Social Science Baha
Official

Understanding Nutritional Behaviour of Pregnant and Postpartum Women in Dhanusha District, Nepal

Vikas Paudel, Naomi Saville, Joanna Morrison, Dharma S Manandhar, Bhim P Shrestha, Kristen Ormston

Background
Poor nutrition is believed to be the underlying cause of 35-50% of all child deaths, and 20% of maternal deaths.  It is also a large contributor to ill-health in these groups.  Dhanusha district in Nepal suffers from particularly poor nutritional outcomes, contributing to high maternal and child mortality rates. 40.7% of reproductive age women have low body mass, and 43% are iron-deficient. While children under two years have high levels of anaemia, stunting, wasting, 37.2% of them are also underweight.

Traditional food beliefs and practices in pregnancy and postpartum could further exacerbate under-nutrition, with additional negative impacts on neonatal and maternal outcomes. Hence, we sought to understand the local context and prevailing beliefs about food and to explore the underlying social, economic, and cultural determinants of food beliefs, and mechanisms for change. 

Methods
Over four years, prospective quantitative data were collected from 16,265 postpartum women regarding pregnancy and postpartum food behaviours. This was complemented by 11 focus group discussions with women from varying backgrounds and their experience of pregnancy in Dhanusha district, in order to explore reasons behind behaviours. This analysis was supported with a field visit to understand the context, as well as five semi-structured interviews with local female NGO staff in order to clarify the findings from the discussions. Statistical analysis was performed using Stata/SE version 12.1. Transcripts were indexed using N-Vivo software, and data was rearranged into charts by thematic content.

Results
We discovered a marked secular decline in avoidance of foods, under eating, and fasting during pregnancy, but an increase in postpartum food taboos over these four years. Logistic regression showed an association of food taboos and under eating in pregnancy with food insecurity, low asset scores, lower BMI, primigravidity, and younger age. Our data showed that traditional eating practices are higher in people from the plains than the hills, but other differences between ethnic groups were less significant. Qualitative research revealed that some women under eat during pregnancy because they fear a difficult delivery and are worried that food takes up space, and therefore there is less growing space for the baby.  Other reasons commonly mentioned by respondents included affordability of food, physical discomfort, and the requirement of continuing physical work during pregnancy. Although women seem to have more control over their food intake during pregnancy, traditional practices in the early postpartum period ensure that food intake remains predominantly under the control of others such as the mother-in-law. 

Conclusions
Traditional eating behaviours, although entrenched in culture, are not obstinate and can change significantly over time, depending on various factors like economic status, food security, access to media, education, and ultimately empowerment. Despite this, there are still vulnerable groups of women who are more likely to continue traditional eating practices in pregnancy, including poorer, more food insecure, younger, and more undernourished women.