Introduction

Food insecurity is a multidimensional health risk characterized by anxiety over accessing sufficient, safe, and nutritious food. This includes concerns about the quantity, quality, and frequency of food consumption, as well as limited access to affordable and culturally appropriate food options1,2. In 2023, the American Food and Agriculture Organization (FAO) estimated that 733 million people were undernourished worldwide, while 2.33 billion people experienced moderate or severe food insecurity, including 864 million facing severe food insecurity3. It was also reported that approximately two billion people worldwide are at risk of moderate or severe food insecurity4. In 2020, the prevalence of food insecurity was 60% among people in Africa, 40% in the Caribbean and Latin America, 25% in Asia, and 8.8% in Europe and North America2.

Determinants of food insecurity include socioeconomic status, household size, education, and gender, though their importance varies across populations5. Studies have shown that the negative impact of food insecurity on health outcomes is more pronounced in certain population groups. These include disadvantaged communities, young children, women in reproductive age, and pregnant and breastfeeding women6,7,8,9. In fact, women living in low- and middle-income countries are more at risk of food insecurity during pregnancy and breastfeeding because of increased nutritional needs, socio-economic restrictions, social norms, intensity of agricultural work, and short spacing between pregnancies10.

Studies found that food insecurity is related to adverse pregnancy outcomes such as obesity11, excessive gestational weight gain11,12, gestational diabetes13, hypertension14, anemia14, preterm pregnancy15, reduced quality of life and psychosocial outcomes (anxiety, stress and depression)16,17, and other pregnancy problems. Furthermore, food insecurity in pregnant women has a subsequent negative effect on the child health and development8. Intergenerational effects cause an increase in infant mortality and their long-term negative consequences18,19. A study in the USA showed that maternal food insecurity was associated with an increased risk of low birth weight (LBW)17 and birth defects such as transposition of the great arteries, Tetralogy of Fallot, cleft palate, spina bifida and anencephaly20. Finally, food insecurity increases the burden of health costs in society4.

Given that societal health and progress are significantly influenced by the health of women, and recognizing the profound impact of pregnancy and childbirth on women’s well-being21, the health of pregnant women has become increasingly critical. Pregnancy is a stage of life in which there are short- and long-term health consequences for the mother and child. Therefore, this is a golden opportunity for health providers to positively influence the health of the mother and child. One of the goals of Sustainable Development Goals (SDGs) is to end hunger by 2030. This includes ensuring access to safe and nutritious food for all people throughout the year, with a specific focus on the needs of pregnant and lactating women22. This goal obliges governments to consider the factors that threaten the food supply of pregnant women and caregivers and the adequacy of nutrition for children. It is crucial to consider both endogenous and exogenous economic shocks, including sanctions, as these can significantly impact family welfare, leading to poverty and compromising household food security, particularly for pregnant women and children23. Existing research provides insufficient evidence best summarizing the factors associated with food insecurity in Iran, specifically among pregnant women. Identifying these factors is crucial to understand and know how and when to implement strategies that specifically target food insecurity in this population group24. We previously conducted a research examining the prevalence of food insecurity and its associated factors among households in Ahvaz, Iran in 2013. Previous studies on food insecurity in pregnant women were also conducted in the cities of Tehran25, Yazd26, Rasht27, and Khorramabad28 in Iran. Since 2018, Iran has faced a significant increase in sanctions. This has contributed to rising inflation, while wages have failed to keep pace. This economic disparity can severely limit individuals’ access to adequate food.

Despite the limited studies investigating food insecurity among pregnant women in Iran, no study has addressed this topic in south of Iran. Therefore, this study aimed to determine the prevalence of food insecurity and to identify its associated factors among pregnant women attending public health centers in Ahvaz, southwest Iran.

Materials and methods

Study design

This cross-sectional study was conducted on 692 pregnant women referring to public health centers in Ahvaz, Iran from April 2023 to May 2024. The Research Ethics Committees of Ahvaz Jundishapur University of Medical Sciences approved the study protocol (Ref. ID: IR.AJUMS.REC.1402.022).

Inclusion criteria

Pregnant women aged 18–45 years old who were admitted to a public health center and were willing to participate in the study were eligible to be included in the study.

Exclusion criteria

Exclusion criteria were having particular diseases that presented health complications or necessitated special needs (e.g., chronic diseases like diabetes, hypertension, etc.).

Sample size

The initial sample size was calculated based on Rasti et al.’s study29 and ratio estimation formula where α = 0.05, d = 0.05, P = 51%, and design effect (df) = 1.8. The final sample size was calculated to be 692 participants.

$$\begin{aligned} & {\text{N}} = {\text{ Z}}^{2} _{{{\text{(1}} - \alpha )}} {\text{p}}(1 - {\text{p}})/{\text{d}}^{2} \\ & {\text{(1}}{\text{.96)}}^{{\text{2}}} {\text{ (0}}{\text{.51) (0}}{\text{.49)/ (0}}{\text{.05)}}^{{\text{2}}} = {\text{384}} \\ & {\text{384}} \times {\text{1}}{\text{.8}} = {\text{692}} \\ \end{aligned}$$

Although to increase statistical power and also considering that some questionnaires might be incomplete, the sample size was increased to 702 people.

Data collection

Data collection involved multi-stage sampling. In the first stage, stratified random sampling was done to select public health centers. Using the list of Ahvaz public health centers, health care centers were classified into two strata, namely East and West. From each stratum, one to three health centers were randomly selected, based on the size of the population served. Then, each health center was considered as a cluster. A list of pregnant women of each center was prepared. Participants entered the study randomly (using random table) based on the number of pregnant women nominated by the health center. Participants who met the inclusion criteria were contacted by phone and briefed on the study objectives and procedures. Informed consent was obtained from eligible women. The questionnaire was completed by face-to-face interview in a private room.

Measurements

Gestational age (GA) was calculated using the first day of the last menstrual period (LMP), or ultrasound in the first trimester of pregnancy. Height and weight were measured by one of the researchers (FR) using a stadiometer and a scale. The mother’s body mass index (BMI) was calculated by dividing the weight (kg) by the squared height (m2). Demographic characteristics as well as the obstetrics and medical histories of the mothers were recorded. Also, the information required for further communication with mothers was obtained and recorded. Finally, the Household Food Insecurity Access Scale (HFIAS) was completed. Women were asked to answer the questions on behalf of their entire household.

Instruments

Demographic and obstetrics questionnaire

The demographic and obstetric questionnaire included information related to age, education level, occupation of the woman and her husband, economic status, type of family (nuclear or extended), number of children, and information about pregnancy including LMP, planned or unplanned pregnancy, and gestational age.

Food insecurity of [articipants were measured using the Household Food Insecurity Access Scale (HFIAS). This scale was developed by the food and agricultural organization (FAO) of the United States and the food and nutrition technical assistance project (FANTA) in 2007. This scale contains 9 items scored based on a four-point Likert scale as follows: 0 = never, 1 = rarely (1 or 2 times per week), 2 = occasionally (3–10 times per week), 3 = frequently (> 10 times per week). It assesses food access of family members. This scale examines three areas of food insecurity: concern and uncertainty about household food supply, inadequate quality (including variety and food preferences), calorie intake and its physical effects. The scoring range for each question is 0 to 3, yielding a total score range of 0 to 36 for the instrument. According to the total scores of questionnaire, food insecurity is classified into four areas: (1) Food security (score 0–1), (2) Mild food insecurity (score 2–7), (3) Moderate food insecurity (score 8–14), and (4) Severe food insecurity (score 15–27)30.

The face, content, and construct validity of the Persian version of the questionnaire was confirmed by Salarkia et al. The validity of the questionnaire was assessed using factor analysis, and its reliability was confirmed by obtaining a Cronbach’s alpha of 0.9531.

Statistical analysis

Statistical data analyses were conducted in SPSS version 23.0 (SPSS, Inc., Chicago, IL, USA). Kolmogorov-Smirnov test was used for assessing the normality of variables, and the data were reported as mean ± SD and frequency (percentage). The relationship between categorical variables was investigated using chi-square test. The relationship between quantitative variables and food security of pregnant women was checked using one-way ANOVA and Post-hoc Tukey test, binary logistic regression, and multiple logistic regression. P < 0.05 were considered statistically significant.

Ethics and dissemination

This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (Ref. ID: IR.AJUMS.REC.1402.022). All participants gave their informed permission. The study’s findings will be shared via the publishing of peer-reviewed articles, talks at scientific conferences and meetings with related teams.

Results

This study investigated the food security status of 702 pregnant women. The mean age of the participating women was 26.07 ± 6.36 years (15–44 years), and the mean gestational age was 32 weeks. Also, 94% of women were housewives, and 33.3% had secondary high school education (Table 1).

Table 1 Sochiodemographic and pregnancy characteristics.
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The prevalence of food insecurity among pregnant women was 48.4%. Of these, 18.2% experienced mild food insecurity, 16.7% moderate food insecurity, and 13.5% severe food insecurity (Fig. 1).

Fig. 1
figure 1

Prevalence of food insecurity during pregnancy.

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As presented in Table 2, there was a significant relationship between age (women and husband) and food insecurity, with older women having significantly more food insecurity (P < 0.001). More food insecurity was also observed among women with lower educational attainment (P < 0.001). The same was true for lower educational attainment of husbands (P = 0.007). The family’s lower economic status was associated with more food insecurity (P < 0.001). Also, food insecurity was more common in extended families compared with nuclear families (P < 0.001). The severity of food insecurity was associated with the husband’s employment. Unemployed husbands were more likely to experience higher levels of food insecurity followed by those were as freelancers, manual workers, and employees (P = 0.007). No relationship was found between food insecurity and women’s occupation (P = 0.172) and ethnicity (P = 0.398).

Table 2 The crude and adjusted odds ratios of the assessed factors for predicting food insecurity of pregnant women using the logistic regression model.
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The findings show the relationship between food insecurity and some obstetrics variables. Food insecurity increases with decreasing gestational age (P = 0.04). Tukey’s test indicated the severity of food insecurity increased from mild to severe with an increase in gravidity (P < 0.001, F = 11.34), parity (P < 0.001, F = 8.88), live births (P < 0.001, F = 10.21) and abortion (P = 0.02, F = 3.04). However, food insecurity had no statistically significant relationship with stillbirth, planned pregnancy, contraceptive method, and BMI before and during pregnancy (P > 0.05) (data are not shown in tables).

Table 2 shows the results of crude and adjusted logistic regression. The crude odds ratios obtained by the logistic regression model showed that food insecurity significantly increased with higher maternal and paternal age, poor economic status, lower gestational age, higher gravidity, higher parity, a history of abortion, and the number of live births (P < 0.05). Nuclear family exhibited a 1.4-fold reduced odds of experiencing food insecurity compared to extended family (OR = 0.674, 95% CI 0.461–0.986, P = 0.042)). Also, employed women were 2 times less likely to experience food insecurity than housewives (OR = 0.512, 95% CI 0.265–0.991, P = 0.047)). In contrast, no significant associations were seen between food insecurity and BMI prior to pregnancy, contraception method, desired pregnancy, and stillbirths (Table 2).

After adjusting for potential confounders in the multiple logistic regression model, the odds of experiencing food insecurity increased by 30% for each additional abortion (OR = 1.308, 95% CI 1.119–1.529, P = 0.001) and by 38% for each additional live birth (OR = 1.383, 95% CI 1.068–1.791, P = 0.014). The adjusted odds of women’s food insecurity increased 2.74 times in women married to men with middle school education compared to those whose husbands had a university degree (OR = 2.747, 95% CI 1.310–5.761, P = 0.007)). Furthermore, poor and moderate economic status was associated with a 5-fold increase in food insecurity (OR = 5.016, 95% CI 3.141–8.008, P < 0.001) compared to good economic status. Gestational age was not significantly associated with food insecurity in the adjusted model (Table 2).

Discussion

The aim of this study was to investigate the prevalence of food insecurity and the associated factors among pregnant women referring to public health centers in Ahvaz, southwest of Iran. Access to sufficient, diverse and quality food resources or food security is essential for human growth and development32. Food insecurity during pregnancy poses a significant risk due to the critical role of adequate nutrition in supporting optimal fetal growth and positive pregnancy outcomes. Also, Pregnancy-related healthcare costs can further exacerbate food insecurity due to increased financial strain33.

The prevalence of food insecurity among pregnant women in this study was 48.4%, with 18.2% experiencing mild, 16.7% moderate, and 13.5% severe food insecurity. Fathi Beyranvand et al. reported a food insecurity prevalence of 43.2% among pregnant women in Iran28. Also, the prevalence of food insecurity in general population was 44% in Iran in 201429 The prevalence of food insecurity was reported to be 67.4% in Ethiopia5, 14.7% in the United States, and 15.6% in California34. These results indicate that food insecurity has increased in Iran, partly due to sanctions, high inflation rate, and reduced incomes of Iranian households34.

The results of present study showed a direct relationship between age and food insecurity. Similar results were reported by Laraia et al.11 and Walker et al.35. However, several studies did not find such an association between age and food insecurity5,28,36,37. Aging is often associated with increased caregiving responsibilities towards children and family. This can lead to a prioritization of their nutritional needs over one’s own, increasing the risk of food insecurity for the caregiver. Also, nutritional needs change with increasing age, which is not noticed in many regions of the world11.

Our study showed a significant association between low educational attainment and higher levels of food insecurity. Notably, a low level of education among husbands was particularly strongly linked to an increased risk of food insecurity among their wives. Various studies in California35, Malaysia38, Canada39, South Australia40, the United States41 and other areas32,42,43,44,45 have found an inverse relationship between education level and food insecurity. Higher levels of education are typically associated with increased awareness of health and nutrition, which empowers pregnant women and their partners to make more informed and healthier dietary choices5,28. In addition, a higher level of education leads to better job opportunities and increased income, which can facilitate access to higher-quality and more nutritious food5.

Our study identified the husband’s employment status and the family’s economic status as significant factors influencing household food security. According to our results, poor economic status was the strongest factor related to food insecurity. In our study, we did not find a significant association between the woman’s employment status and food insecurity. This finding contrasts with previous research, which has demonstrated that employed pregnant women generally experience lower levels of food insecurity compared to unemployed women5,32,45,46,47. Previous studies have also shown that pregnant women with higher economic status are less likely to experience food insecurity11,38,42,46,48,49. In most families, men are typically the head of the household and their job affects the income and economic status of the family and pregnant women. Poor pregnant women with a low wealth index may have no or only one source of income. Extreme poverty in such situations can severely restrict access to nutritious food, making it difficult to meet the dietary needs of the family and exacerbating food insecurity5. In fact, in economically disadvantaged households, there is a tendency towards increased consumption of energy-dense, nutrient-poor snacks, such as sweets and soft drinks. These readily available and inexpensive options often displace more nutritious and balanced meals, contributing to dietary inadequacies50,51. Furthermore, poor families often cut out at least some food items, which can seriously exacerbate food insecurity.

Although we did not find a relationship between BMI and food insecurity, but Fathi Beyranvand et al.28, Olson52 and Laraia et al.11 found a direct association between BMI and food insecurity. These discrepancies could be attributed to prevalence of childhood food insecurity among the populations examined. Past long-term food insecurity causes short stature and affects BMI28. Household food insecurity may increase the consumption of highly palatable foods through a stressful pathway and/or through economic dependence on cheap and energy-dense foods, leading to obesity and increased BMI16.

Our results showed a direct relationship between food insecurity and gravidity, parity, and live births. In addition, the rate of food insecurity in pregnant women was higher in extended families compared with nuclear ones. Areba et al. reported a direct relationship of gravidity, parity, and family size with food insecurity5. Shariff et al.38 and other studies also found an association between food insecurity in pregnant women and the number of children and gravidity11,28,36,41. Laraia et al. reported that food insecurity is more common in extended families53. The results of above-mentioned studies confirm our results. Household composition affects food insecurity, and larger households generally require greater food resources. Having a child in the family is associated with expenses such as education, school transportation, clothing, and health care. In households with limited income, increased non-food expenses can necessitate a reduction in food expenditures. Consequently, larger households, with their increased demands for food and higher overall expenses, may experience a decline in the quantity and quality of meals, thereby increasing the risk of food insecurity. In fact, as the number of family members increases, the demand for food naturally rises. This increased demand can strain the food budget, potentially leading to reduced food access and inadequate food intake for all members28.

In our study, a relationship was observed between abortion and food insecurity. In households experiencing poverty, food insecurity, and limited economic resources, particularly those with large family sizes, there may be an increased risk of intentional abortions. These abortions are often performed under unhygienic and potentially dangerous conditions, leading to significant health risks for women. Furthermore, the costs associated with these unsafe procedures can exacerbate financial hardship, potentially further impacting household food security54. Furthermore, food insecurity indirectly contributes to abortion by affecting the health of pregnant women and causing diabetes and blood pressure13,14.

Our results showed an inverse relationship between gestational age and food insecurity. However, we did not observe a relationship between food insecurity and factors like contraception method and desired pregnancy, which is consistent with Areba et al. who did not find a relationship between desire for pregnancy and food insecurity5.

Recommendations for policymakers

To address food insecurity among pregnant women in Southwest Iran, policymakers should implement multifaceted strategies targeting the key determinants identified in this study. Economic support programs, including financial aid, subsidies, or employment opportunities, are essential to assist low-income households, which are most vulnerable. Promoting educational opportunities for women and their partners can increase nutritional awareness, improve income potential, and empower healthier food choices. Targeted interventions should prioritize large and extended families, as these households face higher food demands. Additionally, culturally sensitive maternal nutrition programs can ensure pregnant women receive adequate and diverse food, while considering family dynamics that may prioritize other members. Finally, coordinated efforts between governmental and non-governmental organizations are recommended to simultaneously address economic, educational, and reproductive health factors, thereby effectively improving food security among pregnant women in the region.

Limitations of the study

This study employed a cross-sectional design, which inherently limits the ability to establish causal relationships or determine temporal effects. Furthermore, the subjective nature of self-reported food insecurity data introduces potential biases. Participants may overestimate or underestimate their experiences with food insecurity, potentially impacting the accuracy of the findings.

Conclusion

Our results showed a high prevalence of food insecurity among pregnant women, which is affected by obstetric and demographic factors. The effect of economic status was stronger than other variables. It is recommended that, health policy makers as well as governmental and non-governmental organizations consider new strategies to improve food security by changing the influencing variables, creating space for education, employment, and better income, especially in low-income households with large households.