Dietary knowledge, attitudes and practices of pregnant and postpartum Sub-Saharan African immigrants in Finland

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DIETARY KNOWLEDGE, ATTITUDES AND PRACTICES OF PREGNANT AND POSTPARTUM SUB-SAHARAN AFRICAN IMMIGRANTS IN FINLAND

M. Johanna Walker Master’s Thesis Clinical Nutrition School of Medicine Faculty of Health Sciences University of Eastern Finland February 2021

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Itä-Suomen yliopisto, Terveystieteiden tiedekunta

Kansanterveystieteen ja kliinisen ravitsemustieteen yksikkö Ravitsemustiede

WALKER M JOHANNA: Raskaana olevien ja synnyttäneiden Saharan etelänpuolisesta Afrikasta

tulleiden Suomessa asuvien maahanmuuttajanaisten ravitsemustieto, -asenteet ja -käytännöt Pro gradu -tutkielma, 167 sivua, 6 liitettä (19 sivua)

Ohjaajat: Yliopistonlehtori, dosentti, FT, Arja Erkkilä

Yliopistonlehtori, FT, Sohaib Khan

Helmikuu 2021______________________________________________________________________

Avainsanat: ruokatottumusten akkulturaatio, maahanmuutto, ravitsemus, raskaus

RASKAANA OLEVIEN JA SYNNYTTÄNEIDEN SAHARAN ETELÄNPUOLISESTA AFRIKASTA TULLEIDEN SUOMESSA ASUVIEN MAAHANMUUTTAJANAISTEN RAVITSEMUSTIETO, -ASENTEET JA-KÄYTÄNNÖT Afrikkalaiset maahanmuuttajat edustavat suhteellisesti nopeimmin kasvavaa maahanmuuttajaryhmää Suomessa. Heidän joukossaan on yhä enemmän Saharan etelänpuolisen Afrikan (SSA) naisia, jotka käyttävät maan äitiyspalveluita. Raskaana olevilla SSA-naisilla katsotaan olevan suuri riski erilaisille lääketieteellisille haasteille, jotka johtuvat suurelta osin taustalla olevista terveysolosuhteista. Siitä huolimatta, että SSA-naisten maahanmuutto länsimaihin on lisääntynyt viime vuosikymmeninä, maahanmuuton vaikutuksista heidän ruokavalioonsa ja raskauteen on vain vähän tietoa. Tämän kvalitatiivisen tutkimuksen tavoitteena oli siis saada syvällisempi käsitys odottavien ja synnyttäneiden SSA-maahanmuuttajaäitien ruokavaliotiedoista, -asenteista ja -käytännöistä Suomessa.

Tutkimukseen osallistujat rekrytoitiin lumipallo näytteenottomenetelmällä. Sopivat osallistujat olivat alun perin kotoisin SSA maasta ja olivat muuttaneet Suomeen viimeisen vuosikymmenen aikana.

Osallistujat asuivat pääkaupunkiseudulla ja pystyivät kommunikoimaan suomeksi tai englanniksi, ja tämän lisäksi heillä oli käytössä älypuhelin tai kamera, jolla he pystyivät dokumentoimaan syötyjä aterioita. Haastattelun aikana kukin osallistuja oli joko raskaana tai oli synnyttänyt viimeisen kahden vuoden aikana. Kenelläkään osallistujalla ei ollut kroonista sairautta tai vastaavaa terveydentilaa, jonka takia he olisivat joutuneet tekemään merkittäviä ruokavaliomuutoksia raskauden aikana. Tutkimukseen osallistuneet henkilöt viettivät raskausajan Suomessa.

Ensisijaisena tiedonkeruumenetelmänä oli kymmenen kasvotusten tapahtuvaa syvähaastattelua.

Lisäksi osallistujat pitivät valokuvausruokapäiväkirjaa ja valokuvia käytettiin yhtenä tietolähteenä.

Tämän lisäksi myös havainnollisia menetelmiä käytettiin tietolähteenä. Haastattelut litteroitiin kirjaimellisesti ja analysoitiin käyttämällä sisällönanalyysiä induktiivisella lähestymistavalla.

Tulosten perusteella useimmat osallistujat keräsivät tietonsa raskauden aikaisesta ravinnosta eri lähteistä. Näitä lähteitä olivat terveysklinikat, ystävät ja perhe, koulu ja Internet. Yleisin

ravitsemustiedon lähde oli suomalainen neuvola. Lisäksi enemmistö osallistujista oli sitä mieltä, että raskauden aikana tulisi noudattaa tasapainoista ja terveellistä ruokavaliota. Kaikkien osallistujien ruokailutottumukset olivat kaksikulttuurisia. Lisäksi tutkimuksessa todettiin, että erilaiset tekijät, kuten ruokatottumusten akkulturaatio, uskonnolliset vakaumukset, perinteisen uskomukset,

henkilökohtainen asenne raskaudenaikaista painonnousua kohtaan sekä raskauden aiheuttama pahoinvointi, oksentelu (NVP) ja mieliteot muokkasivat osallistujien ruokakäytäntöjä.

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Yhteenvetona voidaan todeta, että SSA-maahanmuuttajat Suomessa keräävät raskausajan

ravitsemukseen liittyvän tiedon eri lähteistä. Heidän ruokavaliotansa muokkaavat eri tekijät, kuten ruokatottumusten akkulturaatio, uskonto, perinteiset uskomukset, asenteet painonnousua kohtaan sekä NVP ja raskausajan mieliteot. Tämän tutkimuksen tulokset saattavat auttaa ohjaamaan tulevia terveyden edistämisinterventioita raskaana olevien ja synnyttäneiden SSA-maahanmuuttajanaisten parissa.

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University of Eastern Finland, Faculty of Health Sciences Institute of Public Health and Clinical Nutrition

Nutrition

WALKER M JOHANNA: Dietary knowledge, attitudes and practices of pregnant and postpartum Sub-

Saharan African immigrants in Finland

Master’s thesis, 167p. and 6 attachments (19 pages) Supervisors: Arja Erkkilä, PhD; Sohaib Khan, PhD.

February 2021______________________________________________________________________

Keywords: Dietary acculturation, immigration, nutrition, pregnancy

DIETARY KNOWLEDGE, ATTITUDES AND PRACTICES OF PREGNANT AND POSTPARTUM SUB-SA- HARAN AFRICAN IMMIGRANTS IN FINLAND

African immigrants represent proportionally the most rapidly growing group of immigrants moving to Finland. Among them, there is a growing number of Sub-Saharan African (SSA) women who use the nation’s maternity services. SSA pregnant women are considered to have a high risk for various medical challenges that are largely due to underlying health conditions. Despite the fact that immigration of SSA women to Western countries has risen in recent decades, there is scarce information on the impact that immigration has had on their diets and pregnancy. Thus, the aim of this qualitative study was to gain a deeper understanding of the dietary knowledge, attitudes and practices of expectant and postpartum SSA immigrant mothers in Finland.

The study participants were recruited via a method called snowball sampling. The eligible participants were natives of a SSA country and had moved from the SSA region to Finland within the past decade.

They were residents of the greater Helsinki region and were able to communicate in Finnish or Eng- lish. Additionally, they owned a smartphone or camera allowing them to document their eaten meals.

At the time of the interview, each participant was either pregnant or had given birth within the past two years. None of the participants had any chronic diseases nor conditions that would severely alter their diets and their pregnancies took place in Finland.

A total of ten face-to-face in-depth interviews were conducted and they served as the primary mode of data collection. Additionally, the participants kept a photographic food diary, and the photos were used as a complimentary source of data. Additionally, non-participant observational methods were used as a source of information during the interviews. The interviews were transcribed verbatim and analyzed by using content analysis with an inductive approach.

Most participants gathered their knowledge of nutrition in pregnancy from various sources. These sources included health clinics, friends and family, school and the internet. The most common source of dietary information was Finland’s maternity and child health clinic. Furthermore, most of the participants were seeking to follow a balanced and healthy diet in pregnancy, and they applied some level of bi-cultural eating patterns. Additionally, the study found that various elements, such as the process of dietary acculturation, religious convictions, traditional beliefs, attitudes toward weight gain in pregnancy, as well as pregnancy induced nausea and vomiting (NVP) and cravings shaped the dietary practices of the participants.

In conclusion, SSA immigrants in Finland gather their dietary knowledge from diverse sources. Their dietary practices are shaped by a range of factors, including dietary acculturation, religion, traditional beliefs, attitudes toward weight gain, as well as NVP and cravings. Findings of this study may help to direct future interventions regarding pre- and postnatal health care for SSA immigrants

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ACKNOWLEDGEMENTS

There is an old African proverb that says “If you want to go fast, go alone. If you want to go far, go to- gether.” I have come far, and therefore, I would like to acknowledge the people who have helped me to get to this point.

First, I want to express my gratitude to my supervisors Arja Erkkilä and Sohaib Khan. I could have not asked for more supportive and competent people to work with.

I also would like to thank my husband Tim, who was willing to move our family to another city, put his own career on a hold and stay home with our children twice, in order to support me in my studies. I am forever grateful for his love and support.

Espoo, December 2020 Johanna Walker

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1 INTRODUCTION

Finland has traditionally been a country of emigration. During the 20^th century, an estimation of 1 million people moved out of the country. The two most common countries that Finns were traditionally migrating to were Sweden and North America (Statistics Finland 2018). Sto- ries of success, new opportunities and work, were the primary reasons for Finns to leave their motherland and start a new life elsewhere (Söderling 2018).

The nature of migration took a shift in 1990, and Finland started receiving immigrants from other countries. The year 1991 was a crucial year in the Finnish migration history. Suddenly 13000 more people were moving into the country than leaving it (Statistics Finland 2018).

At the dawn of the 21^st century, the number of immigrants moving to Finland continued to rise. In the past few years, approximately 30 000 people have been annually immigrating to Finland (Miettinen 2016) and today, more than 300 000 residents with a foreign background reside in Finland (Statistics Finland 2019). Today, one resident out of seven is of foreign origin in the capital city (City of Helsinki 2018). It has been predicted that the immigrated population in Finland will continue to grow, and by 2035, the number of foreign-born residents in the capital area will be expected to double or expand even beyond that (City of Helsinki 2019).

Although, people’s health has improved over the past two decades and global life expectancy has increased by 5.5 years (World’s Health Organization (WHO) 2019b), researchers have found that immigrants usually suffer from poorer health compared to non-immigrant residents (Castaneda et al. 2012). Diverse ideas can be found on health and sickness, individual and community, and death and life among different cultures. These traditions and beliefs may cause misunderstanding and suspicion between a healthcare provider and the patient (The National Advisory Board on Social Welfare and Health Care Ethics (ETENE) 2004). Considering the rapid demographic change in Finland, it is evident that reliable information is needed about immigrants in Finland and their wellbeing (Castaneda et al. 2012).

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African immigrants represent proportionally the most rapidly growing group of immigrants moving to Finland (Government Institute of Economic Research (VATT) 2014). Among African immigrants, there is a growing number of Sub-Saharan African (SSA) refugee women moving to developed countries, who participate in their maternity services (Carolan 2010). Refugees are foreigners who are, or may be, at risk for persecution due to their origin, religion, national- ity, political opinion or involvement in a certain group (Finnish Immigration Service (MIGRI) 2020). Based on findings, the SSA pregnant women are considered to have a high risk for various medical challenges that are largely due to their previous health conditions. Even after the resettlement process, SSA women have higher rates of infant mortality and morbidity. Mater- nal risk factors are not the only reason behind the poorer infant health outcomes, but con- strained access to health care presents an additional challenge for them (Carolan 2010).

Despite the fact that immigration of SSA women to Western countries has been on the rise for the past decades, there is not enough information available on the impact that immigration may have on their diets and pregnancy (Lindsay et al. 2012). Further research could help de- velop and design more culturally appropriate care and services for SSA women residing in developed countries (Carolan 2010).

Consequently, the purpose of this thesis is to gain deeper understanding of the knowledge, attitudes and practices for gestational nutrition of expectant and postpartum SSA immigrant mothers in the greater Helsinki region.

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2 LITERATURE REVIEW

2.1 Background

This section discusses the topics of African migration to Europe and the current demographics and health issues regarding the African population in Finland.

2.1.1 African migration to Europe

The subject of African migration, the core reasons for it and its significance to European countries is widely misrepresented, according to the International Organization on Migration (IOM). Aside from the sporadic peak in migration flow to Italy in 2015, over 80 percent of African migration takes place within the continent. It was estimated that in 2015, there were a total of 21 million migrants in Africa, of which 18 million were natives of Africa, and the rest coming from other continents. Additionally, more than a quarter of the world’s refugees are accommodated by Africa. Although, emigration from Africa has seen a rise over the past decade, nevertheless, the number of African emigrants is one of the lowest in the world in reference to Africa’s total population. IOM reports that the emigration flow from Africa to Europe has been reasonable steady in the most recent years (IOM 2017).

About one third of Europe’s African immigrant population comes from SSA (Lindsay et al. 2012). SSA region is geographically and culturally diverse area that involves many different countries. Due to the disadvantageous economic-, political-, and ecological conditions of many of these countries, people continue to emigrate from SSA. Other contributing factors for departing from the SSA region are potential work- and education opportunities in the Western world (Lindsay et al. 2012).

During the past decades, there has been a peak in immigration of SSA women to developed countries.

Yet how their nutritional status and pregnancy outcomes are affected by immigration, is unclear. De- spite the fact that undernutrition still exists in SSA, there is a simultaneous nutrition transition taking place, which has caused a rise in obesity and chronic disease (Lindsay et al. 2012). It is often the poor,

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who experience undernutrition and the wealthy, who encounter overnutrition (de-Graft Aikins 2014).

Undernutrition is considered an extreme form of nutritional status, but so is obesity, and therefore, both extremes have implications for pregnancy outcomes and the offspring’s future health (Lindsay et al. 2012).

Majority of the African emigrants are of higher socioeconomic status and the most common countries where European SSA immigrants originate from, are Ghana, Senegal and Nigeria. Nigeria is the most populated country in Africa and also the leading country in international migration. Subsequently, Ni- gerians constitute the largest SSA-born immigrant group in many of the Western countries. SSA immigrants most commonly settle in the UK, France, Germany, Belgium and the Netherlands, but also more recently in Italy, Spain and Ireland. The UK and USA are known to look for highly skilled workers, especially in the area of healthcare, and Nigerian immigrants have been filling the need (Lindsay et al.

2012).

2.1.2 Demographics of Africans in today’s Finland

The number of people with a foreign background in Finland has steadily grown since the past two decades. In 2017, there were 385 000 people with a foreign background living in Finland, of which 84

% were first generation residents of a foreign background and 16 % were of second generation (Sta- tistics Finland 2019).

Somalis were the first large refugee group to arrive in Finland, and therefore, their entrance plays a significant role in the Finnish immigration history (Open Society Foundations 2013). Before the first Somali immigrants arrived, Finland had had limited global and European immigration compared to other Nordic countries.

The first wave of Somali immigrants was a highly educated group of people, whereas the next wave consisted of less privileged people who had very poor writing and reading skills. The first Somali immigrants looked radically different from the majority of the people in Finland and practiced an un- known religion in Finland, and as a result, they faced some difficulties in assimilation. They also arrived

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in the middle of an economic crisis in Finland, which created even more doubt in the minds of the Finnish people whether they could afford to accommodate the newcomers into the financially strug- gling country (Finnish Somali League 2017). The phenomenon has been referred to as the “Somali Shock” (Open Society Foundations 2013).

Today, the Somali language is the fourth most commonly spoken foreign language in Finland after Russian, Estonian and English (Miettinen 2016), and Somalis continue to be the largest immigrant group from Africa (Statistics Finland 2019). Nigerians in Finland hold the second place, followed by Moroccans, and then Ethiopians as the fourth largest group of African immigrants living in Finland (Statistics Finland 2019). Most foreigners in Finland are living in cities, of which the capital city of Hel- sinki, has the largest proportion of people with a foreign background. In 2017, 9,5 % of the residents of Helsinki were foreigners (The Family Federation of Finland 2019).

2.1.3 Health challenges among African immigrant population

The process of immigration is multi-faceted and can involve very stressful circumstances that may have long-lasting negative health consequences for an individual. These health effects may be trig- gered long before the process of migration has begun. Some of the known effects of stress are cardi- ovascular problems, higher risk of obesity, type 2 diabetes and a strain on the immunity (Jasso et al.

2005).

There is an assumption that immigrant women from SSA countries are of higher socioeconomic group and therefore, possess a better health. However, according to studies, immigrant women from SSA countries have poorer obstetric outcomes than their native counterparts (Lindsay et al. 2012). A study from Finland showed that women of African origin had the most health problems during their pregnancies and childbirth and had the poorest perinatal mortality (Malin and Gissler 2009). Another study found that women of SSA origin had the highest risk of delivering a low birth weight (LBW) baby in Europe, along with Latin-American and Caribbean women (Urquia et al. 2010). A child is considered LBW when the weight at birth is less than 2,500 grams (United Nations Children’s Fund (Unicef) and WHO 2004).

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Findings reveal that refugee women originating from Africa are in an especially vulnerable position and suffer from poorer general health (Carolan 2010). Many migrants are also economically and so- cially vulnerable and therefore, are prone to malnutrition (Hunter-Adams and Rother 2016). According to WHO: “Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.” (WHO 2016).

The state of undernutrition may have been occurring for years, even before migration took place (Kähkönen 2017), and as a result, immigrants often have poorer immunities (Carolan 2010). Addition- ally, some immigrants have intestinal parasites and are at risk for developing iron-deficiency anemia or rickets (Kähkönen 2017), which is a growth and development condition among infants, children and adolescents, due to vitamin D and calcium deficiency (Munns et al. 2016).

Other common health issues, that immigrants face, are stomach- and digestive problems, as well as low vitamin D levels (Kähkönen 2017). According to a Swedish study, vitamin D deficiency is common among immigrant women (Andersson et al.2013). Another Swedish study found that pregnant Somali women living in Sweden suffer from severe vitamin D deficiency (Sääf et al. 2011). Also, immigrant children are at risk for low vitamin D levels according to a Danish study (Glerup et al. 2004).

Some of the reasons that may explain poor obstetric outcomes among African immigrants are barriers- and delays to antenatal care (Lindsay et al. 2012), the care you receive from your health professionals in pregnancy (NHS 2016), but also language difficulties, lower socioeconomic status and low attendance on scheduled appointments. Other contributing factors are pre-existing conditions, closely spaced pregnancies, high number of previous pregnancies, disadvantageous pre-migration health and nutritional status (Lindsay et al. 2012). Without access to a culturally appropriate care, unwanted health outcomes may occur (Higginbottom et al. 2014). The most reasonable approach for offering culturally appropriate care is to focus on preventive nutritional care and simultaneously treat acute conditions. When an immigrant’s nutritional status recovers, their ability to receive new information improves (Kähkönen 2017).

Although, similar illnesses and conditions do exist between immigrants and natives of a Western country, the prevalence varies by ethnic background, age and gender. According to the Finnish

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institute for Health and Welfare (THL), African immigrants in Finland suffer more from anemia and experience more dental problems than the native Finnish population. For Somali immigrants in Finland, they have a higher tendency to be overweight and obese, and have diabetes, when compared to their Finnish counterparts. On the other hand, immigrants in Finland rarely have asthma or allergies (THL 2018a).

Similarly, lifestyle differences exist between native population and immigrant groups. Studies have shown that African immigrants in Finland use fresh produce sparingly, exercise minimally, abstain from alcohol, or use it sparsely, and brush their teeth regularly (THL 2018a). Furthermore, an Australian study found that the dietary changes that SSA immigrants made post-migration, were not health promoting and could lead to weight- and chronic health issues (Renzaho and Burns 2006).

Due to the limited amount of data, further investigation is needed on dietary intake, general health and poor pregnancy outcomes among SSA immigrants, in order to understand the connecting links between these issues. However, there is compelling amount of evidence to suggest that pregnant SSA immigrants should be seen as a potential high-risk group by maternity hospitals and clinics in West- ern nations. It is also noteworthy that nowadays many labor migrants from SSA countries are women.

This could rise the attendance rate of SSA women at antenatal care clinics in developed countries (Lindsay et al. 2012). Table 1 portrays the negative and positive factors influencing the health and wellbeing of immigrants.

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Table 1. Factors that strengthen and weaken the wellbeing and health of immigrants (THL 2018b).

Factors that strengthen the wellbeing and health of immigrants

Factors that weaken the wellbeing and health of immigrants

Contentment with the current living circumstances

Experiences in the country of origin and memories from the journey over

Feelings of satisfaction with the current quality of life

The challenges of the time spent in the reception center

The support of one’s own family and community

The difficulties faced in the process of assimilation (trying to participate in language learning, finding a job, becoming a member of a community etc.)

Trust in the Finnish social services Untreated illnesses and the difficulty of finding appropriate services in the new country

Certain lifestyle factors, such as limiting the use of alcohol

Concerns over distant family members Special concerns and traditions (for example genetic diseases and female cir- cumcision)

Experiences in the new country of resi- dence (for example discrimination and lack of social support)

2.2 Nutrition in pregnancy

It was first observed in Holland during famine that low food intake in pregnancy results in low birth weight (Painter et al. 2005). This is due to the reduction of glucose for the fetus. Since then, research has shown that fetal growth and development are largely shaped by the nutritional, hormonal and metabolic surroundings contributed by the mother. These nutritional surroundings at the beginning of life have short-term and long-term health effects. The short-term effects are growth, organ development, body composition and functions of the fetus. Whereas, the long-term effects are adulthood risks associated with health, morbidity, mortality, and the progression of neural functions and behavior, also known as ‘metabolic programming’ (Tzanetakou et al. 2011).

The impact of maternal malnutrition on the fetal growth is most drastic on the third trimester of pregnancy. Furthermore, famine occurring within the uterus increases the risk of perinatal mortality by a

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sixfold when compared to subjects who are not exposed to famine (Imdad et al. 2012). Some of the health risks associated with maternal malnutrition in pregnancy are intrauterine growth restriction (IUGR), preeclampsia, and cretinism (Wu et al. 2012). In IUGR, the baby in the womb fails to grow at the expected rate during the pregnancy (Hirsch 2014). Whereas, in preeclampsia, which is a multisys- tem syndrome, a pregnant woman develops a new-onset hypertension that is usually accompanied by new-onset proteinuria (Henderson et al. 2017). And lastly, cretinism is identified by impaired neuro- logical development along with permanent growth stunting in the child (Wu et al. 2012). Figure 1 describes in more detail the health risks associated with maternal malnutrition in pregnancy.

Today, famine is not the only manifestation of poor nutrition. The number of overweight young women is growing in developed nations, and surprisingly also outside of Western societies. This is mostly due to rapidly changing environment, specifically concerning lifestyle and diet. Despite the vast amount of information on the importance of a healthy diet in pregnancy, there seems to be a growing number of women of reproductive age, who possess extreme dietary habits and nutritional status.

This phenomenon is prevalent all over the world and an extensive amount of evidence suggests that the consequences of such behavior lead to poorer health for the mother and the child. Pursuing

“Western” dietary habits and lifestyle lead to short-term and long-term consequences in pregnancy.

The short-term consequences may lead to higher incidence of pregnancy-, delivery- and neonatal complications, whereas the long-term consequences impact the future health of the woman and her baby (Henriksen 2006).

Both, over- and undernutrition in pregnancy have been linked with maternal, fetal and infant morbidity and mortality by convincing epidemiological studies (Wu et al. 2012). Since they both represent extreme forms of nutrition, they can be defined as malnutrition. Surprisingly, there are common elements between them. These are: an imbalance of nutrients, increased blood cortisol levels and oxida- tive stress (Wu et al. 2012).

Despite the extensive research on the importance of nutrition in pregnancy, most women have insufficient knowledge of nutrition and their dietary intake does not meet the current recommendations (Fowles 2002). Barriers to eating well during pregnancy include lack of knowledge of certain

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nutritional recommendations or lack of skills to improve one’s diet. Other obstacles are food aversions, cravings, nausea, vomiting, fatigue, constipation, hemorrhoids and heartburn (Forbes et al.

2018).

The most recent scientific literature supports the idea that lifestyle factors, including nutrition, have a crucial role in the health of the mother and child (Marangoni et al. 2016). During pregnancy, the need for many vitamins and minerals is higher; yet energy needs are elevated only slightly. Therefore, nutrient-dense foods that contain plenty of vitamins and minerals, and which are lower in calories, should be consumed frequently (THL 2019). According to the WHO: “A healthy diet during pregnancy con- tains adequate energy, protein, vitamins and minerals, obtained through the consumption of a variety of foods, including green and orange vegetables, meat, fish, beans, nuts, pasteurized dairy products and fruit” (WHO 2017).

It has been shown that nutrition is of importance even during the preconception days (Marangoni et al. 2016). About 10 percent of the population suffer from infertility. Although not all causes of infertility are controllable, the mother’s and father’s proper nutrition and healthy body weight can have a major role in their chances of conceiving (Kaufman 2017). Therefore, pursuing healthy dietary choices is ideal for women and men of reproductive age, even before pregnancy takes place (APA 2015, Panth et al. 2018).

Pre-pregnancy nutrition does not only impact fertility but also the course of the pregnancy. During the first trimester of pregnancy, the growth of the fetus is mostly based on the nutritional status of the mother prior to conception (THL 2016). An increasing number of epidemiological studies researching human populations suggest that a meager nutritional intake around the time of conception may result in a higher chance of having a premature birth. Additionally, poor dietary choices during the time of conception increase the risk of hypertension, heart disease and obesity later as an adult (Oliver et al. 2007). Diet also affects ovulatory maturation and the quality of the ova that a woman’s body pro- duces (Wynn et al. 1988). Besides the importance of pre-pregnancy nutrition, diet continues to matter during the pregnancy and breastfeeding period (Marangoni et al. 2016).

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Pregnant women’s nutritional status can be advanced by educating them on nutritional issues and by giving them dietary counseling. These are widely used strategies and the available evidence suggests that they may result in positive health outcomes. Examples of such outcomes are an optimal gestational weight gain, reduction in the risk of anemia in late pregnancy, increasing the infant’s birth weight and lowering the risk of preterm delivery. Especially in undernourished populations, nutritional counselling can be used as an influential tool when it is combined with nutrition support, for example whole food or micronutrient supplementation (WHO 2017).

In conclusion, pregnancy calls for a versatile diet that is composed of high-quality nutritious foods.

The need for many vitamins and minerals increases significantly but energy needs are elevated just slightly. Folic acid and vitamin D supplement are often recommended for all pregnant women,

whereas other nutrients can be obtained from eating a variety of different foods. A health care profes- sional assesses a mother’s need for supplemental iron, calcium or iodine (THL 2016).

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Figure 1. Health risks associated with maternal malnutrition in pregnancy.

Source: Modified figure from (Wu et al. 2012).

2.2.1 Nutritional requirements

It is suggested that all pregnant women eat a variety of nutrient-rich foods from different food groups every day (The Academy of Nutrition and Dietetics (AND) 2019). An excess of calories may be as dam- aging as a deficiency of them (Marangoni et al. 2016).

Maternal hemorrhage

or anemia

Preterm delivery

Birth defects

Cretinism

Preeclampsia and eclampsia

Growth and development problems (in the

child) Maternal insulin

resistance Fetal, neonatal

and postpartum complications Longterm

adverse health effects (on both)

Cognition and behaviour

Intrauterine growth restriction

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The Academy of Nutrition and Dietetics in the United States recommends that pregnant women would eat a balanced diet that includes whole grains, fruits, vegetables, lean proteins, low-fat or fat- free dairy and healthy fats. Extra calories from sugar and solid fats should be avoided and certain high-energy, low-nutrient foods, such as soda, fried foods and sweets, should be reduced to mini- mum. The academy emphasizes the importance of getting enough nutrients from eating a variety of foods for a healthy pregnancy (AND 2019).

Accordingly, the national nutritional guidelines in Finland recommend that vegetables, fruits, berries and whole grains would be the basis of a diet for a pregnant woman. These foods are great sources of folate, which is an essential nutrient for pregnancy. Additionally, Finnish rye bread, soy, green leafy vegetables, beans and pulses are recommended as a good source of iron in pregnancy. For sufficient calcium intake, the guidelines encourage women to consume fat-free dairy products, that also provide pregnant women additional vitamin D and iodine, that are important nutrients needed for a healthy pregnancy. Besides the foods mentioned above, the Finnish guidelines highlight the importance of favoring foods that contain unsaturated fats and essential fatty acids such as plant oils, margarines and fish. Fish is recommended to be consumed two to three times a week, and by altering different kinds of types of fish (THL 2016).

2.2.2 Macronutrients

Macronutrients are energy providing nutrients. They are required in large amounts to maintain body functions and to carry out the activities of daily life. There are three broad classes of macronutrient:

proteins, carbohydrates and fats (WHO 2019a). Having a healthy pregnancy requires additional macronutrients (Marangoni et al. 2016).

Protein

An international community agrees that it is important to have an increased protein intake during pregnancy. A demand for protein is at its highest during the third trimester of pregnancy, when it is needed for protein synthesis to maintain maternal tissues and fetal growth (Marangoni et al. 2016).

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Protein has also been found to be the most crucial macronutrient impacting the birth weight (Cuco et al. 2006). Besides impacting the growth of the fetus and the birth weight, protein is the most effective macronutrient for reducing pregnancy-induced nausea (Green 2010). Additionally, balanced protein- energy supplementation in pregnancy has been found to be impactful at lowering the risk for LBW and small-for-gestational-age births, particularly in women who are undernourished (Imdad and Bhutta 2012).

Nevertheless, taking high-protein supplementation during pregnancy does not guarantee additional benefits for the mother or the child but may even impair fetal growth. Comparably, protein or energy restriction is not advised during pregnancy, and may lead to unwanted results (Kramer 1993), such as detrimental effect on the fetal development, especially if protein restriction takes place during the first trimester and is accompanied by a deficiency of micronutrients.

The individual needs of a pregnant woman determine the amount of protein that is needed for a healthy pregnancy. These needs include caloric needs, the current trimester she is on and whether it is a multiple pregnancy or not. Good sources of protein during pregnancy are eggs, beans, lentils, seafood (with some exceptions), poultry, lean meats and low-fat dairy products (Klemm 2018).

Fat

Another relevant macronutrient in pregnancy is fat. The quality of the dietary fat is more important than the amount of it (Marangoni et al. 2016). Polyunsaturated essential fatty acids (alpha-linolenic, ALA acid and linoleic acid) are essential for the development of the nervous system, eyesight, and im- mune system of the fetus. Good dietary sources of these fatty acids are vegetable oil, margarine and fatty fish (THL 2016).

One fatty acid that is needed in higher amounts during pregnancy is docosahexaenoic acid (DHA) (Makrides 2009). DHA is a long-chain polyunsaturated fatty acid and is needed for normal growth of the brain, including cognitive development. DHA can be found in seafood or in dietary sup- plements (Braarud et al. 2018). Typically, pregnant women in Western countries have a low intake of DHA despite the human body’s ability to transform ALA to DHA via adaptive metabolic mechanisms.

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Enlarged maternal cell mass, the growing placenta, as well as the additional needs of the fetus esca- late the metabolic need for DHA during pregnancy. Nonetheless, it remains unclear whether these increased needs are met (Makrides 2009).

Carbohydrate

Various studies have found that carbohydrates are a fundamental component of a balanced maternal diet (Tzanetakou et al. 2011). Glucose, derived from carbohydrates, serves as the major fuel for red blood cells, retinal cells and kidney medulla cells during pregnancy, for both the mother and the child (Wu et al. 2012). When carbohydrates are replaced by high levels of dietary protein, studies have shown that it can lead to health problems, such as high blood pressure and increased cortisol secre- tion in response to psychological stress in the offspring. Also, by emphasizing quality carbohydrates in the maternal diet during pregnancy and lactation can serve as a preventative measure for diet-induced adiposity and associated metabolic disruptions in the offspring (Tzanetakou et al. 2011).

The recommended amount of carbohydrates does not change in pregnancy but remains within the same range (50-60% of energy) as for the general population (Meija and Rezeberga 2017). The Finn- ish national guidelines for pregnancy indicate the importance of involving whole grains in the diet.

Whole grains are a great source of dietary fiber and the recommendation is to have 25-35 grams of fiber each day. This can be accomplished by using whole-grain products that have at least 10 % of fiber and by consuming fruits, berries and vegetables each day (THL 2019).

Recent studies have shown that the risk for the onset of type 2 diabetes mellitus is reduced by increasing whole grain intake. Higher intake of whole grains also improves glucose metabolism. There- fore, whole grains can considerably improve the maternal diet, especially for those following a typical western diet (Tzanetakou et al. 2011).

Finally, sugar is a carbohydrate that should be consumed in moderation. The risk for obesity increases when sugar is consumed in excess. Additionally, pregnant women should avoid consuming sweetened

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soft drinks in order to minimize their risk for pre-eclampsia and premature birth (Meija and Rezeberga 2017). The recommendation for sugar is to limit its intake to 10% of total energy (THL 2019).

2.2.3 Crucial micronutrients

Micronutrients are nutrients that are needed only in small amounts. They enable the body to produce enzymes, hormones and other substances, which are essential for proper growth and development.

The consequences of their absence are severe (WHO 2018b). Some of the key micronutrients needed in higher amounts during pregnancy are folate, iodine, calcium, vitamin D and iron (Marangoni et al.

2016).

Iron

Iron plays a role in the transfer of oxygen to tissues, and a lack of it may result in a globally recog- nized problem called anemia (Marangoni et al. 2016). Furthermore, anemia in pregnancy is a risk factor for hemorrhage (Wu et al. 2012). One study found a link between anemic pregnant women (when maternal Hb concentration was lower than 9.0 g/dl) and their one-year-old children’s lower cognitive- and motor development (Mireku et al.2015). The most common symptom caused by iron deficiency is fatigue (Pavord et al.2012). Deficient protein intake can also contribute to anemia (Wu et al. 2012).

A pregnant woman can get half of the iron she needs for a healthy pregnancy from eating a regular diet (THL 2019). Some of the main food sources of iron are meat, fish, legumes and green leafy vegetables (Marangoni et al. 2016). If a pregnant woman has had low levels of hemoglobin in the beginning of the pregnancy (below 110 g/l), an iron supplement can be considered after she has reached week 12 in her pregnancy (THL 2019).

Immigrant women may be especially vulnerable to low levels of iron during pregnancy. According to a Danish study, pregnant immigrant women in Denmark had higher prevalence of anemia than ethnic

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Danish women. The study also showed that the immigrant women’s plasma tests indicated deficiency in iron (Nybo et al. 2007).

Iodine

Another key nutrient for a healthy pregnancy is iodine. Fish, shellfish, milk, eggs and meat are good sources of iodine. Iodine has multiple functions in the body. It is “a major component of thyroid hormones and is essential for their functions, namely growth, formation and development of organs and tissues, in addition to the metabolism of glucose, proteins, lipids, calcium and phosphorus, and ther- mogenesis” (Marangoni et al. 2016). In Finland, the recommendation for iodine during pregnancy is 175 micrograms per day (National Nutrition Council 2014).

Iodine deficiency in pregnancy proposes potential risks for the fetus. The impacts of severe iodine deficiency during pregnancy are well documented and include neurodevelopmental impairments and adverse birth outcomes (Chittimoju and Pearce 2019). Some immigrant groups may be iodine deficient. A recent study reported that Somali immigrants residing in Norway had low iodine intake and their iodine status was less than ideal (Madar et al. 2018).

Calcium

Calcium is another key micronutrient that pregnant women should get enough of. Calcium is needed for the development of the baby’s teeth, bones, heart, nerves and muscles. If a pregnant woman does not consume enough of calcium-rich foods, her body takes the mineral from her own bones for the benefit of the growing baby (AND 2019). Reduced concentrations of calcium in the plasma aid the development of preeclampsia and preterm labor (Wu et al. 2012).

A cross-sectional study found that women with adequate intake of calcium and vitamin D during pregnancy, delivered infants who had higher mean length and 1-min Apgar score at birth when compared to infants of mothers, who had insufficient calcium and vitamin D intake (Sabour et al. 2006).

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According to the Finnish national guidelines, a pregnant woman can get enough of calcium by consuming 5-6 dl of liquid dairy products and by having 2-3 slices of cheese daily (THL 2019).

Vitamin D

Vitamin D levels are impacted by a person’s diet, exposure to sunlight, ethnicity, age and other individual’s characteristics (Marangoni et al. 2016). A study from the United States that was determining the incidence of vitamin D deficiency, insufficiency and sufficiency in pregnant women of different ethnicities, found that race was the most important risk factor for vitamin D deficiency. According to the study, African-American women were most at risk for vitamin D deficiency (Johnson et al. 2011).

Other studies have also confirmed that a person’s background impacts his or her risk for low vitamin D levels. A migrant health and wellbeing study found that immigrants in Finland suffer from low vitamin D levels, especially immigrants of Kurdish and Somali origin (Castaneda et al. 2012). Similar results were found by another European study, where more than half of the non-European pregnant, immigrant women and their newborns were severely vitamin D deficient (Wielders et al. 2006). In Finland, a vitamin D3 supplement is recommended to all pregnant women around the year. The current recommended dosage is 10 micrograms per day (THL 2016).

Folate

In Finland pregnant women are recommended to take a folic acid supplement (0,4 milligrams/day) two months before intending to get pregnant and up to 12 weeks of pregnancy, in order to minimize the risk for neural tube defects (NTD) (THL 2019), which are serious birth defects of the central nervous system that arise during embryonic development when the neural tube fails to close thoroughly (Greene and Copp 2014). Research has shown that recently migrated pregnant women have an increased risk for delivering babies with NTDs. A large population-based case–control study found a sevenfold increased risk for NTD’s among recent Mexican immigrants (Velie et al.2006).

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Taking a folic acid supplement prior to conception can prevent up to 70 % of NTD impacted pregnancies (deRosset et al. 2009). There is consistent evidence for improved fertility when supplemental folic acid is used in higher doses than what is recommended for preventing neural tube defects. Addition- ally, infertility treatments have a higher chance of succeeding and the risk for miscarriage is decreased (Gaskins and Chavarro 2018).

Conversely, many women fail to take a folic acid supplement during pregnancy. A study, conducted in Scotland, found that only 31 % of women were taking a folic acid supplement (Lucas et al. 2014). One factor, that has an impact on a pregnant woman’s intake of folate, is the level of quality in antenatal care. Many pregnant women miss out on the critical time period of early pregnancy, when taking sup- plements such as folic acid would be highly beneficial for their baby’s development, because they are not receiving adequate nutritional guidance until later in their pregnancies (Lucas et al. 2014).

Despite the recommended folic acid supplement, pregnant women are encouraged to consume folate rich foods during pregnancy. Some foods that contain high amounts of folate are green vegetables and whole grains (THL 2019). Many women increase their intake of folate-rich foods during pregnancy. Nevertheless, the most common reasons for having more of folate containing foods in their diet is not to improve their level of folate, but to satisfy a craving, find enjoyment in the food and to decrease their chances of getting ill (Forbes et al. 2018).

2.2.4 Healthy weight gain

Dietary intake in pregnancy has a direct link to weight gain, and moreover, maternal weight gain is a predicting factor for the baby’s birth weight (Fowles 2002). According to European Food Safety Au- thority (EFSA), an increase of 70-260 kcal/day are recommended for the first trimester of pregnancy and 500 kcal/day for the second and third trimesters (Marangoni et al. 2016). Consumption of calories beyond nutritional needs may be detrimental for health and lead to lifelong struggles with weight.

Approximately half of obese women state pregnancy as the beginning of their struggle with excess weight (THL 2016). The ideal pace for gaining weight in pregnancy is 1.6-2.3 kg during the first trimester and 0.5 kg/week during the second and third trimesters (Fowles 2002).

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Weight gain in pregnancy is caused by the weight of the uterus, fetus, placenta, amniotic fluid, blood, extracellular fluids, breasts and other tissue (fat) (The Institute of Medicine (IOM) 2009). IOM has created guidelines for a healthy weight gain during pregnancy. Table 2 represents recommendations for pregnancy weight gain for women of different BMI.

Table 2. Institute of Medicine weight gain recommendations for pregnancy (Modified from: ACOG 2016).

Pre-pregnancy Weight Category

Body Mass Index (BMI) Recommended Range of

Total Weight (kg)

Underweight Less than 18.5 13-18

Normal Weight 18.5-24.9 11-16

Overweight 25-29.9 7-11

Obese 30 and greater 5-9

As table 2 portrays, the more a woman weighs in the beginning of her pregnancy, the less she should gain weight during the course of her pregnancy. Likewise, if a woman is underweight before getting pregnant, ideally, she would gain more weight during her pregnancy than women of normal weight and above the normal weight range (ACOG 2016). Not gaining enough of weight in pregnancy presents a higher risk for a woman to deliver LBW baby, who is more prone to sickness and/or death. Ad- ditionally, slow weight gain in second and third trimesters increases the risk for preterm labor and preterm infants (Fowles 2002).

IOM emphasizes that excessive weight gain should be limited during pregnancy in order to achieve best pregnancy outcomes. Accordingly, if an overweight or obese woman gains weight below the current recommendations there is no clinical evidence showing that this would harm the fetus, as long as the fetus is growing within the normal standards (ACOG 2016).

The number of women, who gain an excessive amount of weight in pregnancy, has risen significantly in the past decades. Excess gestational weight gain (GWG) is linked to numerous adverse health

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outcomes that are detrimental for both mothers and children. A major predictor for postpartum obesity is gaining an excessive amount of weight in pregnancy (Fowles 2002).

Furthermore, weight gain in pregnancy is not equally distributed among women but studies have shown that there are health disparities in the area of excessive weight gain. For example, in the United States, racial and ethnic differences for maternal and child health outcomes exist. Over 40 % of minor- ity women gain above the recommended upper limit (IOM 2009) during pregnancy (Headen et al.

2012). Table 3 summarizes the problems associated with excessive GWG (Orloff et al. 2016)

Table 3. Problems associated with excessive gestational weight gain (Orloff et al. 2016).

Adverse health out- comes for chil- dren/adolescents

Adverse health outcomes for mothers

Other problems

Increased risk for macrosomia

Excess weight retention, overweight and obesity after delivery

Increased cost of obstetric care

Increased risk for over-

weight and obesity Gestational diabetes Perinatal fatality

Hypertension Neural tube defects Preeclampsia

Delivery complications Delivery complications Neonatal hypoglycemia Caesarean sections Lower success in

breastfeeding

Lower success in breastfeeding

As table 3 shows, there are various issues related to excess GWG. Macrosomia, which is defined as a birth weight of >4000 g (Araujo et al. 2017), is one of the problems that can rise from excess GWG and impact the offspring (Orloff et al. 2016). Whereas one of the possible adverse health outcomes of GWG for the mother is gestational diabetes (GDM), a condition in which high blood sugar develops during pregnancy and usually disappears after giving birth (NHS 2019).

At the moment, overweight is considered to be one of the most common high-risk obstetric health threatening conditions (Orloff et al. 2016). Weight management interventions in pregnancy have been found to be ineffective for various reasons. Some of these reasons include the changes that a

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woman’s body undergoes during pregnancy, feelings of losing control, the challenges in interactions with different sources of advice and perceived risks in pregnancy. Instead of focusing on the woman’s weight, a more effective way may be emphasizing healthy diet and exercise (Johnson et al. 2013).

2.2.5 Foods and drinks to avoid

The previous section presented that proper nutrition in pregnancy is vital for the health of the mother and the baby (THL 2019). Likewise, abstinence from fast foods and other harmful foods during pregnancy is crucial for the health of the mother and her offspring (AND 2019). Evidence from different studies show that fast food consumption during pregnancy can have detrimental health consequences. One study found a connection between frequent maternal fast food consumption during pregnancy and asthmatic symptoms in young children (Von Ehrenstein et al. 2015). Another study re- vealed that frequent fried food consumption in pregnancy is significantly associated with a higher risk for GDM (Bao et al. 2014). Furthermore, intake of sweets in overweight/obese pregnant women have been found to have a potential influence on the weight status of the infant (Phelan et al. 2011). More- over, high intakes of sugar and saturated fats have been associated with poorer semen quality and decreased fertility for men (Panth et al. 2018).

Besides eating a balanced diet and limiting the consumption of fast foods, there are certain precau- tions that pregnant women should take in order to limit their risk of getting a food-borne illness or exposing their growing fetus to harmful substances. According to findings, pregnant women are more likely to reduce harmful foods from their diet than increase their consumption of nutrient-rich foods that are essential for pregnancy (Forbes et al. 2018). Table 4 describes a list of foods that should be avoided during pregnancy, according to the American Pregnancy Association (APA) (APA 2017).

A large portion of the foods that APA has listed as foods-to-be-avoided during pregnancy carry a risk of contracting a bacterium called listeria. Listeria is a common bacterium that lives in the soil and wa- ter, as well as in some animals. Unlike most bacteria, listeria can grow even in cold temperatures. In order to kill it, a food needs to be properly cooked or pasteurized. Listeria causes an infection called listeriosis. Pregnant women have approximately 20 times higher risk of getting listeriosis compared to

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generally healthy, non-pregnant population. Listeriosis is not a dangerous infection for the mother, but can cause miscarriage, stillbirth or life-long health problems for the baby. Therefore, following public health guidelines on safe food preparation and consumption is crucial for pregnant women who desire healthy pregnancies (WHO 2018a).

Table 4. Foods to avoid during pregnancy (APA 2017).

Food/Drink The Reason to Avoid

Raw meat Risk of contamination

with bacteria

Deli meat Risk of contamination

with listeria

Fish with mercury Has been linked to developmental delays and brain damage

Smoked seafood Listeria risk

Fish exposed to industrial pollutants Risk of industrial pollutants

Raw shellfish Risk of infection

Raw eggs Salmonella risk

Soft cheeses Listeria risk

Unpasteurized milk Listeria risk

Pate Listeria risk

Caffeine Limit caffeine to 200 mg per day to

avoid the risk of miscarriage

Alcohol Can interfere with healthy development

of the baby

Unwashed vegetables Risk of toxoplasmosis

A study from Belgium, that investigated pregnant versus non-pregnant women on their dietary behavior and the perceived role of food for health, found that pregnant women followed nutritional recommendations on safe food handling practices. They also had a reduced consumption of those foods that have safety risks, and they consumed tobacco and alcohol less than non-pregnant women (Verbeke and Bourdeaudhuij 2007).

In Brazil, the opposite phenomenon was found. A study found that pregnant and lactating Brazilians do not change their food intake to meet nutritional goals. Their high intake of sodium and processed foods, as well as their low intake of health-promoting foods, is a public health concern (Dos Santos et al. 2014). Similarly, a study from the United States found that pregnant women had not understood

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the connection between consuming risky foods in pregnancy and the potential implications for their unborn child. These women had the assumption that their food was safe and demanded strong evidence for proven wrong (Athearn et al. 2004). Section 2.2.7 discusses more in detail why women make certain dietary choices in pregnancy.

Alcohol

Alcohol was first discovered to have a negative impact on the fetus in 1968 (Lemoine et al.1968). This finding was made by studying alcoholic mothers and the harmful health outcomes displayed in their children. In 1973, other researchers confirmed this idea by presenting similar findings. Since then, more evidence has come out about the impact of alcohol on the fetus, and today, the medical community acknowledges that exposing fetus to alcohol can cause a wide range of health problems in the areas of development and emotional-, behavioral- and social health (Clarke and Gibbard 2003). Some evidence suggests that high intakes of alcohol and caffeine, and low intakes of antioxidants, may also be associated with impaired fertility (Derbyshire 2011).

The most common developmental disabilities and birth defects in the western world, related to alcohol consumption during pregnancy, are Fetal Alcohol Syndrome (FAS), which is considered to be part of the Fetal Alcohol Spectrum Disorders (FASD), and Alcohol Related Neurodevelopmental Disorder (ARND) (Clarke and Gibbard 2003). In the United States, it is estimated that 10 per 1000 children are impacted by one of the above disorders/syndromes (May et al. 2018). FASDs are life-long disabilities (May et al. 2018) and include a whole range of different health effects (CDC 2019). The other impacts of alcohol use during pregnancy, besides potential developmental disabilities and birth defects, are higher risk of preterm labor, decreased production of breastmilk, and increased risk for spontaneous abortion, especially during the first trimester (Bhuvaneswar et al.2007).

There are certain risk factors for alcohol use in pregnancy. These risk factors include poverty, home- lessness, preconception substance use, partner’s substance use, physical or sexual abuse and psychiat- ric illness. The strongest predictor of these is preconception substance use (Bhuvaneswar et al.2007). A

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limited number of studies point to the notion that psychological and educational interventions may have a positive impact on women’s drinking behavior during pregnancy (Stade et al. 2009).

The frequency of alcohol consumption in pregnancy changes from country to country. A multinational European study found that almost 16 % of women residing in Europe consumed alcohol while pregnant (Mårdby et al. 2017). However, notable cross-country variations existed. Over half of pregnant women living in Italy, Switzerland and the UK had at least one alcohol unit per month and the two countries with the highest alcohol consumption in pregnancy were the UK (28.5 %) and Russia (26.5

%). On the contrary, the lowest countries for alcohol consumption in pregnancy were Norway (4.1 %) and Sweden (7.2 %). The predictors for consuming alcohol in pregnancy were higher education and smoking before pregnancy (Mårdby et al. 2017). A similar study from the United States reported that 10.2 % of pregnant women used alcohol during pregnancy and 3.1 % engaged in binge drinking in pregnancy (Tan et al. 2015). Worldwide estimation of drinking during pregnancy is 20 % (Stade et al.

2009).

Although alcohol consumption in or outside of pregnancy is not uncommon for women living in western countries, it is rare for women coming from Africa (THL 2018a). The most common drinking pat- tern among African women is a lifetime abstention. Female drinking is traditionally not culturally ac- cepted because of religious-, traditional-, cultural- and gender-based reasons (Martinez et al. 2011).

2.2.6 Dietary practices of pregnant women

Some of the lifestyle changes that women make in pregnancy concern nutrition, and others are related to wanting to avoid harmful substances. One study found that there were significant reductions in smoking patterns and the consumption of alcoholic and caffeinated beverages after a woman be- came pregnant. On the other hand, the study found that there were only little changes in the pregnant women’s fruit and vegetable consumption (Crozier et al. 2009). The most common dietary modifications that pregnant women make, that are in line with nutritional guidelines, consist of decreasing caffeine consumption, staying away from alcohol, abiding by food-safety recommendations and increasing milk-, vegetable- and fruit intake (Forbes et al. 2018).

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Unfortunately, many of the positive nutritional changes made in pregnancy tend to fade away after giving birth. A study examining the dietary behavior of low-income women during pregnancy and postpartum, in a multiethnic sample, found that women consumed more grains, vegetables and fruits during pregnancy. After giving birth, their consumption of fat increased by 37.3 % and their consumption of added sugar increased by 14.4. %. These findings suggest that low-income women show more positive dietary behavior during pregnancy compared to the postpartum period (George et al. 2005).

2.2.7 Factors affecting food choices during pregnancy

Eating and drinking are part of the daily activities that humans engage in. Despite their ordinary nature, “they are complex behaviors that are determined by many factors and their interactions” (Köster 2009). Diet-related behaviors may change in pregnancy due to interactions between different determinants of eating behaviors. These determinants are personal values and beliefs about the ideal diet in pregnancy, advice from professionals, personal preferences, time, money and physical and physiological changes (Forbes et al. 2018).

Typical dietary changes that women make during pregnancy are reduction and elimination of certain foods. When women’s reasons for these changes have been studied, health of the baby, concern, aversions and nausea are listed as the most common reasons for making these changes. On the contrary, when pregnant women’s choices for adding certain foods into their diet have been studied, the most frequent responses are concerning cravings, nutritional content, health, enjoyment, and efforts to decrease the chances of illness (Forbes et al. 2018).

Despite the vast amount of evidence emphasizing the importance of a healthy diet in pregnancy, not all women see the need to make dietary modifications when they get pregnant. Researchers have found that social and biological factors impact the dietary choices that pregnant women make. For example, a compliance with public health recommendations for pregnancy is notable especially among older and more educated women (Crozier et al. 2009). Whereas, younger, less educated women, who have a higher pre-pregnancy weight and who have more children, are more likely to

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have poorer quality diets in pregnancy (Rifas-Shiman et al. 2009). Table 5 lists some general determinants of food choice according to the DONE framework categorization structure (Stok et al. 2017).

Table 5. Determinants of food choice. Source: This table was modified from the original DONE framework (figure 3) categorization structure: Determinants of nutrition and eating (Stok et al. 2017).

Main levels Stem-categories Leaf-categories

Individual Biological 1 Brain and oral function

2 Food related physiology 3 Anthropometrics

4 Sensory perception Demographic 1 Situational demographics

2 Personal socio-economic status

Interpersonal

Environment

Psychological

Situational Social

Cultural Micro Macro

1 Mood and emotions 2 Health cognitions 3 Food knowledge, skills and abilities

1 Situational and time con- straints

1 Family Structure 2 Family food culture 3 Household socio-economic status

4 Social influence 5 Social support 1 Cultural cognitions 2 Cultural behaviors 1 Home food availability and accessibility

1 Characteristics of living area

2 Environment food availability and accessibility 3 Food outlet density 4 Market prices

The following sections will focus on some of the determinants listed in Table 5 that pertain especially to pregnant women’s dietary choices.

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Biological determinants

Pregnancy related nausea, aversions, cravings and changes in olfaction are some of the factors that may alter dietary behavior during pregnancy (Fessler et al. 2002). One of the common foods, that pregnant women often find offensive, is meat (Flaxman and Sherman 2000). Traditionally, meat has been the food most likely to carry pathogens, and it is not until recently that humans have found effective hygienic methods to ensure the elimination of pathogens in meat. A study from an evolution- ary perspective on the topic of pregnancy sickness and meat consumption suggests that these biological mechanisms are in place for a reason during a time of vulnerability (Fessler et al. 2002). Indeed, morning sickness has been found to have a positive effect on pregnancy outcome, including a decreased risk for miscarriage, preterm birth, LBW and perinatal death. Furthermore, decreased intake of calories during early pregnancy is associated with a higher placental weight (Huxley 2000). Section 2.2.8 discusses cravings and aversions during pregnancy more in depth.

Another biological factor that impacts a pregnant woman’s food choices is her pre-pregnancy weight.

One study found that the dietary quality decreases during pregnancy for overweight and obese women (Moran et al. 2012). Whereas women who are underweight or of normal bodyweight have been found to have a better dietary quality during pregnancy (Tsigga et al. 2011). Studies have also shown that obese pregnant women are less likely to follow the guidelines for fruit and vegetable consumption or for meal/snack patterns. Moreover, fiber and folate intake has been reported to be lower among women with a higher prepregnancy BMI (Laraia et al. 2012).

Age is another biological factor that impacts the nutritional choices that women make during pregnancy. Research has shown that younger women tend to have a lower dietary quality in pregnancy (Rifas-Shiman et al. 2009). A Finnish study found that healthy food choices are common among pregnant Finnish women and these choices have a positive correlation with age and education (Arkkola et al. 2006). Additionally, the most influential characteristic that impacts a woman’s adherence to nutritional guidelines in pregnancy is her ethnicity (Morton et al. 2014). Studies based in the United States have reported that there are racial-ethnic differences for maternal and health outcomes, and energy intake and diet quality during pregnancy are one of the possible risk factors for these differences (Headen et al. 2012).

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Finally, a major determinant of food choice and purchasing behavior is taste (Renzaho and Burns 2006). Generally, it is understood that taste changes take place during the course of a pregnancy, however, more scientific evidence is needed to support this claim (Faas et al. 2010). So far, there is evidence suggesting that sex steroids are elevated during pregnancy, and as a result, the taste responses and sensation would be impacted by it (Bhatia and Puri 1991).

The ultimate goal of the changes that may occur in pregnancy in the area of food behavior should serve the needs of the developing baby. According to a review on how pregnancy and sex hormones interfere with taste and food intake: “Many physiological and behavioral changes take place during pregnancy, including changes in taste and an increase in food intake. These changes are necessary to ensure growth and development of a healthy fetus” (Faas et al. 2009).

Demographic determinants

Another significant factor, related to the dietary intake and adequacy in pregnancy, is the country of origin (Rodriguez-Bernal et al. 2012). In Brazil, women do not comply with nutritional guidelines in pregnancy (Dos Santos et al. 2014). Researchers in New Zealand have made the same finding about pregnant women in New Zealand. Likewise, recent data from Australia and Canada show that the level of adherence to nutritional guidelines in pregnancy is low in those countries as well (Morton et al.

2014). Whereas, in Belgium, pregnant women tend to adhere to nutritional recommendations

(Verbeke and Bourdeaudhuij 2007). These cross-country variations pertaining to following dietary recommendations in pregnancy, are also true for alcohol consumption in pregnancy, as section 2.2.5 pointed out (Mårdby et al. 2017).

Psychological determinants

Besides biological and demographic determinants of dietary choices, also psychological factors have been linked with pregnant women’s food intake (Bowen 1992). Some psychological determinants that can impact the dietary choices of a person are mood and emotions, health cognitions, food

Dietary knowledge, attitudes and practices of pregnant and postpartum Sub-Saharan African immigrants in Finland