2.1 Introduction
This chapter reviews the related literature on factors contributing to malnutrition among pregnant women. It is organized according to the objectives which include: the personal factors that contribute to malnutrition among pregnant women the social-economic factors contributing to malnutrition among pregnant women and the cultural factors that contribute to malnutrition among pregnant women.
2.2 Personal factors contributing to malnutrition among pregnant women.
Several studies have shown that educational intervention not only increases knowledge about a proper diet in pregnancy (Rao, et al., 2008), but also are positively correlated with good eating habits (Kim, et al., 2009). In addition, (Liu, et al. 2009) observed that educational intervention enables pregnant women to change unhealthy practices and consequently decrease on the prevalence of postpartum complications. It is therefore of paramount importance to include nutrition as one of the health education topics given to pregnant women during their antenatal checkups.
MA Mbule et al (2013) carried out a cross-sectional descriptive institutional based study in Ethiopia to assess knowledge of pregnant women about maternal nutrition and factors associated with it during pregnancy on a sample of 422 pregnant women during January to June of the year 2013. It was revealed that nutrition knowledge was predictive of change in dietary habits and health advices encouraged expectant women to advance their food intake. This study revealed that out of 422 pregnant women more than half (57.8%) of the respondents did not know the meaning of food.
Regarding attitudes, pregnant women may believe there are no advantages in attending ANC in the first 3 months of pregnancy 37, because ANC is viewed primarily as curative, rather than preventive (MA Mbule et al 2013).
Schaefer, C., e al (2014), reported that pregnant women do not have confidence in the health system because of inadequate services and medicines, which in part contributes to the high usage (73%) of traditional indigenous medicine as an alternative to ANC in Uganda (MA Mbule et al 2013). Such attitudes and misconceptions contribute to the high prevalence of malnutrition among pregnant women. Thus, apart from availing all ANC services and medicines at health facilities, community based health education programs are needed to correct negative attitudes and misconceptions about ANC.
Child spacing: Child spacing means the period between two consecutive pregnancies of the same mother. Because the nutritional burden on the mother between pregnancies depends on the extent of breastfeeding, the inter-pregnancy interval and the ‘recuperative interval’ (duration of the nonpregnant, non- lactating interval) could measure whether the mother has had a chance to recover from the pregnancy. Therefore, it is expected an increased risk for maternal anemia when the inter-pregnancy interval is very short (Dewey, K. G., et al . 2007).
Presence of Minor disorders and medical conditions: A study of more than 81,000 pregnant women in the UK revealed that those who had nausea and vomiting during pregnancy that interfered with their life were 23% more likely to deliver their baby before 34 weeks in comparison with women who said their morning sickness did not substantially affect their lives (UK National Institutes of Health 2011). Poor nutrition and too little weight gain were considered to be the contributing factors to this risk.
A study carried out by Dr Pragya Singh et al (2011), revealed that energy intake of study participants in 2nd and 3rd trimester’s pregnancy were 2308 kcal for 2340 kcal and 1420.5 kcal for 2452 kcal (. Vitamin A intake was 3 micro grams for 800 micro grams. Protein intake of the study respondents in 2nd and 3rd trimester pregnancy was 45.9 g and 31.5g for 71g. Majority (75.2 %) of study participants did not take additional meal during pregnancy. 69.3 % skipped one of their regular meals. Total of 9.2% of the study subjects were undernourished. Energy and most of the nutrients intakes of study participants were lower than recommended intakes. Dietary practices and nutritional status of study participants were not adequate to support their increased energy and nutrient requirement. Therefore (Dr Pragya Singh et al 2011 ) concluded that filling the gap in knowledge of maternal under nutrition and generating information for intervention is important to maternal nutritional during pregnancy.
2.3 The social, economic factors contributing to malnutrition among pregnant women
Employment: Women’s employment increases her economic status in their homes, this in particular improves her nutrition status and household nutrition. Employment may increase women’s status and power, and may bolster a woman’s preference to spend her earnings on health and nutrition. However, employed women without control over their income and decision making authority within the household are deprived of economic and social power and the ability to take actions that will benefit their own well-being.
Level of education: Studies on autonomy and empowerment of women suggest that, education of a woman promotes her empowerment and influences participation in decision making in matters concerning nutrition and access to health services. (Emina et al. 2009). Women who receive even a minimal education are generally more knowledgeable than those who have no education of how to use available resources for the improvement of their own nutritional status together with their families.
Household economic status: In many, nutrition is influenced by income and economic growth. Rich people have the capacity to buy more diverse foods including fruits and vegetables rich in essential vitamins, minerals and other nutrients plus animal products rich in proteins. (Population reference bureau 2012). Poorer populations often lack access to the right variety of foods and the right amount of foods, leading to inadequate nutrition. For the poorer populations, economic growth can boost household incomes, resulting in more spending on food, health, and education, and better individual health and nutrition.
In addition, when national economies are growing, governments have more to spend on social programs and infrastructure necessary for health systems to function, thus increasing the overall health and nutritional status of the nation. Conversely poor people especially in developed countries like the USA are at high risk of obesity because healthy food is often more expensive, whereas refined grains, added sugars, and fats are generally inexpensive and readily available in low-income communities (Drewnowski, 2010; Monsivais & Drewnowski, 2009)
Households with limited resources often try to stretch their food budgets by purchasing cheap, energy-dense foods that are filling that is, they try to maximize their calories per dollar in order to stave off hunger (DiSantis et al., 2013; Drewnowski, 2009). While less expensive, energy-dense foods typically have lower nutritional quality and, because of over consumption of calories, have been linked to obesity (Hartline-Grafton et al., 2009).
According to a household survey carried out in Ethiopia by Demographic and health research (2010), never-married pregnant women were found to be the most affected by under nutrition, followed by divorced/separated/widowed women. Among never-married pregnant women, 35.7% in 2000 and 28.7% in 2005 were chronically undernourished.
Khan, M., et al (2009) laments that among both rural and urban women for both surveys, those married or living together were the least affected by chronic energy deficiency. Among the reasons given is the fact that unmarried adolescent women are often at the bottom of the food chain, with little or no decision-making power in the household about food distribution, could lead to food security issues and may contribute to their poor nutritional status. Moreover, women aged 15-19 need adequate nutrients to support fast physical, mental and emotional growth. Unawareness of adolescent women about their own health and nutritional status could be another reason associated with their poor nutritional status.
Kirunda, B. E et al (2015), in their study revealed that Compared to women of urban areas, women from rural areas were at higher risk of underweight. The widow, divorced and separated women were significantly more likely to be underweight than women who were currently married. Surprisingly, Islam, M. A. (2010), currently working women had greater tendency to be undernourished than nonworking women. This finding may be attributed to the fact that, of the working women, only 9.3% were engaged in a prestigious profession, while 60.5% were engaged in low paid jobs as factory workers, labourers, farmhands, home-based manufacturing, domestic servants etc. who generally enjoy lower autonomy in households as well as in society.
These women are less likely to have a balanced and healthy diet for nutrition, resulting in higher risk of underweight as compared to the non-working women. The women with higher education serve as housewives if they do not get prestigious jobs suitable for them. However, most of the findings of this study are fairly consistent with those conducted in many other developing countries (Goffee, R., & Scase, R, 2015).
2.4 The cultural factors that contribute to malnutrition among pregnant women
According to a descriptive survey study design conducted to assess the knowledge and attitude of dietary practices among pregnant women attending Yerwa Clinic in Nigeria where a total of 294 pregnant women were selected using systematic random sampling technique. It was revealed that majority of the respondents 118 (40%) avoid some good diet during pregnancy because of cultural beliefs (Kever R.T2015).
Another cross-sectional study carried out in Nigeria, where a sample population of 200 child bearing mothers who registered with the Primary Health Centers were used, it was discovered that some causes of malnutrition involved cultural beliefs (Jacinta A et al, 2011). Many of the respondents agreed that cultural beliefs are one of the causes of malnutrition. In Nigeria, people may abstain from eating certain food items of high nutritive value simply because of their ethical or religious beliefs and taboos. Atinmo and Akinyele said that socio cultural factors are important factors in considering the quantity of food.
Food taboos among rural women have been identified as one of the factors contributing to maternal under nutrition in pregnancy. Pregnant and lactating women in various parts of the world are forced to abstain from nutritious and beneficial foods. In various studies, it was seen that pregnant women in various parts of the world are forced to abstain from nutritious foods as a part of their traditional food habits (Merchant, K. M.2014).
According to Paupério, A., et al, (2014), Food taboo is a deliberate avoidance of a food item for reasons other than simple dislike from food preferences. In some societies, food taboos are often meant to protect the human individual and the observation, for example, that certain allergies and depression are associated with each other could have led to declaring food items taboo that were identified as causal agents for the allergies.
According to Meyer-Rochow, V. B. (2009), it is believed that any food taboo, acknowledged by a particular group of people as part of its ways, aids in the cohesion of this group, helps that particular group maintain its identity in the face of others, and, therefore, creates a sense of belonging. The avoidance of certain food items and incorrect knowledge regarding their benefits can deprive women from adequate nutrition, especially during the critical periods of pregnancy when it is of great benefit to the mother and her fetus.
