This study showed that food taboos still exist alongside with the use of modern health care services. Sixty-four percent of the participants in the current study are still practicing food taboos and following traditional recommendations during pregnancy, postpartum period and infant feeding. This high level of practice accords with results of other studies that were conducted in Asian countries including Pakistan , Indonesia , Thailand , China , India , Cambodia , central Asia  as well as in African countries including Ghana , Ethiopia , Nigeria , Kenya , Sudan  and South Africa [51,52]. Our study differs from previous studies done in South Africa because it was focusing on the Zulu culture of women living in a rural area. The study did not only focus on either dietary practice during pregnancy or dietary practice during postpartum recovery but it also extended to dietary practice during infant feeding.
The higher number of participant within middle (31–50 years) and old (51–90 years) age groups in this study resulted from these age groups having the relevant information needed, and were the ones who were most easily available for interviews. Older women also had better knowledge than the young and middle age women on cultural food practices during pregnancy, postpartum period and infant feeding, perhaps because they were culturally more experienced. There were insignificant differences in educational level and income status of the women who followed food traditions and those that did not. Similarly, in Pakistan  and India , literate and illiterate mothers shared the same traditional misconceptions of dietary practice during pregnancy and postpartum period. In contrast, a study in Ethiopia reported that the value of a modern balanced diet during pregnancy was significantly associated with younger, more educated mothers who had attended antenatal clinics . The analysis of the findings of the current study were structured thematically, with the findings, how it relates to literature and how the findings relate to modern science or medicine.
Dietary restrictions during pregnancy
Our findings (Table 1) revealed that cultural food taboos meant that women would avoid certain foods that are essential for a healthy pregnancy. This causes concern, as almost all (96%) of our participant sample had attended antenatal clinics and would have been informed about dietary requirements during pregnancy. The women cited common and nutritious foods – including oranges, mangoes, naartjies, pawpaws, commercial fruit juice, peaches, butternuts and eggs – as being traditionally restricted. Yellow and orange fruits and vegetables were to be avoided, they explained, because of a belief that the baby would then be born with jaundice, a condition causing the newborn’s skin and eyes to become yellow. The same restriction on the grounds that such fruits were responsible for skin discoloration in the baby were also reported in a study in the Eastern Cape, South Africa . The belief could be associated with doctrine of signature, which links yellow and orange fruits to yellow skin. Our study shows that both Zulu and Xhosa (Eastern Cape) cultures share this restriction and for the same reasons.
In previous studies, common reasons for restricting certain fruits during pregnancy included the fear of abortion or miscarriage. For example, in Asian countries, papaya is considered a “hot food” whose consumption could lead to miscarriage [4,5]. Fruits traditionally to be avoided, as reported in our study, are in fact rich in vitamins A and/or C, both of which are essential during pregnancy. Vitamin A is important for cell division, fetal organ and skeletal growth and maturation , and its deficiency affects some 19 million pregnant women, mostly in Africa and south-east Asia . Severe vitamin A deficiency in the mother can lead to low vitamin A reserves in the body, which can detrimentally affect the lung development and survival of the baby in the first year of life . Vitamin C is an antioxidant required for the synthesis of collagen and for prevention of pre-eclamptic toxaemia (characterized by high blood pressure, swollen ankles and protein in the urine) . Dietary intake of vitamin C can be useful in sustaining pregnancy to term; its lack was found to cause premature rupture of the chorioamniotic membrane . Vitamin C is also important for raising the uptake of iron . Thus avoidance of these fruits can lead to complications for the unborn baby.
The current study reported traditional avoidance of eggs in pregnancy for Zulu women, due to a belief that the baby would be born with no hair. Previous studies have noted egg restrictions in various cultures during pregnancy, but for different reasons. They were taboo in Pendhalungan society (Indonesia), which believed that the baby would be born smelling fishy . In India (Tumkur), eggs are restricted because they are thought to cause bluish discoloration in the baby. In Kenya (Uasin Gishu County), consumption of eggs in pregnancy is believed to make a foetus grow excessively big, which causes problems for the mother during childbirth . In the Eastern Cape (South Africa), eggs are taboo for Xhosa people because they are believed to increase the mother’s sexual appetite, which can be shifted to the unborn female child .
However, modern science reveals that eggs offer good value for pregnant women at an affordable price, as they provide essential fatty acids, proteins, choline, vitamins A and B12, selenium, iodine and critical nutrients at levels above or compared to those found in other animal-source food . Consumption of eggs during pregnancy has the potential to improve the child’s birth outcomes and brain development. Inadequate intake of choline by the mother during pregnancy has been associated with neural tube defects and changes in brain structure and functions in the offspring . The vitamin D in eggs can also prevent rickets in the newborn baby and keep the mother’s teeth and bones healthy . Iodine deficiency can increase the risk of spontaneous abortion, perinatal mortality, birth defects and neurological disorder . Restricting egg consumption during pregnancy is therefore a concern, especially as it is common in many cultures.
Almost two-thirds (61%) of our participants reported the belief that avoiding chili and ice during pregnancy could prevent the baby’s skin having burns or dark marks or rash or blisters before birth, diarrhoea in the mother, red spot (ibala) on the back of the baby’s head, and excessive crying. Similar traditional restrictions were reported in Indonesia, where chili was avoided because it makes infants cry easily and also makes them dirty and sick . However, no scientific evidence has been found of any side effects of the consumption of chili during pregnancy. On the contrary, they are a great source of vitamins A, C and E . They also have medicinal properties that include boosting immunity , treating diabetes and obesity , lowering blood pressure, and reducing heart attacks .
In Indonesia (Madura island), consuming ice/cold water was reported to be taboo as it makes the mother’s womb fertile, resulting in a large baby, which could complicate the birth process. In addition, it could cause the mother to give birth to conjoined twins or to experience bleeding during delivery . The consumption of ice is pagophagia, commonly known as pica (the craving for and chewing of substances with no nutritional value), and is closely related to iron deficiency . Women who report cravings for ice during pregnancy, therefore, could be reporting a symptom of a condition that needs to be addressed, and that could go undetected if the tradition of avoiding ice in pregnancy is enforced.
Some of the traditional Zulu food taboos reported in our study are beneficial to health and should be reinforced. Consumption of sweets, sugarcane, commercial juice, sweet food, and honey, for example, was also considered taboo during pregnancy as it could result in a drooling baby with a great deal of saliva and also cause eczema. In Laos in the People Democratic Republic, sugarcane was taboo because it would lead to a fat baby and thus a difficult delivery . Avoidance of sugary foods in pregnancy was also reported in Kenya (Uasin Gishu County), where 11% of the participants believed that the sugar would make the baby salivate excessively. Sugary foods eaten by the mother could also give the baby colic and give the mother and baby malaria . Modern science supports some of these restrictions. Sugar consumed during pregnancy can affect both mother and unborn child: it can shape feeding behaviours and taste preference in the offspring, and increase future possibility of obesity and related metabolic diseases . High maternal intake of sugar during pregnancy can also increase the risk of atopic asthma in the baby . Again, high consumption of added sugar during pregnancy has also been associated with the development of gestational diabetes mellitus . Thus this is a worthy taboo as it prevents a variety of complications in a new-born.
Food taboos can protect mother and foetus from food toxin. For example, alcohol consumption was reported in the present study as a taboo for pregnant women, because it was believed to cause the baby to be born sick, unhealthy, disabled or brain damaged. In Kenya, alcohol consumption in pregnancy is also taboo, because it is believed to suck the baby’s blood, thereby causing low birth weight and stunted children . Science has shown alcohol to be a teratogen that can readily cross the placenta and result in irreversible damage to the brain and other organs of the developing foetus . Prenatal alcohol exposure can cause fetal alcohol spectrum disorders, which include learning difficulties, executive dysfunction, impaired speech, motor problems, and behavioural issues . Consumption of alcohol during pregnancy can also induce preterm labour, lead to decrease breast milk production and, in the first trimester, increase the risk of spontaneous miscarriage . This traditional food taboo, therefore, protects women and their babies from side effects, and is consistent with modern maternity health advices.
Traditional food recommendations during pregnancy
Foods taken by the participants in the current study does not provide all essential nutrients required for successful pregnancy. Dairy, meat, eggs, nuts and legumes were less recommended, thus this may lead to insufficient intake of some nutrients required. In the current study, 51% of the participants recommended leafy vegetables to be consumed when one is pregnant as they believed it provides vitamins, increases blood, healthy mind, build bones and improve growth of the baby. However, some women (21%) perceived that eating green leafy vegetables is a taboo as they believe that the baby will be born with excessive saliva, burned skin or the baby will have dark marks on the skin. Thus, the consumptions of leafy vegetables during pregnancy is controversial as some participants believe it’s a taboo while others recommend it. In India (Tamilnadu), green leafy vegetables are considered as “cold food” and consumption of these food items during pregnancy causes a cold and fever to the mother . Consumption of vegetables was recommended in Thailand, where some women claimed to consume them throughout the pregnancy and other only consume them towards the end of pregnancy . According to a study done in Kenya, 89% of the participants recommended traditional leafy vegetables, as they are believed to increase the volume of the blood in woman’s body and build the body which gives women strength during labor .
Leafy vegetables are rich in iron and folate. Iron form the red blood cells for the mother and the baby. It helps to carry oxygen in the blood from the lungs to the tissue. The baby’s brain and body need iron and oxygen to grow . Iron deficiency may cause anemia and inadequate intake of iron during pregnancy is associated with increased cardiovascular risk for the offspring in adult . Folate plays an important role in many metabolic reactions such as biosynthesis of DNA and RNA, methylation of homocysteine to methionine and amino acid metabolism. Inadequate dietary intake can lead to anemia, leucopenia and thrombocytopenia . Pregnant women should be given a proper education on the nutritional facts of leafy vegetable as some women are avoiding them because they believe that they may have some side effects on the unborn baby. There is no scientific evidence that support that leafy vegetables can cause skin problems to the unborn baby as mentioned by some participants.
The second most recommended food by the participants during pregnancy was fruits which are believed to result in having a healthy baby. Fruits recommended included all variety of fruits except those that were restricted (mango, naartjie, orange, pawpaw, fruit juice, peach). In Indonesia, fruits were suggested during pregnancy because they do not cause nausea . These results are similar to what was reported in Kenya, where 35% of the participants reported that eating fruits was recommended because fruits are believed to increases the mother’s blood volume. Fruits are also believed to improve the mother’s appetite; helping in digestion, and improve the skin (softness) of the baby after birth . They are a rich source of vitamin A, vitamin C and fiber. Fiber is required to prevent constipation, reduce the risk of gestational diabetes and pre-eclampsia .
Liver was the third most recommended food during pregnancy in the current study. The women said it restores, increases and cleanse blood. This result is similar to what was reported in Kenya, where 24% of the participants recommended liver during pregnancy as they believe that it increases the volume of the blood . Liver is a good source of vitamins A, C, B-6, iron, protein and cobalamin. Vitamin A is important for visual health, immune function and fetal growth and development . It exists in two forms, preformed vitamin A which is found in animal sources as well as provitamin A (carotenoids) found in plant sources. Absorption of vitamin A from vegetable sources is poor, thus food of animal origin is necessary to achieve daily requirement . Dietary intake of preformed vitamin A greater than 7000 micrograms may be teratogenic leading to increased risk of congenital malformations . According to the WHO , pregnant women should avoid consumption of liver as it contains retinol thus women should be encouraged to consume more products of plant origin that contain carotenes (provitamins), which is not teratogenic to the foetus and less of preformed vitamin A.
Fish was also recommended during pregnancy as the participants believed that consumption of fish makes the baby clever, woman will deliver easy like a fish swimming in water and it also restore blood. The assumption of fish making the baby clever could be possible as fish consist of nutrients that are required for fetal neurodevelopment. In the study conducted in Tumkur (India) fish was recommended by 78% of the participants during pregnancy as it improves memory, IQ and milk production . However, in other studies fish was considered a taboo, where in west Bengal (India), fish caught by a net are avoided because the net represent the uterus, thus, one will have to break the net in order to deliver the baby, which means delivery through caesarean section . In another study done in Eastern Cape (South Africa), fish was considered a taboo because the baby will be born with scales and with a rash on the skin, eczema, or be born with no hair and rough skin with small pimples .
Fish is a rich source of protein, and other nutrients that are required for fetal neurodevelopment which include iodine, selenium, choline; vitamin D, iron and long chain n-3 fatty acids . Other health benefits of fish consumption during pregnancy include increased birth weight and reduced risk of spontaneous miscarriage . Iodine is essential for the development of the fetal central nervous system . Some fish also contains mercury (accumulated from polluted water) which cause acute toxicity in man and can pass through the placenta , thus it can affect the foetus and it is recommended that pregnant women minimise exposure to mercury . Potential contamination of fish by mercury requires cautious consideration as a dietary recommendation of fish during pregnancy . Research showed difficulty of balancing the benefits of fish with the risk of mercury intake . Thus, women should be educated about the types of fish that are low in mercury and safe for consumption during pregnancy.
Traditional Food Recommendations during postpartum recovery
The most recommended food in the current study was soft porridge (maize meal), as it is believed to restore strength and encourage lactation. Soft porridge is a bulk food of low-nutrient density, which is made by diluting maize meal with water to obtain thin consistency . Soft, not too strong and not too spicy foods were also recommended during postpartum recovery in a study conducted in Brazil . In Limpopo Province (South Africa), special meals such as warm soft porridge and indigenous vegetables with ground peanuts were reported to be consumed to encourage production of milk and promote recovery after birth . In order to regain strength and energy, breastfeeding mothers need a diet high in protein and carbohydrates for milk production , thus women need to be advised on dietary intake of protein to boast milk production.
The second most mentioned food taken during postpartum recovery in the current study was fruits and vegetables to increase and restore blood. These results are contradicting with a study done in China, where 18% of the participants never ate vegetables, while 78% never ate fruits during postpartum period . “Cold foods” (vegetables) were restricted during postpartum recovery as it decreases breast milk production. Rather women were advised to consume “hot food” which includes fruits such as papaya, banana, coconut, pineapple and red chili as it helps the mother to recover from the trauma of labor . In India, green leafy vegetables were not recommended during lactation because they are considered “cold foods” and can cause a cough and cold to the child .
Beetroot was also recommended for postpartum recovery to cleanse, restore loss blood and to avoid constipation. The belief is that since beetroot is red in colour, it symbolise blood, thus it has to be consumed after loss of blood during delivery. Beetroot is a good source of fibre, potassium, manganese, iron, vitamin C, folate and other numerous vitamins and minerals . Taking beetroot for 20 days was reported to increase the serum iron level, mild increase of haemoglobin and ferritin, thus beetroot might have some therapeutic properties for iron deficiency. It was suggested that beetroot should be put within the dietary protocols for women at childbearing age .
Women in the current study reported to consume high volumes of tea and coffee during postpartum recovery as they believe it encourage lactation. This also help them to keep hydrated. However, they need to be advised about the types of tea to consume as some contain caffeine. The World Health Organization  recommended a limit intake of tea and coffee during pregnancy and lactation as it interfere with iron absorption. Caffeine can pass into the breast milk and cause hyperactivity and sleeping problems in the baby. Water was mentioned to be essential during postpartum period as it facilitate lactation. However, this contradict a study done in India, where the participants reported that consumption of water is restricted as it may lead to the swelling of the stomach of the baby . Water restriction was also mentioned in a study done in west Bengal .
Food taboos in infants
The most common restricted food avoided in young children in the current study was meat. It was restricted because their teeth are not strong, they may crave meat their whole life or crave other children’s food, and the baby will grow up sexually active or it can cause diarrhoea and worms. The current study differs from the study conducted in Laos in the People Democratic Republic, where young children were given everything the rest of the family eats . In a study done in Mid-West state of Nigeria, meat and eggs were not given to children because parents believed that children will steal . Animal products are the only foods that contain enough iron, zinc, calcium and riboflavin to supply daily requirements for complementary feeding, while being low in anti-nutrients .
The World Health Organization  recommended that meat, poultry, fish and eggs should be eaten daily, or as often as possible. Meat provides an important role in a diet, as it provides nutrients which are amino acids, vitamin A, vitamin B1, vitamin B2, niacin, vitamin B6, vitamin B12, iron and zinc . Infants and children under the age of five years are at risk of developing iron deficiency anaemia because of their increased requirements for rapid growth and diets that are often lacking sufficient absorbable iron . Deficiency of iron in young children may lead to increased perinatal mortality, delayed mental and physical development, reduced auditory and visual function and impaired physical performance .
The second most mentioned food avoided in the current study was sugar and sweets as they may cause rotten teeth, too much saliva and sores on the tongue. There is no nutritional requirement of any type of sugars in infants . Thus this taboos align with modern nutritional requirements for infants. Added sugar contribute to poor health outcomes, which is a concern to children as excessive consumption of sugar has been linked to several abnormalities and adverse health conditions . Sugar intake has been associated with increased risk of dental caries and adiposity (obesity) . If parents feed their children food with sweet flavours, it is most likely to affect subsequent food preferences and eating behaviours . Again, early-life exposure of excess sugar may also create a predisposition to non-communicable diseases . Reducing added sugar intake and replacing it with water is associated with reduced weight and adiposity in children .
Food taboos during infancy and childhood are also intended to protect children during vulnerable stages in life . Strong (chewable) foods such as cereal, Amadumbe, dry corn and sweet potatoes were also avoided for young children because they are hard to digest due the child’s underdeveloped digestive system. In Tajikistan (Asia), heavy foods (bread, meat, vegetable filled pastry, rice dumpling filled with meat and vegetables) were considered a taboo because it is difficult to digest these meals . In some countries, people practice premastication, or chewing of food by the mother, father, grandmother or sibling to soften strong foods . This is done to ensure that infants with underdeveloped digestive system are able to get enough food to meet daily dietary requirements.