Unravelling taboos and cultural beliefs associated with hidden hunger among pregnant and breast-feeding women in Buyende District Eastern Uganda

doi:10.21203/rs.3.rs-3419172/v1

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Research Article

Unravelling taboos and cultural beliefs associated with hidden hunger among pregnant and breast-feeding women in Buyende District Eastern Uganda

https://doi.org/10.21203/rs.3.rs-3419172/v1

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published 02 May, 2024

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Background: Food taboos and cultural beliefs among pregnant and breastfeeding women influence their food consumption patterns and hence the health of women and unborn children. Cognizant of their neglect in programs aimed to ameliorate hidden hunger among pregnant and breast-feeding women in Buyende and other resource poor communities in Sub-Saharan Africa, we opted for a study to unravel them to inform program design.

Methods: We documented food taboos and beliefs amongst pregnant and breast-feeding women from six sub counties of Buyende district in Eastern Uganda. A mixed-methods approach was used, which was comprised of questionnaire interviews with 489 women, eight focus group discussions with 6-10 participants in each and a total of 15 key informant interviews.

Results: The present study revealed that nearly 40% of the respondents practice food taboos and adhere to cultural beliefs related to their dietary habits during pregnancy and breastfeeding, that are fuelling the prevalence of hidden hunger. The most tabooed foods during pregnancy were Saccharum officinarum (17.9%), fishes (16.0%), Citrus sinensis (5.8%), Ananas comosus (5.6%), eggs (3.6%), chicken (3.3%) and Eleusine coracana(3.0%).Most foods were avoided for reasons associated with pregnancy, labour complications and undesirable effectson the baby. Most women learnt of the taboos and beliefs from elders especially their own mother, grandmother or mother in-law, but there was also knowledge transmission in social groups within the community.

Conclusion: The taboos and cultural beliefs in the study area renders pregnant and breast-feeding women prone to micronutrient deficiency since they are denied consumption of a diversity of nutritious foods. There is a need to educate such women about consumption of nutrient-rich foods like fish, eggs, fruits and vegetables in order to improve their health, that of the unborn and children being breast fed. Additionally, culturally appropriate nutrition education may be a good strategy to eliminate inappropriate food taboos and beliefs with negative impact on the health of pregnant and breast-feeding women.

Micronutrient deficiency

maternal health

food taboos

cultural beliefs

breast feeding women

Hidden hunger is a widespread problem in developing countries, characterized by lack of essential vitamins and minerals nutrients in the diet, despite adequate calorie intake [1] Globally, approximately two billion people especially in low-and middle-income countries experience hidden hunger [2, 3], that has for long been recognized as a public health problem, particularly among vulnerable groups including pregnant and breastfeeding women[4]. In pregnant and breastfeeding women, it has been observed to cause intrauterine growth restriction which adversely affect fetal development, energy production, birth weight, blood formation, brain development, maternal mortality and prenatal complications [5, 6]. Approximately 800 women die from pregnancy or childbirth-related complications around the world every day [7] with almost all the deaths occurring in areas of low-resource settings in developing countries [8], that are predominantly characteristic of rural communities in Uganda, Buyende inclusive. Uganda is ranked among the 10 leading countries with maternal death in the entire world [9]. All these undesired conditions are exacerbated by hidden hunger and could thus be ameliorated through ensuring adequate nutrition of the pregnant and breast-feeding women.

Women’s health, nutrition and well-being across the continuum of preconception, pregnancy, and postpartum are critical for ensuring desirable pregnancy outcomes and long-term benefits for both mothers and their offspring [10, 11]. Maternal malnutrition is not solely a consequence of inadequate nutrition intake but it is also influenced by social and psychological factors, nutritional knowledge and biological changes that impact dietary patterns during pregnancy [12]. Therefore, attention to appropriate dietary behaviour and proper nutrient intake is fundamental for adequate nourishment to both the mother and the fetus. Lack of accurate information concerning food intake of pregnant women could hinder efforts to enhance their nutritional well-being.

Taboos that prohibit the consumption of specific foods for sociocultural or religious reasons have been reported as one of the contributors to hidden hunger worldwide [13]. Cultural norms and customs govern dietary intake behaviors in several traditional societies comprising of critical life stages such as pregnancy [14]. Traditional cultural beliefs are known to create food taboos [15, 16] and barriers to vital maternal and child nutrition efforts in the first 1000 days [17, 18]. For example, in many cultures, mothers believe that respecting food-based taboos will result in a healthy pregnancy [19]. As reported in various studies, nutritious foods are usually avoided during pregnancy, owing to cultural taboos and misinformation [20–23]. Cultural beliefs and taboos limit women’s ability to access some nutrient-rich food during pregnancy and breastfeeding. Many of the forbidden foods are abundant in essential trace elements and their avoidance during critical stages of life could exacerbate trace element inadequacies [13].

Designing interventions to counteract the effect of hidden hunger among pregnant and breast-feeding women would require a clear understanding of the role of cultural beliefs and taboos on food availability and consumption in Buyende since they have been reported by [24] to be counterproductive in the adoption of micronutrient programs in low- and middle-income countries elsewhere. This study examined the food taboos, cultural beliefs and nutritional misconceptions that influence diets of pregnant and breastfeeding women and thus the hidden hunger status in Buyende District. We envisage that the results from the study could inform the development of appropriate nutrition interventions that are cognizant of the cultural beliefs and taboos for wider acceptability by the affected communities. This could significantly contribute towards the attainment of sustainable development goal 2 (SDG-2) that among other things targets to end undernutrition most especially among the vulnerable groups.

Study area

Buyende district is located in the Busoga subregion in Eastern Uganda approximately 96 Km from Jinja City and 180 Km from the capital city Kampala [25]. The district, located in the cattle corridor, occupies a land area of 1,956 Km² most of which is arable with an average elevation of about 1080 m above sea level [26]. It lies within latitudes 0045’N and 10 05’N and longitudes 33047’E and 34005’E (Fig. 1).

Climate

Buyende experiences a tropical climate with an average annual rainfall of 160.7–237.1 mm that is bi-modally distributed with wetter periods occurring from March to May and August to November. However, due to a high rate of deforestation and severe wetland degradation mainly due to the need for arable land, and charcoal burning as a source of income, the micro climate of the district has changed. It is now characterized by prolonged droughts, high temperatures and floods. The annual low temperatures range from 16.82℃-17.17℃ while annual high temperatures range from 27.18℃–29.74℃. Agricultural production in the district is largely rain-fed, dominated by smallholder producers and characterized by low inputs, poor natural resources management and production systems which are highly vulnerable to climate change impacts. Unreliable rainfall both in quantity and timing is still a big challenge to farmers. The adverse weather conditions have often resulted into crop failure and loss of livestock, hence contributing to increased households’ food insecurity and poverty. It is estimated that over 30% of the people of Buyende suffer from chronic food insecurity annually [27, 28].

Figure 1: Map of Buyende district showing the study sites

Demographic characteristics of Buyende district

Buyende has a total population of 323,067 (61,199 households) with 49.1% (158,615) male and 50.9% (164,452) female [27]. About 42% of the population of Busoga where Buyende is located live below the poverty line, spending approximately $1.9/day and experiencing pockets of severe food insecurity [28]. It has a high teenage pregnancy rate of 25% that is higher than the national average (24%) and a fertility rate of 6.9 children per woman, which is also higher than the national average. Other health burdens in the region include high maternal mortality, malaria incidence, parasite prevalence, malnutrition, and anaemia, [28]. All these factors endanger lives of women in the reproductive age in the area which calls for intervention measures.

The local people are mainly of the Bantu ethnic group of the Basoga, Bagwere and Baganda tribes [27]. Up to 12.5% of females aged 12–17 and 22.1% aged 12–19 have given birth. Crop growing is the main activity employing 93.5% of the households, with maize (85.1%) as the main crop. The proportion of households engaged in growing of other crops is in the order: sweet potatoes (54.0%), beans (26.1%), millet (21.9%), matooke (7.8%) and coffee (1.5%). Almost three quarters (70.2%) of the households are engaged in livestock farming. Up to 85.7% of the households depend on subsistence farming as a main source of livelihood. Additionally, 4.8% of the households, aged 5 years and above, consume less than two meals in a day.

Study design

A mixed methods approach that included both quantitative and qualitative techniques was used. A cross sectional survey with purposive sampling method was employed in enrolling study participants to obtain quantitative data. Pregnant and breast-feeding women presenting to the health centres and who consented to participate in the study were enrolled. They were interviewed on their beliefs and food taboos during pregnancy and while breast-feeding. The interview was done using a pretested questionnaire. All interviews were conducted in Lusoga, the respondents’ local language, and in some cases, in English. Both translators and enumerators were trained on how to conduct interviews using the questionnaire, so as to provide full understanding of the questions administered.

In order to obtain qualitative data, focus group discussions and key informant interviews were conducted. Focus group discussions and key informant interviews complemented data from questionnaires. Each focus group comprised of 6–10 members and a total of 8 FGDs were conducted. A total of 15 key informant interviews were conducted. These provided more insights about food taboos and cultural beliefs among pregnant and breast-feeding women in Buyende district. They also enhanced understanding of the perceptions regarding food taboos and cultural beliefs that affect pregnant and breastfeeding women.

Ethics approval

Prior to data collection, permission to conduct the study was obtained. Ethical approval of the study was granted by the Uganda Christian University (UCU) REC on 03/08/2023. The study’s subjects provided written or oral consent before each interview and each focus group discussion.

Quantitative surveys

All the sub-counties of Buyende district (Bugaya, Buyende, Gumpi, Kagulu, Kidera and Nkondo) formed part of the study (Fig. 2). Before fieldwork, a consultative meeting with district officials who included: the Resident District Commissioner, the Chief Administrative Officer, District Internal Security officer, District Health Officer and in charges of all health centres in Buyende district was conducted. The purpose of the meeting was to seek permission to conduct the research from the district administration, build consensus on various aspects of the research, seek for security during the research activity and to obtain first-hand information on the hidden hunger situation in the district. The study was conducted at health centres (II, III and IV) within the sub counties targeting pregnant and breast-feeding women that often visit for different health services. A total of 29 health centres formed part of the study. At each health centre, we targeted pregnant and breastfeeding women seeking antenatal care and immunization services and all who consented formed part of the study participants.

Figure 2: Percentage of respondents per sub-county

Questionnaires were administered on antenatal care and immunization days in order to target pregnant and breast-feeding women respectively. All women that visited the health facility and consented to participate in the study on the given days were interviewed in order to obtain information about the food taboos and cultural beliefs they experience. At the end of the study period, 489 women had been interviewed in the six sub counties as indicated by proportions in Fig. 2.

The questionnaire included some open-ended questions on food taboos and cultural beliefs among pregnant and breastfeeding women, especially related to avoidance or consumption of some foods due to cultural beliefs (food taboos) and reasons advanced for such. Participants were also asked to provide information from where such knowledge was obtained. Women were asked to list the various food items that were associated with taboos and cultural beliefs in their communities and reasons for avoiding the foods during pregnancy or breastfeeding.

Key Informant Interviews

Key informant interviews were conducted at some health centres with the following personnel; nutrition focal person, midwife in-charge and health centre administrator. The key informants provided insight into best practices for nutrition. In total, 15 interviews were conducted.

Focus Group Discussions

Focus group discussions (FGDs) were conducted to attain group interaction on the issues relevant to the study [29, 30], Turunen & Bondas, 2013). Seven FGDs were conducted with women of mixed age groups while one FGD was conducted with elderly men each with 6–10 participants. Data saturation (determined the number of FGDs) was reached when no new additional information was obtained. There were 61 participants in total and these were purposively recruited by the community leaders and officers in charge of health facilities, who also helped with organizing the venues and times for the FGDs. Participant selection targeted those who had not participated in the health center surveys. The composition of the study participants was diverse with regard to age, pregnancy status and whether the participant was a mother. The FGD with men participants was conducted in Kimbaya Village, Bugaya sub-county to triangulate the information provided by women. Sex-specific groupings (females only) were done to ensure that males did not hinder the freedom of female participants to express opinions and openly discuss what are largely deemed as women’s issues. Participants were given numbers, helping the note-taker to recognize who was responding, anonymously. The FGDs were held in a quiet, comfortable and convenient setting and each FGD took between 1–1½ hours. To capture all the information, voice recorders were used and also field note-taking was done. This was done by both the member of the research team and a research assistant (health worker), after consent was provided by the participants. We obtained information on the food taboos and cultural beliefs among pregnant and breastfeeding women in Buyende district and reasons advanced for these. At the end of each day, the field notes were expanded by the note-taker with assistance from the moderator while creating a daily report on data obtained. Thereafter, comprehensive verbatim transcription of the records was performed.

In order to minimise language barrier challenges, research assistants knowledgeable in Lusoga language, culture and its norms were used in the study. All questions asked in the FGDs were open-ended, with new questions arising from the responses given, as participants were able to build on each other’s ideas and comments. During FGDs, prompting questions about the main themes of taboos and cultural beliefs that influence food choices for pregnant and breastfeeding women, prohibited foods and reasons for the practices were asked.

Data Analysis

Quantitative data analysis

Data were entered and cleaned using Microsoft Excel and descriptive statistics were obtained using Statistical package for social Scientists (SPSS) version 25. Descriptive data were presented as means and standard deviations (SDs) (mean ± SD) and percentages.

Qualitative data analysis

At the end of each FGD session, the researcher and the assistant compiled their notes into one document; thus, linking accurately, the statements to anonymously-coded individual identifiers in each group. Data from all the FGDs in field notes and on the voice-recorder were translated from Lusoga to English. Qualitative data were manually coded and categorized into main emerging themes [31]. Themes were then analysed through coding [29]. Most sections of the discussions were quoted verbatim to increase readability. The verbatim transcripts were reviewed for completeness and quality control.

Socio-demographic characteristics of pregnant and breastfeeding women

This study had a total of 489 respondents who were either pregnant (266, 54.4%) or breastfeeding (223, 45.6%). Of all the 489 women interviewed, 195 (39.9%) agreed to practicing food taboos and cultural beliefs. The mean age of these women was 31 years. The mean household size for all the respondents was 7.3 ± 2.9 persons. The respondents were from all the 6 sub-counties of Buyende district (Fig. 1) with majority from Gumpi sub-county (28.04%), followed by Buyende sub-county (17.06%) and Nkondo sub-county (16.37%).

Among the age categories, individuals aged 21–30 years constituted the largest group, accounting for 45% (222) of the respondents while 162 (33%) of the respondents were aged between 31–40 years (Table 1). Furthermore, the study revealed that majority of the respondents (358, 73.2%) had only completed primary education while 83 (16.97%) of them had accomplished secondary education. Only 17 (3.5%) of the respondents had tertiary education qualification (Table 1). The study population predominantly comprised of married individuals, with 87.7% representation.

Table 1

Socio-demographic characteristics of respondents (N = 489)
Socio-demographic factors	Percentage (N = 489)	Socio-demographic factors	Percentage (N = 489
Age category		Marital status
< 20	6.0	Divorced	1.4
21–30	45.0	Married	87.7
31–40	33.0	Single	8.8
41–50	10.0	Widowed	0.6
51–60	5.4	Separated	1.4
> 60	0.2
Education level		Religion
No formal	6.3	African tradition	4.9
Primary	73.2	Anglican	26.2
Secondary	17.0	Catholic	30.3
Tertiary	3.5	Muslim	18.6
Occupation^*		Orthodox	0.8
Civil servant	1.2	Pentecostal	14.7
Farming	90.6	Seventh Day Adventist	4.5
Trading	9.2
Others	4.1
Fishing	1.0

Cultural beliefs and food taboos during pregnancy

The most commonly-known tabooed foods among pregnant women who admitted to following food taboos within Buyende district included Saccharum officinarum (17.9%), fishes (16.0%) Citrus sinensis (5.8%), pineapple (5.6%) and eggs (3.6%) (Table 2). Other foods were cited as taboo foods during pregnancy but were only mentioned by less than 3% of women in each case. Several reasons were advanced for not consuming taboo foods which ranged from issues that may affect the mother during delivery and breast feeding to health issues mostly affecting the child. Others included cultural issues that could hardly be explained since prohibition of a certain food was generally accepted by the culture. These reasons are detailed in Table 2, together with information on where the knowledge on food taboos was acquired. Knowledge on the taboo foods and the consequences of consuming these foods was primarily acquired from all members of the community such as family members, especially grandmothers and mothers, health workers, elders, fellow women and village health teams. However, some women reported that they observed a food taboo because of their own experience from previous pregnancies.

Table 2

Food avoidance due to taboos and cultural beliefs among pregnant women in Buyende district
Scientific/(local/ English name) of food	% respondents	Reasons for prohibition	Source of information
Dioscorea bulbifera L. (Amasoma)	2.5	Causes hives in mothers	Her self
		Reduces breast milk/(Hypogalactia)	Community
		May cause death of baby	Grandmother
Phaseolus vulgaris L.(Bidhandhali)	0.5	They cause diarrhea to the mother	Community
Musa acuminata (Bogoya)	0.5	Causes death when eaten by members of some clans	Grandmother
Manihot esculenta Crantz (muwhogo)	2.8	Causes baby skin disorders Energy	Friend Community Elders
Tea spiced with lemon grass	1.5	Dries up breast milk (Hypogalactia) It delays labour (dystocia) Dries up breast milk (Hypogalactia)	Community, mother in law Neighbours
Chicken	3.3	Culturally women are not supposed to eat but no reason was provided	Elders
Amaranthus dubius Mart (Doodo)	1.5	Causes early contraction (early labour or Preterm labour)	Mother
Solunum gilo Raddi (Scarlet egg plant)	2.5	Causes hives to the baby	Community, aunt, elders, mother-in-law
(Eggs)	3.6	Fetal macrosomia and the mother can fail to push during delivery, Childhood apraxia/speech disorder	Elders
Vigna ungiculata L. (Egobe)	0.5	May cause death of baby	Grandmother
Cleome gynandra L. (Yobyu)	2.1	Causes abortion	Grandmother, aunt
Empengeere	0.5	Development of an enlarged umbilical cord of the baby	Mother in-law
Solanum anguivi Lam. (Endagi)	0.5	Causes skin rash to the baby	Elders

Clarias carsoni L. (Endu)	16.5	Culture, causes bad odour from the vagina It has bad omen because it has breasts and will dry up breast milk//(Hypogalactia)	Culture Mother, grand parents
Arachis hypogaea L.(Amaidho)	0.5	Skin disorder	Friend
Hibiscus sabdariffa L. (Kimuli ekimwifu)	0.5	It is not good for the baby.	Mother
Capsicum frutescens L. (Kalaali)	1.5	Dries up breast milk/(Hypogalactia)	Community
		Congenital eye problems	Mother-in-law
Artocarpus heterophyllus Lam. (Feene)	2.0	Makes baby very fat that causes difficulty during child birth/ Fetal macrosomia, production of too much saliva (Drooling or hypersalivation)	Grand mother
Artocarpus heterophyllus (Feene) seeds	1.02	Make a baby very big to push/ Fetal macrosomia	Grand mother
Ginger	0.5	Oxytocic	Community
Vigna subterranea (L.) Verdc) (kulekula/ mpande)	0.5	Causes macrocephaly in babies	Mother
Citrus limon (L.) Osbeck (Enniimu)	0.5	Causes loss of weight to the baby (Intrauterine growth restriction)	Elders
Liver	1.02	Speech disorder to the baby	Elders
Phytolacca dedocandra L’ Her (Nyante)	1.02	Causes abortion/abortifacient	Elders
Momordica foetida Schumach (Mabombo)	0.5	Causes abortion/abortifacient	Community
Maize porridge	0.5	Baby is born with rough skin	Community
Mangifera indica L (Muyembe)	2.0	Using a knife to eat mangoes causes stillbirth, raw mangoes cause malaria, ripe mangoes cause excessive urination(Polyuria) resulting in wastage of nutrients	Community
Musa paradisiaca L. (Makooke)	1.02	Causes hives to the mother	Husband
Eleusine coracana Gaertn (Milet & millet porridge)	2.04	Diarrhea, makes the baby to have a very big head (fetal macrosomia)	Community, mother
Oryza sativa L.(Rice)	3.04	It causes itchy skin and heart burn to the pregnant woman and also results in	Community
		fetal macrosomia causing difficult delivery
(Much salt)	3.07	Spoils baby's skin and eyes	Community, mother-in-law
(Much sugar)	1.02	Production of too much saliva (Ptyalism) causes cough	Community, mother
Mugide	0.5	Causes abortion/abortifacient	Grand mother
Rastrineobola argentea (Mukene)	0.5	Taboo	Ancestors
Sesamum indicum L. (Mukose)	0.5	Salivating in children/ Drooling /poor saliva control, 'sialorrhoea' or 'dribbling'	Hear say
Corchorus olitarius L (Mutele)	0.5	Baby produces a lot of saliva/ Drooling /poor saliva control, 'sialorrhoea' or 'dribbling'	Community
Solanum anguivi Lam. (Katunkuma)	0.5	It causes skin rash to the baby	Elders
Tamarindus indica L. (Nkooge)	0.5	Causes sores on the body of mother	Mother
Solanum nigrum L. (Eilibwa)on the road side	0.5	Causes curse	Elders
Citrus sinensis (L.) Osb. (Mucungwa)	5.8	Causes skin diseases, excessive secretion of saliva to the baby (Drooling /poor saliva control, 'sialorrhoea' or 'dribbling'), Dyspnea, baby will not grow hair (Short Anagen Hair Syndrome)	Community, mother
Ananas comosus (L.) Merr (Enanhasi)	5.6	Drooling /poor saliva control, 'sialorrhoea' or 'dribbling'), Causes abortion and wounds in baby’s head	Elders, fellow women, mother in law
Pork	1.02	Religious reasons for moslem women	Parents, ancestors
(Rabbit meat)	1.02	Reduces breast milk production (Hypogalactia)	Community, elders
Solanum lycopersicum L.(Enhaanha) which ae raw	0.5	Spoils baby's skin, causes general weakness	Community, mother
Sour foods	0.5	Affect eyes	Elders
Glycine Max (L) Merr. (Soy beans)	0.5	Nuchal cord	Friends
Saccharum officinarum L. (Ekikajo)	17.9	Production of a lot of saliva in baby (Drooling /poor saliva control, 'sialorrhoea' or 'dribbling'),, water in the womb, causes cough, a big baby that becomes hard to push during delivery	Mother, fellow women, elder, grandmother, community
Ipomoea batatas (L.) Lam.	1.55	Causes diarrhoea, reduces energy	Community, elders
(Tea leaves)	0.5	Causes fetal macrosomia	Community
(Water)	0.5	When you take water after delivery you die/ Too much water after delivery hampers the healing of the stitches and slows internal healing too.	Community
Yoghurt	0.5	Big baby (fetal macrosomia)	Mother
Scientific names of prohibited foods are italicized and local/English names are included in parentheses.

Table 2: Food avoidance due to taboos and cultural beliefs among pregnant women in Buyende district

Focus Group Discussions and Key informant Interviews

Major themes that emerged from FGDs regarding food taboos and cultural beliefs were: tribal prohibitions, religious prohibitions and prohibitions by spirits. Some participants in the FGDs admitted to existence of food taboos and cultural beliefs during pregnancy and breastfeeding, while others were not aware of any taboos reasoning that they existed long ago and are no longer applicable. A case in point was elderly women from Mpundwe health centre who revealed that they no longer have tribes that restrict women from eating a particular type of food or sauce except moslems that do not eat pork. One elderly woman from this FGD emphasized that

“ back in the day, they used to restrict women from eating mudfish, but these days we eat”. Another one retorted that “in our years they used not to allow us to eat chicken but these days, women love chicken like nothing”.

Participants in this FGD reported that there were no specific foods that pregnant and breastfeeding women were prohibited from eating. They further revealed that it was only pure original Balalo (traditional cattle keepers) that never ate chicken but they are no longer inhabiting the area. One participant said that

“it is only when her pregnancy does not like that particular food but otherwise, they are not restricted”.

Another responded that

“also may be when she cannot access that food that’s when she may not eat it”.

Apart from the FGD of elderly women in Mpundwe, all other FGDs revealed foods that were mentioned in the survey and gave the same reasons for being prohibited during pregnancy or breastfeeding. The foods mentioned include: chicken, millet, sugarcane, mushrooms, duck, white ants, hard corn, pineapple in addition to excessive sugar and salt. There was a strong emphasis on fish as a taboo food especially among the Seventh Day Adventists (SDA) and Bachwezi tribe from all FGDs. For instance, a breastfeeding woman from Kidera said that,

“on the side of lactating mothers who are SDA, they are told not to eat catfish and yet, if its soup is taken can lead to production of more breast milk”.

Participants from all FGDs also stated that the Bachwezi don’t eat fish. An elderly man from Kimbaya village said that,

“I can’t talk so much about culture but religion because this side, we have religions that prohibit a person from eating fish or anything from water yet these things have nutrients that can build a woman’s life and the baby as well. A woman misses such food values. Regarding culture, our side here, there are people who call themselves the Bachwezi, they stop people from eating silver fish yet they would have eaten and helped strengthening of baby bones and those of the pregnant woman as well”.

Another food taboo that arose from FGDs was that consumption of sugarcane or excessive sugar were believed to cause drooling to the baby. The same information was revealed by the survey. An adolescent mother from Irundu health centre said that,

“I have heard that eating sugarcane when you are pregnant can make a baby to drool”.

Another adolescent mother from Irundu said that

“they say also pineapples when you eat pineapples when you are expecting, you will produce a drooling baby”.

Regarding millet, a midwife from Bukungu health centre during an interview revealed that,

“like when a mother is pregnant, she does not eat millet or take millet flour. They say that when they take and they deliver, that baby dies”.

Prohibition of millet and millet flour were reported in the Bukenye tribe and one participant reported that

“But in the Bakenye tribe, a newly delivered mother cannot eat millet Bwita before the baby’s cord drops off”.

All participants in the group agreed that this belief is still followed up to today.

All participants from FGDs who mentioned chicken as a taboo food revealed that its consumption causes rash. This was reported in mainly two tribes of Bachwezi and Banyankole. For instance, a teenage mother from Buyende health centre III said that

when I ate chicken, I developed rash-like things that are on chicken but there were herbs I was bathed with and they ceased, I now eat.

Another teenage mother also said,

“for us as a tribe (Bachwezi), we don’t eat chicken but when I got pregnant, they said, I eat it and it had no issue. Right now I eat”.

In the same group another participant said

“I can be here when I am a Muchwezi and they restricted me from eating chicken, now when I eat it the other things(spirits) will come and hit me, I then start developing rashes because of eating chicken”.

Regarding mushrooms, a teenage mother said that

“there are tribes that do not eat mushrooms (small type), so when you reach a man’s clan who doesn’t eat those mushrooms, automatically you don’t eat them. If you eat them definitely the feotus has to come out”.

When probed further whether such an incidence has ever happened, she said that,

“Yes, it occurred. There is a lady, I can say she is my inlaw, for us we don’t eat red mushroom but for her she went and looked for that mushroom and ate it, the baby came out”.

With the low levels of education, poverty and limited access to nutritional information we anticipated a higher adherence to food taboos among pregnant and breast-feeding women in Buyende. The study revealed a 39.9% prevalence of food taboo practices among pregnant and breast-feeding women. This prevalence was much higher than that of 27.5% reported in a recent study by Abere and Azene [32] among pregnant women attending antenatal clinics, in North West Ethiopia and lower than the 67.4% reported by Mengie, Dessie [33] among agro-pastoralist pregnant women in Ethiopia. The percentage could be higher than what is revealed by this study since the average age of the respondents was below 35 years, above which according to Zepro [34], and Getnet, Aycheh [35] women are more likely to practice food taboos. Furthermore, the lower prevalence could be ascribed to that fact that respondents were mainly women seeking for antenatal care from health centers. Food taboo practices among such women has been reported to be low by Mengie, Dessie [33].

There is of observance of food taboos among pregnant and breastfeeding women in Buyende district. These taboos are anchored on tribal, religious beliefs and selfish patriarchal tendencies in some African cultures [36]. Like in western Bengel knowledge about food taboos is upheld and enforced by mothers-in-law, aunts and other elderly female relatives [37]. Adherence to food taboos and cultural beliefs collaborates results of other studies conducted in countries like Indonesia [20], Thailand [38], India [39] and China [40]in Asia as well as in African countries like Ghana [41], Ethiopia [42], Nigeria [43],, Sudan[44]and Uganda [45]. The main reasons for not consuming the taboo foods was because of health consequences to the mothers themselves, such as abortion and difficulty during labor and also to safeguard the birth outcomes of the babies, similar to what was believed in other cultures [46–48].Thus, the prohibited foods are those considered problematic for the mother, fetus or baby. Unfortunately, many cultural beliefs and food taboos involve foods that are known to be rich sources of protein, iron and micronutrients, all of which are critical during pregnancy [49] and often not consumed in sufficient quantities by women.

Foods were tabooed to avoid labour complications and undesirable health effects on the baby. Some animal-product foods especially fish and eggs in addition to beans, which are rich in proteins, vitamins and mineral nutrients were avoided for the fear of the mother discharging a foul smell from the vagina, baby becoming too big resulting in a difficult delivery and causing diarrhea. This in conformity with earlier findings reported by Arzoaquoi et al. [41] in a study conducted in Ghana. Eggs were avoided owing to the conviction that they cause overweight in the fetus, which contributes to difficulties during childbirth. However, scientific evidence revealed that eggs contain fatty acids, proteins, choline, vitamins A and B12, selenium and iodine in amounts higher than that found in other animal food source [50]. Some of these nutrients in eggs are critically needed to support the health of the pregnant and breast-feeding mothers and fetus. For example, iodine is essential for the production of thyroid hormones, thyroxine (T4), and triiodothyronine (T3), required for the control of metabolic processes and growth and development, especially of the brain and central nervous system up to 3 years of age [51]. During pregnancy and breast-feeding iodine has also been reported to aid neuronal proliferation, growth of axons and synapses, as well as myelination of neurites [52–54]. Thus, such taboos that precludes the consumption of eggs may contribute to the persistence iodine dietary deficiency or hidden hunger that has been reported by Habib et al. [55] to be rampant in poverty-stricken communities, such as Buyende. An empirical study revealed that inadequate intake of chlorine during pregnancy was associated with neural tube defects and misfunctioning of the child’s brain [56]. Thus, consumption of eggs during pregnancy has potential of improving childbirth outcomes and promoting brain development. Vitamin D in eggs is important in protecting the newborn baby from development of rickets and promotes healthy teeth and bones of the mother [54].

Most foods in the current study were also tabooed to protect a child from being born susceptible to many diseases, including skin rash and eye diseases plus other conditions like excessive production of saliva and being under weight. Pineapples, oranges and sugarcane are not consumed to avoid excessive secretion of saliva, difficulty in breathing and loss of hair in babies. However, restricted consumption of such fruits which are rich in vitamins A and C denies the pregnant women these vital nutrients. A similar study in Uganda revealed that pregnant women were prohibited from consuming milk, eggs, meat, sugarcane and organ meat [45]. Studies in other African countries also reported the avoidance of some of these foods during pregnancy though the reasons given differed from those in the current study. For example,[34] reported the avoidance of oranges and pineapples in Ethiopia for reasons linked to having a baby with discoloured skin; inducement of abortion or stillbirth; and to protect the baby from contracting worms, malaria and diarrhoea during childhood. In South Africa, pineapples were avoided because they were believed to cause a cracked skin of the baby that would be difficult to treat [57] closely related to a reason of causing wounds in a baby’s head in the current study. On the contrary consumption of pineapples during pregnancy was recommended in India with a belief that it leads to production of a clean baby [58].

Cherkose and others [59] reported the avoidance of potatoes by pregnant women to avoid having big babies, which can cause labour difficulties. Fish which was majorly restricted in consumption by pregnant women in the current study was also a taboo food during pregnancy in Tanzania [57]. Indonesia [20] and Malaysia [47] as it was believed to cause difficulties during childbirth. Whereas some foods such as meat, fish, chicken, eggs, and milk were recommended as being beneficial during pregnancy in Egypt [60], they were restricted in the current study. In Buyende, eggs were avoided due to a belief that they make the unborn child fat resulting in difficulties in delivery or that the child will not talk, while a study in Tanzania and other parts of Africa revealed the reason for eggs avoidance as fears related to the animal’s characteristics being transferred to the child or sterility [61]. In fact, there is empirical evidence in support of intake of animal proteins to improve birth outcomes especially to increase neonatal birth weight [62]. Thus, pregnant women who tabooed eggs might have been at risk of lacking enough sources of proteins that could result in underweight babies who often exhibit a lot of complications. Sugarcane and pineapple featured prominently among the tabooed foods in Buyende where it was believed that their consumption results in excessive production of saliva by a baby, increased water in the womb, cough, an overweight baby that becomes hard to push during delivery, abortion and wounds in a baby’s head. Similarly, a study [63] by in Kuala Lumpar reported that pineapple and sugar cane were regarded as taboo foods by more than half of subjects. However, reasons for avoidance in this case were fear of abortion, excessive bleeding during labour, deformed babies, difficult labour, vomiting and oedema. The abortive effect of pineapples was also reported in Malaysia [64] where it was regarded as a hot food capable of causing strong uterine contractions. Avoidance of rice during pregnancy was reported in similar studies in Ethiopia, Nigeria, the Central African Republic, and Tajikistan in India[65] 15, 34, 66] with the aim of suppressing gestational weight gain (GWG) which is associated with labor complications as a result of baby macrosomia. This could be because most of the reasons advanced for avoiding food have no scientific validation. This, therefore calls for nutritional education regarding the food values important during pregnancy and their food sources to avoid being misled by taboos.

The present study revealed that nearly 40% of the respondents practice food taboos and adhere to cultural beliefs related to their dietary habits during pregnancy and breastfeeding, that are fuelling the prevalence of hidden hunger. This finding underscores the significance of addressing these cultural factors in maternal and child nutrition interventions. The mean age of the women participating in the study was 31 years, suggesting that these practices are adopted by very young pregnant and breastfeeding women, which further exacerbates the potential impact of these food taboos to maternal and child health. Furthermore, the study area was characterized by a high mean household size (7.3 persons), high teenage pregnancy rate (25%), poor economic status and low level of education, which further highlight the potential impact on maternal and child health. Additionally, our study revealed that the most tabooed foods among pregnant women were sugarcane, fishes, oranges, pineapple and eggs. However, most of the foods prohibited during pregnancy and breastfeeding have been reported in empirical studies to contain a number of food values necessary to promote the health of both the mother and guard against deformities in the unborn child, and also to provide strength for a breastfeeding mother and to transfer the required nutrients to the baby. Therefore, these dietary restrictions have implications for the nutritional status and overall health of pregnant women, breastfeeding women, the fetus and children. Major reasons advanced for avoidance of such foods included excessive saliva production by baby, a big baby that will cause difficulties during delivery, vaginitis after consumption of fish, skin diseases, breathing difficulties to the baby and abortionon. This diversity in reasons for these food taboos underscores the complexity and multifaceted nature of cultural beliefs and practices surrounding dietary choices during the maternal and child-rearing period. Notable some of the reasons mentioned for not consuming taboo foods were linked to deeply ingrained cultural beliefs that were difficult to explain. Therefore, there is need for a sensitive and culturally informed approach when addressing these practices. This calls for health education programs regarding nutrition which will in turn improve the maternal and child health. We suggest continued maternal education to the general public on these matters by designated health personnel in the district. There is also need to validate the claims so as to address the nutritional deficiencies and demystify the myths which could be caused by such beliefs.

FGDs Focus group discussion

REC Research ethics committee

SDA Seventh day Adventist

SDG Sustainable development goal

SPSS Statistical Package for social scientists

UCU Uganda Christian University

Acknowledgements

The author acknowledges leaders of Buyende district local government and health centres visted for the good rapport, provision of security during fieldwork, linking up the research team with the respondents. Special thanks go to all our Research Assistants that were involved in data collection. Lastly, we thank pregnant and breastfeeding women who provided us the required information for the study.

Author contributions

PT provided formal analysis and writing (original draft). PT, ASM, JES, EM, EBN, EM, FK and AW contributed to data collection. JES and ASM contributed to the project administration and funding acquisition. All authors contributed to the writing (review and editing). All authors approved the final manuscript.

Funding

This research was supported by the government of the Republic of Uganda through the Research & Innovations Fund to Makerere University.

Availability of data and materials

Data generated or analyzed during this study are included in this article and are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was approved by the Research Ethics Committee of Uganda Christian University. Before the data collection, participants were explained the aims and methodology of the study and then were asked to sign a written informed consent letter.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

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Unravelling taboos and cultural beliefs associated with hidden hunger among pregnant and breast-feeding women in Buyende District Eastern Uganda

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Abstract

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Background

Methods and Materials

Study area

Climate

Demographic characteristics of Buyende district

Study design

Ethics approval

Quantitative surveys

Key Informant Interviews

Focus Group Discussions

Data Analysis

Quantitative data analysis

Qualitative data analysis

Results

Socio-demographic characteristics of pregnant and breastfeeding women

Cultural beliefs and food taboos during pregnancy

Focus Group Discussions and Key informant Interviews

Discussion

Conclusion

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