Undernutrition and associated factors among pregnant women attending antenatal care at Awash Sebat Health Center, Afar Region, Ethiopia

Maternal undernutrition remains a major public health problem in low- and middle-income countries, including Ethiopia, where it contributes substantially to adverse maternal and neonatal outcomes. This study aimed to determine the prevalence of undernutrition, identify associated factors, and explore cultural food taboos among pregnant women attending antenatal care (ANC) at Awash Sebat Health Center, Afar Region, Ethiopia. A facility-based convergent mixed-methods study was conducted among pregnant women attending ANC. Systematic random sampling was used to recruit participants for the quantitative component, while purposive sampling was employed for focus group discussions. Descriptive statistics were used to summarize participant characteristics. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with maternal undernutrition. Qualitative data were analyzed using the Framework method. The prevalence of maternal undernutrition was 38.1%. Maternal undernutrition was associated with higher odds among illiterate women (adjusted odds ratio [AOR] = 4.20, 95% confidence interval [CI]: 1.50–10.80), those with a monthly household income below 1500 Ethiopian birr (AOR = 5.62, 95% CI: 2.40–15.98), a birth interval of less than 2 years (AOR = 3.70, 95% CI: 1.15–12.50), no prior ANC utilization (AOR = 5.88, 95% CI: 1.35–25.00), and low dietary diversity (AOR = 3.45, 95% CI: 1.78–6.89). In contrast, women from households with 4 or fewer members had significantly lower odds of undernutrition (AOR = 0.17, 95% CI: 0.08–0.71). Qualitative findings indicated that many pregnant women avoided protein-rich foods, fruits, vegetables, milk products, and semi-solid foods because of cultural beliefs that these foods increase fetal size, complicate childbirth, or adhere to the fetus. These beliefs appeared to contribute to poor dietary diversity, although food taboos were not independently associated with undernutrition. More than one-third of pregnant women were undernourished. Maternal education, household income, family size, birth spacing, ANC utilization, and dietary diversity were independently associated with maternal undernutrition. These findings highlight the importance of strengthening maternal nutrition education, improving socioeconomic conditions, promoting adequate birth spacing, encouraging ANC utilization, and addressing harmful food taboos through culturally appropriate nutrition education to support maternal nutritional well-being in pastoral communities.