Prevalence and Consumption Pattern of Kolanut Among Pregnant Women in Ibadan Metropolis

doi:10.21203/rs.3.rs-1654479/v2

Background

Kolanut is popular in Nigeria and other Sub-Saharan African countries where it is widely consumed in various social contexts. While some studies have suggested that kolanut is consumed by pregnant women, there is a dearth of information on the prevalence, consumption pattern and reasons for kolanut consumption.

Methods

This study investigated these gaps among pregnant women in Ibadan, Oyo State, Nigeria. A cross-sectional study involving 478 consenting pregnant women in all three trimesters and registered at health facilities in Ibadan was conducted. Semi-structured questionnaires were used to collect data on socio-demographic characteristics, obstetric history and kolanut use during pregnancy. Google mapping of all the addresses of the respondents was exported into ArcGIS online to generate the maps. Association between kolanut use and respondent characteristics was investigated using Chi-square test and logistic regression analysis.

Results

The mean age of the women was 28.7 ± 6.3 years, 50.8% had secondary level qualifications, 43.9% were semi-skilled workers. 38.7% were recruited in Primary Health Centres (PHCs), 18% from Secondary Health Centres, 22.6 from Tertiary Health Centres and 20.7 from Traditional Birth Assistants (TBA)/Faith Clinics. 162 (33.9%) of women reported kolanut in pregnancy and 140 (29.3%) in the index/current pregnancy. Frequency of use defined as high (every day), medium (thrice a week), low (≤ once a week) and quantity of use defined as high (≥ 1 nut at once), medium (half to < 1 lobe) and low (quarter to < half lobe). 26.9% reported frequent use, while 12.3% used in high quantity. A high consumption pattern was found with higher consumption at both Ibadan North East and Ibadan North Local Government areas. Significant associations were found between current kolanut use and Hausa respondents (p = 0.014), educational level; secondary (p = 0.032), tertiary (p = 0.006), TBA (p = 0.005). Majority (93.7%) used kolanut to prevent spitting, nausea, and vomiting.

Conclusion

This study has shown that kolanut use is common among pregnant women and it is consumed in large quantities. The results of this study justifyy research into consequences of kolanut use in pregnant women.

Kolanut

Consumption

Prevalence

Pattern

Pregnancy

Alternative-medications

The use of complementary and alternative medications during pregnancy has been on the increase (1), regardless of adequate scientific evidence about the safety of these substances (2). The reported use of alternate medications (local substances/herbs) during pregnancy by pregnant mothers to suppress symptoms of morning sickness is on the increase, in various communities (1). Alternative medications are believed by many to be cheaper than conventional medications, natural and safe, reasons that explain their increased use. (3). About 80% of the world population takes alternate medicines to treat a disease or alleviate the response of a disease [WHO, 2019].

More than half of pregnant women experience morning sickness during pregnancy and this manifests as tiredness, dizziness, nausea and vomiting (4, 5). Although termed morning sickness, this group of symptoms can occur at any time of the day, depending on individual hormonal responses. Majority of pregnant women take different substances (6), to alleviate these symptoms which are more common in the first trimester. These substances can be in the form of drugs prescribed by physicians or pharmacists, or alternate substances based on self-prescription (7), resulting from their observation of other pregnant women or practices passed down by their mothers or relatives (2). The prevalence of consumption of herbal and alternate medicines by pregnant women is between 18% and 56% during pregnancy (3).

In addition to easy accessibility at very low cost and the assumption that they are safe, the proclamation by the WHO in 2016 encouraging alternate medications may have made their use more attractive. These substances, which could be in the form of herbs or traditional plants (1, 8), include kolanut (8, 9). Kolanut, a social snack (10), consumed by every gender and age group throughout tropical and equatorial Africa including Nigeria, is equivalent to tea, coffee, maté and cocoa (11, 12). There is a dearth of information on the prevalence of consumption rate and pattern of kolanut use in pregnant women and the perceived reasons why it is being taken in pregnancy.

There are documented reports that chemicals or substances like kolanut introduced in pregnancy especially during the first trimester could affect the mother and fetus and cause toxic effects such as delay in neuronal migration in the developing brain (3). It has also been established that the effects of these uncensored substances are dose dependent, and the time of consumption could magnify its effects (13). This research was, therefore, designed to document the prevalence and consumption pattern of kolanut (onset of use, amount consumed, duration of use and trimester of use), common reasons for its use during pregnancy, the perceived and reported effects in pregnancy, factors associated with its use in pregnancy and its geographical concentration.

Study area

The study was conducted in Ibadan, the most populous city in Oyo State, Nigeria with over 3 million people (National Population Commission, 2016). Ibadan is the third most populous city in Nigeria after Lagos and Kano, and the country's largest city by geographical area. The city has 11 local government areas (LGAs); five of these (Ibadan North, Ibadan North-East, Ibadan North -West, Ibadan South- East, Ibadan South -West) constitute the core Ibadan municipality and the other six (Akinyele, Egbeda, Ido, Lagelu, Ona-Ara and Oluyole) are the outlying areas which make up the rest of Ibadan city.

Subject Selection

Two LGAs were purposively selected for this study; Ibadan North due to its urban nature and mix of tribes (Ibo, Hausa, and Yoruba) and Akinyele as the peri urban LGA. A list of health care providers/facilities was obtained from the State Ministry of Health. One tertiary hospital, one secondary hospital, two primary health care centres and two TBA centres were selected in each LGA using simple random sampling techniques. The sample size was proportionally allocated across the selected facilities based on the number of registered antenatal attendees in the facility during the preceding year. At facility level, informed consents were obtained from eligible respondents and were recruited consecutively until the facility target was achieved.

Sample size

The sample size for this study was determined to estimate a proportion using a prevalence of 10% with a two-sided alpha of 5%, a difference of 4% and a non-response rate of 20%. This yielded a minimum sample size of 271 respondents. For logistic reasons we approached 500 women and 472 responses were suitable for analysis.

Data collection

This cross-sectional study utilised a structured questionnaire developed by the researchers. The content validity was ensured through extensive review of relevant literature on previous research reports to develop the relevant questions. The questionnaire was pre-tested with 30 pregnant women in two public and TBA facilities outside the selected LGAs. Following the pre-test, appropriate modifications were made to the instrument, ambiguous terms modified, and unnecessary items deleted. The questionnaire contained sixteen (16) questions on socio demographic characteristics, obstetric history, history of index pregnancy and pattern of kolanut consumption; with the frequency of use defined as high (every day), medium (thrice a week), low (≤ once a week) and quantity of use defined as high (≥1 nut at once), medium (half to <1 lobe) and low (quarter to < half lobe). The questionnaire was interpreted and administered to the participants by four trained female research assistants. The assistants were trained to conduct initial entry/engagement, obtain informed consent and information on the required variables from interaction with respondents. The quality of information collected was cross-checked and problems discovered were resolved by the supervisor on the field. All the questionnaires administered during the study were given code numbers and no names were recorded. The data collected from the pregnant women performed in accordance with relevant guidelines and regulations based on code of conducts from the ethical committee . Collection of data was carried out within a period of four months.

Study population

These included pregnant women receiving antenatal care at orthodox medical (public) and registered traditional birthing facilities within the selected LGAs. All consenting women with confirmed pregnancy by ultrasound scanning and having a minimum age of 15 years were included. For pregnant women who later withdrew from the study, only the details obtained prior to their withdrawal were incorporated into the results.

Mapping of kolanut consumption with the respondents

This was done by extracting the coordinates from Google mapping of all the addresses of the respondents and these coordinates were entered into a Microsoft excel and saved as Comma Separated Values (CSV) alongside other variables and was exported into ArcGIS online to generate the maps. Also, the hotspots were generated based on how many pregnant women consumed kolanut in that Local Government. Therefore, each cluster represents the kolanut consumption and the higher the number, the brighter the color.

Statistical analysis

Data were recorded electronically on the REDCap® platform using android tablets, cleaned, and analysed with the STATA package. Continuous variables were summarised as means with standard deviations or medians with interquartile ranges. Categorical variables were summarised as proportions. Chi square tests were used to investigate associations between kolanut use and categorical variables. Univariate and multiple logistic regression was fitted to identify independent factors associated with kolanut use, and odds ratios and 95% confidence intervals were reported. The level of significance for all tests was at <5%.

Sociodemographic characteristics

There were 478 pregnant women with a mean age of 28.7±6.3 years. Most of the respondent were Yoruba (82.0%), while 9.2% were Hausa, 5.7% Igbo and others constituted 3.1%. Fifty percent were of the Islamic faith, 49.2% were Christians and 0.4% had other faiths. The largest educational group were women with secondary level education (50.8%) while 43.9% were semi-skilled workers (Table 1).

Obstetric history

Fifty-three (11.1%) of the pregnant women were in their first trimester, one hundred and sixty-six (34.7%) in their second semester and two hundred and fifty-nine (54.2%) in their third trimester. Three hundred and eighteen (66.5%) were multiparous (≥2), one hundred and thirty-five (28.2%) were primiparous and twenty-five (5.2%) nulliparous (Table 2).

Table 1: Distribution of sociodemographic characteristics (n=478)

Variable	Frequency	%
Age (in completed years)
15-24	124	25.9
25-29	136	28.5
30-34	129	27.0
35-45	89	18.6
Ethnicity
Yoruba	392	82.0
Ibo	27	5.7
Hausa	44	9.2
Others	15	3.1
Religion
Christianity	235	49.2
Islam	241	50.4
Others	2	0.4
Occupation
None	25	5.2
Unskilled	46	9.6
Semiskilled	210	43.9
Skilled	128	26.8
Professional	69	14.4
Educational level
None (No formal education)	21	4.4
Primary School	34	7.1
Secondary School (or equivalent completed)	243	50.8
Tertiary (or equivalent completed)	180	37.7

Table 2: Obstetrics history of respondents (n=478)

Facility type	Frequency	%
Tertiary	108	22.6
Secondary	86	18.0
Primary	185	38.7
TBA/Faith Clinic	99	20.7
Trimester
1^st	53	11.1
2^nd	166	34.7
3^rd	259	54.2
Parity
Nulliparous	25	5.3
Primiparous	135	28.2
Multiparous (≥2)	318	66.5

Number of Miscarriages
0	406	84.9
1	69	14.4
≥2	3	0.6
Number of Children
0-1	157	32.8
2-3	205	42.9
4-8	104	21.8
Missing	12	2.5

Prevalence of kolanut consumption

The study showed that 162 (33.9%) respondents had ever used kolanut at different pregnancies while 140 (29.3%) respondents were currently using kolanut. Out of the one hundred and sixty-two respondents that ever took kolanut, sixty-five (40.1%) of them took kolanut during the first trimester, twenty-nine (17.9%) used in the second trimester while twelve (7.4%) used in the third trimester. However, in the present pregnancy, one hundred and eighteen (84.3%) took the kolanut in the first trimester, twelve (8.6%) had in second trimester and the least, one (0.7%) pregnant woman in the third trimester and missing 9 (0.7%).

Pattern of kolanut consumption

The frequency of consumption of kolanut in the present pregnancy (n=140) was characterized as high for 39.3% of kolanut users, 46.4% average while 6.4% consumed on the low level and 7.9% did not provide information on consumption frequency. The quantity of kolanut used was high for 32.9%, with 45.0% average, while 11.4% of the respondents only consumed on the low level while 10.7% were missing. For the ever use pregnancy, 46.9% frequently consumed on the high level, 38.3% on the verge while 6.8% on the low and 8.0% were missing. The quantity of use of the ever use kolanut was 42.0% on the high, 38.9% on the average while 10.5% on the low and 8.6% were missing (Table 3).

Table 3: Frequency and quantity of kolanut use in current (n=140) and ever pregnancy (n=162)

Frequency of use	Frequency Current Use (n=140)	%	Frequency Ever Use (n=162)	%
High	55	39.3	76	46.9
Average	65	46.4	62	38.3
Low	9	6.4	11	6.8
Missing	11	7.9	13	8.0
Total	140	100.0	162	100.0
Quantity of use
High	46	32.9	68	42.0
Average	63	45.0	63	38.9
Low	16	11.4	17	10.5
Missing	15	10.7	14	8.6
Total	140	100.0	162	100.0

Reasons for kolanut use

Over half (56.8%) of the pregnant women used kolanut due to excessive salivation, 37.0% due to nausea or vomiting, (3.1%) of women used it for cough and for recreation. A small number (2.5%) of them used it to stop dizziness and 0.6% used it to ‘prepare’ the womb for easy delivery. Very few (0.6%) used it because they sell the kolanut while 1.2% used it for no reason.

Benefits and perceived usefulness of kolanut

Ninety percent of the women reported that kolanut consumption helped in reducing excessive salivation, 71.6% for nausea and 16.1% for prevention of vomiting. Six (3.7%) of the women claimed it helped in reducing cough, four (2.5%) reported it refreshes their mouth while six (3.6%) did not provide any benefit.

Sources of introduction to kolanut use in current pregnancy

66 (40.7%) of the pregnant women who used kolanut were introduced to it by friends, 60 (37%) by relatives, 21 (13%) decided to use it of their own volition and 3 (1.8%) by a doctor or nurse while none heard from the media and 12 did not provide an answer.

Association between kolanut use and variables

Table 4 shows results from the logistic regression of kolanut use on variables. Concerning ethnicity, Ibo women were significantly less likely to eat kolanut in current pregnancy compared to Yoruba women (OR = 0.16, 95% CI = 0.04 – 0.70, p = 0.015) in the analysis and after adjustment. Hausa women were now significantly less likely than Yoruba women to report kolanut use (OR = 0.31, 95% CI = 0.12 – 0.79, p = 0.014) and those from other tribes were also less likely than Yoruba women, however, the differences were not statistically significant at 5% level. The ORs were lower with higher educational level with those that had attained tertiary education about four times less likely than women with no formal education (OR = 0.24, 95% CI = 0.10 – 0.62, p = 0.003), after the adjustment, those with secondary (OR = 0.32, 95% CI = 0.11 – 0.91, P = 0.032) and tertiary education (OR = 0.21, 95% CI = 0.07 – 0.63, p = 0.006) were significantly less likely than women with no formal education to report kolanut use. Although women at other educational levels were also less likely to report kolanut consumption than those with no formal education, the differences were not statistically significant. Also significant was the facility type attended, where those that attended TBAs or faith clinics were over four times more likely (OR = 4.14, 95% CI = 2.22 – 7.74, p < 0.001) and those in primary care centers about twice more likely (OR = 1.81, 95% CI = 1.02 – 3.24, P = 0.044) to eat kolanut in current pregnancy compared to those in tertiary hospitals. With the adjustment, women at TBAs or faith clinics remained significantly more likely (OR = 3.17, 95% CI = 1.41 – 7.09, p = 0.005) than those in tertiary centers to report kolanut use. However, the odds ratio for women in primary care centers was no longer statistically significant. Concerning parity, nulliparous women were less likely than primiparous women to eat kolanut in current pregnancy (OR = 0.22, 95% CI = 0.05 – 0.99, P = 0.048), after the adjustment, parity was no longer statistically significant. There were no significant associations with age, religion, occupation, and trimester in both the crude and adjusted analyses (Table 4).

Table 4: Logistic regression analysis of factors associated with kolanut use in current pregnancy – bivariate and adjusted odds

Variable	Bivariate			Multivariate
	Odds ratio (OR)	95% CI	P value	Odds ratio (OR)	95% CI	P value
Age
15-24	1			1
25-29	1.38	0.80 – 2.36	0.247	1.57	0.81 -3.03	0.180
30-34	1.54	0.90 – 2.65	0.118	1.69	0.80 -3.60	0.176
35-45	0.78	0.41 – 1.49	0.453	0.78	0.31 – 1.97	0.597
Ethnicity
Yoruba	1			1
Ibo	0.16	0.04 – 0.70	0.015	0.31	0.07 – 1.47	0.139
Hausa	0.45	0.21 – 1.00	0.051	0.31	0.12 – 0.79	0.014
Others	0.15	0.02 – 1.12	0.064	0.16	0.02 – 1.44	0.103
Religion
Christianity	1			1
Islam	1.37	0.92 – 2.03	0.125	1.03	0.64 – 1.63	0.916
Work Experience
None	1.19	0.42 – 3.33	0.741	0.79	0.23 – 2.70	0.704
Unskilled	1.21	0.52 – 2.80	0.665	0.36	0.12 – 1.04	0.060
Semiskilled	1.14	0.61 – 2.13	0.683	0.54	0.25 – 1.17	0.120
Skilled	1.72	0.89 – 3.31	0.107	0.69	0.30 – 1.59	0.381
Professional	1			1
Educational level
None (No formal education)	1			1
Primary School	0.38	0.12 – 1.17	0.092	0.32	0.08 – 1.20	0.091
Secondary School (or equivalent completed)	0.45	0.19 – 1.12	0.085	0.32	0.11 – 0.91	0.032
Tertiary (or equivalent completed)	0.24	0.10 – 0.62	0.003	0.21	0.07 – 0.63	0.006
Facility type
Tertiary	1			1
Secondary	1.17	0.57 – 2.37	0.674	0.85	0.37 – 1.91	0.687
Primary	1.81	1.02 – 3.24	0.044	1.63	0.77 – 3.44	0.202
TBA/Faith Clinic	4.14	2.22 – 7.74	<0.001	3.17	1.41 – 7.09	0.005
Trimester distribution
1^st	1			1
2^nd	0.69	0.35 – 1.37	0.291	0.76	0.36 – 1.61	0.475
3^rd	0.98	0.52 – 1.85	0.953	0.93	0.45 – 1.91	0.849
Parity
Primiparous	1			6.78	0.14 – 323.31	0.332
Multiparous	1.17	0.75 – 1.83	0.486	1
Nulliparous	0.22	0.05 – 0.99	0.048	2.01	0.04 – 96.77	0.724

Distribution of kolanut consumption

The distribution of kolanut consumption was shown in figure 1. The blue dots indicated the location of those that consumed kolanut in pregnancy and red dots showed those that did not consume kolanut in pregnancy within the Local Government areas. Higher percentage of kolanut consumption was more in the pregnant women as depicted as hotspots in Ibadan North East and Ibadan North Local Government Areas and minimally high at Akinyele Local Government area, while there is a low consumption rate at Ona Ara and Egbeda Local Governments areas (Fig. 2).

The TBAs/Faith clinic and the primary health facilities had higher number of kolanut use attending pregnant women than other facilities.

This study confirms that kolanut is frequently consumed at relatively high quantity by pregnant women. The most reported reasons for use were for the prevention of excessive salivation, nausea, and vomiting. Factors that remained significantly associated with current use of kolanut were ethnicity, with the highest use among Yoruba women, those with lower educational levels and those attending antenatal care at primary health care centers or TBAs especially within Ibadan North East and Ibadan North Local Government areas.

A significant number of studies that have reported higher risk of adverse pregnancy outcomes such as miscarriages (14–18), among pregnant women consuming high levels of caffeine-containing substances in pregnancy. Caffeine can cross the placenta into the amniotic fluid and the fetus, resulting in adverse pregnancy outcomes (19), such as small for gestational age birth (20), and a delay in neuronal migration and gliosis (21), caused by kolanut. An understanding of patterns of kolanut use and associated factors as provided from our findings will support the design of interventions that could target pregnant women with kolanut use in pregnancy in Nigeria. The current study showed a prevalence of 33.9% of kolanut consumption in previous pregnancy and 29.3% reported use in the current pregnancy, this shows a high consumption of kolanut in pregnancy. However, other Nigerian studies that collected kolanut consumption data among pregnant women reported lower prevalence of kolanut use, this could be because kolanut consumption in pregnancy was not their primary focus. An exception to this is a study conducted in Jos, North Central Nigeria (22), that reported a prevalence of 61.9%. Studies with less emphasis on kolanut use by Fawale and his colleagues (23), who investigated Restless Legs Syndrome in Hausa/Fulani women in Northern Nigeria and reported a prevalence of 8.4%. Another Nigerian study (24) of self-medication among women in South-South Nigeria found that only 1% of women reported kolanut intake in pregnancy. Ifesanya and Oke (9) reported a prevalence of 44.2% of kolanut/bitter kola consumption in pregnancy while looking at adverse gingival conditions among pregnant women in South-West Nigeria. In Ghana, a neighbouring West African country, Abu et., al (25), in a study of pica use found that 3.6% of women reported kolanut use. The present study showed a higher rate of kolanut use compared to those in Northern and South-South Nigeria with Yoruba women, constituting 82% of the sample while the study in North-Central Nigeria (22) with a much higher prevalence than the present study did not report the ethnicity of the women studied. Also, the higher proportion of use found in the present study could be because of kolanut use being the focus of this study while it was not of primary interest in the ones cited.

Even though there is a limited number of studies on kolanut consumption in pregnancy, several studies have examined psychoactive substances use among secondary school students with lifetime use as high as 86% (26) and 63.5% (27) in South-West and South-East Nigeria, respectively. Another study of students however reported 18.8% from the South-East (28). Further, a prevalence of 15.8% has been reported among commercial motorcyclists in Zaria, Northern Nigeria (29). Altogether, these studies of kolanut use in diverse populations suggest that kolanut use is popular in Nigeria and as stated by previous authors, some of the reasons for this include that it is cheap, readily available, and socially acceptable (22,26).

In contrast to the findings from this study, other studies outside Nigeria focusing on caffeine use and not kolanut specifically report that almost all women take caffeine containing foods for different reasons at different points of pregnancy (16,30,31). For example, an Ethiopian study (30) investigated the consumption of caffeinated beverages and foods in a community sample of pregnant women and found that 98.2% of the beverages and foods had caffeine; with 17.6% of the women reporting excessive caffeine intake. These studies of caffeine use that are not restricted to kolanut alone highlight the possibility of greater caffeine consumption in pregnancy due to other sources such as coffee, energy drinks, soda such as Coca cola, and tea.

Kolanut use in this study was most frequently reported in the first trimester (32.1%). Most women studied reported medium (thrice in a week) or high frequency (daily) kolanut use, while most women also reported high (at least 1 nut at once) or medium (half to less than 1 lobe) quantity. These findings suggest that users tend to consume significant quantities relatively frequently and highlight the need for efforts to identify these women and offer interventions that will get them to discontinue use. Health providers have a crucial role to play in this regard, especially given that history of kolanut use may not be routinely asked during antenatal care, a concern similarly shared by other authors (32,33). Additionally, women who are managed for nausea and vomiting, have a greater chance of using kolanut for treatment and could be important targets for identifying those who may be using kolanut. Hämeen-Anttila et.al., (34) showed that the need for health information was significantly higher among pregnant women using herbal preparations, supporting the argument for the provision of health information to women who may be using substances like kolanut.

The most common reason for kolanut use was the prevention of excessive salivation, nausea and vomiting, reported in about 56% and 37% respectively of women that reported ever using kolanut. In support of the importance of nausea and vomiting warranting kolanut use, a study in North Central Nigeria reported that preventing nausea and vomiting was the reason mentioned by all women reporting kolanut use in pregnancy (22). It is noteworthy that in contrast to the reasons for kolanut use in pregnancy, students and commercial motorcyclists populations are more likely to report use for staying awake, suppression of fatigue and peer group pressure (26,29).

It was also noted that kolanut use was significantly higher among women with lower educational level, women attending primary health care centers and TBA clinics, after adjusting for other demographic characteristics and reproductive health related variables. The higher amount of kolanut use among Yoruba women compared to other ethnic groups in Nigeria has been discussed earlier when comparing the findings from this study to others from other regions of the country. The reasons for ethnic differences in kolanut use could include the availability of kolanut in some regions compared to others and cultural beliefs that could promote use in pregnancy. However, the ethnic differences found in this study must be interpreted with caution given the inadequate sample sizes for non-Yoruba ethnic groups. The higher rates among women with lower education could be due to poor knowledge of foods safe for consumption in pregnancy (35), compared to more educated women. It could also reflect poor socioeconomic status of women with lower education who may lack funds to seek healthcare for treatment of symptoms such as nausea and vomiting, thereby, visiting PHCs and TBA clinics, resulting in higher amount of kolanut use in these centers. In addition to women with excessive salivation and nausea and vomiting, interventions aimed at reducing kolanut use in pregnancy need to target women in PHCs or TBA clinics, Yoruba women, and those with lower education. There were no significant differences in kolanut use by age or parity, although nulliparous women were less likely to currently use kolanut. However, the very small number of nulliparous women casts doubt on the results. The non-significant difference in kolanut use by age has been reported in another study(22).

Limitations of the study

The limitations of this study include the potential for recall bias concerning kola nut use in previous pregnancies. Additionally, some of the women studied in the first and second trimester could use kolanut later in their pregnancy, potentially underestimating kolanut use. However, majority of the women studied were in the third trimester and most current kolanut use would have been captured. In addition, the assessment of ever-use of kolanut is likely to capture most women that use the substance. Other limitations include the inability to quantitatively estimate the amount of the kolanut use as there are currently no guidelines for determining levels that are likely to result in adverse outcomes. This contrasts with caffeine-containing foods in the developed world such as coffee and soda that have been extensively studied.

Recommendations

Studies designed with large sample sizes of the ethnic groups and including qualitative methodology are needed to understand kolanut use patterns in pregnancy by ethnicity. Also, multiple sources of caffeine in the Nigerian context and estimation of total caffeine intake through kolanut should be studied. Furthermore, health information about hazards of substances like kolanut should be included in routine counseling in ANC clinics. Finally, further studies with a wider coverage within the country should be considered as this would give a better picture of kolanut consumption among pregnant women.

This study has shown that kolanut use is quite common among pregnant women and frequently used in large quantities. Interventions need to focus on Yoruba women, those with nausea and vomiting, less educated women, and those attending lower levels of healthcare.

LGA – Local Government Area

PHC – Primary Health Centre

TBA – Traditional Birth Assistant

WHO – World Health Organization

CSV - Comma Separated Values

Ethical considerations

Ethical approval for this study was obtained from the University of Ibadan/University College Hospital, Ibadan Ethical Review Committee and permission from the Ministry of Health, Oyo State, Nigeria. Also, consent to participate was obtained from the participants. All the principles of ethical conduct of research were strictly adhered to.

Consent for Publications

This was obtained from the participants and authors.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the Fellow. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

Authors Contributions

F.A. conceived the research idea, conducted the data collection, analysis and wrote the first draft of the manuscript, O.A. assisted in study implementation and data analysis, A.O. and A.O. supervised the process of research conceptualization. All authors reviewed the manuscript.

Acknowledgement

We appreciate all the participating pregnant women and health workers in the different health facilities of the two LGAs for their cooperation and willingness to support this study. Also, we are grateful to Consortium for Advanced Research Training in Africa (CARTA) for sponsoring this research. Finally, we appreciate Dr. Tunde Adedokun for his immense contributions to the analysis of the findings of this study.

Authors Information

Same as in the title page.

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No competing interests reported.

Prevalence and Consumption Pattern of Kolanut Among Pregnant Women in Ibadan Metropolis

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