Over the centuries as indicated by many researchers, it has been vivid that healthy children are the foundation of a healthy population. A prerequisite for children to be healthy is a healthy dietary practice and care that should be started by all women of child bearing age before or during pregnancy [
To reinforce desirable attitudes, dietary behavior and positive infant and maternal outcomes among pregnant women, nutrition education and counseling has to be instituted correctly and it has to be achievable [
The effect of education is not a one-off impact that leads individuals into given contexts. The benefits of education are more dynamic. Nutrition education and counseling being one of the core preventive measures is basically concerned with improvement of social communication strategies that can bring long lasting behaviors affecting the knowledge and practice of pregnant women towards nutrition. An important point to be noted here is that the ultimate purpose of the education and counseling is behavioral change rather than just telling women what to consume and what not to consume [
The antenatal period is the period where pregnant women come into frequent contact with health professionals during their routine antenatal visits. Therefore, ANC providers be it the doctors or midwives hold the key in the promotion and introduction of positive dietary behaviors among pregnant women. As indicated in the research by Arrish et al., pregnant women have a good character of catching up to nutrition related information and this is a good quality where we all have to make good use of it. There is also an evidence from a study indicating that pregnant women who were educated and counseled introduced positive changes to their dietary behavior compared to those who were not [
Specifically health and nutrition education to improve and ensure regular consumption of foods rich in iron, folate and vitamin C and to reduce consumption of interfering substances has appeared to be a core strategy for the prevention and control of anemia [
However, the reality is far from the ideal situation. Studies done in United States and other western countries indicate that health providers are suffering from barriers like low knowledge and confidence level, lack of time, lack of incentives and lack of training in nutrition counseling [
In addition to the above statements, there are no available guidelines except for the focused antenatal care guideline which is general and does not specifically inform health professionals on how to approach pregnant women with regards to nutrition advice. The need for a guideline has also been addressed in study by Bareto Malta et al in 2012. In that study, the distribution of printed materials acted like a job aid in guiding the ANC providers in selecting and providing the most relevant information to pregnant women at each visit [
Single group pre-post quasi-experimental study design with pre-intervention, immediate post-intervention was employed in July of 2018 in Asmara, the capital city and largest settlement in Eritrea. According to the Municipality of Asmara, there are a total 114,640 households in the city and it is home to a population of around 416,367 people.
There are 18 health facilities in Asmara out of which 17 provide ANC service. Of these 3 are health centers, 3 are community hospitals and 11 are health stations. The community hospitals have a catchment population of around 50,000 and they provide service for more than 3 subzones. There are approximately 59 health care providers with exclusive ANC service in the facilities. Health assistants, comprehensive nurse midwives and nurse midwives who were working as ANC providers during the study period were the study population for this study.
Complete enumeration of the health professionals working in five randomly selected health facilities was undertaken for the study. There were 17 health professionals working in the selected health facilities and all were invited to participate in the study. Only one refused to do so. The health professionals were 5 from Godaif health station, 4 from Edaga Hamus community hospital, 3 from Semenawi Asmara health center, 2 from Bet Mekae community hospital and 2 from Geza Banda health station.
All health professionals providing ANC and willing to participate in the study were included in the study. Providers who were not working at the ANC during the study period (Due to rotation in the other units such as EPI, leave or training) were excluded from the study.
The intervention of this study was a health education program concerning nutrition during pregnancy prepared based on a training manual by the research team. A hand out was synthesized that the health professionals can use as a reference. A job aid and leaflet containing the core messages for every topic was developed that the health professionals can use as a memory aid. The prepared materials were reviewed by expertise for their appropriateness and adequacy. The teaching materials contained; an introductory messages regarding nutrition during pregnancy, hazards of maternal malnutrition on mother and fetus, sources of the main food groups and micronutrients. It also focused on important supplements to be taken during pregnancy, harmful substances to be avoided, gestational weight gain and GATHER (Greet, Ask, Tell, Help, Explain, Return) counseling skill.
The training program was carried out in the form of lecture using power point presentations, group discussion, case presentations, self-reading of hand outs and leaflets. The intervention was implemented in two sessions. The sessions were of 2 hours each accompanied by refreshment programs. The training was given by a qualified trainer (a midwife with a deep knowledge regarding nutrition during pregnancy) based on the prepared teaching materials. The education was given in the premises of Edaga Hamus Community Hospital.
The knowledge level of health professionals regarding nutrition was assessed at two times, prior to receiving the manual based training and immediately after the end of the training session. A questionnaire sheet for health professionals was adapted from an Ethiopian study done on the effect of nutrition education by health professionals on pregnancy specific nutrition knowledge and practice of pregnant women [
Phase I of the data collection from the health professionals (baseline assessment) using a questionnaire immediately before receiving training took place from July 23rd to July 25th. Phase II or post intervention data collection was done after the completion of the training. The quantitative data which is the knowledge questionnaire was administered via a face-to face interview method after the participants were informed briefly about the study and their written consents were obtained. Two professionals who have bachelor of science in nursing for data collection and one clinical nurse for the purpose of supervising the data collection period were trained for one day on the overall research objective and methodology, data collection tools, interviewing and recording skills in addition to strict instructions on consistency and completeness of the tool. To assess if the provider will give pregnancy specific messages related to nutrition and if he/she is counseling the participants with the appropriate skill, non-participatory observation method using an observational checklist that consisted of 17 questions was used. Non participatory observation took place from July 31st to August 9th. A total of 226 pregnant women were counseled as part of the study. During the non-participatory observation, the ANC providers’ practice of nutrition counseling was cross checked against the checklist components and recorded as “not done”, “partially done”, and “completely done” while providing nutrition education and counseling for two different ANC clients. The specific variables of the checklist were considered to be “completely done” if the ANC provider does it right in at least one client. Items were scored on a scale of three in which score 2 stood for ‘completely done’, 1 for ‘partially done’, and 0 stood for ‘not done’. Consequently, the possible range of the total score of the checklist was 0-34. Recruitment of participants, intervention and data collection was all done in the ANC settings of the health facilities.
The face and content validity of the data collection instruments was ensured as the tool was reviewed by nutrition experts from the MOH, clinical nurses and advisors from the college. Considering their suggestions and recommendations, the tool was modified and finalized to fit the local context.
The two outcome variables in this study were the knowledge level of health professionals at two different times on nutrition and their counseling skills after intervention. Composite scores of knowledge and counseling skills of each health professional was computed. The pregnancy specific nutrition education was the independent variable in this study. Co-variables on health professionals were age, sex, work experience, qualification, recent training on nutrition, self-reported level of confidence and monthly salary.
The goal of the statistical analysis for this study was to test the hypothesis. The cleaned data was coded and entered in to SPSS version 22.0 and was analyzed. Normality of the entered data was checked with Kolmogorov-Smirnov test and Fisher’s measures of skewness and kurtosis. Descriptive analysis of the socio-demographic and other covariates was done using frequencies (percentages), mean (SD) and median (IQR) as appropriate. Scores of the knowledge of health professionals at pre and immediate post were computed. A non-parametric test, Wilcoxon signed rank test was used to compare the differences in mean scores of knowledge of health professional’s pre and post intervention. Comparison of the counseling skills of health professionals with their socio-demographic characteristics was done using non-parametric statistic, namely, Mann-Whitney U test. Finally the results were presented using tables. A statistical significance was considered at
This study sought to answer the question of whether training given to health professionals had an effect in bringing a positive change in their knowledge and counseling skills. A total of 17 health professionals were approached to participate in the study and 16 agreed to do so making the response rate at 94.2%.
Table 1 indicates the socio-demographic profile of health professionals. Of the participants, 13 (81.3%) were females, the mean age of the participants was 42.19 (SD=15.57) while the age range was 22-65. Three fourth (75%) of the respondents were married. Only 1 respondent was a degree holder while the majority (62.5%) were at diploma level. Less than half (43.8%) of the respondents had worked for 15 years or more.
|
|
|
|
||
Male | 3 | 18.8 |
Female | 13 | 81.2 |
|
||
BSM | 1 | 6.3 |
Nurse midwife | 6 | 37.5 |
Comprehensive nurse | 4 | 25.0 |
Associate nurse | 5 | 31.2 |
|
||
Single | 3 | 18.8 |
Married | 12 | 75.0 |
Divorced | 1 | 6.2 |
|
||
Yes | 6 | 37.5 |
No | 10 | 62.5 |
|
||
Not confident | 1 | 6.3 |
Moderately confident | 4 | 25.0 |
Fully confident | 11 | 68.7 |
|
|
|
Age | 42.19 (15.57)a | 22, 65 |
Monthly Salary | 2600 (541)a | 1600,3500 |
Years of service/Experience | 17.60 (13.75)a | 1,43 |
M=Mean, SD=Standard Deviation, Md=Median, IQR=Interquartile range, Min=Minimum,
Max=Maximum,
aMean (SD) is reported
Only 6 (37.5%) claimed to have received in-service training regarding nutrition and only 1 (6.3%) believed to have lacked confidence on nutrition education provision. The mean years of service was 17.60 (SD=13.75) with an average monthly salary of 2600 (SD=541).
The majority (87.5%) of the respondents had a correct knowledge on how frequently and what amount a pregnant woman should eat, after intervention the proportion increased to 100%. As indicated as in Table 2, need of folate and iron supplementation early during pregnancy was correctly addressed by 16 (100%) and 15 (93.8%) proportion of the respondents respectively. The first knowledge parameter’s value remained the same but the latter increased to 16 (100%) in the post education assessment. All of the respondents had the right knowledge regarding dose of folic acid in a woman who had a prior child with a neural-tube defect and dosage of daily elemental iron in a woman with anemia after intervention. All of the studied health professionals knew that pregnant women should use iodized salt at both assessments. All of the respondents stayed true to the fact that alcohol and cigarette are completely restricted during pregnancy while coffee consumption should only be reduced after the intervention. Results of questions raised regarding maternal complications of under nutrition during pregnancy showed that all of the respondents knew anemia as a complication while preeclampsia was known to only 1 participant but after intervention 10 (62.5%) came to know about it. Miscarriage as a complication of under nutrition was mentioned by only 6 (37.5%) participants, but after intervention those who mentioned it were more than half (68.8%). There was a huge increase in the number of respondents who correctly knew GWG (from 6.3% to 93.8%) in comparison to a no change in those who answered the importance of folic acid, i.e. to prevent birth abnormalities of the nervous system of the unborn baby (100% to 100%). Meaning of intermittent iron and folic acid supplementation was known to 15 (93.8%) after the intervention. Similar proportion of the respondents were familiar with duration of iron supplementation before intervention but after intervention every single respondent was familiar with the correct duration.
|
|
|
|
||
Increased infections | 8 (50) | 13 (81.3) |
Preeclampsia | 1 (6.3) | 10 (62.5) |
Anemia | 16 (100) | 16 (100) |
Preterm birth | 10 (62.5) | 16 (100) |
Miscarriage | 6 (37.5) | 11 (68.8) |
How frequently and what amount a pregnant woman should eat | 14 (87.5) | 16 (100) |
Energy requirement during pregnancy | 8 (50) | 16 (100) |
Gestational weight gain | 1 (6.3) | 15 (93.8) |
Need of folate supplement early during pregnancy | 16 (100) | 16 (100) |
Need of iron supplement early during pregnancy | 15 (93.8) | 16 (100) |
Timing of folic acid initiation | 4 (25) | 16 (100) |
|
||
To prevent preterm labor and delivery | 6 (37.5) | 16 (100) |
To prevent birth abnormalities of the nervous system of the unborn baby | 16 (100) | 16 (100) |
Dose of folic acid | 9 (56.3) | 16 (100) |
Dose of folic acid in a woman with a prior child with a neural-tube defect | 12 (75) | 16 (100) |
Duration of iron supplementation | 15 (93.8) | 16 (100) |
Dosage of daily elemental iron in a woman with anemia | 16 (100) | 16 (100) |
Meaning of intermittent iron and folic acid supplementation | 1 (6.3) | 15 (93.8) |
Usage of iodized salt during pregnancy | 16 (100) | 16 (100) |
Alcohol and cigarette restriction in pregnancy | 15 (93.8) | 16 (100) |
Concerning sources of main food groups as indicated in
|
|
|
|
||
InjeraRiceMaizeWheatMilletFruits | 10 (62.5) | 16 (100) |
14 (87.5) | 16 (100) | |
14 (87.5) | 16 (100) | |
13 (81.3) | 16 (100) | |
9 (56.3) | 16 (100) | |
5 (31.3) | 10 (62.5) | |
|
||
LegumesEggsCheese, Milk, YogurtNuts and seedsCereal, Wheat, corn and riceMeat, poultry and fishPeanut | 11 (68.8) | 16 (100) |
11 (68.8) | 16 (100) | |
11 (68.8) | 16 (100) | |
8 (50) | 16 (100) | |
16 (100) | 13 (81.3) | |
14 (87.5) | 14 (87.5) | |
9 (56.3) | 13 (81.3) | |
|
||
SunflowerAvocado, vegetable oils, margarine butterFatty meat, milk and cheeseEggsFish | 4 (25.5) | 13 (81.3) |
10 (62.5) | 15 (93.8) | |
14 (87.5) | 15 (93.8) | |
6 (37.5) | 16 (100) | |
7 (43.8) | 14 (87.5) | |
|
||
FruitsVegetables | 16 (100) | 16 (100) |
14 (87.5) | 16 (100) | |
|
||
Meat and fishGreen leafy vegetablesLegumesEgg yolkFruits | 10 (62.5) | 13 (81.3) |
10 (62.5) | 16 (100) | |
7 (43.8) | 14 (87.5) | |
8 (50) | 15 (93.8) | |
5 (31.3) | 8 (50) |
In order to assess the effect through time on knowledge before and after educational intervention, a non-parametric test, Wilcoxon signed rank test was used
as shown in
|
|
|
|
|
Pre intervention | 30.5 (8) | 22,37 | -3.52 | <0.001 |
Post intervention | 44 (3.5) | 37,46 |
In order to accurately measure the counseling skills of health professionals, two different evaluations using the same tool at different time periods by the same evaluator were performed. The scores for practice of nutrition counseling as revealed in
|
|
|
|
|
Measures weight | 1.88 (0.34) | 14 (87.5) | 2 (12.5) | 0 (0.0) |
Informs the measured weight to the client | 1.4 (0.8) | 10 (62.5) | 3 (18.8) | 3 (18.8) |
Informs GWG to the client | 1.53 (0.49) | 9 (56.3) | 7 (43.8) | 0 (0.0) |
Informs maternal complications of under nutrition to the client | 1.84 (0.35) | 14 (87.5) | 2 (12.5) | 0 (0.0) |
Informs fetal complications of under nutrition to the client | 1.87 (0.34) | 14 (87.5) | 2 (12.5) | 0 (0.0) |
Asks diet related symptoms | 1.7 (0.44) | 12 (75.1) | 4 (25.0) | 0 (0.0) |
Gives information on what things to avoid during pregnancy | 1.87 (0.34) | 14 (87.5) | 2 (12.5) | 0 (0.0) |
Mentions food sources of carbohydrates | 1.87 (0.34) | 14 (87.5) | 2 (12.5) | 0 (0.0) |
Mentions food sources of proteins | 1.87 (0.34) | 14 (87.5) | 2 (12.5) | 0 (0.0) |
Mentions food sources of fats | 2 (0) | 16(100.0) | 0 (0.0) | 0 (0.0) |
Mentions food sources of vitamins | 1.96 (0.12) | 15 (93.8) | 1 (6.3) | 0 (0.0) |
Mentions food sources of iron | 2 (0) | 16 (100) | 0 (0.0) | 0 (0.0) |
Gives information to the client on addition of one meal, small portions and frequent feeding | 1.87 (0.28) | 15 (93.8) | 1 (6.3) | 0 (0.0) |
Checks for adherence to iron supplement | 1.96 (0.12) | 15 (93.8) | 1 (6.3) | 0 (0.0) |
Gives information on how to take iron supplement | 2 (0) | 16 (100) | 0 (0) | 0 (0.0) |
Gives information on use of iodized salt | 1.75 (0.44) | 12 (75.0) | 4 (25) | 0 (0.0) |
Motivates client to ask questions and answers them clearly | 1.53 (0.61) | 10 (62.6) | 5 (31.3) | 1 (6.3) |
More than three quarter (87.5%) of the respondents weighed the pregnant mother up on first encounter with her, but only 62.5% of them clearly informed the client on her weight. More than half (56.3%) of health professionals accurately mentioned the weight one mother is supposed to gain based on her current weight throughout her pregnancy. Fetal and maternal complications of under nutrition during pregnancy was discussed by similar proportion (87.5%) of ANC providers. Three quarter (75.1%) of the ANC providers asked their clients about pica, nausea and vomiting. Avoiding alcohol, smoking, caffeine and other items was discussed with clients by 87.5% of the ANC providers. Counseling on eating of variety of food and addition of extra meal during pregnancy was done by almost all providers (n=15, 93.8%). Sources of main food groups (fats, iron) was discussed by all participants. More than eighty percent (93.8%) checked for adherence to iron supplement and none of the respondents failed to give information on how to take the supplement and three quarter of the respondents gave information on use of iodized salt. More than half (62.6%) of the study participants motivated their clients to ask questions at the end of counseling session.
According to this research the mean nutrition counseling practice score of health professionals was 30.97 (SD=1.26)/34. Shown in
|
|
|
|
|
|||
Male | 31.0 (*) | ||
Female | 32.0 (2.25) | 16.5 | 0.704 |
|
|||
Associate Nurses | 32.0 (1.75) | ||
Comprehensive Nurses/Midwives | 32.25 (5.88) | 21.0 | 0.679 |
|
|||
<15 Years | 32.0 (2.25) | ||
>=15 Years | 31.0 (7.5) | 18.0 | 0.174 |
|
|||
Yes | 31.5 (3.38) | ||
No | 32.0 (3.50) | 28.5 | 0.875 |
IQR cannot be computed because Q3 was not found.
The present study assessed an educational intervention undertaken with ANC providers in the hope of answering the question whether training given to them had an effect in bringing an increment in their knowledge and appropriate counseling skills. The results were positive in terms of improving the heath professionals’ knowledge regarding appropriate nutrition during pregnancy.
In this study the median knowledge score of health professionals was 44/47 after intervention. This result, upon changing the scores to percentage, was higher than a similar Ethiopian study which was 7.5/11 [
An Australian study found that 79.3% of the interviews had received nutrition information during their midwifery education and/or during practice [
In the pre intervention of this study major knowledge gap among health professionals was evidenced on maternal complications of under nutrition during pregnancy, especially on complications like preeclampsia (6.3%), GWG (6.3%), meaning of intermittent iron and folic acid supplementation (6.3%). This concept was also seen in similar Ethiopian study where the overall knowledge on maternal complications of under nutrition was 29.2% and knowledge on GWG was 37.5% [
The mean nutritional counseling practice score of health professionals was 30.97/34, this upon changing the scores to percentage was much higher than an Ethiopian’s study result which was only 2.87/12 [
The ability of ANC providers to manage weight is essential given the high rates of inappropriate weight gain among childbearing women [
An Australian survey reported that 27% of the respondents advised about iron-rich food sources and 23% gave advice on general healthy eating. As cited in the same study, a study by Wulf and Ekstrom reinforced that recommendations provided in clinical guidelines were not always applied in practice, with only 15% recommending iron supplementation to all pregnant women [
The following limitations need to be considered while interpreting the findings of the study. The possible effect of other sources like TV, books, magazines and radio broadcasting within the training period on the change in the knowledge could not be controlled. Baseline assessment of counseling skills of health professionals was not taken. The presence of supervisors during nutrition counseling may have had an effect on the performance of ANC providers. Retention test was not done so it couldn’t be identified for how long the improvement in knowledge could be maintained.
Training provided to health professionals resulted in a significant increase in their knowledge of appropriate nutrition during pregnancy and their counseling abilities to pregnant women. Major gap in knowledge of health professionals was seen in the complication of maternal under nutrition and gestational weight gain. The proportion of health professionals who had received in-service training regarding nutrition was low implying the need for creation of programs that enhance the knowledge and counseling skills of health professionals. The analysis showed that there was no significant difference in the mean score of counseling skills of health professional’s across the categories of demographic characteristics. Dietary counseling requires the coordinated effort of dietitian and ANC providers.
ANC: Antenatal care; ANOVA: Analysis of Variance; GWG: Gestational Weight Gain; MOH: Ministry of Health; SPSS: Statistical Package for Social Sciences
Ethical clearance and support letter for the study was obtained from the ethical and scientific committee of ACHS then the researcher visited the head of the branch of MOH of Zoba Maekel for further permission. Moreover the head nurses and medical directors of each study site were approached with full explanation of the general purpose and nature of the study. Informed written and signed consent was taken from the participants after the purpose of the study was thoroughly explained to them beforehand. Above all, the participants’ information was handled with great confidentiality. Health professionals were also informed that their participation was voluntary and that they could withdraw from the study at any time during the research.
All authors read and approved the final manuscript
The complete dataset used and/or analyzed during the current study are available from the corresponding author and can be accessed upon reasonable request.
LG: Designed the study, coordinated recruitment of participants, education of participants, preparing of teaching materials and in writing of all drafts and final manuscript. SA: Designed the study, coordinated recruitment of participants, education of participants and participated in writing manuscript. HG: Coordinated recruitment of participants, education of participants, writing of all drafts and the final manuscript. EHT: Assured quality of data collection, led data analysis, writing manuscript, and in writing of all drafts and the final manuscript. All authors read and approved the final manuscript.
The authors declare that there is no conflict interest regarding the publication of this paper.
This research was supported by the National Board of higher Education. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
The authors would like to thank the participants who took part in this study, National Board of Higher Education (NBHE) for funding the research and for all who contributed one way or another to the successful completion of the project.
1.Arrish J, Yeatman H, Williamson M. Self-reported nutrition education received by Australian midwives before and after registration. J Preg. 2017;2017:5289592. doi:
2.Zelalem A, Endeshaw M, Ayenew M, Shiferaw S, Yirgu R. Effect of nutrition education on pregnancy specific nutrition knowledge and healthy dietary practice among pregnant women in Addis Ababa. Clin Mother Child Health. 2017;14(3):265. doi:
3.Whitworth M, Dowswell T. Routine pre-pregnancy health promotion for improving pregnancy outcomes. Cochrane Database Syst Rev. 2009;4(4):CD007536. doi:
4.Mugyia ASN, Tanya ANK, Njotang PN, Ndombo PK. Knowledge and attitudes of pregnant mothers towards maternal dietary practices during pregnancy at the Etoug-Ebe Baptist Hospital Yaoundé. Health Sci Dis. 2016;17(2).
5.Harvey LB, Ricciotti HA. Nutrition for a healthy pregnancy. Am J Lifestyle Med. 2014;8(2):80-7. doi:
6.Mudor H, Bunyarit F. A prospective of nutrition intake for pregnant women in Pattani, Thailand. Procedia Soc Behav Sci. 2013;91:179-84. doi:
7.Malta MB, Carvalhaes MAdBL, Takito MY, Tonete VLP, Barros AJ, Parada CMG, Benício MHDA. Educational intervention regarding diet and physical activity for pregnant women: changes in knowledge and practices among health professionals. BMC Preg Childbirth. 2016;16(1):175. doi:
8.Arrish J, Yeatman H, Williamson M. Midwives and nutrition education during pregnancy: A literature review. Women Birth. 2014;27(1):2-8. doi:
9.da Silva Lopes K, Ota E, Shakya P, Dagvadorj A, Balogun OO, Peña-Rosas JP, De-Regil LM, Mori R. Effects of nutrition interventions during pregnancy on low birth weight: an overview of systematic reviews. BMJ Glob Health. 2017;2(3):e000389. doi:
10.Fallah F, Pourabbas A, Delpisheh A, Veisani Y, Shadnoush M. Effects of nutrition education on levels of nutritional awareness of pregnant women in Western Iran. Int J Endocrinol Metab. 2013;11(3):175-8. doi:
11.Girard AW, Olude O. Nutrition education and counselling provided during pregnancy: effects on maternal, neonatal and child health outcomes. Paediatr Perinat Epidemiol. 2012;26;Suppl 1:191-204. doi:
12.Middleton P, Lassi Z, Tran T, Bhutta Z, Bubner T, Flenady V. Crowther C: nutrition Interventions and Programs for Reducing Mortality and Morbidity in Pregnant and Lactating Women and Women of Reproductive Age: A Systematic Review: op110. J Paediatr Child Health. 2013;49:71.
13.Ota E, Hori H, Mori R, Tobe‐Gai R, Farrar D. Antenatal dietary education and supplementation to increase energy and protein intake. Cochrane Database Syst Rev. 2015;6(6):CD000032. doi:
14.Mohannad A, Rizvi F, Irfan G. Impact of maternal education, and socioeconomic status on maternal nutritional knowledge and practices regarding iron rich foods and iron supplements. Ann Pak Inst Med Sci. 2012;8(2):101-5.
15.Nyagawa DR. The effect of health and nutrition training among health workers on Anaemina in rural areas of Tanzania: a study in Iramba and Kondoa district; 2001.
16.Kushner RF. Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Prev Med. 1995;24(6):546-52. doi:
17.Lucas CJ, Charlton KE, Brown L, Brock E, Cummins L. Antenatal shared care: are pregnant women being adequately informed about iodine and nutritional supplementation? Aust N Z J Obstet Gynaecol. 2014;54(6):515-21. doi:
18.McDonald SD, Pullenayegum E, Taylor VH, Lutsiv O, Bracken K, Good C, Hutton E, Sword W. Despite 2009 guidelines, few women report being counseled correctly about weight gain during pregnancy. Am J Obstet Gynecol. 2011;205(4):333:e331-333. e336. doi: