Food-related taboos and misconceptions during pregnancy among rural communities of Illu Aba Bor zone, Southwest Ethiopia. A community based qualitative cross-sectional study

A community based qualitative cross-sectional study was conducted in eight rural Kebeles (the lowest administrative unit) selected from four districts of Illu Aba Bor Zone, Southwest Ethiopia. The zone is one of the twenty-one zones in Oromia regional state. The Zonal town, Mettu is found at a distance of 600kms from the capital of Ethiopia to the southwest direction. There are 14 districts in the zone with a total population of 933,345 where 467,553 are males. The dominant means of livelihood in the Zone is agriculture and cereals such as maize, sorghum, millet, and legumes like beans and peas are the commonly grown crops. Fruits and vegetables also grow in the area and coffee is the main cash crop of the zone.

An exploratory study was conducted from May to June 2019 using a qualitative method mainly Focus group discussions (FGDs) and in-depth interviews of Key informants (KIIs). These qualitative methods were used to best explore the food taboos and dietary habits since they are sensitive issues and it is necessary to uncover the why and the how behind such practices. To thoroughly investigate the cultural and community factors related to food taboos during the prenatal period, four health care providers, four Health Extension Workers (HEWs), and four elders (mothers-in-law), a total of 12 key informants were interviewed. Eight FGDs (four with husbands and four with pregnant women) having 8–10 purposively selected participants were conducted. The number of in-depth interviews and FGDs were determined based on the level of information saturation which was determined by transcribing the discussions of each day’s session. Purposive sampling was used to select the KII and FGD participants. The criteria for FGD eligibility required that women should be pregnant, able to understand and speak the local language and give consent, and husbands of a pregnant woman who is also able to understand and speak the local language and give consent. Homogeneity was maintained by sex and education. The criteria for KII participants’ selections were being health care workers, health extension workers, and the elderly. The conduct and reporting of this study are compiled using the guidelines outlined in the consolidated criteria for reporting qualitative research (COREQ) [8]; all details are provided in the Additional file 1.

Piloted interview guide questions were used for both the FGDs and IDIs (Additional file 2). All the participants were approached face-to-face and none of them declined to participate to the study. The FGDs were held with pregnant women and their husbands, separately so that they can express their opinions without fear of being arbitrated by their respective partners. The KIIs were conducted with health care workers, health extension workers, and the elderly (grandmothers /mothers-in-law). Both the FGDs and in-depth interviews were held at the nearby health posts and health centers. During the KIIs, the participants were encouraged to take an active role in establishing the flow of the interview. All questions used in the FGDs and KIIs were open-ended and new questions arising from the responses from the respondents, as participants were able to build on each other’s ideas and comments. Redundancy of responses was considered to be saturated and was removed every evening after transcribing the day’s work and preliminary analysis. New questions were added, whenever an information gap was identified. The data collection team was composed of the principal investigator (PI) and a research assistant, who had tertiary level qualifications. The principal investigator is a Ph.D student. The research assistant was a BSc holder in public health and trained before the actual data collection period. Before the commencement of the study, the research assistant did not have a relationship with the participants. However, participants were notified of the reasons for conducting the research in the study area. The principal investigator (PI) and one recorder/note-taker facilitated each focus group discussion (FGD) and key informant in-depth interviews (KIIs) with the participants. The data were audio-recorded and to assure triangulation of the data with the record, the team took note including memos of participant’s behavior and contextual aspects. The focus group discussions took a minimum of an hour and half whereas the indepth interviews took a minimum of half an hour.

The quality of qualitative research is assured by meeting standards of trustworthiness through addressing credibility and transferability [9]. To satisfy credibility, participants from different districts and different backgrounds were included. Additionally, Focus group discusions, in-depth interviews, and field notes were used in the analysis of the data. The study provided descriptions of the setting, sample size and sampling procedure, eligibility criteria, interview processes, and findings to strengthen the transferability to different contexts. Validity and reliability were ensured by triangulation of the data gathered from the interviews with the information obtained at the FGD and then after sharing the results with the attendants.

The tape-recorded FGDs supported by handwritten field notes were transcribed verbatim and analyzed manually using the principle of systemic text condensation [10]. Transcripts were reviewed repeatedly to gain a thorough sense of the overall content in the texts, to identify central meaningful units in the material, condense the content through color-coding of the text, and finally create categories that contain the condensed meaning of the main themes in the material. The data were then organized into themes. Sections of the discussions were quoted verbatim, and a few were modified to enhanced readability. The results were presented using narratives using the verbatim of the study participants as illustrations to substantiate major assertions. Quotes were translated from the local language (Afan Oromo) to the English language. Phases of the thematic analysis of the qualitative data is indicated in Table 1 below.

A total of seventy-nine (79) respondents participated in the eight FGDs and Twelve KIIs. The participants comprise twenty-six pregnant women, twenty-four men (husbands of pregnant women), four health professionals, four health extension workers four elderly (mothers-in-law). The participants represented a wide age range (20–63 years) and the educational status of the respondents ranged from no formal education to secondary school and above. (Table 2).

From a thorough review and readings of the scripts, the following three themes were identified:

The respondents were asked whether they were aware of any foods that are culturally prohibited during pregnancy. Differing opinions were noted regarding the practice of food taboos.

Some pregnant women, their husbands, and mothers-in-law believed that some foods should be avoided during pregnancy to protect and support maternal health. A KII participant mother-in-law said,

“…When they have morning sickness they cannot eat oily foods. Restriction of oily foods is

practiced early in pregnancy to reduce the likelihood and severity of morning sickness...”

Similarly, another mother-in-law, explained the following corroborating what was said earlier,

“… Intake of oily foods may be limited throughout pregnancy and that, in general, pregnant women don’t eat as much oily food...”

FGD participant pregnant mother also stated,

"…pregnant women should be careful and avoid certain foods, particularly towards the last

trimester. Our community strongly believes that what a pregnant woman eats in the last months of her pregnancy goes directly to the womb to feed the baby. Thus, some foods can hurt the fetus…”

In contrast, the health care workers and health extension workers believed that food taboos are becoming an old story.

One KII participant said,

“…I do not think many people still believe that pregnant women need to avoid some foods… except few women that live in far-off areas, …”

Similarly, another KII participant detailed,

“… ihhhhh, though in the former times there was the restriction of foods like egg, milk and milk products, due to the belief that it makes the fetus big and gets attached to the fetal body,… nowadays there is no such practice in our community…"

Another KII participant also stated,

“…most of our community members are now questioning the reason behind these taboos and the need for adherence, so the practice is not widely observed in the district ...”

Another KII participant stated the following substantiating the same opinion,

“... Educated people are not strongly upholding the taboo and beliefs…”

Pregnant women, their husbands, and mothers-in-law believed that certain foods should be avoided during pregnancy (Table 3).

FGDs across participant groups pointed to restriction of high carbohydrate foods particularly.

sugarcane. The consumption of this food was perceived to be associated with having bigger babies, which is believed to lead to difficult labor and delivery.

FGD participant and husband of pregnant mentioned,

“…Our community strongly believes that if a pregnant woman eats sugarcane, she may have a big baby which endangers her life by making labor difficult, but I doubt the effect …”

Similarly, FGD participant pregnant women stated,

“…if you eat these kinds of foods or meals you will have difficulty during birth. Consumption

of “a lot of sugar” during pregnancy leads to an increase in weight and a risky delivery

as the increase in weight during pregnancy makes the baby very big…”

Similarly, the discussants’ reported that foods like fruits specifically banana and avocado, and some types of vegetables like cabbage, pumpkin, and taro (Colocacia esulenta) are considered as taboo for pregnant women particularly as the gestational age advances. The reason attached to the taboo of these foods as stated by the discussants is that cabbage may cause abdominal cramps to the baby when born, whereas pumpkin, banana, Avocado, and Taro (Colocacia esculenta) locally named “Godare” are believed to pass to the fetus in the womb and get plastered to the head of the fetus. In explaining this instance a mother in law, KII participant stated,

“….if a pregnant woman consumes banana, avocado and taro (locally known as Godare) particularly as the gestational age advances; it can pass to the womb and get attached to the baby’s body while cabbage causes abdominal cramp to the fetus after birth. …”

Likewise, FGD participant husband of a pregnant woman uttered,

"… I heard some people saying that pregnant women should not consume pumpkin... But I

do not know the reason…”

By the same token, the consumption of dairy products (milk, yogurt, cheese) and eggs during pregnancy is considered harmful to the fetus and the mother. One of the FGD participant pregnant women said,

"….it is believed that pregnant women should avoid consuming dairy products like yogurt and cheese, particularly in the last weeks of her gestation. This is because dairy products can pass to the womb and attach to the baby’s body…”

One of the respondents had the following to say, which reaffirms the assertions of the other discussants stated above:

“…A pregnant woman shouldn't eat some foods such as eggs. This is because the fetus will become very big and the mother will have difficult labor and delivery...”

The underlying reasons for adherence to the food taboos from explanations provided by study participants were grouped into three broad categories: cultural influence, social context, and beliefs of the pregnant women themselves.

The majority of the study participants viewed the existence of traditional practices and beliefs about foods held as taboos are inherent in the community. They stated the reasons for their practice of food taboos stem from cultural influences. One FGD participant, husband of pregnant women, stated the following to elaborate the matter,

“… Our community strongly believes that if a pregnant woman consumes foods that are held

as taboo, she may have a big baby which makes labor difficult and endanger her life …”

The pressure from important others surrounding the pregnant women is a critical driver of the adherence to the food taboos. The discussant expressed that husbands and mothers-in-law impose cultural and traditional beliefs on pregnant women. One FGD discussant also mentioned peer influence. To substantiate this state affair, a KII participant Mother-in-law, stated,

"….pregnant women should avoid foods like banana, avocado, and taro (locally known as Godare) …if she consumes particularly as the gestational age advances; it can pass to the fetus in the womb and gets attached to the baby’s body …”

Similarly, one pregnant woman indicated,

“… It is believed that some foods can pass to the fetus in the womb and plastered on the fetal body…and women laugh at each other if a woman gives birth to a baby full of the white substance on the body…that is why we follow the food restrictions…"

This study revealed that recipients of the cultural practices, pregnant women, were without an understanding of why they do what they do. However, some of the discussants believed that consumption of the foods held as taboo may hurt the fetus. A pregnant woman mentioned,

"… if you eat certain kinds of foods or meals you will have difficulty during birth. …”

Similarly, another pregnant woman, FGD participant stated,

“… it is believed that consumption of the tabooed food may cause damage to the fetus, and … I do not want my baby hurt, that is why I avoid the foods held as taboo…”

The reasons for the food taboos are deeply embedded in the person’s believes and attitudes of the pregnant women, who are nested within the influence of the social environment surrounding her (important others) and the traditional beliefs and values of the society in general. The interrelationships between drivers at the different levels are illustrated in Fig. 1.