Lifestyle and Dietary Changes During Pregnancy among Attendees of Antenatal Care Clinics

Women often make dietary changes during pregnancy but little is known of these dietary changes...


Introduction
A healthy, balanced diet during pregnancy is essential to support optimal growth and development of the fetus and to meet the rapid and profound physiological changes from conception until birth.
During pregnancy, the development of maternal tissues, fetal growth, and breast milk production increase nutritional requirements [1].
Deficiencies in key macronutrient and micronutrient can have a substantial impact on pregnancy outcomes and neonatal health [2]. Examples of micronutrients supplementation to prevent health outcomes are folic acid to prevent neural tube defects, iodine to prevent cretinism, zinc to reduce of preterm birth, and iron to reduce the risk of low birth weight [3]. Consumption of fast food and soft drinks have been associated with increased risk of gestational diabetes mellitus [4]. The Barker hypothesis proposed that adverse nutrition in early life, including prenatally increases susceptibility to the metabolic syndrome which includes obesity, diabetes, insulin insensitivity, hypertension, and hyperlipidemia and complications that include coronary heart disease and stroke [5]. Furthermore, a recent systematic review found an inverse association between the healthy dietary pattern and prenatal anxiety and depression scores [6].
Several international organizations advocate dietary recommendations and guidelines for pregnant women [1,7].
However, the extent to which pregnant women abide with these guidelines is unknown. Changes in lifestyle behaviors around the time of pregnancy have been well described in the literature [8].
Some studies have described the use of herbal medicines during pregnancy, including research from the Middle East [9,10]. The prevalence of herbal use varied between regions and reached up to 82% in the Middle Eastern countries [10] compared to 26.7% in South West England [11] and 36% in Australia [12]. With few exceptions, the beneficial and harmful effects of these herbal supplements remain inconclusive [13]. Therefore, it is deemed essential to describe the types of herbal remedies used and the reasons for which they are being used.

Design
This cross-sectional survey was conducted with pregnant Bahraini women at any stage of their conception attending the antenatal clinics of primary health care centers as participants.

Sample Size
Based on the estimate of 5220 pregnant women attending the antenatal clinics at the health centers during 2018 [14], and with a 95% confidence level and 6% margin of error, 254 participants were needed to represent the population. However, we aimed to survey300 pregnant women to be certain that we obtained complete data for at least the required 254.

Sampling Method
There are 28 health centers distributed in the five health governorates of Bahrain. We selected two health centers from each health region by simple random sampling. In each selected health center, 60 participants from the antenatal waiting area were invited to participate in the study. We used convenience sampling to identify the eligible participants. During the antenatal visit, women undergo checks of their vital health measures, and weight, and have obstetric examination.

Measures
We developed a survey instrument based on the tools used in the research we have identified, [15] related to each of the topics in our study. We also collected demographic data from participants.
We piloted the survey on 50 participants who were not included in the study. The reliability of the questionnaire was tested and yielded a Cronbach alpha of 0.72.

Data Analysis
The uni-variate analyses provided information on the prevalence of each lifestyle choice and are reported as frequencies and percentages. Chi square test was used to test the association between selected maternal knowledge items and sociodemographic variables. The selected items are: "I know about good dietary practice, the type of food influence pregnancy outcomes, poor maternal nutrition cause low birth weight". A P-value of ≤0.05 was considered significant.

Ethics
We obtained ethical approval from the respective research

Demographic Details
Three hundred questionnaires were distributed and 299 responded yielding a response rate of 99.6%. Mean (SD) age of participants was 30.0 (SD 5.7), median 29 years and range 29 (maximum 48.0 years, minimum 19.0 years). Women, on an average, had 1.45 (SD 1.37) children (Table 1).

Maternal Dietary Habits and Nutritional Practices
Over half of participants reported good appetite with consumption of three meals daily. The majority (60.0%) consumed fruits and vegetables daily and only 40.6% consumed chicken or meat daily. Fish was consumed twice a week by 61.3%and once week or less by almost 15.0%. Candy was the most disliked (30.6%) during pregnancy followed by eggs (21.8%). When asked about food item they would avoid during pregnancy, the majority chose cinnamon (69%), pineapple (22%), postpartum stew (made from garden cress seeds) (20%) and saffron (16.9%). All participants denied smoking and drinking alcohol during pregnancy (Table 2).

Maternal Knowledge of Dietary Habits
The participants identified family (43.3%) and social media (43.7%) as their main sources of information about dietary recommendations during pregnancy. Most of the women in our study believed that the type of food they consume can influence their pregnancy outcome and can result in low birth weight (74.7% and 78.6%, respectively). Most women agreed that smoking and drinking alcohol have harmful effects on the fetus (97.7% and 98.3%, respectively) ( Table 3).    Note: a More than one option may be selected b Made from garden cress seeds Note: aMore than one option maybe selected

Pattern of Herbal Remedy Use
In ( Among those who used herbs 67% believed that they were effective in relieving the symptoms that they were used for.

Association Between Maternal Knowledge And Sociodemographic
The association between selected items on the maternal knowledge questionnaire and sociodemographic data is presented in (Table 5). A Chi square test of independence was calculated and a significant interaction was found between "women should eat more during pregnancy" and categories of education (P-value=0.033) and employment (P-value=0.008). Further, a significant interaction was found between "Type of food influence pregnancy outcomes" and education (P-value<0.000) and employment (P-value=0.004) categories.

19.6
Note: aMore than one option maybe selected portions/day of fruits and vegetables [1]. About 16% disliked fish and 70% reported consuming fish twice weekly or less, thereby missing out its nutritional benefit for the fetus. Similar results were reported in international studies [16]. Fish is rich in Vitamin D and omega-3 fatty acids that are important for the development of a fetus's brain, eyes, and nervous system [17]. The recommendation is to eat 2 to 3 servings per week [18]. Although fish such as shark, tuna and swordfish are not advised because of their high mercury content, [18] we did not inquire about types of fish in our study but about eating fish in general.
When they were asked about food they would avoid during pregnancy, our participants were mostly focused on food that might increase their risk of miscarriage. It is concerning that women did not include food that is a rich source of vitamin A (such as liver) or raw uncooked food as food to avoid during pregnancy despite their well-documented harmful effect on the fetus [19,20]. Instead, they mentioned cinnamon and pineapple as two main avoided items because they were perceived as risk factors for miscarriage.
Similar results of avoiding cinnamon and pineapple were reported in a study from Saudi Arabia [21]. Scientific evidence regarding the benefits and harms of cinnamon and pineapple is either lacking, inconclusive [22]or negligible [23]. Further, the uterine stimulant theory of these products and the belief that they induce abortion or labor does not specify the amount that should be consumed to see the harmful or beneficial effect [23]. This is an area that needs definitive research to support or refute widespread beliefs in Bahrain. In concordance with the published literature, [16] pregnant women recognize that a healthy, balanced diet and healthy life style are "important" to fetal health and are more likely during their pregnancy to be mindful of nutrition and life style habits. This was reflected in that the majority agreed that maternal diet affects fetal outcomes and that almost all participants refrained from smoking and drinking alcohol and agreed on their harmful effect on the fetus.
Often, family and social media were the sources of information our participants used. The same has been documented in other Middle Eastern studies [10]. This reflects the influence of social media, which contains many articles advertising and promoting non-evidence-based dietary practices [10]. It also implies the importance of including the family in any dietary and lifestyle interventions in this part of the world. The most popular herbs used in our study were mint, green tea, ginger, aniseed and Arabic gum, which is very similar to what has been reported in studies from this region [10]. In agreement with other studies, the herbs were mostly used to treat the bothersome symptoms of nausea and vomiting [10]. However, only 17.0% of the study participants admitted using herbal remedies during pregnancy. This percentage is reversed in the Saudi study where about two thirds of women used herbal products [21]. One should be cautious interpreting this finding because women might not consider some products they habitually use as herbal remedies. In general, herbal supplementation is complex, vaguely defined in the literature and there is confusion on what it constitutes [25]. Ginger is the only well-established herbal product as an effective treatment for nausea and vomiting [26].
However, ginger was used by only one third of participants who admitted to using herbal remedies.
Factors influencing maternal knowledge in this study were education and employment. This is in agreement with other international studies [27,28]. One should note that majority of these studies were conducted in underdeveloped parts of the world with limited resources which makes the comparison rather unfair.
Other well document influential factors reported in these studies Also, although the study clinics were randomly selected, we used convenience sampling to enroll participants from within the sampled clinics and this may have biased the study in the direction of including women who attend more carefully to their health. Our survey lacked detailed nutritional questions relating to number of servings, standard serving size and nutrient content of certain food.
Further, the survey did not allow for an overall knowledge score to be calculated and hence used for analysis. This limited our ability in conducting further bivariate and multivariate analyses.
We recommend that health care providers play a greater role in educating pregnant women regarding the recommended dietary habits and screening women for non-prescribed supplements and herbal remedy use. Further research is needed to explore the detailed nutritional content of maternal diet and prescribed and non-prescribed supplements.

Conclusion
Women are aware of the importance of their diet during pregnancy and its effect on fetal outcomes. However, their knowledge and dietary practices are limited and not entirely compliant with international recommendations. Herbal remedies use was representative of the culture and traditions and was often influenced by family and social media.