49

Original Article

Effect of Counseling on Nutritional Status During

Pregnancy
Aashima Garg and Sushma Kashyap
Department of Food & Nutrition, Lady Irwin College, New Delhi.

ABSTRACT
Objective. To assess the nutritional status and dietary practices among underprivileged pregnant women, identify the lacune,
outline implement and assess the effect of nutritional counseling on their dietary intake, anthropometric status and anemia
status.
Methods. Hundred pregnant women belonging to low socio-economic status were interviewed. Based on lacune, nutrition
education (NE) was given in the form of simple messages to 50 subjects (NE-group) over 10-16 weeks period, while the
remaining 50 formed the comparison group (Non-NE group). Tools used were individual counseling, weekly home visits and
group meetings. Anthropometric measurements taken were height and weight. Dietary data was collected using 24-hour recall
and food frequency questionnaire. Hemoglobin estimation was done. Effect of intervention was assessed by monitoring
changes in dietary practices, weight gain, and nutritional status of the subjects.
Results. Baseline findings- low mean maternal body weight (51.05 7.26 kg), 96.3% anemia prevalence and severely sub
optimal dietary intakes. Post-NE results revealed a significant increase in quality and quantity of the diets consumed. Mean
hemoglobin levels significantly increased (Post-NE vs Non-NE = 9.65 0.97 vs 7.85 1.58, p<0.001) and anemia prevalence
reduced (Post-NE vs Non-NE = 78.7% vs 96%) in post-NE group.
Conclusion. Individual counseling with weekly reinforcement can bring about improvement in nutritional status during
pregnancy. [Indian J Pediatr 2006; 73 (8) : 687-692]

Key words : Pregnancy; Nutritional status; Nutrition education

Poor maternal nutrition and the resulting low birth

weight (LBW) infants remain the single most important
cause of infant morbidity and mortality in the world and
reduction in the rate of LBW has been named by WHO as
one of the global indicators of progress. 1 In majority of
LBW infants the seed of death is sown much before they
are born which increases the risk of perinatal, neonatal
mortality and growth retardation and chronic diseases as
adults.2
Maternal nutrition plays a fundamental role in
optimizing pregnancy outcome and unlike other factors,
such as heredity or pre-existing conditions, the nutritional
status is amenable to change. Research relating to
pregnancy outcome has documented the critical need of
nutrition education (NE) for optimal pregnancy
outcome.3,4 Hence, the present study was undertaken with

Correspondence and Reprint requests : Dr. Aashima Garg, Junior

Research Fellow, KI-8 Kavinagar, Ghaziabad, U.P. 201002, India. Ph:
9810588903, 9310009192.

Indian Journal of Pediatrics, Volume 73August, 2006

following objectives in mind: (a) To study the nutritional

status and dietary practices prevalent amongst the
pregnant women belonging to low socio-economic status
(SES). (b) To outline and implement NE and counseling
for pregnant women (completed 5-7th month of gestation).
(c) To assess the effect of counseling pregnant women
(completed 8 th/9 th month of gestation), in terms of
maternal nutritional status.
MATERIALS AND METHODS
Baseline Design: The study was conducted in a villageIndragarhi of district Ghaziabad, Uttar Pradesh. A core
sample of 100 pregnant women belonging to low-SES and
in varied periods of gestation ranging from completing
their 5th month to completing their 9th month of gestation
was selected purposively through domiciliary visits.
Detailed information was gathered on subjects
background, obstetric history, work status, dietary intake
and other food practices and beliefs, anthropometry and
hemoglobin status using a pretested interview schedule.
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Aashima Garg and Sushma Kashyap

Dietary intake of the subjects was assessed by 24-hour
recall and food frequency and amount questionnaire
(FFAQ). 5 Weight and height of the subjects were
measured by standard techniques using Krups bathroom
scale (0.5 Kg sensitivity) and non-stretchable measuring
tape (0.1 cm sensitivity), respectively. Hemoglobin
estimation was done by cyanmethemoglobin method
using filter paper technique.6
Intervention Design: Lacune were identified during the
baseline survey and based on these, simple NE messages
were designed. The messages covered the 6 key areas
identified: (1) increasing quantity of food (eating 1 or 2
additional meals, increasing the amount of food
consumed and adding a teaspoon of oil to prepared food);
(2) improving the quality of food ( consuming cereal
pulse combination, incorporating greens in staples,
consuming fermented foods, consuming yellow fruits and
vegetable, adding lemon to food for better iron absorption
and consuming milk products like buttermilk and curd);
(3) promoting consumption of iron-folic acid (IFA) tablets
(consume one IFA tablet regularly from 4 th month
onwards, side effects subside after sometime, collect IFA
tablets from anganwadi workers (AWWs) or auxiliary
nurse midwife (ANM)); (4) rest during pregnancy (rest
for atleast 2-3 hours during the day, do not do heavy
strenuous manual work in the last trimester of
pregnancy); (5) Injection tetanus toxoid (TT)
immunization and antenatal checkups (ANC) (getting 2
TT injections immunization completed at an interval of
one month from ANM or doctor, undergoing periodic
health check-ups for weight gain, blood pressure and
anemia) and (6) use of iodized salt (using iodized salt in
all food preparations).
At baseline, to study the changes occurring with the
advancement of pregnancy, data was categorized as
middle gestation (completed 5th-7th month of gestation)
and late gestation group (completed 8th/9 th month of
gestation). No statistically significant difference was
found between the 2 groups in relation to socio
demographic profile, obstetric history and other general
characteristics. Thereafter, nutrition education (NE) was
imparted to 50 pregnant women in the middle gestation
group over a period of 2.5-4 months. This formed the NE
group and the late-gestation group without any
intervention was referred to as non-NE group for
comparisons. Since, limited time was available for the
study, the control group (non-NE) could not be studied
parallel to the intervention group (NE). Channels used for
the intervention were individual counseling, weekly
home visits and group meetings.
The individualized counseling sessions ranged from
about 30-40 minutes at the start of intervention, where the
subjects were asked to follow certain behaviors based on
the lacunas identified at baseline. This was followed by
weekly home visits to reinforce the messages, listen to
subjects problem and check the compliance which
688

included checking the IFA tablet strips and cross checking

with family members if the subject was following the
emphasized behaviors. The counseling sessions at the
mid-intervention lasted to about 20-30 minutes where the
messages were again reinforced based on subjects 24
hour dietary recall, FFAQ and weight gain. Finally,
towards the end of the intervention, the sessions lasted to
about 15-20 minutes for further reinforcement. Monthly
weighing of the subjects proved to be a motivating factor
and helped to reinforce the messages. Whenever possible,
the family members especially the husband and the
mother-in-law of the subject were also encouraged to take
extra care of the subject. Nine group meetings were
planned, with one meeting in each of the 9 anganwadi
centers (AWCs) of the village, but only 6 meetings could
be conducted due to poor subjects response and
coordination from some of the AWWs.
Once the subjects of the intervention group reached
late gestation, their post-NE assessment of the practices
adopted, dietary intake, weight gain and hemoglobin
estimation was carried out and birth weight (BW) was
recorded within 48 hours after the delivery. However,
due to certain limitations of available facilities in the field,
the recording of BW could not be very accurate and
standardized, hence that data is not being presented in
the article.
Data Treatment: The statistical analysis was performed
using SPSS/PC (version 10.0) package. The dietary intake
was computed using Indian food composition tables.7
Students t-test and chi-square were used for inter and
intra group comparisons of nutrient intake,
anthropometric measurements and hemoglobin levels. A
value of p< 0.05 was considered statistically significant.
RESULTS
Baseline Information
Subjects Profile : The mean age of the pregnant women
was 24.46 4.1 years, with 82% subjects being between
20-29 years of age. About 27% of the subjects were
primipare and other 47% with a parity of 1 or 2. More
than half (57%) of the subjects were illiterate with few
(19%) husbands being illiterate. Most (95%) subjects were
housewives with husbands working as laborers, rickshaw
pullers, tempo driver, shop keeper, factory worker, fruit
and vegetable seller etc. With meager resources and an
average family size of 5.2, the average per capita income
was Rs. 699.5.
Anthropometry: The mean heights of the subjects was
154.33 3.95 cm and 153.47 4.11 cm, respectively for
middle and late gestation groups with their respective
mean weights being 49.36 7.49 kg and 52.75 6.67 kg.
The corresponding mean values of weights for heights
according to gestational age were 90.34 13.55 % and
91.65 10.55 % of the reference values. 8
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Effect of Counseling on Nutritional Status During Pregnancy

Anemia: The prevalence of anemia (Hb < 11g/dL) was
found to be high in the study sample being 96.3 %. The
mean hemoglobin levels of the subjects in the middle and
late gestation group were 8.84 1.12 g/dL and 7.85 1.58
g/dL, respectively. The percentage of subjects with severe
anemia (Hb < 7.0 g/dL) were 6.4% in the middle gestation
and 34.3% in the late gestation group, thus giving the
picture that anemia worsens with advancement of
pregnancy.
Food Intake: Food habits of the subjects were simple
with 2 main-meals a day pattern. There were wide
variations in the consumption of different foodstuffs by
the subjects and no alteration in food habits during
pregnancy was seen. No significant difference was found
in mean intake of foods and nutrients of subjects with
advancement of pregnancy (Fig 1).
The mean percentage of recommendations for almost
all the foodstuffs was much below the recommended
guidelines9 (Fig 1). Only cereals and sugar met on an
average 40-50 % of the recommendations; intake of
potato, fat and milk was 30-40% of recommendations.
Pulse and other vegetables intake was poor being only
about 20% of the recommended intake. Green leafy
vegetables (GLVs) and fruit intake was even less than 10%
and 20% of the desired levels, respectively. The daily
mean calorie and protein intake was about 835-924 kcal
and 25-28 g, respectively, with both meeting only about
40% the RDA. Similarly, the intake of other nutrients was
also grossly inadequate.
Analysis of FFAQ revealed that wheat was the staple
and rice was eaten only occasionally. In majority of
subjects (70%), the consumption of pulses was only once
a week or once fortnightly. Most (90%) reported
consuming GLVs and fruits only once or twice a week
due to economic constraints. About 64% of the subjects
were non-vegetarian, but due to economic crunch the
frequency of consumption was only 1-2 times/month.
Mustard oil was uniformly consumed throughout the
village. Food especially eaten by the subjects during
pregnancy were reported to be milk, egg, ghee, moong

dal, water and coconut and those avoided during

pregnancy were tea, egg, meat, pulses, cauliflower, brinjal
and jackfruit.
Other Practices : In the study population, majority of
subjects, with 82% subjects in the middle gestation and
84% subjects in the late gestation group were using
iodized salt. The mean resting hours during the day
reported by the subjects were 1.51 0.58 hours and that
during the night were 7.51 0.94 hours.
Changes Brought About by Education Intervention
Dietary Intake: There was a significant increase in the
amount of almost all the food groups consumed in the
post-NE as compared to non-NE and pre-NE group. In
case of cereals and pulses increase was more in the
amount consumed than the frequency and a similar trend
was seen in the intake of other foodstuffs (Table 1).
Similar significant increase was also seen in case of all the
nutrients (Table 2). However, this improvement could not
reach the level of nutritional adequacy except for fat,
vitamin A and vitamin C intake. During the intervention
it was observed that in many cases subjects husband and
mother-in law played important role in motivating them
and keeping a check on the emphasized behaviors.
Anthropometry : The mean % reference weight for
height according to gestational age during pregnancy
(subjects completed 8th/9th month of gestation) improved
slightly to 92.65 % in post-NE as compared to 91.65% in
non-NE group, but this difference could not reach the
level of significance. The weight gain per week in the
post-NE group varied between 0.23 Kg to 0.57 Kg with an
average of 0.40 Kg.
Anemia: The mean hemoglobin level in the
intervention group at post-NE was 9.65 g/dL, which was
significantly higher (p<0.001) than non-NE (7.85 g/dL)
and pre-NE (8.84 g/dL) group. No subject was found
severely anemic (Hb < 7.0 g/dL) in the post-NE group as
compared to 6.4% at pre-NE and 37.1% in non-NE group.
A regular shift in the severity of anemia was observed

Fig 1. Mean percentage of recommendations met by the study populalation for different food stuffs and nutrition (Middle gestation: n=50;
Late gestation: n=50)

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Aashima Garg and Sushma Kashyap

TABLE 1. Mean (SD) Daily Intake (g) of Foodstuffs of the Subjects in the Intervention Group at Pre, Post-NE and in the Non-NE group.
Food class (g)

Intervention group
Pre-NE (n=50)
Post-NE (n=46)

Cereals
Pulses
Roots &Tubers
GLVs
Other vegetables
Fruits
Milk
Visible Fat
Sugar
Meats

133.40 (44.39)
10.36 (14.67)
44.00 (41.35)
13.90 (33.55)
22.60 (31.15)
39.50 (62.05)
187.10 (210.78)
12.06 (6.33)
9.85 (5.54)
4.0 (19.79)

1
2

P1

Non-NE group
(n=50)

201.26 (36.12)
20.43 (23.77)
73.80 (58.42)
49.34 (58.30)
17.39 (28.47)
123.15 (88.24)
378.80 (244.74)
17.82 (6.98)
13.64 (6.90)
10.86 (36.38)

122.90 (54.24)
13.82 (16.87)
36.30 (42.04)
12.90 (30.97)
17.20 (27.03)
31.20 (65.67)
163.70 (174.10)
11.07 (6.58)
10.26 (6.73)
2.00 (9.89)

<0.001
<0.05
<0.05
<0.001
NS
<0.001
<0.001
<0.001
NS
NS

P2

<0.001
NS
<0.001
<0.001
NS
<0.001
<0.001
<0.001
<0.05
NS

p-value between pre and post-NE group

p-value between non-NE and post-NE group
NS-Not Significant

TABLE 2. Mean (SD) Daily Intake of Nutrients of the Subjects in the Intervention Group at Pre, Post-NE and Non-NE Group.
Nutrients

Intervention group
Pre-NE (n=50)
Post-NE (n=46)

Non-NE group
(n=50)

Energy (Kcal)
Protein (g)
Calcium (mg)
Iron (mg)
Vitamin C (mg)
Vitamin A (RE)

924.69
27.88
486.84
8.59
23.84
282.57

835.14 (324.45)
25.00 (10.60)
381.96 (301.65)
7.98 (3.97)
23.50 (44.77)
238.39 (330.86)

1
2

(344.06)
(12.24)
(431.22)
(3.80)
(16.14)
(378.87)

1521.28 (303.45)
48.05 (11.08)
956.21 (434.72)
16.35 (5.22)
219.38 (178.05)
728.68 (568.01)

P1

P2

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

p-value between pre and post-NE group

p-value between non-NE and post-NE group

with intervention (Table 3), thus showing the impact of

intervention.
TABLE 3. Percent Distribution of Subjects According to the
Hemoglobin Levels
Hb Levels
> 11.0
9.01-11.0
7.01-9.00
5.00-7.01
>5.0

Non-NE (n=35)

Pre-NE (n=47)

Post-NE (n=41)

5.7
25.7
31.4
34.2
2.9

2.1
48.9
42.6
6.4
0

12.2
58.5
29.2
0
0

Other practices : Success was also achieved in motivating

people to use iodized salt as all the subjects in the
intervention group were using iodized salt for cooking,
against 82% and 84% subjects in pre and non-NE group,
respectively. The percentage of women getting their TT
injection immunization completed by the end of
pregnancy was very high (97.9%) in the post-NE group
than the non-NE group (72%). The compliance to IFA
tablets was found to be much better after educational
intervention. At post-NE, 35% subjects had consumed 100
or more tablets in the intervention group, whereas there
was no such subject in the non-NE group. Table 4 gives
the percent distribution of subjects in the post and nonNE groups according to the number of IFA tablets
consumed. Improvement was observed in ANC visits
690

TABLE 4. Percent Distribution of Subjects in the Post and Non-NE

Group According to the Number of IFA Tablets
Consumed
No. of IFA tablets
consumed
0
20
30
40
50
60
70
80
90
100

Percentage of subjects consuming IFA tablets

Non-NE (n=50)
Post-NE (n=46)
46.0
22.0
16.0
16.0
-

2.1
6.5
8.6
2.1
6.5
8.6
10.8
6.5
13.0
34.7

with 59% subjects in the intervention group going for

atleast one ANC visit against 30% in non-NE group. The
percentage of subjects being registered at the AWC by 8th
or 9th month of pregnancy in the post-NE group was 96%
against 34% only in the non-NE group, suggesting the
impact of the NE imparted, though, not much
improvement could be observed in the rest pattern of the
subjects after the intervention.
DISCUSSION
Baseline : In the study population, the mean daily intake
of almost all the foodstuffs and nutrients fell short of the
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Effect of Counseling on Nutritional Status During Pregnancy

recommendations and no significant difference was found
in the mean intake of food and nutrients of subjects
between the middle and late gestation groups, suggesting
no increase in the food intake with advancement of
pregnancy. Similar results revealing inadequate dietary
intake have been reported in a study done on rural
pregnant women working in stone quarry.10 NNMB also
reported the average intake of pregnant women for all the
foodstuffs to be below the recommended levels. 11
Consistent with the findings of the present study, a
similar mean caloric intake of about 40% of recommended
dietary allowances (RDA) has been reported.10 Deficits in
energy intake of pregnant women were also reported in
other studies. 12, 13
In the present study, the mean height of the pregnant
women was 153.9 cm, which was higher as compared to
national estimates,14 but was similar to a study done on
low-SES urban pregnant women in Delhi, which reported
the mean height to be 154.3 cm. 15 There was a slight
improvement in the % reference weight for height
according to gestational age of the pregnant women
(completed 8th/9th month of gestation) from 91.65% in the
non-NE to 92.65% in post-NE group, but the difference
was not significant. This can be attributed to the fact that
since the intervention occurred for varying period and
only in the third trimester, which is known to be the fetal
period, the fetus rather than the mother herself, enjoyed
the benefits of improved nutrition more. Thus, suggesting
that longer period of intervention say from early
pregnancy would be more beneficial. The prevalence of
anemia was high (96.3%) in the study population and it
worsened with advancement of pregnancy. Some other
studies have also reported the prevalence of anemia to be
high (70-100%) in pregnant women. 15, 16
Impact of Intervention: In the present study, NE, in the
form of simple, easy to follow messages with constant
reinforcement, has shown to bring about an improvement
in the dietary intake of the subjects. Some other studies
have also reported significant improvements in dietary
intake of pregnant women as a result of individualized
nutrition counseling during the third trimester. 3, 17 NE
imparted also played a role in increasing the intake of
foodstuffs, as subjects were also observed practicing
emphasized behaviors at post-NE. Though improvements
were observed in food and nutrients intake after
intervention but still the dietary intake in relation to
recommended guidelines was sub-optimal, this could be
achieved if intervention is started in earlier gestation and
is for a long period. Though, the increase in the intake of
roots and tubers, GLVs and fruits could partly be
attributed to the seasonal differences during the study
period as better availability and cheaper costs of fruits and
vegetables coincided with the post-NE survey. But, since
the awareness was built up through intervention, the
subjects consumed these foods.
In the study, counseling, motivation and periodic
reinforcements to take the iron supplements daily and
Indian Journal of Pediatrics, Volume 73August, 2006

regularly resulting in improved compliance to iron

supplements, combined with the improvements in the
dietary intake especially the GLVs consumption, resulted
in improved mean hemoglobin levels of the subjects in the
intervention group as compared to control group. Some
other studies have also shown that regular daily
supplementation of iron and folate to pregnant women
can significantly contribute to reduction in anemia
prevalence. 18, 19
In the present study, the average weight gain per week
in the post-NE group was found to be 0.40 Kg, which was
higher than that reported by other Indian studies, 10, 20 thus
showing the positive effect of intervention.
CONCLUSION
Simple NE messages using holistic approach of targeting
all the major determinants such as the improved food
intake within the socio-economic constraints, iron
supplements, TT injection immunization, use of iodized
salt and ANC, with periodic reinforcements and
motivation, even if imparted primarily in the third
trimester of pregnancy, but in a sustained manner, can be
effective and can bring about improvements in the
nutritional status of underprivileged pregnant women.
Husbands and the mother-in laws also proved as
important change agents.
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