A biocultural framework for examining maternal cravings and aversions among pastoral women in east Africa

Food taboos and their perceived reasons among pregnant women in Ethiopia: a systematic review, 2022

BACKGROUND

There are foods considered as taboo across different communities in the world and in Ethiopia in particular. Although food taboos exist across all ages or physiologic states, they are predominant among pregnant women and children. Identifying such foods among pregnant women is crucial in providing focused interventions and prevents their negative consequences. Therefore, the aim of this review was to review the available evidence on food taboos and their perceived reasons among pregnant women in Ethiopia to provide comprehensive and precise evidence for decision making.

METHODS

Electronic search of the literature was made from Pub-Med, Google Scholar, Google Scopus, and Medline databases using search terms set based on the PICO/PS (Population, Intervention/exposure, Comparison, and Outcome) and PS (Population and Situation) search table. The search was made from December 05, 2020 - December, 29, 2021, and updated on January, 2022. All quantitative and qualitative studies published in English were included in the review. The systematic review protocol was registered at INPLASY (Registration number: INPLASY202310078). The outcome of interest was food taboo for pregnant women and its perceived reasons. The results of the review was narrated.

RESULTS

After identifying eighty two articles, thirteen were found eligible for the review. Vegetables, fruits, and fatty foods like meat, and dairy products were considered as taboo for pregnant women in different parts of Ethiopia. The reasons stated for the food taboo vary from fear of having a big baby, obstructed labour, and abortion to evil eye and physical and aesthetic deformities in the newborn.

CONCLUSIONS

Though not uniform across the country, there are foods considered as taboo for pregnant women in Ethiopia due to several perceived reasons, misconceptions, and societal influences. This could increase the risk of malnutrition and could have short and long term consequences on both the mother and her growing foetus. Therefore, context specific nutritional counseling with emphasis during ante-natal care and post-natal service is important.

Religion, Fetal Protection, and Fasting during Pregnancy in Three Subcultures

Fasting during pregnancy is an enigma: why would a woman restrict her food intake during a period of increased nutritional need? Relative to the costs to healthy individuals who are not pregnant, the physiological costs of fasting in pregnancy are amplified, with intrauterine death being one possible outcome. Given these physiological costs, the question arises as to the socioecological factors that give rise to fasting during pregnancy. There has been little formal research regarding the emic perceptions and socioecological factors associated with such fasting. This study therefore took an emic approach and investigated the types of fasts that are common in pregnancy, women's perceptions of the consequences of fasting, and the socioecological models of pregnancy fasting in three Indian communities. This cross-sectional study took place in Bhubaneshwar, Odisha state, and Mysore, Karnataka state, among two populations of Hindu women and one population of Muslim women (N = 85). In total, 64% of women fasted in prior pregnancies. Findings revealed variation in the number and types of fasts that are common in pregnancy across the three communities. Each community reported differences in positive and negative consequences of fasting, with varied emphasis on reproductive health, religiosity, and general health and well-being. Finally, quantitative analyses indicated that the best-fitting model for fasting during pregnancy was religiosity, and the poorest-fitting models were resource scarcity and general health. This study provides insight into motivations for such fasting and highlights the need to investigate the relationship between supernatural beliefs and maternal-fetal protection further, as well as social functions of pregnancy fasting within the family and community.

Food taboos and related misperceptions during pregnancy in Mekelle city, Tigray, Northern Ethiopia

INTRODUCTION

Most communities, rural or urban, have taboos regarding foods to avoid during pregnancy, and most have local explanations for why certain foods should be avoided. Such taboos may have health benefits, but they also can have large nutritional and health costs to mothers and fetuses. As such, understanding local pregnancy food taboos is an important public health goal, especially in contexts where food resources are limited. Despite this, information regarding food taboos is limited in Ethiopia. Therefore, this study assessed food taboos, related misconceptions, and associated factors among pregnant women in Northern Ethiopia.

METHODS

A cross-sectional study of 332 pregnant women in antenatal care (ANC) follow-up at selected private clinics in Mekelle city, Tigray, Ethiopa, recruited between April and May, 2017. Using a semi-structured questionnaire, we assessed whether respondents' observed food taboos, what types of foods they avoided, their perceived reasons for avoidance, diversity of respondents' diets during pregnancy, and respondents' socio-demographic characteristics. After reporting frequency statistics for categorical variables and central tendencies (mean and standard deviation) of continuous variables, bivariate and multivariable logistic regression analyses were conducted to identify the socio-demographic factors and diet diversity associated with food taboo practices.

RESULTS

Around 12% of the pregnant women avoided at least one type of food during their current pregnancy for one or more reasons. These mothers avoided eating items such as yogurt, banana, legumes, honey, and "kollo" (roasted barley and wheat). The most common reasons given for the avoidances were that the foods were (mistakenly) believed to cause: abortion; abdominal cramps in the mother and newborn; prolonged labor; or coating of the fetus's body. Maternal education (diploma and above) (AOR: 4.55, 95% CI: 1.93, 10.31) and marital status (single) were found to be negatively associated (protective factors) with observances of pregnancy food taboos. Approximately 79% of respondents had pregnancy diets that were insufficiently diverse, although we did not find any statistical evidence that this was associated with adhering to food taboos.

CONCLUSION

The misconceptions related to pregnancy food taboos should be discouraged insofar as they may restrict women's consumption of nutritious foods which could support maternal health and healthy fetal development. Health providers should counsel pregnant women and their husbands about appropriate pregnancy nutrition during ANC visits.

Investigating the association between stress. Anxiety and geophagy among pregnant women in mwanza, Tanzania

Geophagy, the craving and intentional consumption of soil, is common especially among pregnant women in some low- and middle-income settings. Soils may contain a variety of non-nutritive components such as heavy metals and microbes or substances that interfere with gastrointestinal absorptive processes, posing health risks to pregnant women. Several hypotheses regarding the practice have been proposed but very few have examined the role of maternal stress. The practice of geophagy may help to alleviate stress or anxiety during gestation from perceived dietary or other pregnancy-related concerns. In this study, we evaluated several measures of maternal stress (general anxiety, Pregnancy-Related Anxiety Scores (10-item revised), and Perceived Stress Scores) and other covariates in relation to geophagic behaviour in early pregnancy in 227 women (12-19 weeks gestation) recruited from two hospitals in the Nyamagana district of Mwanza City, Tanzania. Geophagy was reported by 24.7% of the pregnant women. Using LASSO regression, self-reported treatment of nausea or vomiting during pregnancy (adjusted OR = 3.12, 95%CI: 1.43 to 6.83), paternal education level (adjusted OR = 2.79, 95%CI: 1.32 to 5.87 for primary or lower education level), antenatal hospital site (adjusted OR = 3.71, 95%CI: 1.78 to 7.75), prescription drug use prior to pregnancy (adjusted OR = 1.76, 95%CI: 0.87 to 3.56) and general anxiety (feeling worried, tense or anxious in the past four weeks) (adjusted OR = 1.81, 95%CI: 0.88 to 3.72) were associated with geophagic behaviour. Given that relatively little has been done to examine geophagy in relation to the public health risk it may pose to pregnant women, these findings suggest the need for further investigations regarding maternal stress.

Reframing HIV Stigma and Fear : Considerations from Social-ecological and Evolutionary Theories of Reproduction

HIV stigma and fears surrounding the disease pose a challenge for public health interventions, particularly those that target pregnant women. In order to reduce stigma and improve the lives of vulnerable populations, researchers have recognized a need to integrate different types of support at various levels. To better inform HIV interventions, the current study draws on social-ecological and evolutionary theories of reproduction to predict stigma and fear of contracting HIV among pregnant women in South India. The aims of this study were twofold: compare the social-ecological model to a modified maternal-fetal protection model and test a combined model that included strong predictors from each model. The study took place in 2008-2011 in Mysore District, Karnataka, India. Using data from a cross-sectional survey and biological indicators of health, we statistically modeled social-ecological variables representing individual, interpersonal, and community/institutional levels. Participants were 645 pregnant women. The social-ecological and combined models were the best-fitting models for HIV-related stigma, and the combined model was the best fit for HIV-related fear. Our findings suggest that combining reproductive life history factors along with individual, interpersonal, and community/institutional factors are significant indicators of HIV-related stigma and fear. Results of this study support a multifaceted approach to intervention development for HIV-related stigma and fear. The combined model in this study can be used as a predictive model for future research focused on HIV stigma and fear, with the intent that dual consideration of social-ecological and evolutionary theories will improve public health communication efforts.

Demand and Supply Side Barriers that Limit the Uptake of Nutrition Services among Pregnant Women from Rural Ethiopia: An Exploratory Qualitative Study

Despite poverty reduction and increased promotion of improved nutrition practices in the community, undernutrition in Ethiopia remains a concern. The present study aimed to explore the demand and supply side barriers that limit the uptake of nutrition services among pregnant women from the rural communities of the Tigray Region, Northern Ethiopia. A community-based qualitative study was conducted in December through January 2017. A total of 90 key informant in-depth interviews and 14 focus group discussions were undertaken. Study participants were purposively selected for specific characteristics, along with health professionals deployed at various levels of the health system, including health posts, health centers, woreda health offices, and the regional health bureau. Study participants were asked to identify the barriers and implementation challenges that limit access to nutrition services for pregnant women. Participants' responses were transcribed verbatim, without editing the grammar, to avoid losing meaning. The data were imported to ATLAS.ti 7 (qualitative data analysis software) for coding and analyzed using a thematic content analysis approach. The study findings indicated that the dietary quality of pregnant women in the study area remains poor and in some cases, poorer quality than pre-pregnancy. Across study sites, heavy workloads, food taboos and avoidances, low husband support, lack of economic resources, lack of awareness, low educational level of women, poor dietary habits, increased expenditure for cultural and religious festivities, "dependency syndrome", low physical access to health facilities, poorly equipped health facilities, focus on child health and nutrition, poor coordination among nutrition specific and sensitive sectors, and limited sources of nutrition information were identified as the demand and supply side barriers limiting the uptake of nutrition services during pregnancy. In conclusion, the community would benefit from improved social behavior change communication on nutrition during pregnancy and multi-sectoral coordination among nutrition-specific and nutrition-sensitive sectors.

Determinants of dietary practices during pregnancy: A longitudinal qualitative study in Niger

Undernutrition is associated with maternal morbidity and poor pregnancy outcomes. This qualitative study seeks to understand the multilevel factors influencing maternal dietary practices in Niger, including the impact of pregnancy illnesses on diet. Criterion-based, purposive sampling was used to select pregnant women and household members from 24 villages in a rural district of the Maradi Region in south-central Niger. Semistructured interviews (n = 153) and focus group discussions (n = 38) explored 4 primary themes: (a) perceptions of ideal diet during pregnancy, (b) barriers to consuming the ideal diet, (c) coping strategies including dietary responses related to pregnancy illnesses, and (d) changes in perceptions from early to late pregnancy. Longitudinal data collection allowed for repeated interviews of pregnant women to document changes in dietary practices throughout pregnancy. Transcripts were coded using an inductive approach informed by grounded theory methodology. Participants categorized foods into 4 primary dietary taxonomies when discussing ideal maternal diets but cited constraints related to accessibility and availability impeding routine consumption of these foods. Perceptions of "modern," urban foods as healthy, coupled with key structural barriers such as food costs, were identified. Maternal morbidity influenced food consumption, as women reported reducing food intake early in pregnancy in response to illness episodes. Although awareness of optimal foods for supporting healthy pregnancies was moderately high, some misconceptions were observed and multilevel barriers to food security restricted opportunities for consuming these foods. Nutrition-specific and nutrition-sensitive interventions could improve access and availability of acceptable foods for supporting increased dietary intake during pregnancy.

A test of four evolutionary hypotheses of pregnancy food cravings: evidence for the social bargaining model

The onset of cravings for items not typically desired is often considered a hallmark of pregnancy. Given the ubiquity of cravings, this phenomenon remains surprisingly understudied. The current study tested four hypotheses of pregnancy food cravings: behavioural immune system, nutrient seeking, resource scarcity and social bargaining. The research took place in Tamil Nadu, South India, with pregnant women residing in rural villages (N = 94). Methods included structured interviews and anthropometric measures. Findings revealed that unripe mango and unripe tamarind were the two most frequently mentioned food cravings among this population, but were not sufficiently supported by the a priori models. Results confirmed that the social bargaining model was the best explanation for the etic category of toxic/pathogenic food items, suggesting that pregnant women crave dangerous foods when experiencing heightened social pressures. Finally, toxicity/pathogenicity was a confounding factor for the nutrient seeking and resource scarcity models, calling into question the validity of these models in adverse environments. Overall, these findings present important implications for research on pregnancy food cravings, such that in resource-scarce and pathogen-dense environments, cravings might target teratogenic items that signal a need for increased social support.

Addressing barriers to maternal nutrition in low- and middle-income countries: A review of the evidence and programme implications

Adequate maternal nutrition during the "first 1,000 days" window is critical from conception through the first 6 months of life to improve nutritional status and reduce the risk of poor birth outcomes, such as low birthweight and preterm birth. Unfortunately, many programmes have targeted implementation and monitoring of nutrition interventions to infants and young children, rather than to women during pregnancy or post-partum. A literature review was conducted to identify barriers to food choice and consumption during pregnancy and lactation and to examine how low- and middle-income countries have addressed maternal nutrition in programmes. A literature review of peer-reviewed and grey literature was conducted, and titles and abstracts reviewed by authors. Twenty-three studies were included in this review. Barriers to adequate nutrition during pregnancy included cultural beliefs related to knowledge of quantity of food to eat during pregnancy, amount of weight to gain during pregnancy, and "eating down" during pregnancy for fear of delivering a large baby. Foods considered inappropriate for consumption during pregnancy or lactation contributed to food restriction. Drivers of food choice were influenced by food aversions, economic constraints, and household food availability. Counselling on maternal diet and weight gain during pregnancy was seldom carried out. Programming to support healthy maternal diet and gestational weight gain during pregnancy is scant. Tailored, culturally resonant nutrition education and counselling on diet during pregnancy and lactation and weight gain during pregnancy, as well as monitoring of progress in maternal nutrition, are areas of needed attention.

Innate food aversions and culturally transmitted food taboos in pregnant women in rural southwest India: separate systems to protect the fetus?

Pregnancy increases women's nutritional requirements, yet causes aversions to nutritious foods. Most societies further restrict pregnant women's diet with food taboos. Pregnancy food aversions are theorized to protect mothers and fetuses from teratogens and pathogens or increase dietary diversity in response to resource scarcity. Tests of these hypotheses have had mixed results, perhaps because many studies are in Westernized populations with reliable access to food and low exposure to pathogens. If pregnancy food aversions are adaptations, however, then they likely evolved in environments with uncertain access to food and high exposure to pathogens. Pregnancy food taboos, on the other hand, have been theorized to limit resource consumption, mark social identity, or also protect mothers and fetuses from dangerous foods. There have been few tests of evolutionary theories of culturally transmitted food taboos. We investigated these and other theories of psychophysiological food aversions and culturally transmitted food taboos among two non-Western populations of pregnant women in Mysore, India, that vary in food insecurity and exposure to infectious disease. The first was a mixed caste rural farming population (N = 72), and the second was the Jenu Kurubas, a resettled population of former hunter-gatherers (N = 30). Women rated their aversions to photos of 31 foods and completed structured interviews that assessed aversions and socially learned avoidances of foods, pathogen exposure, food insecurity, sources of culturally acquired dietary advice, and basic sociodemographic information. Aversions to spicy foods were associated with early trimester and nausea and vomiting, supporting a protective role against plant teratogens. Variation in exposure to pathogens did not explain variation in meat aversions or avoidances, however, raising some doubts about the importance of pathogen avoidance. Aversions to staple foods were common, but were not associated with resource stress, providing mixed support for the role of dietary diversification. Avoided foods outnumbered aversive foods, were believed to be abortifacients or otherwise harmful to the fetus, influenced diet throughout pregnancy, and were largely distinct from aversive foods. These results suggest that aversions target foods with cues of toxicity early in pregnancy, and taboos target suspected abortifacients throughout pregnancy.

Food Aversions and Cravings during Pregnancy on Yasawa Island, Fiji

Women often experience novel food aversions and cravings during pregnancy. These appetite changes have been hypothesized to work alongside cultural strategies as adaptive responses to the challenges posed by pregnancy (e.g., maternal immune suppression). Here, we report a study that assessed whether data from an indigenous population in Fiji are consistent with the predictions of this hypothesis. We found that aversions focus predominantly on foods expected to exacerbate the challenges of pregnancy. Cravings focus on foods that provide calories and micronutrients while posing few threats to mothers and fetuses. We also found that women who experience aversions to specific foods are more likely to crave foods that meet nutritional needs similar to those provided by the aversive foods. These findings are in line with the predictions of the hypothesis. This adds further weight to the argument that appetite changes may function in parallel with cultural mechanisms to solve pregnancy challenges.

Fetal Protection : The Roles of Social Learning and Innate Food Aversions in South India

Pregnancy involves puzzling aversions to nutritious foods. Although studies generally support the hypotheses that such aversions are evolved mechanisms to protect the fetus from toxins and/or pathogens, other factors, such as resource scarcity and psychological distress, have not been investigated as often. In addition, many studies have focused on populations with high-quality diets and low infectious disease burden, conditions that diverge from the putative evolutionary environment favoring fetal protection mechanisms. This study tests the fetal protection, resource scarcity, and psychological distress hypotheses of food aversions in a resource-constrained population with high infectious disease burden. The role of culture is also explored. In the first of two studies in Tamil Nadu, India, we investigated cultural explanations of pregnancy diet among non-pregnant women (N = 54). In the second study, we conducted structured interviews with pregnant women (N = 94) to determine their cravings and aversions, resource scarcity, indices of pathogen exposure, immune activation, psychological distress, and emic causes of aversions. Study 1 found that fruits were the most commonly reported food that pregnant women should avoid because of their harmful effects on infants. Study 2 found modest support for the fetal protection hypothesis for food aversions. It also found that pregnant women most commonly avoided fruits as well as "black" and "hot" foods. Aversions were primarily acquired through learning and focused on protecting the infant from harm. Our findings provide modest support for the fetal protection hypothesis and surprisingly strong support for the influence of cultural norms and learning on dietary aversions in pregnancy.

Interpreting habits in a new place: Migrants' descriptions of geophagia during pregnancy

BACKGROUND AND INTRODUCTION

Previous studies of soil eating, or geophagia, among pregnant women in sub-Saharan Africa indicate the practice is widespread. Various explanations have been explored to explain the global phenomenon of soil eating, with the most compelling explanation focused on clay's ability to prevent or treat intestinal infection. The urban South African context for clay eating is not well understood. This paper explores clay consumption amongst pregnant migrants who are nationals of countries where clay consumption may be common.

METHODS

I conducted in-depth interviews with a purposively selected group of Somali, Congolese, and Zimbabwean women (n = 23). Interviews included questions broadly related to maternal and infant nutrition. In addition, I conducted nine focus group discussions (n = 48) with adult Somali, Congolese (DRC), and Zimbabwean men (N = 3) and women (N = 6), segregated by country of origin and gender. This paper focuses specifically on responses related to geophagia.

RESULTS

While Somali women did not report consuming clay or charcoal, Congolese and Zimbabwean participants self-reported commonly consuming clay during pregnancy, and at times also when not pregnant. Despite having heard public health messaging that discouraged the practice, participants largely did not describe this consumption in terms of health, but rather in terms of craving and habit. Participants described continued consumption of clay in South Africa, and the only reason for ceasing consumption was in cases of severe constipation.

DISCUSSION

The widespread consumption of clay soil by Congolese and Zimbabwean women during pregnancy may be a mechanism through which identity was reasserted and reproduced in a foreign country. Participants' emphasis on clay consumption seemed related to the absence or expense of other craved foods, and perhaps also to feelings of loss in Cape Town.

Pregnant in a foreign city: A qualitative analysis of diet and nutrition for cross-border migrant women in Cape Town, South Africa

How do migrant women navigate their food environment during pregnancy? Foods are imbued with new meanings in a new place, and in low-and-middle-income countries including South Africa, a changing food environment leaves the poor, including many migrants, vulnerable to malnutrition. Thus, one of the ways economic and social vulnerability may be experienced and reproduced is via the foods one consumes. Examining food perceptions in the context of pregnancy offers a potentially powerful lens on wellbeing.

METHODS

Nine focus group discussions (N = 48) with Somali, Congolese, and Zimbabwean men and women, and 23 in-depth interviews with Congolese, Somali and Zimbabwean women living in Cape Town were conducted, exploring maternal and infant nutrition. We used thematic analysis to guide analysis.

RESULTS

(1) Participants described longing for self-categorised "traditional" foods, yet had limited access and little time and space to prepare these foods in the manner they had back home. (2) Sought-after foods available-and even celebratory-for migrants in Cape Town during pregnancy tended to be calorie-dense, nutrient poor fast foods and junk foods. (3) The fulfilment of cravings was presented as the embodiment of health during pregnancy. (4) Iron-folic acid supplementation was perceived as curative rather than preventive. (5) While participants did not describe hunger during pregnancy, food scarcity seemed possible.

DISCUSSION

Food perceptions during pregnancy reflected migrants' orientation towards home. Fast foods were widely acceptable and available during pregnancy. These foods were not perceived to have negative health consequences. Nutrition interventions targeting migrants should consider the symbolic nature of food, the increasingly globalised food environment in urban LMIC settings, as well as the contexts in which health perceptions evolve.

Gender roles and perceptions of malaria risk in agricultural communities of Mwea Division in Central Kenya

We examined gender differences in the perception of high malaria risk in women and factors associated with a high number of malaria episodes in the Mwea Division of Central Kenya. Ethnographic and successive free listing interviews (an open-ended data collection technique used to show the relation of items in a given domain) with 53 key informants and structured interviews conducted from June to October 2010 with 250 respondents who represented the socioeconomic and geographical diversity of the area were analyzed. Qualitative text analysis and inferential statistics were employed. While a greater proportion of men (51.6%) attributed women's high malaria risk to their "biological weakness," most women believed that their high malaria risk was related to their role in the agricultural fields (43.6%) and to their household responsibilities (23.1%). Compared to men, women were more likely to work in wet aspects of agricultural activities (χ(2) (2, N = 153) = 13.47, p < .01). Women were nearly twice as likely as men to report high episodes of malaria (adjusted odds ratio: 2.54; 95% confidence interval: 1.05-6.15). Culturally prescribed gender roles in agricultural communities in Mwea may play an important role in explaining disparity in reported malaria incidence. While identification of ecological and economic determinants of malaria is important, gender-based research can make a significant contribution to the development of effective and sustainable malaria reduction strategies.

Biocultural considerations of food cravings and aversions: an introduction

Food is fundamental to our existence as humans, but assertions about the kinds of foods that are appealing or repulsive vary widely. This thematic issue deals with assessments of food as desirable, or not, in order to understand the complex reasons why some foods are strongly craved while others are avoided. To do this, the five articles in this issue situate food cravings and aversions bioculturally, in the contexts of our history as a species, in the landscape of cultural heritage, and in the individual life course. By exploring both the biological and cultural mechanisms that shape food preferences, we reveal the complex and important underpinnings of the critical endeavor of food selection.