Globally, 295 000 women die annually as a result of pregnancy and childbirth complications, with 95% of these deaths occurring in low- and lower-middle-income countries (World Health Organization (WHO), 2019; UNICEF, 2020). The majority of these deaths are preventable, and sustainable development goals 3.1 and 3.2 aim to reduce the global maternal mortality ratio to less than 70 per 100000 live births and end preventable deaths of newborns and children under 5 years of age by 2030 (WHO, 2021a). Currently, there are indications that the world may fall short of meeting the target for reducing maternal deaths (WHO, 2021a).
Pregnant women's nutrition and diet are vital, as they significantly impact children's physical and mental development throughout life (Likhar and Patil, 2022). In particular, the nutritional practices of a pregnant woman during the first trimester of her pregnancy impact the first 1000 days of the pregnancy and a child's future health, including the infant's immune system, organ development and metabolism (Likhar and Patil, 2022). In this regard, the practice of clay ingestion by pregnant women, known as geophagy (Abrahams and Parsons, 1996), is of great significance in public health. However, little attention has been given to this practice (Mireku et al, 2018; Davies, 2023).
The prevalence of clay ingestion is debatable and current evidence among pregnant women is scarce. However, a study in Ghana by Kortei et al (2019) reported a prevalence of 48.4% while another in Ethiopia reported 17 % (Getachew et al, 2021). Historical evidence from sub–Saharan Africa suggested ranges from 28–84% (Luoba et al, 2004; Kawai et al, 2009; Nyaruhucha, 2009; Seim et al, 2013), with Uganda having a prevalence of up to 50% (Seim et al, 2013). This practice is culturally and socially embedded and widely acceptable during pregnancy (Njiru et al, 2011; Madziva and Chinuoya, 2020; 2023; Orisakwe et al, 2020). This is exemplified by clay ingestion practices among migrant pregnant African women living in high-income countries, including the UK, Austria, the Netherlands, the USA and Belgium (Al-Rmalli et al, 2010; Reeuwijk et al, 2013; Lin et al, 2015; Madziva and Chinouya, 2020). Migrant pregnant women reportedly continue cultural practices and beliefs from their home countries, despite relocation (Benza and Liamputtong, 2014; Cousik and Hickey, 2016; Quintanilha et al, 2016; Chinouya and Madziva, 2020).
Clay ingestion is frequently under-reported because clinicians do not often ask about it (Mishori and McHale, 2014). Additionally, pregnant women may avoid reporting if they engage in this practice, since it conflicts with the hygiene principles of Western medicine, bringing shame and stigma. However, some women view clay ingestion as a normal aspect of pregnancy (Njiru et al, 2011).
Clay ingestion is considered a mineral supplement (Kortei et al, 2019) and a remedy for appetite challenges, nausea, morning sickness and salivation during pregnancy (Madziva and Chinouya, 2020), as well as a treatment for diarrhoea and intestinal parasites (Vermeer and Ferrell, 1985). However, studies suggest that clay nutrient value is overestimated, and clay ingestion exacerbates micronutrient deficiencies (Geissler et al, 1999; Hooda et al, 2004), as well as being linked to parasitic worm infestation (Getachew et al, 2021; Ulaganeethi et al, 2023). Some clays contain levels of lead and arsenic, among other metals, associated with adverse health issues such as low birth weight in children, impaired intrauterine growth, intestinal blockages and impaired neurodevelopment, with implications for IQ and attention span reduction, antisocial behaviour and reduced educational attainment (Reeuwijk et al, 2013; Nyanza et al, 2014; Lars et al, 2015; Frazzoli et al, 2016; Gundacker et al, 2017; WHO, 2021b).
While there is a large body of scientific evidence pointing to the dangers associated with clay ingestion during pregnancy, studies documenting women's lived experiences of adverse health effects attributed to clay ingestion are scarce. By exploring women's self-reported adverse health experiences as well as the measures taken to mitigate these, this study aims to diversify the knowledge base that communities, public health practitioners and public health agencies draw from. Furthermore, unpacking such experiences may go some way towards fostering empathy, shifting understanding and reducing bias among public health practitioners and relevant public health agencies. This is crucial in designing relevant and culturally sensitive public health interventions to improve maternal health outcomes in this population (Ogunbayo et al, 2017;Veldmeijer et al, 2023; Lewis and Foye, 2022). The inclusion of women's voices in such interventions potentially builds trust in practitioners as well as acceptance of interventions (Beames et al, 2021).
Methods
The study used interpretative phenomenology analysis, as it is suited to uncovering the meaning and key structures of participants' lived experiences with clay ingestion (Bynum and Varpio, 2018). Interpretive phenomenology analysis enabled the study to address research questions relating to self-reported adverse health experiences attributed to clay ingestion as well as the mitigating remedies and precautions taken during pregnancy among African migrant women.
Participants
Participants were self-identifying Black African women over 18 years old living in a London borough. The inclusion criteria were that they had experienced clay ingestion during pregnancy in England in the last 10 years. Recruitment took place from May to August 2020 using a combination of purposive, snowballing and quota sampling. Snowballing worked well with recruiting a hard-to-reach group (Ritchie at al, 2013). As a result of COVID-19 restrictions, participants were initially approached through community networks, as well as remotely via emails and telephone calls by two community mobilisers whom researchers had trained to recruit using the set criteria. To mitigate the risk of recruiting a homogeneous sample in relation to country of origin, quota sampling was introduced during field work to improve sampling pool diversity. After recruiting three or four participants from the same country, sampling pool members were asked to only refer participants from different countries.
Data collection
Semi-structured in-depth interviews were used to gain insight into the 30 participants' adverse health experiences as well as mitigating measures taken. An interview guide was created, informed by literature as well as previous study findings by researchers (Madziva and Chinouya, 2020). The guide was pretested on the first six participants and adjusted accordingly. As part of a wider study, the key question leading to the theme of adverse health experience was ‘can you tell me about your experiences (positive/negative) of eating clay during pregnancy?’. Depending on the response, participants who did not mention negative health effects, problems or challenges were directly asked whether they experienced negative effects that they attributed to clay. If they did experience issues, they were asked how they responded/managed them.
Interviews were conducted remotely by researchers via telephone calls or WhatsApp, depending on the participant's preference. Each interview lasted approximately 40–60 minutes and was audio recorded, transcribed and had manuscripts printed for interpretive phenomenological analysis.
Data analysis
Manuscripts were read while listening to corresponding audio files to ensure accuracy. The analysis followed the process outlined by Willig (2008), starting with encountering the text, which entailed repeated reading of each manuscript, with researchers' thoughts and observations noted, to create codes. Codes were grouped into themes, followed by clustering, where themes with shared meanings and hierarchical relationships were identified and discussed. A summary table of themes was created with brief quotes for illustration and line numbers for extraction from each manuscript. Integration of all cases into one table enabled the researchers to look through all the data while referring to individual scripts.
Ethical considerations
The study was granted ethical approval by London Metropolitan University Ethics Review Committee (reference: ID-016). In line with ethical requirements, all participants were provided a participant information sheet that detailed the aims of the study, issues of consent, confidentiality, voluntary participation and the right to withdraw at any time. Informed consent was obtained from participants and to ensure confidentiality, all responses were anonymised.
Results
A total of 30 participants were recruited from 14 London boroughs. Their countries of origin were Zimbabwe, Uganda, Cameroon, South Africa, Ghana, Republic of Congo, Nigeria, Congo Brazzaville and Guinea Bissau. Participants' ages ranged from 29–45 years old and they had a median of 2.5 children. The participants predominantly worked in the health and social care sector as social workers, nurses, support workers and healthcare assistants, apart from those employed in the financial sector.
The findings were grouped into four main themes: constipation, anaemia, helminth infections, no adverse health experiences.
Constipation: drinking ‘lots of water’, green juice and laxatives
Constipation was the most reported adverse health experience attributed to clay ingestion during pregnancy. Two of the participants relied on drinking a lot of water, as well as vegetable juice, to mitigate this.
‘The downside of me eating clay was constipation. I experienced … quite bad constipation. I would drink lots of water and fruit and things like that. But I will still have the clay, and I will still have constipation. And I know that when I eat the clay, I will have constipation and when I don't, my bowels are ok. But
I kind of bear with the consequences and still eat it anyway’. P6, Ghanian
‘If I didn't have enough vegetables in my body, then I'll get constipated, so I made sure I drank lots of water … I had lots of vegetables to avoid constipation. With t[clay ingestion], you would have to make sure you have your green juices like spinach and kale, you just blend all that together and drink it first and then eat your clay… that way, you are safe’. P14, South African
In some cases, participants experienced severe constipation that required medical intervention in the form of laxatives.
‘Always I had constipation. I could go to toilet after 5 days or 1 week [after ingesting clay], but normally I go after 2 days or 3 days, that's my way. Now when I was taking clay, I was going after 5 days, and I was taking laxatives which I got from the hospital to go to toilet’. P12, Congolese
The amount of clay ingested appeared to determine the severity of constipation experienced.
‘I will say that eating clay makes it very difficult for you to go to the toilet. I know about that as I could never go. So sometimes when I eat it, I have to take laxatives just to ease my stools … Maybe because of the amount that I was eating as I said, I was eating nonstop and as much as I can and as much, I could see [find] it’. P13, Cameroonian
Another participant reported changes in stool colour, as well as having to rely on a water enema.
‘The only bad effects were constipation. Sometimes I'm not going to do number two [open bowels]. I would use … a pump [constipation pump/enema], you put warm water and then you put it on your back passage … that's to help … sometimes the colour was grey. [Clay] changed the colour’. P5, Congolese
However, not all participants who encountered severe constipation continued with clay ingestion. One participant reported stopping because of the pain caused by straining and rectal bleeding, despite using laxatives.
‘My own thing was the severe constipation. I had to stop. Because it was quite severe … I had to go weeks without going. When I go, it's literally pushing, I had to even take laxatives at some point, and it was hurting to the point where there was blood, so I had to stop’. P22, Cameroonian
Some participants reported relying on traditional herbs mixed with clay to mitigate constipation.
‘The only problem is that it causes constipation, that's why you need to eat the [clay] mixed with herbs in the morning, because the herbs help you to flash out everything. The rest of the day you can have your clay anytime’. P11, Ugandan
However, for some, constipation was only a problem if ingested to excess. When taken in moderation, there were no adverse issues.
‘I too know [constipation] is a side effect, but everything must be consumed with moderation. If you eat anything with exaggeration, it has side effects. Even ordinary water, if you drink too much of water, you still have issues. So, if we eat anything in large quantities its harmful, but right quantity it's not’. P3, Zimbabwean
Iron deficiency anaemia: ‘where has your blood gone?’
Some participants who reported severe constipation also reported experiencing anaemia. One participant stopped clay ingestion after a blood transfusion.
‘[Clay ingestion] can be dangerous in terms [of] causing constipation. I would go to different markets in London looking for clay. And when I find where it is, I will buy like 12 kg … I would carry it in my pocket to work. I became very anaemic … And when I had a blood test … the doctor came in, he said “where has your blood gone?”, so I had to have units of blood, but I have my clay in my pocket … I never ate it after that’. P27, Bissau-Guinean
A Zimbabwean participant experienced constipation, severe back pain and reduced iron levels requiring iron infusion near the end of her pregnancy.
‘I decided to eat [clay] only when I was really craving for it because I felt it was too much … I was suffering from constipation, I used to open my bowels every other day, but I would go for 5 days [without] … I had a really bad back pain and when I go, I would strain in the toilet … my iron levels were not good, and I ended up having iron infusion [intravenous iron therapy] … that was nearer the end of my pregnancy’. P4, Zimbabwean
The larger the quantities ingested, the more severe constipation and risk of anaemia that required medical intervention.
Helminth infections
Helminth infections were also reported by some participants. One participant had a long history of clay ingestion before pregnancy.
‘Before I was pregnant, I used to have intestinal worms … I used to have a lot of parasites [from clay ingestion] … It's more of the parasites, that's the danger when you eat the clay… I met a lady from my country, who also eats clay a lot. She told me she put it in the oven at high temperatures to kill the parasites. I never got that information until I met her. P20, Cameroonian
While subjecting clay to high temperatures was used to mitigate helminth infection, persistent ingestion was reportedly associated with more adverse health effects experiences.
No adverse health experiences
Despite most participants reporting experiences of constipation, anaemia and, less frequently, helminth infections, a few participants reported not experiencing any adverse health experiences they perceived to be linked to clay ingestion.
‘If it's something our parents ate, and we ate it … It has never affected anyone … I haven't experienced any health problems and in our community, I have no experience of health issues [from clay ingestion]. Some just say that it is not good for you’. P9, Congolese
One participant drew comparisons with people who were not observing COVID-19 health messages during the pandemic.
‘For me, none [adverse health experiences] at all. It's like these days of coronavirus, I see a lot of all these junkies, they don't wear face masks, they don't wash their hands, but they are very strong, they don't have coronavirus. So, it's the same thing like [clay ingestion], we are talking about, since I have been having [clay], I have never had even headache or stomachache’. P23, Nigerian
Discussion
This study explored the experiences of Black African women in London who ingested clay during their pregnancy. The most common adverse health experiences reported by the participants were constipation, of varying severity, anaemia and, in some cases, helminth infections. A small number of participants experienced no adverse effects at all.
Constipation
Most participants reported experiencing constipation, which they associated with clay ingestion. Some experienced severe cases that led to straining and rectal bleeding during bowel movements. However, pregnancy is a well-known risk factor for constipation (Kuronen et al, 2021), which is the second most prevalent lower gastrointestinal symptom in pregnancy (Zielinski et al, 2015). Reasons for this include elevated progesterone levels during pregnancy (Müller-Lissner et al, 2005), which is known to restrict gastric bowel movement (Hakim et al, 2024), as well as lifestyle factors, such as lack of adequate exercise, insufficient water intake, low dietary intake of fibre-rich food as well as drug intake (Fan et al, 2020). Given the known association between pregnancy and constipation, participants' experiences cannot be solely attributed to clay ingestion.
Despite this, it is noteworthy that some participants reported differences in bowel movements before and after clay ingestion. In cases where clay ingestion was either stopped or drastically reduced because of the severity of constipation, positive outcomes in terms of bowel movement were reported. This suggests that in some cases, clay ingestion was a contributing factor. This resonates with Young et al's (2010) findings among Tanzanian pregnant women in Zanzibar, which sought to determine an association between pica and anaemia and gastrointestinal distress. Their findings showed that a significantly higher proportion of women who had eaten clay in pregnancy experienced constipation and abdominal pain than those who had not (Young et al, 2010).
Other than reducing or stopping clay ingestion because of constipation, participants in the present study also reported engaging in self-help methods, such as increasing fibre intake (vegetables and fruits) and drinking plenty of water, which are both recommended by the NHS (2024) for tackling constipation during pregnancy. While some participants reported mitigating constipation by first taking blended vegetables, described as ‘green juice’, followed by clay ingestion, some relied on taking clay mixed with traditional herbs.
In cases where applied self-help measures failed, and clay ingestion was neither reduced nor stopped, participants sought medical interventions in the form laxatives and constipation pumps for relief. While no formal diagnostic criteria were used in this study, the severity of self-reported constipation appeared linked to quantities ingested. Some participants knew the consequences and carried on with clay ingestion, suggesting that the perceived benefits, such as quelling nausea and improving appetite, among others (Madziva et al, 2024), outweighed the drawbacks. While laxatives are effective in reliving constipation, over-use can cause medical complications resulting from chronic diarrhoea and electrolyte disturbances (Roerig et al, 2010). Women may not be aware of these potential risks.
Anaemia
Among participants who reported severe constipation, some experienced iron deficiency anaemia and needed medical interventions, such as a blood transfusion or iron infusion. Iron deficient anaemia during pregnancy is a concerning public health issue, affecting 37% of pregnant women aged 15–49 years old (WHO, 2023a). Approximately 30% of non-pregnant women of the same age are affected globally (WHO, 2023a), with an average of 17% in high-income countries and 42% in low-income countries (Stevens et al, 2022).
Genetic blood disorders, nutrition deficiencies, infections (such as intestinal helminths) and inflammatory diseases are frequently cited as reasons for anaemia (Chaparro and Suchdev, 2019; Stevens et al, 2022). During pregnancy, the body requires more iron than usual for the baby's growth and brain development (Miller, 2013). However, the role of clay ingestion in iron deficient anaemia during pregnancy should not be overlooked. While evidence points to a strong negative association between clay ingestion and impaired iron absorption (Geissler et al, 1998; Nchito et al, 2004; Young, 2007; Njiru et al, 2011), some clays are known to provide iron along with other minerals, such as potassium, calcium and zinc (Kortei et al, 2019). However, while these minerals may exist in clay, they coexist with toxic elements associated with varying risks (Kortei et al, 2019).
A study by Churchill et al (2022) examined data from 860 pregnancies and births derived from 86 maternity units in the UK and Ireland. They found an overall prevalence of iron deficient anaemia during pregnancy of 30.4%, with women from minority groups being more likely to be anaemic. Anaemia during pregnancy is associated with poor maternal and birth outcomes, such as low birth weight, preterm birth and increased risk of maternal mortality (WHO, 2023a), which are more prevalent in ethnic minority groups (Office for National Statistics, 2021). Therefore, the presentation of constipation or iron deficient anaemia in clinical encounters in this group presents an opportunity to engage pregnant women regarding clay ingestion, as part of a wider dialogue on healthy nutrition dietary intake.
Helminth infections
Parasitic worms, or helminths, feed on a host's blood and cause chronic intestinal blood loss, particularly in adolescent girls and women of reproduction age, resulting in anaemia (WHO, 2023b). Helminth infections attributed to clay ingestion were rarely reported by participants in this study. However, the proportion of women ingesting clay during pregnancy affected by helminth infections in some regions in Ethiopia have been identified at 20% (Getachew et al, 2021), 51% (Gebrehiwet et al, 2019) and 71% (Feleke and Jember, 2018). While researchers acknowledged other influencing variables pertaining to hygiene, clay ingestion significantly increased infection risk, with variations attributed to factors such as hygiene in clay handling and the source, type and ingestion method. Subjecting clay to high temperatures is known to kill off parasitic infections, because of the lack of moisture required for survival and embryonation (Shinondo and Mwikuma, 2009). While this may be the case, this does not mitigate risks associated with toxicity.
No adverse experiences
A number of participants reported that they did not experience any adverse health issues in relation to clay ingestion. Their confidence in this practice was boosted by the perceived positive experiences of previous generations, as well as others in the community, who engaged in the practice. This strengthened the participants' belief that clay ingestion was risk free. However, some of the associated adverse effects may not be immediate and obvious, such as low birth weight, impaired neurodevelopment (with implications for IQ and attention span reduction), antisocial behaviour and reduced educational attainment in children (Al-Rmalli, 2010; Reeuwijk et al, 2013; Nyanza et al, 2014; Lars et al, 2015; Frazzoli et al, 2016; Gundacker et al, 2017; WHO, 2021b).
Implications for practice
It is important to engage women regarding the risks of clay ingestion. Public Health England's (2013) guidance is that ‘if you discover that your patient is using Calabash chalk, they should be dissuaded from doing so’; this approach may not be effective. Using the patient explanatory model, clinicians can elicit in-depth information from patients about beliefs, personal and social meanings attached to their illness and symptoms (Kleinman et al, 1978). However, in the absence of illness or symptoms that patients may attribute to clay ingestion, it can be challenging for clinicians to ‘discover’ whether a woman is engaging in these practices in routine clinical encounters, such as the booking appointment. Women are unlikely to disclose clay ingestion in clinical encounters (Madziva and Chinouya, 2020) because of the perception of it being shameful behaviour (Njiru et al, 2011). The lack of ‘discovery’ of those engaging in the practice and non-disclosure in clinical encounters perpetuates the taboo associated with clay ingestion through silence.
A proactive approach that aims to engage women regarding the short- and long-term risks outside of pregnancy related clinical encounters is required. Public health practitioners and authorities such as the UK Health Security Agency would do well to collaborate with community groups in designing bottom up, culturally sensitive interventions. Tackling clay ingestion in the community will go some way to informing clinical interventions, as well as improving effectiveness. As posited by Chinouya (2004), African communities can be engaged in public health initiatives if they feel that they ‘own’ the problem and are given the platform to design interventions that sit well in their diverse cultures. Social capital is a strength of community groups because of the presence of relationships of mutuality and trust, which can be tapped to advance health and wellbeing agendas (Brinkerhoff, 2002), particularly among migrant communities. The inclusion of community groups in clay ingestion related interventions would tap into this area of strength.
Limitations
This study relied on self-reported experiences, mainly from memory of events during pregnancy before interviews, which has recall bias implications. This was mitigated by recruiting women who had ingested clay during pregnancy in the last 10 years. The majority had young children and their experiences spanned across multiple pregnancies, which shortened the recall period. External bias through social desirability was drastically reduced as researchers were partial insiders to the practice through a shared African heritage.
Conclusions
This study explored women's self-reported adverse health experiences attributed to clay ingestion and adapted mitigating measures to inform public health interventions. Participants reported experiencing constipation, iron deficiency anaemia and, less commonly, helminth infections. Reported remedies for constipation included increased fibre and water intake and a traditional mixture of herbs and clay. In severe cases, medical interventions were used. A few participants confidently reported not experiencing any adverse health issues. Given that some adverse effects associated with clay ingestion, especially with regards to children, may not be immediately obvious, community-led interventions that engage women regarding potential health risks should be prioritised.