CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Malnutrition in pregnancy remains unacceptably high in underdeveloped countries. Cameroon is one of the underdeveloped countries and found in the sub-Saharan Africa with maternal malnutrition especially in pregnancy. According to the 2018 World Health Organization (WHO) African regions data, between 2000 and 2015, nine countries in Africa had a prevalence rate of malnutrition above 15%. Cameroon was amongst the countries which were rated the lowest rate of underweight amongst women.

The World Health Organization (WHO) defines malnutrition as ‘the cellular imbalance between the supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance, and specific functions’. Contrary to the common use, the term malnutrition refers not only to deficiency states but also to excess and imbalance in the intake of calories, proteins and/or other nutrients. A balanced amount of nutrients is necessary for the proper functioning of the body system. Nutrition is a fundamental pillar of human life, health and development throughout the entire life span (World Bank, 2006). Proper food and good nutrition are essential for survival, physical growth, mental development, performance and productivity, health, and wellbeing. However, nutrition requirements vary with age, gender, and during physiological changes such as pregnancy. Pregnancy is such a critical phase in a woman’s life when the expecting mother needs optimal nutrients of superior quality to support the developing foetus.

 Pregnant women are amongst the most vulnerable segments of the population from the nutritional point of view. Numerous studies in Africa and beyond have shown that in chronically undernourished women on unchanged dietary intake in pregnant women have adverse effects on maternal nutritional status. (Arimond et al; 2010; Brinkman et al; 2009).

 Malnutrition manifests itself as a function of many and complex factors that affect the national child status. It is directly linked to inadequacy in diet and diseases underlining conditions that include crisis in household food supply, inappropriate childcare and feeding practices, unhealthy place of residence and insufficient basic health services for those in poor socioeconomic situations, cultural beliefs, and lack of parents’ education, especially that of  mothers. Malnutrition is inadequate intake of nourishing food or consumption of a particular type of food item that has little or no nutritional value. Malnutrition  in  adults, especially  women,  can either  take  the  form  of  under nutrition (thinness),  over-nutrition  (obesity)  or micronutrient  deficiency. Both obesity and under nutrition have severe consequences on the health of women. Some of  these  include  increased  rates  of  infection, lethargy and general body weakness  – leading to  reduced  productivity,  increased  risk  of maternal  complication  and  death.  Micronutrient  deficiency  is  the  most  common form  of  malnutrition  found  among  pregnant and lactating mothers. Micronutrients are only needed  in  small  amounts;  however,  any  form of  their  deficiency  can  be  severe.  Other causes of micronutrient deficiency may include presence of diseases in individuals, leading to reduction in the absorption of micronutrients from foods.    In  developing countries,  the  common  forms  of micronutrient deficiency  among  women  are  iron  deficiency, causing iron deficiency anaemia (IDA); vitamin A  deficiency,  causing  Vitamin  A  deficiency disorder  (VADD);  iodine  deficiency,  causing iodine deficiency disorder  (IDD)  (Tyndall  et al., 2012). IDA  is  the  most  prominent  among  these deficiencies,  and  is  of  great  public  health concern  even  in  developed  countries.  IDA affects more women than men, and symptoms include  lack  of  energy, feelings  of  weakness, decreased  performance,  urge  to  eat  dirt  and other  non-food  substances  among  others (Tyndall  et al., 2012). IDA is a major cause of perinatal and  maternal  mortality; it  increases the  risk  of  premature  delivery  and  low  birth weight (NPC/ICF,  2014).  According  to  a nationwide  food  consumption  and  nutrition survey  conducted  in  Nigeria,  VADD  increases  the  risk  of  diseases  and death due to severe infections. The deficiency is often characterised by impaired vision. In pregnant women,  VADD  leads  to  night blindness  and  increased  risk  of  mortality (Tyndall  et  al.,  2012). Foetal brain damage, congenital malformation, abortion, stillbirth and prenatal deaths are characteristics associated with IDD.  Among women, and adults in general, deficiency of iodine is characterized by goitre – enlargement of the thyroid gland. Among  pregnant  women,  a prevalence of 10.5%  has  been  reported  for IDD  and other  micronutrient  deficiencies  among pregnant  and  lactating  women  include  zinc and folate deficiencies. Zinc deficiency impairs growth  and  behaviour  changes  and  it  is  a leading  cause  of  diarrhoea  (Awobusuyi  et  al., 2014). A  prevalence  of  28%  and  42%  was reported  for  zinc  deficiency  among  mothers and pregnant women respectively. Folate plays an important role in foetal development; low stores of folate in pregnant women can lead to a condition called neural tube defect in the foetus. It can also increase the risk of pre-term delivery and low birth weight. An adequate nutritional status of pregnant women is essential for their health and pregnancy outcomes. Poor nutrition before, during and after pregnancy is strongly linked with anaemia in pregnancy, mortality and adverse birth outcome such as low birth weight (LBW), and preterm birth(PTB) (https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3682760/).  Malnutrition continues as such to be major nutritional problem in Cameroon especially in rural population. Despite the quantity and numerous foodstuffs produced in ten Regions of Cameroon, the population still suffers from the nutritional problems which seems not to be linked to lack of food, but to inappropriate uses of available food resources. Beyond the age of 24 months in rural area in Cameroon, there is very little information on child malnutrition. Although in Cameroon several studies in urban areas report on the nutritional status of children, their food habits, complementary food, and health, very few exists that explain the real life, feeding practices and nutrition insecurity of infants living in rural areas particularly in Bamenda III Subdivision. Despite significant gains and progress in the last decade, malnutrition remains a major public health problem in Mezam. Pregnant and lactating women (PLW), along with children, are among the most vulnerable groups of population during emergencies and droughts due to their higher nutritional needs and detrimental effects of poor nutrition on the health of the mothers and their children. The Mezam Demographic Health Surveys (DHS) data revealed 30.5% and 26.9% of chronic energy deficiency among non-pregnant and non-postpartum women, respectively. Similarly, a prevalence of 27% from DHS 2011 confirmed that the problem remained unchanged. Malnutrition is known to increase the risk of poor pregnancy outcomes, including obstructed labour, premature or low-birth-weight (LBW) babies and postpartum haemorrhage. Severe anaemia during pregnancy is associated with increased maternal mortality.        

1.2 Problem Statement

The nutritional status of the mother at conception is a key factor for development and foetal growth. So a healthy, balanced diet is essential before, during, and after pregnancy. Malnutrition  has  been  identified  as  a  key underlying  cause  for  maternal  deaths  in  Africa.  Malnutrition  pre-disposes  women,  particularly pregnant  and  lactating  women,  to  various forms  of  health  conditions  such  as  increased  risk  of infection,  anaemia,  visual  impairment,  goitre  amongst  others. These  in  turn  lead  to  gestational  and postnatal  complications  such  as  obstructed  labour,  gestational  diabetes,  hypertensive  disorders, haemorrhage and  in  fatal  cases,  death.

 (https://www.nichd.nih.g.v/health/topics/pregnancy/conditioninfo/complications)  Malnutrition may also  increase  the  risk  of  intra-uterine  growth retardation  (IUGR)  and  neural  tube  defect  in  the  children  born  to  these  malnourished  women (De Benoist B et al 2005). Consequences for maternal health may also lead to increased risk of maternal complications and death, increased infection, anaemia and lethargy and weakness, lower productivity and for the foetal or infant, it may increase risk of foetal, neonatal, and infant death, Intrauterine growth retardation, low birth weight, prematurity, birth defects, cretinism, brain damage and increased risk of infection.  According to UNICEF (2009), each year more than half a million women die from causes related to pregnancy and childbirth. Nearly 4 million new born die within 28 days of birth. Many of the 200 million women who become pregnant each year, most of them in developing countries suffer from on-going nutritional deficiencies and repeated infections

During pregnancy a woman needs good nutritional status for a healthy outcome. With pregnancy, the mother’s diet provides energy and nutrients to both herself and the foetus growth and for future lactation. Most “Barker Hypothesis” suggests that chronic diseases in adulthood are in relation with the “foetal programming”, through which any stimulus or insult during embryonic development would have a permanent effect on the structure and physiology of the human body. Nutrient reduction, deprivation or imbalance before implantation, could result in somatic hypo-evolutism at birth, alterations in endocrine and metabolic functions during postnatal life and, often, impaired maturation of the reproductive system. From clinical, epidemiological, and experimental studies, several nutrients influence the regular course of pregnancy and the embryo-foetal development in different animal species, including humans. In relation to humans, to evaluate the specific influence of different nutrients on prenatal development is difficult, since a severe maternal under nutrition, with a reduction in caloric intake, will trigger a proportional increase in catabolic activity of the maternal tissues that cause the release in blood, and then in maternal-foetal circulation, of many amino acids, vitamins and minerals that will balance the deficit “diet” of the foetus. Women who have a poor nutritional status at conception are at higher risk of disease and death; their health depends greatly on the availability of food, and they may be unable to cope with their increased nutrient needs during pregnancy in situations of food insecurity. Infections such as malaria and HIV and infestation with gastrointestinal parasites can exacerbate such women’s under nutrition. (https://www.nature.com/articles/s41598-020-5903-y, published, February 5, 2020).

Environmental  and  economic  conditions  have  huge  impacts  on  the  nutritional  status  of  women  in Sub-Saharan Africa; poverty in this population limits food choices, thus affecting their quality of diet and ultimately, nutrient absorption. Micronutrient malnutrition, also called hidden hunger, is the main form  of  malnutrition  found  among  pregnant  and  lactating  women  in  Africa,  this  coupled  with under nutrition have severe implications on the wellbeing  of these women. Micronutrient supplementation and food-based strategies such as diet diversity, food fortification and bio-fortification have been reported in many studies as vehicles to combat the malnutrition scourge in Sub-Saharan Africa. (Bailey  RL,  West  KP,  Black  RE  (2015))    This project therefore seeks to assess the prevalence of malnutrition in pregnant women in Bamenda III Subdivision.

1.3 Objective of the Study

To assess the prevalence of malnutrition in pregnant women in Bamenda III Subdivision, in the North West region of Cameroon

Specific Objectives

• To assess the dietary intake of pregnant women in Bamenda III Subdivision.
• To identify the causes of malnutrition in pregnant women in this community.

1.4 Research Questions

 The following research questions guided the study:

• What is the nutritional status of pregnant women in Bamenda III Subdivision?
• What are the possible causes of malnutrition in pregnant women in this community?