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Pregnancy diets, migration, and birth outcomes Lalitha D'Souza, Hiranthi Jayaweera & Kate E. Pickett To cite this article: Lalitha D'Souza, Hiranthi Jayaweera & Kate E. Pickett (2015): Pregnancy diets, migration, and birth outcomes, Health Care for Women International, DOI: 10.1080/07399332.2015.1102268 To link to this article: http://dx.doi.org/10.1080/07399332.2015.1102268
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HEALTH CARE FOR WOMEN INTERNATIONAL 2015, VOL. 0, NO. 0, 1–15 http://dx.doi.org/10.1080/07399332.2015.1102268
Pregnancy diets, migration, and birth outcomes Lalitha D’Souzaa, Hiranthi Jayaweerab, and Kate E. Pickettc
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a Nuffield Health, Surrey, United Kingdom; bCentre on Migration, Policy and Society, University of Oxford, Oxford, United Kingdom; cDepartment of Health Sciences, University of York, York, United Kingdom
ABSTRACT
ARTICLE HISTORY
Women in low- and middle-income countries are known to make changes to their diets during pregnancy. We set out to explore the subject of traditional pregnancy diets with a view to finding out if migrant women follow these practices, and if such information might help explain differences in birth outcomes between migrant women and destination-country-born women. This review found that traditional pregnancy diets vary from region to region, that migrant women may follow some of these practices, and that there is a dearth of studies looking into the impact of pregnancy diets on birth outcomes.
Received 21 March 2015 Accepted 21 September 2015
In low-income countries of the global south, women are known to change their diets during pregnancy. They carry with them their beliefs about traditional pregnancy diets when they migrate. Epidemiologists have shown that there are differences in birth outcomes between subgroups of migrant women, and equally importantly that while some migrant subgroups have better birth outcomes compared with destination-country-born women, others have worse outcomes (Urquia et al., 2010). These differences are not well understood. Factors including “acculturation,” socioeconomic status, social support, linguistic isolation, premigration health, and access to health care are thought to play some part in explaining these differences, whereas traditional pregnancy diets have not been adequately considered. We conducted a structured review to explore the subject of traditional pregnancy diets to find out if migrant women follow these practices in destination countries and if there has been any work linking them to birth outcomes. This information may help explain differences in birth outcomes between migrant women and women born in the destination country, and between migrant subgroups.
CONTACT Lalitha D’Souza [email protected]; Lalitha.D’Souza@nuffieldhealth.com Haxby Road, York YO31 8TA, UK. © 2015 Taylor & Francis Group, LLC
Nuffield Hospital,
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Background Traditional pregnancy diets
In some Asian, African, Latin American, and Middle Eastern countries, women make changes to their diets during pregnancy. The exact practices vary from society to society. They are passed from one generation to the next and are deeply rooted in religious, cultural, and traditional beliefs (Satia, 2010). It is thought that these dietary practices evolved over time to protect mother and child because of historical trends in high maternal and infant mortality in those societies (Forestell & Menella, 2008).
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Migrant women and perinatal health
Birth outcomes of migrant women have often been found to be either better or worse than destination-country-born women. In their review of international migration and perinatal health Urquia and colleagues (2010) found that the association between foreign-born status and birth outcomes was not uniform and depended on both migrant subgroup and destination country (Urquia et al., 2010). Migrant subgroup was defined by a combination of maternal race/ethnicity and migrant status, or by world region of origin and actual destination. Compared with destination-country-born mothers, those born in sub-Saharan Africa, Latin America, and the Caribbean were at higher risk of delivering low birth weight (LBW) babies in Europe but not when they migrated to the United States, while those born in South-Central Asia were at higher risk in both continents with slightly worse outcomes when they migrated to Europe. It is well known that women from some migrant subgroups, most prominently Hispanic migrants in the United States, despite having socioeconomic disadvantage and barriers in access to health care, experience similar or better birth outcomes compared to U.S.-born women. It is not known what impact, if any, traditional pregnancy diets have on these differences in birth outcomes.
Methods This structured review was conducted to map the literature on the subject of traditional pregnancy diets. PubMed Central and the Trip and Cochrane databases were searched to identify relevant publications from 1960 to August 2014 in the English language. Search terms included “dietary practices” and “pregnancy”; “pregnancy diets,” “beliefs,” and “practices.” The outcomes of interest were birth outcomes—small for gestational age (SGA), LBW, and preterm birth (PTB). Following this, reference lists of key papers were searched to identify other publications of relevance to this review. Publications citing key papers on pregnancy diets were also considered for inclusion. Studies were included if authors looked into dietary practices during pregnancy, whether or not perinatal outcomes were studied. Those papers where researchers report exclusively on nutrients, caloric values, nutritional status, and supplements with no information on dietary practices were excluded, as were studies investigating dietary practices of pregnant women with diabetes, obesity, and infections including HIV.
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Table 1. Sample characteristics of women in studies conducted in low- and middle-income Countries. Country
Sample size
Education
Christian et al., 2006
Nepal Rural
234 pregnant women
de Boer & Lamxay, 2009
Lao People’s Democratic Republic Rural Ghana Urban/rural
Women in 354 households in 10 villages
Literacy rate Cases with night blindness - 5.9% Controls without night blindness - 12.6% No information on educational attainment
Ebimoyi, 1988
Nigeria Rural
730 women of which 360 were pregnant
Engelin, 2009
India Rural
41 women
Gao et al., 2013
China Urban/Rural
201 women
Hartini et al., 2005
Indonesia Urban/Rural Burkina Faso Rural
450 pregnant women
Liamputtong et al., 2005
Thailand Urban/rural
30
Mukhopadhyay & Sarkar, 2009
India Rural
199
Nag, 1994
India Urban/Rural India Rural Pakistan Urban
Over 7,500 women
School attendance Attended school - 16.2% Not attended school - 83.8% Education Primary - 11 Secondary level - 7 Diploma - 4 Tertiary level - 8 Literacy Literate - 73.9% Non-literate - 26.1% Not clear.
319 women
No information on educational attainment
400 women
Pakistan Urban
150 women
Literacy Literate - 86% of which 48% were ‘intermediate and above. Non-literate - 14% Schooling No schooling - 26 Primary - 23 Secondary - 46 Post-secondary - 55
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de-Graft Aikins, 2014
Huybregts et al., 2009
Reddy, 1990 Ali et al., 2004
Zobairi, et al 1998
35 women
37 (qualitative study) 394 (24 hour diet recall)
Literacy No education - 1 Primary education - 2 Secondary education - 7 Tertiary education/University - 5 (Possible printing error in Table 1 of paper where numbers do not add up to 35) Literacy rate Non-literate - 77.9% Primary education - 15.2% Post primary certificate education - 6.9% Literacy rate No education - 5 1–8 years education - 12 9–10 years education - 12 11–12 years education - 6 Unknown - 2 Education 95.5% completed at least primary education No information on educational attainment
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Findings We found two groups of relevant studies. In the first group of studies, researchers describe dietary beliefs and practices among women residing in low- and middleincome countries, while in the second, researchers report dietary practices of migrant women who relocated from low- and middle-income to high-income countries.
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Pregnancy diets in low-income countries
In 13 studies including one master’s dissertation and one review, researchers describe dietary beliefs and practices followed by pregnant women in low-income countries. See Table 1 for sample characteristics of women included in this group of studies. Participants were from mixed socioeconomic backgrounds with many living in rural areas and having little or no education. Common themes were “eating down,” beliefs about “hot” and “cold” foods, food avoidances and taboos, pregnancy cravings, and concerns for the well-being of the newborn. The impact of traditional pregnancy diets on birth outcomes was not purposefully investigated by researchers in any of these 13 studies. Eating down, eating more
Eating down (consuming less food) in pregnancy is a commonly reported practice and has been the subject of public health concern in low-income countries where undernutrition is prevalent and birth outcomes poor. Pregnant women in India tend to eat down, they say to avoid having large babies, which might put them at risk of having a difficult labor (Nag, 1994). The precise scale of complicated births directly related to large babies is not known. What women in underdeveloped areas do know is that access to emergency obstetric care is limited by distance, travelling time, and cost. Pregnant women in Pakistan similarly cited one of their reasons for eating less as assurance that the baby would not be too large (Zobairi, Freitas, & Wasti, 1998). Christian and colleagues (2006) found that in Nepal, pregnant women ate less because of loss of appetite, aversion to certain foods, non-availability of food items they desired at the time, and poor purchasing power (Christian et al., 2006). They did not intentionally eat less to avoid having large babies. Researchers studying practices in other countries, however, report different trends. Ghanaian women for example reported eating more at different times during their pregnancy (de-Graft Aikins, 2014); while pregnant women in Burkina Faso did not appear to restrict their diet significantly (Huybregts, Roberfroid, Kolsteren, & Van Camp, 2009). Thus we have seen that mediating factors for eating less or more are variously reported as the desire to have an easy delivery, economic constraints, cultural representations of motherhood, and the unpredictable demands of the pregnant body (Christian et al., 2006; de-Graft Aikins, 2014; Hartini, Padmawati, Lindholm, Surjono, & Winkvist, 2005 Nag, 1994; Zobairi et al., 1998). The impact of gender differences on intrahousehold food allocation on women’s diets during pregnancy has not been adequately studied.
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Food avoidances, restrictions, and taboos
The concept of “hot” and “cold” foods is widespread in Asian countries and forms the basis for dietary restrictions and proscriptions relating to life events and various customs. In countries such as India and Nepal, for example, pregnancy is thought to be a state of increased “heat” (Christian et al., 2006; Nag, 1994). On a similar note, Pakistani women believe that the womb is a source of heat production (Zobairi et al., 1998). Foods thought to be “cold” are preferred while those believed to increase body heat or “hot” foods are avoided during pregnancy. Papaya, aubergine, pineapple, jackfruit, jaggery, sesame seeds, dates, molasses, fish, shellfish, all kinds of meat, eggs, milk, and spices are reported to be avoided. Women believe that some of these foods overheat the already “hot” pregnant body. The overwhelming fear is of miscarriage. Papaya avoidance is discussed in several studies conducted in India (Nag, 1994). The raw green fruit contains high concentrations of latex, which is thought to increase uterine contractions and is believed to have potential for miscarriage. The ripened fruit has less latex, however, while containing high concentrations of Vitamin A. Vitamin A is a much-needed nutrient among pregnant women in countries where Vitamin A deficiency is prevalent among the poor. We found in our review of the literature that beliefs can vary considerably across the world. In Nepal, women may have more of the ripe papaya fruit during their pregnancy depending on its availability and the individual woman’s taste preference, and in Ghana it is one of the recommended food items for pregnant women (Christian et al., 2006; de-Graft Aikins, 2014). On a similar note, in China women believe that pregnancy causes an imbalance between the forces of “yin” and “yang,” so that the woman is “cold” in the first trimester, “neutral” in the second, and “hot” in the third trimester (Gao et al., 2013). Accordingly, they will start eating “cold” foods in the second trimester to counterbalance the “hot” stage in the third trimester. Increase in consumption of certain preparations such as soups containing Chinese olives, green beans, and salsola grass was based on their belief that they need to reduce the internal “heat” of the fetus. Researchers report other food restrictions and taboos followed in African and Asian countries (Ebomoyi, 1988; Gao et al., 2013; Huybregts et al., 2009; Liamputtong, Yimyam, Parisunyakul, Baosoung, & Sansiriphun, 2005; Mukhopadhyay & Sarkar, 2009; Sultan Ali et al., 2004). Gao and colleagues (2013) found that pregnant women in China avoided a number of protein-rich foods such as snake, eel, and beef. They consumed more of other foods that they considered nutritious, however, such as fish soup. In rural Nigeria traditional healers discouraged women from eating rabbit meat, warning them that if they did, the baby might turn out to be a kleptomaniac (Ebomoyi, 1988). Other meats including monkey, pork, snail, crocodile, and snake are avoided, based on similar beliefs about babies appearing or behaving like the animal. These recommendations were unlikely to be questioned by the women in this study who were likely to have little or no education and few opportunities to access scientific dietary information.
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The major food groups avoided by low-income pregnant women are likely to contribute to an already poor state of nutrition.
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Benefits for the baby
Women in very low-income groups reported that they wanted their babies to be small and strong as opposed to what they perceived as big and weak, and they made changes to their diets accordingly (Nag, 1994). Other reasons for changing their diets are beliefs that the child might benefit in terms of appearance and for improving the odds for the more favored male offspring (Reddy, 1990). Women in the Southern State of Tamil Nadu, India, ate saffron (“red flower”) during pregnancy and avoided any item of food colored black, such as black grapes and dates, to increase the chances of their child being born fair-skinned, which is a highly valued trait in a community where higher caste is linked to fair skin (Engelin, 2009). Symbolism of this nature appears to be more common in regions where women lack educational opportunities. Chinese women included in their diets soups containing cuttlefish to improve birthweight; Chinese redbud flower and pig’s stomach, which they believed was good for the baby’s stomach; goose eggs to avoid boils in the newborn baby; and walnut for promoting the baby’s intelligence (Gao et al., 2013). Pregnancy cravings
Craving for particular items of cooked and uncooked regional foods, as well as yearning for items such as mud, clay, and ice, were cited in several studies. Researchers of four studies reviewed by Nag (1994) describe a wide variety of cravings among pregnant Asian Indian women. Women in Burkina Faso spoke about similar cravings for food and non-food items (Huybregts et al., 2009). McGilvray (1982) suggests that cravings are generated when the demands of the fetus drain the nutritional resources of the mother. In an anthropological study of women in late 1950s Sri Lanka, Gananath Obeyesekere (1963) provides some insight into pregnancy cravings. At that time “Dola Duka,” the regional term for pregnancy cravings, was understood as a sociocultural construct thought to be deeply rooted in pregnant women’s psychological problems of adjustment, ambivalence toward her children, and male envy. More importantly, cravings were not seen to be significantly related to nutritional needs in pregnancy. Herbs
Plants and herbs are used in less-developed areas of the world for women’s health, and they form part of tradition and culture that has been ignored after the introduction of formalized health care. Researchers of an ethnopharmacological study of plant use in South East Asia mention plant use during pregnancy, although they found the evidence somewhat limited (de Boer & Lamxay, 2009). “Kashaya”, a decoction of herbs taken during pregnancy, is thought by women in Southern
Sweden
USA
USA
Norway
USA
USA
Australia
USA and India
Ahlqvist & Wirf€alt, 2000
Cassidy, 1982
Chakrabarti, 2010
Garnweidner, 2013
Guiterrez, 1999
Lagana, 2003
Mitchell, 1995
Sathyamurthy, 2012
Destination country
Asian Indian
Vietnamese
Mexican
Mexican Mexican American
Middle Eastern, African, Asian
Black American, Mexican American, Puerto Rican, Asian Indian, other Asian, Bengali Indian, Bangladeshi
Iranian
Ethnicity
106
110
29
46
21
40
>1,600
14
Sample size
Table 2. Sample characteristics of migrant women in studies conducted in destination countries.
Not clear
108 D 0 to 14 years 2 D> 15 years
Not clear (half born in USA, half born in Mexico)
3 months to 18 years
2 to 35 years
9 months to 22 years
Not clear
2 to 20 years
Length of stay in destination country
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(continued)
Education < 10 years’ education - 3 10–12 years education - 11 13–16 years education - 17 >16 years education - 9 Education Not clear Education Elementary school - 9 Junior high school - 18 High school - 13 High school graduate - 6 Education Mean number of years in education - 11.5 years (Range 1–18 years) Education Primary education - 30% Secondary - 61% Tertiary - 9% Education Details unclear
Education Primary education - 2 Secondary education - 10 University education - 2 Education Not clear
Education
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UK
UK
UK
Woollett, 1995
Yeasmin & Regmi, 2013
Destination country
Woollett & Dosanjh, 1990
Table 2. (Continued)
British Bangladeshi
Asian, Non-Asian
Indian, Pakistani
Ethnicity
26
143
32
Sample size
Not clear
67% Asian women resident in UK for >10 years
1 to 25 years (Mean 12.9 years)
Length of stay in destination country
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Education Not clear More than minimum education Asian women - 28% Non-Asian women - 21% Education Primary education - 38% Secondary education - 46% Graduates - 15%
Education
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India to aid in an easy delivery (Engelin, 2009; Reddy, 1990). Similarly, Liamputtong and colleagues (2005) report that women in Thailand consume “ya tom” or “herbal medicine” to prepare themselves for an easy birth. The content and effectiveness of herbal remedies such as “Kashaya” or “ya tom” were not described.
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Pregnancy diets among migrant women in destination countries
Researchers of one review and 10 studies, including one unpublished study and one doctoral dissertation, describe traditional dietary practices among migrant women. See Table 2 for sample characteristics of women in this group of studies. Participants in these studies were migrant women from mixed socioeconomic backgrounds living in the United States, United Kingdom, Australia, and Europe. Where educational data were collected, most had secondary education, while some were graduates and a few were postgraduates. Only in one study did researchers examine the impact of traditional pregnancy diets on birth outcome. What do women want?
Migrant women appear to want to continue with their traditional pregnancy diets (Ahlqvist & Wirf€alt, 2000; Garnweidner, 2013; Mitchell & Mackerras, 1995). While a proportion in some migrant subgroups retain some of the practices known in their ethnic groups, others exchange them for those followed in the destination country (Satia, 2010). Mitchell and Mackerras (1995) found that as many as 57% of Vietnamese migrants in Australia continued with traditional humoral diets during pregnancy. There appears to be a continuum ranging from strict to flexible approaches to traditional pregnancy diets. Dietary beliefs and practices among migrant women
Themes resonant with those found by researchers in the previous group of studies conducted in low-income countries are described among migrant women—eating down, ideas about “hot” and “cold” foods, and food avoidances and restrictions. Iranian women in Sweden said they ate less to lower the birth weight of the baby (Ahlqvist & Wirf€alt, 2000). On this topic, older Iranian respondents recalled how “formerly many women died,” drawing attention to historical links between large babies and maternal and infant mortality. A diet low in carbohydrate was encouraged in the weeks leading to childbirth. Cassidy (1982) also records dietary changes to facilitate an “easy” labor among Mexican American and Black American women in the United States. These practices, however, are not universal. Bangladeshi women in the United Kingdom made no mention of eating less during pregnancy (Yeasmin & Regmi, 2013). The concept of “hot and cold” foods and of avoiding certain foods while preferring some food categories to maintain the hot–cold balance during pregnancy was mentioned by migrant subgroups in Sweden, the United States, and the United Kingdom (Ahlqvist & Wirf€alt, 2000; Cassidy, 1982; Satyamurthy & Raj, 2012 Woollett &
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Dosanjh-Matwala, 1990; Woollett et al., 1995; ). In a similar vein, balancing “yin” and “yang” by avoiding certain foods was deemed important for Vietnamese migrants in Australia (Mitchell & Mackerras, 1995). Other food avoidances and taboos demonstrate a continuing belief in traditional practices. British Bangladeshi women avoided papaya and pineapple because they feared miscarriage (Yeasmin & Regmi, 2013). Other dietary changes included avoidance of food at extreme physical temperatures (Cassidy, 1982).
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Influences on cultural dietary practices
Migrant women were influenced by advice from female relatives both in the destination country and in their home country, by other women in their community, and by health care professionals (Chakrabarti, 2010; Guiterrez, 1999; Yeasmin & Regmi, 2013). Yeasmin and Regmi (2013) found that while family influences among the British Bangladeshi Muslim participant women was strong, some of them actively sought and followed health care professional advice. Daylight fasting during Ramadan is not considered mandatory for pregnant women according to Muslim religious teaching. Despite being aware of this and of health care professional advice against the practice, women observed the fast in keeping with their preferences. Women’s decisions about which dietary practice or advice to follow were influenced primarily by concerns about the baby, but also by concerns for their own health and longer-term survival (Ahlqvist & Wirf€alt, 2000; Guiterrez, 1999; Yeasmin &Regmi, 2013). Access to food items considered desirable by pregnant women was influenced by their socioeconomic status, as also by ecological conditions in the destination country (Ahlqvist & Wirf€alt, 2000). “Acculturation”
Researchers have defined “acculturation” as a multidimensional process whereby individuals whose primary learning is in one culture go on to adopt characteristic ways of living from another culture (Harley & Eskenazi, 2006). Until recently the “acculturation” model was used to explain various sociocultural changes and public health trends among migrants, most importantly diet and trends in birth outcomes. In her study, “Come Bien, Camina y No Se Preocupe—Eat Well, Walk and Don’t Worry,” Kathleen Lagana (2003) looked into the meaning of “biculturalism” among Mexican migrant women in the United States. About eating well, a low-fat, high-protein, and naturally nutritious diet was cited by women as the most common determinant of a healthy birth outcome. While women placed great importance on a healthy diet, they found it difficult to continue to eat well if they were employed, and they felt frustrated about the closing down of choices resulting from changes to their socioeconomic status after migration. With “acculturation,” pregnant Mexican adolescents lost some of their traditional cultural beliefs relating
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to pregnancy (Guiterrez, 1999). Other studies have shown that the impact of “acculturation” can vary. Seasonal farm workers from Mexico working in the United States, for example, who maintained strong ties with the home country, regularly returned home during winter months (Harley & Eskenazi, 2006). Constant travel between origin and destination country would allow them to buy special foods and give them opportunities to recall traditional dietary advice. Pregnant Bengali women in New York City formed networks of care in neighborhood spaces, places of worship, and in workplaces where they sought help from friends, neighbors, and colleagues (Chakrabarti, 2010). Offers of traditional home-cooked Bengali food prepared with due consideration of cravings, proscriptions, and avoidances was very much part of the support these women received. Furthermore, Chakrabarti (2010) found that falling costs of access to telephone and Internet connections have enabled transnational social networks to thrive. Frequent communication with mothers and grandmothers in the home country mean continuity of care, guidance regarding healthy practices during pregnancy, and dietary advice. We found only one study in which authors compared views and practices between women in their origin and destination countries. Sathyamurthy and Raj (2012) compared traditional dietary beliefs and practices during pregnancy among Asian Indian women in the United States with those of their compatriots in the home country, India. More women in India believed that “hot” foods caused “overheating” and miscarriage, while a significant proportion of migrant Indian women in the United States disagreed with these beliefs. There were differences in stated practices about food avoidances and nutritional needs between U.S.-born Indian women and those born in India. The use of herbal preparations was not obvious in any of the studies included in this section of the review. It cannot be inferred from this gap in the literature, however, that herbal preparations are not used by pregnant migrant women. Indeed, there is anecdotal evidence that herbal preparations are sent across from home countries to migrant women in the United States and United Kingdom. Pregnancy diets and birth outcomes
We found only one study of the impact of traditional diets on birth outcomes. Mitchell and Mackerras (1995) compared the diets of migrant Vietnamese women in Australia who followed traditional humoral diets with those who did not. There were no significant differences in birth weight between the two groups.
Discussion Main Findings
In our literature review we found some information about beliefs and reported dietary practices followed by pregnant women in low- and middle-income countries,
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and of these practices among migrant women in high- income destination countries. Only Mitchell and Mackerras (1995) investigated the impact of traditional diets on birth outcomes. As can be seen from Table 1, sample characteristics of studies conducted in lowincome countries show that a large proportion of women had relatively low levels of educational attainment that may not have prepared women to question beliefs such as eating down to prevent giving birth to large babies and avoiding foods believed to have abortifacient properties. In these resource-poor areas, the strong influence of poorly informed relatives and traditional healers is compounded by the lack of reliable professional advice. Among women migrating from low- to high-income countries, there appears to be a range of practices varying from strict adherence to total abandonment of traditional pregnancy diets, likely due to changes in sociocultural circumstances, educational attainment, and adoption of recommendations from health care professionals in the destination country. Gaps in the literature
In her article, “Rites de Passage of Matrescence and Social Construction of Motherhood,” Poonacha (1997) writes that until recently women’s lives were only sketchily documented by men who had almost exclusive power to determine historical discourse. Women created a niche for themselves in oral cultures, passing down information from generation to generation. In a similar vein, de Boer and Lamxay (2009) note that expertise and knowledge of plant use in Lao People’s Democratic Republic is exchanged and applied in secrecy between women as traditional knowledge relating to women’s health, with a view to empowering themselves while undermining male dominance. These observations may help explain why traditional pregnancy diets from certain world regions may have been slow to come into the public domain and, to some extent, the relatively small number of studies we found on the subject. We found more studies about beliefs and reported practices compared with research into actual practice. Few researchers of studies reviewed here looked into women’s views about their own nutritional status, their knowledge about nutrition in pregnancy, their views about how to redress the lack of adequate food before and during pregnancy, or their views about inequalities in intrahousehold food allocation. Most importantly, there has not been enough study on the potential impact of pregnancy diets on birth outcomes in low- and high-income countries. In our structured review, we found important gaps in the literature on pregnancy diets among migrant women. More focused quantitative and qualitative studies are needed to address knowledge gaps.
Conclusion Immigration appears to select the healthiest individuals whose premigration healthy behaviors influence their health outcomes in the destination country
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(Kennedy, Kidd, McDonald, & Biddle, 2014). Findings from our review suggest that women participating in the studies carried out in their home countries were from poor backgrounds (see Table 1), many with little or no education, whereas those participating in studies in the destination countries (see Table 2) had higher educational attainment and were higher on the socioeconomic scale. Research into the impact of traditional pregnancy diets on birth outcomes needs to include comparison groups of women who did not migrate, along with data on birth outcomes, socioeconomic status, and access to health care in both groups. Women’s views will further improve our understanding of the subject of this review. Longitudinal research considering the entire suite of practices that women observe during pregnancy—food preferences, taboos and proscriptions, availability of special foods, traditional herbal preparations, quantification of dietary intake and energy expenditure, work restrictions and ethnographic data— are needed to understand further the impact of traditional pregnancy diets on birth outcomes.
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Garnweidner, L. M. (2013). Promoting a healthy diet in antenatal care: Qualitative studies of barriers to nutrition communication among women of different ethnic backgrounds in the Oslo Area. University of Oslo. Retrieved from http://urn.nb.no/URN:NBN:no-37087. Gutierrez, Y. M. (1999). Cultural factors affecting diet and pregnancy outcome of Mexican American adolescents. Journal of Adolescent Health, 25(3), 227–237. Harley, K., & Eskenazi, B. (2006). Time in the United States, social support and health behaviors during pregnancy among women of Mexican descent. Social Science & Medicine, 62(12), 3048–3061. Hartini, T.N.S., Padmawati, R. S., Lindholm, L., Surjono, A., & Winkvist, A. (2005). The importance of eating rice: Changing food habits among pregnant Indonesian women during the economic crisis. Social Science & Medicine, 61(1), 199–210. Huybregts, L. F., Roberfroid, D. A., Kolsteren, P. W., & Van Camp, J. H. (2009). Dietary behaviour, food and nutrient intake of pregnant women in a rural community in Burkina Faso. Maternal & Child Nutrition, 5(3), 211–222. Kennedy, S., Kidd, M. P., McDonald, J. T., & Biddle, N. (2014). The healthy immigrant effect: Patterns and evidence from four countries. Journal of International Migration and Integration, 1–16. Lagana, K. (2003). Come bien, camina y no se preocupe—Eat right, walk, and do not worry: Selective biculturalism during pregnancy in a Mexican American community. Journal of Transcultural Nursing, 14(2), 117–124. Liamputtong, P., Yimyam, S., Parisunyakul, S., Baosoung, C., & Sansiriphun, N. (2005). Traditional beliefs about pregnancy and child birth among women from Chiang Mai, Northern Thailand. Midwifery, 21(2), 139–153. McGilvray, D. B. (1982). Ethnography of fertility and birth. In C. P. MacCormack (Ed.), Ethnography of fertility and birth. New York: Academic Press. Mitchell, J., & Mackerras, D. (1995). The traditional humoral food habits of pregnant Vietnamese—Australian women and their effect on birth weight. Australian Journal of Public Health, 19(6), 629–633. Mukhopadhyay, S., & Sarkar, A. (2009). Pregnancy-related food habits among women of rural Sikkim, India. Public Health Nutrition, 12(12), 2317–2322. Nag, M. (1994). Beliefs and practices about food during pregnancy: Implications for maternal nutrition. Economic and Political Weekly, 2427–2438. Obeyesekere, G. (1963). Pregnancy cravings (Dola-Duka) in relation to social structure and personality in a Sinhalese Village. American Anthropologist, 65(2), 323–342. Poonacha, V. (1997). Rites of passage of matrescence and social construction of motherhood: Coorgs in South India. Economic and Political Weekly, 101–110. Reddy, P. H. (1990). Dietary practices during pregnancy, lactation and infancy: Implications for health. In J. C. Caldwell et al. (Eds.). What we know about health transition: The cultural, social, and behavioural determinants of health (Vol. 2, pp. 595–601). Canberra: Australian National University Health Transition Centre. Health Transition Series 2. Sathyamurthy, M., & Raj, S. (2012). A comparison of traditional beliefs, practices and health seeking behaviors that influence dietary practices during pregnancy of South Asian Indian women in India and the United States. Journal of the Academy of Nutrition and Dietetics, 112(9), A20. Satia, J. A. (2010). Dietary acculturation and the nutrition transition: An overview. Applied Physiology, Nutrition, and Metabolism, 35(2), 219–223. Urquia, M. L., Glazier, R. H., Blondel, B., Zeitlin, J., Gissler, M., Macfarlane, A., & Gagnon, A. J. (2010). International migration and adverse birth outcomes: Role of ethnicity, region of origin and destination. Journal of Epidemiology and Community Health, 64(3), 243–251.
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Woollett, A., & Dosanjh-Matwala, N. (1990). Pregnancy and antenatal care: The attitudes and experiences of Asian women. Child: Care, Health and Development, 16(1), 63–78. Woollett, A., Dosanjh, N., Nicolson, P., Marshall, H., Djhanbakhch, O., & Hadlow, J. (1995). The ideas and experiences of pregnancy and childbirth of Asian and non-Asian women in East London. British Journal of Medical Psychology, 68(1), 65–84. Yeasmin, S. F., & Regmi, K. (2013). A qualitative study on the food habits and related beliefs of pregnant British Bangladeshis. Health Care for Women International, 34(5), 395–415. Zobairi, S. E., Freitas, M. L., & Wasti, S. A. (1998). Diet and nutrition: A knowledge, attitude and practice study of pregnant women in Karachi. Australian and New Zealand Journal of Obstetrics and Gynaecology, 38(2), 188–193.
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Pregnancy diets, migration, and birth outcomes Lalitha D'Souza, Hiranthi Jayaweera & Kate E. Pickett To cite this article: Lalitha D'Souza, Hiranthi Jayaweera & Kate E. Pickett (2015): Pregnancy diets, migration, and birth outcomes, Health Care for Women International, DOI: 10.1080/07399332.2015.1102268 To link to this article: http://dx.doi.org/10.1080/07399332.2015.1102268
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HEALTH CARE FOR WOMEN INTERNATIONAL 2015, VOL. 0, NO. 0, 1–15 http://dx.doi.org/10.1080/07399332.2015.1102268
Pregnancy diets, migration, and birth outcomes Lalitha D’Souzaa, Hiranthi Jayaweerab, and Kate E. Pickettc
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a Nuffield Health, Surrey, United Kingdom; bCentre on Migration, Policy and Society, University of Oxford, Oxford, United Kingdom; cDepartment of Health Sciences, University of York, York, United Kingdom
ABSTRACT
ARTICLE HISTORY
Women in low- and middle-income countries are known to make changes to their diets during pregnancy. We set out to explore the subject of traditional pregnancy diets with a view to finding out if migrant women follow these practices, and if such information might help explain differences in birth outcomes between migrant women and destination-country-born women. This review found that traditional pregnancy diets vary from region to region, that migrant women may follow some of these practices, and that there is a dearth of studies looking into the impact of pregnancy diets on birth outcomes.
Received 21 March 2015 Accepted 21 September 2015
In low-income countries of the global south, women are known to change their diets during pregnancy. They carry with them their beliefs about traditional pregnancy diets when they migrate. Epidemiologists have shown that there are differences in birth outcomes between subgroups of migrant women, and equally importantly that while some migrant subgroups have better birth outcomes compared with destination-country-born women, others have worse outcomes (Urquia et al., 2010). These differences are not well understood. Factors including “acculturation,” socioeconomic status, social support, linguistic isolation, premigration health, and access to health care are thought to play some part in explaining these differences, whereas traditional pregnancy diets have not been adequately considered. We conducted a structured review to explore the subject of traditional pregnancy diets to find out if migrant women follow these practices in destination countries and if there has been any work linking them to birth outcomes. This information may help explain differences in birth outcomes between migrant women and women born in the destination country, and between migrant subgroups.
CONTACT Lalitha D’Souza [email protected]; Lalitha.D’Souza@nuffieldhealth.com Haxby Road, York YO31 8TA, UK. © 2015 Taylor & Francis Group, LLC
Nuffield Hospital,
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Background Traditional pregnancy diets
In some Asian, African, Latin American, and Middle Eastern countries, women make changes to their diets during pregnancy. The exact practices vary from society to society. They are passed from one generation to the next and are deeply rooted in religious, cultural, and traditional beliefs (Satia, 2010). It is thought that these dietary practices evolved over time to protect mother and child because of historical trends in high maternal and infant mortality in those societies (Forestell & Menella, 2008).
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Migrant women and perinatal health
Birth outcomes of migrant women have often been found to be either better or worse than destination-country-born women. In their review of international migration and perinatal health Urquia and colleagues (2010) found that the association between foreign-born status and birth outcomes was not uniform and depended on both migrant subgroup and destination country (Urquia et al., 2010). Migrant subgroup was defined by a combination of maternal race/ethnicity and migrant status, or by world region of origin and actual destination. Compared with destination-country-born mothers, those born in sub-Saharan Africa, Latin America, and the Caribbean were at higher risk of delivering low birth weight (LBW) babies in Europe but not when they migrated to the United States, while those born in South-Central Asia were at higher risk in both continents with slightly worse outcomes when they migrated to Europe. It is well known that women from some migrant subgroups, most prominently Hispanic migrants in the United States, despite having socioeconomic disadvantage and barriers in access to health care, experience similar or better birth outcomes compared to U.S.-born women. It is not known what impact, if any, traditional pregnancy diets have on these differences in birth outcomes.
Methods This structured review was conducted to map the literature on the subject of traditional pregnancy diets. PubMed Central and the Trip and Cochrane databases were searched to identify relevant publications from 1960 to August 2014 in the English language. Search terms included “dietary practices” and “pregnancy”; “pregnancy diets,” “beliefs,” and “practices.” The outcomes of interest were birth outcomes—small for gestational age (SGA), LBW, and preterm birth (PTB). Following this, reference lists of key papers were searched to identify other publications of relevance to this review. Publications citing key papers on pregnancy diets were also considered for inclusion. Studies were included if authors looked into dietary practices during pregnancy, whether or not perinatal outcomes were studied. Those papers where researchers report exclusively on nutrients, caloric values, nutritional status, and supplements with no information on dietary practices were excluded, as were studies investigating dietary practices of pregnant women with diabetes, obesity, and infections including HIV.
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Table 1. Sample characteristics of women in studies conducted in low- and middle-income Countries. Country
Sample size
Education
Christian et al., 2006
Nepal Rural
234 pregnant women
de Boer & Lamxay, 2009
Lao People’s Democratic Republic Rural Ghana Urban/rural
Women in 354 households in 10 villages
Literacy rate Cases with night blindness - 5.9% Controls without night blindness - 12.6% No information on educational attainment
Ebimoyi, 1988
Nigeria Rural
730 women of which 360 were pregnant
Engelin, 2009
India Rural
41 women
Gao et al., 2013
China Urban/Rural
201 women
Hartini et al., 2005
Indonesia Urban/Rural Burkina Faso Rural
450 pregnant women
Liamputtong et al., 2005
Thailand Urban/rural
30
Mukhopadhyay & Sarkar, 2009
India Rural
199
Nag, 1994
India Urban/Rural India Rural Pakistan Urban
Over 7,500 women
School attendance Attended school - 16.2% Not attended school - 83.8% Education Primary - 11 Secondary level - 7 Diploma - 4 Tertiary level - 8 Literacy Literate - 73.9% Non-literate - 26.1% Not clear.
319 women
No information on educational attainment
400 women
Pakistan Urban
150 women
Literacy Literate - 86% of which 48% were ‘intermediate and above. Non-literate - 14% Schooling No schooling - 26 Primary - 23 Secondary - 46 Post-secondary - 55
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de-Graft Aikins, 2014
Huybregts et al., 2009
Reddy, 1990 Ali et al., 2004
Zobairi, et al 1998
35 women
37 (qualitative study) 394 (24 hour diet recall)
Literacy No education - 1 Primary education - 2 Secondary education - 7 Tertiary education/University - 5 (Possible printing error in Table 1 of paper where numbers do not add up to 35) Literacy rate Non-literate - 77.9% Primary education - 15.2% Post primary certificate education - 6.9% Literacy rate No education - 5 1–8 years education - 12 9–10 years education - 12 11–12 years education - 6 Unknown - 2 Education 95.5% completed at least primary education No information on educational attainment
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Findings We found two groups of relevant studies. In the first group of studies, researchers describe dietary beliefs and practices among women residing in low- and middleincome countries, while in the second, researchers report dietary practices of migrant women who relocated from low- and middle-income to high-income countries.
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Pregnancy diets in low-income countries
In 13 studies including one master’s dissertation and one review, researchers describe dietary beliefs and practices followed by pregnant women in low-income countries. See Table 1 for sample characteristics of women included in this group of studies. Participants were from mixed socioeconomic backgrounds with many living in rural areas and having little or no education. Common themes were “eating down,” beliefs about “hot” and “cold” foods, food avoidances and taboos, pregnancy cravings, and concerns for the well-being of the newborn. The impact of traditional pregnancy diets on birth outcomes was not purposefully investigated by researchers in any of these 13 studies. Eating down, eating more
Eating down (consuming less food) in pregnancy is a commonly reported practice and has been the subject of public health concern in low-income countries where undernutrition is prevalent and birth outcomes poor. Pregnant women in India tend to eat down, they say to avoid having large babies, which might put them at risk of having a difficult labor (Nag, 1994). The precise scale of complicated births directly related to large babies is not known. What women in underdeveloped areas do know is that access to emergency obstetric care is limited by distance, travelling time, and cost. Pregnant women in Pakistan similarly cited one of their reasons for eating less as assurance that the baby would not be too large (Zobairi, Freitas, & Wasti, 1998). Christian and colleagues (2006) found that in Nepal, pregnant women ate less because of loss of appetite, aversion to certain foods, non-availability of food items they desired at the time, and poor purchasing power (Christian et al., 2006). They did not intentionally eat less to avoid having large babies. Researchers studying practices in other countries, however, report different trends. Ghanaian women for example reported eating more at different times during their pregnancy (de-Graft Aikins, 2014); while pregnant women in Burkina Faso did not appear to restrict their diet significantly (Huybregts, Roberfroid, Kolsteren, & Van Camp, 2009). Thus we have seen that mediating factors for eating less or more are variously reported as the desire to have an easy delivery, economic constraints, cultural representations of motherhood, and the unpredictable demands of the pregnant body (Christian et al., 2006; de-Graft Aikins, 2014; Hartini, Padmawati, Lindholm, Surjono, & Winkvist, 2005 Nag, 1994; Zobairi et al., 1998). The impact of gender differences on intrahousehold food allocation on women’s diets during pregnancy has not been adequately studied.
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Food avoidances, restrictions, and taboos
The concept of “hot” and “cold” foods is widespread in Asian countries and forms the basis for dietary restrictions and proscriptions relating to life events and various customs. In countries such as India and Nepal, for example, pregnancy is thought to be a state of increased “heat” (Christian et al., 2006; Nag, 1994). On a similar note, Pakistani women believe that the womb is a source of heat production (Zobairi et al., 1998). Foods thought to be “cold” are preferred while those believed to increase body heat or “hot” foods are avoided during pregnancy. Papaya, aubergine, pineapple, jackfruit, jaggery, sesame seeds, dates, molasses, fish, shellfish, all kinds of meat, eggs, milk, and spices are reported to be avoided. Women believe that some of these foods overheat the already “hot” pregnant body. The overwhelming fear is of miscarriage. Papaya avoidance is discussed in several studies conducted in India (Nag, 1994). The raw green fruit contains high concentrations of latex, which is thought to increase uterine contractions and is believed to have potential for miscarriage. The ripened fruit has less latex, however, while containing high concentrations of Vitamin A. Vitamin A is a much-needed nutrient among pregnant women in countries where Vitamin A deficiency is prevalent among the poor. We found in our review of the literature that beliefs can vary considerably across the world. In Nepal, women may have more of the ripe papaya fruit during their pregnancy depending on its availability and the individual woman’s taste preference, and in Ghana it is one of the recommended food items for pregnant women (Christian et al., 2006; de-Graft Aikins, 2014). On a similar note, in China women believe that pregnancy causes an imbalance between the forces of “yin” and “yang,” so that the woman is “cold” in the first trimester, “neutral” in the second, and “hot” in the third trimester (Gao et al., 2013). Accordingly, they will start eating “cold” foods in the second trimester to counterbalance the “hot” stage in the third trimester. Increase in consumption of certain preparations such as soups containing Chinese olives, green beans, and salsola grass was based on their belief that they need to reduce the internal “heat” of the fetus. Researchers report other food restrictions and taboos followed in African and Asian countries (Ebomoyi, 1988; Gao et al., 2013; Huybregts et al., 2009; Liamputtong, Yimyam, Parisunyakul, Baosoung, & Sansiriphun, 2005; Mukhopadhyay & Sarkar, 2009; Sultan Ali et al., 2004). Gao and colleagues (2013) found that pregnant women in China avoided a number of protein-rich foods such as snake, eel, and beef. They consumed more of other foods that they considered nutritious, however, such as fish soup. In rural Nigeria traditional healers discouraged women from eating rabbit meat, warning them that if they did, the baby might turn out to be a kleptomaniac (Ebomoyi, 1988). Other meats including monkey, pork, snail, crocodile, and snake are avoided, based on similar beliefs about babies appearing or behaving like the animal. These recommendations were unlikely to be questioned by the women in this study who were likely to have little or no education and few opportunities to access scientific dietary information.
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The major food groups avoided by low-income pregnant women are likely to contribute to an already poor state of nutrition.
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Benefits for the baby
Women in very low-income groups reported that they wanted their babies to be small and strong as opposed to what they perceived as big and weak, and they made changes to their diets accordingly (Nag, 1994). Other reasons for changing their diets are beliefs that the child might benefit in terms of appearance and for improving the odds for the more favored male offspring (Reddy, 1990). Women in the Southern State of Tamil Nadu, India, ate saffron (“red flower”) during pregnancy and avoided any item of food colored black, such as black grapes and dates, to increase the chances of their child being born fair-skinned, which is a highly valued trait in a community where higher caste is linked to fair skin (Engelin, 2009). Symbolism of this nature appears to be more common in regions where women lack educational opportunities. Chinese women included in their diets soups containing cuttlefish to improve birthweight; Chinese redbud flower and pig’s stomach, which they believed was good for the baby’s stomach; goose eggs to avoid boils in the newborn baby; and walnut for promoting the baby’s intelligence (Gao et al., 2013). Pregnancy cravings
Craving for particular items of cooked and uncooked regional foods, as well as yearning for items such as mud, clay, and ice, were cited in several studies. Researchers of four studies reviewed by Nag (1994) describe a wide variety of cravings among pregnant Asian Indian women. Women in Burkina Faso spoke about similar cravings for food and non-food items (Huybregts et al., 2009). McGilvray (1982) suggests that cravings are generated when the demands of the fetus drain the nutritional resources of the mother. In an anthropological study of women in late 1950s Sri Lanka, Gananath Obeyesekere (1963) provides some insight into pregnancy cravings. At that time “Dola Duka,” the regional term for pregnancy cravings, was understood as a sociocultural construct thought to be deeply rooted in pregnant women’s psychological problems of adjustment, ambivalence toward her children, and male envy. More importantly, cravings were not seen to be significantly related to nutritional needs in pregnancy. Herbs
Plants and herbs are used in less-developed areas of the world for women’s health, and they form part of tradition and culture that has been ignored after the introduction of formalized health care. Researchers of an ethnopharmacological study of plant use in South East Asia mention plant use during pregnancy, although they found the evidence somewhat limited (de Boer & Lamxay, 2009). “Kashaya”, a decoction of herbs taken during pregnancy, is thought by women in Southern
Sweden
USA
USA
Norway
USA
USA
Australia
USA and India
Ahlqvist & Wirf€alt, 2000
Cassidy, 1982
Chakrabarti, 2010
Garnweidner, 2013
Guiterrez, 1999
Lagana, 2003
Mitchell, 1995
Sathyamurthy, 2012
Destination country
Asian Indian
Vietnamese
Mexican
Mexican Mexican American
Middle Eastern, African, Asian
Black American, Mexican American, Puerto Rican, Asian Indian, other Asian, Bengali Indian, Bangladeshi
Iranian
Ethnicity
106
110
29
46
21
40
>1,600
14
Sample size
Table 2. Sample characteristics of migrant women in studies conducted in destination countries.
Not clear
108 D 0 to 14 years 2 D> 15 years
Not clear (half born in USA, half born in Mexico)
3 months to 18 years
2 to 35 years
9 months to 22 years
Not clear
2 to 20 years
Length of stay in destination country
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(continued)
Education < 10 years’ education - 3 10–12 years education - 11 13–16 years education - 17 >16 years education - 9 Education Not clear Education Elementary school - 9 Junior high school - 18 High school - 13 High school graduate - 6 Education Mean number of years in education - 11.5 years (Range 1–18 years) Education Primary education - 30% Secondary - 61% Tertiary - 9% Education Details unclear
Education Primary education - 2 Secondary education - 10 University education - 2 Education Not clear
Education
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UK
UK
UK
Woollett, 1995
Yeasmin & Regmi, 2013
Destination country
Woollett & Dosanjh, 1990
Table 2. (Continued)
British Bangladeshi
Asian, Non-Asian
Indian, Pakistani
Ethnicity
26
143
32
Sample size
Not clear
67% Asian women resident in UK for >10 years
1 to 25 years (Mean 12.9 years)
Length of stay in destination country
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Education Not clear More than minimum education Asian women - 28% Non-Asian women - 21% Education Primary education - 38% Secondary education - 46% Graduates - 15%
Education
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India to aid in an easy delivery (Engelin, 2009; Reddy, 1990). Similarly, Liamputtong and colleagues (2005) report that women in Thailand consume “ya tom” or “herbal medicine” to prepare themselves for an easy birth. The content and effectiveness of herbal remedies such as “Kashaya” or “ya tom” were not described.
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Pregnancy diets among migrant women in destination countries
Researchers of one review and 10 studies, including one unpublished study and one doctoral dissertation, describe traditional dietary practices among migrant women. See Table 2 for sample characteristics of women in this group of studies. Participants in these studies were migrant women from mixed socioeconomic backgrounds living in the United States, United Kingdom, Australia, and Europe. Where educational data were collected, most had secondary education, while some were graduates and a few were postgraduates. Only in one study did researchers examine the impact of traditional pregnancy diets on birth outcome. What do women want?
Migrant women appear to want to continue with their traditional pregnancy diets (Ahlqvist & Wirf€alt, 2000; Garnweidner, 2013; Mitchell & Mackerras, 1995). While a proportion in some migrant subgroups retain some of the practices known in their ethnic groups, others exchange them for those followed in the destination country (Satia, 2010). Mitchell and Mackerras (1995) found that as many as 57% of Vietnamese migrants in Australia continued with traditional humoral diets during pregnancy. There appears to be a continuum ranging from strict to flexible approaches to traditional pregnancy diets. Dietary beliefs and practices among migrant women
Themes resonant with those found by researchers in the previous group of studies conducted in low-income countries are described among migrant women—eating down, ideas about “hot” and “cold” foods, and food avoidances and restrictions. Iranian women in Sweden said they ate less to lower the birth weight of the baby (Ahlqvist & Wirf€alt, 2000). On this topic, older Iranian respondents recalled how “formerly many women died,” drawing attention to historical links between large babies and maternal and infant mortality. A diet low in carbohydrate was encouraged in the weeks leading to childbirth. Cassidy (1982) also records dietary changes to facilitate an “easy” labor among Mexican American and Black American women in the United States. These practices, however, are not universal. Bangladeshi women in the United Kingdom made no mention of eating less during pregnancy (Yeasmin & Regmi, 2013). The concept of “hot and cold” foods and of avoiding certain foods while preferring some food categories to maintain the hot–cold balance during pregnancy was mentioned by migrant subgroups in Sweden, the United States, and the United Kingdom (Ahlqvist & Wirf€alt, 2000; Cassidy, 1982; Satyamurthy & Raj, 2012 Woollett &
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Dosanjh-Matwala, 1990; Woollett et al., 1995; ). In a similar vein, balancing “yin” and “yang” by avoiding certain foods was deemed important for Vietnamese migrants in Australia (Mitchell & Mackerras, 1995). Other food avoidances and taboos demonstrate a continuing belief in traditional practices. British Bangladeshi women avoided papaya and pineapple because they feared miscarriage (Yeasmin & Regmi, 2013). Other dietary changes included avoidance of food at extreme physical temperatures (Cassidy, 1982).
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Influences on cultural dietary practices
Migrant women were influenced by advice from female relatives both in the destination country and in their home country, by other women in their community, and by health care professionals (Chakrabarti, 2010; Guiterrez, 1999; Yeasmin & Regmi, 2013). Yeasmin and Regmi (2013) found that while family influences among the British Bangladeshi Muslim participant women was strong, some of them actively sought and followed health care professional advice. Daylight fasting during Ramadan is not considered mandatory for pregnant women according to Muslim religious teaching. Despite being aware of this and of health care professional advice against the practice, women observed the fast in keeping with their preferences. Women’s decisions about which dietary practice or advice to follow were influenced primarily by concerns about the baby, but also by concerns for their own health and longer-term survival (Ahlqvist & Wirf€alt, 2000; Guiterrez, 1999; Yeasmin &Regmi, 2013). Access to food items considered desirable by pregnant women was influenced by their socioeconomic status, as also by ecological conditions in the destination country (Ahlqvist & Wirf€alt, 2000). “Acculturation”
Researchers have defined “acculturation” as a multidimensional process whereby individuals whose primary learning is in one culture go on to adopt characteristic ways of living from another culture (Harley & Eskenazi, 2006). Until recently the “acculturation” model was used to explain various sociocultural changes and public health trends among migrants, most importantly diet and trends in birth outcomes. In her study, “Come Bien, Camina y No Se Preocupe—Eat Well, Walk and Don’t Worry,” Kathleen Lagana (2003) looked into the meaning of “biculturalism” among Mexican migrant women in the United States. About eating well, a low-fat, high-protein, and naturally nutritious diet was cited by women as the most common determinant of a healthy birth outcome. While women placed great importance on a healthy diet, they found it difficult to continue to eat well if they were employed, and they felt frustrated about the closing down of choices resulting from changes to their socioeconomic status after migration. With “acculturation,” pregnant Mexican adolescents lost some of their traditional cultural beliefs relating
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to pregnancy (Guiterrez, 1999). Other studies have shown that the impact of “acculturation” can vary. Seasonal farm workers from Mexico working in the United States, for example, who maintained strong ties with the home country, regularly returned home during winter months (Harley & Eskenazi, 2006). Constant travel between origin and destination country would allow them to buy special foods and give them opportunities to recall traditional dietary advice. Pregnant Bengali women in New York City formed networks of care in neighborhood spaces, places of worship, and in workplaces where they sought help from friends, neighbors, and colleagues (Chakrabarti, 2010). Offers of traditional home-cooked Bengali food prepared with due consideration of cravings, proscriptions, and avoidances was very much part of the support these women received. Furthermore, Chakrabarti (2010) found that falling costs of access to telephone and Internet connections have enabled transnational social networks to thrive. Frequent communication with mothers and grandmothers in the home country mean continuity of care, guidance regarding healthy practices during pregnancy, and dietary advice. We found only one study in which authors compared views and practices between women in their origin and destination countries. Sathyamurthy and Raj (2012) compared traditional dietary beliefs and practices during pregnancy among Asian Indian women in the United States with those of their compatriots in the home country, India. More women in India believed that “hot” foods caused “overheating” and miscarriage, while a significant proportion of migrant Indian women in the United States disagreed with these beliefs. There were differences in stated practices about food avoidances and nutritional needs between U.S.-born Indian women and those born in India. The use of herbal preparations was not obvious in any of the studies included in this section of the review. It cannot be inferred from this gap in the literature, however, that herbal preparations are not used by pregnant migrant women. Indeed, there is anecdotal evidence that herbal preparations are sent across from home countries to migrant women in the United States and United Kingdom. Pregnancy diets and birth outcomes
We found only one study of the impact of traditional diets on birth outcomes. Mitchell and Mackerras (1995) compared the diets of migrant Vietnamese women in Australia who followed traditional humoral diets with those who did not. There were no significant differences in birth weight between the two groups.
Discussion Main Findings
In our literature review we found some information about beliefs and reported dietary practices followed by pregnant women in low- and middle-income countries,
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and of these practices among migrant women in high- income destination countries. Only Mitchell and Mackerras (1995) investigated the impact of traditional diets on birth outcomes. As can be seen from Table 1, sample characteristics of studies conducted in lowincome countries show that a large proportion of women had relatively low levels of educational attainment that may not have prepared women to question beliefs such as eating down to prevent giving birth to large babies and avoiding foods believed to have abortifacient properties. In these resource-poor areas, the strong influence of poorly informed relatives and traditional healers is compounded by the lack of reliable professional advice. Among women migrating from low- to high-income countries, there appears to be a range of practices varying from strict adherence to total abandonment of traditional pregnancy diets, likely due to changes in sociocultural circumstances, educational attainment, and adoption of recommendations from health care professionals in the destination country. Gaps in the literature
In her article, “Rites de Passage of Matrescence and Social Construction of Motherhood,” Poonacha (1997) writes that until recently women’s lives were only sketchily documented by men who had almost exclusive power to determine historical discourse. Women created a niche for themselves in oral cultures, passing down information from generation to generation. In a similar vein, de Boer and Lamxay (2009) note that expertise and knowledge of plant use in Lao People’s Democratic Republic is exchanged and applied in secrecy between women as traditional knowledge relating to women’s health, with a view to empowering themselves while undermining male dominance. These observations may help explain why traditional pregnancy diets from certain world regions may have been slow to come into the public domain and, to some extent, the relatively small number of studies we found on the subject. We found more studies about beliefs and reported practices compared with research into actual practice. Few researchers of studies reviewed here looked into women’s views about their own nutritional status, their knowledge about nutrition in pregnancy, their views about how to redress the lack of adequate food before and during pregnancy, or their views about inequalities in intrahousehold food allocation. Most importantly, there has not been enough study on the potential impact of pregnancy diets on birth outcomes in low- and high-income countries. In our structured review, we found important gaps in the literature on pregnancy diets among migrant women. More focused quantitative and qualitative studies are needed to address knowledge gaps.
Conclusion Immigration appears to select the healthiest individuals whose premigration healthy behaviors influence their health outcomes in the destination country
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(Kennedy, Kidd, McDonald, & Biddle, 2014). Findings from our review suggest that women participating in the studies carried out in their home countries were from poor backgrounds (see Table 1), many with little or no education, whereas those participating in studies in the destination countries (see Table 2) had higher educational attainment and were higher on the socioeconomic scale. Research into the impact of traditional pregnancy diets on birth outcomes needs to include comparison groups of women who did not migrate, along with data on birth outcomes, socioeconomic status, and access to health care in both groups. Women’s views will further improve our understanding of the subject of this review. Longitudinal research considering the entire suite of practices that women observe during pregnancy—food preferences, taboos and proscriptions, availability of special foods, traditional herbal preparations, quantification of dietary intake and energy expenditure, work restrictions and ethnographic data— are needed to understand further the impact of traditional pregnancy diets on birth outcomes.
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