Under nutrition and poor health from preventable causes disproportionately affect the well-being of millions of people in the developing world. Factors at individual, household and community level, or a combination of these factors, may contribute to poor nutrition and health status 1 . In particular, malnutrition among women is likely to have a major impact on their own health as well as their children’s health. More than 3.5 million women and children under age five in developing countries die each year due to the underlying cause of under nutrition 1 .

Women are more likely to suffer from nutritional deficiency than men for several reasons, including their reproductive biology, low social status, poverty and lack of education. In addition, socio-cultural traditions and disparities in household work patterns can also increase women’s chance of being malnourished 2 . Between 5 to 20 percent of women in various African countries are underweight. Many African women display low weight-for-height as measured by a body mass index of less than 18.5 3 .

Women in low-income settings often consume inadequate amount of micronutrients because of resource limitation. They have a limited intake of animal source foods, fruits and vegetables. Intake of micronutrients less than the recommended values increase women’s risk of micronutrient deficiencies 4 . Adequate nutritional status of women is important for good health and increased work capacity of women themselves as well as for the health of their offspring 5 .

Severely malnourished mothers have reduced lactation performance contributing to the increased risk of child mortality 6 .

Nutritional requirements during lactation are greater than during pregnancy. If a mother is well nourished during pregnancy, she will have adequate fat and other nutrient reserves that can be used to compensate partially for her additional requirements. Mothers should be counseled about the need for an adequate diet in order to achieve optimal lactation and sustain it without depleting their own nutrient stores. Particular attention should be given to intakes of protein, calcium and vitamins 7 .

Lactating mothers from low-income settings are considered as nutritionally vulnerable group. Due to the nursing process mothers are subjected to nutritional stresses. Frequent pregnancies followed by lactation increase the health risk of mothers resulting in a high maternal mortality 8 . A nursing mother produces 0.7 to 0.8 liters of milk per day, containing 330 milligrams of calcium per liter. This requires an extra energy expenditure of at least 500 calories per day 9 . The quality of breast milk is only affected in extreme cases of deprivation, or by excessive intake of a particular food 10 . But the quantity of milk depends very much on the mother's diet. Food absorbed by a nursing mother not only fulfills her own nutritional needs, which are greater during the postnatal period, but also enables her to produce milk 9 .

Research based information regarding maternal nutrition from the study communities is lacking. Information on the feeding practices, nutritional status and associated factors of the lactating women are urgently needed for prioritizing, designing and initiating intervention programs aimed at improving maternal nutrition. The process for priority setting should start with the assessment and analysis of the situation that lactating women face in their environment. Thus, this study was carried out to provide information regarding the feeding practices, nutritional status and associated factors of the lactating women in the study area.

This study assessed the feeding practices, nutritional status and associated factors among lactating women from Samre woreda, South Eastern Zone of Tigray, Ethiopia. According to the essential nutrition action (ENA), taking at least two additional meals per day during lactation is recommended for all lactating women 19 . Nevertheless, slightly below three fourth’s 285 (71.3%) of the study participants do not take any additional meal during their lactation time. The median dietary diversity score of the study participants was 5.0, which was lower than half of the food groups on FAO food grouping i.e. 14 food groups 14 .

The prevalence of chronic energy deficiency (BMI <18.5 Kg/m²) among the lactating mothers was 25%, a prevalence which was very much lower than that of the Tigray region finding in the EDHS report of 2005 (37.5%) 13 . The probable reason for this discrepancy could be the interventions on maternal health, nutrition and other women empowering programs by the government as well as other non-governmental organizations in the study area.

But, this finding was comparable with the finding of the Ethiopian Health and Nutrition Research Institute nutrition baseline survey report (28.8%) 20 . On the contrary, our results were much lower than that of the prevalence in lactating mothers from the Southern region of Ethiopia (37%) 21 . The proportion of lactating mothers with a MUAC of less than 21 cm was 13%. This figure was lower than the finding of the survey report on the situation analysis of women in Tigray in 2011 (18.1%) 22 .

The dietary assessment from one day weighed food record showed that the energy and almost all nutrient intakes of the lactating women in the study area were below the recommended nutrient intakes of FAO/WHO/UNU 18 . This finding was consistent with the finding of Huffman and his colleagues 23 . According to this study, many women in Africa suffered from chronic energy deficiency, inadequate weight gain during pregnancy and poor nutritional status. The additional energy needed for lactation is 20-25% of energy needs in the non-pregnant non-lactating state 24 . But, in the current study these energy needs were not met or were below the requirement of the lactating mothers. This might be due to their involvement in energy demanding workloads during the whole course of lactation and taking no additional meals from available foods in the household during this time.

The protein intake of the study participants was close to the recommended intake of FAO/WHO/UNU 18 . The quality of the dietary protein can be improved by combining protein sources (grains and legumes) with different limiting amino acids 25 . Thus, mixtures of plant proteins can serve as complete and well balanced source of amino acids for the lactating women from the study communities. In agreement with our findings, inadequate protein intake in lactating women was reported from Southern region of Ethiopia 21 and Malawi 26 , where lactating women were predicted to be at risk of inadequate intakes of dietary protein.

The current study also revealed that micronutrient intakes especially zinc and calcium of the lactating women were below the recommended levels. However, iron intake (118 mg) was above the recommended intake of the FAO/WHO/UNU 18 . This was comparable to a study done in Tigray by Adish and his colleagues 27 . This may be due to the high content of iron in the Ethiopian diets as has been emphasized by Gebremedhin and his colleagues 28 . According to this study, the consumption of the indigenous cereal teff (E.teff), oleaginous seeds and Ethiopian kale (B. carinatabraun), and all foods that appear to contain relatively high levels of iron enhance increased iron intake.

In the present study, it was also found that dietary zinc intake of the lactating women was lower than the recommended intakes of FAO/WHO/UNU 18 . This might also be related to the much lower intake of animal source foods that contain highly bio-available zinc than the foods of plant origin. Yewelsew and her colleagues also reported low dietary zinc intake in pregnant women from Sidama Zone, Southern Ethiopia 29 . As it was observed with the other micronutrients, the calcium intake was also lower than the recommended nutrient intake in the study participants. Inadequate intake of calcium among pregnant women from Sidama Zone, Southern Ethiopia was also reported by Yewelsew and her colleagues 29 . The majority of the study subjects were consuming cereal based foods (99.2%) and legumes (74.2%), which are known to contain significant amount of phytate that reduces the bioavailability of the zinc, iron and calcium absorption 30 .

Women of reproductive age are thought to be vulnerable to vitamin A deficiency during pregnancy and lactation 31 32 . In the current study, it was found that the lactating women’s dietary intake of vitamin A (194 micro grams) was very much lower than the recommended intake (850 micro grams). The much lower intake of animal source foods (for vitamin A) as well as vitamins A and C rich fruits and vegetables might explain the lower intake of vitamin A in the lactating women.

Socio-economic and demographic factors affecting the nutritional status of the participants were size of farm land, length of years of marriage, maize cultivation, frequency of ANC visit and age of breastfeeding child. Those who had a land size of 0.26-0.75 hectares were 5.1 times more likely to be malnourished (MUAC < 21 cm) than those who had a land size of greater than 0.75 hectares. The strong association between land size and nutritional status might be explained by the fact that those who had a larger land size had an increased and diversified crop production as compared to those who had a smaller land size. Similarly, those whose years of marriage was between 11-20 years were 71% less likely to be malnourished (MUAC < 21 cm) than those whose years of marriage was less than or equal to 10 years. By the same token, the association between length of years of marriage and nutritional status could be explained by early marriage, i.e. those who were in a marriage for less than or equal to 10 years were mostly adolescents. A study by Teller and Gugsa conducted in Ethiopia reported similar finding, i.e., adolescent women were more likely to be malnourished compared to the other groups 33 . Furthermore, growing of maize was also associated with the nutritional status (using MUAC) of the study participants, i.e., those who were not growing maize were 3 times more likely to be malnourished (MUAC < 21 cm) as compared to those who were growing maize. The probable reason could be because of the diversified cultivation of crops as those who were growing maize had better land size than those who were not growing maize.

Study conducted in Hadiya Zone showed that religion, ethnicity, household size, age and parity, land and livestock holding were not associated with malnutrition, as measured by BMI and MUAC. Instead, level of education, sickness and estimated production of staple crops were found to be significantly associated with malnutrition 6 . In this study, nutritional status classified as MAUC < 21 cm or ≥ 21 cm did not reveal any statistical association with regard to family size, farm animal ownership, maternal educational status, number of meals per day, length of breast feeding, number of parity and eating additional food during lactation.

On the other hand, women who had ANC visit of less than or equal to 3 times were 2.9 times more likely to be malnourished (BMI < 18.5 kg/m²) than those who had more than 3 ANC visits per pregnancy. This might be because those who frequently visit the health institutions were getting health and nutrition educations as well as advice by the respective health professionals. Similarly, those women who had children aged greater than 12 months were 2.8 times more likely to be malnourished (BMI < 18.5 kg/m²) than those who had children aged less than or equal to 12 months. This could also be because of the increased nutritional requirement of the growing child but not increased food intake by the mother. Other probable reasons could also be giving less attention/care to the mother, work load and closely spaced pregnancies.

But, nutritional status of study participants according to BMI classification had no significant association on maternal educational status, household asset (radio) ownership, family size, maternal age, number of meals per day, number of parity, farm animal ownership and residence of the lactating mothers. This was in contrary to the study conducted on women’s nutritional status which had significant association on marital status, household assets, age of women and maternal education 33 .

Major strengths of this study were the community based approach and random selection of the study households. This may made generalization possible to the study communities as an attempt was made to identify randomized households and lactating women from the study communities. Though weighed food record method is considered as a “gold” standard method for dietary assessment, the presence of data collectors in women’s homes for collecting weighed food records might alter the feeding behavior of the mothers, which may be considered as one of the limitations of this study. The seasonal variation of food availability that will have an effect on dietary intake and diversity was not considered due to the cross sectional nature of the study. Furthermore, it was difficult to establish a cause-effect relationship between the dependent variable (nutritional status) and the independent variables though association was observed.

Majority of the lactating women (71.2%) who participated in the current study reported that they were not taking additional meal during the time of lactation. This study revealed that the energy and other nutrient intakes of the lactating women in Samre Woreda were below the recommended nutrient intakes of FAO/WHO/UNU 18 . Based on the anthropometric assessment, the prevalence of chronic energy deficiency (BMI <18.5 Kg/m²) among the lactating mothers was 25%, which is a high prevalence according to the WHO Expert Committee of 1995 34 . The proportion of women whose height is less than or equal to 145 cm and whose weight is less than or equal to 45 kg was 2.2% and 31%, respectively.

Dietary intakes which were below the recommendation might lead the study subjects to poor nutritional status. Furthermore, the situation can be aggravated by the high phytate content food consumption of the study participants such as cereal based foods and legumes reported in the 24 hr recall and observed from the weighed food record. The important risk factors/predictors of having a MUAC <21 cm (under nutrition) were size of farm land, length of years of marriage and growing of maize. On the other hand, frequency of antenatal care and age of breast feeding child were the important predictors/risk factors for having a BMI of < 18.5 kg/m².

In general, the feeding practices, dietary intakes and nutritional status of the lactating women in the study area were short of the national and international recommendations and were not adequate to support their increased energy and nutrient requirements. This implies the need for a sustained health and nutrition education to the women, their families and communities regarding increased food intake, proper dietary practices and dietary diversification during their lactation time in order to improve their health and nutrition outcomes. Thus, efforts should be made to improve the ANC services, diversify diet, increase consumption of vitamin A and C rich fruits and vegetables and reinforce traditional household technologies such as cooking, soaking, fermenting and sprouting to reduce the phytate content of the cereals and legumes consumed by majority of the study participants. Furthermore, research is required to determine the factors impeding the transfer of health and nutrition education in to action as well as to assess the dietary adequacy of the lactating mothers in the study area.

We, the authors, have no any competing interests.

KH: initiation of the study, design, implementation, analysis and writing. AM: design, implementation, analysis and writing. MG: design, implementation and co-writing. All authors read and approved the final manuscript.