Pregnancy related cultural food practices among Pakistani women in the UK: a qualitative study

Migrant communities preserve ethnic food patterns in order to maintain their cultural identities, especially in crucial times like pregnancy (Vallianatos and Raine, 2008; Terragni et al, 2014; Popovic-Lipovac and Strasser, 2015). Women's consciousness about their diet during pregnancy, out of concern for the baby's health as well as naturally occurring cravings for particular foods (Forbes and Graham, 2018), has developed globally. Cultural food habits significantly influence women's food choices during pregnancy (D'Souza et al, 2016). For example, South Asian women continue to follow their traditional food habits during pregnancy (Withers et al, 2018). The South-Asian diaspora around the world, such as in Canada (Higginbottom et al, 2014; Davey and Vallianatos, 2018), the US (Cousik and Gail Hickey, 2016), Portugal (Coutinho et al, 2014), the UK (Yeasmin and Regmi, 2013) and Norway (Mellin-Olsen and Wandel, 2005) replicate this trend of sticking to tradition.

People originating from Pakistan are the second largest immigrant group in the UK and comprise 2% of the total population; an estimated 1 174 983 people (Office of National Statistics, 2011). Ethnicity has been known to influence birth outcomes (D'Souza et al, 2016), and maternal nutritional habits affect the health of the fetus and babies. James-McAlpine et al (2020) suggested that the lack of emphasis on food that is conveniently available, together with an inclination towards traditionally prepared foods, might be the cause of low-average birth weights prevalent in this culturally and linguistically diverse group of women. The researchers concluded that the dietary practices of culturally and linguistically diverse women result in substandard birth outcomes. However, offering a different perspective Page (2004) has highlighted that the better nutritional intake of Mexican migrants and/or immigrants in the US led to better birth outcomes for this group than for women of the destination country.

For better or worse, the birth outcomes of immigrant women differ from those of the destination country's women. After immigration, women tend to follow the traditional dietary beliefs pertaining to pregnancy; so if the traditional dietary practices of their culture are healthy, the birth outcome remains positive in the destination country and vice versa. Khadduri et al (2008) highlighted that in Pakistan, the antenatal maternal diet was suboptimal. Women were inclined to eat less to prevent their babies from growing bigger as it was believed a large baby would produce complications during delivery. Poor maternal diet may lead to poor birth outcomes (Bundey et al, 1991) which might have been the case with Pakistani women immigrants in the UK.

Pakistani immigrant women engage in a variety of cultural food practices during and post pregnancy, such as special cultural meals (eg a dish made of clarified butter, wheat flour and sugar), which are prepared a) to provide the pregnant woman with strength and b) to nourish the unborn baby. In addition, a period of 40 days is observed postpartum so that women can avoid what would be perceived as the ‘evil eye’(Ghilzai and Kanwal, 2016). Further, Pakistani immigrant women also eat fat and protein-rich foods to regain strength after delivery and during the postpartum period (Qureshi et al, 2016). In addition, a form of ‘pica’ was also observed by the participants. Pica is the practice by pregnant women of consistently eating non-nutritional food items (Simpson et al, 2000; Mortazavi and Mohammadi, 2010; Bhatia and Kaur, 2014), such as charcoal (López et al, 2012), clay and ice (Rabel et al, 2016).

Knowledge of the dietary practices of immigrant Pakistani women takes the medical practitioners halfway in developing culturally sensitive interventions, where a greater emphasis is required on the ‘meaning-making’ process of these practices and the cultural significance of the multiple sources that act as their reinforcement. Previous studies have placed the research into food practices either in the ‘migration’ (D'Souza et al, 2016) or ‘acculturation’ (Qureshi et al, 2016) frameworks. The sociological perspective of exploring the intricacies of the ‘meaning-making’ process of these practices remains understudied, particularly for this Pakistani immigrant community in the UK. Thus, the present study aims to uncover the complex cultural processes through which these practices are produced, instilled and perpetuated in the immigrant Pakistani women living in the UK. By understanding these processes, a multi-faceted and multi-targeted cultural competence can be developed to deal with this large number of immigrant women during a crucial period of their lives.

Methods and design

Epistemologically, the study draws on social construction to explore how cultural food habits are collectively constructed within the social, cultural and religious contexts of UK-based Pakistani community actions and interactions (Berger and Luckmann, 1967; O'Reilly, 2012). Social construction is complementary to the interpretivist paradigm which allows deeper insights into the processes in a social setting that motivate participants' actions and interactions (Benton and Craib, 2011; Silverman, 2011). In other words, while understanding how food patterns are socially constructed, the authors collected data from the participants, and then interpreted the meanings that participants attach to their food behaviour during pregnancy; thereby addressing the aim of this study. Indeed, what is understood or identified to be ‘a belief or practice’ is constituted via social constructs of pre-existing knowledge and is subject to change under different social, cultural, political and historical conditions (Bourdieu, 1977).

The researchers carrying out this study recruited first-generation Pakistani immigrant women through a voluntary organisation working with ethnic minorities; specifically, with people from Pakistan. As of 2019, Pakistan was among the top three countries of origin for UK immigrants, only exceeded by India and Poland (Rienzo and Vargos-Silva, 2020). Thus, first-generation immigrants constitute a sizeable group in the UK, facing culturally embedded challenges associated with the process of immigration (Thompson and Begum, 2005). Hayes et al (2011) suggest that risk factors associated with negative outcomes are much worse for first-generation women, as compared to their second-generation counterparts. The UK-born ethnic minority women view themselves as familiar with the healthcare system due to them having been born in the country (Puthussery et al, 2008).

The lack of English-language proficiency of the first-generation immigrant women further limits their good experience of antenatal care in the UK (Higginbottom et al, 2019). That linguistic deficit creates hurdles in understanding the prescriptions from the health professionals and also creates a cultural distance between giver and receiver in providing support. Health professionals report that language proficiency and awareness of the healthcare system within the UK-born ethnic minorities created ease in providing medical support and advice (Puthussery et al, 2010). This familiarity is absent in many first-generation Pakistani immigrants. Christmas and Barker (2014) have highlighted that the level of bicultural orientation, derived from the concept of acculturation, was higher in the second-generation immigrants, as compared to their first-generation counterparts. It was suggested that this variation in bicultural orientation is due to the fact the first-generation immigrants do not readily or easily assimilate into the culture of the host country. All these reasons make first-generation immigrants a unique community with distinct challenges.

The present study focused on first-generation Pakistani women who experienced at least one pregnancy. A total of 10 first-generation immigrant women were recruited through a voluntary organisation by convenience sampling technique after which they were interviewed. Recruitment began with the distribution of the research information sheet, written in the appropriate language, which contained all the details about the research, informed consent, and confidentiality. The women from the ages of 30–40 signed the consent from and agreed to participate in the research. The consent form was presented in ‘Urdu’, the native language of the respondents, and was verbally explained to them by the Urdu-speaking researcher in their native language, as the participants did not speak English. The respondents then signed the form by writing their names in their native language. The form ensured the participants that the information they share during the interview will be anonymised and their real names will not be used while reporting the data. The names used in the section of ‘findings’ are therefore pseudonyms. Communication with the respondents took place entirely in the native language of those respondents because, as noted above, one of the researchers had proficiency in the use of the native language.

Of the 10 respondents, three experienced their pregnancy in the past few years (thus they were reflecting on their recent past pregnancy in the UK) and seven were pregnant at the time of the interview. Also the participants were only able to read or write at a very basic level in their native language.

Ethical clearance for this research was granted from the School of Sociology and Social Policy, University of Nottingham, and administrative consent was obtained from the coordinator at the voluntary organisation.

The researchers obtained the telephone number of an on-site counsellor from the voluntary organisation coordinator and this information was shared with the participants. A Pakistani community link worker from the voluntary organisation was also present during the interviews. As one of the authors was able to communicate in the native language of the participants, there were no linguistic or cross-cultural problems evident in the interview process (Sands, 2007; Squires, 2020).

The semi-structured interviews, which lasted between 20–30 minutes, were conducted in a local community centre in the presence of the female Pakistani community link worker from the voluntary organisation. The link worker was present in the capacity of a facilitator. Her presence built confidence in the women to respond openly to the interview questions. As the topic focused mainly on food practices, it was not considered as ‘too sensitive’ or private to be influenced by the presence of the link worker. Although the duration of the interview was not more than half an hour, the data obtained were detailed and captured some useful perspectives from the participants' views which enabled the researchers to develop deep and meaningful interpretations of the information provided.

Data analysis

The data were translated verbatim into English by the first author who is from Pakistan. An inductive thematic analysis was performed on the interview transcripts (Braun and Clarke, 2006). The thematic analysis followed three stages 1) the identification of common phrases in the data which were referred to as ‘codes’ 2) clusters of codes which were referred to as ‘categories’ and 3) themes which were short titles from combined categories (Braun and Clarke, 2006). Table 1 summarises the themes and codes.

Findings

Classification of food

The participants used ‘hot’ and ‘cold’ for classifying food choices, rather than using the vocabulary of modern scientific nutritional values (protein, carbohydrates, vitamins). This classification was based on the perceived effect of specific foods on the body of pregnant women. The reasons provided for this classification were related to the biological consequences that such foods were believed to produce.

Explaining ‘hot’ and ‘cold’ classifications of foods, Zareena Begum said that:

‘Fish, eggs, meat, nuts and some fruits like mango and dates produce heat in the body and increase the body temperature. While foods like apples, grapes give coolness to the body.’

The participant added a temporal dimension to her classification while discussing the anatomy of pain amidst the delivery phase. She continued and shared her understanding on the practice with further details:

‘The “hot” foods should be strictly avoided in the first and second trimester, as these foods increase heat in the body and cause miscarriage. However, if a woman starts eating these “hot” foods before one month of the pregnancy, these foods will have a good effect in terms of labour during delivery. Eating “hot” foods in the third trimester opens and stretches the muscles of the pregnant woman. So, it becomes less painful during delivery. During this time, “cold” foods are not good for the pregnant women. “Cold” foods expand the muscles and delivering the baby becomes difficult and painful. The woman may have to go through an operation which is more painful and not good for the health of the mother later on in her life.’

Food with symbolic meanings

The process of attaching symbolic meanings to the food items is a global cultural practice. This theme shows that the participants had different symbolic meanings for different foods. The most pronounced idea highlighted was the creation and perpetuation of white colour stereotypes and their relation to the archetypal concept of beauty. Shaheen Akhter explained:

‘If a pregnant woman used foods which have white colours such as milk, it is sure that the colour of the baby will be white (authors' note: in Pakistan, white colour of the skin is appreciated/desired in terms of its beauty and as a sign of good health). Using black coloured food during pregnancy, such as tea, will bring black colour for the baby … from inside, the colour of watermelon is red, so, eating watermelon increases the blood in the body which is good for health.’

Certain foods bear religious symbolism in the way they are made, the way they are eaten or both. Rendering food to be sacred and having divine properties was a way of organising social relations. The concept of sacredness will ascend to become a symbol of one's identity. Rashida further elaborated:

‘Our Holy Prophet has used honey which shows that it is pious and good food. Using honey is good in the third trimester. It will bring blessings for the mother and the baby.’

The above comments clearly shows that the varied symbolic meanings related to social, cultural or religious ideals which are attached to foods significantly affect the food choices of Pakistani women in pregnancy.

Medico-cultural conflict

‘Medico-cultural conflict’ is a term used when there are conflicting views and practices about the phenomenon of disease and illness, specifically between the biological model of the disease, and the social and cultural model of the illness (Zakar, 1998). Participants recounted feeling conflicted when they had to decide whether to use the modern medical treatment or listen to the alternative advice from their family members and in-laws, particularly the woman's mother-in-law. This alternative advice created an overwhelming atmosphere of ambiguity and fear. Zareena Begum illustrates this point:

‘The doctor will advise you to take multi-vitamin tablets, whereas my mother-in-law strictly prohibited me from using such tablets during pregnancy … these tablets are made of chemicals which are full of poison… it may kill the delicate baby in the womb. I got confused between the understandings of my mother-in-law and the doctor's advice.’

This conflict was also evident in the quantity of food to be consumed during pregnancy. The physiological changes in pregnancy call for extra nutrients and energy to meet: a) the demands of an expanding blood supply, b) the growth of maternal tissue, c) a developing fetus, d) loss of maternal tissues at birth and e) preparation for lactation. It was found that all the women reduced their food intake because of a belief that an increase in the intake of food would increase the size of the baby, making it difficult to deliver. Asifa reflected this belief:

‘…doctors and nurses suggest that pregnant women should eat more, compared to her normal eating. But our mothers, mothers-in-law, and some friends said if you eat more, the size of the baby will be bigger and it will be difficult to deliver, and the delivery will become painful, and you may die during labour. Therefore, sometimes I do not eat even though I am feeling hungry because of the fear of delivering a bigger baby.’

Sources and compliance of food practices

Food patterns during pregnancy are acquired through socialisation within the woman's cultural group (Pakistani), mainly on the advice of mothers (in law). Nasira Bashir exemplified this issue:

‘When I got pregnant, my mother gave me a long list of things to do and not to do. My mother told me about eating and resting along with praying to God regularly … Whenever I telephoned my mother, my mother used to first ask about my daily routine and health and this continued until my son was two years old.’

Nasira's account above suggests the expected strict compliance of cultural food practices during pregnancy. Moreover, the surveillance and control of the family network was another challenge highlighted by the participants. They seem to be succumbing to the prevalent cultural practices that are rooted in the traditional power of the family members. Rashida Bibi, living with her mother-in-law, comments:

‘All these things about eating are told to me by my mother-in-law. Whenever I became pregnant, my mother-in-law used to check what I was eating. She regularly gave me advice in this regard and I have to obey her as she is older than me … disobeying her can create relationships problem in the family. And if something bad happens to me with regard to my health during pregnancy, I will be blamed and criticised in the family for not obeying my mother-in-law’

Rashida continued:

‘I think these cultural things are true. They are coming from generation to generation’.

Motherhood morality

The Pakistani women in this study readily classified food items in two categories: those good for their own health and those good for the health of their expected baby. However, almost all the women showed greater concern for the health of their expected baby than for themselves. Ayesha emphasised that:

‘A good mother is one who thinks of her baby first, in terms of health and food eating, and if a mother is careless in this she is not a good mother … she will be disrespected by her peers and family.’

Nasim, another participant, echoed Ayesha's views above and expressed her own views in terms of the child's rights and active motherhood by projecting herself as a saviour and having God-like property of being a cherisher, a creator. She says:

‘It is the obligation of the mother to not eat anything which can cause any kind of harm to the expected baby.’

Discussion

The present study aimed to understand a) the food habits of UK-based Pakistani women during pregnancy and b) the meanings attached to these food habits during pregnancy by the Pakistani-immigrant women. This study highlights the different socio-cultural practices of Pakistani women in the UK which influenced their pregnancy related food choices. The study found that ‘hot’ and ‘cold’ or ‘good’ and ‘bad’ foods are classified by the pregnant Pakistani-immigrant women either according to the foods' perceived effect on their body or the socially constructed symbolic significance that is embedded in the Pakistani women's culture. With food practices being socially constructed cultural practice in Pakistani society (Berger and Luckman, 1973), advice on the dietary practices provided by the medical practitioners was mostly overshadowed by the advice of the elder women of the family, particularly the pregnant woman's mother-in-law and mother. Compliance with the cultural dietary practices was ensured internally by instilling a motherhood morality and externally by treating cultural dietary deviance with social disapproval.

D'Souza et al (2016) suggests that the ‘hot’ and ‘cold’ classification of food serves as the basis for food restrictions during pregnancy in many Asian countries. However, the present study has also noted ‘good’ and ‘bad’ classifications of food. To an extent, therefore, this study has identified an original classification of food in relation to the chosen population; information which was scarce in the existing literature. As such, this finding offers a significant benchmark for comparative examination of pregnancy related cultural food patterns in other immigrant communities within and outside the UK. In their most common usage, ‘good’ and ‘bad’ food classifications are used in Pakistani society to judge the moral standards and behaviour of individuals. The coining of ‘good’ and ‘bad’ lexicon in relation to food practices emphasises the need for further investigation. Indeed et al (2019) have argued that in order to promote healthy food choices, and design acceptable nutrition interventions, health professionals (including midwives) must fully understand how and why people classify the food they eat. Arrish et al (2017) have suggested that Australian midwives recognise the lack of knowledge of food choices of other cultures as a barrier to providing effective nutritional advice for their pregnant women clients.

The ‘hot’ and ‘cold’ food classification, and its perceived relationship with pregnancy, caused participants to avoid protein-rich foods, such as eggs, meat, fish and nuts in the first trimester. D'Souza et al (2016) found that migrant women in the UK and US observe traditional dietary customs during pregnancy, particularly regarding the prohibition of ‘hot’ foods.

The participants in this research unquestionably complied with cultural food practices during their informal socialisation in the family, as well as and with their peers, in order to be perceived as ‘good’ and ‘wise’ mothers by the rest of the family and the society. This compliance can also explain the medico-cultural conflict and why preference was given to the advice of the mothers-in-law over that coming from doctors (Zakar, 1998). Leung et al (2005) found a similar situation among Chinese women who often felt conflicted between the advice of doctors and that which was offered by senior community members. The adapted food ‘plate’ or diet for South Asian families should be developed by nutritionists in consultation with their female clients and later used by the midwives when discussing diet with South Asian women. In this way, culturally acceptable ‘food plates’ can be merged with medically approved diets and a long-lasting positive nutritional intervention can take place for South Asian women.

Generally, this study's participants were more concerned about the health of their unborn baby than their own health. Forbes and Graham (2018), in their research on exploring the reasons behind dietary changes that women make during pregnancy, found that one of the most powerful factors that contributed to good food practices during pregnancy was the maternal concern about the wellbeing of the baby and the role of motherhood. Similarly, Heisler and Ellis (2008) reported that mothers were expected to make sacrifices for the infant. Murphy (2000), who defines a ‘good mother’ as one who maximises physical and psychological outcomes for her child, suggested that in whatever ways mothers decide to feed their babies, they are expected to vigorously pursue infant feeding as a moral responsibility, or they will be criticised by their social network and the midwives attending them (Murphy, 1999).

The women interviewed could only verbally communicate in vernacular and therefore had major challenges regarding reading any UK-written material advising on maternal food choices provided by the midwives, thus they were less likely to encounter conflicting advice. When asked about their sources of information on food practices, they cited their mother-in-law or their mother. Studies have shown that women also receive advice from female relatives who help them navigate their pregnancy when they immigrate to the UK (Qureshi and Pacquiao, 2013; Yeasmin and Regmi, 2013; Cousik and Gail Hickey, 2016) and/or when such relatives visit from abroad for the birth of the baby (Cousik and Gail Hickey, 2016). However, Goodwin et al (2018) report that UK midwives working with Pakistani women perceive the involvement of female relatives as a barrier to forming meaningful relationships with the pregnant women. This impediment is mainly because the mothers-in-law dominates the consultation which results in conflicting nutritional information being aimed at the pregnant and confused mother-to-be.

In addition, a form of ‘pica’ was also observed by the participants. As noted above, ‘pica’ is a practice of consistently eating non-nutritional items (Mortazavi and Mohammadi, 2010; Bhatia and Kaur, 2014), such as charcoal (López et al, 2012), clay and ice (Rabel et al, 2016). Expectant mothers tend to eat non-food items recommended by elder women to give birth to a baby with fair skin which is a socially desirable complexion in the Pakistani community. Simpson et al (2000) highlighted that pregnant women, upon receiving such advice, consume non-food items during pregnancy. Pica is known to have poor birth outcomes and negatively affects the health of both the expectant mother and the unborn fetus (Khoushabi et al, 2014). Consuming non-nutritional, non-food items can have serious negative outcomes; as mentioned above having elders enforce this unhealthy practice makes it extremely difficult, if not impossible, for the expectant mother to refuse. This social pressure can and frequently does lead to the practice being perpetuated. As the cause of pica in the present study was associated with a ‘fair-skinned’ baby, it is important to understand the significance of this cultural ideal in order to develop a targeted intervention for the prevention of this practice.

Implications

The findings of this study indicate that the cultural food practices of pregnant Pakistani women in the UK are varied and greatly influenced by socio-cultural factors. These cultural practices dictate what women eat and what foods to avoid. Thus, there is a need to understand cultural diversity in relation to pregnancy related food practices before interventions are developed to change the dietary behaviour of ethnically diverse populations, particularly those where cultural practices are socially constructed and, as such, embedded in the community. Also, it is important for midwives who are providing care to women of Pakistani origin in the UK to be culturally competent, an attribute that is an important aspect of nursing and midwifery practice globally (Nursing and Midwifery Council, 2019). In other words, any strategy intended to change the dietary behaviour of pregnant Pakistani women should involve knowledge of that ethnic community, including interpersonal relationships with female relatives in families because food practices are socio-culturally contingent.

Limitations and recommendations

The present study highlighted important aspects of the pregnancy related cultural food practices of first-generation Pakistani women immigrants in the UK; however, the research is not without its limitations. Firstly, the researchers recognise the sampling limitations of the study, as most of the women were not in the desirable age bracket which was between 25–35 years. However, the participants provided rich and diverse data regarding the research topic and, as such, enabled the study to meet its aim.

Secondly, since the scope of the study was limited to recording in detail the perceptions of the broader research population (Pakistani women in the UK) regarding their food intake during pregnancy, the consequences of these food practices on the fetus or babies could not be covered in the present study. This study recruited participants from a single voluntary organisation, thereby limiting appropriate levels of diversity in the participants. In future, studies can be undertaken using a non-convenience sampling approach and involving community based samples to obtain respondents. Studies can also be conducted on second and third generations of Pakistani women in Western countries in order to understand their food practices during pregnancy. The study recommends a communication strategy which produces maternal, nutrition-related educational material in ‘native’ languages in order to inform non-indigenous pregnant women resident in the UK about healthy food practices.

Key points

• Food behaviours of Pakistani-immigrant women during pregnancy are influenced by their cultural and religious identities
• Motherhood morality contributed significantly to decision making surrounding food choices among the participants
• Interventions by midwives to change unhealthy food patterns of pregnant Pakistani women should align with the meanings that these women, and their significant others, attach to their food practices

CPD reflective questions

• How can we embed Pakistani food practices for pregnant women into the UK midwifery training programme?
• How might we engage with Pakistani mother-in-laws and other female family members to collaborate with UK midwives to develop a working relationship?
• Can the socially constructed food practices of Pakistani culture be taught to UK midwives to enable an understanding of additional nutritional needs of pregnant Pakistani women?
• Are student midwives sent on placements to settings where Pakistani women and other non-UK citizens engage in their food practices?
• What are the plans for including alternative food practices in the nursing and midwifery codes and government policies?