Food Craving and Aversion Among First Time Pregnant Women in Selected Health Facilities in Enugu Metropolis Enugu State

FOOD CRAVING AND AVERSION AMONG FIRST TIME PREGNANT WOMEN IN SELECTED HEALTH FACILITIES IN ENUGU METROPOLIS ENUGU STATE

MADU NGOZI BENEDETH PG/MSC/09/53793

MSC NURSING DISSERTATION PRESENTED TO

DEPARTMENT OF NURSING SCIENCES FACULTY OF HEALTH SCIENCES AND TECHNOLOGY COLLEGE OF MEDICINE UNIVERSITY OF NIGERIA ENUGU CAMPUS

APRIL, 2016

FOOD CRAVING AND AVERSION AMONG FIRST TIME PREGNANT WOMEN IN SELECTED HEALTH FACILITIES IN ENUGU METROPOLIS ENUGU STATE

MADU NGOZI BENEDETH PG/MSC/09/53793

MSC NURSING DISSERTATION PRESENTED TO DEPARTMENT OF NURSING SCIENCES FACULTY OF HEALTH SCIENCES AND TECHNOLOGY COLLEGE OF MEDICINE UNIVERSITY OF NIGERIA ENUGU CAMPUS

IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTERS DEGREE IN COMMUNITY HEALTH NURSING

SUPERVISOR: DR. NWANERI, A, C.

APRIL, 2016

Approval

This is to certify that dissertation was originally carried out by Madu Ngozi, Registration number PG/M.Sc/09/53793 in the Department of Nursing Sciences, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus.

…………………………… ……………………….

Student Date

Dedication

I humbly dedicated this work to God Almighty

Acknowledgement

Unto him that sits upon the throne, with whom I have to do all by His power, I reverently appreciate Him and His loving kindness.

With utmost sense of respect and humility, I wish to extend my gratitude to Dr. A Nwaneri, my erudite and worthy supervisor whose efforts make this project work a meaningful achievement and kept encouraging me to go on with her unlimited support and constructive comments in shaping this work without any hesitation.

I equally express my gratitude to my Senior lecturer Dr. Mrs. Ogbonnaya .N. and other academic and non academic staff of Nursing Science Department for their contributions in one way or the other to enhance the reality of this project work. I am indebted to my husband Prince Uche Madu for his academic, moral and financial support. My special thanks goes to Rev. Fr. A.I Madu and Rev. Sr. M.C Madu and Rev. Sr. Susan N –Paul for their prayers throughout my period of study. Ifunanya, Chidiebere and Uchechukwu although very young, exhibited a great sense of understanding and calm all through the period of this research work.I wish to acknowledge the high degree of contribution of the Statistician Mr Uche ,typist Miss Oluchi and all those whose ideas have contributed in writing this dissertation (whom I have inadvertently not named here),I owe my gratitude.

TABLE OF CONTENTS

PAGE

Abstract i

Table of Contents ii

List of Tables v

List of Figures vi

CHAPTER ONE: INTRODUCTION 1

Background to the Study 1

Statement of Problem 3

Purpose of Study 5

Objectives 5

Research Question 5

Hypotheses 5

Significance of the Study 6

Scope of the Study 6

Operational Definition of Terms 7

CHAPTER TWO: LITERATURE REVIEW 8

Conceptual Review 8

Concept of Nutrition in Pregnancy 8

Nutritional Requirement in Pregnancy 10

Benefits of Good Nutrition in Pregnancy 16

Causes of Poor Nutrition in Pregnancy 17

Consequences of Poor Nutrition in Pregnancy 18

The Effects of Poor Nutrition on the Pregnant Woman 19

Concept of Food Craving in Pregnancy 20

Measures Taken by Pregnant Women to Substitute/Manage Food Craving and Aversion 24

The Reasons for Food Craving and Aversion in First Time Pregnant Women 25 6

Implication of Food Craving and Aversion 29

Demographic Status and Food Craving and Aversion in First Time

Pregnant Women 30

Theoretical Review 31

Review of Empirical Studies 35

Summary of Literature and Critical Analysis of Empirical Studies Reviewed 47

CHAPTER THREE: RESEARCH METHOD 49

Research Design 49

The Area of Study 49

Population of Study 50

Sample 50

Instrument for Data Collection 52

Validity of Instrument 53

Reliability of the Instrument 53

Ethical Consideration 53

Procedure for Data Collection 54

Method of Data Analysis 54

CHAPTER FOUR: PRESENTATION OF RESULTS 55

Summary of Major Findings 71

CHAPTER FIVE: DISCUSSION 73

Discussion of Major Findings 73

Implication of the Study 81

Limitation of the Study 82

Suggestions for the Further Studies 82

Summary of the Study 82

Conclusion 84

Recommendations 86

References

Appendix I: Questionnaire

Appendix II: Sample Size Calculation

Appendix III: Reliability

Appendix IV: Ethical Clearance Certificate

Appendix V: Administrative Permission Letter

LIST OF TABLES

Table 1: Distribution of Sample Size in each Selected Health Facility 52

Table 2: Demography o f the Respondents 56

Table 3: Stage of Pregnancy at which the First Time Pregnant Women Experience

Craving 58

Table 4: Types of Food Craved by First Time Pregnant Women 59

Table 5: Stage of Pregnancy at which the First Time Pregnant Women Experience

Aversion 61

Table 6: Types of Food Aversed by First Time Pregnant Women 61

Table 7: Reasons for their Specific Food Craving and Aversion 62

Table 8: Awareness of the Implication of Food Craving and Aversion in Pregnancy 64

Table 9: Measures First Time Pregnant Women take to Substitute for Food Craving and

Aversion in Order to Meet up with their Required Nutritional Value (needs) 66

Table 10: Association Between Level of Education and Food Craving 67

Table 11: Association Between level of Education and Food Aversion 68

Table 12: Association Between Residential Location and Food Craving 68

Table 13: Association Between Residential Location and Food Aversion 69

Table 14: Relationship between Awareness of Implication of Food Craving and aversion in

First Time Pregnant Women 70

LIST OF FIGURES

Fig 1: Respondents who crave for food 58

Fig 2: Respondents who have aversion for food 60

ABSTRACT

This study was aimed at examining the food craving and aversion among first time pregnant women in selected health facilities in Enugu metropolis. The objectives of this study were to determine the type of food first time pregnant women crave for or have aversion to, identify their reasons for their specific food craving and aversion, determine the first time pregnant women’s awareness of the implication of food craving and aversion in pregnancy and to identify measures taken by first time pregnant women to substitute for food craving and aversion in order to meet up with their required nutritional needs. Cross sectional descriptive research design was used for this study. A sample size of 366 respondents who met the inclusion criteria were drawn from the target population of 2000 first time pregnant women using Taro Yameni’s formular. Proportional stratified sampling method was used to select a representative sample size from each randomly selected health facilities and convenience sampling technique was used to reach the respondent. Data was collected using researchers developed questionnaire with a reliability of 0.87. Data collected was analyzed with the help of International Business Machine Statistical Package for Social Sciences (SPSS) version 23. Descriptive statistic which include frequency, percentage, mean and standard deviation were used to analyze and answer research questions. Hypotheses were tested using Pearson Chi- square; level of significance was set at P less than 0.05. The result of the study showed that majority(74.8%) of respondents crave for or averse to at least one food item and the type of food craved for were fruits. The type of food aversed to are beans based products. Majority (42.6%) of the respondents indicated that they do not know most of the effect of food craving and aversion on the health of mother and fetus. Majority (52.7%) of the first time pregnant women do nothing to substitute for food nutrients needed in pregnancy when experiencing food craving and aversion. Based on these findings, it was concluded that first time pregnancy women craved for or averse to at least one food item and majority of the first time pregnancy were not aware of the implication of food craving and aversion in pregnancy. It is recommended that health personnel/nutritionist should be encouraged to educate pregnant women especially the first time pregnant women on nutritional needs during pregnancy and should involve men in nutritional education bearing in mind of male dominance in certain culture and tradition.

CHAPTER ONE

INTRODUCTION

Background to the Study

Good nutrition before and during pregnancy builds a healthy fetus and protects the mothers own nutritional health. (Dickason, Silverman & Schultz, 2010). In early weeks of pregnancy significant developmental changes occur that depend on a woman’s nutrient stores. The food pregnant mothers eat on a daily basis affects how their bodies work and how they maintain energy and strength (Handisco, 2014). It also determines the basic nutritional health that their children are born with and provides a model for their eating habits during childhood and beyond.

Pregnancy is the time in women’s life when their eating habits directly affect their fetus

(Demissie, Muroki, & Makau, 2012). Their decision to incorporate nutritious food into their eating plan during pregnancy will give them strength and helps them to give birth to healthy baby. The risk of giving birth to a low birth weight baby is related to women’s nutritional status (Handisco, 2014). Therefore dietary consumption during pregnancy can have significant health implications for both mother and fetus. (Demissie, Muroki, & Makau

2012). According to Knox (2013) studies showed that maternal nutrition can affect a range of factors including the course of pregnancy and the incidence of prematurity and congenital malformations in the infant.

Pregnancy is often accompanied by a variety of nutritionally linked problems that most of the time pregnant mothers have to cope with (Dickason et al, 2010). In order to cope with these problems and to proceed with a successful pregnancy, mothers experience a number of physiological and behavioral adjustments such as food craving and food aversion during pregnancy. Food craving are intense desire to obtain certain foods which are very interesting to the individual and may not be accessible at that time. On the other hand food aversion is 12 strong dislike of a particular food during pregnancy (Olusanya & Ogundipe, 2012). Food craving and aversion if not properly managed may interfere with the dietary intake of the pregnant women and sometimes causing serious problem such as low birth weight baby and diet deficient in iron, calcium, protein, vitamins A,D B6 and folic acid.

Safaii (2013) however stated that some researchers believe that food craving is a mechanism to protect the fetus and the mother from nutrient deficiencies and suggest that craving is triggered when a deficiency in one or more nutrients arises. This opinion appears to be supported by a study done by Demissie, Muroki & Wambui, (2012) which revealed that 43% of pregnant women crave for nutritious foods that are lacking in their diet .According to

Nyaruhucha (2012) some women crave for non-food substance like soil, clay, chalk, charcoal and some believe that ingestion of non-food substance relieves nausea and vomiting.

Nyaruchucha (2012) also suggested that the ingestion of non food substances suggest deficiency of essential nutrients such as calcium or iron. Glans (2013) further noted that aversions are physiological mechanism that protects the fetus either from nutrient deficiencies by prompting mothers away from quality and monotonous foods or from excess foeto-toxic substance present in the food, thus food aversion could be beneficial.

The food crave by pregnant women includes fruits like oranges, water melon, mangoes, snacks, soft drinks, vegetables, meat, plantain and egg. In developed countries the foods commonly craved for include yoghurt, ice cream, chocolate, candies among others.

(Olusanya and Ogundupe, 2012). The food aversed to pregnant women include Beans, egg, snail, pear, bush animal meat, three leafed yam (Ona), mushroom, bitter kola (Akuilu), Green vegetable, pumpkin leaf, ice fish, palm wine. In developed countries foods commonly avoided are: coffee, alcoholic beverages, cigarette.

According to Safaii (2013) some first time pregnant women have increase desire for certain food and aversion to some and adhere to them without looking for substitutes to maintain an adequate diet. Certain demographic factors like age, religion, educational status, occupation and income level could contribute to first time pregnant women craving and aversion to certain foods. Most of the first time pregnant women may not know the implication of food craving and aversion on their health and that of their fetus and also the nutritional value of certain foods due to level of education. Some may prefer certain types of foods but may not afford them due to level of income while some may believe that certain food are appropriate because it is what is obtainable in the social class they live in; Most of the studies were carried out in developed and developing countries.

There is paucity of data on food craving and aversion among the first time pregnant women in Nigeria and Enugu metropolis in particular. Hence the researcher intends to examine the food craving and aversion of first time pregnant women using health facilities in Enugu metropolis.

Statement of Problem

Food craving and aversion in first time pregnancy is observed to be of concern to health care providers. Due to the physiological and hormonal changes in pregnancy, first time pregnant women do have increase nausea and vomiting as a result of high Oestrogen, progesterone and human chorionic gonadotrophin (HCG) (Knox, 2013), This interferes with the dietary intake of the pregnant women and sometimes cause serious problems like anaemia (Thomas, 2013).

Study by Nargia, Cooper and Kumar (2010) on assessment of pregnancy outcome in primigravida in Pakistan showed an alarming incidence in nutritional related disorder where it was observed that all the patients whether booked or unbooked were anaemic; 42% of them were severely anaemic. WHO (2011) estimatess that more than half of the pregnant women

14 in the world have a haemoglobin level indicative of anaemia (<11mg/dl); the prevalence may be however as high as 52% in developing countries compared with 23% in developed world.

This is a major cause of premature labour and low birth weight which are major causes of prenatal mortality and maternal mortality in developed countries.

Ojofemitimi and Tanimowo (2014), after conducting a study in which anaemia is more in primigravida, states that the higher incidence of low birth weight and anaemia in primigravida in developing countries compared to developed countries is a reflection of poor nutrition that may occur due to food craving and aversion and lack of health education on how to substitute for food craving and aversion in other to meet up with the required nutritional value for pregnant mothers.

The researchers clinical experiences in antenatal clinic revealed that about 75% of first time pregnant mothers crave for certain types of food which seem to have negative impact on them and the unborn child. Various maternal and child health program were geared towards improving the nutritional status of pregnant mothers like focused antenatal clinic and nutritional education in other to prevent complications in pregnancy and child birth.

Unfortunately much importance is not given to this group of women “First time pregnant women” as study by Ezeugwu et al (2009) shows that first time pregnant women have an increased incidence of low birth weight which poor nutrition is the major predisposing factor.

Most of the empirical studies reviewed were works done outside Nigeria. Only few were work done in Nigeria. However no study was found by the researcher on food craving and aversion among first time pregnant women in Nigeria. This led the researcher’s intention to study food craving and aversion among first time pregnant women in Enugu metropolis to fill the existing gap in literature. The question therefore is what are the type of food the first time pregnant women crave or averse to, their reasons, whether they are aware of the

15 implication of choice of food, whether they know how to substitute for food craving and aversion in order to meet up with their required nutritional values(needs).

Purpose of Study

This study is aimed at examining the food craving and aversion among first time pregnant women in selected health facilities in Enugu metropolis

Objectives

Specifically, the objectives are to:

1. Determine the type of food first time pregnant women crave for or have aversion to.

2. Identify the first time pregnant women’s reasons for their specific food craving and

aversion.

3. Determine the first time pregnant women’s awareness of the implication of food

craving and aversion in pregnancy.

4. Identify measures taken by first time pregnant women to substitute for food craving

and aversion in order to meet up with their required nutritional values (needs)

Research Question

1. What are the types of food preferred or aversed to by first time pregnant women?

2. What are the first time pregnant women reason for their specific food craving and

aversion?

3. How aware are the first time pregnant mothers of the implication of food craving and

aversion in pregnancy?

4. What measures do first time pregnant women take to substitute for food craving and

aversion in order to meet up with their required nutritional value (needs)?

Hypotheses

1. There is no statistical significant association between level of education and food

craving and aversion in first time pregnant women

2. There is no statistical significant association between residential location and food

craving and aversion in first time pregnant women.

3. There is no significant association between awareness of implication of food craving

and aversion in pregnancy and food craving and aversion in first time pregnant

women.

Significance of the Study

If the information obtained indicate that the first time pregnant women have poor awareness on implications of food cravings and aversion, how to cope with food craving and aversion or substitute to get adequate required nutrient for pregnant women, it will sensitize health workers/nutritionists to provide appropriate nutrition counseling and education to guide first time pregnant mothers make a wise choice of food in order to improve their health and nutritional status.

The findings when communicated to the appropriate governmental agencies and ministries will develop specific policies to control and prevent both micronutrients and energy deficiency during pregnancy in order to reduce the high maternal morbidity and mortality due to malnutrition and anaemia in pregnancy in Nigeria.

The findings of this study will also help the pregnant women to be aware when communicated to them of the implication of abnormal food choice, like pica which can lead to severe health problem such as lead poisoning, bowel blockage, iron deficiency anaemia and other nutrient deficiencies.

The information obtained from this study may be of help to other researchers interested in working in this field as it will serve as a reference material for further research.

Scope of the Study

The study was delimited to only first time pregnant mothers attending antenatal clinic in health facilities in Enugu south Local Government Area of Enugu metropolis. It will also be delimited to the assessment of food craving and aversion in pregnancy. Specifically, it is delimited to foods craved for or aversed to, reasons for the craving/aversion, their awareness of the implications of food craving and aversions in pregnancy, the measures they take to substitute for food craving and aversion and if these food craving and aversions are determined by their demographic status.

Operational Definition of Terms

1. Food craving/preference: covers edible substances that pregnant mothers have

intense urge to eat e.g. soft drinks, banana, breadfruit, popcorn, ice cream, mango,

oranges, water melon among others.

2. Food aversion: means edible substances pregnant mother avoid to eat e.g. egg,

garlic, beans, grass cutter meat, cassava, ice fish, snail among others.

3. First time pregnant women: means mother that are pregnant for the first time in

health facilities in Enugu metropolis without chronic disease

4. Reasons for food aversion and craving: means what makes the mother to take or

avoid a specific food e.g. the smell of the food, fear of gaining much weight, fear of

difficult labor among others

5. Awareness of implication of food craving and aversion by first time pregnant

women: Means what the first time pregnant women know about the effects of food

craving and aversion. The implications include abnormal brain development, low

birth weight, prematurity, increased risk of heart disease on the fetus and anaemia in

pregnancy, pregnancy induced hypertension, excessive weight gain.

6. Demographic profile: Are level of education and residential location (urban and

rural setting).

CHAPTER TWO

LITERATURE REVIEW

This chapter review related literature on food caving and aversion during pregnancy. The related literature was organized under the following subheadings – conceptual review: concept of nutrition in pregnancy, nutritional requirement in pregnancy, benefits of good nutrition in pregnancy, causes of poor nutrition in pregnancy, consequences of poor nutrition in pregnancy, concept of food craving and aversion in pregnancy, the types of food craving and aversion by pregnant women, the reasons for the food craving and aversion, the implications of food caving and aversion in first time pregnant women, substitution for food craving and aversion, the influence of geographical states in the food craving and aversion in pregnant women, theoretical review, empirical studies and summary of literature reviewed.

Conceptual Review

Concept of Nutrition in Pregnancy

Nutrition is the selection of foods, preparation of foods and their ingestion to be assimilated by the body (Payne et al 2014). Nutrition in pregnancy refers to the nutrient intake and dietary planning that is undertaken during pregnancy (WHO 2011). The conception and the subsequent weeks afterwards is the time when it is at its most vulnerable as it is the time when organs and systems develop within. The energy used to create these systems comes from the energy and nutrients in the mother’s circulation and around the lining of the womb; such is the reason why correct nutrient intake during pregnancy is so important (Haida et al

2013). During the early stages of pregnancy, since the placenta is not yet formed, there is no mechanism to protect the embryo from the deficiencies which may be inherent in the mother’s circulation.

The frequent consumption of nutritious foods help’s to prevent nausea, vomiting and cramps.

Supplementing one’s diet with foods rich in folic acid such as oranges and dark green leaf

20 vegetables, helps to prevent neural tube birth defects in the baby. Consuming food rich in iron such as lean red meat and beans help to prevent anaemia and ensure adequate oxygen for the baby. Thus it is critical that an adequate amount of nutrient and energy is consumed.

Nutrient is a substance that provides nourishment for growth or metabolism. There are two

types of nutrients macro-nutrient (needed in large amounts) or micronutrients (needed in

smaller quantities). Macro –nutrients are carbohydrate, and vitamin ( Haida et al 2013).

During pregnancy nutrient is important on three counts: the health of the mother, her developing fetus and alleviation of minor disorders of pregnancy (Haida et al 2013). Proper nutrition ensures that all essential nutrients (carbohydrates, fats, protein, vitamins, mineral and water) are supplied to the body to maintain optimal health and wellbeing. Good nutrition is also essential for resistance to infection and diseases and for the ability to repair bodily damage or injury (Haas, 2015). Pregnant women need a well-balanced high quality diet that includes go to 100grams of protein, adequate salt (to taste) and water as well as calories from all the food groups (Haas, 2015). The world health organization recommends that a pregnant women eat a minimum of 75 grams of protein per day, but protein has to be obtained from a wide variety of whole food sources in order to get all the important nutrients a woman needs during pregnancy (WHO 2011) while the government food pyramid is a good example of a well balanced diet, pregnant women need more protein and calories in general. This means including the following in their diet.

2 to 3 servings of meat, fish, nuts or legumes

2 to 3 servings of diary (milk or egg)

2 servings of green vegetable

3 servings of fruits

3 servings of whole grain (bread, cereal or high complex carbohydrates) 21

6 to 8 glasses of clean water each day.

This will supply the 300 calorie per day to make a healthy mother and baby (Haas 2015).

During pregnancy a women’s blood volume increases as much as 40 to 60 percent and in order to reach this necessary level and maintain it, a women’s body needs adequate protein salt, calcium, potassium and water from the diet. Calcium also may help to reduce the incidence of pre-aclampia (Haas, 2015).

According to Dickason (2012) the food and Drug Administration now recommends that bread should be fortified with folic acid to ensure that all women of child bearing age get enough of it and 400 microgram of folic acid a day is recommended. A long as junk food and excessive sweets (sugar) are avoided, pregnant women will not gain much weight and because the number of extra calories needed during pregnancy is not large (300 cal/day) “empty calories” from junk foods like meatpie, doughnuts, popcorn, soft drinks could fulfill the calorie requirement without providing needed nutrients. Emphasis on avoiding these foods and eating nutrient dense foods can make a dramatic difference in maternal nutrition.

Nutritional Requirement in Pregnancy

Protein

Protein is needed for building and repairing all maternal and fetal tissue and specifically for

the increase in blood volume, the growth of the placenta and fetus and the formation of the

amniotic fluid. More than 20 different amino acids combine in different ways to form

proteins. Eight essential amino acids are not synthesized by the body and must be supplied

by diet, if dietary protein contains all eight of the essential amino acids, it is a complete

protein. Most complete protein come from animal sources such as meat or milk. Most

vegetable sources of protein are incomplete and required combination with another source

that will supply the missing essential amino acids ( Payne, June &Canter 2014). The

American Dietetic association (ADA) recommends that during pregnancy at least four 22

serving of milk or food made from milk and three serving of meat or other protein food each

day .If carbohydrate or fat intake is insufficient, protein will be used for energy instead of

building tissue which will be problem especially for adolescence among the first time

pregnant mother who have higher protein requirements because their bodies are still

growing. Sources of protein include –meat, poultry, fish eggs, milk cheese, peas, the

recommended daily requirement of protein is 75grams per day (WHO 2011)

Carbohydrate

Carbohydrates are the main source of energy in the diet, most carbohydrates should come

from complex carbohydrate such as whole grain bread, cereals and vegetables. These food

have the benefit of containing other nutrient as well as fiber. Fiber intake helps to combat

constipation which is a frequent complaint in Pregnancy (Dickason, 2010) simple

carbohydrates should come from naturally occurring sources such as fruit and fruit juice

rather than from sweets. The recommended daily requirement of carbohydrates for pregnant

women according to American college of Obstetricians and Gynaecologists(AGOG) is

200kcal (840kj) per day

Fat

Fats are essential part of a healthy diet and source of energy for a pregnant woman. In addition to supplying energy fat provides essential fatty acids that are needed for myelinization of nerves and membranes synthesis .Fat also helps to secrete certain hormones

,Fat found in salmon, vegetable oil and avocado keep the heart healthy by stabilizing cholesterol level (WHO,2011) Fat also supplies and carries the fats soluble vitamins A, D.E and K. A fat deficient diet is extremely rare. The more common problem is a high intake of fat at the expense of other nutrients. If a pattern of high weight gain seems to linked with calorie intake, a diet craving history often reveals high fat choices (Haider, 2013).A diet high in saturated or trans fat can raise the pregnant woman cholesterol and may put her at risk for

23 heart disease. The recommended daily intake (RDI) of fat during pregnancy is 42 to 62 gram

(WHO, 2011)

Vitamins

Vitamin helps regulate metabolism of carbohydrate fat and protein. Most vitamins need to be supplied daily in the diets in as much as they are not manufactured by the body. A balanced diet will supply most needed vitamins and minerals with the possible exception of iron and folic acids (Haider, 2013).

The fat soluble vitamins A, D ,E and K are stored in the body and thus large doses can be harmful. Mega doses of vitamins A and D have been shown to cause teratogenic effects.

Excesses of this usually come from supplements rather than from diet. Vitamin A, which helps form and maintain skin and membrane tissue, is important in the mineralization of the fetal skeleton and in tooth bud formation (Payne et al 2014) Some vitamins e.g D can be produced by the body when skin is exposed to sunlight but it is also readily available in fortified foods such as milk. Vitamins E helps to maintain the structure of cell membrane and increases absorption of Vitamin A. Vitamin K is necessary to form prothombin for normal blood clotting. (Slattery, 2008). Water –soluble vitamins are not stored in the body, and this deficiencies are more common with these vitamins that is Vitamin C and the B complex

Vitamins –thiamine(B1), riboflavin(B12) ,niacin(B6) ,folacin (folic acid) and B12 . Vitamins

C help to form collagen which holds cells and body tissues together (Slattery, 2008).

The B complex vitamins function mainly as co enzyme working with other enzymes in metabolic reaction in the body. Thiamin help in carbohydrate metabolism riboflavin and niacin in the metabolism of fat, carbohydrate and protein, folic acid in DNA and RNA synthesis and B12 in protein metabolism (Dickason, 2012).The recommended daily intake of vitamin during pregnancy is 770mcg per day.

Source of vitamins A include

Liver, dark-green vegetables, whole milk, vitamins B; meat, eggs dried beans, peanut ,milk, cheese, ice cream, wholegrain bread and cereals, leafy vegetables, fish potatoes bananas, sweet potatoes, legume, vitamin C Citrus of fruit, strawberries, Mango, green pepper, cabbage, lightly cooked green, tomatoes (Hearly & Gibney, 2011).

Vitamin D - fish liver oil, milk

Vitamin E - vegetable oil, corn soy-beans

Vitamin K - Green leafy vegetable, liver, eggs, vegetable oil

(Hearly & Gibney, 2011).

Minerals

Iron is a key minerals needed to maintain the wellbeing of the mother and fetus; specifically

it is needed in the formation of hemoglobin, which carries oxygen to the cells. An increased

intake is needed during pregnancy because of the increase in maternal blood volume, fetal

blood formation, fetal iron stores for early infancy, and blood loss during delivery iron

absorption from the diet, however increases from the usual 10% to 20% to as high as 50%

during pregnancy and some iron is conserved with the cessation of menstruation, even so

the pregnant mother still require extra iron in her diets. Coffee, tea, milk and calcium

supplements decrease absorption of iron. Absorption is best if iron is taken at bedtime with

citrus but it causes gastrointestinal upset, it may need to be taken with a meal. (Slattery,

2008).

The main functions of calcium and phosphorus in pregnancy is to facilitate mineralization of

the fetal skeleton and deciduous teeth. The fetus acquires most of the phosphorous and

calcium in the last month of pregnancy, but if the mother is to have sufficient stores to meet

the demand, it is important that she increases her intake during the entire pregnancy. If the

25 mother’s stores are inadequate, demineralization of her bones may occur to supply the fetus, this can contribute to osteoporosis later in life particularly with frequent pregnancies.

Iodine- is a necessary component for the thyroid to regulate growth, metabolism and reproduction, lodine deficiency can cause retarded mental and physical development in the fetus. In area where iodine content of waters is low, use of iodized salt provides adequate intake (Dickason et al 2010). The recommended daily intake of iodine is 150 micrograms per day(Haas 2014)

Zinc

Zinc is a component of insulin, helps maintain the acid base balance in tissue and is important in RNA and DNA synthesis, meats and other protein foods have a fairly high zinc contents. Thus a diet with adequate protein intake should have adequate zinc .Because the safe upper limit of zinc supplementation has not been established, indiscriminate use of zinc supplement is not as well as other nutrients, it is a varied, well chosen diet.

Sources of zinc – pumpkin seeds, squash seeds, sunflower seeds, organ meats, mush room, soya beans, egg, wheat, meats, turkey). Sodium – fluid retention increases in a normal pregnancy, a slightly large amount of sodium is needed to maintain an adequate blood volume. Therefore, severe restriction of sodium is not advisable in as much as it may cause neonatal hyponatremia (low blood sodium) as well as problem for the mother, moderate intake of salt–seems appropriate during pregnancy. Sodium intake should be 2 to 3g per day, a goal easily reached in most African diets (Dickason et al 2010).

Iron

Iron is a mineral that makes up an important part of haemoglobin, the substance in blood that carries oxygen in muscles, helping them function properly. In addition iron helps increase the resistance to stress and disease. The body absorbs iron efficiently during pregnancy, therefore it is important to consume more iron while pregnant that the mother and baby gets enough oxygen and it functions as part of enzymes involved in tissue 26 respiration .The U.S Recommended Daily Allowance (USRDA) for iron is 30 milligram

(mg) per day for pregnant women(Payne et al 2014). The sources include liver eggs, red meat, dried beans, and cereals, greens leafy vegetable (Dickason, 2012)

Fluids

Water is a vital component of the nutritious diet which aids in digestion, absorption of nutrients, excretion of wastes and maintenance of blood volume. It also helps maintain body temperature. It also helps to prevent nausea and constipation. The pregnant woman should drink at least 6 to 8 glasses of fluid per day. The best choices are water, milk juice rather than soda with its empty calories and additives or caffeine –containing coffee and tea with their cream and sugar calories. Some Herbal tea can induce labour, harm the fetus or act as a diuretic or emetic and should be avoided by pregnant mothers (Haider et al 2013).

Principle of proper nutrition during pregnancy, Good nutrition during pregnancy is essential for.

1. The well being of the mother and the developing fetus

2. Development of effectives uterine musculature

3. Development of breast tissue

4. Development of an adequate functioning placenta poorly developed placenta have a

reduced ability to synthesize substances needed by the fetus to facilitate the flow of

needed nutrient and to inhibit passage of potentially harmful substances (Slattery,

2008).

5. Development of infants weight, length, bones and development of brain cells. If

optimum nutrient is provided after birth effects on the brain may be reversible.

6. Continued development of the infant after birth(WHO 2011)

Caloric Requirements in Pregnancy

1. Daily caloric requirement for a pregnant mother are about 300 calories more than

their normal requirements of 2300 to 2700 calories. The exact requirement on the

maternal age, multiple birth and the maternal activity, calories should be selected for

quality rather than quantity.

2. Pregnancy is not time to correct weight problem. Maintenance of a minimum of 1000

calories a day is essential for development throughout pregnancy . Pregnant women

who gain extra weight the first seven months then decided to cut back so as not to go

overweight deprive the fetus of the nutrients necessary when the fetal brain cells are

growing.

3. Food rich in protein, iron and essential nutrient are recommended to be eaten on a

daily basis. During the first two trimesters of pregnancy, iron is transferred to the

fetus in moderate amount but during the last trimester the fetus builds its reserve, the

amount transferred is accelerated ten times.

4. Recommended weight gains for a normal pregnancy is 24 to 30 pounds (Dickason et

al 2010)

Benefits of good nutrition in pregnancy

There are a number of benefits for both pregnant woman and the baby to eating healthy food during pregnancy which include the following;

Reduces pregnancy complications:- pregnant women are vulnerable to number of complications during pregnancy including high blood pressure and gestational diabetes.

Eating an adequate diet can keep the pregnant woman blood pressure, blood sugar levels and weight at healthy levels to reduce the incidence of such complications. Eating healthy foods can also help prevent or treat common pregnancy disorders such as morning sickness, or leg cramps. Ensuring that her diet is full of lean protein, healthy fats and complex carbohydrates can help lessen or prevent these symptom (Dana 2012). 28

Reduces incidence of birth defects: when a pregnant woman eat healthy diet the chances of birth defect such as neurological impairments and development delays is reduced. It is important to eat natural unprocessed foods as much as possible during pregnancy to avoid harmful substances (Haas 2015). Ensures a healthy weight for the baby: pregnant women should ensure that she is eating nutritious food and adequate calories per day to promote healthy weight gain of the baby and reduce incidence of low birth weight. Sets the stage for good health: what the pregnant woman eat during pregnancy can influence the baby’s development and what he or she eats later in life. Eating healthy food will prevent the baby from developing a taste for food that are low in nutrition to prevent childhood obesity and other serious diseases like diabetes (Dana 2012).Helps the pregnant woman lose weight faster: most women are keen to lose their extra pregnancy weight as quickly as possible.

Eating nutritiously throughout pregnancy not only makes it more likely that she will gain a healthy amount of weight but also makes it easier for the pregnant woman to shed that weight after pregnancy. Eating nutritious diet during pregnancy sets up healthy habits that the woman can continue after delivery making it easier for her to eat well and maintain a healthy weight. (Dana, 2012).

Causes of Poor Nutrition in Pregnancy

According to Tomm (2015) poor nutrition affects rich and poor countries alike. However its severity causes nutritious disorder in pregnancy. The causes of poor nutrition in pregnancy are as follows:-

1. Food craving and aversion:- when a pregnant woman craves for non nutritious food

and has aversion for nutritious diet, it causes poor nutrition in pregnancy (Dana 2012).

2. Poverty: poverty and lack of resources are also causes of poor nutrition that

contribute to the estimated 925 million people worldwide suffering the effects of

malnutrition and its companion diseases (Tomm, 2015).

3. Access to food stores/market:- in some locations access to fast food joint; grocery

stores and market can influence their choice of food especially pregnant women living

in urban area. Some pregnant women living in a locality where they have access to

foods can choose wisely or wrongly. In some locations access to food grocery stores

or market is limited by distance. This may not affect their nutritional status if they

choose nutritious locally available food and may affect them if they choose non

nutritious diet in their locality (Tomm, 2015).

4. Age related and social issues:- young pregnant women are more involved in

choosing poor diets. Peer influences and addictive behavior of eating fast food when

single or not pregnant can cause them still craving for those non nutritious diet during

pregnancy (Dickason, 2012).

Consequences of poor nutrition in pregnancy

The effects of poor nutrition on a fetus

Abnormal Brain Development: According to Juhasz (2013) research on the fetuses of poorly fed baboon mothers by Southwest foundation for Biomedical Research was published in the “Proceedings of the National Academy of Sciences”, demonstrating the major role nutrition plays in fetal brain development. When baboons were deprived of nutrients, especially during the first half of pregnancy, researchers found disturbance in the development of brains of their fetuses at both the cellular and molecular levels. Hundreds of genes were found to be disordered, impacting cell division and cell to cell connections. In human studies, pregnant women whose folate levels were low because their diets lacked foods containing the B-complex vitamins, increased the risk of defects in the neural tubes of the newborn babies that forms their spines and brains.

Increased risk of diabetes:- The way a child responds to food over a lifetime depends partly on whether or not overfeeding or underfeeding takes place during fetal development.

According to Tomm (2015) babies who weighed less than 6 pounds at birth were more likely 30 to suffer later from type 2 diabetes. This is attributed to the differences between the prenatal nutritional status of the mother. This disparity provokes abnormalities in the endocrine functions and energy metabolism.

Increased risk of Heart Disease and Hypertension:- A healthy diet is crucial because the initial organ development of the fetus takes place especially in first trimester of pregnancy.

The calories, fluids and protein pregnant woman eat affect the maternal blood volume and pressure, the development of the placenta and the cardiovascular future of the child. If the nutritional status of the mother is insufficient, the baby is put to greater risk for heart disease

(Juhasz, 2013).

Increase Risk of Obesity: According to Haas (2015) if the fetus is exposed to high levels of blood sugar or fat due to the food choice of the mother through food craving. It can affect the development of the fat cells of the fetus and the pathways in the fetal brain that regulate appetite. High fat and high sugar foods during pregnancy predispose the baby to becoming obese later in life

Possible lowering of intelligent quotient:- According to (Juhasz 2013)poor nutrition during pregnancy by altering the development of fetal organs including the brain , may have lifetime effects , potentially lowering the IQ and heightening the risk of behavioural problems.

The Effects of Poor Nutrition on the Pregnant Woman

Pregnant women with poor nutrition can be vulnerable to complications like the following:-

Anaemia in Pregnancy:- This may be seen in pregnant women with iron deficiency and other nutrient deficiencies.

Pregnancy – Induced hypertension (PIH) this may be seen in more patients with poor diets gestational diabetes.

Excessive weight gain:- when craving for starchy and sweet food, it can lead to excessive weight gain which will predisposing the pregnancy women to pregnancy. Induced hypertension and gestational diabetes (Tomm, 2015)

Concept of Food Craving in Pregnancy

In order to sustain a successful pregnancy a mother experiences a number of physiological

and behavior adjustments; food craving is an examples of such changes. Food cravings are

generally described as distinct state characterized by an intense urge to obtain certain food

(Mercer & Holder, 2013).It differs from regular craving in the sense that it is about a million

times stronger. A pregnant woman may wake up with a burning desire for a particular food

and will go out of her way to satisfy that craving. She may drive miles upon miles to meet

the craving and have no regret in waking the husband up in the middle of the night to buy

and cook a certain foods for her. The craving that people experience all the time will

continue to occur during pregnancy (Mane Wala, 2013) .Sometimes it is harmful to crave for

certain foods which may affect the development of the fetus

Sometimes an alcoholic mother may remain abstinent from alcohol during pregnancy.

Pregnant mothers may crave for food that they did not even enjoy prior to pregnancy. It

starts during pregnancy usually in the first trimester, peaking in the second trimester and

generally disappear between delivery. Craving seems unpredictable and may even differ

from first pregnancy to the next. There are factors that play as well. For example women in

different cultures clearly crave foods based on what regionally and culturally available.

Hormonal factor also play a role in food craving, pregnant mother that developed gestational

diabetes has a type of glucose intolerance that is specific to pregnancy. According to

Maneywala (2013) research does include that these women will crave sweets at a very highs

rate especially during the second trimester. Over half of the women with this type of

diabetes will crave sweets and this craving tends to resolve by the time the woman delivers.

Food craving may not necessarily be a problem or cause imbalance in a pregnant woman

diet if she seems to be craving healthier food like fruits or milk but giving in to craving

every time especially if they are frequent and cravings is of high –calorie foods, is a good

way to pack on more pounds than intended. If a pregnant woman seem to be craving and

eating much of anything else she may become deficient in important nutrients (Tessmer

2013). According to Tessmer (2013) pregnant mothers should try their best to crave

nutritionally balanced diet. As long as they are eating a balanced diet and getting the

essential nutrients they need for development of the fetus and themselves. Food craving get

less intense as the pregnancy progress and giving in to craving once in while is probably

good.

According to Brody (2014) when a pregnant mother crave nonfood items such as paint

chips, laundry starch, soil, clay a condition known as pica, she is lacking one of the

minerals, she should not indulge in pica because nonfood substances can counteract the

absorption of iron and also potentially toxic for the baby and mother. The pregnant mother

have to report in the hospital as this can lead to nutritional deficiencies. Some pregnant

mothers crave food that are harmless in small quantities but can lead to gatrointestinal pain

or other problems if eaten in large quantities. Eg. corn starch. Other food that may be a

health risk during s pregnancy include raw fish and raw eggs.

Common Food Cravings include the following

Fruits – apple, banana, mango, water melon oranges. These are healthy craving, if a mother have a high fat diet the body may be craving for fruits for its ability to lower cholesterol level

(Thomas 2013). Other cravings includes African salad, maize pudding ,pigeon pea

(agbugbu)three leaf yam, guinea fowl egg meat, potatoes, ice cream, legumes, cereals, fish, fatty meat, livestock, beverages, vegetables, plantain, breadfruit, soft drinks, meat pie, roots among others.

Unusual Craving

Some pregnant others crave food that can be harmful to health. These include paint chip, chalk, starch, clay, soil, ice, charcoal, cigarette ashes, (Nyaruhucha 2013). According to

Nyaruhucha (2013) a theory suggest that the ingestion of these substances relieves nausea and vomiting and another theory suggests that deficiency of essential nutrients such as calcium or iron results in the eating of non food substances.

Food Aversion in Pregnancy

Food aversion is a strong feeling of dislike, opposition, repugnance or antipathy for certain

food (Douglas, 2010). Food aversion in pregnancy is classified into four types ;food that was

rejected because they felt that they are harmful to the baby, inappropriate for a pregnant

woman due to their culture, disgusting or distasteful due to hormonal changes in pregnancy

(Knox, 2013). Pregnant mothers dietary habits is not just about what she wants but also

about the food she can’t stand to eat, smell or even see sometimes .The idea of putting this

food in the mouth may provoke nausea and vomiting for some pregnant women (Michele et

al 2014), food aversion’ can last through the first trimester of first time pregnancy but it

can be experienced throughout period of pregnancy .Food aversion to certain food especially

non nutritious food is harmless but when averse nutritious food without any substitution may

lead to nutritional disorder.

According to Michele (2014) some experts theorize that food aversion is caused by body’s

inherent mechanism to protect itself from any perceived threat. If the body finds a particular

food repulsive, it will act in a protective way which explains the nausea and vomiting

associated with food aversions. However this strong reaction towards food is largely

attributed to hormonal changes in pregnancy (Bayley, 2005).

Pregnant woman can easily avenge her aversion without compromising her nutritional ideals

just by practicing substitution. There are always healthier alternatives that a pregnant woman

with food aversion can turn to when she averse certain foods. For example if a pregnant

woman find beans repulsive, she can eat moi moi, okpa or other legumes.

Common Aversion

During pregnancy, mother can become grossed out by any and all foods but protein is a common trigger. Some suggest this was an evolutionary purpose as too much protein may prove harmful to the baby’s health (Knox, 2013). Egg, beans, chicken, red meat, are common aversion others include garlic or bitter kola (akuilu). It is not only the taste but also the smell of the food that causes aversion (Nyaruhucha, 2009).

Types of Food Craving and aversion by Pregnant Mothers

Food craving and aversion during pregnancy have a significant input on pregnancy progress and outcome, therefore understanding the types of food crave and averse by pregnant mothers is important to ensure that mother and fetus attain adequate health and nutrition (Knox 2013).

According to Turgeon (2014) nutrition scientist states that depending on the trimester of pregnancy mothers taste certain flavor more intensively and either prefer or dislike them. In the first trimester for example mothers found bitter tastes aversive and it was shaped this way so that she would disgust strong-tasting plants or spoiled foods which are more likely to contain a toxin that could harm the baby. This could be why some pregnant mothers who formerly like coffee, alcohol or spicy food turn up their nose on them and as the pregnancy progresses (and the baby critical organ formation completes they tend not to feel sick at the thought or smell of these foods anymore) (Turgeon 2014). According to Hearty (2011) pregnant mothers perception of salty and sweet food changes as well in the first trimester, they averse salty foods more intensely but prefer this more as they approach the second and third trimester.

Citric acid (sour taste) preference also increased through the second and third trimester than the first trimester, a sour preference helps the mother get a more varied diet late in pregnancy 35 so that she can get enough calorie (Brody 2014). Since fruit is typically a combination of sweet and sour tastes, also explain why fruit is the most common pregnancy craving food.

Measures taken by pregnant women to substitute/manage food craving and aversion.

Food craving and aversion during pregnancy is very common and some food crave or averse can undermine the healthy eating habit of the pregnant woman .A pregnant woman can satisfy her craving and aversion and still eat nutritious diet needed for the baby‘s development and her good health. When a pregnant woman is craving for high calorie, fat or sugar ,she have to substitute that and still satisfies the pregnancy craving .

The following are ways to substitute or manage food craving and aversion in pregnancy

Instead of craving for ice cream, the mother should try low fat frozen yoghurt.(Thomas,

2013).

When craving for soft drinks, the mother should take fresh juice e.g. orange juice or water lemon juice(Eric et al 2013)When carving for junk fast food like meat pie, cake ,popcorn, doughnut ,fish pie among others she should try carrot, pawpaw, banana (Thomas 2013) The mother should eat a good, healthy breakfast skipping meals such as breakfast can increase the cravings for certain foods later in the day.(Walker et al 2013)She should eat plenty of complex carbohydrates such as yam, rice , cocoyam ,potato among others. Complex carbohydrates take longer to digest and therefore help to keep blood sugar level consistent, reduction in blood sugar can cause cravings (Slattery, 2008).The pregnant mother should take a closer look at her total diet, keep a food diary for a week and review it to make sure that she is eating an adequate diet and getting the nutrients that she needs.(Knox, 2013)She should stay active and exercise regularly. Exercise can help curb hunger and tame cravings. The mother should make sure that she has stable emotional status. Pregnancy can cause mood swing which may cause her to turn to food for comfort.(Thomas, 2013)If the mother is

36 carving for non food and cannot resist the craving, she should inform the health personnel

(Tessmer,2013).

Dealing with food aversion

If a pregnant woman averse meat, she can eat soy-based products such as fish, soy based milk. If a pregnant mother cannot eat green leafy vegetable she will be advice to crave fruits instead because they are generally easier on the palate and they also contain the same nutrients found in many vegetables example Guava, Pawpaw, mangoes, pineapple among others. Another strategy of dealing with food aversion is sneaking the food in when cooking.

For example a mother may conceal vegetable in favorite food such as maize pudding, African salad, achicha among others. If she has aversion for milk, it can be added to soups, sauce and other dishes. (Thomas, 2013). The pregnant mother has to be flexible and methodical about food evaluation because the food that she had aversion for in the morning due to morning sickness (nausea and vomiting) can be palatable at noon and evening time (Tessmer, 2013).

The Reasons for Food Craving and Aversion in First Time Pregnant Women

There are factors that influence food craving and aversion in first time pregnant women which include the following;

Physiological factor

During the course of a normal pregnancy, the mothers experiences physiological changes that affect nearly every function of the body. These changes are necessary to support the growth of the fetus and to prepare the mother for labour, delivery and lactation. As these changes occur, the nutrient need of the mother increases. Pregnancy is accompanied by a 50% increase in maternal blood volume. To produce the additional blood needed to support the growth of the fetus, the body needs extra fluid, irons and vitamin B12 (Eric et al 2013). To support the growths and developments of the fetus a pregnant woman requires extra amount of nearly all essentials nutrients. This makes many pregnant women experience intense food

37 cravings and aversion. In addition the sense of taste and smell is frequently altered during pregnancy. These changes can lead to excessive consumption of certain foods and insufficient consumption of other foods. This is a concern if the foods that are frequently consumed contain lots of calories and fat and few vitamins and minerals (Carr et al, 2013).

According to Demissie (2013) Food carving and aversion in pregnancy is physiological mechanisms that protect the fetus either from nutrient deficiencies (by prompting mothers away from low quality and monotonous food) or from excess foeto toxic substances present in the foods. The feeling of fullness during second trimester result in a woman decreasing her dietary intakes. The occurrence of morning sickness which is associated with nausea and vomiting is commonly linked with foods aversion associated with pregnancy. Up to two third of all pregnant women may suffer from morning sickness (Walker, et al 2013).

Hormonal factor

Hormonal variation is a typical feature of pregnancy and is known to have multiple function and effects concerning the health of both mother and fetus. There are several hormonal mechanisms reported to affect the incidence of cravings and aversions. These involve the influence of endogenous opioid peptides, estrogen and progesterone, prolactin and the metabolism of glucose (knox 2013).

Endogenous opioid peptides

According to Mercer and Holder (2013) the change in palatability during pregnancy may reflect change in endogenous opioid peptide (EOP) level during pregnancy. Pregnancy and the accompanying stress is associated with changes in the opioid system, endogenous opioid peptides and opioid agonists were found to decrease food intake through blocking the receptor binding of specific EOP’s The foods with high levels of glucose are more frequently craved than foods with lower glucose because when glucose interacts with opioid systems in the brain a craving triggering effect occurs. (knox, 2013).

Estrogens and Progesterone

Progesterone and estrogen are two primary hormones required to conceive and sustain a pregnancy. This explains the observed increase in circulation throughout the course of the pregnancy.

According to knox (2013) there is evidence that progesterone acts as an appetite stimulant while estrogen acts as an appetite regulator and this plays a role in food craving and aversion.

Prolactin

According to Grattan et al (2013) prolactin is renowned for various regulatory functions of the brain and it is argued that this hormone is responsible for the increase and changes in appetite during pregnancy.

Psychological Factors

Pregnancy is often associated with increase physical requirements from the mother, which often leads to heightened psychological and emotional demand.

Pregnant women who are more fatigued, stressed and anxious consume more food and are more likely to experience food craving and aversion (Hurley, 2014).

According to Brody (2014), message pregnant mothers received during pregnancy specifically about what kind of food they should eat, may in fact cause them to eat or drink more of these foods. Expectations about getting craving might also cause them to start having craving.

Anecdotes that some pregnant women having heard other pregnant mothers especially during antenatal clinic discussing eating certain food for breakfast may cause the pregnant mother to have some urges of her own (Hurley, 2014).

Turgeon (2013) noted that foods that make pregnant mothers feels good is likely to be craved on; that‘s a simple pavlovian fact. He states that mental imagery is an important component of any food craving and if a pregnant mother picture a food clearly in her mind she is going to have a strong craving for the food. Another mechanism suggested to explain food craving 39 and aversion is taste aversion learning, where foods associated with illness are subsequently avoided. Bayley et al (2005) conducted a study investigating this concept and found a significant relationship between experiencing morning sickness and incidence of food aversions. Therefore this indicates that psychological factors may also play a role in influencing eating behaviours such as craving and aversion during pregnancy.

Culture/Belief

Culture is one of determinant of food craving and aversion. Eating habits result from early teaching and belief about what foods should be consumed. Pregnancy is a period of time that is influenced by belief of the community the pregnant woman is residing in concerning diet to be consume by pregnant woman and the pregnant woman is expected to adhere to it (Eric et al 2013). Some belief that pregnant mother should limit what she eats in order to prevent giving birth to a large baby (Mercer and Holder, 2013) Another belief is that a pregnant mother will crave foods that are calcium and energy rich but will avoid food that are rich in protein (Knox, 2013) Some craving and aversion are based on the belief that pregnant woman should crave certain food such as include water melon , ice cream, pepper soup and have aversion for bush meat. Others belief that an over eaten of craved food will have an adverse effect on the baby, for example, a skin infection may result from eating too much pear during pregnancy and drawling of saliva of the baby results from craving for snail during pregnancy . Another type of craving pregnant women have that affects the mother and will influence the diet is pica. The origin of pica is not well understood but when questioned, women respond that they had to have it and it felt like running out of cigarette for addicts when they can’t lay their hands on it (Turgeon, 2014). The consumption of these non-food items may cause a feeling of fullness thus the intake of a nutritious food items may be decreased. Self imposed cultural restrictions may severely affect the adequacy of the food consumed. (Douglas, 2010) Some religion abhor certain food and it affects food craving and aversion of pregnant mothers; for example, some religion prohibit snail, pig, meat among 40 others which may cause pregnant mothers to averse the food. Pregnant mothers income level age, life style and educational level affect their food craving and aversion (Lachting et al

2014).

Implication of Food Craving and Aversion

Food craving and aversion that is associated with nausea and vomiting are common during pregnancy. This interferes with the dietary intake of essential nutrients and sometimes causing serious problem (Nyaruchucha, 2013).When food low in adequate diet is craved, it can lead to a smaller placenta which limits the transfer of nutrients to the fetus leading to poor fetal growth (Slattery, 2008).

When a pregnant mother has increase desire for sweets (Carbohydrates) it could lead to gaining much weight and excessive weight gain can increase her risk of gestational diabetes, high blood pressure and also can cause childhood obesity as the baby record pathway may be influenced by the mother ‘s diet behavior of overeating sugar and fat (Safaii, 2013)

Craving for inadequate food can also affect the health of the mother and growth and development of the foetus leading to anaemia, low birth weight, congenital malformation, malnutrition among others. Craving for non food substances such as soil, clay can interfere with the absorption of certain mineral element such as iron leading to iron deficiency anaemia. It also may indicate that the baby is deficient in iron and certain minerals (Thomas,

2013). Craving for nutritionally adequate diet and getting the essential nutrients the mother need for development of the baby and maternal wellbeing is encouraging and indulging in food craving (healthy food) in moderation is harmless (Tessmer, 2013). Food aversion on non nutritious food for pregnant mothers for example alcohol, cigarette, coffee , among others is harmless and encouraged. (Turgeon, 2014). Food aversion on nutritious food plays a negative role in maternal nutrition because it reduces the mothers food option by causing decrease to her intake of healthy food. When food aversion get in the way of healthy eating, the mother need the assistants of health personnel (the midwife, doctor and nutritionist) for advice on 41 how to substitute (Isaac et al 2004). When appropriate measures are not taken to substitute, it can lead to low birth weight, malnutrition, anaemia congenital malformation among others.

Therefore, understanding the implication of food craving and aversion during pregnancy is important in ensuring that a mother and fetus attain adequate health (Knox, 2013).

Demographical Status and Food Craving and Aversion in First Time Pregnant Women

The prevalence and nature of food craving varies significantly depending on the geographic region under investigation (Hormes, 2014). One cannot crave for what she has not seen before rather what one has seen and may have tasted (Knox, 2014). First time pregnant women being younger are more likely to experience food cravings with prevalence decreasing steadily with age (Orloff & Hormes, 2014). The food crave in USA include Ice

Cream, Chocolate, Pizza etc

According to Hormes (2014) studies indicate that the level of education can influence dietary craving or aversion during pregnancy if the knowledge lead to direct action and not when the individual is unsure of how to apply the knowledge. Educational level of the husband also enhances good and nutritious food craving as he advice the pregnant woman on food craving and aversion when experiencing it.

In today’s economy, some pregnant mothers income do not go very far, after paying the bills, such as rent, utilities and car, there might not be much money remaining. What is left must still buy not only food but other essential items such as toiletries, diaper, baby clothing among others. When there is not enough money to pay the bills and buy necessary living items, the food budget might be reduced since the food bought is determined by the amount of available money. This reduction could result in the type of food crave or aversion by pregnant mothers (Lachtig et al, 2014).

Theoretical Review

The Health Belief Model

The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behavior. This is done by focusing on the attitudes and beliefs of individuals.

The Health Belief Model helps explain why individual patients may accept or reject preventive health services or adopt healthy behaviours. Social psychologists originally developed the Health Belief Model to predict the likelihood of a person taking recommended preventative health action and to understand a person’s motivation and decision-making about seeking health services. The Health Belief Model proposes that people will respond best to messages about health promotion or disease prevention when the following four conditions for change exist.

• The person believes that he or she is at risk of developing a specific condition.

• The person believes that the risk is serious and the consequences of developing the

condition are undesirable.

• The person believes that the risk will be reduced by a specific behaviour change.

• The person believes that barriers to the behaviour change can be overcome and

managed.

The Health Belief Model was spelled out in terms of four constructs representing the perceived threat and net Benefits, perceived susceptibility, perceived severity, perceived benefits and perceived barriers, added concepts, cue to action or self efficacy would activate readiness and confidence in the ability to successfully perform an action.

This theory has been applied to a broad range of health behavior and subject population and is supported by empirical evidence.This theory was applied among Vietnamese women over

40 years to obtain breast cancer screening. It reveals that belief commonly held by women about breast cancer-screening predicted their screening status. The findings suggest that

43 breast cancer screening could be increased by facilitating women belief in the efficacy of the screening machines and dispelling the belief that it is embarrassing or she cannot cope if it is dictated early.

Perceived Susceptibility: Perceived susceptibility in the theory of Health Belief Model tries to look at one’s opinion of chances of getting a disease and prompt people to adopt healthier behaviours. The greater the perceived susceptibility the greater the likelihood of engaging in behaviours that will decrease the risk. This is what prompts the first time pregnant women to substitute to nutritious diet whenever they observed that they are craving for non nutritious food or aversing nutritious food in order to prevent nutritional disorders in pregnancy. When people believe they are at risk for a disease, they will likely want to do something to prevent it from occurring. It is observed that increase susceptibility is linked to healthier behaviours and decreased susceptibility is linked to unhealthy behavior.

Perceived Severity: The construct of perceived severity is the one’s opinion or belief about severity of a condition. The perceived severity is often based on health information and knowledge of the consequences of a condition. There is wide variation in a persons feeings of severity and often a person considers the medical consequences (nutritional disorder) and social consequence, e.g (lowering intelligent quotient of a child) when evaluating the severity. First time pregnant women’s’ opinion on how serious nutritional disorder is and its consequences are, determines the women’s action. For example, a pregnant woman’s knowledge about benefit of good and adequate nutrition during pregnancy and the consequences of not practicing it determines how the pregnant woman will perceive severity and the perceived severity in turn will influence her action.

Perceived Benefit: The construct of perceived benefits is one’s belief on the value of a new behaviour in decreasing risk of developing a disease. This refers to a persons perception of the effectiveness of various actions available to reduce the threat of illness. The course of action a person takes in preventing disorder relies on consideration and evaluation of both 44 perceived susceptibility and perceived benefit such that the person would accept the recommended health action if it was perceived as beneficial. First time pregnant women tend to adopt healthier behaviour of eating adequate diet when they believe that this will decrease chances of developing nutritional disorder in pregnancy. Pregnant women found to be eating nutritious diet beneficial in order to prevent complications of nutritional disorder which include anaemia, low birth weight, premature labour and delivery among others often practice it religiously.

Perceived Barriers: Perceived barrier is ones opinion of the tangible and psychological costs of the advised action. This construct of HBM addresses issue of perceived barrier to change.

This is an individual own evaluation of the obstacles that will prevent her from adopting a new behaviour. The feeling of fullness from enlarging uterus and experience of nausea and vomiting especially during the first trimester could be a barrier for first time pregnant women to eat adequate diet. The personal and cultural belief on restrictions on certain food items because the particular foods should not be consumed during pregnancy would also be a barrier to behavioural change.

Modifying Variables: The Constructs believe that the four major constructs of perception are modified by other variables such as educational level and residential location. These are individual characteristics that influence personal perception. It is believed that educational level or income can affect the pregnant womans’ choice of food. It could also be said that residential location could affect the choice of food because it is what is seen that one craves for; a pregnant women cannot cave what she has not seen in her locality or heard of.

Cues of Action: Cues to action is the strategies to activate readiness, providing information, promote awareness and reminder. Examples include, distribution of flyers or pamphlets containing recipe to first time pregnant women for them to always identify food that is adequate for them during each antenatal visit and demonstration which should be

45 accompanied with teaching, media reports, mass media campaign on benefits of good nutrition during pregnancy and it ‘s benefits and consequences.

Self Efficacy: This refers to the extent of an individual’s belief in his or her abilities.

Because self efficacy is based on feeling of self confidence and control. It is a good predictor of motivation and behaviours. Health care professionals can have an impact on self efficacy and that changes in self efficacy are associated with changes in behaviour. Some example of ways to enhance a patients self efficacy include;

Skill Mastery: refers to the technique of breaking down skills to be learned into very small manageable tasks so that it is likely the task will be done successfully. People are more likely to adopt a health behaviour if they think they will be successful in doing it. This intervention should increase confidence by giving patients many little “successes” in the process of behavioru change. Nutritional education for first time pregnant women using the technique made them to adopt substitution or manage food craving and aversion in pregnancy. When the first time pregnant women have efficient knowledge on nutrition in pregnancy, the implications of nutrition in pregnancy, how to substitute effectively and crave for food diet, she will be confident in what she crave or averse to and practice eating healthy diet.

Modeling: Is a self efficacy technique by which the patient becomes aware of seeing someone else with a similar problem. Support groups and patient groups such as Arthritis foundation self help course and the American Cancer Society’s Reach to Recovery program are based on modeling. First time pregnant women seeing a pregnancy mother with nutritional disorder due to food craving and aversion, influence their craving and aversion positively.

Social Persuasion: Refers to individual efforts to influence behaviour. One aspect of persuasion that is particularly effective is to urge and encourage the patient to do slightly more than he or she is now doing. When the first time pregnancy are encouraged on how to

46 substitute on nutritious food when craving and aversing certain food item will prompt them to substitute to nutritious diets.

Review of Empirical Studies

A study was done by Olusanya and Ogundipe (2012) titled “food craving and aversion among pregnant women in Akure, Ondo State Nigeria. The prevalence and type of food crave for and averse to during pregnancy were studied. 243 pregnant women in Akure North and South

Local Government attending antenatal clinic were involved in the study. Descriptive study was used and simple random sampling was used to select five government and three private hospitals. Questionnaire and mid upper arm circumference (MUAC) and Triceps skin fold

Thickness (TSFT) were used to assess the nutritional status and demographic and other information on the subjects. The data were analyzed using both descriptive and inferential statistics. The result shows that majority of the respondents were between 30 and 39 years old while 22.2, 11.3 and 7.0% fell between 20 and 29, over 40 years and below 20 years old respectively. 42.8% had no aversion for any food, 57.2% avoided at least one food while

28.3% avoided >1 food. With respect to craving 38.7% had no craving for any food, 61.3% craved for at least one food and 23.9% craved for >I food. The result of the anthropometric parameter (MUAC and TSFT) showed that there was significant difference between the

MUAC and TSFT among the respondents with and without food aversion (P < 0.05). No significant differences were observed in the MUAC and TSFT among respondents that craved and did not crave for food. This study indicates that aversion and craving during pregnancy are significantly associated, while significant difference in nutritional status was observed among pregnant women that had aversion with and without craving for specific food. Culture has influence on the craving and aversion among pregnant women. The study also revealed lack of adequate and correct nutritional knowledge among the pregnant women.

Hence, there is need to intensify nutrition education at the antenatal clinics.

Tsegaye Muroki & Wambui (2012) studied “food aversions and cravings during pregnancy: prevalence and significance for maternal nutrition in Ethiopia”. A sample of 295 pregnant women from rural and urban communities 51% and 49% respectively were used. Descriptive study design was used and the subjects were purposively selected. Questionnaire was designed to gather demographic and socio-economic data information on food craving and aversion and the reasons for them were done. The Mid upper arm circumference (MUAC) and triceps thickness (TSFT) measurements and weight were used to assess nutritional status.

The data were processed and analyzed using both descriptive and inferential statistics. The result of the study shows 71% of the pregnant women craved one or more foods, whereas about two-thirds (65%) avoid at least one food. Cereal food were avoided by more women

(41% than any other foods. Livestock products were craved by more women (55% than any other food. Comparisons using various anthropometric indicator revealed that women who avoided foods had significantly higher MUAC and TSFT than those who did not. (P<0.05) whereas there was no difference in nutritional status between women who craved foods and those who did not. Those craving women who managed to get the desired food had significantly higher weight gain (P<0.05) but not significantly higher MUAC or TSFT than those who did not. Aversion and craving are positively associated (c2 = 10.66, P< .001; odds ratio, 2.36). Thus women who avoided food were 2.4 times more likely to crave food than those who did not avoid food. This implies that aversion and craving are complementary processes geared towards ensuring optional nutrition during pregnancy; aversion results in the avoidance of monotonous diets, whereas craving calls for varied and nutritious food.

Ogunbjuyigbe, Ojofeitini, Sanusi, Akinlo, Liasu, & Owolabi (2012) study “Food aversion during pregnancy: a major cause of poor pregnancy outcome in Nigeria”. The research design used is descriptive survey design. Eight hundred and forty four (844) women of reproductive age (15-49 years) were used for the study, six local government area in Osun state were

48 purposively selected and 844 women were randomly selected using simple random sampling from the six local government area. Focus groups discussion (FGD) were held to gather qualitative data from the pregnant women, health care providers and traditional birth attendants. The data were analyzed using descriptive and inferential statistics. The result of the study shows that majority of respondents in both urban and rural areas fell within age range 20 – 29 (52% and 50.8% in rural and urban areas respectively). High proportion of respondent in age group 20-29 (63 in rural and 105 in urban areas) have aversion for some food items when they were pregnant while age has significant influence on food aversion in the urban area (P = 0.020) it does not in the rural areas (P = 0.177). Most of the respondents that had food aversion for some food items had secondary school education seem not to have significant influence on food aversion in both urban and rural area. In rural areas Christian religious affiliations had negative impact on food avoidance (P = 0.001) but not in urban areas (P = 0.890). The effect of occupation on food aversion appears unclear in rural areas though there is significant association (P = 0.008) between occupation and food avoidance in the urban areas. The reasons for food avoidance apart from socio-cultural excuses include vomiting, odour, stomach pain, heaviness, chest pain, fear that it may affect the fetus and indigestion and fear that it may increase size of the fetus. Findings show that there are still food avoidance aversion by pregnant women in this part of the country and food avoided are common sources of essential nutrition’s like vegetable called Ewedu, Plantain, Mango,

Guava among others.

A study was carried out by Nyaruhucha (2009) on food craving, aversions and pica among pregnant women in Dar es Salaam Tanzania. The study was carried out using descriptive survey to determine the frequency and duration of pronounced dietary cravings, aversions and pica during pregnancy. 204 pregnant and lactating women attending two health facilities in Dar es Salaam city is involved in the study. Purposively 2 health facilities were selected 49 for the study, convenience sampling technique was used to select 204 pregnant and lactating women. Questionnaires were designed to gather information. The data were analyzed using descriptive and inferential statistics. The result of the study shows that the proportion of women who reported pronounced cravings and aversions was 75.5%. Out of these, 70.1% experienced both cravings and aversions of certain foods. 3.4% experienced cravings alone and 2.0% aversion alone. Food cravings were reported in 73.55, out of these 34.3% craved one food while 39.2% craved more than one food. Intensity of craving was reported to be highest (43.6%) in the first trimester than in the second (21.6%) and third trimester (5.4%).

Only a small proportion (2.9%) of women reported to maintain craving throughout pregnancy period, although with less intensity. Food aversion was reported in 70.1%; out of these 30.9% disliked one food while 39.2% disliked more than one food. The most widely craved foods are meat, mangoes, yoghurt, organs meat, plantain and soft drinks. Fruits were craved by largest proportion of women (34.8%) followed by vegetable (23.2%). The most commonly avoided food were rice (36.4%) meat (36.4%) and fish (30.8%) meat and fish were disliked by largest proportion of women (67.0%) followed by grains and grain products (47.7%).the majority of the women (58.3%) did not have reason for their food aversion. However 10.3% insisted that aversion were caused by changes in the taste and/or smell of the food during pregnancy 11.8% believed that aversions of certain foods help to overcome the symptoms of nausea and vomiting, 3.9% believed that aversions were caused by “a dislike” of the food by the fetus. Pica was reported by 63.7% of the women consumption of soil has largest proportion of 60.0% followed by Ice (16.1%).

A study was conducted by Phom, Tippawan, Virasakai, Praneed, Vosasit & Melta (2010) on

Inadequate nutrients intake a major cause of poor pregnancy outcome in the Deep South of

Thailand. A cross sectional survey was used for the study and Narathiwat province was purposely selected to be the study setting. A total of 380 pregnant women were involved in 50 the study using simple random sampling. A self administered structured questionnaire was used to collect data. The data were analyzed using descriptive and inferential statistics. The result of the study shows that the prevalence of Carbohydrate (86.8%), Protein (59.2%), Fat

(78.8%), Calorie (83.5%) Calcum (29.5%) Phosphorus (45.2%), Iron (85.0%), Thamime

(3.8%), Riboflavin (43.2%) Retinol (0.8%), Niacin (0.0%), Folic acid (0.0%), and Iodine

(0.8%) deficiency respectively. Maternal age, educational level, gestational age were significantly associated with inadequacy of carbohydrate, protein, phosphorus, iron,

Thiamine and niacin intake.

A study was done by Almurshed, Bani, Alkanbal & Al-Amri (2007) on maternal dietary intake and effect of poor nutrition in pregnancy in Rigyadh, Saudi Arabia. A descriptive study design was used for the study. 114 pregnant Saudi women were selected by systematic random sampling from the antenatal clinic at Prince Salman Hospital in Riyadh Saudi Arabia.

Nutritional status was assessed in a personal interview, weighing, mid upper arm circumference and triceps skinfold thickness measurement were also used. Pregnancy outcome date, birth weight and head circumference were obtained during physical examination of the newborn infant by the midwife within 2 l hours of delivery. Infants who were less than 2500 grams at birth were considered as infants with low birth weight.

Questionnaire covering 24 hours diet recall was used. Dietary habits including food craving and aversion were recorded. Coulter counter machine was used for haemotological analysis.

The result of the study shows that 56% of the women and 32.5% of their husband had a low level of education. The majority of women (89.5%) were housewives and 10.5% of them had jobs outside the home. Pregnant women with specific cravings for certain foods, pica and aversion was 28.1%, 13.2% and 47.4% respectively. Differences in food craving and aversion were possibly in response to beliefs about what should be consumed. The result of the study on maternal anthropometric measurements were not significantly correlated with pregnancy 51 outcome and 19% of the mothers were anaemic which emphasize the importance of nutritional profile of pregnant women.

Ademuyiwa and Sanni (2013) studied consumption pattern and dietary practices of pregnant women in Odeda local government area of Ogun state. Descriptive study design was used for the study and 50 pregnant women were selected using purposive sampling technique from 3 health centers. Structured questionnaire was used to elicit information on socio-economic status, consumption pattern and dietary practice. The data was analysed using descriptive and inferential statistics. The result of the study indicated that about 58% of pregnant women were below the age of 30 while 42% were aged 28-40 years. Only 16% had tertiary institution education while (38%) had secondary education. Food they crave mostly is rice

(52%), followed by Pap (38%). For protein intake (36%) consumed bean cake while (66%) crave for moimoi, orange (48%) and Green vegetable (40%). On food with animal origin higher percent of the respondents consumed fish (76%) and meat (58%) their reason for choosing the food is because they are both good sources of protein and some other nutrients required for healthy pregnancy. The study also reveals that most of the respondent do not take snacks after breakfast (70%), Lunch (82%) and Dinner (94%). The study shows that there is influence of low level of education on food craving and aversion in pregnancy. Some women avoid fruits and vegetable because of lack of information on the nutritional benefit of such commodities.

Ejei-Okeke and Analuba (2014) conducted a study on prevalence of food craving and aversion during pregnancy in women in Asaba, Delta state. 50 pregnant women accessing antenatal clinic in two government hospitals Federal Medical Centre and General Hospital

Okwe in Asaba metropolis were used. Descriptive survey was used for the study. Simple random sampling technique was used for selecting the subjects. Questionnaire was used for

52 data collection which were the socio-demographic characteristics of the respondents, food consumed, food craved or aversed, observed reasons for such behaviour, experience of nausea and vomiting, causes of nausea and vomiting and effects of craving and aversion.

Data was analysed using descriptive statistics. The result of the study show that the prevalence of food craving and aversion in Asaba metropolis was relatively high since all the women studied experienced it in one time or the other (82%) experience it while (18%) do not. It also reveal that first class protein foods such as fish (100%), beef (80%), poultry (80%) and eggs (70%), fruits and leaf vegetable (100% each) were highly craved for by pregnant women. Food aversed are fried foods (60%) highly spiced foods (8%) and fatty foods (32%).

On how the pregnant women manage craving and aversion, they consumed the food they found that they like because they felt that it was good for their health (60%), it reduces nausea and vomiting (20%), it was good for growth and development of the baby (20%). 90% believe that food they averted were those that they felt caused them nausea and vomiting.

Majority (80%) of the pregnant women believe that poor food craving and aversion are implicated in maternal/fetal health and can lead to negative pregnancy outcomes.

Another study conducted by Sholeye, Badejo & Jemirusi (2014) titled “the food preference of pregnant women in Ogun East Senatorial Zone, Ogun State Nigeria”. A cross sectional comparative study of the dietary intake of 720 pregnant women accessing antenatal care at selected rural and urban primary health centers in Ogun State was carried out using multi- stage sampling technique. Data was collected using semi-structured, interview administered questionnaire and 24 hours dietary recall forms. Data was analyzed using inferential statistics.

The result of the main intake of most nutrients was significantly higher (P < 0.005) among the rural women than their urban counterparts, except for vitamin A, zinc and iron. There was no significant difference (P > 0.05) in the types of vegetables consumed by rural and urban respondents. The types of snacks consumed were significantly different (p=0.032) but there 53 was no difference (p = 0.652) in frequency of snack consumption between both groups. The rural women had higher nutrient consumption compared to their urban counterparts.

Continuous nutrition education will go a long way in ensuring adequate nutrient intake among pregnant women.

A study was conducted by Mckerracher, Collard & Henrich (2014) titled ‘food aversion and cravings during pregnancy’ on Yasawa Island, Fiji. Descriptive study was used and 70 pregnant women were selected using random sampling in three villages used for the study.

Focus groups were held to collect qualitative data from the pregnant women. The data were analysed using descriptive and inferential statistics. The result of the study shows 50 women

(71%) reported developing at least one aversion during the period of study and 20 women

(29%) reported having experience no aversion. Fish (70%) was the most commonly averse food followed by Cassava (20%), all 70 women reported experiencing at least one food craving during pregnancy. Banana/Plantain (59%) was followed by other fruits (mango)

(36%), vegetable (17%).

Hackley (2014) studied parental weight gain: the relationship between food craving and weight gain. Retrospective chart review study was carried out to describe the frequency of cravings, association between craving and weight gain and to determine what factors were predictive of reporting more craving in pregnancy. A total of 1,259 charts were reviewed of women receiving care in an urban community health centre between 2006 and 2012. Out of

812 eligible women, 620 were excluded due to incomplete data, the sample study is 192 women. Regression analysis is used to analyze the data. The result of the study shows that craving were reported by 75.3% of women in early pregnancy and 81.4% in late pregnancy.

No differences in parental weight gain were seen between women with and without cravings.

The result of multiple regression analysis indicated the two predictors age and stress in late 54 pregnancy accounted for 8.7% of variance in the numbers of cravings reported in pregnancy

(R2 = 0.70, F (2, 108) = 5.14, p = .007) Younger age was associated with reporting a greater number of craving, B = .205, t (110) = -2.222 p = .028, as was higher stress in late pregnancy

B = .201, t (110) = 2.184, p = .031. The finding suggests that cravings are not related to prenatal weight gain.

A study was conducted by Handisco (2014) on “prevalence of food aversion, cravings, pica during pregnancy and their association with nutritional status of pregnant women in dale

Woreda, Sidama Zone, SNNPRS, Ethiopia,to know prevalence of these practices and their association with nutritional status of pregnant women, community based cross-sectional study was conducted among 605 pregnant women in Dale Woredo. Two stage clusters sampling techniques was used to select representative sample. Population proportion to size

(PPS) used to select six Kebeles from 36 kebeles than in selection of individual a simple random sampling method was used. Structured questionnaire was used to gather data, MUAC measuring tape and TSFT measuring. Holtain Caliper were used to collect anthropomeric measurement of pregnant women in the study. Data was analyzed using descriptive and inferential statistics. The result of the study shows that 49.9% of their husband have no formal education and are mainly farmers, most of the pregnant women (90.4%) were housewives 6% of the pregnant women averse a certain food 43.5% crave for a food or more and 30.4% have pica. The food mostly craved were meat (23.6%), egg (9.8%) vegetable

(2.8%) cereal products (2.5%), legumes (0.7%), Fruits (2.3%). From this report more than one third of the participants (38.9%) crave food due to flavor of the food and 4.6% of participants craved due to attractive colour of the food. One third of the study participants crave non-nutritious substance called pica. The most avoided food by the study participants were enset product (21.5%) cereal product (9.6%) roots (8.6%) vegetable like cabbage, carrot

(7.3%) fruits like mango and avocado (6.6%) egg (3.8%) meat (1.3%) fish (0.8%) milk 55 products (.9%). In this study 26.9% of the study participants reported that they avoided food due to smell of food. 9.6% of pregnant women avoided food due to heart burn and 31.4% avoided food due to personal dislike during pregnancy. The anthropometric measurement of

MUAC revealed that 15.2% of the respondents were undernourished (MUAC < 21cm). The reason for under nutrition was suggested to be the poor educational status of husbands and mothers, pica practicing behaviour and 50.5% of the study participants crave for cereal based food more than once a day which is known to contain significant amount of phytate that reduce the bioavailability of zinc, iron and calcium.

Koryo –Dabrah, Nti & Adanu (2012) studied Dietary practices (Food craving, food aversion and pica) and Nutrient intake of pregnant woman in Accra Ghana. The aim of the study was to assess potential changes in dietary habits during pregnancy, nutrient intake and effect of socio demographic factors on nutrient of pregnant women. The research design was cross sectional design. A systematic random sampling technique was used to recruit 279 pregnant women from antenatal clinic of the Korle –Bu Teaching hospital and Osu Maternity Home in

Accra. An interview guide was used as instrument for data collection on socio demographic data and food craving, aversion and pica in pregnancy and then 3 day recall form was used to measure food intake. Data were analyzed using descriptive statistics and inferential statistics.

The result of the study shows that greater number of the pregnant women (67.7%) crave for at least one food item during pregnancy. Food commonly crave for included chocolate

(17.9%), candies (10.8%) ice cream (10.3%) quite a large number of women (17.9%) crave cereal products of food belonging to starchy roots and plantain group. Reason expressed by the pregnant women for food craving were for satisfaction (45%) and to prevent nausea or salivation (4%). Almost half of the women who crave for certain food (51%) could not associate any reason to their strong desire for a particular food, nearly half (44.8%) of the pregnant women in the study avoided at least one kind of food. Food avoided included meat 56 and fish (10.8%) egg and milk (4.3%) green leafy vegetables and cereals (23.3%) and fruits

(2.2%). The reasons associated with food avoidance were taste/smell of food (27%), texture of food (26%). Feeling of nausea and vomiting (2.2%) 45% avoided certain foods with no associated reason. There are no significant difference between educational level except protein and mean intake of energy. There was a significant difference between income level and mean intake of protein (P<0.001) and zinc (p<0.02). There was significant difference between meal frequency and mean intake of protein (P<0.001 and zinc (P<0.001).

A study by Kroskey (2013) titled Dietary practices knowledge of outcome of poor nutrition in pregnant women in Arizona United States; a descriptive design was used to discover associations among certain variables. A convenience sampling was used to select 20 pregnant women that attend antenatal clinic at Air Force Base Hospital in Arizona. Data were collected using questionnaire, MUAC and TSFT (Triceps Skinfold Thickness). Data were analyzed using descriptive statistics and inferential statistics. The result of the study shows that 25% of the subject listed all the food groups correctly but gave two incorrect response in regards to the required servings per day. 10% (2) of the subject listed all the food groups correctly and also the required servings per day. 50% (10) of the subject were not aware of the basic food group 15% listed few food groups correctly and few required servings per day.

On MUAC only 30% (6) of the subjects had a muscle circumference greater than the 50th percentage. The other 70% (14) had an upper arm muscle circumference below that level.

These women were slightly or severely malnourished on awareness of the implication of poor nutrition 10% (2) were aware that poor nutrition can affect the fetus and mother negative

50% (10) were aware that the pregnant women only can be affected negatively 40% (8) were not aware that poor nutrition can affect both the mother and fetus.

A study was conducted by Hook (2014) titled “Dietary cravings and aversions during pregnancy. The research design used for the study is descriptive survey and 2 hospitals were selected purposively in New York USA. 250 women who delivered a live born infant without any abnormality were selected using simple random sampling. Structured questionnaire was the instrument used for data collection and data was analyzed using descriptive statistics. The result of the study shows that 49% of the women have aversion for beverage soda 55 Coffee,

44 women alcoholic drinks. On their reason for the aversion 25 mothers cited nausea, 4 cites smell and nausea. On food crave most 80% of the women crave milk, 3% crave tea, 3% crave soda. Their reason for craving 29.2% cited concern for personal health/infant, 15.9% concern for infant health, 12.6% said doctor’s advice. On substitution of averse and crave food women (15.6%) substitute when the averse nutritious diet, (50.6%) do not know how to manage food aversion. On food craving 19.4% substitute with nutritious diet when they crave for unhealthy food. 56.9% do not know how to manage food craving. On implication of food craving and aversion. 39.3% eat nutritious food because of concern for personal health/infant,

11% concern for the infant 14% taking doctors advise to eat nutritious diet 28.2% not aware of any implication of food craving and aversion.

Another study was conducted by Demissie, Muroki & Makau (2012) on food taboos among pregnant women in Haduya zone, Ethiopia. A cross sectional study assessing the prevalence of food taboo during pregnancy, the type of food averse by pregnant women due to food taboo and association of some of the socio economic parameters to food taboo was carried out. 295 healthy pregnant women who attended antenatal clinic were selected using simple random sampling. Questionnaire was used to collect data. The data collected was analyzed using descriptive statistics and inferential statistics. The result of the study reveal that 27% avoided at least one type of food due to food taboo, the type of food averse include milk

(16%) fatty meat (11%). The reason for avoiding food include fear of difficult delivery (51%)

58 discoloration of the fetus (12%) fear of abortion (9.7%). Among socio economic variable studied education and income were found to influence food taboo. Having significant difference of (P.<0.05).

Summary of Literature and Critical Analysis of Empirical Studies Reviewed

The reviewed literatures in this study were focused on concept of nutrition in pregnancy, food craving and aversion among pregnant women. It was conceptualized that there are daily calorie requirements for a pregnant mother which has to be attained in order to have a healthy mother and baby and that food craving and aversion can influence the pregnant mother positively or negatively depending on the food she craves or averses whether nutritious or not.

Eric et al (2013) states that there are many reasons why pregnant women crave or averse certain food which include physiological, hormonal, psychological, culture/belief. The type of food most craved by pregnant women especially first true pregnant women depend mostly on the trimester, in the first and second trimester pregnant women craves for sweet and savory food and averse bitter food and it was shaped this way so that she would disgust strong tasting plants or spoiled foods which are more likely to contain a toxin that could harm the baby. Food mostly craved are fruits and also unusual craving of non food substances like clay, soil, charcoal and cigarette ashes, ice cream, yoghurt milk, beverages, garlic, egg. How to deal with food craving and aversion was also looked into.

The implication of food craving and aversion and effect of geographical status of food craving and food aversion in pregnant women were further discussed. The measures taken by first time pregnant mothers on how to substitute/manage food craving and aversion in order to meet up with required nutrients in pregnancy was also discussed.

Literature in this study further discussed theoretical framework that is applicable to this study which is Health Belief Model which fits the challenges of changing habitual unhealthy behavior and dealt with craving of unhealthy food and averse healthy food.

The reviewed literature also discussed studies on food craving and aversion among the first time pregnant mothers. The results on the types of food craving and aversion by pregnant women supported the view that most pregnant women averse and crave for at least one food.

On the reasons for food craving and aversion some reported that nausea and vomiting

(physiological factor) was their reason for aversion or craving for certain food.

On studies on awareness of implication of choice of food in first time pregnant women, some reported that there is lack of nutritional knowledge and satisfactory dietary practice. On studies on geographical status influence on food craving and aversion, some reported that first time pregnant women crave on food easily available in the locality (fast foods). On whether educational level affect food craving and aversion, some reported that educational level of the pregnant women and husband enhance craving for nutritious food. Only one study found no significant association between educational level and food craving and aversion.

CHAPTER THREE

RESEARCH METHOD

This chapter will discuss the research design; the area of study; population of study; sample and sampling procedure; instrument for data collection; validity and reliability of instrument; ethical consideration; procedure for data collection; and method of data analysis.

Research Design

The research design for this study was cross sectional descriptive design. Shettleworth (2008) defines descriptive research design as a scientific method which involves observing and describing the behaviour of a subject without influencing it in any way. Cross sectional design is considered appropriate for the study because it allows for collection of data from a group of people at the same time for the purpose of describing a phenomenon under study.

Ogunbjuyigbe, Ojofeitimi, Sanusi, Akinbo, Liasu & Owolabi (2012) successfully used descriptive/cross sectional design to assess food aversion during pregnancy and the consequences this may have for the pregnant women in Osun State. Therefore, this design is considered suitable for this study on food craving and aversion among first time pregnant women in selected health facilities in Enugu metropolis.

The Area of Study

This study was carried out in selected urban and rural health facilities in Enugu South Local

Government Area of Enugu metropolis, Nigeria. Enugu South is one of the seventeen local government areas in Enugu metropolis. It’s headquarter is in Uwani and it has an area of

67km2 and a population of 198,723 (NPC 2006). The residential areas in the Enugu South urban include Achara Layout, Awkunanaw, Idaw River, Phase I and II, Garikki, Uwani and

Maryland. The rural part of Enugu South Local Government Area include Akwuke, Ugwuaji,

Amaechi, Obeagu, Amaechi Uno and Amaechi Ugwuaji. It is bounded in the North by Enugu

North Local Government in the West by Nkanu East Local Government and in the South by

Nkanu West Local Government Area. There is road network that connects or links to each of the areas that make up Enugu South Local Government. Enugu South urban is an educational, commercial, industrial and administrative base of the local government. The biggest market within the urban is Kenyetta market Uwani. As the administrative part of the state, a reasonable percentage of the inhabitants are civil servants. They work in various government establishment and offices. The rural part of the local government consists of five communities. Traditionally, they are subsistence farmers, although in recent years the people seem to be abandoning their interest in farming for white collar jobs due to the fact that their various communities are closer to Enugu urban. The communities have traditional rulers that see to the welfare of their various communities. There are 10 public health care facilities in the local government, four in the urban area and six from the rural area. There are also 67 registered private health care facilities in Enugu South Local Government, 45 of them are offering antenatal services. (Ministry of Health Enugu State Statistics).

Population of Study

The target population were first time pregnant women receiving antenatal care in selected public and private healthcare facilitates in Enugu South Local Government Area which is

2000 pregnant women (Based on record provided by the selected health facilities antenatal clinic register from May to October 2015 statistics).

Sample

The sample size of the study is 366 first time pregnant women receiving ANC in healthcare facilities in Enugu South LGA. This was determined using the sample determination formular by Taro Yamane. The formular is given as follows:

Where

n = sample size

N = the finite population size

e = Level of Significance (or limit of tolerable error)

I = unity (a constant)

(see appendix 1for details)

Inclusion Criteria

• All first time pregnant women attending antenatal clinic in selected public or private

healthcare facilities in Enugu South urban and rural areas.

• Absence of chronic disease such as diabetes, hypotension and other pregnancy

complications.

• First time pregnant women resident in the urban or rural part of Enugu South Local

Government Area.

• Willingness to participate in the study

• Present at the time of data collection

Sampling Procedure

A multi stage sampling technique was utilized. Enugu South Local Government Area is purposively chosen for the study because it has both urban and rural area. Simple random sampling technique was used to select 2 public and 2 private hospital in urban part of Enugu

South and 2 public and 2 private hospitals in rural part out of 10 public and 45 private hospitals in Enugu South Local Government Area. Because the population of first time pregnant women in each selected health facilities is known, a proportional stratified sampling method was used to select a representative sample size from each of the randomly selected hospitals using the following formular

(see table 1 for more details)

The respondents that met the inclusion criteria were reached for data collection using convenience sampling technique. No participant was permitted to respond twice.

Table 1: Distribution of Sample Size in each selected health facility

S/N Name of Health Facility Target Population Sample Size 1 Uwani Cottage Hospital 450 82 2 Ikirike Health Centre 30 5 3 Eastern Nigeria Medical Centre 140 26 4 Balm of Gilead 750 137 5 Amaechi Cottage Hospital 85 16 6 Obeagu Amachi Health Centre 70 13 7 St. Getrude Hospital & Maternity 350 64 8 St. Merkin Hospital & Maternity 125 23 2000 366

Instrument for Data Collection

Instrument for data collection was questionnaire developed by the researcher and questions were generated based on the objective of the study. It consists of two parts, Section A and B.

Section A obtained information on socio-demographic and reproductive characteristics of the respondents and it is made up of 11 items both in open and closed ended format. Section B is made up of 13 items in closed ended format and elicited information on food craving and aversion in first time pregnant women. The researcher’s developed questionnaire consists of

24 questions. Question 1-10 elicited information on the demographic characteristics of the respondents and question 11 dealt on reproductive characteristic of the respondents .Question

12-19 captured information on the type of food crave for or averse to by first time pregnant women. Question 20 and 21 obtained information on the reasons for the craving and aversion. 64

Question 22 and 23 tapped information on their awareness of implication of food craving and aversion while question 24 elicited information on measures to manage/substitute food craving and aversion. Responses to questions in sections A and B were used to determine the relationship between socio-demographic characteristics of the pregnant women and food craving and aversion

Validity of Instrument

The questionnaire was presented to the researcher’s supervisor and two experts in maternal and child health and a statistician to assess the face and content validity of the items. They were given a draft copy of the questionnaire, purpose of study and the research questions to critically assess for relevance of content, clarity of statement and accuracy of the instrument.

Their suggestions and corrections were used to make adjustment in the questionnaire items.

Final corrected instrument was signed by the supervisor.

Reliability of the Instrument

Reliability of the research instrument was determined using test-retest reliability. A pilot testing of the instrument was conducted using 37 pregnant women that met the inclusion criteria but not part of the study area. The instrument was administered twice at 2 weeks interval. The scores from the administrations were correlated using the Cronbach’s Alpha method. A correlation co-efficient of 0.87 was obtained which showed that the instrument is reliable.

Ethical Consideration

The letter of identification and research proposal were used to seek for ethical approval from ethical committee of UNTH Ituku Ozalla, Enugu and the clearance was obtained. Permission was sought from the heads of selected health facilities used for the study, and informed oral consent was obtained from each of the respondents. Participants were assured of confidentiality of any information given. 65

Procedure for Data Collection

With an introductory letter from the Head of Department of Nursing Sciences University of

Nigeria, Enugu Campus (UNEC) and the ethical approval, permission to carry out the study in the local government area was obtained from the Head of Health Department Enugu South

Local Government Area. Permission was also be obtained from the proprietors of the public and private antenatal care providers respectively before administering the questionnaire. Four research assistants were involved in data collection. They were instructed on the purpose and objectives of the study, content of the research instrument, how to administer the instrument and how to collect data from the respondents. They were also instructed on the purpose and key words in the research instruments to enable them collect data from participants who are not literate. The researcher and the assistance visited the head of each facility for self introduction before the collection of data. Upon accepting to participate in the research, the questionnaire was used to obtain information from literate pregnant women who met the inclusion criteria while the questionnaire was interpreted to the illiterate first time pregnant women. Data collection was done on antenatal days of each selected health facilities before the arrival of the doctor to avoid much distractions and questionnaire collected immediately from the respondents. Data collection lasted for two weeks and return rate was 98%.

Method of Data Analysis

Data collected was coded, entered and analyzed using IBM statistical package for social science (SPSS) version 23. Descriptive statistics which includes frequency, percentage, means and standard deviation were used to analyze and answer the research questions.

Hypotheses were tested using Chi-square and level of significance was set at P less than

0.05. Results were presented in Tables and charts.

CHAPTER FOUR

PRESENTATION OF RESULTS

The data collected for this study were statistically analyzed and presented in this chapter.

Tables and pie chart were used in the presentation .The Tables and figures contain information derived from the research objectives.

Table 2: Demography o f the respondents n=357 Item/Question Frequency Percent Age group, Mean = 27.07± 4.05 <=25 134 37.5 26 – 30 164 45.9 31 – 35 48 13.4 36 – 40 8 2.2 41 – 45 3 0.8 Marital status Married 349 97.8 Single 2 0.6 Widow 2 0.6 Separated 2 0.6 Divorced 2 0.6 Ethnic group Igbo 338 94.7 Yoruba 15 4.2 Hausa 4 1.1 Educational level No formal education 3 0.8 Primary 27 7.6 Secondary 165 46.2 Tertiary 162 45.4 Husband’s educational level No formal education 11 3.1 Primary 49 13.7 Secondary 142 39.8 Tertiary 155 43.4 Occupation Unemployed 63 17.6 Civil servant/public servant 100 28.0 Student 59 16.5 Self employed 110 30.8 Employed in private setting 25 7.0 Husband’s occupation Unemployed 6 1.7 Civil servant/public servant 110 30.8 Student 1 0.3 Self employed 201 56.3 Employed in private setting 39 10.9 Religion Christian 349 97.8 Muslim 8 2.2 Income per month Not working 119 33.3 < 10000 17 4.8 10000-20000 42 11.8 21000-30000 40 11.2 31000 – 40000 25 7.0 41000 – 50000 27 7.6 >50000 87 24.4 Residential area Urban 241 68.0 Rural 116 32.0 Pregnancy stage Ist trimester 44 12.3 2nd trimester 180 50.4 3rd trimester 133 37.3

Out of 357 first time pregnant women that responded in the study,134 (37.5%) were <=25 years of age,164 (45.9%) were between 26-30 years ,48(13.4%) were between 31-35,8(2.2%) were between 36-40 and 3(0.8%) were between 41-45.The mean age(27years) indicate that the respondents were mostly young women. Nearly all the pregnant women [349 (97.8%)] were married. 2(0.6%) were single, 2 (0.6%) were widow, 2 (0.6%) were separated and 2

(0.6%) were divorced. The majority [338 (94.7%)] were Igbo, 15 (4.2) were Yoruba and 4

(1.1%) were Hausa. 3 (0.8%) have no formal education, 27 (7.6%) had primary, 165 (46.2%) had secondary and 162 (45.4%) had tertiary. education 11 (3.1%) of the husbands have no formal education, 49 (13.7%) had primary, 142 (39.8%) had secondary and 155 (43.4%) had tertiary.education 63 (17.6%) respondents were unemployed, 100 (28.0%) were civil servants/public servants, 59 (16.5%) were students and 110 (30.8%) were employed in private setting. 6 (1.7%) of the husbands were unemployed, 110 (30.8%) were civil servants/public servant, 1 (0.3%) student, 201 (56.3%) self employed, and 39 (10.9%) employed in private setting. The majority [349 (97.8%)] of the respondents were Christians and 8 (2.2) Muslims. Out of 357 respondents, 122 (34.2%) are not working, 17 (4.8%} earn less than N10, 000. 42(8.2%) earn N10,000 to N 20,000. 40 (11.2%) earn N21,000 to N

30.000.25 (7.0%) earn N 31.000 to N 40.000. 27(7.6%) earn N 41.000 to N 50,000and

87(24.4%) earn more than N 50,000.

241(68.0%) of the respondents indicated residing in the urban part of the study area. While

116 (32,0%) of the respondents indicated residing in the rural part of the study area. As regards to the gestational age of the respondents, majority [180(50.4%)] were in second trimester, 133(37.3%) were in their third trimester while 44 (12.3%) were in their first trimester.

Research question one: What are the types of food craved for or aversed to by first time pregnant women?

(Questions-12 -19 were used to answer the above questions)

Question 12; do you crave for any food?

No Food Craving At least one food is being craved

More than one food is being craved

Fig 1: Respondents who crave for food

Fig 1 shows the frequency of Food Craving among the respondents, 90(25.2%) had no craving for any food, 109 (30.5) averse at least one food while, 158(44.3) crave more than one food.

Table 3: Stage of pregnancy at which the first time pregnant women experience craving

S/N Item Stage of Frequency Percentage pregnancy

13, At which stage of pregnancy do 1st trimester 251 94.0 you experience the food craving?

2nd trimester 16 6.0 3rd trimester 0 0

Total 267 100

Table 3 shows the stages of pregnancy at which food craving is experienced. 251(94.0%) experience it at 1st trimester, 16(6.0%) experienced it at 2nd trimester while none experienced it at 3rd trimester.

Table 4: Types of food craved by first time pregnant women S/N Items Response Frequency Percent 14, The specific Cassava based food 48 18.0 food craved for Cereal based food 36 13.5 Meat and meat product 35 13.1 Vegetable 64 24.0 Fruits 152 56.9 Fish and fish products 43 16.1 Beverages 43 16.1 Yam based food 28 10.5 Plantain 66 24.7 Beans based food 20 7.5 Snacks 109 40.8 Soft drinks 128 47.9 Milk and milk products 51 19.1 Noodles 59 22.1

15, Craving for non food No non food item is craved 273 76.5 items At least one non food item Is being craved for 79 22.1 More than one food item is being craved for 5 1.4

16, non food item craved for Soil 4 4,8 Soft white stone 67 79.8 Charcoal 6 7.1 Ash 7 8.3 71

This table shows the types of food crave for or aversed to by first time pregnant women. The most commonly craved food were fruits 152 (56.9%) followed by soft drinks 128 (47.9%) then snacks 109 (40.8%) others are plantain 66 (24.7%), vegetable 66 (24.0%) nodules 59

(22.1%), milk and milk products 51 (19.1%), cassava based food 48 (18.0%), fish and fish products 43 (16.1%), beverages 43 (16.1%), cereal based food 36 (13.5), meat and meat product 35 (13.1%) and beans based food 20 (7.5%).

The result also showed that among the 357 respondents, majority [273 (76.5%)] have no craving for non food items, [79(22.1%)] crave for one food item and few [5(1.4%)] crave for more than one food item. The most craved food item were soft white stone 67(79.8%), ash

7(8.3%), charcoal 6(7.1%) and soil 4 (4.8%).

Question 17: Do you have aversion for any food item?

No Food Item Aversion

At least one food is being aversed

More than one food item is aversed

Fig 2: Respondents who have aversion for food

Fig. 2 shows the frequency of food aversion among first time pregnant women, the proportion of women who reported no food aversion experienced were 94(26%), 195(55%) averse at least one food item and 64(19%) averse more than one food item.

Table 5: Stage of pregnancy at which the first time pregnant women experience aversion

n = 259 S/N Item Stage of Frequency Percentage pregnancy

18, Stages of pregnancy food 1st trimester 249 96.1 aversion is experience 2nd trimester 9 3.5 3rd trimester 1 0.4

Total 259 100

This table shows that majority of the respondents [249 (96.1%)] experience aversion in 1st trimester than the 2nd [9 (3.5%)] and 3rd trimester [1 (0.4%)]. Question 19

Table 6: Types of food aversed by first time pregnant women

n = 259 S/N Item Responses Frequency Percentage

19, The specific food Cassava based food 54 20.5 aversed to Cereal based food 34 12.9 Meat and meat product 37 14.1 Beans based food 104 39.5 Milk and milk product 32 12.2 Vegetables 18 6.8 Fruits 14 5.3 Fish and fish products 32 12.2 Beverages 39 14.8 Yam based food 19 7.2 Plantain 4 1.5 Snacks 10 3.8 Soft drinks 16 6.1 Spices eg. garlic 42 16.0

The most commonly aversed foods were beans based food [104 (39.5%)] followed by cassava based food [54 (20.5%)] and spices eg. garlic [42 (16.0%)] others were beverages [39

(14.8%)], meat and meat products [37(14.1%)] Cereal based food [34(12.9%)] ,milk and milk products/fish and fish product 32(12.2%) respectively, vegetable 18(6.8%), soft drinks[16(6.1%), fruits 14(1.3%) , snacks 10(3.8%) and plantain 4(1,5%). .

Research question 2: What are the first time pregnant women reason for their specific food craving and aversion? (Question 20 and 21 were used to answer the above research question).

Table 7: Reasons for their specific food craving and aversion n = 259 S/N Item Response Frequency Percentage

20, Reasons for food For good health 97 36.3 craving. Colour of food 6 2.2 Culture/believe 11 4.1 Availability 53 19.9 Food flavor 26 9.7 Easy to prepare 36 13.5 It reduces nausea and 48 18.0 vomiting For satisfaction 106 39.7 No reason 27 10.1 21, Reasons for craving Smell of pica substance 13 15.5 non food items Prevent nausea and 48 57.1 vomiting Get satisfaction 15 17.9 No reason 8 9.5

22, Reasons for food Can affect the size of 69 26.2 aversion the baby Causes stomach pains 30 11.4 Taboo/believe 32 12.2 Nausea and vomiting 133 50.6 Causes heart burn 99 37.6 No reason 27 10.3 74

The majority of the respondents 106(39.7%) reported that their reason for food craving is for feel of satisfaction. However 97(36.3%) of the respondent reported that it is for good health,

53 (1.9%) believed that craving is because of availability 48 (18.0%) believed that craving reduces nausea and vomiting, 36 (13.5%) reported that the food is easy to prepare 27 (10.1%) had no particular reason for their craving, 26 (9.7%) reported that the food flavor made them to have intense urge to consume the food, 11 (4.1%) stated that culture/belief influence their food craving and few respondents 6 (2.2%) reported that colour of food made them to crave for such food.

48 (57.1%) of the respondent reported that non-food substance prevent nausea and vomiting,

15 (17.9%) of the respondent believe that they get satisfaction from it. Other reasons include smell of pica substances 13 (15.5%) and no reason 8 (9.5%).

The majority of the pregnant women 133 (50.6%) believed that food aversion of certain foods help to overcome the symptoms of nausea and vomiting, 99 (37.6%) reported that averse food causes heart burn,69 (26.2%) believed that certain food were avoided because they can affect the size of the baby other reasons were Taboo/belief 32 (12.2%) and causes stomach pains 30

(11.4%).

Research question 3: How aware are the first time pregnant mothers of the implication of food craving and aversion in pregnancy? Question 23 and 24 were used to answer the above research question

Table 8: Awareness of the implication of food craving and aversion in pregnancy n = 357 S/N item Response Frequency Percent 23, Effect of food Craving and aversion on health of the mother Anaemia 103 28.9 Malnutrition 133 37.3 Obesity 71 19.9 Increase risk of Pregnancy induce Hypertension 20 5.6 Premature labour 24 6.7 Do not know 152 42.6 Effects on the fetus Birth defect 32 9.0 Low birth weight 155 43.4 Increase risk of diabetes 39 10.9 in childhood Increase risk of obesity 48 13.4 Possible lowering of 14 3.9 intelligent quotient Prematurity 68 19.0 Do not know 167 46.8 24, Source of information Nutritionist 22 6.2 Health workers 71 19.9 Mass media 20 5.6 Relatives/friends 95 26.6 No information 149 41.7

Data in table 8 shows that majority of the respondents 152 (42.6%) do not know of the effect of food craving and aversion on the mother133 (37.3%) stated that malnutrition is an implication of food craving and aversion others include 103 (28.9%) anaemia, 71 (19.9%) obesity and 24 (6.7%) premature labour

Concerning effect of food craving and aversion on the fetus, majority of the respondents 167

(46.8) do not know the effect of food carving and aversion on the fetus, 155 (43.4%) of the respondents stated that low birth weight is the effect of food carving and aversion on the fetus, followed by prematurity 68 (19.0%) increase risks of obesity 48 (13.4%), increase risk of diabetes in childhood 39 (10.9%) , birth defect 32 (9.0%) and possible lowering of intelligent quotient 14 (3.9%).

On sources of information on effect of food carving and aversion on fetus and the mother, majority of the respondents 149 (41.7%) have no information on effect of food carving and aversion on pregnant women, 95 (26.6%) of the respondent stated that they heard of the effects of food carving and aversion from the relatives/friends, 71 (19.9%) from the health worker 22 (6.2%) from the nutritionist and 20 (5.6%) received information from mass media.

Research question 4: What measures do first time pregnant women take to substitute for food craving and aversion in order to meet up with their required nutritional value

(needs)?

Questions 25 were used to answer the above research question.

Table 9: Measures first time pregnant women take to substitute for food craving and aversion in order to meet up with their required nutritional value (needs)

n = 259

Items Frequency Percent

• When aversing nutritious food, eat other 68 19.0 foods that contain the same nutrient • Avoid skipping meals which increases food 83 23.2 craving • Keep food diary to make sure that you are 41 11.5 eating an adequate diet • Active exercise to curb hunger 44 12.3

• Eating food that has longer digestion 24 6.7 process such as yam, cassava, potato • Does nothing to meet up with food 188 52.7 nutrients needed in pregnancy • When craving for soft drinks take fresh 45 12.6 juice such as orange juice • Make sure that you have stable emotional 54 15.1 status

• Inform the health personnel when craving 26 7.3 for non food item

Table 9 revealed that 188 (52.7%) of the respondents do nothing to meet up with food nutrients needed in pregnancy; the measures some first time pregnant women take include : avoid skipping meals which increases food craving[83 (23.2%), when aversing nutritious food, you eat other foods that contain the same nutrient 64(17.9%), You make sure that you have stable emotional status 54(15.3%), when craving for soft drinks you take fresh juice

78 such as orange juice 45(3.6%), active exercise to curb hunger 44(12.3%), keep food dairy to make sure you are eating adequate diet 41(11.5%) you inform the health personnel if you when you crave for non food items 26(7.3%) and eating food that has longer digestion process such as yam , cassava and potatoes 24(6.7%)

Hypothesis 1: There is no significant association between level of education and food craving and aversion in first time pregnant women.

Table 10: Association between level of education and food craving.

n = 357

Food craving

No food At least one More than one craving food is being food is being 2 P value experience craved for craved for n (%) n (%) n (%) No formal 2 (2.2) 0 (0.0) 1 (0.6) 9.724 0.137

Primary 2 (2.2) 11 (10.1) 14 (8.9)

Secondary 42 (46.7) 55 (50.5) 68 (43.0)

Tertiary 44 (48.9) 43 (39.4) 75 (47.5)

Since the P value (P = 0.137) of the chi square statistics is greater than 0.05 level of significance, the null hypothesis is hereby accepted. Therefore, there is no significant association between level of education and food craving.

Table 11: Association between level of education and food aversion.

n = 357

Food aversion

No food At least one More than one aversion food is being food is being 2 P value n (%) aversed aversed n (%) n (%) No formal 1 (1.1) 0 (0.0) 2 (2.9) 18.674 0.005

Primary 1 (1.1) 22 (11.3) 4 (5.9)

Secondary 41 (43.6) 96 (49.2) 28 (41.2)

Tertiary 51 (54.3) 77 (39.5) 34 (50.0)

Since the P value (P = 0.005) of the chi square statistic is less than 0.05 level of significance, the null hypothesis is hereby rejected and the alternative accepted. Therefore there is a significant association between level of education and food aversion. Hence first time pregnant women with higher level of education experience food aversion more.

Hypothesis 2: There is no significant association between residential location and food craving and aversion in first time pregnant women Table 12: Association between residential location and food craving n = 357

Food craving

No food At least one More than one craving food is being food is being 2 P value experience craved for craved for n (%) n (%) n (%) Urban 61 (69.3) 70 (63.6) 110 (60.2) 0.501 0.779

Rural 27 (30.7) 40 (36.4) 49 (30.8)

Since the P value (P = 0.779) of the chi square statistics is greater than 0.05 level of significance, the null hypothesis is hereby accepted. Therefore, there is no significant association between residential location and food craving.

Table 13: Association between residential location and food aversion n = 357

Food aversion

No food At least one More than one aversion food is being food is being 2 P value n (%) aversed aversed n (%) n (%) Urban 63 (68.5) 126 (64.6) 52 (74.3) 9.181 0.010

Rural 29 (31.5) 69 (35.4) 18 (25.7)

Since the P value (P = 0.010) of the chi square statistic is less than 0.05 level of significance, the null hypothesis is hereby rejected and the alternative accepted. Therefore, there is a significant association between residential location and food aversion. Hence first time pregnant women in the urban area experience food aversion more.

Hypothesis 3: There is no significant association between awareness of implication of food craving and aversion and food craving and aversion in first time pregnant women.

To test this hypothesis, the raw scores generated from questions 12,17 and 22 in the questionnaire were subjected to Pearson’s chi-square (x2) analysis. Those that do not know were coded” NO’ and those that know at least one implication of food craving and aversion were coded “YES”. The results of the analysis was presented on table 14 and 15.

Table 14: Relationship between awareness of implication of food craving and food craving in first time pregnant women n = 357

Food craving

No food At More than craving least one one food experience food is is being 2 P being craved for value n (%) craved for n (%) n (%)

Awareness of the Yes 51(53.1) 71 (61.7) 111 (67.3) 5.543 0.063 implication of food craving in pregnancy No 45 (46.9) 44 (38.3) 54 (32.7)

Since the P value (P = 0.063) of the chi square statistic is greater than 0.05 level of

significance, the null hypothesis is hereby accepted. Therefore, there is no significant

association between awareness of implication of food craving and food craving in pregnancy

Table15: Association between awareness of implication of food craving and aversion and food aversion in first time pregnant women. n = 357

Food aversion

No food At least More than aversion one food is one food is 2 P being being n (%) aversed aversed value n (%) n (%)

Awareness of Yes 60(60.0) 125 (62.2) 48 (64.0) 0.524 0.770 the implication of food aversion in pregnancy No 40 (40.0) 76 (37.8) 27 (36.0)

Since the significant value (P = 0.770) of the chi square statistic is greater than 0.05 level of significance, the null hypothesis is hereby accepted. Therefore, there is no significant association between awareness of implication of food aversion and food aversion in pregnancy

Summary of Major Findings

The major findings in this study include the following:

v Majority of the first time pregnant women crave for (74.8%) or averse to (74%) at

least one or more food item.

v Majority (76.5%) of the first time pregnant women do not crave for non food item.

The few who craved for non food items craved mostly for soft white stone (nzu).

v The majority of first time pregnant women experience food craving (94%) or

aversion (96.1%) at first trimester.

v The type of food crave for by first time pregnant women are fruits, soft drinks and

snacks

v The type of food mostly averse by first time pregnant women are beans based food,

cassava based food and spices e.g. garlic.

v The majority of first time pregnant women reason for food craving and aversion is for

satisfaction (39.7%), good health (36.3%) and availability of food items in their

locality (19.9%). Majority (57.1%) of the respondents reason for craving non food is

to prevent occurrence of nausea and vomiting.

v Majority (42.6%) of the respondent do not know most of the effect of food craving

and aversion on the health of mothers and fetus. The most known effect on the mother

was malnutrition and for the fetus was low birth weight.

v Majority (41.7%) of first time pregnant women have no information on food craving

and aversion, most of the respondents that have the information got it from

relatives/friends. 83 v Majority (52.7%) of the first time pregnant women do nothing to meet up with food

nutrients needed in pregnancy when they experience food craving or aversion. v There is no significant association between level of education and food craving

(P=0.137) while there is significant association between level of education and food

aversion (P=0.005). Hence first time pregnant women with higher of level education

experience food aversion more. v There is no significant association between residential location and food craving in

first time pregnant women (P=0.779) while there is significant association between

residential location and food aversion in first time pregnant women (P=0.010). Hence

first time pregnant women in the urban area experience food aversion more. v There is no significant association between awareness of implication of food craving

and aversion in pregnancy and food craving (P=0.063) and aversion (P=0.770) in first

time pregnant women.

CHAPTER FIVE

DISCUSSION OF MAJOR FINDINGS

This chapter discussed the major findings with regard to stated objectives and analyzed data based on the following subheadings; discussion of findings, implication of the study to

Nursing, limitation of the study, suggestion for further studies, summary of findings, conclusion and recommendation .

DISCUSSION: The major findings of the study are discussed based on the set objectives and hypotheses of the study.

Research Question 1: What are the type of food crave for or averse to by first time pregnant women?

The study revealed that majority of the first time pregnant women crave for and averse to at least one or more food items. The physiological and hormonal changes that is intense during first time pregnancy according to Dickson (2012) could contribute to high prevalence of food craving and aversion found in this study, for there is need to support the growth and development of the fetus which require extra amount of nearly all the essential nutrients. The high prevalence of food craving and aversion found in this study is comparable with other studies done both in developed and developing countries like Nigeria which ranges from 50-

80% (Olusanya & Folashade, 2012; Tsegaye et al, 2012; Ogunbjuyigbe et al, 2012;

Nyaruhucha, 2009; Ejei-Okeke & Analuba, 2014; Koryo et al, 2012; & Kroskey, 2013).

Craving for non food item is at the minimal as majority do not crave for any non food item.

This finding implied that it was only about one quarter of the respondent crave for non food item which is better because craving for non food item could counteract with the absorption of iron and also potential toxic for the baby and mother. Concerning the type of food first time pregnant women crave for or have aversion to, the result shows that that majority crave 85 fruits, soft drinks and snacks. These findings could be attributed to the addictive behavior of craving for fast food when single which still persists or increase during pregnancy. Secondly small family size (living alone or with the husband only) could increase craving for easily available food like fruits, snacks and drinks since the burden of cooking and shopping for large family is not there. This finding is in line with Nyaruhucha (2009) which reported that food mostly craved by largest proportion of pregnant women were fruits. This was also supported by Ejei-Okeke and Analuba (2014) who reported that fruits and vegetables were mostly craved by pregnant women. This finding however disagreed with the study by

Handisco (2014) who reported that pregnant women mostly craved food were meat and egg.

This finding also refuted Koryo et al (2012) and Hook (2014) findings that reported that pregnant women crave chocolate, candies and milk based product most. Their finding could be attributed to the kind of food items available in the area of study. The non food item mostly crave by first time pregnant women was soft white stone (nzu) 67(79.8%). The soft white stone (nzu) is popularly known in the study area and being consumed by both pregnant and non pregnant women in the locality, it is obvious that the belief that it prevents nausea made the first time pregnant women to crave for this non food item. This study is also contrary to the study by Nyaruhucha (2009) who reported that the type of non food craved by pregnant women is soil.

Result in this study revealed that food craving and aversion were mostly experienced during the first trimester. These findings, however, are likely to be associated with hormonal hyperactivity during the first trimester (Nyaruhucha, 2009) leading to increase salivation and nausea and vomiting, most pregnant women experience this during the morning hours and is called morning sickness . Morning sickness is the body ‘s reaction to the pregnancy hormone human chorionic gonadotrophin which is produced at higher level during the morning and

86 first trimester than at any other time during pregnancy. This finding is in accordance with those of Nyaruhucha (2009) and Michele et al (2014) which observed that food craving and aversion are experienced mostly during the first trimester.

Majority of the first time pregnant women averse / avoid beans based food followed by cassava based food and spicies e.g. garlic. This finding suggest that there could be inadequate intake or consumption of protein among the first time pregnant women in the study area and this will lead to loss of essential nutrients. There is need for health workers / nutritionist to provide appropriate nutrition counseling to guide the first time pregnant women. The aversion for garlic support the observation by Knox (2013) which stated that garlic is a trigger as taste and smell causes nausea and vomiting among some pregnant women. The finding is also comparable with the report by Koryro et al (2012) who observed that pregnant women mostly avoid protein which include meat and fish. Moreover Knox (2013) observed that protein is a common trigger. This finding is however, contrary to the study by Ejei Okeke and Analuba (2014) who reported that the mostly aversed food by pregnant women were fried and fatty food. This may be linked with their knowledge that much intake of fatty food may lead to obesity.

Research Question 2: What are the first time pregnant women reasons for their specific food cravings and aversion?

The study revealed that reason given by a great number of first time pregnant women for food craving was that they felt satisfied whenever they consume the craved food item. A closer look at the reason given for craving of food items indicated, revealed that they were not nutritionally correct as majority indicated fruit still they consumed it for satisfaction. This suggests that in spite of the high literacy rate (91.6%) among the respondents, they lacked correct and adequate nutritional knowledge as it concerns food craving and aversion. This

87 finding is in line with report by Koryo, Nti and Adamu (2012) who reported that reasons expressed by the pregnant women for food craving is for satisfaction. The respondents second main reason for food craving is good health which is in line with the study by Hook (2004) who stated that the reason for pregnant women craving is concerned for personal health/fetus.

The finding also revealed that the majority of the first time pregnant women indicated that ingestion of these substances relieves/prevent nausea and vomiting. This finding tally with the report by Nyaruhucha (2009) who pointed out that the reason for craving non food item is because of belief/culture and attitude. This is understandable since most of them craved for food during the first trimester which is the period when most pregnant women experience nausea and vomiting.

Concerning the reason for food aversion, the result shows that the majority of the first time pregnant women indicated that occurrence of nausea and vomiting made them to averse certain food items. The hormonal changes during pregnancy could be associated with nausea and vomiting which will lead to consuming food tolerated and aversing food items that trigger the nausea and vomiting and this may lead to inadequate intake of required nutrient in pregnancy and loss of essential vitamins, mineral and electrolyte. This study affirmed the finding by Ogunbjuyigbe et al (2012) who pointed out that the reason for food aversion on pregnant women were nausea and vomiting.Associating certain food items with nausea and vomiting may cause pregnant women to avoid such food items.

Research Question 3: How aware are the first time pregnant women of the implication of the food craving and aversion in pregnancy?

Majority of the first time pregnant women do not know the effect of food craving and aversion on the mother and fetus (see Table 8). These women were ignorant of the consequences of poor food craving and aversion such as anaemia in pregnancy, prematurity,

88 increase risk of obesity for the mother and effects on the fetus such as birth defect, increased risk of obesity and possible lowering of intelligent quotient. It was observed in the study that, the majority of first time pregnant women crave for fruits, soft drinks and snacks for satisfaction. This poses even more concern with the fact that the women involved in the intervention attend antenatal clinic, with high level of education revealed in the study and were thus presumably better informed than their counterparts who did not patronize orthodox health facilities.This finding is contrary from a study by Ejei-Okeke and Analuba (2014) which stated that pregnant women crave for first class protein such as fish and,Beef to aid in development and growth of the fetus and good health of the mother

Concerning the sources of information on the effect of food craving and aversion on fetus and mother, 41.9% of the first time pregnant women have no information on the effect of food craving and aversion and 26.6% of the respondent stated that they heard the information from friends/relatives. The reason for lack of information on effect of food craving and aversion could be assumed that nutritional education especially on food craving and aversion were not delivered to these women during the antenatal visit. On the source of information being from friends/relatives, the reason for this finding is obvious as first time pregnant women were often the most affected as several advices, opinions and recommendations pour in from friends, family and even complete strangers on what they have to eat and not eat during pregnancy which may be detrimental to their nutritional status. The finding in this study is in line with the report by Ademuyiwa and Sanni (2013) which stated that some pregnant women avoid nutritious food because of lack of information on nutritional benefit of such commodities. This finding also support the study by Olusanya and Ogundipe (2012) which revealed lack of adequate and nutritional knowledge among pregnant women. Hence, there is need to intensify nutritional education especially for first time pregnant women at the antenatal clinic as first time pregnant women being excited and eager for information

89 concerning their nutrition are vulnerable to wrong information. This finding is contrary from a study by Ejei-Okeke and Analuba (2014) which pointed out that majority of the pregnant women believe that poor food craving and aversion are implicated in maternal fetal health and can lead to negative pregnancy outcomes. The earlier finding on husband’s educational level on this study reveal that majority of the first time pregnant women husband (43.4%) had higher level of education and this finding did not influence the awareness of implication of food craving and aversion in pregnancy of the respondents. This finding also disagrees with

Handisco (2014) who reported that the majority (49.9%) of respondent husband have no formal education and it is a contributory factor to poor knowledge of nutrition in pregnancy.

There is need for the husbands of the first time pregnant women to be involved in nutritional education so that they will create positive impact on their nutritional need.

Research question 4: What measures do first time pregnant women take to substitute for food craving and aversion in order to meet up with their required nutritional value

(needs)

The result shows that more than half of the first time pregnant women do nothing to meet up with their required nutritional value (needs). This finding agrees with the report by Hook

(2014) which stated that majority of the pregnant women (50.6%) do not know how to manage food aversion and 56.9% do not know how to manage food craving. This finding is an indication that majority of first time pregnant women yield to their food craving and aversion without considering whether the foods have the required nutrient for the fetus and mother. This could be attributed to lack of knowledge of the consequences of food craving and aversion as this revealed lack of information on how to substitute in order to meet up with their required nutritional value most importantly the food groups. The knowledge of the classes of food will assist the pregnant women in substituting for food item that have the same nutritional status if they are aversing or craving certain food. This was pointed out by

Kroskey (2014) who observed that the pregnant women used for the study were not able to list food groups correctly. Another reason for poor management of food craving and aversion could be due to barrier to substitution; this can be related to earlier findings on income per month of first time pregnant women which revealed that majority 119(33,3%) were not working. The first time pregnant women may have perceived that they have to substitute for crave or averse food item but may not have the money to buy its equivalent. There is need for health workers/nutritionist to map out strategies to activate and promote awareness on food craving and aversion by distribution of flyers containing recipe to first time pregnant women for them to identify the cheaper and available food they will substitute to when they averse food in the food group.

Hypothesis 1

There is no significant relationship between level of education and food craving and aversion in first time pregnant women.

There is no statistically significant relationship between level of education and food craving

(P = 0.137). The result shows that both first time pregnant women with higher level of education and lower level of education craved for one food item or more. This may be attributed to physiological and hormonal changes that occurs in pregnancy that affects majority of pregnant women which is at increase in first time pregnant women, irrespective of their educational level.

There is a significant association between level of education and food aversion (P = 0.005).

This implied that the first time pregnant women with higher level of education experience food aversion more than the counterparts with lower level of education. This may be attributed to the belief that certain food especially proteins foods should be avoided during pregnancy. The finding is however surprising since education helps to give better

91 understanding on such issues as this and therefore the educated mothers are expected to have known more. However, since the experiences of pregnancy differ from one women to the other, it also mean that they simply aversed food items that affected them negatively in pregnancy. This finding is in line with the finding by Koroy, Nti and Adanu (2012) who reported significant difference between level of education and food aversion of protenous and staple foods).

Hypothesis 2

There is no significant association between residential location and food craving and aversion in first time pregnant women.

There is no significant association between residential location and food craving (P = 0.779).

This finding indicated that both pregnant women in rural and urban area of the study area crave for at least food item or more. This finding could be attributed to pregnancy hormone that affect majority of the pregnant women. Traditional belief could also have played a role, since urban and rural areas are presently inhabit by people that still uphold these beliefs.

There is significant association between residential location and food aversion in pregnancy (P = 0.010). This finding is in line with report by Ogunbjuyigbe et al (2012) who pointed out that more of the urban respondents than the rural respondents avoid at least one or more food item. This implied an increase in the frequency of food aversion among the urban resident compared to their rural counterpart. This could be attributed to first time pregnant women in urban area belief that certain food items have to be avoided during pregnancy particularly foods that triggers nausea and vomiting. The result of the finding in this study suggest that the principle behind the aversion are based on folklore rather than on scientific evidence. Food diversity is much higher in the urban area than the rural area and could contribute to food aversion being experience more in urban part of the study area. Pregnant women with few food options

(rural residents) are unlikely to avoid specific foods as commonly as pregnant women who have more choices. Hypothesis 3

There is no significant relationship between implication of food craving and aversion in pregnancy and food craving and aversion in first time pregnant women.

There is no significant relationship between awareness of implication of food craving and aversion in pregnancy and food craving and aversion in first time pregnant women. (see table

14 and 15) This implied that majority of the first time pregnant women that experience food craving and aversion were not aware of the implication of food craving and aversion in pregnancy. This finding is in line with the report by Ogunbjuyigbe et al (2012) who stated that some of the food avoided by the respondents are common source of essential nutrients and respondents were apparently ignorant of the consequencies of low birth weight to the immediate and future growth of their infants. This was obvious in the responses on the reasons for food craving where majority indicated for satisfaction. This showed that they are not aware that craving for food low in adequate diet can lead to a smaller placenta, which limits the transfer of nutrients to the fetus leading to poor fetal growth, anaemia, low birth weight, congenital malfunction, malnutrition among others. They were not aware that food aversion on nutritious foods plays a negative role in maternal nutrition because it reduces the mothers food option by causing decrease to her intake of healthy food. This development can be related to minor role played by the health workers on nutritional education as indicated on the earlier finding on the source of information on effect of food craving and aversion in pregnancy. The poor knowledge could be that first time pregnant women could not have heard or seen a woman whose nutritional disorder was attributed to poor food craving and aversion in pregnancy.

Implication of the Study

The findings of the study showed that first time pregnant women in the study area have high prevalence of food craving and aversion and were without adequate knowledge of the effect of food craving and aversion and measures to substitute for food craving and aversion in order to meet up with their required nutritional value. This has implication for health workers especially nurses and nutritionists. There is need for nurses/nutritionists to provide nutrition counseling for the first time pregnant women in both urban and rural part of the study area on the effect of food craving and aversion and measures to substitute for craving and aversion in order to meet up with the required nutritional value. Men should be involved in the nutrition education since male dominance is obtainable in certain culture. It also implied that some first time pregnant women are not working and the fact that majority of these women have high educational level, employment/empowerment becomes paramount on the side of the government. When the women have adequate information and are empowered financially, they will be able to substitute when experiencing food craving and aversion.

Limitations of the Study

Some of the responses given by the respondents may have been estimations or even exaggerations. The challenging terrain to access the rural communities examined. First time pregnant women were reluctant to fill the question and several visits were made.

Suggestions for the Further Studies

Ø A study could be done on the strategies for improving nutritional education on food

craving and aversion in antenatal clinics

Ø A study to determine socio economic factors affecting food craving and aversion in

first time pregnant women

Ø A further study could be done on the impact of food craving and aversion in

pregnancy using prospective cohort study design.

Summary of the Study

The purpose of this study was to investigate the food craving and aversion among first time pregnant women in Enugu South local Government Area in Enugu metropolis. The specific objective were to determine the type of food first time pregnant women crave for or have aversion to, identify the first time women’s reason for their specific food craving and aversion; determine the first time pregnant women’s awareness of the implication of food craving and aversion in pregnancy; identify measures taken by first time pregnant women to substitute for food craving and aversion in order to meet up with their nutritional values

(needs) and to determine significant association between demographic status of the first time pregnant women and food craving and aversion. Available literature related to the study were reviewed to authenticate the theoretical background of the study. A cross sectional descriptive design method was adopted for this study. A sample size of 366 respondents who met the inclusion criteria was drawn from the target population using Taro Yameni’s formula.

Simple random sampling was used to select health facilities for the study and proportional stratified sampling method was used to select a representative sample size from each of the randomly selected hospitals. Data was collected using researcher’s developed questionnaire with a reliability of 0.874. Data collected was coded, entered and analyzed using IBM statistical package for social science (SPSS) version 23. Descriptive statistic which include frequency, percentage, means and standard deviation were used to analyze and answer the research questions. Hypotheses were tested using Pearson chi-square inferential statistics.

The level of significance was set at P - value less than 0.05. Results were presented in tables and charts. The major findings of this study include;

Majority of the first time pregnant women indicated that they crave for and averse to at least one or more food item and that the type of food crave by first time pregnant women are fruits, soft drinks and snacks. The finding also revealed that majority of the first time pregnant women do not crave for non food. It was also observed that first time pregnant women experience food craving and aversion mostly in the first trimester. Majority of the first time pregnant women indicated that the reason for craving food item is for satisfaction, and personal health which ranked second; high percentage of the first time pregnant women indicated that to prevent nausea and vomiting they crave for soft white stone. Majority of the first time pregnant women averse beans based product, cassava based product and garlic. A significant percentage of first time pregnant women do not know the effect of food craving and aversion. The most known effect of food craving and aversion were malnutrition, anaemia for the fetus, low birth weight and prematurity. Majority of the first time pregnant women lack the knowledge on the effect of food craving and aversion in pregnancy.

Majority of the first time pregnant women do not know the measures taken to substitute for food craving aversion in order to meet up with their required nutritional values. There is no significant association between level of education and food craving (P=0.137) while there is significant association between the level of education and food aversion (P=0.005). There is no significant association between residential location and food craving (P=0.779) while there is significant association between residential location and food aversion

(P=0.010).There is no significant relationship between awareness of implication of food craving and aversion in pregnancy and food craving (P=0.063) and aversion (P=0.770) in first time pregnant women.

Conclusion

Based on the findings of this study the following conclusion were made:

v Majority of the first time pregnant women crave for or averse to at least one or more

food item.

v Majority of the first time pregnant women do not crave for non food item. The few

who craved for non food items craved mostly for soft white stone (nzu).

v The majority of first time pregnant women experience food craving or aversion at

first trimester.

v The type of food crave for by first time pregnant women are fruits, soft drinks and

snacks

v The type of food mostly averse by first time pregnant women are beans based food,

cassava based food and spices eg. garlic.

v The majority of first time pregnant women reason for food craving and aversion is for

satisfaction, good health and availability of food items in their locality. Majority of

the respondents reason for craving non food is to prevent occurrence of nausea and

vomiting.

v Majority of the respondent do not know most of the effect of food craving and

aversion on the health of mothers and fetus. The most known effect on the mother was

malnutrition and for the fetus was low birth weight.

v Majority of first time pregnant women have no information on food craving and

aversion, most of the respondents that have the information got it from

relatives/friends.

v Majority of the first time pregnant women do nothing to meet up with food nutrients

needed in pregnancy when they experience food craving or aversion.

v There is no significant association between level of education and food craving

(P=0.137) while there is significant association between level of education and food

aversion (P=0.005).Hence first time pregnant women with higher of level education

experience food aversion more.

v There is no significant association between residential location and food craving in

first time pregnant women (P=0.779) while there is significant association between

residential location and food aversion in first time pregnant women (P=0.010).Hence

first time pregnant women in the urban area experience food aversion more.

v There is no significant association between awareness of implication of food craving

and aversion in pregnancy and food craving (P=0.063) and aversion (P=0.770) in first

time pregnant women.

Recommendation

Based on the findings of the study, the following recommendations were made;

ü The government should empower women through employment opportunities so as to

enable them to earn enough money for their health care and not always relying on

their husband’s money.

ü Health personnel/nutritionist should be encouraged to educate pregnant women

especially the first time pregnant women on nutritional needs during pregnancy and

the implication of food craving and aversion in pregnancy.

ü Health personnel/nutritionist should involve men in nutritional education bearing in

mind of male dominance in certain culture and tradition.

REFERENCES

Ademuyiwa, M.O & Sanni, S.A (2013) Consumption pattern and Dietary Practices of Pregnant. Women in Odeda Local Government Area of Ogun State International Journal of Biological, Biomolecular Agricultural Food and Biotechnological Engineering . 7. (11);Nov 2013.

Almurshed, K.S, Bani, I.A, Kanhal, M.A & Amri, M.A.(2007) Maternal Dietary Intake during Pregnancy in Riyadh, Saudi Arabia Journal of family & Commodity Medicine Med Know Publications Saudi Arabia 14;(1) 9-13 April 2007.

Bayle, T (2005). Food Cravings and Aversion during Pregnancy relationship with nausea and vomiting. Appetite 38, Pp 45-51.

Brody, S. (2014). What is causing your Craving? American Baby Journal , 33, pp 48-54.

Carr, Tanya, Descheemaker & Koen. (2013). Food Craving and addiction facts and fallacy nutrition and health current topics Garant P.69.

Dana, V. (2012). The Benefits of Eating Healthy during pregnancy. Word press. Com Ohio USA.@http//www.the pregnancy zone.com/category/health issues.assessed 15/10/2015

Demissie,, T. Muroki, N.M. & Makau W.K. (2012) Food aversions and cravings during pregnancy: Prevalence and significance for maternal nutrition in Ethiopia. Health and Nutrition Research Institute Journal.19, 1.

Dickason, E.J, Silverman, B.L & Schult, M.O (2010) Maternal-Infant Nursing care New York USA Von Hoffmano Press Inc.pp 221-240

Douglas H. (2010) The American Heritage Standard Dictionary, Houghton Midline Company USA. http://www.dictionarysociety.com.retrieved 7/8/2015.

Ejei-Okeke, L.A & Analuba, R. (2014). Prevalence of Food Craving and Aversion during pregnancy in Women in Asaba Delta State. Multidisciplinary journal of Research Development 22( 1)July 2014.

Eric, Wendy & Brundige. (2013). The Science of Food Craving American journal of clinicalNutrition, 34, pp 128-134.

Ezeugwu, E. C, Onah, H.E, Odetunde I.O & Azubike, J.C (2009) Singleton low Birth Weight Babies at a Tertiary Hospital In Enugu, South East of Nigeria.Enugu metropolis University Teaching Hospital Enugu.Clinical and Molecular Teratology.2009:85;874- 878@ ispub.com/ijpn/13/1/5499

Glanz, K. Rimer, B.K & Lewis, F.M (2002) Health Behaviour and Health Education Theory Research and practice San Francisco Wiley & Sons Press pp 405- [email protected]

Grattan. D. (2013) Prolactin Receptors in the Brain During Pregnancy and Lactation, Implications for Behaviour Hormones and Behaviour 40 115-124.@ sctence direct 99

Haas, A (2015) Nutrition During Pregnancy Midwifery Today journal Issue 5 @https://www.midwifery today.com.retrieved 16/10/2015 .

Hackley J.B (2014) Prenatal Weight gain the relationship between food craving and weight gain. Desertion university of Arizona.

Itaida, B.A, Olofia, I. & Wang M. (2013) Anaemia parental iron use and risk of adverse pregnancy outcome systematic review and meta analysis “British Medical Journal 2013;346:[email protected]/content/346/bmj.f3443.

Handisco, V.H (2015) Prevalence of Food aversion craving and pica during pregnancy and their association with nutritional status of pregnant women in Dale Woreda, Sidama Zone, SNNPRS, Ethiopia International Journal of Nutrition and Metabolism 7 (1) Pp 1-14.Jan 2015.

Hearty, A.P, Gibney, M.J (2011) Dietary Patterns in Irish Adolescents, a Comparison of Cluster and Principal Component Analysis Public Health Nutrition Journal 13pp 1-10.

Hook, E.B (2014) Dietary Craving and Aversion during pregnancy American Journal of Clinical Nutrition 31 Pp 1355-1362.

Hurley, T. (2005) Psychosocial Influence in Dietary Patterns During pregnancy. Journal of the American Dietetic Association 105pp.6.

Juhasz, F. (2015) The effects of poor Nutrition on a fetus livestrong Foundation journal Demand Media @.Livestrong.com .retrieved 15/10/2015

Knox, T. (2013) Food Preference During Human Pregnancy: A review Food quality and preference. Human Reproduction Journal 2 Pp 131-154.

Koroyo-Dahrah, A, Nti, C.A & Adanu R. (2012) Dietary Practices and Nutrient Intakes of Pregnant Women in Accra, Ghana. Current Research Journal Biological Sciences 4 (4),pp 358-365.

Kroskey, D.L (2013) Dietary Practices and Outcome of Poor nutrition in pregnant women knowledge of outcome of poor nutrition in pregnant women in Arizona ; Dissestion master of Science in Arisona University of Arizona USA.PP105.

Manejwale, O. (2013) What Really Causes pregnancy Cravings, American Pregnancy Association Jorunal 20/health profs.com retrieved 10/10/2015.

Mercer, M & Holder, D. (2013) Food Craving Endogency Opioid Peptides and Food Intake. A review Appelite 30 Pp 23-29.

Michele, I. Gliksman, M.D & Digeronimo, T.F (2004) Guide to Pregnancy and Child Birth USA. Alpha Publishers Penguin Group pp [email protected].

Mckerracher, L, Collard, M & Henrich, J (2014) Food Aversion and Craving During Pregnancy on Yasawa-Island, Fiyi Appetite 44 253-267.

100

Nargia, N, Cooper, D.A, Kumar, P.H.(2010) Food Craving and Aversion in pregnancy England Journal of Medicine 12pp 1-4

Nyaruhucha, C. N (2012) Food Craving, Aversion and Pica Among Pregnant women in Dares Salam Tanzania. Tanzania journal of Health Research 11( 11)p 29-34.

Ogunyuyigbe, PO, Ojofeitimi E.O, Sanusi, R.A Orji, E.O, Akinlo, A., Liasu, S.A and Owolabi, O.O (2012) Demographic Research Journal 2 pp 44-54.

Ojofemitimi, E. O. & Tanimowo, C. M. (2012) Nutritional Beliefs Among Pregnant Women “International Journal of Gynecology and Obstetrics 18, 66.

Olusanya,T. O. & Ogundipe, F. O. (2012) Food Aversion and Craving among pregnant women in Akure Ondo State, Nigeria International Journal of Tropical Medicine 4/Issue 3/Page No. 100 – 103.

Payne, P. June, R. & Canter, D. (2014). The Profession of Dietetics, Jones & BartlettLearning

pp 3@ www.ebay.com retrieved 11/10/2015

Phnom, S.; Tippawan, L.; Virasakdi, C.; Praneed, S. Vosasit, S. & Melta, K. (2010). Inadequate Food Nutrients Intake a Major Cause of Poor Pregnancy Outcome in the Deep South of Thailand 8660 Rockwille Pike Publishers Bethsida, [email protected] central.com/assessed 15/10/2015.

Safaii, S. (2013). Food Habits May Start in The Womb. University of Idaho Coeurd Alene press Idaho May [email protected]. retrieved 10/10/2015.

Sholeye, O. O.; Badejo, C. A.; & Olubukunola, J. A. (2014). Dietary Habits of Pregnant Women in Ogun-East Senatorial Zone Ogun State, Nigeria: A Comparative Study. International Journal of Nutrition and Metabolism 6 (4) pp. 42-49.

Shuttleworth, M. (2008). Descriptive Research Design. Retrieved Oct. 29, 2015 Explorable Com. https://expoloarable.com/descriptive research design.

Slattery, M.C. (2008). Dietary Consumption: Is the Sun Greater Than its part American Journal of Clinical Nutrition 88; 14-5.

Tessmer, K. A. (2013). Coping with Food Craving American Journal of Clinical Nutrition 45 pp. 36-40.

Thomas, P. (2013). Food Craving and Aversion during Pregnancy, London U.K Publishing. [email protected] .retrieved 10/10/2015

Tomm, S. (2015). Leading Causes of Bad Nutrition Demand Media, [email protected]/leading causes retrieved 11/10/2015

Turgeon, H. (2014). Food Craving during Pregnancy U.S.A Wait Disney company Los Angeles USA.@https//archieve.org.Assessed 11/10/2015

101

Uzoagulu, A. E. (2011). Practical Guide to Writing Research Project Reports in Tertiary Institutions. John Jacobs Classic Publishers Ltd, Enugu Nigeria.

Walker, A. R.; Walker, J. J.; Veravid, M.; & Walker, C. (2013). Nausea and Vomiting, Cravings and Aversions During Pregnancy in South African Women. British Journal of Obstetrics and Gyneecology 92, 484 – 489.

World Health Organization (2011), WHO 10 Facts on Nutrition Retrieved 2011-08-07.

102

APPENDIX I

Information Letter Department of Nursing Science University of Nigeria Enugu Campus Enugu

Dear Respondent,

The study on Food Craving and Aversion among First time pregnant women in Selected Health facilities in Enugu state is being conducted by Madu Ngozi (Mrs) of Nursing Sciences Department, University of Nigeria, Enugu Campus, Enugu. The result of this research will enable the health care personnel to identify areas of emphasis while educating the pregnant women on Food craving and aversion

Participants to the study are expected to respond to some questions which will not take much of their time .No anticipated adverse effect will be experienced for being a participant and you can withdraw from participating after the commencement of the study if you so desire without any repercussion. You do not require putting down your name .All information collected will be treated confidentially.

The study has been reviewed and received ethical clearance from the involved health institution.

Yours faithfully,

Madu Ngozi (Mrs)

103

SECTION A Demographic characteristics and reproductive information or first time pregnant women Please tick [ü] in any of the boxes designed below as applicable to you 1. What is your age? [ ] 2. What is your marital status? (a) married [ ] (b) single [ ] (c) widow [ ] (d) separated [ ] (e) divorce [ ]

3. What is your Ethnic group? (a) Igbo [ ] (b) Yoruba [ ] (c) Hausa [ ] (d) Others specify …………......

4. What is your educational level?

(a) no formal education [ ] (b) primary [ ] (c) secondary [ ] (d) tertiary [ ] 5. What is your husband educational level? (a) no formal education [ ] (b) primary [ ] (c) secondary [ ] (d) tertiary [ ]

6. What is your occupation? (a) unemployed [ ] (b) civil servant/public servant [ ] (c) student [ ] (d) self employed [ ] (e) employed in private setting [ ] 7. What is your husband occupation? (a) unemployed[ ] (b) civil servant/public servant [ ] (c) student [ ] (d) self employed [ ] (e)employed in private setting [ ] 8. What is your religion: (a) Christian[ ] (b) Muslim [ ] (c) traditional[ ] (d) atheist [ ]

9. Where are you residing? (a) Uwani [ ] (b) Idaw-River [ ] (c) Achalla layout [ ] (d) Maryland [ ] (e) Garriki [ ] (f) Obeagu Amechi Uno [ ] (g) Amechi [ ] 10. What is your pregnancy stage: (gestational age) [ ] 11. What is your pregnancy stage: (gestational age) [ ]

104

SECTION B 12. Do you crave for any food? (a) No food craving experience [ ] (b) at least one food is being crave for [ ] (c) more than one food is being crave for [ ]. 13. At which stage of pregnancy do you experience the food craving? [ ] 14. Mention the specific food you crave for by ticking [ ü] Tick as many as applied to you. (a) Cassava based food [ ] (b) Cereal based food [ ] (c) Meat and meat produce [ ] (d) Vegetables [ ] (e) Fruits [ ]

(f) Fish and fish products [ ] (g) Beverages [ ] (h) Yam based food [ ] (i) Plantain [ ] (j) Beans based food [ ] (K) Snacks [ ]

(L) Soft drinks [ ] (m) Milk and milk product [ ] (n) noodles [ ] (o) others specify------15. Do you crave for any non- food item? (a) no non food item is craved [ ] (b) at lest one non food item is being craved for [ ] (c) more than one non food item is being crave for [ ] 16. Which of the under-listed non food item do you crave for? (a) Soil [ ] (b) soft white stone [ ] (c) charcoal [ ]

105

(d) ash [ ] (e) others specify………………………………………………….. 17. Do you have aversion for any food item below? (a) No food item aversion [ ] (b) at least one food item is being averse [ ]

(c) more than one food item is being averse [ ] 18. At which time of pregnancy do you experience the aversion?...... 19. mention the specific food you averse to by ticking[ ü] in the box as many as applied to you. (a) Cassava based food [ ] (b) Cereal based food [ ] (c) Meat and meat products [ ] (d) Beans based food [ ] (e) Milk and milk products [ ]

(f) Vegetables [ ]

(g) Fruits [ ] (h) Fish and fish products [ ] (i) Beverages [ ] (j) Yam based food [ ] (k) Plantain [ ]

(l) Snacks [ ] (m) Soft drinks [ ] (n) Species e.g. garlic [ ] 20. What are your reasons for craving for the food/foods? (a) for good health [ ] (b) colour of food [ ] (c) culture/belief [ ] (d) availability [ ] (e) food flavor [ ] (f) easy to prepare [ ]

106

(g) it reduces nausea and vomiting [ ] (h) for satisfaction [ ] (h) no reason [ ] (i) others specify………………………………………………………. 21. What is your reason for craving non-food substances?

(a) smell of pica substance [ ] (b) prevent nausea and vomiting [ ] (c) get satisfaction [ ] (d) no reason [ ] (e) others specify------

22. Reasons for food aversion (a) can affect the size of the baby [ ] (b) causes stomach pains [ ] (c) taboo/belief [ ] (d) nausea and vomiting [ ] (e) causes heart burn [ ]

(f) no reason [ ] (g) others specify------23. What are the effect of food craving and aversion on health of the mother? ( you can tick as many as you want)

(a) anaemia [ ] (b) malnutrition [ ] (c) obesity [ ] (d) increase risk of pregnancy induce hypertension [ ] (e) premature labour [ ] (f) do not know [ ] What are effects on the fetus ( you can tick as many as you want) (a) birth defect [ ] (b) low birth weight [ ] (c) increase risk of diabetes in childhood [ ]

107

(d) increase risk of obesity [ ] (e) possible lowering of intelligent quotient [ ] (f) prematurity [ ] (g) do not know [ ] 24. What is your source of information as on effect of food craving and aversion in pregnancy? (a) Nutritionist [ ] (b) Health workers [ ] (c) Mass media [ ] (d) Relatives/friends [ ] (e) no information [ ] 25. When you realize you crave or averse some foods what do you do to meet up with the food nutrient you need during pregnancy (you can tick as many as you want) (a) when craving for fast food like pop corn or meat pie, you try pawpaw, banana [ (b) when aversing nutritious food, you eat other foods that contain the same nutrient [ ]

(c) you avoid skipping meals which increases food craving [ ] (d) keep food diary to make sure that you are eating an adequate diet [ ] (e) active exercise to curb hunger [ ] (f) eating food that has longer digestion process such as yam, cassava, potato [ ] (g) does nothing to meet up with food nutrients needed in pregnancy [ ] (h) when craving for soft drinks you take fresh juice such as orange juice [ ] (i) you make sure that you have stable emotional status [ ] (j) you inform the health personnel when you crave for non food item [ ]

108

APPENDIX 1I

The formular is given as follows:

Where

n = sample size

N = the finite population size

e = Level of Significance (or limit of tolerable error)

I = unity (a constant)

The target population is 2000 e = 0.05

Therefore the sample size will be 333. Given an anticipated non complete response rate of

10%, the sample size is calculated as

= 33.3

333 + 33.3 = 366.3

This is approximated to 366.

For example: Uwani Cottage Hospital

109

APPENDIX III

Reliability

Scale: ALL VARIABLES

Case Processing Summary N % Valid 37 100.0 Cases Excludeda 0 .0 Total 37 100.0 a. Listwise deletion based on all variables in the procedure.

Reliability Statistics Value .839 Part 1 N of Items 37a Cronbach's Alpha Value .730 Part 2 N of Items 37b Total N of Items 74 Correlation Between Forms .874

a. The items are: b1, b2, b3a, b3b, b3c, b3d, b3e, b3f, b3g, b3h, b3i, b3j, b3k, b3l, b3m, b3n, b4, b5, b6, b7, b8a, b8b, b8c, b8d, b8e, b8f, b8g, b8h, b8i, b8j, b8k, b8l, b8m, b8n, b9a, b9b, b9c. b. The items are: b9d, b9e, b9f, b9g, b9h, b9i, extra9a, extra9b, extra9c, extra9d, extra9e, extra9f, b10, b11a, b11b, b11c, b11d, b11e, b11f, extra11a, extra11b, extra11c, extra11d, extra11e, extra11f, extra11g, b12, b13a, b13b, b13c, b13d, b13e, b13f, b13g, b13h, b13i, b13j.

110