Introduction
Nigeria still has an extremely high maternal mortality ratio 704 per 1000000 live births implying that with about 2.4 million live births annually, some 170000 Nigerian women die as a result of complication associated with pregnancy and child birth (Adelakan, Alimi, Anyawale and Afonja, 2005).Women are more likely to suffer from nutritional deficiency than men for several reasons, including their reproductive biology, low social status, poverty and lack of education. In addition, socio-cultural traditions and disparities in household work patterns can also increase women’s chance of being malnourished (Ransom & Elder, 2003).
During pregnancy a woman needs good nutritional status for a healthy outcome. Women who have a poor nutritional status at conception are at higher risk of disease and death; their health depends greatly on the availability of food, and they may be unable to cope with their increased nutrient needs during pregnancy in situations of food insecurity. Women’s nutrient needs increase during pregnancy and lactation. Some of the increased nutrient requirements protect maternal health while others affect birth outcome and infant health. If their requirements are not met, the consequences can be serious for women and their infants (Freedom from Hunger, 2003). Under nutrition and poor health from preventable causes disproportionately affect the well-being of millions of people in the developing world. Factors at individual, household and community level, or a combination of these factors, may contribute to poor nutrition and health status (Ronsmans, Collin & Filippi, 2008). In particular, malnutrition among women is likely to have a major impact on their own health as well as their children’s health. More than 3.5 million women and children under age five in developing countries die each year due to the underlying cause of under nutrition (Ronsmans, 2008).
Poverty influences to a great extent the nutritional status of women especially pregnant women. According to Adelakaan et al (2005), data on mother’s energy intake indicated poverty levels higher than presented in the World Bank poverty assessment (World Bank, 2003). A study in Ibadan by Maclean (2002) on pregnancy and food taboos, it was discovered that pregnant women were warned not to eat large plantains with cleft so as not to have babies with rigid skulls. In Ile-Ife, many traditional healers discourage pregnant women from eating snails or okra soup, as these would harm the babies. Chiwuzie and Okolocha, (2007) discovered that many pregnant women were advised not take milk and egg during their pregnancy that it lead to their babies growing up to be a thief.
Conceptual framework
The notable effects of malnutrition during pregnancy are problematic labor, premature birth, and delivering babies with low-birth weight. A baby born to a malnourished mother is prone to infections, retarded growth, and cognitive impairment. Pregnancy is such a critical phase in a woman’s life, when the expecting mother needs optimal nutrients of superior qualities to support the developing fetus. Naturally, the urge to eat more is experienced by nearly all pregnant women. However, one should be aware of what would happen if there is a lack of nutrients in the gestation period and the effects of malnutrition during this phase. It is quite obvious that it would negatively affect the health of both the mother and the baby. Malnutrition and Pregnancy Malnutrition is defined as the lack of sufficient nutrients, which are essential for the body’s normal functioning. Over time, it affects the bodily organs and results in mild to severe medical problems. One of the malnutrition facts is that the number of hungry people is more in the developing countries. Consequently, the occurrence rate of malnutrition during pregnancy is higher in the countries of Asia and Africa. As per medical data, pregnant women, lactating women, and children below 3 years are more susceptible to malnutrition effects than others. From the moment that a woman conceives, she holds the responsibility of following a healthy diet in large quantities to support the growth of an entire life inside her womb. An expecting mother should understand that her daily nutrition is not only important for her health, but it is crucial for maintaining good health of her baby for the entire life (Rambo, 2009).
Taking this into consideration, malnutrition during this phase is a leading cause for poor pregnancy consequences. Effects if a pregnant woman is malnourished, it is understandable that the baby in the mother’s womb is not receiving enough nutrients. In other words, the nutrients and trace minerals essential. For developing a whole life are not provided in sufficient amounts. As a consequence, the baby will exhibit poor growth rate and low weight. The general effects of malnutrition on the body are weak immune system, greater risk to illnesses, low stamina level, and lesser height.
Some effects of malnutrition when pregnant are carried by the child throughout his/her entire life. Say for example, a malnourished baby is prone to infections not only in the early stages of growth, but also in the adulthood phases of life. Also, it is claimed that cognitive impairment and low IQ are directly linked to malnutrition symptoms, especially during pregnancy and infancy period. Pregnant women, who have been through malnutrition, deliver babies with low-birth weight. Such children are prone to retarded growth, less coordination, poor vision, learning difficulty, and many other diseases. Anemia is one of the malnutrition diseases that affect several pregnant women worldwide. It increases the risk for mortality of mother and baby at childbirth. Other serious effects are premature delivery, obstructed labor, postpartum hemorrhage, and birth defects. The effects of malnutrition on child development are attributed to lack of nutrients during pregnancy and also, during lactating period. In both the stages, consuming a well-planned pregnancy diet and diet for breastfeeding mother is crucial for the baby’s health. Indeed, the health and well-being of an individual would largely depend on the nutrition provided in the three stages, viz., gestation, lactation, and early childhood (Rambo, 2007).
In order to minimize these effects, a woman planning for conception should develop good eating habits and dietary changes. Staying fit before pregnancy is also imperative, because the developing fetus depends on the mother’s stored nutrients for fast growth during the initial months.
Factors associated with nutritional status of pregnant women
- Early age at marriage
Early age at marriage is still one of the factors that are associated with some health problems during pregnancy among women in the GCC countries. This is particularly true in the rural and urban areas. Several studies showed that many women got married before 16 years of age. The hazards of teenage pregnancy are that it can cause maternal death and infants with low birth weight (LBW <2.5 kg), which in turn affects infant survival. In Bahrain, it was demonstrated that mothers aged I 5- 19 years were more likely to deliver low-birth-weight infants (II %) than mothers in other age groups (7%) 11. In addition to teenage pregnancy, the risk of LBW increased with the first pregnancy. It was found that the incidence of LBW was 10.6% for Bahraini mothers who delivered for the first time compared with 6.3% for mothers who have one child or more.
- Multiple pregnancies
Multiple pregnancies without enough spacing between the pregnancies may cause several health and nutritional problem among both the women and their fetus. Statistics showed that the fertility rate of the Gulf mothers is relatively high (ranging from 4.6 per 1000 women aged 15-44 years in Bahrain to 7.1 in both Oman and Saudi Arabia). Multiple deliveries tend to lower the hemoglobin level in mothers, because closely spaced pregnancies deplete the iron stores of the mothers, especially when there is no iron supplementation during pregnancy.
- Unsound food habits
There are many unsound food habits during pregnancy which may affect the weight of infants. Few mothers are interested in improving their diet during pregnancy. In Bahrain, it was reported that only 31% of mothers consumed more fresh fruit during pregnancy. As a result the intake of some nutrients may be affected. In Kuwait, Prakash et al found that the intake of calcium, iron and vitamin C by pregnant mothers was below 75% of US recommended daily allowances (RDA), while among lactating mothers, all nutrients (except protein) were below the RDA.
- Traditional beliefs and attitudes
Traditional beliefs related to nutrition are an important risk factor in pregnancy. For example, in some areas in the Gulf, mothers decrease their intake during pregnancy believing that extra food will cause an over large baby, while others believe that they should eat for two. Many pregnant women believe that the intake of iron supplement may cause enlargement of the fetus and the subsequent difficult delivery or even abortion.
- Social change and lifestyle
In general most of women countries are unemployed and few of them practice exercise. These factors play an important role in increasing the risk of overweight and obesity. The availability of housemaids, cars, television and sophisticated Home appliances has decreased the physical activity of the women, and the sedentary lifestyle has become a norm. In addition the intake of fast foods and other food rich in fat has increased significantly. These factors lead to high increase in the weight of women during pregnancy (Rolls et al, 2008).
Empirical review
A study conducted on 17,196 British births compared the fetal death rate in each of five social classes and found that the death rate for babies from 20 weeks of gestation to one week of life increases as the family moves down the socioeconomic ladder [The Lancet, 2001]. Thus, not only is the fetus at a greater risk for retarded development, but it is also at a greater risk for death. Nutritional education concerning the correct diet during pregnancy will have an impact on the fetal outcome (Rambo, 2009). Without proper knowledge concerning nutritional needs, and the dietary changes needed during pregnancy, the woman cannot be expected to eat an adequate diet. A California study of 683 subjects done by Del Tredici et al, (2001) provided low income pregnant women with instructions concerning 20 improved eating habits, how to shop and cook economically and essential information on nutrition and handling of food storage, sanitation and safety. This study found that women who received these instructions had an improved nutritional state. From this study it may be hypothesized that where essential knowledge is lacking, nutritional status is poor but when dietary knowledge is improved, the nutritional status also improves. This alteration in nutritional status is evidence of information processing, learning, and improved Judgment which are all aspects of Roij’s cognator mechanism.
Eating habits result from early teachings and beliefs about what foods should be consumed. Foods that were eaten during infancy and childhood will largely determine what food choices are made during adulthood (Rolls, 2008). Also, food experiences such as the unpleasant experience of nausea and vomiting following food consumption will strongly influence food aversions (Rolls, 2008 & Rozin, 2005). Pregnancy is a period of time that is influenced by beliefs about eating. Not only will eating habits be affected by the previously mentioned Factors, but they will also be influenced by specific beliefs concerning eating during pregnancy.
Some factors influencing diet during pregnancy are common beliefs such as a woman should have an appetite surge during pregnancy (King, Bronstein, Fitch & Weininger, 2006) or a woman should limit what she eats in order to prevent bearing a large baby (Ritenbough, 2003). Another common belief is that a pregnant woman will crave foods that are calcium and energy rich, but will avoid Foods that are rich in proteins (Worthington-Roberts et al., 2005). Some cravings are based on the belief that pregnant women “should” crave certain foods, examples include watermelon, pickles and ice cream (Ritenbaugh, 2004). Others believe that an overeaten craved food will have an adverse effect on the infant. For example, a strawberry birth mark will result from eating too many strawberries during pregnancy (Worthington-Roberts et al., 2005). Another type of craving that will influence the diet is pica. Pica is eating any non-food items such as dirt, clay or laundry starch. The origin of pica is not well understood, but when questioned, women respond that they “had to have it” and it “Felt like when you run out of cigarettes” (Lackey, 2001). This is not an uncommon problem; a study by Lackey (2008) found that 23% of blacks and 27% of white pregnant women practiced pica.
The consumption of these non-food items may cause a feeling of fullness, thus the intake of nutritious food items may be decreased. Older medical theories, now disproved, have reinforced Food restricting beliefs. A woman with a small pelvis was once prescribed the Prochownick diet; this diet consisted of fluid restrictions, low carbohydrates and high protein. It was believed that this eating regimen would yield a smaller baby. In time its use was expanded to other women, not just those with inadequate pelvis. This particular diet is still practiced today as well as other outdated information that actually is detrimental to fetal health (Worthington-Roberts et al., 2005). Other food restricting factors are cultural and religious beliefs (Rambo, 2006).
The restrictions are prescribed because the particular foods may cause “bad” outcomes during pregnancy and childbirth (Ritenbaugh, 2008). It is evident then that cultural and personal beliefs will have a strong influence on what a woman chooses to eat during her pregnancy. Some cravings may be harmless. Self-imposed or cultural restrictions may severely affect the adequacy of the food consumed, greatly restricting nutrients and vitamins essential for proper fetal growth and development. Nutritional status during pregnancy is an important variable to measure because the fetus is directly affected by the mother’s nutritional state. When pregnant, the woman needs to change her food intake in order to compensate for the increase in her metabolic rate. An increased basal metabolic rate requires an increase in calories in order to maintain optimal physical function (Rambo, 2006). Actually, during the pregnant state, a woman’s calorie consumption should exceed her expenditure. This imbalance will allow for the deposition of glycogen, fat and protein which are needed to sustain fetal growth and development, and at the same time maintain the woman’s own physical functioning.
Phillips and Johnson, (2007) conducted a study which correlated specific nutrients in the diets of pregnant women with the birth weight of their infants. The information was collected from women of various socioeconomic groups. A questionnaire concerning what foods were eaten was completed by each woman at multiple times during her pregnancy. The data collected indicated that there is a positive correlation between the infant’s birth weight and the quality of the mother’s diet.
Theory of reasoned action
The theory of reasoned action is a model for the prediction of behavioral intention, spanning predictions of attitude and predictions of behavior. The subsequent separation of behavioral intention from behavior allows for explanation of limiting factors on attitudinal influence. The Theory of Reasoned Action was developed by Martin Fishbein and Icek Ajzen, derived from previous research that started out as the theory of attitude, which led to the study of attitude and behavior. The theory was “born largely out of frustration with traditional attitude–behavior research, much of which found weak correlations between attitude measures and performance of volitional behaviors” (Hale, Householder & Greene, 2002).
Derived from the social psychology setting, the theory of reasoned action (TRA) was proposed by Ajzen and Fishbein (1975 & 1980). The components of TRA are three general constructs: behavioral intention (BI), attitude (A), and subjective norm (SN). TRA suggests that a person’s behavioral intention depends on the person’s attitude about the behavior and subjective norms (BI = A + SN). If a person intends to do a behavior then it is likely that the person will do it.
Behavioral intention measures a person’s relative strength of intention to perform a behavior. Attitude consists of beliefs about the consequences of performing the behavior multiplied by his or her evaluation of these consequences (Fishbein & Ajzen, 1975). Subjective norm is seen as a combination of perceived expectations from relevant individuals or groups along with intentions to comply with these expectations. In other words, “the person’s perception that most people who are important to him or her think he should or should not perform the behavior in question” (Fishbein & Ajzen, 1975).
To put the definition into simple terms: a person’s volitional (voluntary) behavior is predicted by his attitude toward that behavior and how he thinks other people would view him if he performed the behavior. A person’s attitude, combined with subjective norms, forms his behavioral intention.
Fishbein and Ajzen suggest, however, that attitudes and norms are not weighted equally in predicting behavior. “Indeed, depending on the individual and the situation, these factors might be very different effects on behavioral intention; thus a weight is associated with each of these factors in the predictive formula of the theory. For example, you might be the kind of person who cares little for what others think. If this is the case, the subjective norms would carry little weight in predicting your behavior” (Miller, 2005).
Miller (2005) defines each of the three components of the theory as follows and uses the example of embarking on a new exercise program to illustrate the theory:
- Attitudes: the sum of beliefs about a particular behavior weighted by evaluations of these beliefs
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- You might have the beliefs that exercise is good for your health, that exercise makes you look good, that exercise takes too much time, and that exercise is uncomfortable. Each of these beliefs can be weighted (e.g., health issues might be more important to you than issues of time and comfort).
- Subjective norms: looks at the influence of people in one’s social environment on his behavioral intentions; the beliefs of people, weighted by the importance one attributes to each of their opinions, will influence one’s behavioral intention
- You might have some friends who are avid exercisers and constantly encourage you to join them. However, your spouse might prefer a more sedentary lifestyle and scoff at those who work out. The beliefs of these people, weighted by the importance you attribute to each of their opinions, will influence your behavioral intention to exercise, which will lead to your behavior to exercise or not exercise.
- Behavioral intention: a function of both attitudes toward a behavior and subjective norms toward that behavior, which has been found to predict actual behavior.
Your attitudes about exercise combined with the subjective norms about exercise, each with their own weight, will lead you to your intention to exercise (or not), which will then lead to your actual behavior.
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