Results presented in Table 2 suggests low socio-economic status characterized by subsistence farming, low education levels, low occupation levels, polygamous family settings, conditions that predispose WCBA to poor dietary intake and consequently, nutrition status. Such low socio-economic status coupled with complex demographic factors can present a critical bottle neck to the success of nutrition interventions in Karamoja sub-region. From a policy perspective, efforts that lead to improvement of such socio-demographic and economic conditions are likely to have a positive nutrition outcome among WCBA in Karamoja sub-region.
The result (Table 3) indicates that generally, the intake of energy and nutrients was significantly higher during planting season than harvesting season. This is contrary to what is expected during harvesting season. However, according to FEWWSNET 2019 report [42], food security begins to improve in Karamoja as the harvest begins and sorghum prices decline. One of the probable reasons is based on the observation during data collection that harvesting of most of staple foods such as sorghum span up to February and food was still adequate at the households during the second phase of data collection (planting season). The high proportion of pregnant women failing to meet RDAs for folate, iron and zinc (Table 5) can be attributed to their high micronutrient requirements in this physiological category than women in other physiological status [40] and consumption of foods poor in micronutrients (Table 4). This suggests that women were generally nutritionally deficient before they conceived and experienced even higher deficiencies during pregnancy and lactation owing to their failure to meet the increased energy and nutrient requirements. Nutrient intake in the prenatal period is one of the most important determinants of fetal growth and development, and supports maternal health [43–45]. During pregnancy, dietary energy and nutrient requirement demands are increased because of raised metabolism, blood volume and red cell mass expansion in pregnant women, and the delivery of nutrients to the fetus [46]. Such high demand for nutrients and energy makes pregnant women more vulnerable to malnutrition resulting in both short term effects such as miscarriages, low birth weight, low maternal weight, frequent disease episodes and long term effects such as non-communicable diseases (obesity, type 2 diabetes, hypertension and cardiovascular diseases) in later life [47]. The result therefore implies that pregnant women in Karamoja sub-region are predisposed to inadequate dietary intake which can impact negatively fetal growth and later on the health and nutrition status of the children.
As shown in Table 5, most of the non pregnant/non lactating mothers did not meet RDAs for micronutrients in both seasons. This implies that from nutritional point of view, most mothers conceive when they are undernourished. The nutritional demand by lactating women is also considerably greater than when pregnant, while diet can affect the synthesis, composition, and secretion of milk [48]. Mothers who are well nourished during pregnancy will have adequate fat and other nutrient reserves to fall back on when lactating [49]. It is apparent that women in Karamoja sub-region do not consume adequate nutrients to support their health and the health of children that nutritionally depend on them. Compromised nutrient intake during the critical period immediately before and following conception can adversely influence pregnancy outcome, increases risk of birth defects, can alter nutrient composition of breast milk, condition infants and children to altered growth trajectories and predisposes them to chronic diseases in later stage of life [50]. While the effects of pre-pregnancy dietary intake are not well characterized, improvements prior to pregnancy may decrease the risk of poor maternal and fetal outcomes [31].
As shown in Table 4, plant-based foods constitute a major part of the household diet in Karamoja sub-region and consumption varies from season to season. This consistent with the literature that most diets in a SSA are plant based [51]. The positive contributions of such plant-based foods to micronutrients and other bioactive substances [52] are of limited by antinutritional factors (e.g; phytates, polyphenols, oxalates, tannins) [53, 54] affecting already heightened nutrient needs of WCBA in Karamoja sub-region.
Regarding seasonality, a similar study [55] that examined dietary diversity and the nutritional status of women in rural Burkina Faso reported that dietary diversity scores (DDSs) were sensitive to seasonal variations. Their findings are in agreement with the current study (Table 3) which showed variation in energy and nutrient intake and consumption of food groups between the harvesting and the planting seasons. Whereas it is generally recommended that pregnant women should consume three meals and two or more snacks per day to reduce the risk of preterm delivery [56], this was not the case for WCBA in Karamoja sub-region (Figure 1.1a and 1.1c) and was worsened by consumption of alcohol by WCBA (Figure 1.1b and 1.1d). Prolonged periods of time without food may induce physiological stress during pregnancy [56] while alcohol consumption increases the risk of physical and mental damage to their babies referred to fetal alcohol syndrome [57] adversely affect micronutrient absorption and availability during that physiological state [30]. During period of breastfeeding, alcohol consumption may place newborns at an additional disadvantage as teratogenic effects of alcohol are increased when micronutrients such as iron, zinc and choline are deficient [30]. The habitual intake of alcohol in Karamoja by WCBA observed in the current study suggests that children in Karamoja sub-region are more likely to experience mental and behavioural challenges such as deficits in cognitive functioning (such as general intellectual functioning, learning of new verbal information, and performance on visual-spatial tasks) and fine- and gross-motor performance [58]. It can therefore be asserted that WCBA in Karamoja sub-region are at high risk of malnutrition and poor health during the season of inadequate food intake (harvesting season), and that these risks have important implications for the well-being and development of children in the community.
Linear regression on the 10 independent variables reported in the current study (Table 6) significantly predicted inadequate intake of energy, and selected mircronutrients (calcium, zinc, folate and vitamin A) among WCBA depending on the seasons. It is not surprising to note that being a lactating mother predicted limitations in the intake of energy. This is because lactation/breastfeeding is often associated with increased energy need, requiring the mothers to increase dietary energy intake above that recommended for normal adult women to support breast milk production and prevent maternal malnutrition [59]. Unfortunately, in Karamoja sub-region, the positive coefficients for inadequate energy intake imply that energy among lactating mothers was low. This situation has serious ramifications for nutrition and health wellbeing of these mothers and children in Karamoja sub-region. This is because previous studies have indicated that inadequate energy intake leads to poor health and nutrition outcomes [60] and possibly increased risk of mortality [61, 62].
Other socio economic and demographic factors such as maternal age and education have previously been associated with dietary patterns and nutrition outcomes among mothers [63]. However, the current study (Table 6) indicates that a unit increase in maternal age and occupation of the household head was associated with a decrease in inadequate intake of calcium but increased inadequacy of intake of folate among WCBA. In addition, increase in education level of both the spouse and the household head was associated with a decrease in inadequacy of intake of vitamin A. A reduction in inadequacy of calcium intake with age suggests that pregnant and lactating women are less likely to experience calcium deficiency as they grow old. However, this is a subject matter proposed for further investigation. The findings regarding education level are consistent with a study involving 530 pregnant women at Ile-Ife in Nigeria [61], which indicated that overall, there was a significant relationship between the level of education and knowledge and dietary intake. Education plays a key role in determining maternal under-nutrition [64]. According to Serbesa et al.[65], education status of pregnant women and lactating mothers affected nutrition in the sense that being educated was associated with a higher income, ability to make better decisions for her nutrition and that of the child. The authors further argued that educated pregnant women and lactating mothers were more careful about what they ate than the uneducated counterparts. A similar study [66] also affirmed that antenatal mothers with good education background had higher nutritional knowledge and enhanced understanding of information disseminated through mass media. However, the results of the current study (Table 2) indicate high proportion of women who never attained any formal education, thus, suggesting limited ability of WCBA in Karamoja sub-region to comprehend nutrition information provided. Considering the significance of nutrition information in fostering good nutrition behaviours [67, 68], adult education could be implemented to improve education status of WCBA in Karamoja sub-region. Occupation of women limited the intake of calcium, zinc and vitamin A depending on season and nutrient type (Table 6). The observed disparity in the influence of occupation on intake of nutrients in the current study might have been confounded by such dichotomy. This is consistent with the long-held view that results of regression models should be interpreted with care [69], taking in to account the dichotomy that exists in terms of types and quantity of foods available for consumption between planting and harvesting seasons by reporting the adjusted coefficients [70]. The influence of occupation on maternal nutrition was argued in previous studies that women who are employed outside the home for long duration have less leisure time because of work pressure, and hence they cannot take proper care of their health and frequently neglect dietary intake [71]. For the case of Karamoja, due to low education attainment, most of the inhabitants are not formally employed. Inadequacy in the intake levels of nutrient due to occupation could arise from the fact that most of the women engage in subsistence agriculture where they spend long hours in the garden without paying attention to their dietary intake.
Being married is generally believed to be of benefit for maternal nutrition. It has been argued that being married enhances family income and wealth, provide social support and other noneconomic resources that help individuals withstand periods of economic uncertainty or stress, though the benefits of marital support may be smaller for women than men [72]. However, the results of the current study indicate that being married was associated with increased inadequacy of vitamin A intake among WCBA. Thus, illustrating from a nutrition point of view and based on the results, there is limited efficacy of marital support in fostering nutritional wellbeing of WCBA in a food insecure location such as the Karamoja sub-region. The significance of marital status in nutrition wellbeing of WCBA seems to be dependent on the nature of marriage type (monogamy and polygamy). This is because polygamy tends to have a negative effect on energy and nutrients, confirmed by the result that an increase in the number of women married in a household increased inadequacy of intake of vitamin A (Table 6). This finding implies that marrying more than one woman in a food insecure environment as is the case in Karamoja sub-region predisposes WCBA and other vulnerable members of the household such as children to more food and nutrition insecurity, and malnutrition. Considering the positive impact of adequate nutrition on health wellbeing of WCBA, children [73] and human-factor related development [74-77, community dialogue could be attempted to discourage polygamy if food and nutrition security situation in the sub-region persists.
Potential limitations to data collection process were that the data could have been affected by recall bias due to the 24-hour recall period and that the estimates for nutrients did not take into consideration their bioavailability. In addition data were collected once in each season which could have influenced the reliability of the results. Hence, there could have been over estimates or under estimates as a result of measuring the portion sizes. However, because the data were obtained from a fairly large sample size, these findings provide important information regarding the intake levels of energy and nutrients among WCBA.