Food habits and Pregnancy outcomes

Introduction: Nutrition during pregnancy plays an important role for an optimum outcome of pregnancy. Women may be malnourished even before they become pregnant and this may further adversely affect the pregnancy. Maternal undernutrition can lead to poor intrauterine growth and low weight of the baby at birth. Moreover, the leading causes for maternal deaths like hemorrhage and infection are related directly or indirectly to nutrition. Aim of the Study: To study the impact of existing food habits on pregnancy outcome in a south Indian population. Materials and Methods: This prospective study was conducted at a tertiary health care and research institute in India. From the antenatal clinic, 350 women who satised the following inclusion and exclusion criteria were admitted to the study. Results: The majority of pregnant women belonged to the age group of 21-25 yrs (47%) followed by the 26-30 yrs age group (40%).The number of teenage pregnancies was 30 (8%) whereas 5% of pregnant women belong the age group of 31-35 yrs.83% of the study population belonged to the low socioeconomic class. Majority of the babies (66%) had the birth weight in the range of 2.5-2.9 kgs. 29 % of babies had birth weight in the range of 3-3.5 kgs. There was a signicant association (p value < 0.05) between the socioeconomic status of the mother, parity and her calorie intake. The present study found a statistically signicant association between the maternal nutritional status, the birth weight of the baby and the need for NICU admission (p value < 0.05). Conclusion: Maternal food habits have an impact on the pregnancy outcome. Maternal food habits are inuenced by many factors like socioeconomic status, parity, social food taboos and pregnancy itself. The pregnancy outcomes like birth weight, need for NICU admission and postnatal complications are inuenced by maternal nutritional status.


Introduction
An adequate availability of nutrients during gestation is probably the single most important environmental factor in uencing pregnancy outcome (1). An inadequate supply will risk the well-being of both mother and the conceptus.
A woman with poor nutritional status has an increased risk of complications like anemia and adverse pregnancy outcomes such as postpartum hemorrhage, preterm births and fetal growth retardation which in turn increases the risk of Prematurity and low birth weight. The National Family Health Survey-4 (NFHS) indicates that 20.2% of men and 22.9% of women are undernourished (2).
Maternal nutrition is indirectly assessed by her weight gain during pregnancy. According to the guidelines of Institute of Medicine the total weight gain during the course of a singleton pregnancy for a healthy woman averages 11.5-16 kg, with a weight gain of 1-3kgs during rst trimester and about 0.35-0.5kgs per week during second and third trimester (3).
Mothers are subjected to nutritional stress owing to the nursing process and their health risk is multiplied by frequent pregnancies, pregnancy complications like hyperemesis, coupled with a lack of access to and control over income, inadequate education, and excessive demands on their time, and so on (4) .As in many other countries, there are traditional beliefs in India regarding speci c food items a pregnant woman should or should not eat during pregnancy. This leads to misconceptions like the belief of 'eating down' -the belief that pregnant women should eat less than before pregnancy or should not increase the diet during pregnancy quite widespread in India .Foods perceived as 'hot' in Tamil Nadu communities are more in number ( papaya, pineapple, mango, animal foods, wheat and sesame seeds) (5). Awareness of these being myths is not created in women. There is an urgent need to overcome the cultural practices that are traditionally affecting the nutritional and health status of women .
There is no doubt that maternal nutrition during pregnancy plays an important role in optimum outcome of pregnancy. The present study was undertaken to study the effects of food habits on pregnancy outcome.

Materials And Methods
This prospective study was conducted in the Department of Obstetrics and Gynecology of a Multispecialty Hospital and Research Institute in India. From the antenatal clinic, 350 women who satis ed the following inclusion and exclusion criteria were admitted to the study .A proper informed consent was obtained from all the mothers who were admitted to the study.

Methodology
From the antenatal clinic, 350 women who satis ed the inclusion and exclusion criteria were admitted to the study. At the rst visit, a detailed history regarding her present pregnancy was recorded along with a detailed past obstetric history and family history. All pregnant women who participated in the study were interviewed at regular intervals of (14 to 16wks, 24 to 26 wks, 28 to 30wks and 32 to 36 wks of gestational age). During such visits Dietary intake of the subjects was assessed by 24-hour Recall method .Maternal weight, hemoglobin and fetal growth pro le was noted during such visits. A general physical and obstetric examination was done at such visits. Nutritive value was calculated for every case .

Assessment of food habits
In this study the dietary intake of the subjects was assessed by 24-hour Recall method.

Follow up
All the women who participated in the study were called for regular antenatal check-up and care was provided as per the routine protocol. During the regular antenatal check-ups, maternal weight gain, BMI, hemoglobin and fetal growth pro le, was assessed. All the women were counseled about the importance of adequate nutrition. The onset of labor spontaneous or induced, type of delivery whether spontaneous vaginal delivery, instrumental vaginal delivery or LSCS was noted.

Perinatal outcome
The Perinatal outcome was assessed by the usual parameters of GA, birth weight, Apgar score and presence or absence of congenital anomalies.

Statistical analysis:
At the end of the study the impact of food habits on pregnancy outcome in terms of mode of delivery, birth weight and NICU admission was assessed and the results were analyzed using appropriate Chi-Square statistical method.

Ethical justi cation:
This study did not involve any invasive procedures. However ethical justi cation was obtained from the ethical committee of the hospital.

Data availability Statement-
The data that support the ndings of the present study are available within the paper.

Results
This prospective study was conducted to study the effects of food habits on pregnancy outcome . This prospective study was conducted in the Department of Obstetrics and Gynecology, Voluntary Health services, Multi-specialty Hospital and Research Institute, Chennai. The study was carried out between January 2013-July2014. From the antenatal clinic, 350 women who satis ed the inclusion and exclusion criteria were admitted to the study.

Age distribution
Age distribution of women who participated in this study is shown in the table 1.
[Please see the supplementary les section to view the tables.] From the above table it is seen that the maximum number of pregnant women belonged to the age group of 21-25 yrs (47%) followed by the 26-30 yrs age group (40%).The number of teenage pregnancies was 30 (8%) whereas 5% of pregnant women belong the age group of 31-35 yrs.

Parity
Half of the pregnant women (50%) in the study group were primigravidas and (43.5%) were second gravidas . In this study, 6 % and 0.5 % of pregnant women were third and fourth gravidas respectively.

Socio economic status
The socio economic status of the respondents as per Kuppuswamy's classi cation It is seen from the above table that 83% of the study population belonged to the low socioeconomic class .14 % and 3 % of the study population belonged to the upper lower and middle lower socioeconomic class respectively . Majority of women in this study belong to low socioeconomic class this institute provides medical care In the mothers with low B.M.I , milk and banana was added by 75% of mothers followed by apple and dates by 50% of mothers.
In the mothers with B.M.I within normal range, milk was added by 68% of mothers followed by apples ( 47 %), dates( 50%) and bananas(44%). Eggs were added by 51% mothers in their diet.
In the mothers with B.M.I >25 kg/m 2 , 54 % of mothers added milk followed by eggs (60%),dates (60%) and apples by 56% of mothers Association between the socioeconomic status and calorie intake The association between the socioeconomic status and calorie intake of the mothers is shown in the table 4 The above table 4, shows the association between the calorie intake and socioeconomic status . As shown in the above table, there is a signi cant association between the socio-economic status of the mother and the calorie intake .

CALORIE INTAKE
The average calorie intake of the mothers belonging to different groups during each visit is shown in table 5 The above table shows us the average calorie intake of the mothers belonging to

Mode of delivery of participant mothers
Maximum number of women (65%) had a normal delivery. About 30% of women underwent a cesarean section. Only 5% of the pregnant women underwent an instrumental delivery .

Birth weight
The above tables shows the birth weight of the babies in the present study . Majority of the babies (66%) had the birth weight in the range of 2.5-2.9 kgs .29 % of babies had birth weight in the range of 3-3.5 kgs .5% of babies had birth weight in the range of 2-2.49 kgs.
Association between the parity and calorie intake Above table shows the association between parity and the calorie intake of the pregnant women. As per the statistical analysis, there is a signi cant association between parity and calorie intake during the pregnancy. There is a declining trend in the calorie intake especially in multiparous mothers .

CALORIE INTAKE AND BIRTH WEIGHT
The association between the calorie intake and birth weight of the baby is shown in the table 7 Above table shows the association between the calorie intake of pregnant mother and weight of the baby at birth. As shown in the above table, there is a very signi cant association between the calorie intake of the mother and birth weight of the baby.
Proper calorie intake of the mother has a positive impact on the baby weight.

CALORIE INTAKE AND NICU ADMISSION
In the present study 3 babies had NICU admission for the fetal distress.
The association between the calorie intake of the mother and need for NICU admission for fetal distress is shown in the table 8. Table 8 shows the association between the calorie intake and the (NICU) Neonatal intensive care unit admission at birth for fetal distress.

Condition at discharge
All the mothers who participated in this study were discharged on third day in case of a normal delivery and on eighth day in case of a cesarean section.
All the babies including those admitted in NICU were discharged on day 3 after checking their bilirubin levels.
There was no case of neonatal death, postnatal complications like puerperal sepsis and anemia in this study .

Discussion
An adequate availability of nutrients during gestation is probably the single most important environmental factor in uencing pregnancy outcome (1,5). Although physiological adjustments in nutrient utilization and metabolism are geared to improve the utilization of dietary nutrients during pregnancy, these adjustments may be insu cient to meet the demands for pregnancy and lactation if the woman is in poor nutrient status at conception. An adequate supply of nutrients is required to maintain the delicate balance between the needs of the mother and those of the fetus. An inadequate supply will cause a state of biological competition between the mother and the conceptus in which the well-being of both is at serious risk (1).
All societies have traditional beliefs regarding harmful and bene cial foods for women during, pregnancy (6,7,8).There are also beliefs regarding the optimal amount of food to be taken during pregnancy for a successful reproductive outcome. These beliefs may or may not conform to the modern biomedical notions about the proper types and amount of food needed by pregnant women to safeguard maternal nutrition, adequate growth of fetus and safe delivery (9,10) .This prospective study was conducted to study the effects of food habits on pregnancy outcome.

Socioeconomic status
In this study majority of the women ( 83%) belonged to lower socioeconomic class as per Kuppuswamy's classi cation. 14 % of women belonged to upper lower class and 3% belonged to middle lower socioeconomic class respectively.
The present study found a statistically signi cant association ( p value < 0.05) between the socioeconomic status and calorie intake of the mothers. Ayesha et al (11)reported the impact of maternal socioeconomic limitations on the calorie intake.

PARITY
The majority of women in this study were primigravida (50%) or second gravida (43.5%) . 6% and 0.5 % of women were of birth order 3 and 4 .The present study found a signi cant association between the parity and maternal calorie intake .Sonneveldt et al reported a statistically signi cant relationship between the high parity and maternal nutrition(12).

Mode of delivery
In the present study 65% of women delivered normally.30 % of women underwent a cesarean section and 5% of women had instrumental deliveries. The present study shows no statistically signi cant association between the mode of delivery and calorie intake (p value > 0.05). Similar results were found in study conducted by Thilothammal N and et al(13).

Birth weight
In the present study 66% of the babies had birth weight in the range of 2.5-2.9 kgs.29% of babies had birth weight in the range of 3-3.5 kgs and 5% of babies had birth weight in the range of 2-2.49 kgs respectively.
The present study found a very signi cant association between the maternal calorie intake and birth weight of the baby. M  The mothers whose preprgnancy BMI was low were given nutritional advice and it was noted that there was a marginal increase in their caroric intake in subsequent visits. However, this is not su cient to in uence the pregnancy outcome.
All these mothers belonging to low SE group are covered under the ICDS scheme and receive nutritional supplement during the entire pregnancy.

Conclusions
Among the 350 women who participated in this study majority of the women belonged to the age group of 21-30 yrs and to a lower socioeconomic class with the pre-pregnancy B.M.I within normal range of 18.5-24.9 kg/m 2 .
The average calorie intake of mothers with normal B.M.I was 2012kcal/day .The average calorie intake of mothers with B.M.I <18.5 kg/m 2 and mothers with B.M.I >25 was 1866 kcal/day and 1975 kcal/day respectively.
The food items consumed by the mothers during pregnancy consisted of rice, sambhar, milk, idly , fruits like apple, banana, dates, rassam and mutton soups.There was a signi cant association (p value < 0.05) between the socioeconomic status of the mother,parity and her calorie intake. The present study found a statistically signi cant association between the maternal nutritional status ,the birth weight of the baby and the need for NICU admission (p value < 0.05).
Maternal food habits have an impact on the pregnancy outcome. Nutrition education and awareness generation among the women is needed (18,19).Maternal food ood habits are in uenced by many factors like socioeconomic status, parity, social food taboos and pregnancy itself .The pregnancy outcomes like birth weight, need for NICU admission and postnatal complications are in uenced by maternal nutritional status.

Declarations Con icts of Interest
The author declares no con icts of interest
Con icts-None to declare. This study was approved by the Institutional Ethical committee.