Healthy eating is seen to be an important aspect of pregnancy. Yet, in the changing cultural climate of the UK the needs of different migrant women are not met appropriately. Dr Aniebiet Ibanga Ekong, Public Health Nutritionist, University of Aberdeen, highlights why midwives and maternity workers should ensure all advice is tailored to individual cultural needs.

______________________________________________________________________________________________________________________________________________________________________

Midwives supporting migrant pregnant women to eat well

Eating a healthy diet is protective against all forms of malnutrition, non-communicable diseases, and certain forms of cancer. Healthy eating, especially during pregnancy, is essential to safeguard the woman’s health during childbirth and improve child health outcomes. How to eat healthily has become common knowledge, and obesity/overweight is sometimes seen as the individual’s fault. After all, government guidelines suggest what can and should be consumed and in what proportion. For instance, there is the UK’s healthy eating guide, also known as the Eatwell Guide, which visually represents the types and proportions of foods recommended for a healthy, balanced diet. The guide is designed to be culturally appropriate for the UK population, considering the dietary habits, food preferences, disease patterns, and nutritional needs of different groups. There are additional guidelines in pregnancy (Have a healthy diet in pregnancy – NHS (www.nhs.uk) ) in the UK around foods that women should and should not eat, and healthy nutrition is promoted during pregnancy with the goal of maintaining it after birth to help women lose weight over the long term, with midwives being strategically placed to offer women healthy eating advice.

Additionally, studies have shown that pregnancy is when women are more inclined to adopt healthier behaviours for the sake of the baby, such as smoking cessation and healthy eating (O’Brien, et al., 2017; Lindqvist, Lindkvist, Eurenius, Persson, & Mogren, 2017; Bauld, et al., 2017). Suffice it to say that pregnant women might be more inclined to take on healthy eating advice during pregnancy. This, however, has not been the case. Studies show that pregnant women in the general population are disconcerted by the lack of/conflicting variety of information about healthy eating presented in pregnancy (Ferrari, Siega-Riz, Evenson, Moos, & Carrier, 2013; Bryant, Waller, Cameron, Sanson-Fisher, & Hure, 2019) as well as other things such as a lack of time during consultations. That could be solved if we say that the focus should be on producing more streamlined and better information and improving consultation time. This view  is focused on something other than antenatal consultation times in the UK. It focuses on healthy eating information offered in pregnancy and how individuals engage with that advice. Specifically, my Ph.D. study explored engagement with healthy eating advice by Black immigrant pregnant women. Additionally, I explored how midwives engaged with this population when/if they offered healthy eating advice to them.

 

Why did I choose this population?

Migration numbers are on the increase, including from countries in sub-Saharan Africa to countries in Europe and the Americas. What this means is that these countries’ cultural and health landscapes are changing. Consequently, health services provision would need to change to accommodate the changing landscape. For instance, protein-energy malnutrition is still highly prevalent in some countries and regions in sub-Saharan Africa, with prevalence rates exceeding 20% in countries like Senegal and Eritrea (Onubi, Marais, Aucott, Okonofua, & Poobalan, 2016) . Pregnant women from West African countries like Nigeria and Cameroon have an increased risk of developing iron deficiency in pregnancy in addition to the increased burden of vitamin D deficiency (Ayoya, Bendech , Zagre, & Tchibindat, 2012; Van der Pligt, et al., 2018; Zegeye , et al., 2021). These statistics have implications for health post-migration. Additionally, there are reports of adverse pregnancy outcomes for this population. The 2019 confidential enquiry into maternal deaths report showed that 40% of women who had died in pregnancy from all causes were Black African women from countries in Sub-Saharan Africa mainly Nigeria, Eritrea, and South Africa (Knight , et al., 2019). Fourteen percent of the women who died, died from pre-existing cardiac diseases, of which certain factors such as high blood pressure, overweight/obesity, and black ethnic background increases the risks. Furthermore, the process of migration can be complex. There are reports that recently migrated women were more likely than not to show a lack of understanding of the healthcare system in the UK, and inadequate utilisation of the antenatal care system has been shown to increase the risks of maternal deaths. This has been compounded by post-migration issues such as inequalities in maternal care and access, problems with communication, and racism (Higginbottom, et al., 2019). These issues can increase the risks of adverse pregnancy outcomes for this population. Exploring healthy behaviours such as healthy eating, which may reduce the chances of adverse outcomes in pregnancy and beyond in this population, is necessary.

During my Ph.D. study, I interviewed a cross-section of Black immigrant pregnant women and midwives who provided their care. One of the themes that emerged from the study, which I am discussing here, focused on the changing cultural landscape for Black African immigrant pregnant women and how that impacted their decisions. For most women, the antenatal care system was their first contact with health services in their now host country. Before that, they had existed within their own cultural entity despite migrating to a different country. The decision to stay within their culture provided a sense of familiarity, which they expressed in their choice of food, communities, and social networks within this new country. Although some women tried to blend into their new environment for the sake of friendships, for instance, trying new foods on night outs, they would eventually return to the things they were familiar with. Changes in food availability as a consequence/product of migration have also meant that migrants have access to familiar foods that existed in their countries of origin, thus making it easier for individuals to maintain their cultural dietary pattern post-migration.

The healthy eating advice offered during pregnancy changed the cultural landscape for the Black immigrant women that I interviewed. Immigrant pregnant women in the study felt that the healthy eating information offered during pregnancy was unrelated to them. The foods they were asked to eat/not eat were unfamiliar. As a result, they could not relate to the advice nor engage with It. A few pregnant women tried to adopt the recommendation, but the change was not sustained. The pregnant women therefore depended on their home and abroad social networks, especially their mothers, for general and eating advice during pregnancy. The women referred to the advice offered by their social network as sometimes applicable but at other times steeped in cultural/food taboos, which the women would practice either out of fear or because they have deemed it not harmful. On the other hand, most interviewed midwives acknowledged that the healthy eating information offered was not culturally appropriate. However, there was a lack of knowledge regarding the best guidance that could be given. Most other interviewed midwives had no idea that Black women would require a different healthy eating information, while some wondered why the women would not just adapt.

All the pregnant women interviewed talked about their struggles with weight gain, loss, and maintenance before pregnancy and their desire to eat well for the baby’s sake and health. This information lends credence to the desire to change behaviours, especially during pregnancy. They also talked about having the advice tailored in such a way that it reflected their ethnicity and culture.

“I would have loved that leaflet to have something like my African foods tailored in the same way as the English one is done so that …you understand. It really matters; it matters to me.”– pregnant woman.

In order to promote healthy eating among migrant populations in the UK, it is essential to consider cultural traditions and dietary practices. One approach is to provide education and resources that support healthy eating choices within the context of a person’s cultural background.

As we embrace migration as a part of global growth, health services, and society will need to change in such a way that they can accommodate the changes that come with migration. Various factors, including cultural traditions, availability of food, and access to resources, can influence migration and healthy eating. In the UK, migration patterns have brought diverse cultures and cuisines, which can provide opportunities for healthy eating choices but can also pose challenges.

References

Ayoya, M. A., Bendech , M. A., Zagre, N. M., & Tchibindat, F. (2012). Maternal anaemia in West and Central Africa: time for urgent action. Public health nutrition, 916-927.

Bauld, L., Graham, H. M., Sinclair , L., Flemming, K. A., Naughton, F., Ford, A., . . . Eadie, D. (2017). Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study. Health Technoligy Assessment , 1-158.

Bryant, J., Waller, A. E., Cameron, E. C., Sanson-Fisher, R. W., & Hure, A. J. (2019). Receipt of information about diet by pregnant women: A cross-sectional study. Women and Birth, e501-e507.

Ferrari, R. M., Siega-Riz, A. M., Evenson, K. R., Moos, M. K., & Carrier, K. S. (2013). A qualitative study of women’s perceptions of provider advice about diet and physical activity during pregnancy. Patient education and counselling, 372-377.

Higginbottom, G. M., Evans , C., Morgan, M., Bharj, K. K., Eldridge , J., & Hussain, B. (2019). Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review . BMJ open, e029478.

Knight , M., Bunch , K., Tuffnell, D., Shakespeare , J., Kotnis , R., Kenyon, S., & Kurinczuk , J. J. (2019). on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care- Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford.

Lindqvist, M., Lindkvist, M., Eurenius, E., Persson, M., & Mogren, I. (2017). Change of lifestyle habits–motivation and ability reported by pregnant women in northern Sweden. Sexual and Reproductive Healthcare , 83-90.

O’Brien, O. A., Lindsay, K. L., McCarthy, M., McGloin, A. F., Kennelly, M., Scully, H. A., & McAuliffe, F. M. (2017). Influences on the food choices and physical activity behaviours of overweight and obese pregnant women: A qualitative study. Midwifery, 28-35.

Onubi, O. J., Marais, D., Aucott, L., Okonofua, F., & Poobalan, A. S. (2016). Maternal obesity in Africa: a systematic review and meta-analysis. Journal of Public Health, e218-e231.

Van der Pligt, P., Willcox, J., Szymlek-Gay, E. A., Murray , E., Worsley, A., & Daly, R. M. (2018). Associations of maternal vitamin D deficiency with pregnancy and neonatal comolications in developing countries: a systematic review. Nutrients, 640.

Zegeye , B., Anyiam, F. E., Ahinkorah, B. O., Ameyaw, E. K., Budu, E., Seidu, A. A., & Yaya , S. (2021). Prevalence of anemia and its associated factors a,ong married women in 19 sub-Saharan African countries. . Archives of Public Health , 1-12.

 

 

Dr Aniebiet Ibanga Ekong

Public Health Nutritionist, is a Research fellow in Maternal Health research at the University of Aberdeen and an Associate fellow of the Higher Education Academy

April 2023