IJPHCS International Journal of Public Health and Clinical Sciences

Open Access: e-Journal e-ISSN: 2289-7577. Vol. 5:No.1

January/February 2018

KNOWLEDGE OF NUTRITION DURING PREGNANCY AND

ASSOCIATED FACTORS AMONG ANTENATAL MOTHERS

Lim Z.X.1, Wong J.L.2, Lim P.Y. 3, Soon L.K.1*

1
School of Health Sciences, Health Campus, University Sains Malaysia
2
Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Bandar Sungai
Long, Malaysia
3
Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia

*Corresponding author: Soon Lean Keng, School of Health Sciences, Health Campus,
Universiti Sains Malaysia
Email: soonlk@usm.my

ABSTRACT
Background: Nutritional requirement increases during pregnancy can influence the growth,
development, and health of the mother and her newborn child. Understanding the antenatal
mothers’ nutrition knowledge is essential to developing effective strategies to curb
malnutrition and encouraging healthier dietary behaviors. The aim of this study was to assess
the level and associated factors of nutritional knowledge during pregnancy among antenatal
mothers in a tertiary teaching hospital in northeast Malaysia.
Materials and Methods: A cross-sectional study was done on 88 randomly selected antenatal
mothers at the Obstetrics and Gynecology Clinic during their antenatal care visits. Data was
collected using a pretested self-administered questionnaire between December 2015 and
February 2016. The Kruskal-Wallis test was used to determine the association of selected
socio-demographic variables and obstetric data with nutritional knowledge score among
antenatal mothers.
Results: The mean age of the participants was 32.06 ± 5.56 years. More than half (63.6%) of
the antenatal mothers had good nutritional knowledge level. Higher occupational status
(p=0.030) and monthly household income (p=0.016) of participants were significantly
associated with higher nutritional knowledge score.
Conclusion: These findings highlight the current knowledge gap that exists in antenatal
mothers. It can be concluded that nutritional education ought to be intensified to address this
issue.
Keywords: Nutritional knowledge, antenatal mothers, pregnancy, Malaysia

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1.0 Introduction
Nutrition during pregnancy has a major impact on the outcome of pregnancy and accredited
as an important determinant for a healthy and successful pregnancy including the life-long
health of future generation (Adikari et al., 2016; Han et al., 2011; Bawadia et al., 2010;
McDonald et al., 2010). Though nutrition is the intake of food necessary for optimal health,
several studies have revealed that inadequate maternal nutrition could lead to malnutrition
which causes poor pregnancy outcomes, such as fetal growth failure, low birth weight,
preterm birth, prenatal and infant mortality and morbidity (Abu-Saad & Fraser, 2010;
National Population Commission & ICF International, 2014). On the contrary, excessive
nutrition intake during pregnancy can lead to complications such as preeclampsia, gestational
diabetes, macrosomia, dystocia, and higher prevalence of cesarean section (Rocco et al.,
2005).
Knowledge on nutrition is a vital element to ensure positive pregnancy outcome and is the
integral to achieve healthy dietary behaviors and subsequently improves their diet quality
(Zalilah et al., 2008; Mugyia et al., 2016). Mitra et al. (2012) highlight the importance that
antenatal mothers could benefit through nutritional knowledge. Despite recommendations
nutrition intake (RNI) in Malaysia exist which aim to improve the nutritional status of
mothers and reduce the risks of adverse pregnancy outcomes, an increasing proportion of
antenatal mothers’ weight exceeded healthy range (Malaysian Dietary Guidelines, 2017). As
reported by the RNI, nutritional knowledge during pregnancy is necessary to ensure optimal
gestational weight gain and reduces complications, both of which are linked to positive birth
outcomes and contribute to mothers’ overall health. However, evidence revealed that
antenatal mothers during pregnancy do not always adopt these recommendations and the
reasons for this are poorly understood (Malaysian Dietary Guidelines, 2017). Research related
to maternal nutrition knowledge are not abundant in the local context. Despite maternal
nutrition during pregnancy is crucial in reducing maternal mortality and infant mortality
which are the target area in achieving the Millennium Development Goal in Malaysia, a
dearth of study has been conducted to assess the level and associated factors of nutritional
knowledge during pregnancy among antenatal mothers. It is thus important to investigate this
issue. This paper reports a study that sought to fill this gap in knowledge and share it at the
national, regional and international level to contribute to the evidence base for informing
future antenatal care when dealing with maternal nutritional knowledge.

2.0 Materials and Methods

A cross-sectional study was carried out between December 2016 and February 2017. The
study population constituted randomly selected antenatal mothers aged 18 years old and
above, with varying gestational ages receiving antenatal care at the Obstetrics and
Gynecology Clinic, Hospital Universiti Sains Malaysia, Kelantan. Simple random sampling
was undertaken using the Microsoft Excel software to recruit eligible study participants.
The calculated sample size required for this study was 88 participants. Several parameters
were used for sample size calculation, and the highest estimated sample size was chosen to
maximize the required sample size. A simple mean formula, = (1.96 x / )2 was used to
calculate the selected sample size, with standard deviation ( ) of 3.4 and effect size ( ) of
0.75 referred from Mitra et al.’s (2012) study. A 10% dropout rate ( /
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) was considered in the sample size calculation to anticipate participants who

will not respond to the distributed questionnaires.
Data was collected using a self-administered questionnaire, comprised of two parts, which has
been tested for validity and reliability (Cronbach α knowledge = 0.819). Part I consists of
questions related to socio-demographic, obstetrics and medical questions. Part II consist of 15
knowledge indicators used to evaluate the antenatal mothers’ nutritional knowledge during
pregnancy, assessed using a dichotomous response of ‘Yes’ or ‘No’. A score of 1 was given
for correct answer and 0 for the wrong answer. For Part II, they were scored on a scale
ranging from 0 to 15 after analyzing their knowledge. The knowledge scores were categorized
as good (≥75%), moderate (51% to 74%) and poor (≤50%) as suggested by the Technical
Working Group on Research Ministry of Health, Malaysia (Norimah et al., 2008).
The study was approved by the participating hospital and local institutional ethics committee
(USM/JEPeM 16110462) and performed in accordance with the ethical standards of the
Declaration of Helsinki. Participants who met the research inclusion criteria were given
information about the research, and participation was voluntary.
Statistical analyses were conducted using the Statistical Package Social Sciences (SPSS)
software version 24. Descriptive analyses were performed, and the mean and its standard
deviation were reported for numerical variables. For categorical variables, the frequency and
its percentage were reported. Normality distributions were checked for numerical variables.
The Kruskal-Wallis test was used to determine the association of selected socio-demographic
variables and obstetric data with nutritional knowledge score among antenatal mothers. The
level of significance was set at P-value < 0.05.

3.0 Results

3.1 Participants’ demographic characteristics

Table 1 summarizes the socio-demographic characteristics of 88 study participants. The mean
age of the participants was 32.06 ±5.56 years. The majority were Malay ethnicity (96.6%),
employed (58%), had monthly household income RM1500 and less (37.5%), multigravida
(80.7%), parity two and above (70.5%), and had university education level (44.3%). The
mean gestational week was 29.23 (8.17). Sixty-two (70.5%) had parity two and above.
Amongst the participants, forty-one (46.6%) were classified as normal BMI pre-pregnancy,
nineteen (21.6%) as overweight, sixteen (18.2%) as obese, and twelve (13.6%) as
underweight. More than three-quarter of antenatal mothers (95.5%) had received information
of maternal nutrition during pregnancy. Out of 88 of the total participants, 24.4% received the
sources of information from the doctor, 24% from nurses, 23.3% were mass media, 14.3%
from friends, 13.2% from family members, and 0.8% were others.

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Table 1: Participants’ socio-demographic characteristics, obstetrics and medical data (n=88)

Variables n (%) Mean (SDa)

Age (Years) - 32.06 (5.56)
18 – 24 5 (5.7)
25 – 29 25 (28.4)
30 – 34 31 (35.2)
35 and above 27 (30.7)
Ethnicity -
Malay 85 (96.6)
Chinese 2 (2.3)
Others 1 (1.1)
Highest education level -
Primary 1 (1.1)
Secondary 34 (38.6)
College 14 (15.9)
Tertiary 39 (44.3)
Occupation -
Housewife 33 (37.5)
Self-employed 4 (4.5)
Employed 51 (58.0)
Monthly household income (RM) -
≤ RM 1500 33 (37.5)
RM 1501 - 3500 30 (34.1)
> RM 3500 25 (28.4)
Gestational week - 29.23 (8.17)
First trimester (1 – 12) weeks 2 (2.3)
Second trimester (13 – 27) weeks 31 (35.2)
Third trimester (28 – 40) weeks 55 (62.5)
Number of pregnancies -
Primigravida 17 (19.3)
Multigravida 71 (80.7)
Parity -
0-1 26 (29.5)
>2 62 (70.5)
Pre-pregnancy BMI (kg/m2) - 24.30 (5.51)
Underweight (<18.5) 12 (13.6)
Normal weight (18.5 – 24.9) 41 (46.6)
Overweight (25.0 – 29.9) 19 (21.6)
Obese (≥ 30.0) 16 (18.2)

3.2 Knowledge of antenatal mothers on maternal nutrition during pregnancy

Knowledge was measured using 15 question about nutrition during pregnancy. The answers
to all questions were a dichotomous answer of 'Yes' or 'No'. The mean knowledge score of the
total sample was 11.8 (1.74), indicating 78.6% correct responses. More than half of

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participants (63.6%) had good knowledge level, 28 (31.8%) had moderate knowledge level,
and only 4 (4.5%) had poor knowledge level (Table 2).
Table 2: Knowledge on maternal nutrition during pregnancy of participants (n=88)
Yes No
No. Statement n (%) n (%)
1. A balanced diet is important during pregnancy 83 (94.3) 5 (5.7)
2. Women nutrition during pregnancy is different from 83 (94.3) 5 (5.7)
others
3. Iron is a source of vitamin 80 (90.9) 8 (9.1)
4. The daily recommended intake of iron for a woman 61 (69.3) 27 (30.7)
during pregnancy is 27 mg
5. The daily recommended intake of protein for a 67 (76.1) 21 (23.9)
woman during pregnancy is 25g
6. During pregnancy, a woman needs more folic acid 84 (95.5) 4 (4.5)
and iron than a woman who is not pregnant
7. A pregnant woman must have at least 600 µg of folic 65 (73.9) 23 (26.1)
acid from daily diet
8. Women should get 1000 mg of calcium daily during 65 (73.9) 23 (26.1)
pregnancy
9. Omega-3 and Omega-6 fatty acids are essential for 83 (94.3) 5 (5.7)
brain and retina development of fetus
10. Nutrients deficiency during pregnancy could affect 86 (97.7) 2 (2.3)
health status of mothers and baby
11. If woman was a normal weight before pregnancy, she 55 (62.5) 33 (37.5)
should gain weight between 11.5 kg and 16.0 kg
during pregnancy
12. Body mass index (BMI) of less than 18.5 kg/m2 is a 33 (37.5) 55 (62.5)
suitable weight during pregnancy
13. Additional energy needs should be tailored based on 76 (86.4) 12 (13.6)
the woman’s BMI before pregnancy
14. Underweight mother can affect fetal well-being and 82 (93.2) 6 (6.8)
growth
15. Obese women are at an increased risk of several 85 (96.6) 3 (3.4)
pregnancy problems

Table 3: Knowledge level on maternal nutrition during pregnancy of participants (n=88)

Knowledge Level Frequency (%) Mean (SD)

- 11.80 (1.74)
Good 56 (63.6) -
Moderate 28 (31.8) -
Poor 4 (4.5) -

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Table 3 shows the frequency, percentage, mean and standard deviation of maternal nutrition
knowledge level among antenatal mothers in the study. More than half of participants 56
(63.6%) had good knowledge level, 28 (31.8%) of them had moderate knowledge level, and
only 4 (4.5%) had poor knowledge level. Mean (SD) of nutritional knowledge score was
11.80 (1.74), indicating 78.6% correct responses.
3.3 Association of socio-demographic characteristics and obstetrics data with knowledge
score of participants on maternal nutrition during pregnancy
Table 4 describes the association of socio-demographic characteristics and obstetrics data
with nutritional knowledge score of the 88 antenatal mothers who participated in the study.
Occupation (p=0.030) and monthly household income (p=0.016) were significantly associated
with nutritional knowledge score. The median of nutritional knowledge score among antenatal
mothers with 3 types of occupational status was significantly different. Employed antenatal
mothers have significantly higher nutritional knowledge score (Median: 13, IQR: 2) compared
to a housewife (12, 2, p=0.036), and self-employed (13, 4, p=1.776). Post hoc analysis with
Bonferroni’s correction was done by multiplying p-value with 3 pairs of group comparison,
housewife and self-employed (p=0.534), housewife and employed (p=0.036), self-employed
and employed (p=1.776). The score between housewives and employed antenatal mothers
was significantly different (p=0.036). Regarding the monthly household income, the median
nutritional knowledge score of participants was significantly different among 3 categories.
The monthly household income of participants that was > RM 3500 has a significantly higher
nutritional knowledge score (13, 1) compared to ≤ RM 1500 (11, 3, p=0.018), and RM 1501 –
3500 (13, 2, p=0.786). Post hoc analysis with Bonferroni’s correction were done by
multiplying p-value with 3 pairs of group comparison, ≤ RM 1500 and RM 1501 – 3500
(p=0.195), ≤ RM 1500 and > RM 3500 (p=0.018), RM 1501 – 3500 and > RM 3500
(p=0.786). It was found that the score among participants with monthly household income
between ≤ RM 1500 and > RM 3500 was significantly different (p=0.018).
Table 4: Association of socio-demographic characteristics and obstetric data with maternal
nutritional knowledge score

Variables n (%) Median Chi-square

p-valueb
(IQR) statistic (df)
Age 2.989 (3) 0.393
18 – 24 5 (5.68) 12 (2)
25 – 29 25 (28.41) 12 (4)
30 – 34 31 (35.23) 13 (2)
35 and above 27 (30.68) 12 (2)
Ethnicity 1.856 (2) 0.395
Malay 85 (96.59) 12 (2)
Chinese 2 (2.27) 11 (-)
Others 1 (1.14) -
Highest education level 7.052 (3) 0.070
Primary 1 (1.14) -
Secondary 34 (38.64) 12 (2)
College 14 (15.91) 13 (2)
Tertiary 39 (44.32) 13 (2)
Occupation 7.019 (2) 0.030*
Housewife 33 (37.50) 12 (2)
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Self-employed 4 (4.50) 13 (4)

Employed 51 (58.00) 13 (2)
Monthly household income (RM) 8.249 (2) 0.016*
≤ RM 1500 33 (37.50) 11 (3)
RM 1501 - 3500 30 (34.09) 13 (2)
> RM 3500 25 (28.41) 13 (1)
Gestational week 1.945 (2) 0.378
First trimester 2 (2.27) -
Second trimester 31 (35.23) 12 (2)
Third trimester 55 (62.50) 12 (2)
Pre-pregnancy BMI 5.328 (3) 0.149
Underweight 12 (13.64) 13 (2)
Normal weight 41 (46.59) 12 (2)
Overweight 19 (21.59) 12 (2)
Obese 16 (18.18) 11 (4)
b
Kruskal-Wallis test
* Level of significant at p < 0.05

4.0 Discussion
The findings of this survey of 88 Malaysian antenatal mothers provides new and valuable
insight into the nutritional knowledge during pregnancy. The majority of the antenatal
mothers were aged 30 and above (65.9%) and were Malay (96.6%), which is the predominant
race group on the northeast coast of Peninsular Malaysia. As for the participants’
employment status, nearly two-thirds of the participants were working mothers (62.5%), and
having an education level up to tertiary education (60.2%). Our study results illustrated that
there was a significant association between occupation and nutritional knowledge score
among antenatal mothers. More than half of the employed antenatal mothers had better
nutritional knowledge as compared to non-employed mothers. This finding matches those
observed in Mitra et al.’s (2012) study in Malaysia which showed that antenatal mothers with
better nutritional knowledge levels are significantly higher in occupational status. There are
several possible explanations for this finding. Employed mothers may have better access to
internet, books, and magazines as a source of information (Mitra et al., 2012) as well as
opportunity to share their experiences with others in the workplace compared to housewives
(El-Nagar et al., 2010).
Our study revealed that there was a significant association between monthly household
income and nutritional knowledge score among antenatal mothers. These findings match
those observed in earlier studies (Zahara et al., 2014; Zhang et al., 2009). This also accords
with See, Tey, Fauziah, and Soon (2015), who suggested that monthly household income may
exhibit a positive effect on increasing antenatal mothers’ knowledge during pregnancy. This
finding may explain by the supposition that cost may be a barrier to attending antenatal
follow-up visits among antenatal mothers from lower socioeconomic status. The challenge of
cost for them was their inability to attend antenatal care, thus may contribute to low maternal
nutrition knowledge as their opportunities to receive complete nutritional information are
reduced.

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Educational level was one of the important predicting factors for nutritional
knowledge among antenatal mothers and explained that antenatal mothers with a good
education was associated with higher nutritional knowledge and enhanced their understanding
of information disseminated by mass media (Burchi, 2010; Daba et al., 2013; Mitra et al.,
2012). A similar study conducted in Malaysia also demonstrated that antenatal mothers with
higher education level may have learned more and had a better understanding when being
exposed to nutrition education (Zahara et al., 2014). However, our present results did not find
any association between highest education level and nutritional knowledge score among
antenatal mothers. This highlighted that the ongoing efforts of antenatal health care providers
in delivering nutritional information to antenatal mothers regardless of their education level
greatly improved their nutritional knowledge.
More than half (63.6%) of the antenatal mothers had good knowledge of the
importance of good maternal nutrition before and during pregnancy, which is in line with
studies by Zahara et al. (2014), Daba et al. (2013) and Mitra et al. (2012). This finding is in
agreement with that of Kever et al. (2015) on the knowledge of antenatal mothers towards
dietary practices in Nigeria, where 65.31% of the participants showed good knowledge about
dietary practices during pregnancy despite the high level of illiteracy among the participants.
However, another study reported from Egypt at El-Menshawy Hospital showed that about
half of the childbearing women did not have enough knowledge regarding the meaning, the
importance, and the constituents of a well-balanced diet (Fouda et al., 2012). The possible
explanation that educational background of the study participants could be the reason for the
good level of nutritional knowledge demonstrated in this present study as almost all (98.8%)
of them had at least secondary education. However, the current study differs from Fouda et al.
(2012), where 16.1% of the antenatal mothers had primary education. This probably explains
that antenatal mothers were educated in the study, and possess the ability to perceive, gaining
knowledge and understanding of maternal nutrition. Our findings had provided an insight into
the importance of education on nutritional information among antenatal mothers.
The present study revealed that there was no association between a gestational week
and nutritional knowledge score among antenatal mothers, which is parallel with study in
Western Kenya that reported gestational age was negatively associated with health knowledge
score (Perumal et al., 2013). However, our finding contradicts the findings from Zahara et al.
(2014) which revealed that nutritional knowledge score among Malay antenatal mothers
improved as the gestational week increased. The probable reason for the discrepancy may be
due to differences among study sample size as nearly all of the participants in the present
study (97.7%) were in the second trimester and above, which slightly higher than that of
participants (82.2%) in Zahara et al.’s (2014) study.
The result of this study revealed that antenatal mothers with higher pre-pregnancy
BMI shown no association towards their nutritional knowledge score. Similarly, a study in the
United Kingdom on food intake and nutrition knowledge in severely obese antenatal women
reported that the study participants had lower scores in general nutrition knowledge (Mohd-
Shukri et al., 2011). This similarity could be justified by the fact that overweight and obese
antenatal mothers may not receive any advice for weight gain during pregnancy from
healthcare professionals, which is supported by findings in Tovar et al.’s (2010) study.
Adequate nutrition during pregnancy is the most important aspect of the antenatal mother’s

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life. During pregnancy, nutrition has impacts on the mothers’ quality of life, as well as on her
newborn’s well-being after delivery, and consequently her family members and community
(Payghan et al., 2014). Notably, a similar study done by Mitra et al. (2012) concluded that the
level of nutritional knowledge was satisfactory and suggested frequent continuing education
for the pregnant mother.
Our study revealed that there was no association between age and nutritional
knowledge score among antenatal mothers. This interpretation differs from that of Daba et al.
(2013) who found that age had a strong statistical association with nutritional knowledge of
mothers during pregnancy in a bivariate analysis. The older maternal age in the present study
did not increase the nutritional knowledge during pregnancy, this may suggest that the
availability of nutritional information could be easily obtained from different resources such
as mass media.
As for the participants’ monthly household income, most of them (38.9%) was in the
middle-income category while another 37.5% were in the low-income category, leading to the
presence of food insecurity which subsequently affects the nutritional food intake among
antenatal mothers. Regarding the obstetric data, nearly two third of the antenatal mothers
(62.5%) were in the third trimester, with mean 29.23 (8.17) week, and most of them (80.7%)
were in second or more pregnancy. The present study revealed that majority of the antenatal
mothers (70.5%) had delivered fetus more than twice and 46.6% of them were within the
normal weight, slightly lower compared to a study by Loy, Marhazlina, and Hamid (2013) in
the same targeted area. These differences could be due to the different study sample recruited.
Moreover, only a quarter of participants has been diagnosed with a medical history of
associated disease before pregnancy.
The current study found that doctor, nurse and mass media played a major role in
delivering information regarding maternal nutrition during pregnancy. This result may be
explained by the fact that doctors and nurses are healthcare professionals have frequent
contact with antenatal mothers during their antenatal check-up. It is somewhat surprising that
antenatal mothers rarely obtained information from the dietitian but from friends and family
members. For this reason, it seems possible that the lack of role of the dietician may be
explained that nutrition information was accessible for antenatal mothers with a medical
condition who require the specialized intake of food sources.
Nutrition during pregnancy is a well-known factor that could affect both fetus and
mothers. It is essential to ensure fetal development which could affect the well-being of
newborn after delivery. Hence, making them more susceptible to nutritional deficiency during
the gestational period due to their dietary behaviors influenced by nutritional knowledge
(Adikari et al, 2016; Han et al., 2011; Bawadia et al., 2010; McDonald et al., 2010).
Potential generalizability of the findings was increased by random selection of antenatal
mothers for participation in the study. The questionnaire was considered valid and reliable for
investigating the antenatal mothers’ knowledge on maternal nutrition during pregnancy. This
study was limited to one tertiary teaching hospital in Northeast Peninsular Malaysia.
Therefore, this study’s findings may not reflect the knowledge of antenatal mothers in other
settings or regions in Malaysia (for example those in West Coast Malaysia and East
Malaysia).

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5.0 Conclusion and recommendation

In conclusion, the knowledge level of these antenatal mothers about nutrition during
pregnancy was inadequate. Therefore, nutritional education ought to be intensified to
empower antenatal mothers to understand the importance of nutrition in pregnancy, a vital
determinant for optimal maternal and infant health outcomes. The current study revealed that
the associated factors such as occupation and monthly household income of antenatal mothers
may influence the individual mother’s nutritional habits during pregnancy. Realizing this
association, future research in this area may help health policies to investigate to what extent
these factors influenced antenatal mothers’ behaviour.

Acknowledgements
The authors wish to thank the antenatal mothers who took part in this study for being
generous with their time.

Declaration
Author(s) declare that the information above is correct and the manuscript submitted by us is
original. We have no conflict of interest to declare and certify that no funding has been
received for the conduct of this study and preparation of this manuscript.

Author(s) contribution
Author 1: Idea and concept, literature search, conduct the study, analyzing and writing the
draft
Author 2: Writing draft and reviewing
Author 3: Idea and concept, data analysis and interpretation, and reviewing
Author 4: Idea and concept, data analysis and interpretation, reviewing and editing the article

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