Effect of Nutrition Education and Counseling Intervention on the Dietary Diversity Practice of Pregnant Women in Ethiopia: A systematic Review and Meta-analysis

Present Address:

GizawSisay1,2✉Phone+251 91 158 0679Emailgizsisay@gmail.com

MahletBirhan1,2

TsionMulatTebeje1,2

1Department of Public Health, College of Medicine and Health ScienceDilla UniversityDillaEthiopia

2Department of Human Nutrition, College of Medicine and Health ScienceDilla UniversityDillaEthiopia

Authors Name: Gizaw Sisay^1*, Mahlet Birhan² and Tsion Mulat Tebeje¹

Author affiliations¹: Department of Public Health, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia

Author affiliations²: Department of Human Nutrition, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia

^*Correspondence: Gizaw Sisay, Tel: +251 91 158 0679, E-mail: gizsisay@gmail.com

Abstract

Background

A diversified diet plays a crucial role in in determining pregnancy outcomes and the future health of the child. In Ethiopia, inadequate dietary diversity among pregnant women remains a significant public health concern, contributing to maternal undernutrition, low birth weight, and poor infant development. Nutritional education and counseling intervention during pregnancy are the best strategies to improve dietary diversity practice of the pregnant women.

Objective

This systematic review and meta-analysis aimed to estimating the pooled effects of nutrition education and counseling intervention on the pregnant women dietary diversity practice in Ethiopia.

Methods

The relevant studies searched from distinct databases such as (PubMed, African journals online, Google scholar, web of science and the institutional repository of Ethiopian universities were used. Data were extracted using Microsoft Excel, and analysis was performed using STATA-17. A random-effects model was used to estimate the overall effect size of nutritional education and counseling intervention on the dietary diversity practice of pregnant women. The pooled effect size was expressed as risk ratio (RR) with a 95% CI.

$\:{I}^{2}$

-test statistics was used for assessing heterogeneity between included studies. Egger's test and funnel plot were used for assessing publication bias.

Results

A total of nine peer-reviewed studies that met the inclusion criteria with a total of 3739 pregnant women were involved in this study. The pooled effect of nutritional education and counseling intervention was RR: 1.78 with 95% CI (1.44, 2.18). There was a high heterogeneity (

$\:{I}^{2}$

= 91.1%) was observed between includes studies.

Conclusions

Nutrition education during pregnancy have a positive effect in improving dietary diversity practice of pregnant women. Therefore, we recommend that health care providers and stakeholders offer nutrition education and counseling alongside routine services for pregnant women, ensuring they are equipped with essential knowledge about healthy dietary behaviors during pregnancy.

Registered on the PROSPERO database (CRD42025106769)

Key words:

Nutrition education

dietary diversity

pregnant women

meta-analysis

Ethiopia

Background

An unbalanced diet during pregnancy has a significant contribution for maternal morbidity and mortality, unfavorable birth outcomes, and an elevated risk of chronic disease later in life [1, 2].

According to a report by UNICEF, about 25% of pregnant women worldwide are undernourished, with the highest rates found in crisis countries such as those with conflicts or natural disasters [3]. In Africa, 23.5% of pregnant women are malnourished, and in sub-Saharan Africa, nearly 68% of rural pregnant women are malnourished [4]. In Ethiopia, 32% of pregnant women experienced the burden of under nutrition [5], and maternal undernutrition accounts for more than half of newborn and child fatalities [6].

Worldwide, 25% of pregnant women were exposed for malnutrition. The consumption of fruit and vegetables (FV) is recommended as part of a balanced diet. However, intake during pregnancy is often below the recommended amounts worldwide. [7].

Sustainable Development Goal (SDG) aims to eliminate all types of malnutrition and meet the nutritional requirements of pregnant women by the year 2030. The World Health Assembly has set a goal to reduce pregnancy-related anemia by 50% by 2025, which is linked to maternal nutritional diet [8]. Thus, evaluating the pooled effect of nutrition education and counseling intervention for the improvement of dietary diversity could help to generate comprehensive evidence for policy and for decision making process.

In Ethiopia, the dietary food consumption of pregnant women is inadequate in both quantity and quality, characterized by low energy and nutrient content, with percentages ranging from 12.8% to 74.5%. [9, 10]. The primary cause of this inadequate nutritional food consumption is the lack of awareness among pregnant women regarding their dietary requirements [9].

Nutrition education and counseling interventions are effective strategies to improve dietary diversity practices for the better health outcomes of pregnant wome [11]. Nutrition education is critical in nutrition behavior change attempts because it improves participants’ nutrition and food literacy. Food literacy encompasses both nutrition literacy and the capacity to apply that knowledge to make sound decisions, whereas nutritional literacy is the set of skills required to comprehend and analyze information about food and its nutrients [12].

WHO suggests that ANC providers offer adequate, specific, and acceptable nutrition education to ANC followers during each visit health care facilities, aiming to enhance the dietary practices of pregnant women [13]. The Ethiopian government also recommends nutrition counseling throughout pregnancy [9]. However, the routine nutritional counseling service in providing quality nutrition education is ineffective in changing the behavior of pregnant women [10].

Even though there are small-scale studies, there is no a comprehensive systematic review and meta-analysis investigating the effect of nutrition education intervention on the dietary diversity practice of pregnant women in Ethiopia. Therefore, this study aimed to review the existing evidence to determine the pooled estimate of the effect of nutrition education intervention on the improvement of dietary diversity practice among pregnant women in Ethiopia. The result of this review and meta-analysis could help to provide comprehensive evidence for policy makers, for planners and for program evaluators.

Methods

Protocol registration and reporting

This review was conducted according to the protocol that has been registered at PROSPERO. The results of this systematic review and meta-analysis were reported based on the PRISMA reporting guideline to ensure transparent and complete reporting in review processes [14]. During the review, a wide range of databases were searched using electronic databases, reference lists of included studies, and cross-referencing to minimize the omission of relevant studies.

Search Strategy: This review use relevant studies searched from international electronic databases such as PubMed, Scopus, Cochrane Library, Web of Science, Google Scholar and Hinari. Moreover, open google and the reference lists of eligible articles were search to get additional studies. Eligible primary studies were accessed using the following key words, searching terms, and Medical Subject Headings: “effect of nutrition education and counseling”[MeSH Term] AND "Pregnant Women "[MeSH Term] AND "dietary diversity "[MeSH Term] AND “Random”[MeSH Terms] OR “Randomized ”[MeSH Term] OR “Randomized Controlled trial” [Text word] AND ”"Ethiopia". The keywords and searching terms were connected by “AND” / “OR” Boolean operators to retrieve appropriate and sufficient search results.

Eligibility Criteria

The eligibility criteria of the included studies were defined based on the PICOS (participants, intervention, comparison, outcomes and study designs) framework. Two authors (GS and MB) were assigned to filter the studies based on their title, abstract and full-text. Arguments concerning the study eligibility solved by discussion with team members.

Inclusion and Exclusion Criteria

The authors includ studies conducted on the effects of nutritional education and counseling intervention on dietary diversity practice of pregnant women in Ethiopia. Studies conducted using randomized controlled trial and qusi-expermental studies were included in this review. Qualitative studies, case studies, crossectional studies and ongoing studies with insufficient PICOS information were excluded.

Risk of Bias (Quality) Assessment

The risk of bias assessment for the included studied perfomed using the revised Joanna Briggs Institute (JBI) quality-assessmen tool, specifically designed for randomized controlled trials (RCTs) and quasi-experimental studies [15]. The tool has 13 questions for RCTs and 9 questions for quasi-experimental studies.

Two reviewers (GS and MB) assessed the methodological quality of the included studies independently. Any disagreements and issues relating to the evaluation and classification of the articles were resolved by a third author. Finally, the studies were classed as low risk, medium risk, and high risk of bias based on the overall risk of bias evaluation.

Outcome Variable

This systematic review and meta-analysis primarily assessed the pooled effect of nutrition education and counselling intervention on pregnant women’s dietary diversity practice. Based on the included studies, dietary diversity practice of pregnant women was evaluated by asking women whether they had consumed various food items in the past 24 hours. Women who consumed five or more food groups in the previous day was categorized as having good dietary diversity practice, otherwise not.

Approachs of Nutrition Education

This review emphasizes the effect of nutrition education as an intervention aimed at enhancing the knowledge of pregnant women and promoting positive dietary behaviors among pregnant women. The contents of provided nutrition education includes identifying locally available nutritious food groups and the importance of a diverse diet during pregnancy for maternal and fetal health. These strategies highlight the significance of dietary changes during pregnancy, including increasing meal variety and frequency, as well as enhancing the intake of iron-rich foods during pregnancy.

Based on the included studies nutrition education mainly involves group sessions at health posts or community gatherings, direct (face-to-face) or indirect (eg, phone calls and video conferencing) teaching methods through interactive discussions with and without visual aids such as pictures, pamphlets, videos, etc, for certain periods. Nutrition education and counseling was given by an experienced health education and nutrition experts and delivered to the intervention group.

Data Extraction

Two reviewers (GS and MB) checked titles and abstracts of the studies based on the eligibility criteria. The first author's name, publication year, study region, study setting, sample size, and events in intervention and control groups were extracted using Microsoft Excel format.

Statistical Analysis

The extracted data were exported into STATA-17 for statistical analysis. The pooled estimate of nutritional education and counseling intervention on pregnant women’s dietary diversity practice were assessed by a random-effects model, and xpressed as risk ratio (RR) with a 95% confidence interval. The heterogeneity between the included studies was assessed using the Cochrane

$\:{I}^{2}$

statistics. The heterogeneity was handled by conducting subgroup and sensitivity analysis. The subgroup analysis were performed based on median sample size, study setting and region. Leave-one-out analysis was perform to identify small study effects on the pooled effect estimate. Publication bias was also assessed using the graphical (funnel plot) and statistical (Regression based egger’s) tests.

Results

The literature serarch results of the combined electronic databases yield a total of 326 articles. Of these, 258 duplicate articles were removed. Through rigorous navigation of titles and abstracts, 46 articles were not retrieved. About 22 articles were screened for full text article. Additionally, 55 studies were excluded since it is not conducted in Ethiopia, not randomized controlled trial and systemic review. Finally, nine studies were included for this review and meta-analysis (Fig. 1).

Fig. 1

PRISMA 2020 flow diagram describing the selection of studies for systematic review and meta-analysis.

Characteristics of Included articles

In this systematic review and meta-analysis, nine primary studies with randomized controlled trial and quasi-expermental study designs were used to estimate pool effect of nutrition education and counseling intervention on dietary diversity practice of pregnant women. A total of 3944 study participants ((intervention group = 2012, control group = 1962) were involved with the smallest sample size (138) from Amhara region and largest sample size (744) from Oromia region. Four studies were conducted from Oromia region, two studies from Amhara region, one study from southern Ethiopia and two studies were conducted in Adiss Ababa city administration (Table 1).

Table 1 shows a descriptive summary the studies included in this systematic review and meta-analysis.

Authors, publication year	Region	Study Setting	Study design	Sample size	Event in Intervention	Event in Control	Reported Outcomes
Beressa G., et al 2024 [16]	Oromia	CB	RCT	447	101/204	69/223	The proportion of adequate DD was 14.15% higher in the intervention compared to the control group (45.09% versus 30.94%).
Demilew Y., et al. 2020 [17]	Amhara	CB	RCT	645	175/313	66/332	In the intervention group, DDS improved by 24.6%, where as in the control group, it showed a 15.9% reduction, with an overall difference of 40.5%.
Diddana T.,2018 et al 2014 [18]	Amhara	CB	RCT	138	58/69	50/69	Intervention group had 84.1% good dietary practice versus 72.5% in control group. this is statistically significance difference improvement (P < 0.001)
Gebremichael, M. et al. 2023[19]	Oromia	CB	RCT	744	233/372	144/372	The proportion of pregnant women with optimal dietary practices increased by 34.7% in the intervention group, and this is a significant difference (p < .001)
Mohammedsanni et al. 2018 [20]	AA	IB	RCT	500	243/260	150/240	Women who received NEC had a significant improvement on dietary diversity (consumption of ≥ = 5 food groups)
Sisay et al, 2023[21]	SE	IB	RCT	235	64/115	83/120	The intervention group showed significant improvements in dietary practices.
Tesfaye A., et al. 2025 [22]	Oromia	CB	RCT	426	87/207	35/219	Pregnant adolescents who had NEC, the dietary practices increased by 20.3%. However, pregnant adolescents in the control group, the dietary practices decreased by 5.6%.
Tsegaye D., et al 2022 [23]	Oromia	CB	QE	403	102/207	68/196	Pregnant women who received NEC had higher dietary diversity scores compared with women in the control group.
Zelalem A., et al 2017 [24]	AA	IB	QE	406	340/406	190/406	Dietary practice of pregnant women after NEC increased from 46.8% to control group 83.7%. But The study didn’t show a significant effect on increased.

Abbreviations: AA: Addis Ababa; CB: community based; IB: institutional based; RCT: randomized controlled trial; RR: risk ratio; QE: quasi experimental; NEC: Nutrition education and counseling

Table 2
Sub-group analysis for the pooled effect of nutrition educationand counselinfg intervention on dietary diversity among pregnant mothers in Ethiopia.
Variables	Subgroup	No. of included studies	RR with (95% CI)	Heterogeneity across studies		Heterogeneity between group (p-value)
Variables	Subgroup	No. of included studies	RR with (95% CI)	$\:{I}^{2}$ (%)	P-value	Heterogeneity between group (p-value)
Region	AA	2	1.63(1.37, 1.95)	81.2	0.02	0.544
	Amhara	2	1.33(0.99, 1.79)	70.3	0.06
	Oromia	4	1.56(1.15, 2.12)	87.0	0.001
	S/Ethiopia	1	1.80(1.32, 2.47)	00	0.00
Study Setting	CB	6	1.48(1.19, 1.83)	83.0	0.001	0.379
Study Setting	IB	3	1.66(1.44, 1.91)	65.2	0.057	0.379
sample size	138–426	5	1.56 (1.17, 2.09)	90.1	0.001	0.880
sample size	447–744	4	1.53(1.42, 1.65)	00.0	0.820	0.880

Risk of bias Assessment

The risk of bias for included studies was assessed using revised Joanna Briggs Institute (JBI) quality-assessmen tool, specifically designed for randomized controlled trials (RCTs) and quasi-experimental. Based on this tool, six studies were assessed as having a high quality and three studies had medium quality.

Pooled Effect of Guided Nutritional education and Counselling

Seven randomized control trials and two qusi-expermental studies were included to estimate the pooled effect of nutrition education and counseling intervention during pregnancy on the dietary diversity practice of pregnant women. Based on the random effects model, the pooled effect size was AOR: 1.54: 95% CI (1.34, 1.76), P-value = 0.001 with a high heterogeneity (

$\:{I}^{2}$

= 80.7%) (Fig. 2). The result of the pooled estimate declared, there is a strong association between guided nutrition education and counseling on woman’s dietary diversity practice during pregnancy. Women who received nutrition education and counseling during pregenancy were 1.54 times more likely to practice dietary diversity tham pregnanet women in the control group.

Fig. 2

Forest plot showing the pooled effect of NEC on dietary divercity practice of preganant women in Ethiopia.

Handling Heterogeneity

To evaluate the observed heterogeneity, subgroup and sensitivity analysis were conducted to identify the source of heterogeneity for the pooled effect of nutritional education and counseling intervention on dietary diversity practice during pregnancy. Subgroup analyses were carried out by region, study setting, and by median sample size. Studies done from Oromia region of Ethiopia showed that the effect of nutrition education and counseling intervention on dietary diversity practicee were statisticaly significant (RR = 1.56; 95% CI (1.15, 2.12) with p-value = 0.001. And there was a high heterogeneity among studies (

$\:{I}^{2}$

= 87.0%). However, studies done from other regions did not indicate a significant difference on the intervention effect.

Subgroup analysis based on the median sample size of studies showed that, dietary diversity of pregnant women in studies with sample size between 138–426 (RR = 1.56 with 95% CI (1.27, 2.09) were showed that significant difference on the intervention effect (

$\:{I}^{2}$

= 90.1 and p-value = 0.001). Similarly, in subgroup analysis by study setting, community based study settings were higher as compared to studies using institutional based studies. The highest pooled RR was observed among studies conducted in community based settings and lowest was observed among studies conducted in Amhara region RR = 1.33 wth 95% CI (0.99, 1.79). Subgroup analysis indicated that the effect of nutrition education on dietary diversitypractice of women during pregnancy did not significantly differenc based on pace of region, study setting and median sample size (Table 2).

Publication Bias

A leave-one-out sensitivity analysis was conducted and was declared that the absence of any influence of a single study on the overall effect estimate since the confidence intervals of all omitted studies contain the overall estimate effect size (Fig. 3).

Fig. 3

Sensitivity analysis of the effect of nutrition education and counseling intervention and 95% confidence limits.

There was a symmetrical funnel plot that showed the absences of publication bias (Fig. S1). And also, the egger regression test result (P-value: 0.0831) indicating no significant publication bias. Furthermore, the Galbraith plot showed that a favorable positive impact of nutrition education on the dietary diversity practice pregnant women. Three studies fell outside the 95% CI of the standardized log RR, indicating presence of potential heterogeneity or outlier studies. Estimating the overall effect after removing this studies, a slight change in the overall RR was observed, and it reduced the heterogeneity by 12.81% (RR = 1.59; 95% CI: (1.61, 1.98);

$\:{I}^{2}$

= 68.4%) (Fig. S2).

Discussion

Nutritional education and counseling interventions focused on maintaining diversified food diet and participating in physical activity have been recommended by the WHO for all pregnant women. Guided nutritional education and counseling interventipon is a widely used approach to enhance the dietary diversity of women during pregnanc [25]. This systematic review and meta-analysis evaluated the effect of nutrition education and counseling intervention on the dietary diversity practice of pregnant women in Ethiopia. The finding of theis review showed that pregnant women in the intervention group were 1.54 times more likely to practice dietary diversity (RR = 1.54: 95% CI (1.34, 1.76) as compared with women in the control group. This finding indicated that nutrition education and counseling intervention during pregenancy significantly improved the dietary diversity practice of pregnant women. This finding is inline with the study conducted in Pakistan [26], in Malawi [27], in Iran [28], and in BurkinaFaso [29]. The possible justification for this might be that nutrition health education and counseling can help women in understanding the importance of a varied diet during pregnancy and inspire continuous efforts to keep-up on a wide diet [30].

Similarly, this review report is supporeted by study coducted in Kenya. This might be because of nutritional education and counseling interventions are effective strategies to improve pregnant women's dietary practice and calorie intake, which helps enhance their nutritional diet [31].

The UNICEF report also supported the findings of this meta-analysis, indicating that nutrition education and counseling interventions during pregnancy can improve the intake of diverse foods for women and their families, empowering them to make informed decisions and take action to enhance women's dietary practice [8].

Ethiopian women often reduce their food intake during pregnancy, despite increasing nutritional needs with gestational age, due to the belief that increased nutrient consumption results in having a larger baby, which may lead to complications during delivery. Consequently, they tend to eat less while pregnant compared to their eating habits before pregnancy [32–35]. This is due to pregnant women’s difference in beliefs and understanding on the type and quantity of food groups required during pregnancy. The second possible justification might be the counseling practices of the routine health service provided during ANC follow-up and at the community level by health experts with a focus on the need for pregnant women to eat one additional meal from available foods. This usual counseling service fail to bring about behavioral change towards having good dietary practice during pregnancy [36].

World Health Assembly had target to reduce maternal under nutrition especially anemia and low birth weight through nutritional education and training. Additionally, nutritional counseling is help the pregnant women on focusing heathy diet eating that contain adequate energy, protein, mineral and vitamin [37]. All of these evidences were aligned with this systematic review and analysis report.

Limitation

This systematic review had moderate heterogeneity which may affect the interpretation of pooled estimates.

Study Implication

The result of this meta-analysis showed that nutritional education and counseling intervention had a significant effect on pregnant women’s dietary diversity practice than women got routine counselling service. This meta-analysis helps the policy makers and stakeholders to focus on guided and individual based nutrition education and counselling for pregnant women.

Conclusion and recommendations

This meta-analysis revealed the pooled estimate of nutrition education and counseling intervention is important to improve the dietary diversity practice of pregnant women than the routine counselling service. Thus, nutrition education and counseling interventions should be provided to pregnant women starting from in the first vist for ANC service.

Acknowledgements:

The authors would like to thank the authors of the studies included for this systematic review and meta-analysis.

Author Contributions:

GS: Conceptualization; formal analysis; methodology; validation; writing the original draft. MB: Conceptualization; methodology; validation; review & editing the manuscript. TM: Data curation; methodology; software; writing, review & editing the manuscript.

Ethical approval and consent to participate:

Not applicable; since we did not use primary data that needs ethical approval and consent to participate.

Conflicting Interests:

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding:

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Consent for publication:

Not applicable

Availability of data:

The datasets supporting the findings of this article are available in the manuscript or from the corresponding author upon request.

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