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BOOK NUMBER 
ACCESSION NO.
T2
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NUTRITIONAL HABITS OF PREGNANT 
GHANAIAN WOMEN AND EFFECTS ON PREGNANCY OUTCOME.
BY
FRANCIS AYISI KWAME TAYIE
A THESIS SUBMITTED TO THE DEPARTMENT OF 
NUTRITION AND FOOD SCIENCE, UNIVERSITY OF GHANA,
IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD 
OF A MASTER OF PHILOSOPHY DEGREE IN NUTRITION
Department of Nutrition and Food Science 
University of Ghana,
Legon.
October, 1995
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3 343357
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TABLE OF CONTENTS
Page
Acknowledgement ..........................................  } ,
Declaration ..............................................
Dedication ...............................................  I11
Abstract .................................................  iv .
List of pictures ........................................
List of tables ..........................................
List of figures .........................................  xii
List of appendices ...................................... xiii
CHAPTER 1: INTRODUCTION AND OBJECTIVES
1.1. Introduction..................................  1
1.2. Rationale..................................... 4
1.3. OBJECTIVES OF STUDY.........................  6
CHAPTER 2 : LITERATURE REVIEW
2.1. Nutrition and human Reproduction.........  7
2.2. Nutrient supplementation in pregnancy.... 11
2.3. Energy need during pregnancy.............. 14
2.4. Protein need during pregnancy............  17
2.5. Iron need in pregnancy....................  18
2.5.1. Dosage of iron.............................. 18
2.6. Nutrition and safe labour.................  19
2.7. Infant birth-weight........................  20
2.8. Maternal physiological adjustment
during pregnancy...........................  21
2.8.1. Pregnancy weight-gain...................... 21
2.8.2. Oedema in pregnancy........................  2 4
2.8.3. Anaemia in pregnancy....................... 2 5
2.8.4. Blood-volume and composition during
pregnancy...................................  2 9
2.8.5. Plasma composition in pregnancy..........  31
2.8.6. Cardiovascular dynamics in pregnancy....  3 3
2.8.7. Respiratory function during pregnancy.... 34
2.8.8. Total body water during pregnancy........  35
2.9. Geophagia in pregnancy....................  3 6
2.10. Alcoholism in pregnancy...................  37
2.11. Effects of physical activity on
pregnancy outcome .........................  3 8
2.12. Food taboos and beliefs in pregnancy....  39
2.13. Birth-spacing, breast-feeding and
pregnancy outcome..........................  4 0
CHAPTER 3: MATERIALS AND METHODS
3.1. The study areas............................  4 2
3.2. The subjects................................  42
3.3. Data collection............................  42
3.4. Epidemiological data....................... 43
3.5. The longitudinal study....................  43
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3.5.1. The anthropometric measurements ......... ..........4 3
Weight measurements........................ ..........44
Height measurements........................ ..........44
3.6. The biochemical study................................45
3.7. The dietary study.......................... ..........45
3.8. Analysis of the data....................... ..........46
3.9. Characteristics of the subjects.......... ..........4 7
CHAPTER 4: RESULTS
4.1. Conduct of the ant^-natal clinics
of study................................... 51
4.2. Epidemiological data.......................  54
4.2.1. Infant birth-weight........................  54
4.2.2. Educational level of the mother and
infant birth-weight........................  54
4.2.3. Mother's occupation and infant birth
weight.......................................  57
4.2.4. Gestational age at which mothers 
seek ante-natal care and effect
on birth-weight............................. 58
4.2.5. Nausea during pregnancy and effect on
infant birth-weight .......................  60
4.2.6. Vomiting during pregnancy and effect
on birth-weight............................. 62
4.2.7. Alcoholism during pregnancy...............  63
4.2.8. Pica practice of the pregnant women and
their reasons...............................  66
4.2.9. Foods avoided by women during pregnancy.. 7 0
4.2.10. Diet modification during,pregnancy and
effect on birth-weight..................... 72
4.2.11. Oedema during pregnancy and effect on
infant birth-weight........................  73
4.2.12. Effect of parity on infant birth-weight.. 74
4.2.13. Mothers preference of infant size and
reasons...................................... 7 6
4.2.14. Measures taken by mothers to achieve
preferred infant size...................... 77
4.2.15. Mothers preference of infant size at 
birth in relation to birth-weight of
their infants...............................  78
4.2.16. Effect of duration of mineral and 
vitamin supplementation during
pregnancy on infant birth-weight.........  7 9
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4.3. THE LONGITUDINAL STUDY
4.3.1. ANTHROPOMETRIC DATA................................  82
4.3.2. Pattern of maternal weight-gain during
pregnancy...................................  82
4.3.3. Maternal weight-gain and effect on infant 
birth-weight.............................. • • 85
4.3.4. Maternal height and effect on infant birth
weight.......................................  87
4.3.5. Maternal body mass index at beginning of 
pregnancy and effect on infant birth-weight
and maternal weight-gain..................  88
4.3.6. Occupation of women and maternal weight
gain.........................................  90
4.3.7. Effect of parity on maternal weight-gain. 91
4.3.8. Effect of clay intake on maternal weight
gain..................................  93
4.3.9. Effect of oedema during pregnancy on
maternal weight-gain....................... 94
4.3.10. Nausea and effect on maternal weight-gain
weight.......................................  95
4.3.11. Effect of vomiting on maternal weight
gain during pregnancy...................... 96
4.4: DIETARY INTAKE DATA 100
4.4.1. Energy intake of the pregnant women and 
effects on infant birth-weight and maternal 
weight-gain.................................  101
4.4.2. Influence of maternal protein intake on 
infant birth-weight, maternal weight-gain
and haemoglobin level....................  102
4.4.3. Dietary iron intake and effect on birth 
weight, maternal weight-gain and
haemoglobin level..........................  105
4.5. HAEMOGLOBIN DATA.
4.5.1. Maternal haemoglobin levels during 
pregnancy and effect on infant
birth-weight................................  107
4.5.2. Evaluation of iron and vitamin 
supplementation during pregnancy..........  108
4.5.3. Nausea and effect on haemoglobin level... 109 
4.5.4 Effect of vomiting during pregnancy on
haemoglobin level of mothers.............. Ill
4.5.5. Effect of clay intake during pregnancy
on maternal haemoglobin level............  113
4.6. Correlation analyses of factors affecting 
pregnancy outcome..........................  114
CHAPTER 5 DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS 117
5.1. EPIDEMIOLOGICAL DATA.
5.1.1. Infant birth-weight.........................  117
5.1.2. Effect of mothers' educational level on
infant birth-weight........................ 118
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5.1.3. Effect of mothers' occupation on
pregnancy outcome......................... 119
5.1.4. Effects of parity on pregnancy...........  121
5.1.5. Nausea during pregnancy and effect on
pregnancy outcome..........................  122
5.1.6. Prevalence of oedema during pregnancy
and effect on infant birth-weight........  125
5.1.7. Alcohol intake during pregnancy..........  126
5.1.8. Pica during pregnancy...................... 128
5.1.9. Food avoidance during pregnancy..........  132
5.1.10. Modification of diet during pregnancy
and effect on infant birth-weight........  133
5.1.11. Gestational age at which women 
attended ante-natal clinic and effect
on infant birth-weight....................  134
5.1.12. Mothers preference of infant size in 
relation to maternal nutrition and
labour outcome.............................. 13 6
5.1.13. Effect of duration of mineral and 
vitamin supplementation during
pregnancy on infant birth-weight.........  139
5.2. ANTHROPOMETRIC DATA
5.2.1. Effect of maternal height on birth-weight
and maternal weight-gain..................  140
5.2.2. Women's body mass index in first 
trimester and effects on infant birth
weight and maternal weight-gain..........  141
5.2.3. Maternal weight-gain and effect on
infant birth-weight........................  143
5 . 3 DIETARY INTAKE DATA
5.3.1. Energy intake and effects on infant
birth-weight and maternal weight-gain.... 144
5.3.2. Protein intake of the pregnant women 
and effects on infant birth-weight, 
maternal weight-gain and haemoglobin
level........................................  146
5.3.3. Iron intake of the pregnant women 
and effects on infant birth-weight, 
maternal weight-gain and
haemoglobin level.........................  148
5.4. HAEMOGLOBIN DATA
5.4.1. Maternal haemoglobin level and effects
on infant birth-weight....................  150
5.4.2. Effects of iron and vitamin 
supplementation on maternal haemoglobin
level during pregnancy...................  1 5 1
5.5 CONCLUSION. 153
5.6. RECOMMENDATIONS. 155
BIBLIOGRAPHY 156
APPENDIX 167
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A K N O W L E D G E M E N T
I express my sincerest gratitude to Mrs. Anna Lartey 
(my supervisor), Professor S. Sefa-Dedeh (Head of Department), Dr. 
E. Asibey-Berko, the medical doctors, nurses and mothers who were 
at the various ante-natal clinics, Mr. Noah 0. Aguh, Mrs. Annabel
0. Adjei, members of the Nutrition and Food Science Department for 
their invaluable contributions towards the successful execution and 
presentation of this thesis report.
My sincere thanks also go to Mr. Richard D. Azasu,
Secretary of the Iodine Deficiency Disorders (IDD) Project for 
typing the script.
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D E C L A R A T I O N
This project was conducted and presented by me at the 
Department of Nutrition and Food Science, University of Ghana, 
Legon, under the supervision of Mrs. Anna Lartey.
...... .......................
FRANCIS AYISI-KWAME TAYIE
(CANDIDATE)
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D E D I C A T I O N
This work is dedicated to all institutions and organizations 
concerned with the prevention of maternal and infant mortality.
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A B S T R A C T
Reduction of infant and maternal mortality is a part of 
the WHO/UNICEF goals set in 1991 to be achieved by the 
year 2000. Maternal and infant mortality can be reduced 
by ensuring favourable outcome of pregnancy.
This study sought to assess the effects of nutrition and 
health habits of pregnant women on pregnancy outcome.
A total of 502 pregnant women attending ante-natal 
clinics in the Greater Accra region participated in an 
epidemiological study, which involved a study of food 
habits, pica practice, alcohol intake, parity, 
preference for infant size at birth, ante-natal care, 
oedema and nausea during pregnancy. A sub-sample of 128 
pregnant women participated in a longitudinal study 
which assessed maternal nutrient intake, height, weight 
gain and nutrient supplementation during pregnancy, 
infant birth-weight and maternal haemoglobin levels. 
Results showed that women who experienced nausea during 
pregnancy had infants of lower birth-weights. Oedema was 
present in about 40% of the women and this correlated 
with higher birth-weights.
Mothers who have had three or four previous pregnancies 
had infants of higher birth-weights than nulliparous
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(first-delivery) mothers and those with seven or more 
previous pregnancies. Pregnant women who received 
ante-natal care in the first trimester had
infants of higher birth weight than those who received it 
in the second or third trimesters. About 48% of the 
pregnant women practiced pica. Eating clay was the major 
form of pica among the pregnant women. It correlated 
negatively with maternal haemoglobin level but had no 
effect on infant birth weight and maternal weight-gain. 
The prevalence of alcohol intake among the pregnant women 
was 9.36%. A substantial number- 62.35%, of the subjects 
avoided some kind of food during the pregnancy. Majority 
of the women, 72.71%, did not increase their dietary 
intake during pregnancy. Dietary intakes were lower 
where nausea occurred. To avoid difficult labour, 40.60% 
of mothers preferred small infants, and about 10% of 
these mothers reduced their food intake in order to 
achieve this. Among the 502 pregnant women, the 
prevalence of low birth-weight delivery was 8.4%. In the 
longitudinal study, maternal weight-gain and haemoglobin 
levels were lower for women who experienced nausea. 
Maternal height was positively associated with infant 
birth-weight and maternal weight-gain.
The average maternal weight-gain of the 128 mothers 
was 10.531 ± 1.681kg.
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Mothers who have had three or four previous pregnancies 
had higher maternal weight-gain than nulliparous mothers 
and those with seven or more previous pregnancies. Oedema 
had no significant effect on maternal weight-gain. The 
daily intakes of energy, and iron were lower than the 
recommended amounts for pregnant women. However mean 
protein intake met the recommended allowance. Energy 
and protein intakes had positive effects on infant 
birth-weight and maternal weight-gain. High dietary iron 
intake was associated with high maternal weight-gain and 
haemoglobin level but had no effect on infant birth 
weight. Mineral and vitamin supplementation during 
pregnancy had:little effect on overall haemoglobin 
levels of the mothers. It however helped mothers to have 
infants of higher birth-weight. The mean monthly maternal 
haemoglobin level was 11.503 ± 0.603g/dl. (WHO standard 
for pregnant women: ll.Og/dl; Tomkins and Watson, 1991) 
From the total of 12 8 pregnant women, about 2 0% were 
anaemic throughout pregnancy.
Recommendations include the need for early ante-natal 
care for pregnant women, education against the practice 
of pica, intensification of mass education on good
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nutrition and health practices, during pregnancy and the 
need for more health posts to encourage ante-natal 
attendance.
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LIST OF PICTURES
Picture Page
1: Pregnant women waiting to be interviewed... xv
2: Interviewing pregnant women...................... xvi
3: Taking the height of a pregnant woman...... .... xvii
LIST OF TABLES
Table Page
1. Mean birth-weight according to 
socio-economic status of women in
various communities.........................  9
2. Reported energy intakes of poorly
nourished child-bearing women................  16
3. Energy intakes of pregnant women from 
industrialized countries..................... 17
4. Maternal weight changes during pregnancy
of women from industrialized countries.... 23
5. Haemoglobin levels indicative of anaemia
in populations living at sea level.........  26
6. Interpretative guide for anaemia diagnosis.. 27
7. Characteristics of the pregnant women
involved in the study........................  4 8
8. Clinic attendance schedule for the
pregnant women................................  51
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Table Page
9. Birth-weight of infants in relation
to mothers' educational level.............  55
10. Effect of mothers' occupation on birth
weight of infants............................. 58
11. Age of pregnancy at which mothers seek 
ante-natal care and effect on
infant birth-weight..........................  59
12. Reasons given by mothers for visiting 
ante-natal clinic at the observed
gestational ages of first visit............  60
13. Effect of nausea during pregnancy on
infant birth-weight..........................  61
14. Effect of duration of vomiting during
pregnancy on infant birth-weight............  63
15. Types of alcoholic drinks and quantities
taken by mothers during pregnancy..........  65
16. Mothers' reasons for taking alcohol
during pregnancy...............................  66
17. Types of materials ingested by women during 
pregnancy and their reasons..................  68
18. Mothers reason for eating clay
during pregnancy...............................  69
19. Effect of clay ingestion on infant
birth-weight.................................. 70
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Table Page
20. Foods avoided by women during pregnancy
and reasons....................................  71
21. Women who modified their diet during 
pregnancy, their reasons and effect
on birth-weight................................  7 3
22. Effect of oedema during pregnancy on
birth-weight of infants....................... 7 4
23. Number of previous pregnancies in
relation to birth-weight of infants.........  75
24. Mothers' reasons for having three or
more children..................................  7 6
25. Mothers preference of infant size
and reasons....................................  77
26. What mothers do to achieve preferred
infant size....................................  78
27. Mothers preference of infant size at 
birth in relation to birth-weight
of their infants............................... 79
28. Duration of mineral and vitamin 
supplementation during pregnancy
in relation to birth-weight..................  80
29. Mean values of some measured indices
on the pregnant women.........................  83
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Table Page
30. Birth-weight of infants and maternal 
weight-gain in relation to height of
the mother during pregnancy..................  88
31. Infant birth-weight and maternal 
weight-gain in relation to body mass index
of mother during the first trimester........  89
32. Effect of mothers occupation on
maternal weight-gain..........................  91
33. Effect of parity on maternal weight-gain.... 92
34. Effect of clay ingestion on maternal
weight-gain..................................... 93
35. Effect of oedema during pregnancy on
maternal weight-gain..........................  94
36. Effect of nausea during pregnancy
on maternal weight-gain.......................  96
37. Effect of duration of vomiting on
maternal weight-gain..........................  97
38. Mean monthly maternal weight-gain
in relation to duration of vomiting.........  98
39. Average energy,protein and iron
intake of the pregnant women................  100
40. Energy intake of pregnant women 
and effect on maternal weight-gain
and infant birth-weight.......................  102
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Table Page
41. Maternal weight-gain, haemoglobin leveland infant 
birth-weight in relation to
protein intake.................................  104
42. Maternal dietary iron intake and
effect on infant birth-weight, maternal
weight-gain and maternal haemoglobin level.... 106
43. Birth-weight of infants in relation to
maternal haemoglobin level...................  108
44. Effect of nausea during pregnancy
on maternal haemoglobin level................ Ill
45. Effect of duration of vomiting on mothers 
haemoglobin level and maternal weight-gain.. 112
46. Effect of clay intake on mean
monthly maternal haemoglobin level..........  113
47. Correlation values of factors which
showed relationship with birth wight.........  114
48. Correlation values of factors which 
showed relationship with birth
weight in the longitudinal study............  115
49. Correlation values of factors which showed 
relationship with maternal weight-gain...... 116
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LIST OF FIGURES
Figure Page
1. Theoretical model of factors affecting 
women's physiological state and
pregnancy outcome............................. 11
2. Distribution of infants according to 
birth-weight..................................  56
3. Types of materials ingested by mothers
during pregnancy.............................. 67
4. Effect of duration of mineral and 
vitamin supplementation of the mother
on infant birth-weight.......................  81
5. Mean monthly maternal weight-gain
during pregnancy.............................. 8 4
6. Effect of maternal weight-gain on
birth-weight of infants...................... 86
7. Effect of vomiting during pregnancy
on 'maternal weight-gain...................... 99
8. Mean monthly maternal haemoglobin level
at various gestational ages.................  110
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LIST OF APPENDICES
Appendix Page
1. Basic indicators of nations categorized 
as having very high under-five-mortality
rate (U5MR)..................................... 167
2. Composition of mineral and 
multivitamin supplementary tablets 
used for supplementation at the
ante-natal clinics............................. 168
3. Extra daily nutrient allowance for
pregnant women.................................  169
4. Pregnancy weight-gain in some countries....  170
5. Distribution of infants by level of
birth-weight...................................  17 0
6. Number of mothers and weight of infants,
according to health centre of study.........  171
7. Maternal weight-gain and haemoglobin
level according to health centre of study.. 171
8. Mean monthly maternal weight-gain
during pregnancy...............................  17 2
9. Effect of maternal weight-gain on
infant birth-weight...........................  172
10. Mean monthly haemoglobin level of the
pregnant women at various gestational age... 173
11. A sample of the questionnaire used for
the data collection..........................  174
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Picture 1 pregnant women waiting to be interviewed at La (top) 
and Kaneshie Polyclinic (down)
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Picture 2: Interviewing pregnant women at the La Polyclinic 
(top) and University Hospital (down).
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Picture 3: Taking the height and weight of a pregnant woman at 
Kaneshie Polyclinic.
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CHAPTER ONE
1.1 INTRODUCTION
Like most developing countries, Ghana has a high maternal and 
infant mortality rate. The maternal mortality rate for Ghana is as 
high as 7.9 per 1000 live births (UNICEF, 1990). In a recent 
meeting on safe motherhood, the director of Health Services in 
Ghana quoted the maternal mortality rate as between five (5) and 
fifteen (15) per 1000 deliveries (people's Daily Graphic, January 
20th,1993). Infant mortality rate is reported to be 143/1000 life- 
births (UNICEF,1991).
One of the major contributory factors in the genesis of 
maternal and infant mortality in developing countries is low 
nutritional status of infants and women of reproductive age.
The essential role of nutrition in the development of the human 
organism begins with the conception. The development of the human 
being begins after fertilization of the egg cell in the mother by 
the sperm cell from the father. The embryo resulting from 
fertilization is retained in the womb of the mother who nourishes 
it with nutrients for its proper development into a baby. The 
proper development of the baby will thus depend to a large extent 
on the mother during pregnancy. It is important that the mother be 
in good nutritional status prior to and during pregnancy so that 
the foetus is well nourished. As the pregnancy progresses, the 
amount of nutrients required to maintain the pregnancy 
progressively increases. However it is rare that pregnant women
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alter their diet to suit pregnancy. This behaviour may adversely 
affect the course and outcome of pregnancy.
Pregnancy is accompanied by physiological changes necessary 
for the regulation of maternal metabolism and to prepare her for 
parturition and lactation. These physiological changes accompanying 
the pregnancy may result in nausea, leading to vomiting, loss of 
appetite, salivation, aversion to some nutritious foods, and 
ingestion of alcohol and some non-food items like clay and chalk. 
Oedema may also develop. If the maternal iron store is inadequate 
to augment the increased iron requirement in pregnancy iron 
deficiency anaemia may result presenting general weakness, 
excessive headache and dizziness. The combined effects of these 
discomforts can lead to unfavourable alteration in nutritional 
habits of the pregnant women, and may subsequently interfere with 
favourable pregnancy outcome. However there are some women who do 
not experience nausea in pregnancy. For this category of women, 
nutrition during pregnancy may only be affected adversely by 
factors other than nausea. Some of these factors include wrongful 
beliefs and prohibition of certain nutritious foods during 
pregnancy, family size, alcohol intake, tobacco smoking and low 
socio-economic status of some women. Of the factors which affect 
nutrition in pregnancy, it is nausea which is brought about by the 
direct effect of the pregnancy itself. Unfortunately this has not 
been widely investigated especially in Ghana.
Nutrition during pregnancy may further be hampered because 
certain group of pregnant women believe that if they practise good
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nutrition their infants will be too big and pose labour problems 
especially obstructed labour or caesarian operation (Garner and 
Kramer, 1992). The possible existence of this notion in Ghana 
needs verification.
Mineral and Vitamin supplements are administered to pregnant 
women to augment the insufficient intakes and increased 
requirements of these nutrients during pregnancy. In most cases 
essential mineral elements administered to pregnant women at ante­
natal clinics; include iron and calcium. The vitamins commonly 
administered include folic acid, Vitamin B6, Vitamin B12, retinol. 
Vitamin D, Vitamin E, ascorbic acid, thiamine, riboflavin and 
Niacin. Appropriate amounts of these minerals and vitamins are 
contained in capsules or tablets formulated for this purpose 
(Appendix 2) . Iron tablets mostly administered with vitamin B- 
complex or multivites were fergon and fersolate. Multivitamin and 
mineral supplements widely used for supplementation at the ante­
natal clinics are vitafol, unicap M, neovita, dynavite, and 
forceval. Pregnant women are given these supplements on their 
first attendance at the ante-natal clinic and they continue to take 
daily doses of. these supplements until delivery.Thus pregnant women 
who seek ante-natal care earlier will be on the nutrient supplement 
for longer period than those who delay in seeking ante-natal care.
The effect of iron and vitamin supplementation is exhibited as 
increased levels of haemoglobin in the blood. Therefore haemoglobin 
levels of pregnant women have been used as good indicator for 
effectiveness of supplementation. Haemoglobin level of pregnant
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women is monitored regularly and mostly monthly in most ante-natal 
clinics to prevent nutritional anaemia in pregnancy. Ensuring 
optimum levels of nutrition, circulating red blood cells and 
haemoglobin level will normally contribute to favourable outcome of 
pregnancy by ensuring good health of the woman and normal foetal 
development. A study of the characteristics of pregnant women and 
the factors which contribute to unfavourable outcome of pregnancy 
will assist in our endeavours to alleviate maternal and infant 
mortality.
1.2 RATIONALE.
The first world summit for children on September 30th, 1990, 
set among other goals to be achieved by the year 2000, a 50% 
reduction of both maternal mortality and child malnutrition 
(UNICEF, 1991). A UNICEF report in 1991, on the state of the 
world's children, stated that every year, an estimated half a 
million women die of causes related to pregnancy and child birth, 
and their deaths leave one million children motherless. A recent 
World Bank report indicated that thousand (1000) women over the 
world die every day from child birth (Ghana Broadcasting 
Corporation news,May 8th, 1994). These facts and recent frantic 
efforts being made by the Ministry of Health (MOH) in Ghana to 
ensure safe motherhood are testimonies of the fact that research is 
needed in this area (People's Daily Graphic, January 20th, 1993). 
Encouragement is taken from the idea that some of the causes of 
maternal deaths in Ghana, notably infections, anaemia,
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cardiovascular and respiratory disease, tetanus, Meningitis, 
hepatic failure and haemorrhage are preventable and nutrition 
related. It is imperative therefore that the nutritional and health 
habits of women during pregnancy be studied in the attempt to 
ameliorate the menace of high maternal and child mortality and 
morbidity. There is little data on nutrition during pregnancy, 
obstetric behaviour, as well as general information on Ghanaian 
pregnant women.
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1.3 OBJECTIVES OF STUDY 
Overall Objectives
The main objective of this study was to investigate the 
nutritional and health habits of pregnant women and their effects 
on maternal nutritional status and pregnancy outcome.
Specific Objectives
The specific objectives of this study were as follows:
1. To investigate women's dietary habits in pregnancy and the 
possible effects of these on pregnancy outcome.
2. To study the effects of geophagia, alcohol intake and other 
habits on pregnancy outcome, weight-gain and haemoglobin 
levels during pregnancy.
3. To assess the dietary nutrient intake of pregnant women and 
its effects on pregnancy outcome, pregnancy weight-gain, 
and haemoglobin level.
4. To study the effects of nausea--and oedema on weight-gain and 
haemoglobin level during pregnancy and on pregnancy outcome.
5. To assess the effectiveness of mineral and vitamin 
supplementation during pregnancy.
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CHAPTER TWO 
LITERATURE REVIEW
2.1 Nutrition and Human Reproduction
The relationship of nutrition with human reproduction has been 
established mainly from large scale observations and in crisis 
situations like war and famine (since ethical, moral, and legal 
limitations of investigating the human subject are compounded by 
the need to consider the interests of the child, its father as 
well as the mother (Goodhart and Shils,1989) . The general evidence 
indicates that good nutrition is necessary for efficient human 
reproduction. Perhaps the most dramatic observations are those made 
in Great Britain during World War II. Under the food-rationing 
policy, pregnant women were given special priority, and the quality 
of diets of pregnant women, especially those in the low-income 
groups, were significantly enhanced. Between 1939 and 1945, that 
is the time of war, the stillbirth rate fell from a previously 
rather stable rate of 38 per 1000 live births to 28, a fall of 
about 25% during a period when many aspects of the physical 
environment were deteriorating (Food and Nutrition Board, 1971).
Famine during any part of pregnancy long enough to deplete 
maternal nutrient reserves has been shown to reduce birth-weight, 
increase perinatal complications, and mortality of both mother and 
infant. However, depletion of maternal nutrient stores during the 
first two-thirds of pregnancy may be compensated for by adequate
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nutrition during the third trimester (Stein et a l . 1975). It is 
generally recognised that in populations where chronic 
undernutrition is common, low birth-weight deliveries, poor growth 
and development and even death in infancy are prevalent (Food and 
Nutrition Bulletin, 1984). Bagchi and Bose (1976) found that 
infants born to poorly nourished mothers in Calcutta weighed on the 
average 181g less than those born to well-nourished mothers. In 
industrialized countries where there is an abundance of high 
quality food,land adequate health care, the mean birth-weight is 
about 3,300g as compared to between 2,700g to 3,000g in developing 
countries where chronic maternal malnutrition is prevalent (Food 
and Nutrition Board, 1971). In Ghana, the reported mean birth- 
weight for prosperous groups is 3,188g as compared to 2,879 for the 
general population (WHO, 1971) (Table 1).
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Table 1: Mean Birth-weight According to Socio-economic Status of 
Women in Various Communities
Place Subjects Mean Birth-weights (g)
Madras (India) Well-to-do 2,985
2,736
Wealthy 3,182
South India Poor 2,810
Upper class 3,247
Bombay (India) Upper Middle class 2,945
Lower middle class 2,796
Lower class 2,578
Paying patients 2,851
Calcutta (India) Poor class 2,656
Very well nourished 3,026
Congo Well nourished 2,965
Badly nourished 2,850
Prosperous 3,188
Ghana General population 2,897
Weil-to-do 3,022
I ndones i a Poor 2,816
Source: Food and Nutrition Board, (NRC), U.S.A. 1971.
It is possible that women from prosperous families have better 
nutritional history and hence adequate nutrient stores prior to 
pregnancy. This fact in addition to optimum growth of such 
individuals contributes to efficient reproductive performance. Shah
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(1981) observed that among the many environmental factors taken 
into consideration, maternal nutrition had a significant 
relationship to birth-weight, maternal weight prior to the 
pregnancy being the determining factor affecting foetal nutrition. 
In this report, Shah found that the birth-weight of the infants 
whose mothers weighed 3 8kg or less before pregnancy were 
significantly lower than those of new-born infants whose mothers 
weighed over 41kg (Shah, 1981).
Protein nutritional status has been shown to have a direct 
effect on the birth-weight of infants. Mothers with low levels of 
total circulating protein and albumin mass, frequently deliver low- 
birth-weight babies (Durate, 1974).
Experimental undernutrition in pregnant mammals of some other 
species resulted in foetal growth retardation and alteration in 
cell size or. number which depended upon the timing of the 
nutritional deficiency (Wallace, 1948). Rosso (1974) res^jicted 
the dietary protein of pregnant rats and observed a reduction in 
the transfer of the amino acid analogue a-aminoisobutyric acid 
(AIB) from maternal blood to foetus. It has also been reported 
that foetuses of fasting pregnant sheep have a 50% reduction in 
umbilical uptake of glucose, a reduced metabolic rate and a fall in 
blood glucose level (Boyd and Morris, 1973).
The role of nutrition in human reproduction is enormous. 
However other factors like genetic endowment, biological, social 
and psychological state contribute to the outcome of pregnancy 
(figure 1).
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Figure X: Theoretical Model of Factors Affecting Women's 
Physiological State and Pregnancy Outcome.
(Source: Food and Nutrition Board, NRC, U.S.A. 1971)
2•2 Nutrient Supplementation in Pregnancy
A number of studies have demonstrated that nutrient 
supplementation during pregnancy is beneficial to human 
reproduction. In a study by Viegas et aJL in 1982, twelve
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supplemented undernourished women who received protein, energy and 
vitamin supplements had significantly heavier babies than thirty- 
one undernourished mothers who received either vitamin and energy 
supplements or vitamins alone. In this study it appeared that 
protein had a positive effect on birth-weight. However Rush (1989) 
has recently reviewed supplementation studies and comments that 
higher protein content supplements in well nourished women were 
associated with lower birth-weight among those who were 
supplemented, whereas lower protein density supplements (under 20% 
of calories as protein) were uniformly associated with higher mean 
birth-weight among the supplemented. Atton and Watson (1990) 
studied 2 05 Asian women and found that protein and calorie 
supplementation did not have significant effect on birth-weight of 
these Asians. In a study in India in which poor women were fed an 
additional 500 Kcal and lOg of protein, raising their daily intake 
to 2,500 Kcal and 60g of protein during the last four weeks of 
pregnancy, an extra weight of 1.5kg was gained as compared to a 
control group of women (Iyangar, 1974). In this study the birth- 
weight of babies of the group receiving the extra calories and 
protein were 300g higher than those of the controls. In another 
study in five villages in south India, Pregnant women receiving 
Applied Nutrition Programme (ANP) supplements of 2114 Kcal and 51g 
of protein on an average gained during pregnancy 1.54kg more than 
did the women in another group of villages not receiving ANP 
supplements. Studies in Bogota (Mora et al, 1979) and New York
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city (Rush et al, 1980) showed that supplements were associated 
with increased weight-gain.
A study in Guatemala showed that birth-weight increased 
progressively as dietary intake increased, the risk of low birth- 
weight was about half that in minimally supplemented mothers 
(Shah, 1981). In this study it was found that the caloric intake 
was a more important factor than increased protein intake in 
improving the infant birth-weight. However investigations in 
Montreal (Rush et al, 1980) and Taiwan (Blackwell et al, 1973) were 
not consistent with these results. It seems that in mothers who are 
either severely malnourished or in a state of acute starvation, 
supplementation has positive effect on birth-weight and pregnancy 
weight-gain. In the Gambia, although nutrient supplementation of 
women in moderately negative energy imbalance had a beneficial 
effect on birth-weight, when the same women were in positive energy 
balance, supplementation had no effect (Prentice et al, 1983). 
Extensive supplementation studies in East Java (Kardjati et al, 
1988) concluded that a positive effect of energy supplementation on 
birth-weight was restricted to the group of pregnant women with the 
lowest home dietary intake and/or a low pre-pregnant weight. Panth 
et al (1990) ,; found no effect of vitamin A supplementation on 
birth-weight, however maternal plasma vitamin A level increased 
significantly in the third trimester. In this study it was found 
that vitamin A supplementation enhanced maternal haemoglobin level. 
Most women in developing countries are undernourished and therefore 
there is the need for nutrient supplementation during pregnancy.
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Most of the minerals and vitamins supplemented are expected to 
augment haematopoietic need for these nutrients because of the 
increased erythropoiesis due to expanding plasma volume and 
obligatory placental transfer of these nutrients (Serge and Galan, 
1986),
Extra nutrients are needed during pregnancy. In some cases 
the level of nutrient required cannot be met by food intake, 
especially iron and calcium. The WHO Expert committee on Maternal 
and Child Health has set daily nutrient requirement for adult 
pregnant and non-pregnant woman to ensure adequate nutrient intake 
during pregnancy (Appendix 3).
2.3: Energy Need During Pregnancy
For a typical pregnancy weight-gain of about 12.5kg and a median 
infant birth-weight of 3.3kg, the average extra energy cost of 
pregnancy has been calculated to be about 335MJ (80.000 kcal) over 
the nine-month period (FAO/WHO, 1985) . This amount of energy is 
distributed as an extra 630KJ (150Kcal)/day during the first 
trimester and 1465KJ (350kcal)/day during the second and third 
trimesters (FAO/WHO, 1985). A cautious policy was adopted so that 
an amount of energy allowance of 285kcal/day if healthy women 
reduce their activities during pregnancy (James and Schofield,
1990). However extensive studies on energy metabolism in pregnancy 
showed that the expected increase in intake of 200 or 285kcal does 
not occur (James and Schofield, 1990) . Measurement of basal
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metabolic rate (BMR) show modest increase in late pregnancy with a 
reduction in the metabolic response to food.
Reported studies have indicated that even in women who do not take 
in commensurate amount of energy, enough fat is deposited to 
provide reserve needed for subsequent lactation, and the foetal and 
maternal tissues grow satisfactorily (FAO/WHO, 1985).
The reason is explained by some (Blackburn, 1974, Banejee and 
Shah, 1971) but not all (Nagy, 1983) studies of well nourished 
pregnant women that maternal physical activity is reduced to 
conserve energy during pregnancy. For instance, slowing of self- 
paced work, example in climbing stairs, is common, so that the 
energy expended per unit time is maintained at approximately the 
same level as in the non-pregnant state. On this basis it has 
been suggested (FAO/WHO/UNU, 1990) that a modest increase in intake 
of lOOkcal per day might have been barely detectable but would have 
covered the observed increase in BMR (James and Schofield, 1990). 
On this basis the FAO/WHO Consultative group agreed on three values 
as follows:
a) Pregnancy requirement; lOOkcal/day.
b) Pregnancy sedentary allowance; 200kcal/day.
c) Pregnancy active allowance; 285kcal/day (James and 
Schofield, 1990) .
The energy intake of pregnant women in different communities is 
reported to be variable with pregnant women in developing countries 
having lower energy intake than those in developed countries 
(Tables 2 and 3).
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Table 2: Reported Energy Intakes of Poorly Nourished 
Childbearing Women.
Country Energy Intake (Kcal/day)
New Guinea 1,360
India 1,400/1,410
Guatemala 1,500/2,060
Ethiopia 1, 540
Colombia 1, 620
The Gambia 1,350/1,60/1,700
Tanzania 1,850
Iraq 1,880
Thailand 1,980
Source: Goodhart and Shi Is, 1989.
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Table 3: Energy Intakes of Pregnant Women from Industrialized 
Countries
Country Energy Intake (kcal/day
Scotland 2 , 503
Australia 2 , 090
Sweden 2 , 154
United Kingdom 2, 152
United Kingdom (Cambridge) 1,980
Source: Goodhart and Shi Is, 1989.
2.4: Protein,Need During Pregnancy
T h e .total protein requirement of a woman gaining 12.5kg of 
extra weight during pregnancy and delivering 3.3kg infant has been 
estimated jio* be' _47g per day (FAO/WHO, 1985) throughout pregnancy. 
The rate of storage is not constant. Estimates provided for the 
first, second, third and fourth quarters are respectively, 0.64,
1.84, 4.76 and 6.10g of protein per day (FAO/WHO, 1985). Thus it is 
estimated that the protein requirement should be increased by an 
average of 6g per day throughout pregnancy. These amounts should be 
added to the non-pregnancy allowance (41g per day) and the sum 
corrected for digestibility (FAO/WHO, 1985).
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2.5: Iron Need in Pregnancy
Iron need during pregnancy cannot be met through dietary iron 
intake. It is thus recommended that iron supplementation during 
pregnancy must not be limited to women in whom anaemia has been 
identified (Tomkins and Watson, 1991). Nonetheless, diets can 
increase iron status in three main ways;
a) by increasing the intake of haem iron (from animal products)
b) by increasing the intake of Vitamin C, along with foods 
promoting iron absorption example, acidic and fermented 
foods.
c) by reducing the intake of iron absorption inhibitors, 
example; in coffee, tea, some cereals.
Such dietary modifications in addition to allowing cultural 
constraints especially concerning animal products provide a 
potential solution to reducing iron deficiency anaemia.
2.5.1 Dosage of Iron
In a well- nourished 55-kg woman, on average haemoglobin, iron 
status increase by about 500mg and the total iron need during a 
normal pregnancy is about l,000mg (FAO/WHO,1988).
For prevention of iron deficiency anaemia in pregnant and 
lactating women, 60mg elemental iron (200mg ferrous sulphate, often 
with 250mcg folate) per day (1 tablet) for four months 
is recommended in areas where iron deficiency anaemia is of low 
prevalence. In areas of higher prevalence, 2 tablets i.e. 400mg 
ferrous sulphate per day is recommended (Tomkins and
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Watson, 1991).
The iron dose for treatment of anaemia depends on the degree 
of the anaemia. For severe anaemia, (Hb < 7g/dl) in pregnant and 
lactating women, 60mg elemental iron (200mg ferrous sulphate) three 
times daily is recommended; twice daily for mild-moderate anaemia 
(Tomkins and Watson, 1991).
2.6 Nutrition and Safe Labour
During pregnancy, a number of health intervention measures are 
taken with the aim of ensuring favourable outcome of pregnancy. 
Some of the health measures include immunization against tetanus 
infection (UNICEF, 1991), supplementation of mineral and vitamin 
intakes and advice on good health and nutritional practices during 
pregnancy. These measures lead to adequate weight-gain and also 
increased foetal size and hence increased birth-weight, but their 
effects on pregnancy outcome and labour need careful examination. 
If the effect of such interventions operate across the range of 
birth-weight distribution, one of the effects might be to increase 
the likelihood of difficult labour resulting from cephalopelvic 
disproportion. The trend towards slightly larger infants has been 
accompanied by increased use of caesarian delivery in developed 
countries (Garner and Kramer, 1990) . In places where obstetric 
services are not available, obstructed labour can be a major cause 
of maternal death. Due to economic loss, health risks and death 
associated with cephalopelvic disproportions leading to caesarian 
deliveries, women in localities where obstetric services are
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limited, may avoid doing anything that could increase the size of 
their babies and the consequent risk of difficulties during 
childbirth (Garner and Kramer, 1990).
In Ghana only 40% of births are attended to by trained personnel 
(UNICEF, 1991) and such an attitude cannot be ruled out.
2 .7 Infant Birth-weight
Birth-weight has been used as a good indicator of pregnancy 
outcome. Small babies are considered unfavourable outcome of 
pregnancy because they contribute to early infant mortality and as 
a group have a high incidence of subsequent physical and 
behavioural abnormalities (Silverman, 1970). The term "low birth- 
weight" is applied to all infants who weigh 2.5kg or less at birth 
(WHO, 1971). Two groups of small babies are commonly found. There 
are the low birth-weight but full-term group and those whose low 
birth-weight result from the early onset of labour (Gruewald, 
1971). Those in the first group are described as the small-for-date 
category. These are gestationally mature, but their rate of foetal 
growth has been retarded. The word pre-term has been suggested for 
infants born before 37 weeks gestation, while those born before 28 
weeks of gestation are described as premature (Yerushalmy and 
Berge, 1970). There are some babies who weigh far in excess of the 
normal range. Macrosomia has been used to describe babies weighing 
over 4.0kg (Garner and Kramer, 1992). Babies of high birth-weight 
increase the risk of mechanical difficulties during labour.
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Birth-weight is affected by various factors. pre-pregnancy 
weight and height of the woman as well as nutrition and weight- 
gained during pregnancy are some of the known factors that affect 
birth-weight. Within the small-for-date category, there are the 
intrauterine undernourished infants, some of whom have congenital 
malformations, foetal rubella infection, and probably other foetal 
infections. Other causes of small-for-date infants are maternal 
complications such as toxaemia of pregnancy, multiple pregnancy, 
and prolonged pregnancy (Silverman, 197 0). Acceptable birth-weight 
is an indication of favourable outcome of pregnancy
2.8: Maternal Physiological Adjustment During Pregnancy. 
2.8.1: Pregnancy Weight-gain.
Pregnancy is associated with physiological adjustments and 
synthesis of maternal tissues including the growth of the foetus 
itself. These changes lead to increase in weight of the pregnant 
woman. A strongly positive association exists with the weight of 
the infant. However the size and importance of its effect differs 
according to the condition of the woman entering pregnancy and 
reflects an interaction of weight-gain during pregnancy, pregnancy 
size and body composition (Food and Nutrition Bulletin, 1984).
An average well nourished Scottish woman is estimated 
to gain 12.5kg during pregnancy. However, there are extreme 
variations in ante-natal weight-gain, from a reported average of
11.70kg and 17.0kg in the United Kingdom and the United
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States respectively to an observed weight-gain of 5.30kg in 
primiparae and 6.30kg in multiparae in South India (Shah, 1981) 
(Appendix 4). In Sri Lanka and Ethiopia, it was similarly observed 
that a large proportion of the women gained only 6.5kg during 
pregnancy, whereas in a Gambian village, it was found that the 
total weight-gained by pregnant women varied from 2.7 0 to 5.50kg 
according to the season when the birth took place (Thomson, 197 0) . 
Data on pregnancy weight-gain in Ghana is currently very scarce .
Thomson and Billewcz (1970) reported that in the absence of 
hypertensive complications the total weight-gained during pregnancy 
was about 12.5kg, with an average rate of gain of slightly less 
than 0.5kg per week during the second half of pregnancy. This rate 
of gain is also that which was associated with the lowest overall 
incidence of pre-eclampsia, prematurity (low birth-weight), and 
perinatal mortality, and therefore seems suitable for adoption as 
a physiological norm and the basis for further calculations (Food 
and Nutrition Board, 1971). On the average most women gain weight 
progressively in pregnancy (Table 4).
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Table 4: Maternal Weight changes during pregnancy of women 
from industrialized countries.
Age of pregnancy (weeks) Additional Weight-gained 
(kg)
10 0. 65
20 4 . 00
30 8 . 50
Term (36-40) 12 . 5
Source: Food and Nutrition Board, 1971.
It has been observed that young women tend to gain slightly 
more weight than older women, primigravidas slightly more than 
multigravidas, and thin women slightly more than fat women, but the 
differences are small (Food and Nutrition Board, 1971) .
The extent of weight-gained during pregnancy is affected by a 
number of factors, especially energy and nutrient intake, pre­
pregnancy weight and height of the woman as well as physical 
activity during pregnancy. Women submitted to heavy workload during 
pregnancy do not gain much weight and are more likely to deliver 
small babies (Tafari and Naeye, 1980) . Pregnancy weight-gain and 
pregnancy outcome (birth-weight) improve if a woman maintains 
energy balance by reducing physical work to counter balance reduced 
dietary energy intake (Food and Nutrition Bulletin, 1984).
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2.8.2 Oedema in Pregnancy
Swelling of the feet, hands and face during pregnancy is 
common in some women. When the swelling is in other sites in 
addition to the lower limbs it is said to be a generalized oedema. 
Not all pregnant women develop oedema, but those who do are 
reported to deliver larger babies than those who do not develop 
oedema (Thomson and Billewcz, 1970). Oedema in pregnancy has been 
studied from epidemiological standpoint by Thomson and Billewcz 
(1970) who found that the frequency of recorded oedema is 
remarkably high about 40%, even in patients who showed no other 
sign of pre-eclampsia. About one-third of such normal patients 
showed generalized oedema, that is, in sites other than the lower 
limbs. The incidence was little affected by parity or by maternal 
age and stature, but increased steeply with maternal weight for 
height. Women with oedema had slightly larger babies than those 
with no oedema, and had reduced rates of prematurity. In the 
absence of pre-eclampsia, oedema is not unphysiological (Thomson 
and Billewcz, 1970). It has been reported by Hytten and 
Chamberlain (1980) that women with no oedema gained at term, water 
surplus of about 1 or 2 litres while women with oedema gained water 
surplus of about 5 litres. The presence of hand and facial oedema 
was used as a proxy for adequate blood volume expansion in the 
Collaborative Perinatal Project in the United States (Hytten and 
Chamberlain, 1980). In their study, hand and facial oedema 
positively correlated with blood volume expansion. When pregnancy 
weight-gains were low, perinatal mortality rates were lower if hand
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or facial oedema were present than if they were absent (Food and 
Nutrition Bulletin, 1984). This suggests that at least in thin 
women, blood volume expansion may reduce perinatal mortality rates 
(Hytten and Chamberlain, 1980) .
Though oedema is a common feature of normal pregnancy, little 
is known about its nature and origin. Oedema of the lower limbs is 
probably mainly attributable to mechanical and hydrostatic pressure 
on the venous loose interstitial water, similar in composition to 
an ultrafiltrate of plasma (Food and Nutrition Board, 1971) .
2.8.3 Anaemia In Pregnancy
Haemoglobin production requires adeguate supply of proteins to 
furnish essential amino acids in addition to folic acid, Vitamin B6 
and Vitamin B12. These vitamins serve as co-factors in the 
synthesis of haem and globin. Essential minerals like iron, copper 
and zinc must also be available during blood cell
production (DeMaeyer, 1989) . Inadequate intakes of these nutrients 
will ultimately precipitate anaemia.
Anaemia is usually defined as a significant reduction in the 
concentration of haemoglobin per 100ml of blood, in the volume of 
packed red cells per 100ml of blood, or in the number of 
erythrocytes per cubic millimetre of blood (DeMaeyer, 1989). In 
pregnancy, anaemia is said to exist if the pregnant woman's 
haemoglobin concentration is less than ll.Og/dl of blood (Tomkins 
and Watson, 1991). This value is the cut-off point for anaemia 
diagnosis in pregnant females as compared to 12.og/dl for 
non-pregnant females (Tables 5 and 6).
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Table 5: Haemoglobin Levels Indicative of Anaemia in Populations 
Living at sea level.
Age/Sex group Haemoglobin level (g/dl)
Children
6 months - 5 years < 11
6 - 1 4  years < 12
Adult males < 13
Adult females
non-pregnant < 12
pregnant < 11
Source: Tomkins and Watson, 1991.
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Table 6: Interpretative Guide for Anaemia Diagnosis.
Grade Haemoglobin level (g/dl)
Mild Above 10
Moderate 7 - 1 0
Severe below 7
Source: Tomkins and Watson, 1991.
Pregnancy imposes a substantial burden on the maternal 
haematopoietic system because of the need for augmented 
erythropoiesis in the face of an expanding plasma volume and 
obligatory placental transfer of the two most important micro­
nutrients involved, iron and folic acid. This is a major cause of 
anaemia during pregnancy (Serge and Galan, 1986). Other 
important causes of anaemia in deprived pregnant mothers are:
a) Increased blood loss due to systemic infection including 
malaria, bacterial and viral infections, or intestinal 
parasitism notably, hookworm and round worm infestation;
b) Increased iron requirements for foetal growth;
c) Dietary iron deficiency due either to insufficiency of iron 
in the diet or low physiological availability;
d) Inability of women with initially depleted iron stores to 
make up for blood loss during previous child births because 
pregnancies are too close to each other (Shah, 1981).
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In tropical context other causes of anaemia like inflammatory 
syndrome and sickle cell anaemia are possible (Serge and 
Galan, 1986).
In Ghana data showed that 69% of women tested at ante-natal 
clinics in 1987 were anaemic by World Health Organization (WHO) 
standards, ie. haemoglobin level below ll.Og/dl (UNICEF, 1990). In 
a study at Korle-Bu Teaching Hospital in 1973, on 1098 pregnant 
women, 63.7% were found to be anaemic. A 1986 survey found 
majority of women in Ashanti Region to be anaemic (UNICEF, 1990). 
Ministry of Health (MOH) Nutritional surveys in 1986 and 1988 also 
found greater percentages of women in Volta and Northern regions to 
be anaemic when compared with other regions (UNICEF, 1990). Data 
from seven regions in 1991 from MOH found the highest incidence of 
anaemia, among 492 pregnant or lactating women, in the Central 
region (58.3%), followed by Eastern region (49.3%) and Northern 
region (44.2%). The number of lactating women who were anaemic was 
about twice that of pregnant women in this data (Asibey-Berko,
1991).
A WHO report on Maternal Health and Safe motherhood (1992) 
stated that 56% of women in West Africa have haemoglobin levels 
below normal, and 64% of Ghanaian women have haemoglobin levels 
below normal and of this 11% had haemoglobin level below lOg/dl 
(W.H.O, 1992) .
It is estimated that 1.3 billion people suffer from anaemia 
worldwide of which most is due to iron deficiency (Tomkins and 
Watson, 1991). The frequency of iron deficiency anaemia is more
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than 50% among pregnant women and pre-school children in many 
communities. In developing countries, severe anaemia can be an 
associated cause of 50% and the main cause in up to 2 0% of maternal 
deaths (Tomkins and Watson, 1991).
Investigations in different parts of the developing world have 
indicated high rates of anaemia among pregnant groups. For 
instance 21% in Thailand, and 48% in many areas of South America 
(Ousa and Amatayakul, 1975). In Liberia, Jackson and Jackson found 
78% of pregnant women anaemic by WHO standards (Jackson and 
Jackson, 1987). An exception to this tendency in deprived 
populations seems to be Ethiopia where studies have demonstrated a 
rarity not only of true anaemia but also of physiological anaemia 
of pregnancy, irrespective of the socio-economic groups and parity. 
This has been attributed to their lifelong exposure to a very high 
iron intake combined with the hypoxia due to high altitude (Shah, 
1981).
Maternal anaemia results in intrauterine growth retardation, 
low birth-weight and increased perinatal mortality and iron 
deficiency in infancy and childhood is associated with apathy, 
inactivity and significant loss of cognitive abilities (Tomkins and 
Watson, 1991).
2.8.4 Blood-Volume and Composition during Pregnancy
The volume of’ plasma begins to increase at about the end of the 
third month of pregnancy, and a maximum increase of about 1250 - 
1500ml is reached by about the thirty-fourth week, after which
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there is slight fall of about 200ml towards term (Food and 
Nutrition Board, 1971). This rise represents about 50% of the 
average nonpregnant plasma volume but it is not related to the 
initial size, so that reference to the increase in terms of 
percentage rise is not meaningful. In a study where careful 
attention was jpaid to the selection of normal subjects, the range 
of increase was from 630 to 1940ml and was related to foetal size 
(Hytten and Chamberlain, 198 0). The increase is regarded as an 
adjustment that allows the pregnant woman to expand blood flow to 
her uterus without reducing blood flow to other vital organs 
(Rosso, 1981).
During pregnancy, red cell volume increases, probably 
linearly, from about the end of the first trimester of pregnancy 
until term. In women who do not take medicinal iron it averages 
about 250ml. Where iron is given, the average rise is nearer 400ml 
(Hytten and Thompson, 1970) . The normal physiological rise in red 
cell volume is reported to be about 18% of the average nonpregnant 
red cell volume (DeMaeyer,- 1989) .
In pregnancy, there is more rapid red cell production and more 
young cells are found in the circulation. The amount of 
haemoglobin in the red cells does not change so that the increase 
in circulating haemoglobin in pregnancy amounts to about 85g at 
term (Pritchard et al, 1975) .
The increase in total red cell volume during pregnancy is 
proportionately less than the increase in plasma volume. As a 
result, the concentration of haemoglobin in the blood falls.
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Haemoglobin concentration has shown a fall from an average of about
13.5 - 14.Og/dl in nonpregnant women to between 11.0 and 12.0g/dl 
in late pregnancy. The fall may be modified slightly, but not 
prevented, by giving therapeutic iron (Morgan, 197 0).
The reduced concentration of red cell and haemoglobin is often 
referred to as the physiological anaemia of pregnancy and may be 
evidence of a true iron-deficiency state (DeMaeyer, 1989) .
There is a rise in the concentration of leukocytes in 
pregnancy. Ip a study, Andrews et al (1972) found a rise from 
about 7 00 per cubic millimetre to 10,500 per cubic millimetre of 
blood. This increase might explain the higher "phagocytic index," 
a more rapid clearance of particles from the blood, found for 
pregnant females.
2.8.5 Plasma Composition in Pregnancy
Total protein concentration falls dramatically in pregnancy. 
There is a steep fall in the first trimester from 7g per 100ml of 
plasma to a level of between 5.5 and 6.0g per 100ml that is 
maintained for the remaining period of the pregnancy (Food and 
Nutrition Board, 1971). The fall in total protein is largely by 
albumin, which falls in early pregnancy from 4g per 100ml to 
between 2.5 and 3g per 100ml. The other protein fractions behave 
differently. The concentration of the a-globulin fractions rises 
slightly while B-globulin rises conspicuously. The fall in protein 
concentration would be expected to have a considerable effect on 
plasma osmotic pressure, the sudden reduction of which may explain
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the dramatic rise in glomerular filtration rate that occurs in 
early pregnancy (Food and Nutrition Board, 1971).
Fibrinogen concentration rises considerably throughout 
pregnancy and is accompanied by a decrease in plasma fibrinolytic 
activity (Biezenski and Moore, 1973). Taken together with an 
increase in blood platelet concentration, these changes may 
indicate a protective mechanism against haemorrhage, but there is 
little evidence that intravascular clotting becomes more common in 
pregnancy.
The concentration of most plasma lipids rise during pregnancy. 
Cholesterol rises progressively from under 200mg per 100ml to 
between 250 and 300mg per 100ml (De Avarez et al, 1972) . Total 
phospholipid concentration also rises, maintaining the 
non -pregnancy ratio between phospholipid and cholesterol (Svanborg 
and Zuckerman, 197 6).
The concentration of free, or nonesterified, fatty acids also 
rises markedly, from around 800jueq/litre before pregnancy to as 
much as 1300^eq/litre in late pregnancy (Burt, 1970).
There are increased amounts of many enzymes in the blood during 
pregnancy. Serum alkaline phosphatase may rise to three or four 
times its usual concentration, and the rise is due to a specific 
alkaline phosphatase elaborated by the placenta (Sadovsky and 
Zuckerman, 1975). Large increases have also been described for 
cysteine and leucine aminopeptidases, glutamic oxaloacetic 
transaminase, and lactic dehydrogenase. An exception is the
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notable fall in serum cholinesterase during pregnancy (Food and 
Nutrition Board, 1971).
2.8.6 Cardiovascular Dynamics in Pregnancy
During pregnancy the cardiac output rises from a nonpregnant 
mean of 4.5 to 5.0 litres per minute, to a plateau some 1.5 litres 
per minute higher, probably within the first trimester and 
certainly within the first half of pregnancy (Walters et al, 1976) . 
This level ofjbetween 6.0 and 7.0 litres per minute is maintained 
until late pregnancy. The increase in cardiac output is brought 
about by both an increased heart rate and a larger stroke volume. 
The pulse rate rises progressively throughout pregnancy by at least 
15 per minute. A careful study by Schwarz (1974) suggested that 
the rise might be as high as 20 per minute.
There are blood pressure changes in pregnancy. In general, 
the systolic pressure in the arteries tends to be a little below 
the nonpregnant average but rises to the usual level in late 
pregnancy. Arterial diastolic pressure is conspicuously lower than 
the nonpregnant level throughout most of pregnancy, so that pulse 
pressure is consistently raised. Diastolic pressure returns 
towards nonpregnant levels during the last 2 or 3 months of 
pregnancy (Burwell and Metcalfe, 197 0) . Since cardiac output is 
raised in pregnancy and blood pressure is not, it follows that 
resistance to flow, the peripheral resistance, is decreased.
In contrast to arterial blood pressure there are clear changes 
in venous blood pressure. In the upper part of the body pressures
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are ordinarily unaltered. In the lower limbs, there is a 
progressive rise in venous pressure during pregnancy and an 
associated slowing of blood flow. High venous pressure in the legs, 
possibly helped by the reduced plasma osmotic pressure, probably 
accounts for the commonness of lower limb oedema in normal 
pregnancy (Burwell and Metcalfe, 1970).
It is usually observed in pregnancy that the heart of the 
pregnant mother enlarges and is pushed upward and rotated forward 
by the diaphragm. These changes produce a characteristic clinical 
and radiological picture (Burwell and Metcalfe, 1970).
2.8.7 Respiratory Function Purina Pregnancy
Changes in the anatomy of the chest occur during pregnancy. 
The subcostal angle increases, the lower ribs flare, and the 
transverse diameter of the chest increases. At the same time and 
long before there can be any guestion of displacement by the 
uterus, the level of the diaphragm rises by as much as 4cm (Food 
and Nutrition Board, 1971). In pregnancy, breathing at all stages 
is more diaphragmatic and less costal than in nonpregnant women 
(Food and Nutrition Board, 1971).
The rate of ventilation of the lungs rises progressively 
throughout pregnancy from about 7 litres per minute to about 10 
litres per minute, an increase of more than 40%. Vital capacity of 
the lungs is not affected by the pregnancy but there is a 
rearrangement of its components. The increase in tidal volume is at
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the expense of the expiratory reserve volume, the lung is more 
collapsed than usual at the end of normal expiration.
The residual volume is also reduced, so that the functional 
residual capacity is considerably smaller. The important 
consequences are that the increased tidal volume of air is now 
taken into a smaller residual volume of gas in the lungs, giving 
much more efficient gas mixing. It is estimated that alveolar 
ventilation increases by about 65% (Hytten and Thompson, 1970). As 
a result of this increased ventilation, the partial pressure of 
carbon dioxide (pC02) in the lung falls. The reduced pC02 may 
contribute to the common symptom of dyspnea in pregnancy 
(Hytten and Thompson, 1970). The sensation of dyspnea, 
a conscious need to breathe, is experienced at rest but not on 
moving about during pregnancy.
2.8.8 Total Body Water During Pregnancy
By means of hydrogen isotopes Hytten and Thompson (197 0) , have 
estimated with reasonable accuracy the change in volume of total 
body water during pregnancy. In their series of studies Hytten and 
Thompson (197 0) estimated the overall mean gain of body water 
during pregnancy to be 8.5 litres. In this study women showing no 
evidence of clinical oedema gained, on average 6.84 litres; those 
with oedema of the legs, 7.19 litres; and those with generalized 
oedema, 9.80 litres. In all three categories, the range was wide, 
and the difference between women without oedema and those with leg 
oedema could not be regarded as significant. There was little or no
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difference between primigravidas and multigravidas. Except for 
generalized oedema, all the water gained up to about 30 weeks of 
pregnancy could be accounted for in the product of conception and 
the enlargement of the maternal blood volume and reproductive 
organs. But there was a surplus at term, about 1 - 2  litres. In 
women with generalized oedema a water surplus was present 
throughout pregnancy that amounted at term to about 5 litres. Most 
of the water gained had been lost 6 - 8  weeks post partum, even in 
women with generalized oedema (Food and Nutrition Board, 1971).
2.9 Geophaqia in Pregnancy
Geophagia refers to the ingestion of earth materials like 
clay, chalk and other soils (Food and Nutrition Board, 1971).
During pregnancy, a number of non-food items are ingested 
by pregnant women, especially clinic patients. Some of the 
materials ingested can have deleterious effect on the health of 
both the mother and the infant. For instance, McGanity et al 
(1970) determined that 28% of 861 pregnant adolescent girls 
ingested starch, clay, other soils or refrigerator frost.
The role of pica (ingestion of non-food items), however, in 
the genesis of iron-deficiency anaemia is however not clear. It is 
speculated that some of the components of the soils ingested can 
form chelates with minerals like iron, and prevent their 
absorption. Minnich reported that ingestion of Turkish clay 
markedly decreased absorption of (Minnich et al, 1970). Talkington 
£t a_l, (1971) studied two clays from East Texas that are popular
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with pregnant women and found a minimal impairment of iron 
absorption when the clays were ingested just prior to the iron 
intake. The studies of Talkington et al (1971) indicated that the 
ingestion of starch, may contribute to the development of iron 
deficiency during pregnancy not because iron absorption is 
impaired, but because the starch provides calories without iron. In 
addition to clay and starch, some women may ingest items like coal 
and chalk (Food and Nutrition Board, 1971) .
A black woman (31 years) who ate quantities of clay estimated to be 
200-300g daily during pregnancy ,and during preceding pregnancies, 
had severe anaemia and complete obstruction of the colon, with 
perforation and sepsis which led to her death (Key et al.1982) .
2.10 Alcoholism in Pregnancy.
Alcohol has been reported to be a foetal toxic agent which 
produces foetal abnormalities including foetal-alcohol syndrome 
(Abel, 1982). Apart from the direct toxic effect of alcohol, it 
also causes malnutrition (Burton and Foster, 1988) . Hence a woman's 
habitual alcohol intake during pregnancy should be seen as an 
unhealthy habit which can adversely affect pregnancy outcome. 
Various researches have indicated that alcohol intake has a direct 
effect on the infant. The incidence of low birth-weight increased
2.7 times in the group of new born infants whose mothers consumed 
excessive quantities of alcohol during pregnancy whereas it was 3.9 
times as great in mothers who smoked and consumed alcohol (Sokol et
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al, 1980). In addition to the promotion of malnutrition, severe 
doses of alcohol can cause alcoholic liver disease (Burton and 
Foster, 1988) .
Malnutrition caused by alcohol is exhibited as:
a). Protein malnutrition
b). Multiple vitamin deficiencies, especially in folic acid, 
thiamin, pyridoxine, ascorbic acid and vitamin D.
c). Mineral depletion including potassium, magnesium and Zinc.
Furthermore, adverse effects of alcohol use on nutrition are 
seen as:
1. Deficient intakes of nutrients, since alcohol is a source of 
calories devoid of nutrients.
2. Excess calorie intake since alcohol is a source of calories.
3. Loss of appetite due to gut and liver injury.
4. Inefficient use of available nutrients due to poor digestion 
or malabsorption from gut injury or from deficiency disease 
caused by alcoholism.
5. Extra financial drain on those of limited financial 
resources (Burton and Foster, 1988).
2.11: Effects of Physical Activity on Pregnancy Outcome
Heavy manual labour has been associated with less favourable 
outcome of pregnancy, primarily the delivery of low birth-weight 
babies or the premature onset of labour (Briend, 1980). The degree 
of physical work during pregnancy may also affect the health of the 
mother. It has been demonstrated (Tafari and Naeye, 1980) that
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pregnancy outcome (birth-weight) improves if a woman maintains 
energy balance by reducing physical work to counterbalance reduced 
dietary energy intake.
Briend (1980), observed that a heavy workload during pregnancy 
contributed to the incidence of low birth-weight in Dacca. In Addis 
Ababa, Tafari and Naeye reported that with the same diet over 1600 
kcal per day, those women submitted to heavy workload did not gain 
much weight during pregnancy and had smaller children.
2.12: Food Taboos and Beliefs in Pregnancy
Some kinds of foods are avoided by women during pregnancy. 
The foods may be avoided due to nausea (aversion), taboos and 
beliefs, during pregnancy. Majority of the foods avoided however 
tend to be rich sources of vitamins, minerals and energy, which are 
needed for proper foetal growth and favourable pregnancy outcome 
(Jackson and Jackson, 1987). In Ghana, for instance, pregnant 
women often avoid sugary and nutritious foods such as mangoes and 
ripe plantain for fear that these foods might cause miscarriages, 
particular in the early months of pregnancy (UNICEF, 1990).
Jackson and Jackson (1987) observed that food taboos 
associated with pregnancy tend to restrict the intake of local 
animal-derived foods (eg? monkey, bush cow, red deer, blackdeer, 
fowl, eggs, opposum, freshwater crab and porcupine) in Liberia. 
Additionally, numerous taboos limit the intake of vitamin C 
containing foods like fruits such as pawpaw, pineapple, mango, and
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monkey nut which if eaten together with haem-iron rich foods, could 
enhance iron absorption (Jackson and Jackson, 1987) .
2.13: Birth-spacing. Breastfeeding and Pregnancy outcome
It is known that exclusive breastfeeding tend to delay the 
onset of the succeeding pregnancy (ie. lactational amenorrhoea). 
However, some women may become pregnant during the period of 
lactation. This condition referred to as overlap, is clearly 
likely to increase the stress on woman's health and nutrition 
(Tomkins and Watson 1991) . The phenomenon has been reported to be 
common among women in a number of poor areas. Ramachandram, (1991) 
observed 30% overlap prevalence in Guatemala and Senegal, 40% in 
Indonesia, and as high as 70% in India. In his study, Ramachandram 
(1991) concluded that irrespective of the duration of lactation and 
period of gestation, women who continued lactation during their 
pregnancy had lower body weights than their non-lactating pregnant 
counterparts. Similar observations were made by Martorell and 
Merchant in 1991.
Adequate birth-spacing can mean the proper recuperation of the 
mother after a pregnancy. It can also mean adequate care of the 
preceding child, including its continued breastfeeding. Rapidly- 
succeeding pregnancies are associated with low maternal and infant 
nutritional status due to inadequate maternal nutrient repletion 
before the succeeding pregnancy. This condition has been referred 
to as the maternal depletion syndrome (Tomkins and Watson, 1991). 
The effect of repeated pregnancies and lactation on the health of
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mothers is however variable. Venkatachalan et al (1970) observed 
a fall in body weight with rising parity among the poorly fed 
Chimbu women in New Guinea, which he attributed to the greater 
energy demand made by frequent lactation, whereas Thomson and 
Billewcz (197 0) found no such decrease with increasing parity in a 
South African village. Rajlakshmi (1971) in India also found no 
decrease in body weight, and in fact reported a slight trend 
towards an increase in birth-weight with parity. Increase in birth- 
weight up to the fourth, fifth and sixth pregnancies have been 
reported (Shah, 1981).
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CHAPTER THREE 
MATERIALS AND METHODS
3.1: The Study Areas
Data for the study were collected from four health centres. 
They are: Legon University Hospital, La Polyclinic, Kaneshie 
Polyclinic and Nerzit Maternity at Madina. These centres provide 
ante-natal services to pregnant women.
3.2: The Subjects
Subjects for this study were pregnant women who were attending 
ante-natal clinics on out patient basis. Subjects were within the 
age group of 2 0 - 35 years. A total of 502 pregnant women were 
selected for the study. Pregnant women who were present at the 
ante-natal clinics at the time of the study were those who 
participated in the study.
Subjects who had sickle cell disease, pre-eclampsia, as well 
as complicated pregnancy were not selected for this study.
3.3: Data Collection
A questionnaire (Appendix 11) was used to collect data from the 
pregnant women. Responses to the questionnaire were provided by a 
total of 502 pregnant women.
Data were collected on food and health habits during 
pregnancy,socio-economic status and other determinants of pregnancy
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outcome. A sub-sample of 12 8 pregnant women were selected for 
detailed study in a longitudinal study.
3.4: Epidemiological Data
This 'comprised data collection on biomedical, and 
psychological determinants of pregnancy outcome. Specifically, data 
on food habits, nutrient supplementation, geophagia, nausea, 
oedema, alcohol intake, ante-natal clinics attendance, preference 
of infant size in pregnancy and women's perception of good 
nutrition during pregnancy and safe labour, were obtained by means 
of a questionnaire designed for the purpose.
3.5: The Longitudinal Study
The longitudinal study was in three main parts. Collection of 
anthropometric and biochemical data and dietary intake assessment.
3.5.1: The Anthropometric Measurements
This included measurements of the heights and weights of the 
pregnant women and birth-weight of their infants on delivery. 
Height and weight measurements were in centimetres and kilograms 
respectively (Jelliffe and Jellife, 1989).
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Weight Measurements
Weights of the pregnant women were monitored from the third to 
the ninth month of pregnancy. Monthly weight measurements were 
made over a period of six months using the adult weighing scale 
with a least count of 0.1kg (Seca, M215) . The weight measurements 
enabled the computation of the rate of pregnancy weight-gain over 
the six month period. Pregnancy weight-gain was determined from 
the difference in weight first seen in the third month of gestation 
and that of the ninth month of pregnancy (Hytten and Thompson, 
1970) .
Height Measurements
The heights of the pregnant women were taken in the first 
trimester to eliminate drooping effect of the pregnancy weight. 
The height measurements were done using the stadiometer (adult 
height scale) ;with least count of 1mm (Holtain type).
Weight and height measurements were made in a manner conducive 
with laid down regulations (Jelliffe and Jellife, 1989). Subjects 
were wearing very light clothing, bare-footed, standing upright and 
in attentive position with hands relaxed on their sides, looking 
straight ahead at eye level before measurements were recorded.
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3.6: The Biochemical Study
The biochemical study was a longitudinal study of the 
haemoglobin levels of the pregnant women.
Haemoglobin levels of the pregnant women were determined 
monthly for a period of six months, from the third to the ninth 
month of gestation. Haemoglobin determination was by means of the 
cyanmethaemoglobin method using Drabkin's reagent (Wooton, 1974). 
The haemoglobin levels were determined to evaluate the 
effectiveness of the mineral and vitamin supplementation programmes 
for pregnant women at these ante-natal clinics. The evaluation was 
done by comparing their mean haemoglobin levels to that of the WHO 
standard (ll.Og/dl) to assess anaemia prevalence in the pregnant 
women (Tomkins and Watson, 1991).
3.7: The Dietary Study
The dietary study was aimed at assessing average energy, 
protein, and iron intakes of the pregnant women. This was done by 
means of the dietary recall method. Twenty-four-hour dietary 
recall was performed on the 128 pregnant women on three different 
occasions in the first, second and third trimesters to give the 
true picture of the dietary intake of these nutrients by the 
pregnant women. Average values of energy, protein and iron 
were computed using food composition tables (Eyeson and Ankrah, 
1975). Mean values of these nutrients were then compared
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to the recommended dietary allowances (FAO/WHO, 1985) for pregnant
women.
3.8: Analysis of The Data
1. Data analysis was computer-based, using the Statistical 
Package for Social Scientists (SPSS) programme. Data storage 
was in Dbase 3 Plus.
2. Computed values were expressed as mean ± standard deviation.
3. Analysis of variance (ANOVA) was used where a test for 
significant effects of the variables was required.
4. Walker-Duncan Adaptive Procedure was used to compare the 
means of[variables where ANOVA showed significant effects.
5. Correlation analysis was done to ascertain relationships 
between variables.
6. The student's t-test was used where comparison between two 
means was required.
7- Dietary nutrient intakes were analyzed by the use of FAO food 
composition tables for Africa (1972) together with food 
composition tables formulated by Watson (1971), Eyeson and 
Ankrah (1975).
8. The net protein utilization (NPU) for protein in a mixed diet 
was taken as 70% (FAO/WHO,1973).
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3.9 Characteristics of the Subjects
The general characteristics of the subjects are listed in 
table 7.
Most of the subjects (55.18%) were originally from the Greater 
Accra region while the rest were from other regions but were 
now based in Accra. The mean age of the subjects was 2 7.5 years. 
Most of the subjects attained middle (53.98%) and secondary school 
(33.27%) educational levels. A substantial number of them were 
traders (57.77%) and vocational workers (27.69%).
Majority of the subjects were married (99.40%). Of the total 
number of 502 women, 27.49% of them were nulliparous, and 35.46% 
had had one or two previous pregnancies while 29.88% had 
experienced three or four previous pregnancies. About 7% had 
experienced more than four previous pregnancies.
Pre-eclampsia, antepartum haemorrhage, and other sicknesses 
were absent in the subjects, and most of them (93.0%) had been 
immunized against tetanus. The subjects had normal mean Body Mass 
Index (BMI) of 23.09 and were of acceptable (Table 39) mean height 
(162.17cm) and weight (60.77kg) at the beginning of the pregnancy.
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Table 7: Characteristics of subjects involved in the
study, (n = 502)
Characteristics Number of Percentage of
Mothers mothers
Age groups
20 - 25 245 48.80
26 - 30 161 32 . 07
31 - 35 96 19 . 13
Educational level
None 10 8.56
Primary 46 9. 16
Middle 271 53 . 37
Secondary/Technical/Vocational 167 33.27
University 8 1.59
Region of birth
Ashanti region 43 8 . 56
Brong Ahafo region 2 0.40
Central region 64 12.75
Eastern region 51 10. 16
Greater Accra region 277 55 . 18
Northern region1 9 1.79
Volta region 40 7 . 97
Western region 16 3 . 19
1: Northern region including Upper East and Upper West regions*
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Table 7 (continued): Characteristics of subjects involved in 
___________________  the study (n = 502)______________________
Characteristics Number of Percentage (%)
! mothers
Occupation
Trader 293 58.37
Vocational1 141 28.09
Office worker2 14 2.79
Professional3 33 6.57
Housewife 21 4 . 18
Marital status
Married 499 99 .49
Single 3 0. 60
Number of previous 
pregnancies (parity)
Nulliparous 138 27.49
1 - 2 178 35.46
3 - 4 150 29.88
5 - 6  | 29 5 . 77
7 - 9 7 1.39
1. Vocational worker: hairdresser, seamstress, driver, caterer, farmer, etc.
2 . Officer worker: typist, secretary, receptionist, telephonist, etc.
3. Professional: teacher, lecturer, nurse, police personnel, actress, lawyer etc.
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Table 7 (continued): Characteristics of subjects involved in
the study (n = 502)
Characteristics Number of Percentage (%)
mothers
Prevalence of 
spontaneous abortion
None | 366 72 .91
1 112 22.31
2 22 4 . 38
3 2 0.40
Prevalence of stillbirths
None 483 96.22
1 19 3 . 78
Tetanus immunization
Mothers immunized 468 93 . 0
Mothers not immunized 34 7 . 0
Anthropometric values in
first trimester Mean Standard deviation
Weight (kg) 60.766 10.118
Height (cm) 162.167 5.263
Body Mass index (BMI) 23.094 3 . 582
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CHAPTER FOUR
4.0: R E S U L T S  
4.1: Conduct of the Ante-natal clinics
The health centres where the study was done operated on an 
out-patient basis. The patients (Pregnant women) visited the health 
centres on days scheduled for ante-natal services. The daily 
schedules varied between the health centres.
The frequency of attendance of the pregnant women at the ante­
natal clinics depended on the gestational age of the pregnancy 
(Table 8).
Table 8: Clinic attendance schedule for the pregnant women
Gestational age (Months) Attendance schedule
Conception to 7th month Monthly
7th to 8th month Fortnightly
8th month to term (delivery) weekly
However those with special risk problems like low haemoglobin 
level, high blood pressure (B.P), sickling, poor medical history, 
including bleeding in previous pregnancy, attended more 
frequently. The type of nutrient supplements given to the 
pregnant women are listed in appendix 2. Commonly, the iron 
supplement given was fersolate (B.P 200mg equivalent to 60mg 
elemental iron per tablet). Multivitamin tablets given were
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multivites, folic acid tablets (5mg/tablet), and vitafol (Appendix 
2) . Calcium tablet administered separately to the pregnant women 
was dumocalcin (500mg Ca/tablet/day). Three (3) fersolate and 
multivites were to be taken per day (one each after meals in the 
morning, afternoon and evening). Folic acid and calcium supplements 
were administered at a dosage of one tablet per day. Normally 
fersolate (iron) was administered with multivites, folic acid, 
vitamin B-complex and calcium while the multivitamin and mineral 
tablets (eg. vitafol) were administered with only calcium.
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On the average the pregnant women paid four thousand, five 
hundred Cedis (04,500.00) on their first attendance to the ante­
natal clinics but on subsequent visits amounts between thousand 
eight hundred (01,800.00) to two thousand Cedis (02,000.00) were 
paid. These monies do not cover the cost of drugs, should 
additional drugs be required, in addition to what is given 
routinely. The hospital charges for delivery were on the average 
about twenty-five thousand Cedis (025,000.00) but increased to 
about sixty thousand Cedis (060,000.00) if caesarian section was 
involved. Haemoglobin level, blood pressure and weight of the 
pregnant women were determined on every attendance to the health 
centres. Immunization of the pregnant women against tetanus was 
also done in the fifth month of pregnancy. Malarial 
chemoprophylaxis was also given. In addition nurses at the 
ante-natal centres advised the pregnant women on good nutrition 
and health practices.
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4.2 EPIDEMIOLOGICAL STUDY 
4.2.1: Infant Birth-weight
The range of birth-weights observed in the study was 1.80 - 
4.2kg, with a mean of 2.999 ± 0.511kg. Out of the total of 502 
mothers, 42 (8.37%) delivered infants who weighed between 2.50 and 
4.00kg, while 5 (1.00%) mothers delivered infants who weighed more 
than 4.00kg (Figure 2) (Appendix 5).
Infants delivered by the mothers were of about equal sex 
ratio. There were 265 (52.79%) male and 237 (47.21%) female 
infants.
There was not much variation in infant birth-weight at the 
ante-natal clinics of study. Figure 2, (Appendix 6).
4.2.2: Educational Level of the Mother and Infant Birth-weight.
Table 9 shows the birth-weight of infants in relation to the 
mothers' education level.
No significant (p < 0.05) differences were observed in their 
infants' birth-weights. However mothers who have had tertiary 
education had slightly larger infants as compared to the other 
mothers with lower educational levels.
Majority of the mothers had middle (53.98%) and secondary 
(33.26%) educational levels. Only few had tertiary level education, 
while ten mothers have had no education at all.
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Table 9: Birth-weight of infants in relation to mothers' 
educational level.
Educational level Number of Birth-weight of 
of mothers mothers ( % ) infants1 (kg) 
(mean ± S.D)
None 10 (2.00%) 3.045 ± 0.319 
Primary School 46 (9.16%) 3.072 ± 0.489 
Middle School 271(53.98%) 2.998 ± 0.536 
Secondary/Vocational 167(33.26%) 2.970 ± 0.488 
Tertiary 8 (1.59%) 3.144 ± 0.453
Total 502 2.999 ± 0.511
1: No significant differences were observed, P < 0.05: Duncan's multiple range test*
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Figure 2: Distribution of infants according to birth-weight 
(n = 502) .
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SO
43.63
40
33.47
30
20
13.66
10
0
< 2.6 2.60 -  2.99 3.00  -  3.49  3.60  -  4.00 > 4.00
Infant birth-weight (Kg)
Percentage of infants
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4.2.3: Mothers Occupation and Infant Birth-weight
The birth-weight of infants was found to be related to the 
type of occupation of the mother (Table 10, Duncan's
multiple range test showed significant (p < 0.05) differences 
between the infant birth-weights. Women who were housewives had 
significantly larger infants (3.312 ± 0.352kg) than women who were 
traders (2.976 ± 0.534kg) and vocational workers (2.985 ± 0.478kg). 
However there were no significant (P < 0.05) differences in birth- 
weight of infants born to mothers in the other occupational groups.
Most of the pregnant women were traders (57.77%) and 
vocational workers (27.69%). Office workers (2.79%) and 
housewives (4.18%) were few.
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Table 10: Effect of Mothers Occupation on Birth-weight of
Infants (n = 502)
Mothers' Occupation Number of mothers Infant Birth 
(%) Weight (kg)4
Trader 293 (58.37) 2.97 6a ± 0.534
Vocational1 141 (28.09) 2.985a ± 0.478
Office worker2 14 (2.79) 3.079 ± 0.507
Professional3 33 (6.57) 3.057 ± 0.653
Housewife 21 (4.18) 3.312b ± 0.352
1: Vocational worker; hairdresser, seamstress, driver, caterer, farmer, etc.
2: Officer worker; typist, secretary, receptionist, telephonist, etc.
3: Professional; teacher, lecturer, nurse, lawyer, police personal, actress, etc.
A: Mean values different superscripts are significantly different; Duncan's Multiple range test, P < 0.05.
4.2.4: Gestational Age at which Mothers seek Ante-natal care 
and Effect on Infant Birth-weight
Most of the pregnant women 210 (41.83%) in the study visited 
ante-natal clinic for the first time during the third month (12th 
week) of pregnancy (Table 11). Only 152 (30.28%) of the pregnant 
women visited ante-natal clinic in the first two months of 
pregnancy. Some of the pregnant women visited ante-natal clinic 
for the first time in the sixth and seventh months of pregnancy.
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Pregnant women who received ante-natal care before the end of 
the first trimester (12th week) had infants of significantly (P < 
0.05) higher birth-weight than those who received ante-natal care 
during the second and third trimesters.
The reasons why women visited the ante-natal clinics at the 
observed gestational ages of first visit are shown in table 12.
Table 11: Age of pregnancy at which mother first seeks ante­
natal care in relation to birth-weight of infants 
(n = 502)
Gestational age Number Percentage Birth-weight of 
on first Visit of of infants (kg)1
(weeks) subjects subjects
4 29 5.78 3.158a ± 0.435
8 123 24 . 50 3.078a ± 0.437
12 210 41.83 3.07 2a ± 0.455
16 82 16.33 2.794b ± 0.503
20 36 7 . 17 2.709b ± 0.658
24 14 2 .79 2.800b ± 0.967
28 8 1. 59 2.85 0b ± 0.618
1: Mean values with different superscripts are significantly different from each other;P v 0.05 Duncan's 
multiple range test.
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Table 12: Reasons given by mothers for visiting ante-natal 
clinics at the observed gestational ages of first 
visit.
Mothers' reasons Number of Percentage
mothers
It was not time to visit clinic 166 33.07
Because of sickness or vomiting 114 22.71
To save money or not prepared 71 14 . 14
to visit clinic
For care of the pregnancy. 151 30. 08
Total 502 100.00
4.2.5: Nausea During Pregnancy and Effect on Infant Birth-weight
Various degrees of nausea were exhibited by the pregnant women 
in the study. Of the total of 502 pregnant women, 134 (26.69%) did 
not experience nausea during the pregnancy. Fifty-eight (11.55%) 
lost appetite but did not vomit, whereas 310 (61.7 5%) frequently 
vomited and lost appetite during the pregnancy (Table 13).
Mothers who neither vomited nor lost appetite had infants of 
significantly (P <0.05) higher birth-weight (3.214 ± 0.566kg) than 
mothers who lost appetite with vomiting (2.867 ± 0.0391kg). 
Mothers who lost appetite but did not vomit had infants of slightly 
lower birth-weights than those who did not lose appetite and did 
not vomit (Table 13).
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Table 13: Effect of Nausea during Pregnancy on Infant Birth 
Weight (n = 502) .
Degree of nausea Number of Infant birth-weight 
mothers (%) (kg) (mean ± S.D)1
No loss of appetite and no 134 3.214a ± 0.566
vomiting (26.69)
Loss of appetite but no 58 2 . 912a,b ± 0.638
vomiting (11.55)
310 2.867b ± 0.391
Lose appetite with vomiting (61.75)
1: Mean values with different superscripts are significantly different: P < 0.05# Duncan's test.
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4.2.6: Vomiting During Pregnancy and Effect on Infant Birth 
weight
Table 14 indicates the effect of vomiting on infant birth-weight. 
In the study, different durations of vomiting were observed among 
the subjects. Some of the women 124 (24.70%) vomited frequently 
for less than three months while others 186 (37.05%) vomited for 
more than three months but less than five months. However 192 
(38.25%) of the pregnant women did not vomit during pregnancy.
Vomiting had a significant adverse effect on birth-weight. 
Women who did not vomit during the pregnancy had significantly 
higher birth-weight (P < 0.05) infants (3.214 ± 0.566kg) than those 
who vomited for more than three months (2.738 ± 0.424kg).
In addition, subjects who vomited for more than three months 
had infants of significantly (P < 0.05) lower birth-weight than 
those who vomited for less than three months.
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Table 14: Effect of duration of vomiting during pregnancy on 
infant birth-weight (n = 502)
Duration of Number of Percentage Birth-weight 
vomiting Mothers of of infants 
months) Mothers (kg)1
No vomiting 192 38.25 3.214a ± 
0. 566
Less than three 124 24.70 3.060b ± 
months 0.342
More than three 186 37 . 05 2.73 8° ± 
months 0.424
1: Means with different superscripts are significantly different: P < 0.05, Duncan's test.
4.2.7: Alcoholism During Pregnancy
In the study, it was found that some pregnant women took 
alcohol during pregnancy. Of the total of 502 pregnant women, 47 
(9.36%) took alcohol during pregnancy. Alcoholic drinks taken 
included local gin (Akpeteshie), Schnapps, beer, and guinness. Of 
those who took alcohol during pregnancy, 25 (5.18%) took local gin, 
12 (2.39%) took beer while 10 (1.99%) took guinness 
(Table 15).
The quantities of alcohol taken by the subjects were not 
excessive. Those who took local gin during pregnancy took less 
than 100ml per week, and those who took either beer or guiness took 
on the average, one or two bottles per week.
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The reasons given by the women who took alcohol during 
pregnancy are various (Table 16). While some of the women claim 
they took alcohol to increase appetite 21 (4.18%), others claim 
they took the alcohol to prevent vomiting 11 (2.19%). However 
there were some of the women 15 (2.99%) who developed the taste for 
alcohol during the pregnancy.
Although the number of women who took alcohol is small for any 
meaningful comparison, it is worth mentioning that there were no 
significant (P < 0.05) differences in birth-weights of infants born 
to women who took alcohol (3.079 ± 0.384kg) and those who did not 
(2.992 ± 0.0521kg).
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Table 15: Types of Alcoholic drinks and Quantities taken by
mothers during pregnancy (n = 502)
Number of Mothers Type of Alcohol Quantities taken
25 (5.18%) Local gin/Schnapps Less than 100ml 
per week.
12 (2.39%) Beer 1 - 2  bottles per 
week.
10 (1.99%) Guinness 1 - 2  bottles per 
week.
455 (90.64%) Do not take 
Alcohol -
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Table 16: Mothers' reasons for taking alcohol during pregnancy
Mothers reasons Number of Mothers Percentage of Mothers
For appetite 21 4 . 18
Developed taste for 15 2 . 99
it in pregnancy
To prevent vomiting 
and excessive 11 2 . 19
salivation
Do not take alcohol 455 90. 64
Total 502 100.00
4.2.8: Pica Practice of the Pregnant Women and their Reasons
It was observed in the study that a substantial number of the 
pregnant women ingested clay 143 (28.49%) during the pregnancy. 
Some of them also chewed stick or sponge 4 9 (9.76%) more 
frequently. However few of the pregnant women chewed cola nut 25 
(4.98%), fresh maize dough 14 (2.79%), chalk 6 (1.20%) and raw 
starch 4 (0.80%). About half of the pregnant women did not 
practise pica 261 (51.99%) during the pregnancy. On the whole, 241 
(48.01%) of the pregnant women practised pica during the pregnancy 
(Figure 3, Table 17).
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t
m
J
ffl
s
J
4
*
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Figure 3: Types of materials ingested by the mothers 
during pregnancy (n =502)
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5i.ee
50 -
40 -
Clay Chewing stlckC o la  nu1 Mslze dough Chalk Starch Nona
Type of material
Percentage of mothers
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Table 17: Types of material ingested by women during pregnancy 
and their reasons.
Type of No. of Percentage Mothers' reasons.
material. women. of mothers
Clay. 143 28 . 49 To alleviate
salivation, vomiting 
or flavour was 
Chewing appealing.
stick/sponge1. 49 9.76 To prevent
salivation.
Cola nut. 25 4 . 98 To clear the mouth or
to prevent 
salivation.
Maize dough. 14 2 . 79 The flavour was
appealing.
Chalk. 6 1. 19 Felt for it or
flavour was 
attractive. 
Starch. 4 0.80 Appealing flavour.
None. 261 51.99 -
Total 502 100.00
1: Chewed more frequently than used to.
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Two main groups of pregnant women were found in relation their 
reasons for eating clay (TablelS). One group ate clay to prevent 
spitting (salivation) or vomiting 81 (16.14%) while the remaining 
group ate clay because either they liked the flavour or it was 
appealing to them 62 (12.35%) (Table 18)
Table 18: Mothers' reasons for eating clay during pregnancy,
(n = 502).
Mother's reasons. Number of Percentage of 
Mothers. mothers.
To prevent spitting or 
vomiting. 81 16.14
I like the flavour of 
clay or it is appealing. 62 12.35
Do not eat clay. 359 71.51
Two categories of women were found in relation to clay intake. 
There were pregnant women who ate clay everyday 
14 (2.79%) and those who sometimes ate clay 129 (25.70%).
Majority of the pregnant women did not eat clay 359 (71.51%) during 
the pregnancy.
Clay intake did not have any effect on the birth-weight of 
the infants. There were no significant (P < 0.05) differences in 
the birth-weight of infants born to women who ate clay everyday 
(3.025 ± 0.287kg), who sometimes ate clay (2.994 ± 0.396kg) and
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those who did not eat clay (3.001 ± 0.552kg) during the pregnancy 
(Table 19) .
Table 19: Effect of clay ingestion on infant birth-weight
(n = 502)
Degree of clay ingestion Number of mothers Birth-weight of 
infants (kg)1
Eat clay everyday 14 3.025 ± 0.287
(2.79%)
Sometimes eait clay 129 2.994 ± 0.396
(25.70%)
Do not eat clay 359 3.001 ± 0.552
(71.51%)
1: No significant differences were observed, P<0 05: Duncan's test.
4.2.9: Foods Avoided by Ghanaian Women during Pregnancy
In the study, it was found that more than half of the pregnant 
women avoided some kind of food during pregnancy (Table 20) . High 
protein foods like fresh fish and fresh meat were avoided by some 
of the pregnant women because of the strong scent of these foods. 
Slimy sauces and highly scented fermented foods as well as too 
fatty foods w^re also avoided by some of the pregnant women. Fufu 
was also avoided by some of the women during pregnancy because it 
causes excessive fulness after eating.
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Table 20: Foods avoided by Ghanaian women during pregnancy and 
reasons (values in parenthesis are percentages,
(n = 502)
Kinds of food avoided Number Reasons
of
women
Fresh fish or fresh meat 167 The scent is prohibitive.
(33.27%)
Okro or slimy sauce 54 The slime is not
(10.76%) attractive.
Fermented fish and maize
foods (Kenkey, 49 The scent is too strong.
porridges, etc) (9.76%)
Fatty food 23 Too oily.
(4.58%)
Fufu 20 Gives excessive fullness.
(3.98%)
None 189 I like all foods during
(37.65%) pregnancy.
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4.2.10: Diet Modification During Pregnancy and Effect on Birth 
Weight
More than half of the pregnant women studied did not alter 
their diet to suit the pregnancy (Table 21). Only 33 (6.57%) women 
claimed to have eaten more food during pregnancy. Due to nausea, 
104 (20.72%) reported a decrease in food intake.
The diet modifications reported by the mother did not 
significantly affect the birth-weight of their infants. Women who 
claim they ate more food than before the pregnancy had slightly 
higher infant birth-weights (3.124 ± 0.470kg) than women who 
reported to have eaten lesser amount of food (2.947 ± 0.568kg). 
This was not significant though.
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Table 21: Women who Modified their Diet During the Pregnancy, 
their Reasons and Effect on Birth-weight
Diet Modification Number of Birth-
Type of change in Mother's reasons mothers weight
diet. (%) (kg)
Ate more food than For proper 33
before. development of baby (6.57) 3.124 ± 
0.470
Eat less food than Loss of appetite 104
before the and vomiting or (20.72 2.947 ± 
pregnancy. heart burn. 0 . 568
Did not modify Eat enough food 365 
diet . everyday. (72.71) 3.003 ± 
497
4.2.11: Oedema During Pregnancy and Effect on Infant Birth 
Weight.
No generalized oedema was observed in any of the pregnant 
women. However oedema of the limbs (feet) was present in 205 
(40,84%) of the pregnant women.
Significant difference between the mean infant birth-weight 
for those who developed oedema and those who did not develop oedema 
was observed, with the former having significantly higher birth- 
weights (P<0.05) than the latter (table 22).
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Mothers reported that oedema of the feet was associated with 
slight pains and dumbness of the feet.
Table 22: Effect of oedema during pregnancy on birth-weight of 
infants.
Oedema Number of Birth-weight (kg)1 
Mothers (mean ± S.D)
Did not develop oedema 297 2 . 848a ± 0.501)
(59.16%)
Developed oedema 205 3.22b ± 0.441
(40.84%)
Total 502 2,999a'b ± 0.511
(100%)
1: Means with different superscripts are significantly different: P < 0.’05, Student's t-test.
4.2.12: Effect of Parity on Infant Birth-weight
Table 23 shows the effect of parity on infant birth-weight. 
Mothers who have had three or four previous pregnancies had 
significantly (P < 0.05) larger infants (3.207 ± 0.503kg) than 
nulliparous (2.910 ± 0.504) and mothers with seven or more previous 
pregnancies.
Of the 186 pregnant women who had three or more children,
81 (43.55%) were of the opinion that higher number of children was 
security against child mortality, while 73 (39.25%) had greater 
number of children due to children from a previous marriage. The
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desire to have a child of a different sex among the children was 
the main reason for 32 (17.20%) mothers having more children. 
Mothers who had less than three children attributed it to economic 
hardship (Table 24).
Table 23: Number of Previous Pregnancies in Relation to Birth
Weight of Infants (n = 502)
Number of Previous Number of Birth-weight 
Pregnancies Mothers (kg)1 (mean ± 
(n = 502) S.D)
None (first pregnancy) 138 2.910a ± 0.504
1 - 2 178 2 . 97 5a,b ± 0.520
3 - 4 150 3.207b ± 0.503
5 - 6 29 3 . 039a,b ± 0.437
7 - 9 7 2 . 943a ± 0.468
1: Means with different superscripts are significantly different, P<0.05: Duncan,s test.
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Table 24: Mothers' Reasons for having three or more children
Reasons for three or more Number of Percentage in the 
children mothers group (%) .
(n = 186)
Some of the children may die 81 43 . 55
Multiple marriages 73 39.25
Desire for a different sex 32 17 .20
among the children
4.2.13: Mothers' Preference of Infant size and Reasons.
Table 2 5 shows mother's preference for infant size at birth 
and the reasons for their preferences.
A substantial number 204 (40.60%) of the subjects preferred 
small infants for easy labour. Only 55 (10.90%) wanted big infants 
on delivery with the reason that big infants look bouncy or tough. 
However most of the subjects 242 (48.50%) had no particular 
preference of infant size at labour. They were of the opinion that 
infant was an act of God which cannot be controlled by humans.
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Table 25: Mothers' Preference of Infant size and Reasons
Mothers' reasons for Number of Percentage of 
preferred infant size mothers mothers
Small infants present 204 40. 60
easy labour
Big infants look tough or 55 10.90
bouncy
No Preference, God's 243 48 . 50
decision
Total. 502 100
4.2.14: Measures Taken by Mothers to Achieve Preferred Infant 
size.
Although a substantial number of mothers had particular 
preferences for infant size, majority 145 (71.04%) of them did not 
take any measures aimed at achieving the preferred infant size 
(Table 26). Of the 204 women who preferred small babies, only 21 
(10.2 9%) reported to have eaten less food than their non-pregnancy 
food intakes to achieve the small infant size. One mother in this 
group actually used herbs in order to deliver small infants. 
Thirty-six (65;.46%) of the women who preferred big infants at birth 
claimed they ate more food to achieve their aim.
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Table 26: What Mothers Do to Achieve Preferred Infant size.
Number of Mothers Percentage (%)
Do nothing 201 40. 04
Eat less 21 4 .20
Eat more/right food 36 7.20
Use herbs 1 0.20
No preference for infant 243 59.56
size.
Total 502 100.00
4.2.15: Mothers' Preference of Infant size at Birth 
in Relation to Birth-weight of their Infants
Table 27 shows that even though mothers had particular 
preferences for infant size, actual birth-weight of infants did not 
always tally with mothers' preference. There were no significant 
(P < 0.05) differences between the birth-weight of infants born to 
mothers of theivarious preference levels. However women who wanted 
small infants delivered infants of slightly higher birth-weight 
(3.042 ± 0.554kg) than those who wanted big infants (2.989 ± 
0. 548kg).
Twelve (2.4%) women, out of the total of 502 pregnant women, 
did not have spontaneous labour. These women delivered 
significantly (P < 0.05) bigger infants (3.480 ± 0.295kg) as 
compared to those who had spontaneous delivery who had mean infant 
birth-weight of 2.987 ± 433kg. Though the number of women who
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experienced difficult labour was small, the impression had was that 
high infant birth-weight may pose labour problems.
Table 27: Mothers' Preferences of Infant size at Birth in
Relation to Birth-weight of their Infants (n — 502).
Mothers' Preference Number of Percentage Birth-weight of 
Mothers of Mothers infants (kg) 
(Mean ± S.D)
Small infants 83 16.50 3.042 ± 0.554
Medium size infants 124 24 . 60 3.003 ± 0.405
Big infants 55 10.90 2.989 ± 0.548
No preference 243 48 . 00 2.986 ± 0.538
Total 502 100.00 2.999 ± 0.511
1: No significant differences between birth-weights were observed; (P < 0.05, Duncan's test).
4.2.16: Duration of Mineral and vitamin Supplementation 
During Pregnancy and Infant birth-weight
The results of the effects of mineral and vitamin 
supplementation on infant birth-weight are shown in table 28, and 
figure 1+.
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Pregnant women who had supplementation for more than 20 weeks 
had infants of significantly (P < 0.05) higher birth-weight than 
those who received supplementation for less than 2 0 weeks.
Table 28: Duration of mineral and vitamin supplementation during 
pregnancy in relation to birth-weight (n = 502).
Duration of Number of Birth-weight (kg)1 
supplementation (weeks) Mothers (mean ± S.D)
8 11 2 . 77 4a ± 0.542
12 12 2.775a,b ± 0.248
16 21 2 . 478a ± 0.703
20 54 2 . 714a#b ± 0.579
24 123 2.97 5b ± 0.472
28 171 3. 085b ± 0.473
32 85 3.14lb ± 0.379
36 25 3.219b ± 0.492
1: Means with different superscripts are significantly different, P<0.05; Duncan's test.
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Figure 4: Effect of duration of mineral and vitamin
supplementation of the mother on infant birth-weight 
(n = 502).
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4
3.5 
3.141 3.219
2.975 3.005
3 2.775 2.714
2.6 
2
1.6
1
0.5
0
Duration of supplementation (weeks)
Infant birth-weight (Kg)
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4.3: THE LONGITUDINAL DATA
From the total of 502 pregnant women, a sub-sample of 128 
participated in the longitudinal study. Their energy, protein and 
iron intakes were assessed through a 3-day 24-hour dietary recall. 
Monthly maternal weight-gains and maternal haemoglobin levels were 
also studied. In addition, some of the effects of mineral and 
vitamin supplementation on pregnancy was studied to ascertain the 
effectiveness of the supplementation programme.
The results of the longitudinal study are shown in tables 29 
to 4 5 and figures 5 to 8 .
4.3.1: ANTHROPOMETRIC DATA
Table 29 shows the mean, standard deviation, maximum and 
minimum values of some anthropometric indices including the mean 
monthly haemoglobin level of the pregnant women studied.
The variations in maternal weight-gain and maternal 
haemoglobin level among the health centres of study are shown 
in appendix 7 -
4.3.2: Pattern of Maternal Weight-gain During Pregnancy.
The pattern of maternal weight-gain is shown in figure 5. 
Maternal weight-gains at the various gestational ages was 
significantly (P < 0.05) lower than that of women from developed 
countries throughout pregnancy (Figure 5, Appendix 8).
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Figure 5: Mean monthly weight gain during pregnancy (n = 128).
Legend
Reference weight gain: %  x— X- 
Observed weight gain: , , t «
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Gestational age (weeks)
Maternal weight-gain (Kg)
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4.3.3: Maternal Weight-gain and Effect on Infant Birth-weight.
The mean maternal weight at the beginning of the pregnancy 
(first trimester) was 60.766 ± 10.118kg with a range of 46 - 98kg. 
In the third trimester- the mean weight of the pregnant women was 
found to be 71.276 ± 15.164kg with a range of 55 - 114kg. The mean 
maternal weight-gain during the pregnancy as calculated from the 
individual weight-gain of the pregnant women, was 10.531 ± 1.681kg. 
The range of weight-gain was observed to be 6 - 17kg during the 
pregnancy (Table 29).
Infants born to women who gained above 90% of the reference 
weight-gain (12.5kg; FAO/WHO, 1985) had infants of significantly (P
< 0.05) higher birth-weight than pregnant women who gained below 
90% of the reference standard. Generally, birth-weight was 
observed to increase as the weight-gained by the mother increased 
(Figure6; Appendix 9).
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Figure 6 : Effect of maternal weight gain on birth-weight 
(n = 128).
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3.382
/ 71
60  -  60 %  61 -  70%  71 -  80 %  81 -  90 %  91 -  100% < 100%
Weight gain as percentage of recommended
Infant birth-weight (Kg)
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4.3.4: Effect of maternal Height on infant birth-weight and 
maternal weight-gain.
In the study, the mean height of the pregnant women in the 
first trimester was found to be 162.167 ± 5.263cm, with a range of 
148 - 179 cm (Table 29). Thirteen (10.16%) of the mothers were 
below 156cm. Majority of them (60.94%) were within 
156 - 165cm height group, while 24 (18.75%) were above 165cm but 
below 175cm. Those above 175cm were few 13 (10.16%). None of the 
women was below 148cm.
The mean birth-weight of infants born to pregnant women who 
were above 175cm (3.467 ± 0.375kg) was significantly (P < 0.05) 
higher than those who were below 175cm (Table 30). There were no 
significant differences (P < 0.05) in birth-weights of infants born 
to pregnant women who were above 15 5cm but below 17 5cm. However 
women who were below 156cm had infants of mean birth-weight (2.840 
± 0.475kg) far lower ((P < 0.05) than those above 175cm. A similar 
trend was observed in relation to maternal weight-gain and maternal 
height where pregnant women who were above 175cm had significantly 
(P < 0.05) higher weight-gain (12.00 ± 1.732kg) during the 
pregnancy than those who were below 156cm (10.231 ± 1.409). There 
was a gradual increase in weight-gain as the height of the mother 
increased (Table 30).
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Table 30: Birth-weight of infants and maternal Weight-gain in 
Relation to the Height of the Mother in the first 
trimester (n = 128)
Height groups Number of Birth-weight Maternal 
(cm) mothers (kg) weight-gain 
(kg) l
145 - 155 13 2.840a ± 0.475 10.23la ± 1.409
156 - 165 78 3.054a ± 0.445 10.4 3 8a,b± 1.606
166 - 175 24 3.085a ± 0.466 10 . 854a,b± 1.502
> 175 13 3.467b ± 0.375 12.000b ± 1.432
1: Means with different superscripts are significantly different,
P < 0.05; !Duncan's multiple range test.
4.3.5: Maternal Body Mass Index (BMI) at the Beginning of
Pregnancy. Effect on Infant Birth-weight and Maternal 
Weight-gain.
The mean body mass index (BMI) of 23 . 094 ± 3.582, suggests that the 
pregnant women were of acceptable body size (Table 39) at the 
beginning of the pregnancy. The range for the BMI was 
17.57 - 34.31. Of the 128 pregnant women who participated in the 
longitudinal study, 3 (2.34%) had BMI below 18 and were therefore 
underweight at the beginning of the pregnancy. Majority of the 
subjects 113 (88.28%) had acceptable BMI values. Few were either 
overweight, 5 (3.91%), or obese, 7 (5.47).
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There were no statistically significant (P < 0.05) effects of 
BMI during the first trimester on either infant birth-weight or 
maternal weight-gain at term (Table 31).
Table 31: Infant Birth-weight and Maternal Weight-gain in
Relation to Body Mass Index (BMI) of Mother During 
the First Trimester (n = 128)
Body Mass Index2 Number of Birth-weight Maternal 
(BMI) Subjects of infants Weight-gain 
(%) (kg) at term1 (kg)
< 18 
(Underweight) 3 (2.34) 3.300 ± 0.200 10.667 ± 
2 . 307
18 - 28 
(Acceptable 113 (88.28) 3.038 ± 0.467 10.518 ± 
weight) 1. 568
2 9 - 3 0  ]
(Overweight) 5 (3.91) 2.910 ± 0.292 10.500 ± 
0.866
> 30 
(Obese) 7 (5.47) 3.187 ± 0.426 11.571 ± 
2.936
1: No significant differences were found for the various BMI groups, P < 0.05; Duncan's test. 
2: Source; Jell iffe and Jelliffe, 1989.
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4.3.6: Occupation of Women and Maternal Weight-gain
It was observed that the maternal weight-gain of the women 
during pregnancy was affected by their occupation (Table 32) . 
Analysis of variance (ANOVA) in combination with Duncan's multiple 
range test showed that women who were housewives gained 
significantly (P < 0.05) more weight (11.392 ± 2.055kg) than women 
who were traders (10.238 ± 1.395kg) and those in professional 
occupations (10.400 ± 2.065kg).
Office workers had appreciably high weight-gain (11.250 ± 
1.708kg) but it was not significantly (P < 0.05) different from 
that of women In the other occupational disciplines.
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Table 32: Effect of Mothers Occupation on Maternal Weight-gain 
(n = 128)
Mothers' Occupation Number of Mothers Maternal Weight-gain 
(kg)1 (mean ± S.D)
Trader 48 10.24a ± 1.39
Vocational 40 10 . 61a,b ± 1.88
Office worker 14 11. 25a,b ± 1.71
Professional 10 10 . 40a ± 1.621
Housewife 16 11.39b ± 2.06
1: Means with different superscripts are significantly different, P < 0.05; Duncan's test.
4.3.7: Effect of Parity on Maternal Weight-gain
Parity affected weight-gain in women (Table 33). Though 
insignificant (P < 0.05), women with seven or more previous 
pregnancies had appreciably lower maternal weight-gain 
(10.021 ± 1.256kg) than women with three or four previous 
pregnancies (10.984 ± 2.072kg). With the exception of nulliparous 
women who had slightly lower weight-gain
(10.236 ± 1.417kg), women in the other parity groups had similar 
weight-gains during the pregnancy.
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Table 33: Number of Previous Pregnancies in Relation to Maternal
Weight-gain (n = 128) .
Number of previous Number of Mothers Maternal Weight-gain
pregnancies (kg) 1 (mean ± S .D)
None
(Nulliparous) 35 10.236 ± 1.417
1 - 2 50 10.471 ± 1.640
3 - 4 32 10.984 ± 2.072
5 - 6 6 10.583 ± 0.992
7 - 9 5 10.021 ± 1.256
Total 128 10.531 ± 1.681
1: No significant differences were observed between the mean weight-gains of the various parity 
groups, P < 0.05; Duncan's multiple range test.
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4 .3 .8 : Effect of Clav intake During Pregnancy on Maternal 
Weight-gain.
The effect of clay intake during pregnancy on maternal weight- 
gain is shown in table 34.
There was no significant effect of clay intake on maternal weight- 
gain. Pregnant women who ate clay everyday had similar weight 
gain (10.375 ± 1.377kg) to those who sometimes ate clay (10.345 ± 
1.440kg) and women who did not eat clay (10.595 ± 1.768) during 
the pregnancy j
Table 34: Effect of clay ingestion on maternal weight-gain
(n = 128) .
Degree of clay Number of Maternal weight-
ingestion mothers gain1
Eat clay everyday 12 10.375 ± 1. 377
Sometimes eat clay 21 10.345 ± 1. 440
Do not eat clay 95 10.595 ± 1.768
1: No significant differences between the maternal ueight-gains were observed: P < 0.05, 
Duncan's test.
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4.3.9: Effect of oedema during pregnancy on Maternal Weight-gain
The variation of maternal weight-gain with oedema is shown in 
table 35. There was no significant effect of oedema on maternal 
weight-gain. However women who developed oedema had slightly 
higher maternal weight-gain.
Table 35: Effect of Oedema During Pregnancy on maternal weight
gain (n = 128).
Oedema category Number of Maternal Weight- 
mothers gain1 (kg)
Women who developed 
oedema 52 10.827 ± 1.920
Women who did not develop 
oedema 76 10.329 ± 1.476
Total 128 10.531 ± 1.1681
1: No significant differences between the maternal weight-gains were observed: P < 0.05, 
Student's t-test
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4.3.10: Nausea and Maternal Weight-gain
The relationship of nausea and maternal weight-gain is 
depicted in table 36.
Analysis of variance (ANOVA) combined with Duncan's multiple 
range test showed a significant (P < 0.05) effect of nausea on 
maternal weight-gain.
Pregnant women who lost appetite with vomiting gained 
significantly (P < 0.05) lower weight (10.160 ± 1.705kg) during 
pregnancy than those who lost appetite but did not vomit 
(10.761 ± 1.364kg). These weight-gains were also significantly 
lower than that of pregnant women who neither lost appetite nor 
vomited (11.057 ± l.489kg).
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Table 36: Effect of Nausea during pregnancy on Maternal
Weight-gain
Degree of nausea Number of Maternal weight-gain1 
mothers (kg)
No loss of appetite and 53 11.057a ± 1.489
no vomiting
Lose appetite but no 23 10.761b ± 1.364
vomiting
Lose appetite with 72 10.160° ± 1.705
vomiting
Total 128 10.531 ± 1.681
1: Means with different superscripts are significantly different, P < 0.05: Duncan's test.
4.3.11. Effect of Vomiting on Maternal Weight-gain during 
Pregnancy
Women who vomited during the pregnancy had significantly lower 
maternal weight-gain (P < 0.05) than those who did not vomit during 
the pregnancy^ (Table 37). The mean maternal weight-gain at term 
for women who vomited for less than three months (10.372 ± 1.771kg) 
and that of those who vomited for more than three months (9.8 04 ± 
1.595kg) were significantly lower than the mean maternal weight- 
gain of women who did not vomit (11.057 ± 1.489kg) during 
pregnancy.
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Table 37: Effect of degree of vomiting on Maternal weight-gain
(n = 128)
Degree of vomiting Number of Maternal weight 
(months) Mothers gain (kg)1
No vomiting 53 11.057a ± 1.489
Vomit for less than three 47 10 . 372b ± 1.771
months
Vomit for more than three 28 9.804b ± 1.595
months
1: Means with different superscripts are significantly different, P < 0.05; Duncan's test.
Effect of Duration of vomiting on Rate of weight-gain was apparent 
throughout the pregnancy (Table 38). Those who experienced nausea 
with vomiting had significantly (P < 0.05) lower maternal weight- 
gain throughout pregnancy than women who did not vomit(Figure 7).
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Table 38: Mean monthly Maternal Weight-gain (kg) in Relation 
to Duration of vomiting (n = 128)
Gestational Duration of Vomiting
age (weeks). Less than Greater than No vomiting 
three months, three months, (n = 53)
(n = 47) (n = 28)
16 1.096 ± 0.518 0.982 ± 0.726 1.434 ± 0.567
20 2.776 ± 1.042 2.554 ± 1.383 3.368 ± 1.001
24 4.638 ± 1.245 4.500 ± 1.564 5.538 ± 1.319
28 6.660 ± 1.504 6.357 ± 1.627 7.566 ± 1.566
32 8.830 ± 1.822 8.375 ± 1.642 9.584 ± 1.667
36 10.372 ± 1.771 9.804 ± 1.595 11.057 ± 1.490
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Figure 7: Effect of vomiting on maternal weight 
gain during pregnancy (n=128).
Legend
Do not vomit during pregnancy: -#■ % *  
vomit for less than 3 month: -*— *— ■- 
vomit for more than 3 month: — —̂ X X
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Gestational age (weeks)
Mean weight-gain (Kg)
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4.4: DIETARY INTAKE DATA
The dietary assessment was done through a 24-hour dietary 
recall on three different occasions on the 128 pregnant women who 
participated in the longitudinal study. The food intake data was 
analyzed for energy, protein and iron intakes. Table 39 shows the 
average energy, protein and iron intakes of the pregnant women.
Table 39: Average Energy Protein and Iron intakes of the
pregnant women (n = 128)
Energy (kJ) Protein1 Iron (mg)
(g)
Mean value 9,109 48 .99 25.54
(2,175.5kcal)
Standard 10.042 6 .82
deviation 1,171.83
Maximum value 13,431 74 .79 47 .96
(3,207.Okcal)
Minimum value 6, 315 
(1,508.7kcal) 28.98 14.43
1: Protein values were corrected with NPU of 70% ,(WH0/FA0, 1973).
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4.4.1. Effect of Energy Intake of the Pregnant Women on Infant 
Birth-weight and Maternal Weight-gain.
The mean daily energy intake of 9,109.00 ± 1171.83KJ 
(2,175.5kcal) was found to be similar to the daily energy 
requirement for the non-pregnant woman (9,569.61kJ; 2,27 8.48kcal) 
Among the subjects, daily energy intake ranged from 
6,315.00 - 13,431.00KJ (1508.70 - 3207.00kcal) (Table 39).
The mean energy intake met about 87.8% of the recommended 
energy requirement for pregnant women; 10,409.62kJ (2478.48kcal). 
Protein provided 9.0% of the mean energy intake. The energy intakes 
of 51 (40%) of the subjects were within 80 - 90% of the recommended 
intake (Table 40). Those taking 90 - 100% of the requirement were 
few, 19 (15%). However about 30% of the women met more than 100% 
of their daily energy requirement.
Table 4 0 shows infant birth-weight and maternal weight-gain in 
relation to mothers energy intake.
Women who met more than 100% of their daily energy requirement 
had infants whose birth-weights were significantly 
(P < 0.05) higher than those taking energy below 80% of their daily 
requirement.
Mothers who met more than 100% of their energy requirement had 
maternal weight-gains statistically higher (P < 0.05) than those 
who met less than 90% of the requirement. However no statistical 
differences were observed among mothers who met
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91 - 100% and those who met above 100% of the requirement. This 
indicates that maintaining energy intakes above 90% of requirement 
would improve maternal weight-gain.
Table 40: Effect of Energy Intake of Pregnant Women on Maternal
Weight-gain, and Infant Birth-weight, (n = 128)
(%) energy requirement met (Reference 10,360.1kJ/day (2,478.48kcaI/day) ’
70 80% 81 - 90% 91 100% > 100%
Number of subjects 27 53 35 13
Percentage (%) (21.1) (41.4) (27.3) (10.2)
Birth-weight (kg) 2.947" ± 0.462 3.021”b± 0.462 3.153“'b± 0.470 3.183" ± 0.383
Maternal Weight 10.074” ± 1.172 10.076" ± 1.449 11.371“ ± 1.864 11.077“ t 0.976
gain (kg)
a: means with different superscripts are significantly different:
P < 0.05, Duncan's test.
1: Non-pregnancy energy requirement plus pregnancy allowance (2,278.48 + 
200)kcal/day, based on mean weight of 60.8kg woman, who is moderately 
active; BMR x 1.64 = (14.7 x 60.8 + 496) x 1.64. (FAO/WHO,1985) .
4.4.2: Effect of Maternal Protein Intake on Infant Birth-weiaht. 
Maternal Weight-gain and Haemoglobin Level
From table 41, protein intake by the pregnant women ranged 
from 28.98 - 74.49g/day, with a mean intake of
48.987 ± I0.04g/day. This mean intake met about 104% of the 
estimated pregnancy protein requirement (47g/day)
(FAO/WHO, 1985).
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Of the 128 pregnant women, 61 (47.66%) met more than 100% of 
their protein reguirement while 35(27.34%) women met between 90% 
and 100% of their requirement. None of the women met below 70% of 
their protein requirement.
Pregnant women who met more than 8 0% of their protein 
requirement had significantly (P < 0.05) higher infant 
birth-weights than those who met less than 80% of their requirement 
(Table 41).
In the case of maternal weight-gain, pregnant women meeting 
more than 100% of their protein requirement had significantly 
(P < 0.05) higher weight-gain than those taking 80% of their 
requirement.
Haemoglobin levels in relation to protein intakes were not 
significantly different in all groups (Table 41).
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Table 41: Maternal Weight-gain, Haemoglobin Levels and Infant
Birth-weight in Relation to Protein Intake (n = 128)1
Percentage of Protein Requirement Met. 
(Reference; 47g Protein/day)2
< 81 -90% 91-100% > 100%
80%
Number of 11 21 35 61
subjects 
Percentage (%) 16.41 27.34 47 . 66
8.63
Infant Birth- 2.755a ± 2.983b ± 3.027b ± 3.134b ± 
weight (kg) 0.439 0. 428 0.438 0.461
Maternal weight- 9.864a ± 10. 500a,b 10 . 243a,b 10.828b ± 
gain (kg) 1. 080 ± 1.809 ± 1.714 1. 601
Maternal 11.309a ± 11.53la ± 11.502a ± 11.529a ± 
Haemoglobin 0.487 0. 568 0. 622 0. 633
Level (g/dl)
1: Meansu in the same row with different superscripts are significantly different: P < 0.05, 
Duncan's test.
2: Non-pregnant protein requirement plus pregnancy allowance; (41g +• 6g) Protein/day (FAO/WHO, 1985).
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4,4.3: Dietary iron intake and effect on birth weight, maternal 
weight-gain and haemoglobin level
The dietary iron intake of the pregnant women ranged from 
14.43 - 47.96mg/day, with a mean intake of 25.539 ± 6.819mg/day 
(Table 39).
In view of the difficulty in meeting iron requirement during 
pregnancy through dietary intake only, comparison with pregnancy 
absorbed iron requirement of 24.3mg/day (FAO/WHO, 1988) was not 
done. Instead, levels of dietary iron intake in relation to 
birth-weight was assessed.
The effects of dietary iron intake on birth-weight, maternal 
weight-gain and maternal haemoglobin level are shown in table 42.
Sixteen (12.50%) of the women took below 18mg, while 33 
(25.78%) women took above 30mg of dietary iron per day.
Infant birth-weight was not sensitive to iron intake by the 
pregnant women studied. Pregnant women who took below 18mg had 
significantly (P < 0.05) lower maternal weight-gain than those who 
took above 3 0mg of dietary iron per day.
Haemoglobin levels of the pregnant women were significantly 
(P < 0.05) higher for those who took above 28mg of dietary iron per 
day. However, there were no statistical differences (P < 0.05) in 
haemoglobin levels of women in the other levels of iron intake.
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Table 42:
Level of dietary Iron intake (mg/day)
 < 18 18 -21 25  - 27 28 - 30  > 30
No. of mothers 16 24 21 15 33
Percentage (%) 12.50 18.75 16.41 11.72 25.78
Infant Birth-weight 2.966“ ± 3.087’ ± 3.087’ ± 2.967’ ± 3.042’ ± 
(kg) 0.393 0.548 0.409 0.363 0.494
Maternal 10.031’ ± 10.392’ " ± 10.263“ " ± 10.788" ± 
Weight-gain (kg) 2.053 2.162 1.316 1.750
Maternal haemoglobin 11.562 ’ ± 11.585 ’ ± 11.274 ’ ± 11.797" ± 11.752" ± 
level (g/dl) 0.428 0.733 0.511 0.670 0.575
values in the same row with different superscripts are significantly
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4.5 : HAEMOGLOBIN DATA
4.5 .1 : Maternal Haemoglobin Levels During Pregnancy and Effect 
on Infant Birth-weight
The mean haemoglobin level of the pregnant women throughout 
pregnancy was found to be 11. 503 ± 0.603g/dl, with a range of 
10.01 - 13. 06g/dl (Table 39). The mean haemoglobin level was 
within acceptable level (ll.Og/dl; Tomkins, 1991) for pregnant 
women but below 12g/dl, the acceptable limit for non-pregnant 
women.
Table 43 shows maternal haemoglobin levels during the pregnancy. 
From the total of 12 8 pregnant women, 2 6 (20.31%) had mean 
haemoglobin level below ll.Og/dl from the third to the ninth month 
of pregnancy, and were therefore anaemic by WHO standard (Tomkins, 
1991). Seventy-eight (60.93%) of the pregnant women had 
haemoglobin level above llg/dl but below 12g/dl, while 24 (18.79%) 
had haemoglobin levels above 12g/dl.
The maternal haemoglobin level did not have significant 
(P < 0.05) effect on infant birth-weight. However pregnant women 
with mean haemoglobin level above 12g/dl had infants of slightly 
higher birth-weight than those who had haemoglobin level below 
llg/dl (Table 43) .
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Table 43: Effect of maternal Haemoglobin level on Infant Birth
Weight (n = 128)
Maternal haemoglobin No. of mothers (%) Infant Birth- 
level (g/dl) weight1 (kg) 
(mean ± S.D)
Below 11.00 26 (20.31) 3.066 ± 0.581 
11.00 - 11.99 78 (60.93) 3.011 ± 0.426 
12.00 - 13.00 22 (17.19) 3.157 ± 0.403 
Above - 13.00 2 (1.60) 3.187 ± 0.438
1: No significant differences between infant birth-weights were observed,
P < 0.05; Duncan's test.
4.5.2: Evaluation of Iron and Vitamin Supplementation During 
Pregnancy
Haemoglobin level and infant birth-weight were used as the 
response for the evaluation of effectiveness of iron and vitamin 
supplementation during the pregnancy.
From figure 8 and Appendix 10 it is seen that there was a 
gradual decrease in mean maternal haemoglobin level from the third 
month (11.705 ± l.OlOg/dl) to the seventh month
(11.182 ± 0.746g/dl) and then a sharp decrease in the eighth month 
(10.856 ± 0.719g/dl), and could not recover much in the ninth month 
(11.065 ± 0.524g/dl).
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The observation that maternal haemoglobin level was below 
12g/dl throughout pregnancy indicates that the level of iron and 
Vitamin supplementation could not maintain high maternal 
haemoglobin level during the pregnancy. It did, however, maintain 
an adequate haemoglobin level (> ll.Og/dl) by WHO standard for 
pregnant women.
4 . 5 . 3 : Nausea and Maternal Haemoglobin level.
Loss of appetite for less than three months did not 
significantly (P < 0.05) affect the haemoglobin level of those 
pregnant women (Table 44) . However pregnant women who lost 
appetite with vomiting had significantly lower haemoglobin level 
(11.368 ± 0.571g/dl) than pregnant women who neither lost appetite 
nor vomited (11.695 ± 0.604g/dl).
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Figure 8: Mean maternal haemoglobin level at various 
gestational ages (n = 128).
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Gestational Age (weeks)
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Table 44: Effect of Nausea during Pregnancy on Maternal 
Haemoglobin level.
Degree of nausea Number of Maternal 
mothers haemoglobin 
level1 (g/dl)
No loss of appetite and no 53 11.695a ± 0.604
vomiting
No Loss of appetite but 23 11. 714a,b ± 0.655
vomited
Lost appetite with 72 11.368b ± 0.571
vomiting
Total 128 11.503 ± 0.603
1: Haemoglobin values with different superscripts are significantly different,P < 0.05; Duncan's test.
4.5.4: Effect of Vomiting during Pregnancy on Haemoglobin level 
of mothers.
The effect of vomiting on mothers' haemoglobin levels is 
shown in table 45. No significant differences (P < 0.05) were 
observed between the haemoglobin level of mothers who vomited for 
less than three months (11.354 ± 0.552g/dl) and those who vomited 
for more than three months (11.391 ± 0.603g/dl). However women who 
did not vomit during pregnancy had significantly (P < 0.05) higher 
haemoglobin level (11.895 ± 0.604g/dl) than those who vomited 
irrespective of the duration of vomiting.
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Table 45: Effect of Duration of Vomiting on Mothers' 
Haemoglobin Level During Pregnancy
Duration of vomiting Number of Maternal haemoglobin 
(months) mothers level1 (g/dl)
(mean ± S.D)
No vomiting 53 11.895a ± 0.604
Less than three months 47 11.354b ± 0.552
More than three months 28 11.391b ± 0.603
Total 128 11.503 ± 0.603
1: Means with different superscripts are significantly different,P < 0.05; Duncan's test.
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4.5.5: Effect of Clay intake During Pregnancy on Maternal 
haemoglobin level
The effect of clay intake during pregnancy on maternal 
haemoglobin level is shown in table 46.
Pregnant women who ingested clay during the pregnancy had 
significantly (P < 0.05) lower haemoglobin levels than those who 
did not eat clay. Pregnant women who ate clay everyday had mean 
haemoglobin level (10.863 ± 0.412g/dl) significantly (P < 0.05) 
lower than that of those who ate clay less frequently 
(11.238 ± 0.596g/dl). These mean haemoglobin levels were 
significantly lower than that of pregnant women who did not ingest 
clay during the pregnant (11.611 ± 0.574g/dl).
Table 46: Effect of clay ingestion on mean monthly maternal
haemoglobin level (n = 128)
Degree of Clay Number of Maternal haemoglobin 
ingestion mothers level1 (g/dl) (mean ± 
S.D)
Eat clay everyday 12 10.863a ± 0.412
Sometimes eat clay 21 11.238b ± 0.596
Do not eat clay 95 11.611c ± 0.574
1: Mean with different superscripts are significantly different,P < 0.05; Duncan's test.
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4.6: Correlation analyses of Factors Affecting Pregnancy 
Outcome
The extent to which the factors studied affect pregnancy 
outcome were assessed through correlation analysis 
(Tables 47 - 49)
Table 47: Correlation Values of Factors which showed
Relationship with Birth-weight (Results from 
epidemiological study, n = 502)
Birth-weight
Factors Correlation R2 Remarks'1.
Coefficient (r) (%)a
Nausea. - 0.180 3 . 2 Significant (r)
Mothers'
educational level + 0.093 0.9 - do -
Vomiting level - 0.089 0 . 9 - do-
Oedema + 0.088 0.6 - do -
a:R2 is an index of the extent of association between thevariables(R2100r2) 
b:Significant level of r for a sample size of 502 Cdf , 500) 0.088 (Steel, 1980)
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Table 48: Correlation Values of Factors which showed
Relationship with Birth-weight
(Results from longitudinal study, n = 128)
Birth-weight
Factors Correlation R2 Remarks'3
Coefficient (r) (%)-
Maternal weight-
gain. + 0.484 23.4 Significant (r)
Maternal height + 0.204 4.2 - do -
Protein intake + 0.230 5.3 - do -
Energy intake + 0.180 1.7 Insignificant
(r)
Duration of
supplementation + 0.130 1.7
- do-
Haemoglobin level + 0.047 0 . 8
BMIC - do -
+ 0.082 0 . 7
Dietary Iron - do -
intake + 0.018 0. 03
- do -
a: R2 is an index to the extent of association between the variables
R: = 100r2) .
b: Significant level of r for a sample size of
128 (df; 126) = 0.174 (Steel, 1980)
c: BMI [weight (kg)/height" (m)] is the body mass index in the first 
trimester.
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Table 49: Correlation Values of Factors which showed 
Relationship with Maternal Weight-gain
(results from longitudinal study, n = 128)
Maternal Weight-gain
Factors Remar■k. sh0
Correlation 
Coefficient (r)
Energy intake + 0.295 8.7 Significant (r)
Maternal height + 0.227 5.1 - do -
Protein intake + 0.225 5.1 - do -
Duration of
supplementation + 0. 200 4.0 - do -
Oedema + 0. 146 2 . 1 Insignificant (jr)
BMIC + 0. 143 2 . 0
- do-
Parity 0 . 093 0.3
- do -
Iron intake + 0. 050 0.3
- do -
Malaria — 0. 038 0.1
- do -
Diarrhoea 0. 011 0.1
- do -
a: R~ is an index to the extent of association between the variables
(R2 = 100r2) .
b: Significant level of r for a sample size of 128 
(df; 126) = 0.174 (Steel, 1980) 
c: BMI is the body mass index in the first trimester.
r\J 10& a?
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CHAPTER FIVE
5- DISCUSSIONS AND CONCLUSION
5.1; EPIDEMIOLOGICAL DATA 
5.1.1: Infant Birth-weight
Infant birth-weight is a good proxy for the assessment of 
pregnancy outcome. Favourable pregnancy outcome is usually 
associated with acceptably high birth-weight. It is also a strong 
indicator of the survival of infants and health status of women 
(Food and Nutrition Bulletin, 1984). However, high infant birth- 
weight can pose mechanical difficulties during labour.
It was observed, after studying 502 pregnant women, that 
majority (90.64%) of them had infants of acceptable birth-weight 
(Birth-weight; 2.5 - 4.0kg). The prevalence of low birth-weight 
(birth-weight below 2.5kg; WHO, 1971) observed in the study was 
8.4%, which is lower than the national figure of 17% reported by 
UNICEF in 1991 for Ghanaians (Figure 2, Appendix 5).
The observed mean birth-weight of infants of 2.999 ± 0.511kg, 
is in close agreement with the infant birth-weight of 2.879kg 
reported for the Ghanaian population, but below the value of 
3.188kg for prosperous Ghanaian groups (WHO, 1971).
The prevalence of macrosomia (infant birth-weight above 4.0kg) 
found in the study was low (1.0%) (Appendix 5).
The mean birth-weight observed was below the value of 3.30kg 
reported for developed countries (FAO/WHO, 1985) .
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Infant birth-weight can be adversely affected by many factors. 
Inadequate energy intake, high physical activity, low haemoglobin 
level and poor physiological state of some women during pregnancy 
contribute to the lower birth-weight of infants in less technically 
developed countries. Apart from these, high infant birth-weight 
delivery is reported to be associated with a change in attitude of 
pregnant women due to fear for obstructed labour. These women may 
not engage in;any activity that could lead to an increase in the 
size of the fotetus especially those in communities where obstetric 
services are limited (Garner and Kramer, 1991) . These changes in 
behaviour in addition to other maternal habits like pica and 
alcohol intake, delayed ante-natal care, and nausea during 
pregnancy, can contribute to the delivery of infants of lower 
birth-weight in less developed than developed countries, as 
observed in the study.
The lower prevalence of low birth-weight, observed in this 
study, is because the subjects live in Accra the national capital, 
and therefore have to ante-natal care and other services, which 
may not be available to majority of rural women.
5.1.2: Effect of Mothers' Educational Level on Infant 
Birth-weight
The results obtained in the study (Table 9) suggest that the 
educational level of the mother does not have a significant 
influence on infant birth-weight. However pregnant women who have 
had tertiary education had infants of slightly higher
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birth-weight, than the women with lower educational levels. The 
positive correlation obtained (r = + 0.093) which was significant, 
(Table 47) further suggests that education of the mother is 
associated with an increase in the birth-weight of her infant and 
hence a more favourable outcome of pregnancy.
The slightly higher infant birth-weight for women in the 
tertiary educational level may be attributed to the usually higher 
socio-economic status of women in this category (Table 1). Women 
of high educational level usually have better access to health 
care, and good nutrition during pregnancy (Kaur and Sagar, 1982). 
In addition, they have better social services like that of servants 
and cars including household appliances, which reduce physical 
activities associated with their daily chores. They also have 
small family size (Kaur and Sagar, 1982) and better ability of self 
initiative and care seeking as well as good health practices during 
pregnancy (Food and Nutrition Board, 1971) . All these are 
contributory factors which are favourable for adeguate foetal 
growth. The relatively higher infant birth-weight for women with 
tertiary education can thus be partly due to their relative 
superiority, in this respect, over women of lower educational 
levels.
5.1.3: Effect of Mothers' Occupation on Pregnancy.
Data from Table 10 indicates that pregnant women who were 
housewives had infants of significantly (P < 0.05) higher
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birth-weight than women who were engaged in some form of 
occupation. Traders (mostly hawkers) who tended to be more mobile 
and therefore expended much energy had relatively lower birth- 
weight infants likewise lower pregnancy weight-gain.
It was observed in the study that husbands of women who were 
housewives were of better socio-economic status and possibly 
better nutritional status prior to and during pregnancy than the 
trader or vocational workers who may work until late pregnancy 
(personal observation). The increased maternal weight-gain 
observed in subjects who were office workers may be partly 
explained by their type of occupation which is associated 
with less mobility and therefore less energy expenditure 
(FAO/WHO,1988) .
These observations suggest that women of low physical activity 
are more likely to deliver infants of higher birth-weight and gain 
more weight during pregnancy.
Various researchers have observed similar trends in occupation 
and pregnancy outcome. Briend in 1980 observed that high physical 
activity was associated with the delivery of low birth-weight 
infants (Briend, 1980). Similar observations was also made by 
Tafari and Naeye (1980) in Addis Ababa, that pregnancy outcome 
(birth-weight) and pregnancy weight-gain improved when women 
reduced their physical activity to counterbalance reduced dietary 
energy intake. Also increased fat deposition following decreased 
physical activity during pregnancy is associated with satisfactory
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infant birth-weight (FAO/WHO, 1985) . In this study the energy 
intake of the subjects was low compared to their pregnancy 
requirement, and women whose occupation were less exacting 
energywise tended to have higher infant birth-weights.
5.1.4: Effects of Parity on Pregnancy
The number of previous pregnancies women have had affected 
infant birth-weight in a dual manner (Table 23) . Women who have had 
three or four previous pregnancies had infants of significantly (P
< 0.05) higher birth-weight than women who were in their first 
pregnancy (nulliparous) and women with seven or more previous 
pregnancies (Figure 6).
The effect of parity on maternal weight-gain was similar to 
that on infant birth-weight (Table 32) . Women who have had three or 
four previous pregnancies had significantly higher maternal weight- 
gain than those with seven or more previous pregnancies (Figure 
11) . In this case, although nulliparous women had lower maternal 
weight-gain, the difference was not significant.
These observations suggest that the pregnant women seemed to 
adapt to the pregnancy up to the fourth one after which dwindling 
maternal nutrient stores could not adequately support further 
pregnancies (Tomkins and Watson, 1991), and hence the lower infant 
birth-weight and maternal weight-gain observed for higher parity.
The effect of parity on pregnancy outcome is not clear. While 
Venkatachalan and Shankar (1970) observed a fall in maternal 
weight-gain with rising parity among the poorly fed Chimbu women in
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New Guinea, Thomson and Billewcz (197 0) found no such decrease with 
increasing parity in a South African village. Similarly, 
Rajlakshmi (1971) in India found no decrease in maternal weight- 
gain with rising parity. The result of the present study is 
consistent with that of Venkatachalan and Shankar (1970).
The increase in infant birth-weight up to the fourth pregnancy 
is in agreement with earlier reports by Grover (1982), Shah (1981) 
and Rajlakshmi (1971) who observed an increase in birth-weight with 
rising parity up to the fourth, fifth and sixth pregnancies.
In the study, the fear for death of a child was a strong 
factor in determining the number of children mothers had (Table 
24) . Since large family size in developing communities adversely 
affects adeguate nutrition of women (Dhalival, 1980), it implies 
that high rate of child mortality can adversely affect maternal 
nutrition, because women may have more children as a security 
against child mortality.
5.1.5: Nausea During Pregnancy and Effect on Pregnancy outcome
Physiological changes associated with the pregnancy included 
uncomfortable conditions in some of the pregnant women. Some of 
these discomforts in pregnancy are also clinical signs for anaemia 
(ie. headache, dizziness, heart pounding, joint pains, lack of 
sleep (insomnia), excessive tiredness and general weakness).
From this study, it was observed that not only the presence of 
nausea but also the severity and duration were equally important in 
affecting infant birth-weight and maternal
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weight-gain (Table 13, Figure 4). The major effects of nausea on 
pregnancy were loss of appetite, vomiting, salivation and strong 
aversion to some nutritious foods. Hence the observation in the 
study that pregnant women who did not experience nausea during the 
pregnancy had higher weight-gain and infant birth-weights can be 
due to the adverse effects these discomforts on food intake of the 
affected women during the pregnancy. Nausea correlated negatively 
with birth-weight (r = - 0.180) (Table 47). This significantly 
negative correlation indicates that the experience of nausea by 
pregnant women is associated with a decrease in infant birth- 
weight.
The adverse effect of nausea on maternal haemoglobin level was 
probably partially obliterated by the beneficial effects of iron 
and vitamin supplementation during the pregnancy. However the fact 
that the pregnant women who lost appetite with vomiting had 
significantly (P < 0.05) lower haemoglobin level is an indication 
that the level of nutrient supplementation, especially iron and 
vitamins involved in maternal haematopoiesis, could not sustain 
maternal haemoglobin levels in pregnant women who experienced 
nausea (Table 44).
Singularly, vomiting during pregnancy had significant 
(P < 0.05) adverse effects on pregnancy (Table 14).
The drastically lower (P < 0.05) birth-weight of infants born to 
women who vomited for more than three months, as compared to those 
who did not vomit, can be the conseguence of decreased nutrient 
intake for a longer period due to vomiting during pregnancy. A
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significantly negative relationship (r = - 0.089) was observed for 
birth-weight and vomiting during pregnancy.
Although the pregnant women were on iron and vitamin 
supplements, the level of supplementation could not obviate the 
adverse effect of vomiting on maternal haemoglobin level. The 
consequence of this effect culminated in lower maternal haemoglobin 
level of women who vomited for more than three months during the 
pregnancy.
When the rate of maternal weight-gain was assessed at the 
various gestational ages, it was observed that the difference in 
weight-gain between pregnant women who vomited for less than and 
those vomiting for more than three months became significant after 
the seventh month of pregnancy, a period when those who vomited for 
less than three months might have replenished their nutrient stores 
and had gained much weight (Table 38).
The maternal weight-gain at the ninth month, a period when 
appreciable number of the subjects (24.90%) delivered, was 
significantly (P < 0.05) lower in women who vomited for three 
months or more. This suggests that the adverse effects of vomiting 
was throughout pregnancy. Though it is reported (Food and Nutrition 
Board, 1971) that women who experience nausea in pregnancy become 
voracious in late pregnancy, this habit could not obviate the 
detrimental effect of vomiting on maternal weight-gain in late 
pregnancy.
Apart from the induced reduced food intake, other effects of 
nausea can adversely affect the dietary habits of pregnant women.
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Pelchat and Rozin in 1982, reported that when nausea follows 
ingestion of food, people tend to develop dislike for the taste of 
the food (Pelchat and Rozin, 1982). Nausea also motivates 
avoidance of associated foods through events such as diarrhoea, 
respiratory distress or rashes (Pelchat and Rozin, 1982) . In this 
study, therefore, the presence of nausea in the pregnant women 
might have caused drastic adverse changes in maternal food habits, 
resulting in its observed adverse effects on pregnancy. For 
instance, Baylis and Leeds (1982) observed that women with 
pregnancy sickness had a high preference for dairy products. Also 
the intake of vitamin B6-rich foods,and sucrose were reported to be 
reduced in women who experience nausea (Pickard, 1983) .
5.1.6: Prevalence of Oedema During Pregnancy and Effect on 
Infant Birth-weight
A substantial number of the pregnant women, 2 05 (41%) 
developed oedema during the pregnancy (Table 22) . Oedema of the 
limbs was the commonest type of oedema observed in the pregnant 
women. Generalized oedema (that is, presence of oedema in other 
sites of the body in addition to the limbs) was absent in the 
pregnant women.
Pregnant women who developed oedema had infants of 
significantly (P < 0.05) higher birth-weight than those who did not 
develop oedema. In addition, there was a significantly positive 
correlation (r = + 0.088) between oedema and infant birth-weight.
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Subjects who developed oedema complained of pains and dampness 
at the feet, and described it as uncomfortable.
The oedema prevalence (40.8%) observed in the study is similar 
to that (40%) reported by Thomson and Billewcz in (1970) among 
pregnant women in the Gambia. In the Collaborative Perinatal 
Project in the United States of America, Hytten and Chamberlain 
(1980) observed that the development of oedema was associated with 
adequate maternal blood volume expansion. The observation in the 
present study, that women who developed oedema had infants of 
higher birth-weight might be due to adequate nutrient supply to the 
foetus, following the higher maternal blood volume expansion.
The development of oedema during pregnancy was associated with 
an increase, though not significant in maternal weight-gain during 
pregnancy (Table 35). The significant difference may be attributed 
to the reported view that the water accumulated during pregnancy by 
women who develop oedema is not significantly different from that 
accumulated by women who do not develop oedema (Hytten and 
Thompson, 197 0) .
5.1.7: Alcohol Intake During Pregnancy
There are undesirable effects of alcohol on the human body, 
particularly on nutritional status, on the foetus as well as on 
essential organs like the liver and the brain (Seymour and Halpern, 
1979). This makes the observation that the prevalence of alcohol 
consumption of 9.36% among the pregnant women observed in the study 
must be looked at with all seriousness (Table 15) . Fortunately
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further observation indicated that the quantities of alcoholic 
drinks taken by the subjects were not excessive. Those who took 
local gin during the pregnancy drank less than 100ml per week, 
while on the average one or two bottles (600 - 1200ml) per week 
were taken by those who preferred beer or guiness.
Of the 47 (9.36%) women who took alcohol during the pregnancy, 
21 (45%) were of the view that the alcohol will help them regain 
appetite, while others, 11 (23%), took alcohol to prevent vomiting 
(Table 16). A substantial number, 15 (32%) of those who took 
alcohol developed the taste for alcohol during the pregnancy. 
Clearly, there are other ways of gaining appetite or preventing 
vomiting and alcohol use to achieve these aims is an indication of 
the ignorance, on the part of the pregnant women of the deleterious 
effects of alcohol on the human body. Mass education through the 
media, at ante-natal clinics and at adult literacy classes can help 
reduce alcohol consumption by women, especially during pregnancy.
The rate of alcohol intake was found to be variable among the 
pregnant women. Among those who ingested alcohol during the 
pregnancy, 6 (13%) took alcohol everyday. While in 41 (87%) women, 
alcohol intake was infrequent. Further observation suggests that 
the frequency of alcohol intake by the pregnant women was related 
to the type of alcoholic drink taken. Those who took local gin had 
more frequent intake than those who had preference for beer or 
guiness. The reasons were that the local gin was cheaper and could 
be dispensed in smaller quantities than beer or guiness.
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The number of women (47) who ingested alcohol is small as 
compared to the total number (502) of women in the study. Hence 
the various levels of alcohol intake and effects on pregnancy could 
not fully be discussed based on observations from this study. 
However women who took alcohol had similar infant 
birth-weights (3.077 ± 0.346) to those who did not take alcohol 
(2.992 ± 0.521) during the pregnancy.
Some researchers (Burton and Foster, 1988; Abel, 1982; and 
Sokol et al, 1980) have observed a decrease in infant 
birth-weight upon excessive intakes of alcohol during pregnancy. In 
the present study, small doses of alcohol were taken as compared 
to excessive amounts reported (Sokol et al, 1980).
This difference may be the reason why infant birth-weight was not 
affected by alcohol intake in the present study.
5.1.8: Pica During Pregnancy
The pregnancy is associated with some alterations of maternal 
habits. Notable among these is the practice of pica (the ingestion 
of non-food items). This study showed that about half 241 (48.0%) 
of the 502 pregnant women studied ingested some types of non-food 
materials (Table 17). Clay intake, by 143 (28.5%) women, was the 
most common form of pica practised. Some of the pregnant women 
chewed stick or sponge; 49(9.8%), and cola; 25 (5.0%), more 
freguently than when not pregnant, while few ingested fresh maize 
dough; 14 (2.8%), chalk; 6 (1.2%) and raw starch; 4 (0.8%).
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These findings imply that in addition to aversion to some 
nutritious foods due to nausea, some pregnant women develop taste 
for some non-food items. The combined effects of these on the 
dietary intake during pregnancy can be profound. The non-food 
materials might replace a substantial part of the diet possibly 
preventing adequate nutrition during pregnancy. Some of these non­
food items like chalk and clay can form chelates with essential 
mineral elements like iron and calcium and reduce their 
availability in the gut, and can also cause obstruction of the 
colon (Key et al, 1982) . The reduced availability of iron and other 
mineral elements can aggravate the already high anaemia prevalence 
among pregnant women in developing countries. The high microbial 
contents of items like raw maize dough and fresh starch can also 
induce diarrhoea in women who ingest them.
Pica practice by pregnant women has been reported by 
Talkington et al, 1971. In his report, they observed that the 
ingestion of starch promoted iron deficiency anaemia, not because 
raw starch prevented iron absorption but the raw starch supplied 
energy without iron. The ingestion of coal and chalk is also 
reported to be a common form of pica among some pregnant women 
(Food and Nutrition Board, 1971).
The high prevalence of pica among the Ghanaian pregnant women 
studied is undesirable and can be reduced through efficient public 
education especially at maternal and child health (MCH) clinics and 
also in the mass media.
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Clay eating was observed among some of the pregnant women 
(Tables 18 and 19). While 14 (2.8%) women ate clay everyday, 129 
(25.7%) ingested clay less frequently. In this case clay consumed 
by the subjects is White clay popularly known as " Ayilao " in Ga, 
and as " Shirew " in Akan. Traditionally this white clay is used on 
the body during rituals like Dipo and in some cases on the body of 
the mother during the first few days following parturition.
Two main groups of pregnant women were discovered in relation 
to their motives for eating clay. The first group 81 (16.1%) ate 
clay to allegedly prevent spitting (salivation) or vomiting, while 
the second category, 62 (12.4%) ate clay because they liked the 
flavour of it (Table 18).
Nevertheless, clay intake did not have any effect on the 
birth-weight of infants (Table 19). There were no significant (P 
< 0.05) differences in the birth-weights of infants born to women 
who ate clay everyday, those who ate clay less frequently and those 
who did not eat clay at all during pregnancy.
Maternal;weight-gain was not affected by clay intake (Table 
34). Pregnant women who ate clay everyday had similar maternal 
weight-gain to those who ate clay less frequently, and those who 
did not eat clay during the pregnancy.
Data from table 4 6 indicate that clay intake markedly reduced 
maternal haemoglobin level. Subjects who ingested clay during the 
pregnancy had significantly (P < 0.05) lower maternal haemoglobin 
level than those who did not eat clay. Pregnant women who ate clay 
everyday had a mean haemoglobin level (10.863 ± 0.412g/dl) which
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was significantly lower than that of women who ate clay less 
frequently (11.238 ± 0.596g/dl). Irrespective of the degree of clay 
intake, maternal haemoglobin level was higher for those who did not 
eat clay (11.811 ± 0.574g/dl) than those who did. The mean 
haemoglobin level of women who ate clay everyday indicates that 
they were anaemic by WHO standard (Haemoglobin concentration < 
ll.Og/dl) for pregnant women (Tomkins and Watson, 1991).
The significantly negative correlation (r = -0.322) between 
clay intake and haemoglobin level suggests an association between 
clay intake and anaemia.
Various reasons can be assigned to the ability of clay to 
reduce maternal haemoglobin level. The clay can form chelates with 
essential mineral elements needed for haemoglobin synthesis, such 
as iron and copper, and prevent their absorption. The reduced 
availability of mineral elements needed for haemotopoiesis can lead 
to iron-deficiency anaemia, worsening the already high anaemia 
prevalence among pregnant women. In addition, the absorption of 
mineral elements like calcium and magnesium could be reduced for 
the same reason. Some of the components of clay and other earth 
materials can promote toxaemia and respiratory tract infection, 
including worm infestation in the pregnant women.
A high rate of death was observed among pregnant women who ate 
clay during pregnancy (Key et aJ, 1982). Women who ingested clay 
freguently suffered from severe anaemia, complete obstruction of 
the colon with perforations and sepsis (Key et al, 1982) .
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The role of clay intake in the genesis of iron-deficiency 
anaemia is however not clear. For instance, while Minnich et al 
(1970) reported that Turkish clay markedly decreased absorption of 
iron, Takington (1971) found only a minimal impairment of iron 
absorption caused by the type of clay that is popularly eaten by 
pregnant women in East Texas. It is therefore probable that 
different clay types have different effects on maternal haemoglobin 
level, since the composition of the clay may be different at 
different places. As observed in the study, clay eaten by Ghanaian 
pregnant women adversely affected maternal haemoglobin level.
5.1.9: Food Avoidance During Pregnancy
Data obtained show that food avoidance was common among the 
pregnant women (Table 20). More than half (62.4%) , of the pregnant 
women avoided some kind of food during the pregnancy. 
Unfortunately, high protein foods like fresh fish and fresh meat 
were the types of food mostly avoided by some, (3 3.3%) of the 
pregnant women, because of the strong scent associated with these 
foods. The strong scent of fermented foods discouraged some 
pregnant women (9.8%) from taking such foods. Slimy sauces, 
(1.8%), and foods of high fat or oil content (4.6%) were also 
avoided by some of the women during the pregnancy. In addition, 
physical stress like excess fullness discouraged some of the 
pregnant women (4.0%) from taking heavy foods such as fufu.
The highly selective behaviour of the subjects towards
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foods during pregnancy was mostly prompted by the nausea associated 
with the pregnancy. The significant role of nausea in the selective 
attitude towards food types was reported earlier by Pelchat and 
Rozin in 1982. In the present study, the contribution of taboos 
and beliefs to food avoidance were not noticed.
5.1.10: Modification of Diet During Pregnancy and Effect on 
Infant Birth-weight
During pregnancy, it is expected that women increase their 
dietary nutrient intake above the non-pregnancy intake to ensure 
adequate supply of nutrients to the developing foetus. An 
investigation into this aspect in the study showed that only 6.6% 
of the pregnant women reported to have eaten more food during 
pregnancy (Table 21). About 21% of the women reported a reduction 
in food intake during pregnancy because of loss of appetite and 
vomiting. Most of the pregnant women (72.7%) did not modify their 
diet at all. The observation in the study that most of the women 
did not increase their dietary intake during pregnancy is in 
agreement with an earlier report by James and Schofield in 1990. 
This observation implies that women who do not have enough nutrient 
stores prior to pregnancy are not likely to meet the increased 
nutrient requirement through dietary intake during pregnancy.
Although there was an increase in mean birth-weight of infants 
born to pregnant women who claimed to have eaten more food during 
pregnancy, the mean infant birth-weight was not significantly (P <
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134
0.05) higher than those who either ate less food or ate the same 
amount of food as in their non-pregnant state. The insignificant 
differences in birth-weights suggest that the nutrient intake of 
women who ate more food, was not considerably higher than those who 
either ate less food or did not modify their diet during the 
pregnancy. When women have adequate nutrient intake, which is not 
so in this stiidy, extra nutrient intake does not have significant 
effect on infant birth-weight (Atton and Watney, 1990).
5.1.XI: Gestational Age at which Women Attended Ante-natal 
Clinics and Effects on Infant Birth-weight
Earlier attendance at ante-natal clinic can mean earlier 
intake of vitamin and mineral supplements given at the ante-natal 
centres in addition to earlier benefits from medical examination 
and advice on good nutrition and health practices during pregnancy. 
However it was observed that only 3 0% of the pregnant women visited 
ante-natal clinics in the first two months of pregnancy (Table 1). 
A substantial number (41.8%) attended ante-natal clinic in the 
third month (12th week) of pregnancy. Astonishingly, some of the 
women attended ante-natal clinic for the first time in the sixth 
(2.8%) and seventh (1.6%) months of pregnancy.
Data from table 11 indicate that pregnant women who received 
ante-natal care before the end of the first trimester (12th week) 
had infants of significantly (P < 0.05) higher birth-weight than 
those who received ante-natal care during the second and third 
trimesters.
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This observation is expected since earlier attendance to ante­
natal clinic could lead to longer duration of nutrient 
supplementation including other health benefits from the 
ante-natal clinic which might result in increase infant 
birth-weight.
The main reason for visiting ante-natal clinic is of course 
for ante-natal care. However only few (30.1%) of the mothers were 
of this opinion (Table 12). Some of the pregnant women (22.7%) 
attended ante-natal clinic because they were vomiting while others 
(14.1%) deliberately delayed the attendance to reduce the cost of 
the ante-natal care. This behaviour can be attributed to ignorance 
of some women of the benefits of ante-natal care, especially, when 
some of them (33%) were of the opinion that it was too early or it 
was not time to visit the ante-natal clinic (Table 12).
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The delayed attendance to ante-natal clinics, observed in the 
study, is attributable to various reasons. Firstly, most of the 
women may not be sure of the initiation of the pregnancy until 
after the third month (12th week) because of irregularities in 
their menstrual cycle (Personal observation in the study). 
Secondly, some women deliberately delay, as observed in the study 
to reduce cost of the ante-natal care. The cumulative cost of ante­
natal care, as shown earlier (Section 4.1) can be enormous and 
pregnant women who were of low financial status were deterred from 
attending clinic earlier to reduce the cost. With increasing cost 
of living, the financial cost of ante-natal care can be a strong 
deterrent to clinic attendance by pregnant women of low socio­
economic background. There is thus the need to subsidize ante-natal 
cost by governments to encourage attendance to ante-natal clinic by 
women. In addition, there is the need to educate women on prompt 
pregnancy test when it is suspected, so that ante-natal care can be 
initiated earlier.
5.1.12: Mothers' Preference of Infant Size in relation to 
maternal Nutrition and labour outcome.
In pregnancy, various prenatal intervention measure aimed at 
ensuring proper outcome of pregnancy are taken. The effects of such 
interventions might be to increase foetal size and hence the 
likelihood of difficult labour. This effect can discourage women, 
especially those in communities where obstetric services are
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limited, from engaging in activities that could lead to an increase 
in infant size.
It was found, after studying the 502 pregnant women, that 
although most (48.5%) of the pregnant women had no particular 
preference for infant size, about 41% of them preferred small 
infants for comfortable labour (Table 25). Only few (10.9%) 
pregnant women wanted big infants at birth. Women in the latter 
category were of the opinion that big infants look bouncy or tough.
Data from table 2 6 indicate that although a substantial number 
of the pregnant women had particular preferences for infant size at 
birth, majority of them (71.0%) did not take measures aimed at 
achieving the preferred infant size. Nevertheless, 10.3% of those 
in the group actually reduced their food intake, while one pregnant 
woman used herbs to achieve the small infant size. Most (65.5%) of 
those who preferred big infants at birth claimed to have increased 
their food intake during the pregnancy.
Assessment of the birth-weights of infants born to the 
pregnant women revealed that infant birth-weight did not relate to 
the mothers' choice of infant size (Table 27). In fact, pregnant 
women who preferred small infants had infants of slightly higher 
birth-weights. It was difficult to put in guantitative terms what 
women meant by small, medium and big infants.
The high percentage of pregnant women who preferred small 
infants at labour is an attestation of the fact that labour 
problems can hinder women's compliance to intervention measures 
aimed at ensuring acceptable pregnancy outcome (Garner Kramer,
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138
1990) . The high rate of maternal death associated with child birth 
in Ghana (7.9 per 1000 deliveries; UNICEF, 1991), in addition to 
scarce obstetric facilities in some Ghanaian communities might have 
contributed to the high percentage of women wanting small infants 
for easy labour.
An assessment of the type of labour experienced by the 
subjects indicated that the prevalence of normal or spontaneous 
delivery was high (97.6%), but some of the mothers, 12 (2.4%), 
experienced difficult labour and thus needed extra assistance 
during labour. It was observed that the pregnant women who needed 
extra assistance during labour had infants of significantly (P < 
0.05) higher birth-weight (3.48 ± 0.295kg) than those who had 
spontaneous delivery (2.987 ± 0.433kg). This observation indicates 
that high infant birth-weight poses labour difficulties. The labour 
difficulties may arise due to mechanical difficulties, including 
cephalopelvic disproportion.
Such difficulties can lead to physical deformities in the woman. 
Higher cost of labour services are incurred when such mechanical 
difficulties lead to caesarian section.
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Some of the solutions to this problem may be to provide 
skilled assistance during child birth and to provide adequate 
obstetric services in communities where such services are limited.
5.1.13: Effect of Duration of Mineral and Vitamin 
Supplementation During Pregnancy on Infant Birth Weigh
The gestational age of the pregnancy on the first visit to the 
ante-natal clinics determines the duration of mineral and vitamin 
supplementation in pregnancy.
The duration of supplementation had significant (P < 0.05) 
effect on infant birth-weight (Table 28) . Infants born to pregnant 
women who had mineral and vitamin supplements for more than 2 0 
weeks had significantly higher birth-weights than those who had the 
supplements for less than 2 0 weeks. This observation suggests that 
women who seek ante-natal care earlier in pregnancy are more likely 
to have favourable outcome of pregnancy.
Advice on good nutritional and health practices are given in 
addition to regular medical examination at the ante-natal centres. 
Pregnant women who sought ante-natal care earlier benefitted to a 
great extent from these services including earlier supplementation 
of nutrients which are essential during pregnancy. The beneficial 
effect of this is the higher infant birth-weight observed for 
pregnant women who attended ante-natal clinics earlier.
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5>2: ANTHROPOMETRIC DATA
5.2.1: Effect of Maternal Height on Birth-weight and Maternal 
Weight-gain
Data from table 29 show that the mean height of the pregnant 
women was 162.17 ± 10.12cm with a range of 148 - 175cm. None was 
below 145cm, the height below which women are reported to be 
nutritionally at risk and stunted (Shah, 1981).
Influence of maternal height on infant birth-weight was 
significant (P < 0.05). Pregnant women who were below 156 cm of 
height had infants of significantly lower (P < 0.05) birth-weight 
than those whose heights were above 17 5cm (Table 3 0) . 
Nevertheless, women who were below 175cm but above 156cm had 
infants of slightly lower birth-weight, than those who were above 
175cm of height.
There was a significantly positive correlation (r = + 0.204) 
between maternal height and infant birth weight (Table 48).
In the case of maternal weight-gain, there were no significant 
(P < 0.05) effect of maternal height on maternal weight-gain of 
pregnant women whose heights were below 175cm (Table 30) . Subjects 
whose heights were above 175cm had significantly (P < 0.05) higher 
weight-gain during the pregnancy than those in the other height 
groups. Furthermore, there was a significantly positive correlation 
(r = + 0.227) between maternal height and maternal weight-gain.
There was a gradual increase in maternal weight-gain as the 
height of the women increased. This observation is consistent with
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the general view that maternal nutritional history prior to 
pregnancy has a strong influence on efficiency of reproduction 
(Tomkins and Watson, 1991) . Women in high height category possibly 
have better nutritional history than seemingly stunted 
women (Shah, 1981). The better nutritional history of women in this 
category can mean adequate nutrient stores prior to pregnancy which 
will lead to favourable pregnancy outcome.
5.2.2: Materrial Weight-gain and Effects on Infant Birth-weight.
The mean maternal weight-gain (10.53 ± 1.68kg) (Table 29), 
determined in the study is lower than the observed maternal weight- 
gain for developed countries (12.50kg) (FAO/WHO, 1985). The 
observed mean maternal weight-gain for the subjects of this study 
is about 17% of the mean body weight of 60.8kg in first trimester.
The level of maternal weight-gain observed in the study 
(10.53kg) is similar to the 10.00kg observed by Jansen and Lakhani 
(1983) in Nairobi, who also reported an 18% increase in body weight 
during pregnancy. However Devadas and Chandy (1980) have observed 
a lower increase in maternal weight-gain of 5.9 to 6.7kg in India. 
Furthermore, the observed mean maternal weight-gain is higher than 
that for some developing countries.
(Appendix 4).
There was a significant effect of maternal weight-gain on 
infant birth-weight (Appendix 9). Women who gained above 90% of 
the reference weight-gain (12.5kg; FAO/WHO, 1985), had infants of
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significantly (P < 0.05) higher birth-weight than pregnant women 
who gained below 90% of the reference standard (Figure 9).
It was also observed that infant birth-weight increased as maternal 
weight-gain increased. Further analyses revealed that there was a 
significant correlation (r = + 0.484) of infant birth-weight with 
maternal weight-gain (Table 47). This finding is consistent with 
observations by other researchers (Calandra and Abel, 1981; Devadas 
and Chandy, 1980) . Adequate energy intake leads to adequate fat 
deposition and hence increased maternal weight-gain during 
pregnancy. Fat deposition during pregnancy is a strong determinant 
of infant birth-weight (FAO/WHO, 1985) .
From figure 7 it could be observed that the rate of maternal 
weight-gain at all stages of pregnancy was lower than that for 
pregnant women of developed countries (Food and Nutrition Board, 
1971). The relatively higher rate of weight-gain for developed 
countries can be attributed to the relatively better nutrition and 
health care during pregnancy.
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5.2.3: Women's Body Mass Index (BMI) in First Trimester and 
Effect on Infant Birth-weight and Maternal Weight-gain
Maternal BMI did not influence significantly (P < 0.05) infant 
birth-weight and maternal weight-gain, though obese women had 
slightly higher weight-gain (Table 31). The insignificant 
differences in maternal weight-gain could mean that the lean women 
had relatively higher maternal weight-gain during pregnancy than 
the fat women.
It was further observed that BMI correlated significantly with 
oedema prevalence (r = + 0.306).
The observation that maternal BMI did not correlate 
significantly with infant birth-weight is in agreement with an 
earlier observation by Atton (1990) in European and Asian women. 
However, the observation is not consistent with an earlier one by 
Arteaga (1978) among women in Chile.
The BMI indicates the degree of fatness of the mothers.
If there is no wide variation between the BMI values of the 
pregnant women, as is the case in the present study, then BMI is 
not likely to affect differences in pregnancy outcome.
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5.3: DIETARY INTAKE DATA
5.3.1: Energy Intake. Infant Birth-weicrht and Maternal 
Weight-gain.
Commensurate energy intake during pregnancy is essential for 
proper outcome of pregnancy. In this study, the mean daily energy 
intake of the 128 pregnant women (9,109KJ; 2175.5kcal) was not 
significantly different from the recommended energy intake for non­
pregnant women, and this was within 89% of the recommended level of 
energy intake for pregnant women. Protein provided 9.0% of the 
total energy intake by the pregnant women. This level of energy 
intake suggests that most of the pregnant women did not increase 
their energy intake during pregnancy.
Eaton (198 2) had earlier observed an energy intake of between 
3,800 and 14,300KJ in Asian pregnant women, where protein supplied 
12.3% of total energy intake. Grover (1982) and Benerjee.and Shah
(1981) have also observed energy intakes below the recommended 
dietary allowance for pregnant women.
The lower level of energy intake by the pregnant women agrees 
with studies from other developing countries where energy intakes 
of pregnant women were lower than that for developed countries 
(Table 3) .
Although there were no significant (P < 0.05) difference in 
the birth-weight of infants born to pregnant women meeting energy 
levels between 80% and the recommended daily dietary allowance
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(RDA), pregnant women whose energy intake met over 100% of the RDA 
had infants of significantly (P < 0.05) higher birth-weight than 
those whose intakes were below 80% of the RDA (Table 40). 
Correlation analyses showed a positive but insignificant 
relationship (r = + 0.130) between infant birth-weight and maternal 
energy intake, which is in agreement with observations from other 
researchers (James and Schofield, 1990; Prentice et al ,1983; 
Shah,1981).
Unlike ihfant birth-weight, maternal weight-gain was more 
sensitive to energy intake (Table 40) . Pregnant women meeting more 
than 90% of the RDA for energy had significantly (P < 0.05) higher 
weight-gains.
The significantly positive correlation (r = + 0.295) of 
maternal weight-gain with energy intake indicates that 
undernourished pregnant women could increase their weight-gain 
during pregnancy if they increase their energy intake.
The effects of energy intake on pregnancy most often depends 
on the nutritional status of the women. In well nourished women who 
are in positive energy balance, supplementary energy intake does 
not have effect on infant birth-weight and pregnancy weight-gain. 
Conversely in women who are in negative energy balance, 
supplementary energy intake has a positive effect on infant birth- 
weight (Kardjati et al, 1988). The observation in this study that 
infant birth-weight was higher for pregnant women whose energy 
intake was above their RDA is consistent with observations made by 
some researchers (Prentice et al, 1983; Shah, 1981, Iyangar, 1974)
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that in marginally nourished women high energy intake is associated 
with an increase in infant birth-weight.
Furthermore, the finding that high energy intake was 
associated with high maternal weight-gain, in this study, is in 
agreement with some research findings (Shah, 1981; Rush et al, 
1980; Mora et al, 1979) that commensurate energy intake during 
pregnancy is associated with an increase in maternal weight-gain in 
marginally nourished women.
The effect of the energy intake on maternal weight-gain 
observed in the study is attributable to the accepted fact that 
high energy intake leads to excessive fat deposition and hence high 
maternal weight-gain during pregnancy (FAO/WHO, 1985).
5.3.2: Protein Intake of the Pregnant Women
The effects of maternal protein intake on infant 
birth-weight and maternal weight-gain were similar (Table 41). The 
birth-weight of infants and maternal weight-gain were significantly 
(P < 0.05) higher for pregnant women taking above 80% of the RDA 
for protein. In addition, subjects whose levels of protein intake 
were above the RDA had significantly higher (P < 0.05) maternal 
weight-gain than those whose protein intake was below 100% of the
The positive relationship between protein intake and infant 
birth-weight observed in the study is in agreement with that 
observed in other developing countries for instance (Iyangar, 1974, 
Shah, 1981, and Mora et al, 1979) . However, Atton and Watney
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(1990) did not observe a correlation between protein intake and 
infant birth-weight in Canadian and Asian women respectively.
The effect of protein intake during pregnancy on infant birth- 
weight depends on the protein nutritional status of the women. Rush 
(1989) reported that in well nourished women, a high protein intake 
(above 20% of calories as protein) had no effect on infant birth- 
weight but in some cases it was associated with delivery of low 
birth-weight infants. The positive relationship of infant birth- 
weight and maternal protein intake observed in this study may be 
due to the low protein nutritional status of some of the women 
involved in the study.
Assessment of haemoglobin level indicated that protein intake 
did not affect the haemoglobin level of the pregnant women (Table 
41) . This observation is at variance with that of Kaur and Sagar
(1982) who observed a significantly positively relationship between 
protein intake and haemoglobin level in anaemic women. The 
difference can be attributed to the fact that women in the present 
study were on vitamin and mineral supplements, some of which 
directly affect haemoglobin level.
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5.3.3: Effects of Dietary Iron Intake of the Pregnant Women on 
Infant Birth-weight, Maternal Weight-gain and Maternal 
Haemoglobin Level
Although iron need during pregnancy cannot be met through 
dietary iron intake alone (Tomkins and Watson, 1991), assessment of 
dietary iron intake could help to ascertain the level of iron 
supplementation during pregnancy.
In the study, it was observed that the mean dietary iron 
intake of the pregnant women was undoubtedly lower than the 
reference requirement for pregnant women (Table 39).
The pregnant women were on iron supplement, 18 0mg/day, hence 
differences in dietary iron intake could be obliterated by the 
supplementary iron intake, making the influence of dietary iron 
intake on pregnancy less vivid. Nevertheless, with the exception 
of infant birth-weight, maternal weight-gain and maternal 
haemoglobin level increased as the level of dietary iron intake 
increased (Table 42).
Pregnant women whose dietary iron intake was below 18mg/day 
had significantly lower maternal weight-gain than those whose 
dietary iron intake was above 27mg/day. The observation that iron 
intake improved maternal weight-gain is in agreement with an 
earlier report by Vijayalakshmi and Usha (1981). This observation 
could partly be due to the reported fact that increased iron intake 
leads to increased appetite in animals (Yartey, 1989) .
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In the presence of supplementary iron, maternal haemoglobin 
level was significantly influenced by dietary iron intake during 
the pregnancy (Table 42) . Maternal haemoglobin level was 
significantly (P < 0.05) higher in pregnant women whose level of 
dietary iron intake was above 27mg/day but there were no 
significant differences (P < 0.05) in haemoglobin concentration of 
those whose dietary iron intake was less than 27mg/day.
The marked influence of dietary iron intake on maternal 
haemoglobin level observed in the study is expected since iron is 
necessary for haematopoiesis (DeMaeyer, 1989).
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5.4: HAEMOGLOBIN DATA
5.4.1: Maternal Haemoglobin Level and Effects on Infant
Birth-weight
The mean monthly haemoglobin levels of the subjects were 
within values acceptable for pregnant women (Table 29) . However 
even though the pregnant women were on iron and vitamin 
supplements, about 20% of them were anaemic by WHO haemoglobin 
standard (haemoglobin level below ll.Og/dl; Tomkins and Watson,
1991). This observed prevalence of anaemia should be viewed as the 
prevalence of anaemia among pregnant women who are on iron and 
vitamin supplements (Appendix 2). This level of anaemia prevalence 
indicates that the level of mineral and vitamin supplementation 
could not prevent anaemia in pregnancy. Only 18.85% of the 
pregnant women had haemoglobin level above 12g/dl (Table 43).
The effect of haemoglobin concentration on infant 
birth-weight was not significant (P < 0.05). However pregnant 
women with mean haemoglobin level above 12g/dl had infants of 
slightly higher birth-weight than pregnant women who had 
haemoglobin level below llg/dl. Prema Neelakumari (1981) observed 
a rather stronger relationship of maternal haemoglobin level with 
infant birth-weight. He observed, after studying 3,461 urban 
Hyderabad women, that when haemoglobin level was below 8g/dl, mean 
birth-weight also decreased. A Similar finding was reported by 
Yusufji (1973) among anaemic women in India.
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need in pregnancy. In addition, other factors like the presence of 
parasites in the gut (eg. hookworm) , as well as low adherence 
(compliance) due to side effects from ferrous sulphate can affect 
iron availability to the subjects (Tomkins and Watson, 1991).
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5.5: C O N C L U S I O N
Based on the results of this study, the following conclusions can
be made:
(a) The main determinants of infant birth-weight are; maternal 
weight-gain, height, protein intake, energy intake, level of 
formal education, occupation, oedema, duration of mineral 
and vitamin supplementation and ante-natal care of the 
mother.
(b) The experience of nausea during pregnancy was associated 
with a reduction in infant birth-weight, maternal weight- 
gain and maternal haemoglobin level.
(c) The mean maternal weight-gained during pregnancy by pregnant 
Ghanaians was 10.531 ± 1.681kg
(d) Factors such as maternal energy intake, occupation, height, 
protein intake and duration of nutrient supplementation were 
strong determinants of maternal weight-gain.
(e) Women did not increase their nutrient intake during the 
pregnancy, and in the case of iron and protein had intakes 
lower than the level recommended for pregnant women.
(f) The mineral and vitamin supplementation during pregnancy 
could not maintain maternal haemoglobin level. The mean 
maternal haemoglobin level was 11.503 ± 0.603g/dl.
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(g) Maternal habits such as clay ingestion, alcohol intake, and 
delayed attendance to ante-natal clinics lead to a reduction 
in maternal haemoglobin level.
(h) The prevalences of alcohol intake, pica and clay among 
pregnant Ghanaian women were 9.3 6%, 48.01%, and 
(28.49%) respectively.
(i) The fear for difficult labour had adversely effected some 
women's desire for high birth-weight infants at birth.
(j) Women who seek ante-natal care early are likely to have 
better outcome of pregnancy.
(k) The high cost of ante-natal care discouraged 14.14% of
pregnant women from early attendance to ante-natal clinic.
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5.4.2: Effects of Iron and Vitamin Supplementation— on Maternal 
Haemoglobin Level Purina Pregnancy
Normally some of the effects of iron and vitamin 
supplementation during pregnancy are exhibited as increase in 
maternal haemoglobin level. In this study, mothers haemoglobin 
levels were assessed monthly from the third to the ninth month of 
pregnancy to ascertain the effectiveness of the supplementation 
programmes.
The results showed a gradual decrease in mean maternal 
haemoglobin level up to the seventh month, after which a sharp 
decrease was observed in the eighth month (Figure 8 ) (Appendix 
10) . The continuous decrease in mean monthly maternal haemoglobin 
level during the pregnancy could be because the amount of iron 
absorbed from the supplements was not enough to sustain the 
increased requirements of the pregnancy state. Normally it is 
during the third trimester that iron need during pregnancy is 
greatest (FAO/WHO, 1988), thus for women of marginal iron status as 
the subjects of this study, it is not surprising that haemoglobin 
levels were lowest after the seventh month of gestation. Shukla and 
Verma (1982) have also observed a decrease in maternal haemoglobin 
level with increasing gestational age, while Ross and Read (1981) 
have reported that prophylactic iron supplements do not increase 
maternal haemoglobin level.
The observation in the present study could mean that the level 
of bioavailability of the form of iron (ferrous sulphate) used in 
the supplementation programme may not be high enough to meet iron
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5.6: R E C O M M E N D A T I O N S
There is need to intensify mass education at ante-natal clinics, 
in the media and at adult literacy classes on good nutrition and 
health practices, as well as on the adverse effects of clay and 
alcohol ingestion during pregnancy.
Pica should be avoided since it pre-disposes to low haemoglobin 
levels and anaemia.
Emphasis should be placed on the importance of early 
ante-natal care and good nutritional habits during pregnancy.
Mothers should begin getting Ante-natal care in their first 
trimester to improve chances of giving birth to high-birth-weight 
infants. This is critical to teenage pregnant mothers since they 
reproduce most low-birth-weight infants in Ghana.
Women who experienced nausea during pregnancy should be given 
extra medical and nutritional attention especailly to improve their 
dietary intake.
Since adequate Energy, Protein and iron intake positively affect 
both maternal weight gain and infant birth-weight, these do affect 
pregnancy outcome positively and should be adequately provided.
Obstetric problems could be alleviated by the provision of more 
health posts especially in rural communities. This could allay women's 
fear of labour problems through the availability of skilled health 
personnel and indirectly encourage adequate nutrition during 
pregnancy.
If Ghana had adequate resources, a program of low-priced or free 
food supplementation for pregnant women would be commendable.
The cost of ante-natal care could be subsidized by Government to 
encourage women to seek ante-natal care early.
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APPENDICES
Appendix 1: Basic Indicators of Nations Categorized as Having 
Very High Under-five-mortality Rate (U5MR) (ie. 
Over 140/1000)_____________________  ________
Total U5MR Infant Annual No. % of infants 
U a t- i nn' Population Mortality of birth with low 
(Millions) rate (Under 1 (thousands) birth-weight 
(1989) year) (1980 1988)
1960
19891
1960 1989
1. Mozambique 15.2 331 297 190 173 168 20
2. Afghanistan 15.7 381 296 215 169 776 20
3. Angola 9.7 345 292 208 173 460 17
4. Mali 8.9 369 287 210 166 456 17
5. Sierra Leon 4.0 385 261 219 151 195 17
6. Malawi 8.4 366 258 207 147 475 20
7. Guinea 5.6 336 241 203 142 284
8. Burkina Faso 8.8 363 232 205 135 412
9. Ethiopia 47.9 294 226 175 133 2383
10. Niger 7.5 321 225 191 132 387 15
11. Central 3.0 308 219 183 129 134 15
African Rep. 5.5 325 219 195 129 245
12. Chad 7.3 294 218 175 129 358
13. Soma Ii a 2.0 321 217 191 124 91 11
14. Mauritania 2.5 310 209 184 137 118
15. Liberia
16. Rwanda 7.0 248 201 146 119 356 17
17. Cambodia 8.1 218 200 146 127 324
18. Burundi 5.3 260 196 153 116 254 9
19. Bhutan 1.5 298 193 187 125 57
20. Nepal 18.7 298 193 187 125 721
21. Yemen 11.3 378 192 214 116 587
22. Senegal 7.1 299 189 172 85 321 11
23. Bangladesh 112.5 262 184 156 116 4659
24. 28Madagascar 11.6 364 179 220 117 532 10
25. Sudan 24.5 292 175 170 105 1083
26. Tanzani a 26.3 249 173 147 103 1329
27. 14Namibia 1.7 262 171 155 103 76
28. Nigeria 105.0 316 170 190 102 5083
29. 20Gabon 1.1 287 167 171 100
30. 47Uganda 18.1 223 167 133 100 942
31. Bolivia 7.1 282 165 167 105
32. 302Pakistan 12118.8 276 162 163 106 5452
33. Laos 254.0 233 156 155
34. 106 181Benin 394.5 310 150 185 89
35. 221 8Cameroon 11.4 275 150 163 92 547 13
36. Togo 3.4 305 150
37. 182 92India 153 20835.6 282 145 165
38. 96Ghana 26071 3014.6 224
39. 143 132 87Cote 64411.1 17264 139 165 93
d'Ivoi re 575 14
Sou»ce: UNICEF, 1901.
1: Nations arc listed in descending otder of their 1 989 under livo mortality rates.
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APPENDIX 2 : Composition of Mineral and Multivitamin Tablets used for 
Supplementation at the Ante-natal Centres.
Tablet 1 Nutrient Quanti ty
Multivites Vitamin A (IU) 2,500
Vitamin D (IU) 300
(B.P.C, Dannex) Vitamin B, (mg) 1.0
Vitamin B2 (mg) 0.5
Vitamin C (mg) 15.0
Nicotinamide (mg) 7.5
Vitafol Vitamin A (IU) 6,000
Vitamin D (IU) 400
(West-Ward Pharmaceutical Vitamin E (IU) 30
Corp, Eatontown, NJ 07724) Folic Acid (mg) 1.0
Vitamin C (mg) 60
Thiamine mononitrate (mg) 1.1
Riboflavin (mg) 1.8
Pyridoxine hydrocholride (mg) 2.5
Vitamin B12 (jig) 5.0
Niacin (mg) 15
Calcium (mg) 125
Ferrous fumarate (Iron) (mg) 65
Vitamin A (IU) 5,000
Vitamin B, 2.5
Uni cap Hi Vitamin B2 2.5
Vitamin C 50
(Upjohn Ltd, Crawley, U.K) Vitamin B6 0.5
Vitamin B12 2.0
Calcium pantothenate (mg) 5
Iron (Fumarate) (mg) 30.42
Iodine (KI) (mg) 0.196
Copper (Sulfate) (mg) 3.928
Manganese (sulfate) (mg) 3.076
Magnesium (oxalate) (mg) 9.95
Potassium (sulfate) (mg) 11.142
Calcium (phosphate) (mg) 2.198
Calcium (carbonate) (mg) 87.5
Vitamin D (/ig) 12.5
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APPENDIX 3: Extra Daily Nutrient Allowance for pregnant women
Nutrient Nonpregnant Pregnant
Energy 2,235kcal + 160kcal (let 
trimester) ‘
+ 350kcal (2nd and 3rd 
trimesters)
Protein (g) 41 + 6gb
Retinol (fjg) 800 1000
Vitamin D (pg) 7 . 5 12.5
Vitamin E (mg) 8 10
Vitamin C (mg) 60 80
Riboflavin (mg) 1.3 1.6
Nicotinic acid (mg) 14 16
Vitamin B6 (mg) 2.0 2.6
Folate (pg) 400 800
Thiamin (mg) 1.1 1.5
Calcium (mg) 800 1200
Iron (mg) 18 S+
Zinc (mg) 15 20
a, b: Allowances set by FAO/WHO, 1985
S+: The increased requirement cannot be obtained from the diet and thus 
supplemental iron was recommended.
Source: FAO/WHO, 1974
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Appendix 4: Pregnancy Weight-gain In some countries.
Country Pregnancy weight-gain (Kg)
United states of America 17.0
Scotland 12. 5
United Kingdom 11.7
Sri Lanka 6.5
South India 5.3 - 6.3
Gambia 2.7 - 5.5
Ghana
Source: Food and Nutrition Board, 1971, N.R.C, USA.
Appendix 5: Infant Birth-weight Distribution (n = 502)
Birth-weight Number of Percentage of 
groups infants infants
< 2.50 42 8.37
2.50 - 2.99 168 33.47
3.00 - 3.49 219 43.63
3.50 - 4.00 68 13.55
> 4.00 5 1.00
Total 502 100.00
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Appendix 6: Number of mothers and birth-weight of infants
according to health centre of study
Health Centre Number Percentage Infant birth-weight 
of of mothers (Mean ± S.D) (kg)
mothers
University Hospital 162 32.27 3 085 ± 0.417
La Polyclinic 183 36.45 2 998 ± 0.421
Kaneshie Polyclinic 71 14.15 2 826 ± 0.808
Nerzit Maternity 86 17.13 2 987 ± 0.504
Total 502 100.00 2 999 ± 0.511
Appendix 7 : Maternal Weight-gain and haemoglobin levels according to health
centre of study
Health Centre of Number of Maternal Haemoglobin 
Study mothers weight-gain (Kg) level during 
pregnancy (g/dl)
University Hospital 41 11.171 ± 0.752 11.587 ± 0.752
La Polyclinic 35 10.514 ± 1.931 11.564 ± 0.303
Kaneshie Polyclinc 36 10.014 ± 1.447 11.088 ± 0.443
Nerzit Maternity 16 10.094 ± 1.099 11.503 + 0.603
Total 128 10.531 ± 0.681 11.503 ± 0.603
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Appendix 8: Mean Monthly Maternal Weight-gain during Pregnancy (n - 128). 
______________ (Longitudinal study)_____________________ ________________________ _
Gestational Age Observed weight-gain Reference weight-gain'
(weeks)
(Kg) (Kg)
10 0.65
16 1. 511 2.683
20 3.273 4.00
24 4.981 5.804
28 6.969 7.602
30 8.031 8.500
32 9.043 9.352
36 10.531 10.871
1: Food and Nutrition Boaid, 1971; N .R.C, U.S.A.
Appendix 9: Effect of Maternal weight-gain on Infant Birth-weight (n = 128 )*
Weight-gain as percentage of recommended (Reference weight-gain: 12.5Kg)2
1
50 60% 61 70% 71 80% 81 90% 91 100% > 100%
Number of 3 6 25 35 27 32
subjects
Percentaage 2.34 4.69 19.53 27.34 21.10 25.00
of total
Mean Infant 2.567* ± 2.967 ± 2.818“ ± 2.887s - 3.144b 3.382b + 
bi rth- 0.808 0.489 0.395 0.395 0.293 0.401
weight (Kg)
1: Mean values labelled (a) and Cb) are significantly different from each other 
P < 0.05
Significant test: Duncan's multiple range test.
2. Reference weight-gain; FAO/WHO, 1985.
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Appendix 10: Mean Monthly Maternal Haemoglobin Levels of the
Pregnant Women at Various Gestational Ages 
(n = 128) .
Gestational age (weeks) Mean Monthly Maternal Haemoglobin level (g/dl)
12 11.705 + 1.010
16 11.553 ± 0.927
20 11.465 ± 0.928
24 11.434 ± 0.817
28 11.182 ± 0.746
32 10.856 ± 0.719
36 11.065 + 0.524
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Appendix 11. Sample of the questionnaire used for data 
collection.
DEPARTMENT OF NUTRITION AND FOOD SCIENCE 
UNIVERSITY OF GHANA. LEGON
AN INVESTIGATION INTO THE NUTRITIONAL HABITS OF PREGNANT 
GHANAIAN WOMEN AND THEIR EFFECTS ON PREGNANCY OUTCOME
(A) Background Information on subjects.
Date ....................... Serial No......................
Name of health centre ......
Name of subject .............
Birth date/Age ..............
Place of residence ..........
House number ...............
Region of birth .............
Marital status:
1) Single [ ] 3) Divorced [ ]
2) Married [ ] 4) Widowed [ ]
Educational level of subject:
1) Primary school [ ] 4) Tertiary [ ]
2) Middle school [ ] 5) Other........
3) Secondary/Technical/
Vocational school r 6) None [ ]
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Main Occupation of subject:
1) Farmer [ ] 6) Driver [ ]
2) Trader [ ] 7) Lecturer [ ]
3) Hairdresser [ ] 8) Housewife [ ]
4) Seamstress [ ] 9) Other ......
5) Teacher [ ]
Main occupation of husband:
1) Farmer 6) Driver [ ]
2) Trader 7) Lecturer [ ]
3) Mechanic 8) Unemployed [ ]
4) Mason 9) Other ........
5) Teacher
(B) Biomedical and Psychological determinants of pregnancy 
outcome:
Do you lose appetite in early pregnancy?
1) All the time [ ]
2) Sometimes [ ]
3) Never [ ]
For how long do you lose appetite?
1) Up to 3 months [ ] 2) More than 3 months [ ]
How often do you vomit during pregnancy?
1) All the time [ ] 2) Sometimes [ ]
3) Never [ ]
For how long do you vomit?
1) Up to 3 months [ ] 2) More than 3 months [ ]
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In what month of pregnancy do you stop vomiting..............
Have you developed oedema?
1) Yes [ ] 2) No [ ]
Type of oedema:
1) Generalized [ ] 2) On limbs [ ]
Have you modified your diet (food) because of this pregnancy? 
1) Completely [ ] 2) A little bit [ ]
3) Not at all [ ]
If yes, what have you changed about your diet?
1) Type of food [ ]
2) Quality/quantity of food [ ]
3) Other .................................................
Why did you mdke changes in your diet? .......................
What food do you dislike (avoid) during pregnancy?...........
Reason for not liking it ....................................
Do you eat clay during pregnancy?
1) All the time [ ] 2) Sometimes [ ] 3) Never [ ]
Reason for eating clay ......................................
Do you eat chalk during pregnancy?
1) All the time [ ] 2) Sometimes [ ] 3) Never [ ]
Reason for eating chalk .....................................
What other non-food items do you eat? ......................
Do you take alcohol during pregnancy?
1) AlWays [ ] 2) Sometimes [ ] 3) Never [ ]
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What type of alcohol do you take?
1) Local gin [ ] 4) Schnapps [ ]
2) Beer/Gulder [ ] 5) Other .............
Specify quantity of alcohol:
1) About 100ml per week [ ]
2) Half I bottle per week [ ]
3) 1 or 2 bottles per week [ ]
4) 3 to 5 bottles per week [ ]
5) More than five bottles per week [ ]
Reason for taking alcohol ..............................
Are you on vitamin or mineral supplement?
1) Yes [ ] 2) No [ ]
If yes, what type of supplement?
1) Folic acid [ ] 4) Calcium [ ]
2) Multivites [ ] 5) Other .........
3) Fersolate [ ]
How long have you been on the supplement?
1) One month [ ] 4) Four months [ ]
2) Two months [ ] 5) Five months [ ]
3) Three months [ ] 6) Other .........
Have you been immunized against tetanus?
1) Yes [ ] 2) No [ ]
If no, why not? .........................................
Have you been immunized against others? (specify) ....
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Is this your first pregnancy?
1) Yes [ ] 2) No [ ]
If, no how many pregnancies have you had?
1) One [ ] 5) Five [ J
2) Two [ ] 6) Six [ ]
3) Three [ ] 7) Other .....................
4) Four [ ]
Why this number of pregnancies? .................................
How many times have you experienced spontaneous abortion?
j
1) INone 1 [ ] 4) Three times [ ]
2) Once [ ] 5) More than three times [ ]
3) Two times [ ]
Have you experienced any stillbirths?
1) None [ ] 3) Twice [ ]
2) Once [ ] 4) More than three times [ ] 
What was the age of this pregnancy when you first visited the 
ante-natal clinic?
1) One month [ ] 4) Four months [ ]
2) Two months [ ] 5) Five months [ ]
3) Three months [ ] 6) More than five months [ ] 
Reasons for delayed visit to ante-natal clinic ...................
Have you suffered from some kind of sickness during this 
pregnancy?
1) Never [ ] 3) Three times or more [ ]
2) Once or twice [ ] 4) All the time [ ]
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Type of sickness .............................................
How often hav4 you suffered from the following diseases?
a) Malaria:
1) All the time [ ] 2) Sometimes [ ]
3) Never
b) Diarrhoea:
1) All the time 2) Sometimes [ ]
3) Never
c) Hypertension:
1) All the time Sometimes [ ]
3) Never
Have you suffered from something else? (Specify)
What size of babies do you prefer at birth?
1) Small babies [ ] 3) Big babies [ ]
2) Medium [ ] 4) No preference [ ]
Give reason for your choice ..............................
What do you do to achieve your choice of baby size? ....
What do you think of diet (food) during pregnancy?
1) Important [ ] 4) Dangerous [ ]
2) Has no effect [ ] 5) I don't know [ ]
3) Not necessary [ ]
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THE LONGITUDINAL STUDY
A. Food Intake
Twenty-four-hour Dietary Recall.
List of all food items eaten by the subject a day before the 
interview and their quantities
Meal Pattern Food Item Quantity
Breakfast
Am snack
Lunch
Pm snack
Supper
Bedtime snack
Comments
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B. Height, weight and haemoglobin measurements
Health centre...............................
Name of subject.............................
Age of subject.......
Height of subject (cm) .. 
Pre-pregnancy weight (Kg)
Gestational Maternal Maternal Haemoglobin 
age (weeks) weight (Kg) weight-gain level (g/dl)
(Kg)
8
12
16
20
24
28
32
36
40
Age of pregnancy at delivery:
1) 28 weeks [ ] 3) 4 0 weeks [ ]
2) 3 6 weeks [ ] 4) Other......
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Type of delivery:
1) Forceps [ ]
2 ) Pump/suction [ ]
3 ) Caesarean section [ ]
4 ) Spontaneous [ ]
5 ) Other ...........
Birth-weight of infant
(Kg)......................................
Sex of infant:
1) Male [ ] 2) Female [ ]
Remarks: ................................
Thank you.