCESSIBILITY AND CHALLENGES OF NUTRITIONAL SERVICES

Do RCH providers usually offer nutrition education during ANC? 1. Always 2. Occasionally 3. Not at all

How is nutrition education provided at the ANC? 1. Group education 2. One to one 3. Others specify………………………

What nutrition issues/topics are taught during ANC? Please mention.

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During nutrition education sessions, are some foods emphasized more than others?

1. Yes2. No

If YES, which foods are more emphasized than others and why?

Are you normally given reading materials to read at home? 1. Yes2. No

If YES, the materials related to what issues? 1=Food types2=Nutrition/diet for pregnant women3=Drinks during pregnancy4=All the above

Do the providers give you opportunity to discuss your concerns? 1=Yes 2=No

Do you usually practice dietary advice given to you? 1. Yes2. No

If NOT, what hinders you from practicing what you are advised?

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SECTION D: DIETARY DIVERSITY OF PREGNANT WOMEN

This section is about your dietary diversity, and I will ask you to please describe the type of foods (Meals and snacks or bites) that has been consumed in the past 24hours (day and night)

PART A: 24 HOUR FOOD RECALL

PART B: CHECKLIST FOR FOOD GROUPS CONSUMED BY PREGNANT WOMEN