Sociodemographic characteristics of the study participants

Nine FGDs were held. Key informant interviews were conducted with 32 participants. Altogether, a total of 118 respondents participated in the nine FGDs (8–10 members for each discussion) and 32 KIIs. The final number of in-depth interviews and FGDs conducted was established based on the level of information saturation, which was ascertained after transcribing the discussions of each day’s session by the research team.

The 118 study participants consisted of 86 pregnant women, 8 Rwodi of Ker Kal Kwaro Acholi, 7 health care providers, 9 former traditional birth attendants, 4 village health teams, and 4 spouses of pregnant women. The participants’ age groups ranged from 16 to 82 years old. Their educational status varied widely, i.e., ranging from no education to tertiary formal education. 95% of participants lived in rural areas, and 83.1% engaged in agriculture as their major occupation, except for health care providers and some ‘Rwodi’ (Table 1).

Table 1 Sociodemographic characteristics of respondents

Following rigorous reviews and in-depth analysis of the scripts, five key themes were identified:-

Main factors that determine food choices in the community.

Foods that are considered special to pregnant women and newborn babies.

Foods that are considered taboos in the Acholi community and the reasons linked to them.

Reasons underlying adherence to food taboos and misconceptions.

Misconceptions and other taboos during pregnancy in the Acholi community.

Main factors that determine food choices in the community

Participants were asked about their opinions regarding factors that determined food choices during pregnancy in their communities. Varied views were expressed to explain why some people chose what to eat and what not to eat. Most of the respondents, particularly pregnant women, TBAs, and health care providers, believed that most women have specific food preferences because of the existing medical conditions, cultural beliefs, level of income, availability of food items, prescribed menu, individual preference, state of pregnancy, and knowledge about food and nutrition. A KII participant, a traditional birth attendant, stated,

“……. for me I have ulcers and my doctor advised me not to consume sour food such as oranges, Malakwang, soda, and or eat beans…….”

Another TBA elaborated on how a household or individual’s economic status can influence which food to eat and what food to forgo.

“……. If you do not have money, there is no way you can eat the foods you like. Currently, with the current economic crisis and food insecurity, foods have become very expensive and scarce. You just have to eat whatever is available…….”

One KII participant added,

“…. the Acholi culture dictates what pregnant women should eat and what they shouldn’t. For example, women are banned from eating bush meat when they are pregnant. Thiskind of belief does not only restricts women from eating such food but also affects the entire household’s food choices.…….”

An FGD participant pregnant woman indicated,

“…… The pregnancy period can be a very confusing moment in a woman’s life, especially in the first and second trimesters. I almost detested all foods in my first three months of pregnancy with my second born. Most often, a simple smell of certain food would make me vomit everything from my stomach….”

Another KII participant, a health care provider, associated food preference with the education of the woman. She explained that knowledge about nutrition contributes greatly to determining what one should eat.

“……. If you know the food groups that are good for your health, for example, when you are sick or pregnant, you will rightly choose the types of food to include on the menu…….”

Similarly, another FGD participant pregnant woman reckoned,

“……. Food availability is a major reason for differing food choices. You might have cash, but if the food you want to buy is not available in the local market, what can you do? You will have to change your plan and look for alternatives. For me, if I want to eat fish and I don’t find it in the market, I go for silverfish….”

Foods that are considered special to pregnant women and newborn babies

Pregnant women and their spouses, healthcare providers, TBAs, and VHTs believed that some foods are ‘special’ for expectant mothers and their newborns. For the pregnant mothers, foods such as meat; leafy vegetables (pumpkin leaves, boo, cabbage, Malakwang, Akeyo); silverfish; millet food; soybean porridge; carrots; milk; fruits (pawpaw; Avocado); and pumpkin leaves were reported as special and should be consumed as much as possible. These foods are perceived to fatten and offer general nourishment to the baby while in the womb. Malakwang is consumed specifically to enhance milk let-down during breastfeeding.

For newborns, breast milk is given exclusively in the first two months. Some mothers, however, introduce sugar solution, black tea, and soup immediately after birth. From 3 months onwards, the infants are given soybean, millet, and maize flour porridge mixed with sesame or groundnut paste (peanut butter).

A pregnant mother, a participant of an FGD, indicated,

“……. when my third born was in the womb, I ate a lot of pumpkin leaves, and the baby came out very big that I almost failed to deliver normally…….”

A KII participant, one of the traditional birth attendants, also expressed her experience with her first-born son. She stated,

“…….Pasted foodsare miracle meals during pregnancy. In my first pregnancy, my mother-in-law advised me to include pasted beans,Malakwang, Boo, Akeyo, porridge, and meat in my diet. I did that, and the outcome was amazing when I gave birth. My son came out all glittering and very big…….”

Additionally, another KII participant, a health care provider, stressed that maternal nutrition during pregnancy should be given careful attention. Meal planning should include the different food groups available within the community. These foods should be able to provide essential nutrients for nourishing both the mother and the growing fetus. Thus, foods rich in carbohydrates, proteins, minerals, and vitamins should be included in the daily diet. Micronutrient supplementation, especially of iron and folic acid, is equally important. These can be started immediately before the woman conceives and continued during pregnancy until 3 months postpartum. For infants younger than 6 months, exclusive breastfeeding is advised. The participant added,

“……. We often advise women when they come for their antenatal visit to eat a balanced diet. Those who cannot afford certain foods can opt for alternatives; for example, if fish are expensive, we advise them to buy silverfish. Those who have land can establish a small kitchen garden to grow vegetables. We also give these women combined iron and folic acid tablets and encourage them to continue intake throughout their pregnancy and after they have given birth. Our routine advice to mothers regarding infant feeding is that infants below 6 months should not be given solid foods. The child should be fed entirely on breast milk except for syrups and vitamins. Breastfeeding should continue until the baby reaches two years….”

Foods that are considered taboos in the Acholi community and the reasons linked to them

FGD and KII participants indicated that certain foods are taboos in some Acholi clans and should not be eaten or even touched by pregnant women. Overall, 14 foods are held as taboos across the Acholi community for various reasons (Table 2). FGD and KII participants mentioned avoidance of high carbohydrate foods, especially sugarcane and honey, during pregnancy. Consumption of these foods was viewed to be associated with generalized fetal skin fissures and having a newborn with excessive birth weight, which was believed to lead to a difficult birth. A KII participant, a TBA, stated,

“……. My son almost killed me if I was not an experienced TBA. He was too big because I ate too much honey in the last three months of my pregnancy. I got a lot of tears during delivery….”

Table 2 Summary of foods considered taboos during pregnancy and reasons attached to them, Acholi subregion, Northern Uganda, 2022

Similarly, an FGD participant, a pregnant mother, added,

“…My own brother’s son was born with generalized skin cracks and tears when the mother consumed sugarcane during her pregnancy. It took some time for the wounds to completely heal. In fact, the boy bled too much at the time of his birth that we thought he would die…….“

The consumption of protein-rich and nutrient-dense foods such as offal, smoked meat, fish, chicken, goat meat, and wild meat is restricted during pregnancy for various reasons depending on the clan. Many of the participants believed that eating offal and chicken skin, particularly during advanced pregnancy, causes ‘baby strangling’, a condition in which the umbilical cord ties around the baby’s neck, leading to choking. Handling or eating smoked meat and fish a few weeks prior to childbirth is feared to cause infection of the umbilical cord after the baby is born. The perception behind barring women from eating goat meat and chicken is basically to show respect for the men. One of the KII participants, Rwot, emphasized,

“………In Acholi, women are banned from eating goat and chicken because these foods are very small whenever cooked and so served only to the men. Usually, more than one meal is prepared on the day a chicken or goat is cooked. The women eat the other foods while the meat is left for the men. This is a sign of respect that has been in practice from time immemorial…….”

Likewise, an FGD participant, a pregnant woman, commented,

“……… My neighbor ate goat’s offals in her pregnancy and her baby came out with the umbilical cord wrapped around the baby’s neck. On the day of her delivery, her husband had also bought some smoked meat. A few days later, the baby developed a serious infection on the umbilical cord stump…….”

Participants also reported that foods such as fruits, particularly oranges, lemons, passion fruits, mango, and tamarind, including some types of vegetables such as garden eggs (tula), ‘Lalaa’ (the bitter green leafy vegetable), and ‘Lamola’ (Hyptis spicigera), are considered taboo for women throughout the gestation period. When probed, participants disclosed various reasons attached to the ban on the consumption of these foods. The garden egg, which some people call the bitter eggplant and in the local language it is referred to as ‘Tula’, is known by some communities in Acholi to cause inflammation of the skin of the growing fetus. Lamola (Hyptis spicigera) is believed to cause fetal blindness, and consumption of ‘Lalaa’ is thought to cause impotence to the newborn. A few of the KII participants, TBAs, cited eating sour fruits and/or other foods to cause generalized fetal skin rashes. In a discussion to explain this, a Traditional Birth Attendant, KII participant affirmed that,

“……. it’s forbidden for a woman in my clan to consume anything sour during her pregnancy. Sour foods make the body of the baby look rough and unpleasant…….”

In the same tone, another TBA, KII participant, stated,

“……. If you want to lose the sight of your baby just eat ‘Lamola’ when you are pregnant. It happened to my aunt’s daughter; she was born blind. At first, no one knew what had happened to the eyes, but this was confirmed when the mother disclosed she ate ‘Lamola’ when the baby was still in the womb…….”

Many FGD and KII participants, particularly TBAs, Rwodi, and pregnant women, associated the consumption of raw or roasted groundnuts with the whitish plastered substance that normally appears on the baby immediately after delivery. On the other hand, certain types of wild edible mushrooms are believed to cause miscarriage, infertility in women, and fetal body sores. One of the Rwodi of Ker Kal Kwaro Acholi said,

“…… A ban on the consumption of mushrooms during pregnancy is unfamiliar in some clans in Acholi. This taboo is common to some specific clans. In some clan, the belief is so strong that when a woman consumes mushroom during pregnancy, she loses the fetus instantly or the mother never ever give birth again…….”

In contrast, a pregnant woman one of the FGD participants testified,

“……. I ate lots of raw and roasted groundnuts when I was pregnant with my 2-year-old son, but he came out clean on the day of his delivery. I think some things are simply misconceptions that should be abolished in this generation…….”

Reasons that underlie adherence to food taboos and misbeliefs

Based on the views expressed and submissions made by many of the respondents, the reasons that underlie adherence to food taboos can broadly be categorized into three categories, namely, cultural dictates, individual characteristics, and societal context.

Cultural dictates

It is apparently clear that every clan in Acholi has its own cultural beliefs that they hold so dearly, and it is expected that every member of the clan adheres to them. Failure to comply with the taboos tantamount to being thrown out as an outcast or facing grave consequences. When a man marries a woman, she is first allowed to stay with her mother-in-law for about a year before moving to her own house to start living independently. During this time, she is taken through the dos and don’ts of that family that she must follow. This kind of informal teaching continues for generations after generations. The message about taboo foods is usually passed to children from an informal setting called ‘wang oo’ (literally meaning the fireplace). One KII participant, a traditional birth attendant, testified,

“……. when I eloped, I first stayed with my mother-in-law for eight months. While I was with her, she groomed me into becoming a woman of the home. She told me never to eat meat before I was oriented. She also advised me never to eat mushrooms if I think I’m pregnant to avoid miscarriage…….”

To further support the claim, another FGD participant, a pregnant woman, added,

“……. Back in those days, my father used to tell us from ‘wang oo’ never to eat chicken when I’m married. He added that it was disrespectful for a woman to eat chicken. This got stacked in mind and up to now I still do not eat chicken….”

Individual characteristics

Some taboos are linked to spiritual attachment and/or appeasement. It was vividly expressed by many of the participants that some clans in Acholi have ‘jok’ (the spirit) that they respect. The ‘jok’ can befall any member of the clan. Usually, the spirit demands avoidance of certain foods, and failure to adhere to the wish of the spirit, the individual could face severe consequences. One KII participant, a TBA, expounded,

“……. The ‘jok koma’ (my spirit) does not allow me to eat any four-legged animals. When I eat it, I get paralyzed and develop sores all over my body. This started when I was still young and, in my life, I haven’t eaten any meat from animals with four legs. There was a day I accidentally ate beef from a wedding ceremony, I almost died, I completely became paralyzed, and people could not explain what was happening to me….”

Social dimensions

From the views expressed, certain taboos seem to be losing relevance, but societal pressure and influence appear to play a large role in holding people onto it. Society often expects adherence to preset norms without questioning. There were general concerns that elders, particularly older women, usually impose and/or dictate certain taboos on younger women. Adherence to some taboos was thus linked to fear of reprimand and rejection. One of the FGD participants, a pregnant woman, expressed,

“…….My mother-in-law told me his son would not take cows to our home if I indulged in eating meat. I asked myself how eating meat was related to my marriage…….”

Another KII participant, a TBA, added,

“………When I was a girl, my mother told me never to eat chicken if I wanted to be a respectful girl. She gave me an example of a girl in the neighborhood who was chased from her marital home for eating the gizzard of a chicken….”

Misbeliefs and other taboos during pregnancy in the Acholi community.

Respondents were further asked about their awareness regarding other taboos or misconceptions attached to pregnancy. Most of the KII and FGD participants expressed varied views pertaining to taboos that pregnant women should respect. A total of 9 issues were raised during interviews with key informants and discussions with the focus group participants (Table 3).

Table 3 Summary of other taboos/misbeliefs during pregnancy and reasons attached to them, Acholi subregion, Northern Uganda, 2022

Five out of nine taboos mentioned were linked to miscarriage. KII and FGD participants expressed that most of the Acholi taboos, especially those practiced during pregnancy, aim to protect the fetus. In support of these views, one of the Rwodi of Ker Kal Kwaro Acholi stated,

“……. in our culture, taboos during pregnancy are meant to protect the fetus from coming out preterm. People tend to adhere more to taboos than formal laws because of the immediate consequences associated with taboos. So we use taboos to shape behaviors that would harm lives and societies….”

Although in some clans these beliefs and taboos are still strongly held, the majority of the respondents think that the adherence to such things is waning in most Acholi communities. An FGD participant, a pregnant mother, and a KI respondent put it straight that,

“……. These things called taboos no longer work. Women held needles, sat on hides or skins, and ran over anthills, but nothing happened to them. We need to find a way of detaching ourselves from such attachments…….”

However, one of the spouses of a pregnant woman indicated,

“……It’s unfortunate that today’s generation is losing track of their culture. Taboo in some clans is alive, let no one deceive you that these things are outdated. A case in point, in the neighboring clan last year, a pregnant woman in the fourth month of pregnancy had a miscarriage because she walked over an anthill when she went to fetch firewood. It truly depends on the family one comes from…….”