This dissertation comprises of nine concrete chapters and annexes pertinent for the study. The first chapter is all about introduction containging background, problem statement, significance of the study, hypothesis and objectives of the PhD research. The second chapter is review of literatures relevant to the study. The third chapter comprehensively describes materials and methods of the dissertation research work. The chapters from IV to VIII deal with the findings of each of the four specific obejctives of the dissertation research, while, chapter IX contains general discussions, conclusions and recommendations. Background: Pregnancy is a unique period in a woman's life, characterized by anatomical, physiological, and biochemical changes that affect nearly all organ systems. During this time, a diverse diet is essential to provide the necessary nutrients to meet the increased nutritional requirements. Pregnant women should consume healthy foods, including chicken eggs, fish, lean meats, fruits, vegetables, legumes, whole grains, and healthy fats those are rich sources of essential nutrients. Among these foods, chicken eggs are particularly valuable. They are a nutritionally complete and naturally nutrient-dense option, supplying easily digestible nutrients, including high-quality protein, vitamin D, vitamin A, vitamin B12, folate, choline, and longchain omega-3 fatty acids. Specific nutrients, such as dietary iron and folate, are crucial during pregnancy. They play significant roles in achieving optimal birth outcomes and supporting the rapid growth and development of the fetus. Folate is essential for DNA synthesis and methylation reactions, while iron is vital for the function of red blood cells (RBCs) and white blood cells (WBCs), as well as for tissue oxygenation and blood formation. The requirement for folate during the first 28 days after conception is increased by 0% to 50% and the requirement for iron increases during the second and third trimesters. Globally, 28.8% of pregnant women met the minimum dietary diversity for women (MDD-W) indicating that large number of these women suffer from inadequate intake of micronutrients. The burden of intake of inadequate micronutrient is obviously higher in developing countries, resulting in adverse pregnancy outcomes. In Ethiopia, diets are typically dominated by starchy cereals, root crops and legumes and often include little to no animal products, as well as fresh fruits and vegetables. Consequently, micronutrient malnutrition becomes highly prevalent in the v country. Prior research studies concluded that inadequate micronutrient intake among pregnant women is attributable to poor dietary practices, poor knowledge, and wrong perceptions. This in turn leads low body mass index (BMI), micronutrient deficiencies, subsequent suboptimal weight gain, and increased risk of poor birth outcomes like preterm birth (PTB) and low birth weight (LBW). Several literatures denote that nutrition education is a well-established intervention to enhance optimal dietary practices and is crucial to designing appropriate diet interventions. However, the effects of integrated nutrition education and egg base diet intervention on improving nutrient adequacy, nutritional status and optimal birth outcomes were not well studied in Ethiopia. Objectives: This study was designed to assess the validation of food variety score (FVS) and dietary diversity score (DDS) as proxy indicators of nutrient adequacy; to evaluate the effect of nutrition education on improving nutrient adequacy and serum levels of ferritin and folate, and to examine the effect of an egg-based diet intervention coupled with healthy dietary advice on nutrient adequacy and nutritional status among pregnant women. The study also intended to determine adequate diet during pregnancy is associated with reduced risk of adverse birth outcomes and low serum ferritin and folate levels. Materials and Methods: This study employed a community-based cross-sectional, cluster randomized controlled trial (cRCT) and prospective cohort studies designs. The study was conducted on randomly selected pregnant women from two districts of Northern Zone, Sidama Region, Ethiopia. The women were selected at first trimester. A multiple-pass 24-hour dietary recall method with standard 10-food groups was used to estimate the DDS and FVS. Nutrient adequacy ratio (NAR) was estimated using the mean adequacy ratio (MAR) of the micronutrients. Receiver operating characteristic (ROC) curve analysis that gives maximum sensitivity and specificity was employed to define the cutoff points of DDS and FVS. Additionally, randomly selected pregnant women were recruited in a ratio of 1:1 of intervention and control group for cRCT. Nutrition education intervention (NEI) was delivered using health belief model (HBM) theory for the intervention groups, while the standard health care was given for control groups. Between group differences in mean scores on DDS, nutrient intake, nutrient adequacy and serum ferritin and folate levels were tested using an independent samples t-test. A linear mixed model (LMM) vi was used to evaluate the effect of interventions on adequacy and serum levels of the ferritin and folate accounting for the clustering effect. In egg-based diet intervention trial, chicken and nutrition messages were provided for intervention group at the health post for 12 weeks in two sessions per week, whereas standard healthcare was given to the control group. Between groups differences in mean scores for nutrient adequacy and nutritional status indicators were tested using Chi-square and independent samples t-test in addition to make alnalysis using LLM accounting for the clustering effect. For the prospective cohort study, a total of 438 pregnant women were recruited in the first trimester. The maternal weight and height were measured before 12 weeks‘ gestation. Prepregnancy BMI was calculated in the first trimester, and maternal weight and mid-upper arm circumferences (MUAC) were measured subsequently every trimester until delivery. Serum ferritin and folate levels were measured at first study visit in 12th week of gestation. Pearson‘s correlation test was employed to determine significant relationships between maternal anthropometric indicators. A poisson regression analysis with a robust variance estimate was used to identify predictors of PTB and LBW. Results: Chapter IV presents results on the validation of FVS and DDS as proxy indicators of nutrient adequacy. It was found that MDD-W showed a positive correlation (ρ = 0.159, 95% CI: 0.065-0.250) (p = 0.001), and had good predictive ability (AUC = 0.839, 95% CI: 0.80 to 0.88) (p < 0.001) of MAR of micronutrient. The sensitivity and specificity of the MDD-W in the ≥5 food group‘s standard cutoff were 69.9% and 5.3%, respectively. Chapter V shows results on effect of nutrition education on nutrient adequacy and serum levels of ferritin and folate during pregnancy. A significant difference was observed in mean serum ferritin and folate levels between the intervention and control groups (p < 0.001). NEI was positively associated with adequate intake of folate (β = 28.52, 95% CI: 14.671, 42.367, p<0.001), iron (β = 9.320, 95% CI: 3.119, 15.536, P = 0.003), serum levels of ferritin (β = 12.107, 95% CI: 4.406, 19.809, p = 0.004), and folate (β = 2.263, 95% CI: 1.852, 2.675, p = 0.001). Chapter VI contains results on the effect of an egg-based diet intervention coupled with healthy dietary advice on nutrient adequacy and nutritional status among pregnant women. It was found that nutrition intervention was positively associated with MUAC (β =0.54, 95% CI: 0.281, 0.782, p < 0.001) and MAR (β = 344.019, 95% CI: 275.965, 412.073, p < 0.001). The nutrient intakes vii varied significantly among the study participating pregnant women. For instance, calcium and vitamin D were very low (1.97-19.9%), vitamin B12 42.1%, protein, folate, and vitamin A were moderate (64-80.6%), while iron intake was high, 95.4%. The MAR of individual nutrients were increased from 20.00 ± 0.0 to 161.36 ± 73.58 after introduction ofegg-based diet (p < 0.001). Chapter VII presents results on maternal consumption of inadequate diet during pregnancy are associated with an increased risk of low serum levels of essential micronutrients and adverse birth outcomes. The average gestational age at birth was 37.50 weeks and a low birth weight accounted for 37.3%. The prevalence of preterm birth was higher among women who had an inadequate DDS (AOR=0.52, 95% CI: 0.301, 0.890), consumed dietary folate below recommended level (AOR=1.48, 95% CI: 0.741, 2.932), undernourished women (AOR=1.105, 95% CI: 0.98, 1.24), a women with serum folate level <2.6–15 µg/L (AOR=0.760, 95% CI: 0.552–0.933). The prevalence of low birth weight was higher among women with underweight (AOR=1.126, 95% CI: 1.003, 1.23), short stature (AOR=11.341, 95% CI: 1.097, 11.421), under nutrition (AOR=1.141, 95% CI: 1.025, 1.270), intake of dietary iron bellow <27(EAR) (AOR=6.348, 95% CI: 4.144-9.724), serum ferritin of below <15 µg/L (AOR=1.588, 95% CI: 1.008, 2.502), and inadequate DDS (AOR=2.148, 95% CI: 1.778-2.596). Conclusions: The study demonstrated that NEI improved daily iron and folate intake as well as serum levels in pregnant women. Additionally, interventions that included egg-based dietary advice positively impacted nutrient adequacy and overall nutritional status. However, despite these benefits, there were still high rates of PTB and LBW. Factors such as low DDS, insufficient folate intake and serum levels, inadequate weight gain (less than 11.5-16 kg), and low MUAC < 23 cm were significant predictors of PTB. Similarly, being underweight, having short stature, malnutrition, experiencing PTB, low total GWG, and low serum ferritin levels were significant predictors of LBW. To address pregnancy-related malnutrition caused by micronutrient deficiencies, it is essential to integrate nutrition behavior change communication with egg-based interventions. Healthcare professionals should actively promote egg consumption during pregnancy through targeted communication efforts directed at families and communities. Enhanced public health initiatives that include nutrition support and anthropometric monitoring during antenatal care are crucial for improving birth outcomes.

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EFFECTS OF NUTRITION EDUCATION AND EGG-BASED DIET INTERVENTIONS ON DIETARY INTAKE, NUTRIENT ADEQUACY AND NUTRITIONAL STATUS AMONG PREGNANT WOMEN AND BIRTH OUTCOMES IN THE SIDAMA REGION, ETHIOPIA: A CLUSTER RANDOMIZED CONTROL TRIAL	3

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