Food taboos during pregnancy and lactation among tribal population of South India

INTRODUCTION

Good nutrition paves the way for a fair chance in life.¹ Food taboos exist in all the communities and do vary from one community to another. While some foods considered as a taboo in one community, in another they are not seen as taboos. Food taboos are general and specific in nature as some taboos involve the entire community and others a specific section of the community such as women, men and youths.² All people, whether rural or urban, have their own beliefs and practices. Some are based on centuries of trial and error and have positive values while others may be useless or harmful.³ Irrespective of whether food taboos are permanent or temporary, specific or general, they have different impact on the community and so do the consequences of violation. Although taboos are generally “negative” in nature, that is, prohibiting the people from consuming or carrying out certain activities, they also bring a sense of unity, identity and belonging to the people in a given community.² Pregnant women in developing countries are considered to be nutritionally vulnerable, as they are often subjected to different degrees of nutritional stress, and those who follow traditional food taboos have increased chances of developing a range of negative pregnancy outcomes, including compromised health of the baby in future.⁴ Poor nutrition during pregnancy and postpartum is linked to adverse outcomes for both the mother and her baby.⁵ Pregnancy imposes the need for considerable extra calorie and nutrient requirements. A balanced and adequate diet is therefore, of utmost importance during pregnancy and lactation to meet the increased needs of the mother, and to prevent “nutritional stress”⁶ Hence, there is a need to identify and address this issue of food taboo.

Objectives

Objectives of current study were to study the socio-demographic profile of the tribal pregnant women, to explore food taboos during pregnancy and lactation among the tribal pregnant women and to assess association between sociodemographic characteristics and food taboo among pregnant women.

METHODS

Study design, duration, location and population

This was community based cross sectional study. The study was conducted from July 2022 to August 2022. This study was conducted in tribal area under the jurisdiction of RHTC of the SVIMS, Sri Padamavathi Medical College for Women, Tirupati, Andhra Pradesh, India. There are 12 subcentres under the field area of RHTC of the institute. Out of these 3 sub-centres(villages) where tribal population reside were selected by simple random technique to get desired sample size. Tribal pregnant women from selected area visiting Primary health centre and sub-centres for regular ANC check-ups and immunization on ANC check-up and immunization day.

Sample size and sampling technique

The sample size determination was done with the assumption of confidence level=95%, critical value Z=1.96 (from significance level α=5%), and degree of precision=0.05, by taking 27% proportion from study conducted by Getnet W in Ethiopia.⁷ Sample size calculated was 303 by application of the formula;

4pq/d2

Inclusion and exclusion criteria

Tribal pregnant women who gave consent were included. Those who were not willing to participate were excluded.

Data collection procedure

Study instrument: To collect information, two types of pre-tested structured format was used. Socio-demographic proforma: Proforma included age, place of residence, education, occupation, type of tribe, type of family, type of housing, size of family, monthly family income and socio-economic status, number of deliveries and previous ANC check-ups attended or not etc. Pre-structured, pre-designed questionnaire (Proforma): This questionnaire included questions to collect information about food taboos during pregnancy and lactation.

Statistical analysis

Data was entered in the Microsoft Excel sheet and was analyzed using IBM SPSS Statistics for Windows, Version 26.0. Statistical tests like simple proportions were calculated and chi-square test was used to know the association of socio-demographic variables with food taboos among tribal pregnant women. The association was considered to be statistically significant with p<0.05.

Data quality assurance

Pre-test was done prior to the actual data collection. Data collector was trained in data collection procedure. All the study participants were informed about the purpose of the study and verbal consent was obtained before interview and confidentiality of tribal pregnant women was ensured.

RESULTS

Socio-demographic characteristics of the study respondents (Table 1). The present study was conducted among tribal pregnant women of age group 18-36 in the Tirupati district of south India. Out of the total 303 study respondents (tribal pregnant women), majority of the them were in 21 to 30 age group i.e., 235 (77.6%) followed by 55 (18.2%) in 18 to 20 age group. Only 13 (4.2) were in 31 to 36 age group. Out of all, 303, 286 (94.4%) respondents reside in tribal area while 17 (5.6%) of them reside in urban areas for their work (job). Regarding educational status, majority of the study respondents have completed secondary education 191(63.0%) whereas 48(15.8%) have received primary education and about 24(7.9%) were illiterate.With respect to occupation, majority (274; 90.4%) of the respondents were home makers and 17(5.6%) were daily labourers and 11 (3.6%) were doing some jobs. Among all, majority of the study respondents, 203(67.0%) belonged to joint families followed by 91 (30.0%) who belong to nuclear families. 215 (71.0%) live in pucca houses, followed by 50(16.5%) respondents who live in semi-pucca houses. Only few i.e., 38 (12.5%) live in kutcha house. In the present study, with regard to socio-economic status (as per B G Prasad socio-economic class scale), majority of the study respondents, 119 (39.3%) belonged to middle class whereas 82 (27.1%) respondents belonged to upper middle class followed by 67 (22.1%) respondents who belonged to lower middle class. Upper class respondents were 34 (11.2%). Majority of study respondents were from Yanadi tribal community 125 (41.35%) followed by 83 (27.3%) from Erukula tribal community, Nakkala tribal community respondents were 55 (18.2%) and Vaddi tribal community respondents were 40 (13.2%).

As shown in (Figure 1), 265 (87.4%) respondents reported that they include certain special food items during pregnancy and 263 (86.7%) respondents reported that they include certain special food items during lactation in their diet. 219 (72.3%) respondents reported that they avoid certain foods during pregnancy while during lactation, 149 (49.2%) respondents reported that they avoid certain food items in their diet. Total 84 (27.7%) respondents during pregnancy and 154 (50.8%) respondents during lactation reported that, they don’t avoid any kind of food items and they eat all variety of routine food items cooked at home.

As shown in (Table 2), majority of the study respondents, 194 (64.2%) reported that they include fruits other than papaya and pine-apple followed by eggs by 181 (59.73%) respondents while 161 (53.13%) include milk, 112 (39.96%) include jaggery. 155 (51.15%) consume Chikki (Ground nuts and Jaggary mix) during pregnancy, 132 (43.56%) respondents include cereals(grains) while 38 (12.54%) respondents reported that they eat routine food cooked at home (available at home).

They reported that all these variety of food items they consume during pregnancy for their strength and also they believe that these food items will be beneficial for the growth of the growing foetus. Special foods included in the diet during lactation by study respondents were milk, bread, meat, vegetables, garlic, dry fruits etc. Majority of the respondents, 179 (59.07%) reported that, they include milk in their diet for better lactation. 163 (53.79%) include bread in their diet for better lactation. Also reported that milk and bread helps in post-partum recovery. 58 (19.14%) study respondents include meat in their diet as they believe that meat is a hot food and helps in post-partum recovery. 34 (11.22%) respondents reported that they include vegetables available nearby their area. 49 (16.17%) study respondents reported that, they eat routine food whatever cooked at home while 40 (13.02%) respondents reported that, they don’t have any idea what special food items to be included in the diet. 19 (6.27%) respondents reported they consume garlic and dry fruits like almonds, cashew nuts etc for strength during lactation.

As sown in (Table 3), majority of the respondents,173 (57.09%) avoids fruits during pregnancy like papaya, pine-apple, mango etc. 10 (3.3%) respondents avoids vegetables like brinjal, drumsticks, chillies, ginger and gongura (green leafy vegetable), 37 (12.21%) respondents avoid sesame seeds during pregnancy. 33 (10.89%) respondents avoid black coloured food items like black sesame seeds, black berries, black grapes etc. 37 (12.21%) respondents avoid non-vegetarian food like meat, chicken, fish etc. Spicy foods and cold food items like ice-cream, cold water were avoided by 12 (3.9%) of the respondents. 85 (28.05%) said they don’t include any special food during pregnancy. They do not have any idea what foods to be included in their diet specially during pregnancy. Majority of the respondents, 122 (40.26%) avoids vegetables. 11 (3.63%) respondents avoid meat during lactation. Spices and cold foods were avoided by 31 (10.23%). 153 (50.49%) respondents said that they don’t have any idea about avoidance of food. 44 (14.52%) respondents reported that they don’t have any knowledge about avoidance of food during lactation.

Same respondent answer for multiple food items.

As shown in (Table 4), Majority of the respondents who were educated upto secondary school (77.1%), followed by respondents who were educated upto graduate (75.0%) and primary school (72.9%) avoided food items during pregnancy. These differences are statistically significant (p<0.001). As shown in (Table 5), majority of the respondents who were homemakers (75.5%) and who were doing some jobs (81.8%) were found to avoid food items during pregnancy.

These differences are statistically significant (p=0.001) while during lactation, majority of the study respondents who were housemaids (100.0%) and homemakers (52.2%) were found to avoid food items. These differences are statistically significant (p=0.001).

DISCUSSION

Present study was conducted among tribal pregnant women of age group 18-36 in the Tirupati district of south India. Out of the total 303 study respondents (tribal pregnant women), majority of the them were in 21 to 30 age group ie. 235(77.6%) followed by 55 (18.2%) in 18 to 20 age group. Only 13 (4.2) were in 31 to 36 age group. Out of all, 286 (94.4%) reside in tribal area while 17(5.6%) of them reside in urban areas for their work (job). Regarding educational status, majority of the study respondents have completed secondary education 191 (63.0%) whereas 48 (15.8%) have received primary education and about 24 (7.9%) were illiterate. With respect to occupation, majority 274 (90.4%) of the respondents were home makers and 17(5.6%) were daily labourers and 11 (3.6%) were doing some jobs. Among all, majority of the study respondents, 203 (67.0%) belong to joint families followed by 91 (30.0%) who belong to nuclear families. 215 (71.0%) respondents live in pucca houses, followed by 50 (16.5%) respondents who live in semi-pucca houses. Only few i.e., 38 (12.5%) live in kutcha house. In the present study, with regard to socio-economic status (as per B. G. Prasad socio-economic class scale), majority of the study respondents, 119 (39.3%) belonged to middle class whereas 82(27.1%) respondents belonged to upper middle class followed by 67 (22.1%) respondents who belonged to lower middle class. Upper class respondents were 34 (11.2%). In this study, majority of study respondents were from Yanadi tribal community 125(41.35) followed by 83(27.3%) from Erukula tribal community, Nakkala tribal community respondents were 55 (18.2%) and 40 (13.2%) were from Vaddi tribal community. Among all 303, 77 (25.4%) respondents were primigravida,100(33.0%) were at second gravida, 105 (34.7%) were at third gravida. 141 (46.5%) of the respondents underwent less than 5 antenatal check -ups while 162 (53.5%) respondents underwent more than 5 antenatal visits.

In this study, it was found that, out of 303, 265(87.4%) study respondents during pregnancy and 263 (86.7%) study respondents during lactation were including special food items in their diet. During pregnancy, they were including milk, vegetables specially leafy, fruits, eggs, meat, jaggary, dry fruits like almonds, cashew nuts etc, Chikki (Ground nuts and Jaggary mix) and cereals (grains) Majority of them reasoned that these foods are for their strength and are beneficial for the growth of the growing foetus. Similarly a study conducted by Naik D et al⁸ among nomadic tribes of North Karnataka found that, fruits (48.85 percent), coconut laddu (12.35 percent), light food (39.75 percent), craving foods (84.45 percent), organ meats (36.20 percent) and goat bone soup (12.11 percent) are given during pregnancy. A study by Lakshmi reported that among the tribal women of north coastal Andhra Pradesh, of the 600 women surveyed, 60% believed that certain foods should be specially consumed during pregnancy.⁹ Among the foods recommended almost all foods such as meat, fruits and vegetables rich with nutrients and are necessary for the health of mother and baby.

In this study, 219 (72.3%) study respondents reported that they avoid certain food items during pregnancy while 84 (27.7%) respondents reported that they don’t avoid or restrict any kind of food items. They eat all variety of routine food items cooked at their home or available at their home. Majority of the respondents, 173 (57.09%) avoids fruits during pregnancy like papaya, pine-apple, mango as they consider these fruits are hot foods as they generate heat in the body and causes harm to the growing foetus. Fruits like papaya, pine-apple and mango are hot foods and can cause abortion and affect growth of the baby. Specially they believed that papaya fruit affect baby growth during pregnancy. 10 (3.3%) respondents reported that they avoid vegetables during pregnancy which were brinjal, drumsticks, chillies, ginger and gongura (green leafy vegetable) as they believe that these vegetables cause pain in abdomen during pregnancy. Also, they avoid spicy foods as it may cause pain in abdomen. 37 (12.21%) respondents avoid sesame seeds during pregnancy as they believe that it causes abortion. Also, it was found that 33 (10.89%) respondents avoids black coloured food items like black sesame seeds, black berries, black grapes etc. They believe that these food items causes abortion and the child born will be with dark complexion. Similarly, a study by Shomya reported that respondents were forbidden to eat any dark coloured vegetables to prevent dark complexion of baby.¹⁰ In this study, it was found that, 37 (12.21%) respondents avoid non-vegetarian food like meat, chicken, fish which they believed to be heat-producing and thus should be restricted during pregnancy to prevent abortion. Only one women said she doesn’t eat egg because of smell. Spicy foods and cold food items like ice-cream, cold water were avoided by 12 (3.9%) of the respondents. They believe that cold food items like ice-cream, cold water etc. should not be consumed during pregnancy as they believe that baby born will be weak.

Similarly in a study conducted by Naik D et al among nomadic tribes of North Karnataka reported that, Papaya (49 percent), egg (33.33 percent), pepper (12 percent), sesame (10 percent) were avoided during pregnancy.⁸ They believe papaya, pepper and sesame are hot foods and leads to abortion, egg leads to birth of bald baby. A study conducted by Misra et al among tribal women in Rayagada district found that some food items were restricted in both pregnancy and lactation, i.e., Colocasia, prawn and dry fish were avoided by 81.25% women, brinjal was avoided by 76.25% women, leafy vegetables were avoided by 67.5% women, mutton was avoided by 56.25% women, ripe papaya and ripe jackfruit were avoided by 55% women and egg was avoided by 43.75% women. Konduru et al reported in their study, that, 87% of informants, it means 26 informants describe that pineapple, papaya fruits are not giving to the pregnant women because they believe that above fruits are harmful to the pregnant women especially papaya leads to miscarriage of pregnancy.^11,12 Goswami et al reported in their study that meat especially pork was avoided from the conception till delivery with the belief that these are hot foods.¹³ Egg which was also considered as hot food was avoided for first 3 months for the belief that it will cause bleeding. Similarly, a study conducted by Patil et al.¹⁴ Out of 339, 216 (63.7%) told that some vegetables/fruits should be avoided during pregnancy. Most of the illiterates (91.3%) told that papaya should not be eaten during pregnancy in comparison to 83.9% of literates. Most common reason for restriction of specified fruits/vegetables was abortion. A study by Joshi et al reported that major groups of foods being eliminated were nuts, fruits and vegetables and non-veg food like; milk, meat, eggs having greater importance during pregnancy however as these were excluded by women from lower socioeconomic strata the reason may be affordability apart from the reasons given i.e. hotness or cold foods criteria.¹⁵ Chakrabarti et al reported that taboos were present regarding consumption of various fruits (banana, papaya, jackfruit, coconut), vegetables (brinjal, leafy vegetables), meat, fish, and eggs during pregnancy.¹⁶ These were followed mainly to prevent miscarriage, promote easy delivery, and prevent foetal malformations. Shwetha et al reported that, during pregnancy, some of the foods were specifically restricted during the first and second trimester, while certain others were forbidden throughout gestation.¹⁷ Most common foods were fruits namely Papaya, Guava, Banana followed by water melon, custard apple and black plum. Vegetable and leafy vegetables like drum sticks and drum fish, egg, stick leaves, pumpkin, amaranth, brinjal. Protein rich foods like egg, meat, pea, was one of the most common foods avoided considering that it induces abortion. In different cultures and regions in India, the postpartum period is generally considered a time for women to take on the role of mother and to recover. This period is viewed as critical and specific traditional beliefs and practices are observed to ensure recovery and avoid ill health in later years.¹⁸

In present study special foods included in the diet during lactation by study respondents were milk, 179 (59.07%) for better lactation. 163 (53.79%) respondents include bread in their diet for better lactation. 58 (19.14%) respondents include meat in their diet for postpartum recovery and strength. 34 (11.22%) respondents include leafy vegetables. 49 (16.17%) study respondents said they eat routine food whatever cooked at home while 40 (13.02%) respondents said they don’t have any idea what special food items to be included in the diet.¹⁹ Similarly in a study conducted by Mukhopadhyay et al reported that special foods were taken by 86.4% of mothers during the postpartum. Consumption of fruits was not very common among these mothers whereas consumption of green leafy vegetables (rai sag) was very common as it grows abundantly in the area. The mothers under study reported certain food items as taboo during the postpartum period only.

In this study, it was found that majority of the respondents,122 (40.26%) avoid vegetables as they believe that consumption of vegetables can cause pain in abdomen. Some respondents avoid meat, 11 (3.63%), Spices and cold foods, 31 (10.23%) which they believe that causes pain in abdomen and the baby will be weak.153 (50.49%) respondents said that they don’t have any idea about avoidance of food. They reported that they did not abstain from eating any food. They also said they don’t have any idea or knowledge that some food avoided during lactation. In a study conducted by Naik et al among nomadic tribes of North Karnataka found that, Spices (70.53 percent), chilli (85.20 percent) and garlic (15 percent) were not given during lactation and they believe consumption of these leads to diarrhoea, garlic consumption leads to bad smelling milk.⁸

Mukhopadhyay et al in their study reported that, up to week 6 postpartum, 65.3 % of mothers observed taboos on certain categories of food such as milk, eggs, fish, meat, pulses, green vegetables and fruits, which are most perceivably hot and sour food.¹⁹ In a study conducted by Chakrabarti et al reported that taboos in the lactation included avoidance of small fish, foods with multiple seeds, other "cold" foods, and fluid restriction in some areas.¹⁶ The taboos were followed spontaneously as the inhibitions were imposed only for a definite period. A study by Bista found that, most of the participants expressed that they avoided black pulses (Kalodaal) and pulses as they believed that taking vegetables, daal or pulses after delivery can cause digestive problems to the baby like flatulence and pain in the abdomen.²⁰

In present study, socio-demographic characteristics like educational level, socio-economic status, occupation, type of housing of the study respondents was significantly associated with avoidance of food items during pregnancy and lactation (food taboo practices). Similarly in a study by Tela et al showed a significant association between observance of food taboos by pregnant women and their level of education.²¹ Also in a study by Oluleke et al reported in their study that there is a statistically significant association between respondent’s education, occupation and income with food restriction or avoidance behaviour associated with cultural taboos.²² Also in this study, number of pregnancies of the study respondents was found to be associated with avoidance of food items during lactation.

CONCLUSION

This study results shows that, 219 (72.3%) study respondents avoid certain food items during pregnancy while 149 (49.2%) respondents avoid certain food items during lactation. Socio-demographic characteristics like educational level, socio-economic status, occupation, type of housing of the study respondents was significantly associated with avoidance of food items during pregnancy and lactation (food taboo practices). Study respondent’s cultural belief in food practices are major reason for their food avoidance during pregnancy and lactation. Nutrition education and awareness generation is needed which will bring social and behavioural change among these tribal pregnant mothers.

Funding: Indian council of medical research

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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