Study setting and period
The study was conducted in East Shoa Zone from January 4, 2021 to February 28, 2022. The zone is one of the 20 zones in the Oromia Region. In Ethiopia, a region and zone are the first and second level administrative divisions, respectively. Zones are further divided into a number of woredas. The total population in the East Shoa zone is 1,567,953 of which 48.3% were female. The number of estimated pregnant women was 54,408. According to the East Shoa zone health office, the health service delivery is organized under 3 hospitals, 59 health centers, and 290 health posts. The food production system in the district is characterized by mixed crop-livestock farming.