Poster Presentation 261- By Dr. Francess Dufie Azumah

1. “The Effects of Pre-Pregnancy and Postpartum Food/Nutritional Taboos and Traditions on Women’s Reproductive Health in Ghana; A Case Study of Kumasi Metropolitan Area” Poster Presentation 261- By Dr. FrancessDufieAzumah Department of Sociology and Social Work KNUST –GH @ Penn –ICOWH 18th Congress: Cities and Women’s Health : Global Perspective in Philadelphia, USA 7th -10th April 2010.

2. Post –natal care

3. Introduction • Maternal and reproductive health care has gained much global attention over the last two decades. International bodies Organisation and national governments have put in place policies, programmes such as MDG, as a mechanism to curb incidence of high maternal mortality and morbidity rates especially in developing countries. • In Africa maternal and child mortality rates are on the increase even though fertility rates are decreasing. For example in Ghana, in 2003, fertility rate fell to 4.4% from 1998 levels of 6.4 children per woman. Notwithstanding the decrease rate in fertility, maternal mortality has been on the increase, at 214 per 100, 000 live births, with regional variations as high as 453 per 100, 000 live birth (UNPD, 2004, GSS 2002; GDHS 2004; 2003 GPRS Report, 2004).

4. In Ghana, the government in its quest to meet the MDG goals 4 and 5 had put in place strategies such as providing free maternal care for pregnant women. Irrespective of the Government of Ghana and international bodies to curb increasing maternal mortality rates in Ghana still remains high, 540 death per 100 000 live birth in 2005 with fertility rate at 4.4% (GHS, 2005, UNFPA, 2005; WHO, 2007 ). The question is whether food and nutritional taboos have any effect on women’s reproductive health status? Does these have any effect on women’s reproductive health status? What is the nature and extent of these practices? What are the reasons that underpin their performance? Whether women as ‘victims’ of such practices are aware of the health implications ? These and many other questions is what the research had sought to unearth in this study.

5. OBJECTIVE OF THE STUDY The study examines the effects of food and nutritional taboos and tradition on women’s reproductive health in Ghana. Specifically it seeks to • Examine the nature and extend of food taboos. • Examine the reasons that underpins the performance of these practices by women. • Find out whether the practicing of these have any health implication on women • Find out whether women as ‘victims’ of such practices are aware of the health implications, • Make some recommendations

6. METHODOLOGY The study combined empirically both quantitative and qualitative research methods as a mechanism for verification and validation. Quantitatively it employed survey conducted in Kumasi using the KNUST Hospital Maternal Care center as the area of study .Qualitatively, the use of structured interviews, and focused group discussion were adopted.

7. Sample Design and techniques • The study dealt with a more homogenous group made up of single sex – women. Nonetheless to have a representative sample of all different age groups, and maternal experience, selection was based on two distinct categories- on issues relating to food taboos and their effects on the reproductive health of women. • With an undefined population, the sample size of 65 respondents constituted those used for the effect of food taboos on the reproductive health of women. • Data was collected through the use of structured interview guide, focused –group discussion (3 groups of 9 members), and 8 health officials. Respondents were randomly selected. The research instruments were pre-tested through piloting among student- mothers.

8. In Ghana the two main causes for poor maternal health outcome have been associated with inadequate antenatal care coverage and unsupervised deliveries (2003 GRPS Report 2004). Some factors that impede the use of health facilities by women during delivery are: traditional beliefs, taboos, religion and poor attitudes by staff (ibid) • Generally throughout the developing world, the average food intake of pregnant and lactating mothers is far below that of the average male.

9. In Ghana, maternal care issues have been of great concern to the government. This had led to programmes such as the Safe Motherhood Initiative, and recently the assistance from the British Government (Loan) to provide free maternal care services for all expectant mother’s. • However, these efforts could be impeded when there is an interplay of cultural beliefs and practices such as nutritional taboos associated with pregnancy and postpartum periods .

10. In Ghana , like most developing countries there are traditional/ local beliefs and practices in relation to pregnancy and child delivery, such as precautions against evil spirits, food taboos etc. These cultural beliefs influence the orientations of women and their ways of life.

11. POSITIVE TRADITIONAL PRACTICES Some traditional Practices which are regarded as positive includes: Healthy postpartum practices based on spiritual framework, including rest, cleanliness, love, good nutrition and long period of breast feeding practiced in many parts of Africa, and other developing countries such as Latin America, and Asia (UNFPA, 2005)

12. Breast- feeding

13. Long-term breastfeeding provides optimal nutrients for infants growth and development, enhances infants immuno-logical defenses and facilitates both mother’s recovery from childbirth and mother-infant attachment. Women were mostly to breastfeed their infant between two to three years maximum or minimum 6 months postpartum •  Breastfed children were less likely to have otitis media, allergies, diarrhea, lower respiratory infections and bacterial meningitis (Duncan, et al,1993; Lucas et al,1990)

14. Early Pregnancy and Postpartum Nutritional taboos • Cultural practices, such nutritional taboos, ensure that pregnant women are deprived of essential nutrients, and as a result they tend to suffer from iron and protein deficiencies. Most communities throughout Africa have food taboos specially for pregnant women. Often these taboos exclude the consumption of nutrients essential for the expectant mother and foetus.

15. Social Profile of Respondents

17. Field data on Nutritional taboos • On Issues of relating to maternal care ( pre-and post natal stages) and culture, respondents were asked whether there any rules that governed their health status, and if yes what they were. From a medical perspective expectant mothers and women postpartum could eat anything but this should be balanced. • However, all respondents emphasised on the traditions pertaining to their eating habits. It was revealed that although they were admonished by health officials to eat healthy foods- fruits, vegetables, soups and a balanced diet, there were equally some foods that from a more cultural perspective were forbidden, if they were anticipating to have healthy babes, successful delivery and good health especially before and after birth. • This they learnt especially from their mother’s, and other older female relatives and friends.

18. Early Pregnancy and Nutritional taboos

19. Respondents indicated that traditionally some of the foods that they were forbidden to eat as especially expectant mothers were, salt foods (including fish- ‘koobi’, ‘mononi’), meat and eggs, oily (fatty) foods, banana, ripe plantain okro, garden eggs and snail. • With the proteins (meat and eggs), they indicated that this would facilitate having big babies hence cause complications during delivery, which could led to the loss of life of both mother and baby. These it was believed could also affect the child causing him/her to steal in life. • The ripe plantain and bananas were believed to cause pre matured contractions and subsequently miscarriage. Okro and snail, were said to cause slime in babies or dripping/watery mouth.

20. Reasons underpinning food taboos Ripe Plantain - Waist pains, miscarriage, early push (forced labour), delays removal of umbilical cord Salted Fish/ dried fish- The baby may not be brilliant in the future. These result in swollen feet (odema)

21. Snail and okro caused the baby to slime or have dripping / watery mouth

22. Protein foods Eggs and fresh beef (meat) Provide protein for the woman and the baby which engenders the physiological development of the baby. Beef dries milk of lactating mother. Makes baby grow to become a thief. Duck eggs causes asthma in baby

23. Food taboos and Reasons Beans- Provides protein for the woman and the baby which engenders the physiological development of the baby. It also causes tummy upset or complications. It causes delays in delivery for women above 30 years. Green leaves -(kontomire) caused Stomach/tummy upset or complications

24. Oils and Fatty Foods – causes jaundice Animal Hyde - It delays the removal of the umbilical cord . It also causes miscarriage for women in the first term of pregnancy.

25. Pineapple and coconut this causes miscarriage and abortion Coconut causes ‘white eyes’/ blindness in baby • Pineapple

26. Mangoes and Guava is associated with appendicitis

27. Although specific prescribed and proscribed foods differ considerably from region to region, one item of general agreement is that "hot" foods should be avoided during pregnancy and encouraged in the early postpartum period (Khan, 1981; Thompson,1983; Rea, 1981). • Food taboos during pregnancy to the origins of a specific condition; for example, pineapples were said to cause abortion, and coconuts were believed to make a baby blind, a condition described as "white eye." • Another belief was that duck eggs may cause asthma in the baby. Other restricted foods mentioned were milk, other fish, and cucumber.

28. Some women are not allowed to eat any meat or fish for one month, while Muslim women are restricted from doing so for seven days only. Other forbidden foods after childbirth are bananas , eggs, and leafy vegetables, especially pumpkin leaves. Beef and hilsha fish are thought to dry up the milk of a lactating mother and may also cause postpartum diarrhea. • Among Muslims during the period of seclusion, women may be restricted to one rice meal a day, though they are permitted to eat other cereals and milk during the rest of the day.

29. Food taboos cont. • A ground up mixture of cumin, chili, and garlic (a "hot" food) is commonly eaten in the immediate postpartum period, because it is thought to help heal the birth passage. • It is evident that women were not been allowed to take any food for the first few days, after delivery only water. However for most women, their water intake had also been restricted at this time (Khan, 1981; Goodburn et al, 1995).

30. Nutritional Value of Some Forbidden Foods

32. Pregnant women’s nutrition is a significant component for the development of fetus. Her daily food intake needs to fulfill her body’s needs and her fetus. • The developing fetus demands certain minerals and trace elements, throughout the 9 months gestation. Consequently, some groups of nutrients must be supplemented through her diet. First of all, most of foods have high energetic value and is rich in nutrients. Eggs and meat, rich in proteins helps to build up and regenerate tissues. Ginger vinegar soup helps to restore calcium and iron reserves. • The meat, pigs liver contain large amounts of iron and lipid-soluble vitamins, especially vitamin A, the deficiency of which often prevails during gestation and postpartum period.

33. The biological state of women’s organism is crucial for the pregnancy outcome and child’s further nutrient situation

34. Other traditional practices during pregnancy and postpartum • Generally for pregnant women enema was allowed, using prepared herbs. Women are also allowed to visit spiritualist/ herbalists for protection and the preservation of the pregnancy. However, there are regional variations. • In the Northern region kalogotin( a seed like cola nut) was boiled and given to women to drink when in full term. This served as local cintocinum to facilitate delivery – rupturing of uterus. • In the volta region, the expectant woman during delivery is made to sit in the sand, covers herself, till she delivers and the TBA cuts the cord that links the baby and mother.

35. Postpartum traditions • After birth generally various traditional herbs, are used in the preparation of meals such as soups for mothers. This it is believed to facilitate quick recovery from internal wounds created as a result of the delivery process. • A concoction known as ‘Kokroloso’ is prepared from different branches of trees is boiled for the mother to drink. This is believed to melt all clots of blood retained in the uterus and also facilitate the appetite to eat • Enema is encouraged with the use of pepper, ginger and other spices (including ashes) to allow all by products associated with deliver to come out. Most often among some ethnic groups such as the Nzema’s, hot pepper is inserted into the vagina to facilitate the healing process.

36. Women for the first month are made to sit on boiled water for this purpose, while among the Kessena Nankana’s a pot of hot water is placed on the woman’s belly by her in-laws . • Due to heavy blood flow and discharge after birth, most women use old cloth as sanitary towels, to prevent soiling themselves. • Again, in the absence of corsets, they are made to tire the tummy with cloth. This is believed to quicken the return of uterus to it normal position • Among the people of the Northern sector, the placenta after delivery is sent home for rituals.

37. Some Effects of Food /Nutritional Taboos and Traditions on women’s Reproductive health • Adequate nutrition is vital both to the health and reproductive outcomes of women and to the health, survival, and development of their children. Nutrition deficiencies diminish not only the individual woman’s quality of life but also that of her children. • When respondents were asked if these proscribed practices had any effects on their health, there was an overwhelming affirmation. The majority had stated they believed it had facilitated their safe and sound delivery process. • However, when asked if they experienced any medical symptoms during pregnancy and postpartum periods, the results revealed that majority stated anaemia, dizziness, fatigue, malaria, loss of appetite and weight, swollen feet among others. Less than 10% of the respondent stated they had had more than one miscarriage. These they interestingly did not associate with the eaten patterns.

38. Responses from key informants (the medical point of view) rather indicated that such practices had rather a detrimental effect on their health which could be fatal leading to maternal death. The health center since 2009 although had not recorded any maternal deaths, recorded some appreciable percentage of anemia cases pregnant women and lactating mothers.

39. Key Informant and FG’s indicated that some of the effects of the food and nutritional taboos lead to poor nutritional status of women resulting in outcomes such as : anaemia, hypertensive disorders, immune system disorders, increase risk of infection, malnutrition, pregnancy complications, night blindness, fetal loss, still birth, miscarriage, pre-mature birth and consequently maternal death. • This does not only affect the mother but the product (unborn / or born child) as there is a possibility of causing potential fetal anomaly, low birth weight, adverse infant neurobehavioural development etc. This is because the unborn heavily relies on the mother for its nutritional supplements to survive.

40. Calories intake are every essential during postpartum periods as lactation demands 500 – 600 additional daily calories for the first six months postpartum, which is a substantial increase over the latter part of pregnancy, which only requires an additional 300 calories a day. • A severe reduction or insufficient calories intake can be harmful as: - it reduce the amount of lean tissue in the body and lower basal metabolic rate, thereby inhibiting weight loss; Cause or exacerbate fatigue; Contribute to risks for depression or make existing depression worse and reduce energy needed for a postpartum reconditioning program and taking care of a new baby, perpetuating sedentary lifestyle habits. Fatigue it is evident that undercuts the motivation to be physically active.

41. Dietary allowances for selected nutrients in pregnant women and the results of its deficiency.

43. Permissible compositional range for dietary supplements for pregnancy and lactation: Vitamins

44. Permissible compositional range for dietary supplements for pregnancy and lactation: Minerals

45. Summary of Major Findings • From a health perspective women during the pre and post natal periods are not restricted to their intake of foods (having balanced meal/diet). However, there are some traditional dietary practices that debar women from the foods and nutrients essential for their protection and healthy growth and development of themselves and foetus. These nutritional foods includes a range of energy and protein foods such as ripe plantain, meat, eggs, snails, fish; vegetables and fruits such as green leafs, okro, pineapples , banana, oranges , and grains including beans.

46. Summary • The traditional explanations underpinning the prohibition are that ; for instance protein foods such as Beef and hilsha fish may dry up the milk of a lactating mother and may also cause postpartum diarrhea. Even though meat will provide protein for the woman and the baby which endangers the physiological development of the baby making the child have craven for meat and thus becoming a thief. Again snails and okro would cause the baby to slime, while ripe plantain and pineapple are said to cause waist pain, early labour, or abortion; and coconuts were believed to make a baby blind, a condition described as "white eye."

47. Dietary taboos had consequential effects that were both non-fatal and fatal . These resulted in poor nutritional status of mothers , impairments of their physical and mental health, pregnancy related complications, miscarriage, hemorrhage, infertility, still birth and the fatal outcome of maternal mortality . • WHO (2000b) has defined anemia as mild, moderate, or severe based on the following cutoff values (g/dl) for hemoglobin level: Mild Moderate Severe, with Pregnant 10-10.9 7.0-9.9 <7.0 respectively whiles Non-Pregnant 11-11.9 8.0-10.9 <8.0. In short, pregnant women with a hemoglobin level less than 11g/dl and non-pregnant women with a level less than 12g/dl are considered anemic. • Again the abstinence affects the fetus and lactating child who depends on the mother for these foods and nutritional supplements.

48. conclusion • Women’s nutrition during pregnancy and postpartum periods is an important element for the development of fetus. Her daily food intake needs to fulfill her organismic needs and needs of developing child. • There is a clear evidence of conflict between puerperal woman health needs and the cultural ideology governing maternal health issues. These practices as it is evident have both short and long term physical and psychological effects on its victims which are marked by chronic infections, Gynecological disorders, which eventually contributes to the increased rate of maternal mortality and morbidity, which are variables of a country’s social development indicator.

49. Society’s culture needs to be preserved but harmful ones that do affect the individual, violating their human rights and dignity of families and society as a whole slowing down the economic growth and development of a country, need to be eradicated, if not modified. Women’s rights are human rights; and they have equal rights to health and reproductive health. To enjoy these rights the state has to protect them by enforcing the laws as enshrined in its constitution and other international mandates ensuring the eradication of these belief systems working in collaboration with all stakeholders.

50. RECOMMENDATIONS Health and religious institutions, NGOs, as well as CBOs should provide counseling services for women to deal with pre-pregnancy and postpartum food taboos and traditions on women’s reproductive health. • There is the need for sensitization and attitudinal change towards pre-pregnancy and postpartum food taboos on women’s reproductive health issues through education and awareness creation. • Traditional leaders need to take up their constitutional and legal obligations to ensure that these traditional practices which affect the reproductive health status of women are modernised and given a human face if not eradicated completely.