CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 CreditsTMcan be earned in 2011. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.
Geophagy During Pregnancy in Africa:
A Literature Review
Haron Njiru, BSc, MPH,* Uriel Elchalal, MD, PhD,†
and Ora Paltiel, MDCM, MSc, FRCPR, PhD‡
*International Masters in Public Health Program, Hebrew University Braun School of Public Health,
Jerusalem, Israel; †Professor, Department of Obstetrics and Gynecology, Hadassah University Hospital,
Jerusalem, Israel; and ‡Professor, Department of Hematology, Hebrew University Hadassah School of Public
Health, Hadassah University Hospital, Jerusalem, Israel
Introduction. Geophagy is a form of pica characterized by craving and eating of soil. The main
materials ingested include anthill soils and soft stone. In this review, our objectives were to study the
prevalence of geophagy in pregnancy (GiP), establish the risk factors for GiP, assess the effects of GiP on
pregnancy outcomes, and recommend possible interventions for reducing GiP.
Prevalence. Geophagy among pregnant women is common in many cultures. In some African countries,
GiP prevalence of up to 84% has been observed. In Nigeria, the most populous country in Africa, the prevalence
of GiP is estimated at 50%. The practice has been associated with religious practice, culture, and famine.
Risks. It is postulated that GiP is due to micronutrient deficiencies, cultural influences, and gastroin-
testinal upsets. Despite their potential to supply micronutrients, soils interfere with bioavailability of
micronutrients leading to micronutrient deficiency and can also act as a pathway for ingestion of
geohelminths and heavy metals, putting woman and fetus at risk.
Gaps. Despite its association with anemia, pregnancy, and micronutrients, many antenatal care
guidelines or National guidelines on micronutrient deficiency control are silent on GiP. The guidelines
generally recommend iron supplementation and deworming of pregnant women as anemia control
measures. However, not all women seek antenatal services; hence, there is need for more innovative ways
of addressing micronutrient deficiencies in pregnancy.
Recommendations. It is imperative to enquire whether pregnant women are geophagous and dis-
courage geophagy, strengthen and expand the existing supplementation programs, and mandate flour
fortification to enhance population-wide iron supply and safer pregnancies.
Target Audience: Obstetricians & Gynecologists and Family Physicians.
Learning Objectives. After completing this CME activity, physicians should be better able to analyze
the prevalence of GiP, identify the risk factors for GiP, and assess the effects of GiP on pregnancy outcomes.
In addition to propose remedial interventions for reducing GiP.
Geophagy (also called geophagia) is a form of pica.
Pica is defined as the craving and subsequent purpo-
sive consumption of nonfood substances for more
than one month. There are many forms of pica, but
geophagy, the deliberate eating of soil or clay, is a
common form of pica. The tendency to eat soils
occurs mainly in childhood, during pregnancy, and
among persons suffering from undernutrition and
parasitic infestations. The strength of pica cravings
has been equated with those for tobacco, alcohol, and
A high prevalence of geophagy in pregnancy (GiP)
has been observed in sub-Saharan Africa with preg-
nant women citing nausea, vomiting, heart burn, and
www.obgynsurvey.com | 1
The authors, faculty and staff in a position to control the content of
this CME activity and their spouses/life partners (if any) have dis-
closed that they have no financial relationships with, or financial
interest in, any commercial organizations pertaining to this educa-
Correspondence requests to: Haron Njiru, BSc, MPH, POB
22150–00100, Nairobi, Kenya. E-mail: firstname.lastname@example.org.
Volume 66, Number 7
OBSTETRICAL AND GYNECOLOGICAL SURVEY
Copyright © 2011
by Lippincott Williams & Wilkins
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the need relief from stress, as reasons for engaging in
geophagy. For instance, nearly half of the pregnant
women and ?70% of school children in Kenya are
An analysis of common geophagy soils shows that
the average daily soil intake in geophagous pregnant
women provides an equivalent of 14% of the recom-
mended dietary allowance (RDA) of iron in preg-
nancy. Consequently, some studies have suggested
that geophagy may be an important mineral supple-
ment in resource-poor countries where iron deficien-
cies are common; others recommend disinfection of
geophagic materials to make geophagy a safe prac-
tice.4In contrast, despite the noted high mineral
content in the soils, geophagy can potentially reduce
bioavailability of dietary micronutrients, especially
iron, copper, and zinc.5Additionally, GiP has been
associated with anemia, Ascaris lumbricoides infec-
tion, and may also be a pathway for ingestion of
environmental soil contaminants and potentially
toxic trace elements, especially in industrialized ur-
ban areas where levels of heavy metals are likely to
Studies are not conclusive on whether GiP is
purely a risk factor or a risk marker for anemia. It
may be both. But with the noted high prevalence of
GiP in some African countries, and the association
between geophagy and micronutrient deficiencies
(including anemia), coupled with the potential for
chemical poisoning, there is a need to consider GiP
an indicator of high-risk pregnancy. This should lead
to possible strategies to reduce maternal and fetal
morbidity and mortality rates.
After reading this review, physicians will be able to
analyze the prevalence of GiP, establish the risk
factors for GiP, identify the effects of GiP on preg-
nancy outcomes, and recommend possible interven-
tions for reducing GiP. We reviewed the published
literature using electronic databases and geology and
anthropology books. The following key terms were
used in the search strategy: pica, geophagy or
geophagia, pregnancy, soil, clay, micronutrients,
Geophagy has been observed among people (and
animals) in all parts of the world since ancient times.
early as 1874, geophagy was a notable general habit
among both pregnant and nonpregnant Persian women.
The practice has been associated with religion, bless-
ings, sexual prowess, beauty, detoxification, preven-
tion of birthmarks, relaxation, and making babies
“slide easily” at birth. Others eat soil to fill the
stomach or merely for its bright colors, pleasant taste,
and smell. To those eating termite hills, the multitude
of ants symbolizes procreation, the social life of ants
symbolizes and reinforces the home concept, while
their underground home connects the eater with the
The slave trade, urbanization, and globalization were
instrumental in spreading the culture of geophagy to
different parts of the world. Incidentally, sale of clay is
common especially in urban areas and across country
borders. It is said that residents of Verona had to pay
Emperor Augustus a regular fee for using the soils of
Leucogaeum hill to make alica, a wheat porridge.6,7,10–12
In most African cultures, geophagy is culturally
accepted especially among children and pregnant
women. However, in modern literature and most
societies, human geophagy is reflected as a shameful
and highly suspect behavior limited to the deprived.
The result is that this common and less queried
phenomenon has been neglected by researchers and
Prevalence of Geophagy in Pregnancy
Although the incidence of geophagy is decreasing
in the world, the practice remains common in many
cultures with a significant proportion of women
(65.3%) engaging in geophagy before pregnancy and
46.7% during the second gestational trimester.13,14
The intensity of cravings is reported to be highest in
the first trimester compared with the third trimester
(43.6% and 5.4% of respondents, respectively), less
than 35% of the women have a craving throughout
pregnancy period.15The amount of geophagic mate-
rials consumed daily ranges from 41.5 to 54.2 g.16,17
Studies among pregnant women in selected develop-
ing countries reveal a GiP prevalence of between
14.5% and 84% (Fig. 1).
From these studies, it is evident that geophagy is a
common experience among pregnant women in dif-
ferent countries. It is likely that GiP is underreported
as evidenced by the Western Kenya survey where the
GiP prevalence among mothers attending antenatal
clinic was 21% lower than that reported in the com-
munity survey.19This could be due to the women’s
embarrassment in talking about GiP, or the health
provider’s not asking about the practice. Due to such
underreporting in healthcare settings, geophagy has
received little attention in antenatal care.
2 Obstetrical and Gynecological Survey
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Factors Predisposing Pregnant Women to
Studies are not conclusive on the association be-
tween geophagy and socioeconomic status (SES)—
among Tunisian children, 95% of children with pica
were from homes with low income, whereas in a
Danish National Birth cohort, pica was only reported
in 0.02% of the pregnant women (21.4% were
geophagous).22,23A cohort study of 827 pregnant
women in Kenya found that GiP was more prevalent
among younger women (?30 years), those with low
education, and the unemployed, although the differ-
ences were not statistically significant.17Similarly,
there were no disparities between geophagy and SES
in a study among primary school children in Kenya
been studied for centuries, its etiology is not well un-
derstood. The following 5 hypotheses have been impli-
cated in the etiology of geophagy.
In many communities, geophagy is a deeply rooted
indigenous practice. The most common occasion for
eating dirt in many societies, and the only occasion in
some societies, is pregnancy. Some communities
consider it strange for a pregnant woman to not eat
soils. In one study in Kenya, 32% of the women gave
“being pregnant” as the reason for eating soil.16GiP
is said to strengthen the symbolic link between peo-
ple, fertility, good health, and ancestral blessings.
Where the culture prohibits the practice, the preva-
lence of GiP is considerably low.1,8
Physiological Need for Additional Micronutrients
The demand for nutrients increases during preg-
nancy causing pregnant women with micronutrient
deficiencies to develop a craving for soils to supple-
ment their dietary micronutrient intake, especially for
calcium, zinc, and iron. The intake of nonfood sub-
stances can also reduce bioavailability of potassium,
iron, and zinc, which could lead to micronutrient
deficiencies.25,26Frequent childbearing, the addi-
tional physiological burden of parasitic diseases, and
physical loading from farm labor rapidly depletes the
maternal nutritional reserves leading to GiP.7
The immune system of a woman is suppressed
during pregnancy, yet there is a need to protect the
vulnerable fetus from harmful substances. This in-
stinctively leads to GiP. Exposure to microorganisms
in the soil confers some immunity to the mother and
the fetus when the former produces immunoglobulin
A antibodies. Immunoglobulin A prevents attach-
ment of bacteria and some virus on mucosal services
directly protecting the infant from infections.26–28In
addition, most geophagous clays have high cation-
exchange capacity able to adsorb plant toxins (e.g.,
tannins, glycoalkaloids, and phytotoxins), detoxify-
ing them and making them less harmful. Others, such
as fuller’s earth, diatomaceous earth, kaolin-pectin,
and termite earth can bind microbes, offering protec-
tion to the individual. In addition, smectite clays bind
with mucus in the intestinal mucosa making the
intestinal linings less permeable to toxins and patho-
gens, thus protecting body organs especially during
times of rapid cell division, notably pregnancy and
Some pregnant women eat soil to stop nausea and
vomiting. In one study, 82.8% of the women cited
nausea and vomiting as the reasons for geophagy.13
Some soils contain kaolin and smectite, both of
which are used in modern pharmaceuticals to reduce
nausea and gastrointestinal upsets.26Other women
engage in GiP to alleviate heartburn. Heartburn is
caused by the hydrochloric acid in the stomach
(pH ? 2), therefore ingestion of alkaline clays can
reduce heartburn as has been indicated by women in
some studies.15Other reasons include soil consump-
tion during famine and retaining soils as part of diet
even after the famine and soil consumption in re-
sponse to gastric pain resulting from enteric parasites
such as the hookworms. Geophagy can therefore be
an indicator of hookworm infestation. Eartheaters
frequently have intestinal worms, but it is not clear
whether geophagy causes parasite infestation or vice
versa. Geophagy may also be a result of a compul-
Latin America (20)
ry (and Re
0 10 2030
4050 60 7080 90
Fig. 1. Prevalence of GiP in selected developing countries.
Geophagy During Pregnancy in Africa Y CME Review Article3
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sive neuroses or a form of defensive regression to the
oral stage of development.1,6,13,25,28
Time Dependent Theory
Some studies have suggested that geophagy
serves different functions depending on the time of
pregnancy—in the first trimester, clay binds terato-
genic toxins in diet and suppresses common symp-
toms of pregnancy sickness (nausea and vomiting).
When pregnancy sickness ends in the second trimes-
ter, geophagy supplements the nutrient demand es-
pecially for calcium necessary for formation of fetal
skeletal system, whereas in the third trimester, GiP
softens the pelvic bones thus making parturition eas-
ier. Calcium also reduces the risk of pregnancy-
Effects of Geophagy on Pregnancy Outcomes
Soil analysis shows that the average daily soil
intake by geophagous pregnant women supplies 4.3
mg of iron, which is equivalent to 14% of the RDA
of iron during pregnancy.2,3An average daily intake
of 30 g of clay per day provides a median RDA
benefit of 15% for copper, 9% for zinc, and 4% for
calcium.7This potential to supply nutrients could
explain the “supplementary nutritional value” of
geophagy thus GiP can be viewed as a risk marker of
micronutrient deficiency. Despite the potential nutri-
tional value, various studies have identified the follow-
ing 6 adverse possibilities in relation to geophagy.
Electrolyte Imbalances and Toxicity
It is impossible to determine the correct dose of the
various components in the geophagic materials;
hence, one can easily ingest excess concentrations of
useful minerals along with dangerously high amounts
of toxic and nontoxic materials causing electrolyte
imbalances and toxicity.26,28For instance, consuming
100 g of white clay provides 322% RDA for iron,
whereas similar amounts from the giant mound
would provide 82% RDA for calcium, zinc 12%,
manganese 5715% (57-fold), iron 535% (5-fold),
chromium 730% (7-fold), molybdenum 1000% (10-
fold), and 214% copper (2-fold).10
Potential Contamination Pathway
Before the industrial revolution, geophagy may
have been safer; however, toxic materials in the soil
make it a very risky behavior. Geophagy can be a
pathway for ingestion of many harmful elements like
lead, cadmium, potassium, mercury, arsenic, alumi-
num, dioxins, and radionuclide isotopes. In the
United Kingdom, an analysis of 2 samples of sikor, a
baked geophagic soil, showed average lead concen-
trations of 38 and 20 mg per kilogram.10Hamilton et
al have reported a case of high neonatal blood lead
level (113.6 ?g/dL) due to prenatal geophagy.30In
contrast, ingestion of excess cadmium can lead to
toxicity, carcinogenic effects, and kidney damage.26
Ingesting potassium-rich soils has been associated
with life-threatening hyperkalemia and hypokalemic
myopathy. Geophagy-induced hyperkalemia has
been observed among patients with chronic renal
failure in United States in early 1970s.31–34Risks
from chemical exposures are greatest for the fetus
hence exposure to heavy metals during pregnancy
calls for attention. In addition, accidental poisoning
from soils contaminated with herbicides/pesticides
can lead to maternal death.28
Geophagy and Anemia
Iron deficiency is considered the greatest nutri-
tional problem in the world, with iron deficiency
anemia affecting more than 3.5 billion people in the
developing world, particularly children, and women
of reproductive age.35,36Studies among pregnant
women have identified geophagy as one of the major
risk factors for iron deficiency anemia. In Sudan, the
odds for anemia among geophagous women were
estimated to be 1.6 (95% confidence interval [CI]:
1.05, 2.6) and 2.6 (95% CI: 1.1, 6.28), whereas the
odds were 3.7 (95% CI: 1.1, 12.3) and 2.1 (95% CI:
1.1, 3.9) among geophagous women in Pakistan and
Tunisia, respectively.37–40Anemia has also been iden-
tified as a major risk for still births in Eastern Sudan
(odds ratio 8.4, 95% CI: 2.5–29.4, P ? 0.001).41
Generally, there are about 8 mechanisms through
which GiP could lead to anemia (Fig. 2).6,26,42,43Ow-
ing to the relationship between GiP and anemia,
treating or preventing anemia may reduce GiP. Ane-
mia is treatable through ferrous sulfate supplementa-
tion or improved iron dietary intake.
Geophagy and Low Birth Weight
Maternal nutritional factors account for approxi-
mately 50% of intrauterine growth retardation in
developing countries. Intrauterine growth retardation
is closely associated with low birth weight (LBW)
and premature births. Globally, about 20 million
children (15.5% of all the children) are LBW.44,45The
association between decreased fetal head circumfer-
ence, LBW, preterm birth, and GiP has been docu-
mented.13Poor prenatal nutrition generally continues
into adolescence and adult life. It has been shown
that LBW babies experience high neonatal mortali-
ties, poor development, and poor academic perfor-
4 Obstetrical and Gynecological Survey
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mance leading to low SES in adult life, and a vicious
cycle of poverty.46Furthermore, infants of anemic
mothers, even when they have normal birth weights,
are at a higher risk of becoming anemic in life (odds
ratio of 1.81 [95% CI: 1.34, 2.43]).47
Geophagy and Geohelminths
Significant correlations have been observed between
geophagy and A. lumbricoides re-infestation among
HIV-positive pregnant women in Tanzania (adjusted
prevalence ratio of 1.81 [95% CI: 1.37, 2.40]), geopha-
gous pregnant women in Kenya (RR ? 1.48), and
school children in Kenya (RR of 2.28 [95% CI: 1.02,
5.11] for geophagous children).48–50Intestinal parasites
can lead to malnutrition, hence geophagy can mediate
malnutrition. Alternately, the host may engage in
geophagy to calm gastric pains due to intestinal
Geophagy and Pharmacokinetics
Clays may also bind to pharmaceuticals (e.g.,
digoxin, chloroquine, asipirin, neomycin, and quini-
dine) making the pharmaceuticals ineffective and
posing more dangers to pregnancy, especially in ma-
laria endemic zones where pregnant women are put
on malaria chemoprophylaxis. By binding to the mu-
cus in the intestinal mucosa, geophagy may lead to
severe constipation and intestinal obstruction.26
A significant proportion of maternal and infant
deaths is attributable to anemia during pregnancy.
Although studies are not conclusive on whether
geophagy is purely a risk factor or a risk marker for
iron deficiency in pregnancy; the mere association
warrants an intervention. Although most sub-Saharan
African countries have folic acid and iron supple-
mentation programs for women attending antenatal
clinics (60 mg of iron and 400 ?g of folic acid for 3
months), only 32% of all pregnant women seek an-
tenatal care, others visit antenatal clinic in late preg-
nancy,51with less than 25% of pregnant women in
Ghana and Kenya making their first antenatal visit
before 16 weeks as recommended by the World
Health Organization.52It is therefore important to
revisit the issue of anemia in pregnancy afresh to
ensure that its prevalence and consequences are sig-
nificantly reduced. Indeed, controlling GiP could sig-
nificantly contribute toward the attainment of the
first 5 Millennium Development Goals (Table 1). It
will be difficult for countries in sub-Saharan Africa
to achieve the Millennium Development Goals with-
out adequate investment in maternal nutrition.53
GiP is an important sign of iron deficiency, there-
fore all pregnant women should be asked whether
they have a craving for eating earth. Those in the
habit should be deterred by explaining the risks that
geophagy poses to them and the fetus, and then
recommend an alternative way of fulfilling the crav-
ing, such as iron supplementation and dietary
sources. To reach mothers not seeking antenatal care,
there should be health education through mass
media (and cell phone text messages where appli-
cable) emphasizing importance of antenatal care,
causes and dangers of GiP, and availability of
Strengthen and Sustain the Existing
Periodic iron and folic acid supplementation (60
mg of iron and 400 ?g folic acid for 3 months) is
recommended for adolescent girls and women of
childbearing age living in areas where the prevalence
of anemia exceeds 40%. In addition, all mothers
attending antenatal care clinics should receive iron
Fig. 2. Mechanisms through which GiP could lead to anemia.
Geophagy During Pregnancy in Africa Y CME Review Article5
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and folic acid supplements during the first 3 months
of pregnancy, as shown in Table 2.54
To be successful, there should be adequate buffer
stocks of supplements to avoid stock outs. In addition,
the delivery of the supplements should be diversified to
include other channels besides the antenatal clinics,
such as schools and colleges. Iron supplements should
be re-branded using local names for geophagic materi-
als (e.g., Odowa in Kenya) to increase acceptance. To
increase iron uptake among school-going children, fla-
vored multicolored crackles and sprinkles fortified with
iron should be distributed to primary schools. Opinion
healers, and folk media (e.g., traditional songs) should
be used to propagate knowledge on the importance of
antenatal care, iron supplements, and maternal nutri-
Mandatory Fortification of Flour
Most African countries have flour from maize,
millet, cassava, wheat, barley, or oat forming part of
the stable diet. Fortification of flour with iron has the
potential to reach all community members, including
the adolescent girls and pregnant women, and build
enough iron reserves, minimize craving for soils dur-
ing pregnancy, and subsequently decimate the risks
associated with GiP.
Geophagy has been associated with hookworm and
roundworm infestation during pregnancy. As part of
antenatal care, there should be regular deworming of
pregnant women to reduce the parasite burden hence
the risk of geophagy as well.
All interventions should be coupled with continuous
monitoring and regular evaluation of to track progress
and identify any constraints for timely rectification.
Further research is needed to identify the socioeco-
nomic, ethnical, and spatial distribution of GiP and to
estimate the proportion of undesirable obstetric and
birth outcomes attributable to GiP. This will guide
policy makers in putting GiP on the prenatal and
maternal health agenda.
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MDG and its impact and relationship with GiP
MDG 1: Reduce extreme poverty and hunger
More than half of the worlds’ population includes mothers. Without anemia, mothers will be healthy and economically productive
hence significantly contribute to reduction of extreme poverty and hunger.
MDG 2: Achieve universal primary education
Babies born of healthy mothers will be strong and able to enroll and complete primary education leading to universal primary edu-
cation and a reduction of illiteracy levels in the country.
MDG 3: Reduce gender disparity
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MDG 5: Reduce maternal mortality
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Adolescent girlsAt start of adolescence
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