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R E S E A R C H A R T I C L E Open Access
Food choices and practices during pregnancy of
immigrant women with high-risk pregnancies in
Canada: a pilot study
Gina MA Higginbottom
1*
, Helen Vallianatos
2
, Joan Forgeron
3
, Donna Gibbons
3
, Fabiana Mamede
4
and Rubina Barolia
1
Abstract
Background: Immigrant women may be regarded as a vulnerable population with respect to access and navigation
of maternity care services. They may encounter difficulties when accessing culturally safe and appropriate maternity
care, which may be further exacerbated by language difficulties and discriminatory practices or attitudes. The
project aimed to understand ethnocultural food and health practices and how these intersect in a particular
social context of cultural adaptation and adjustment in order to improve the care-giving capacities of health
practitioners working in multicultural perinatal clinics.
Methods: This four-phase study employed a case study design allowing for multiple means of data collection
and different units of analysis. Phase one consists of a scoping review of the literature. Phases two and three
incorporate pictorial representations of food choices with semi-structured photo-elicited interviews. This study
wasundertakenataPrenatalandObstetricClinic,inanurbanCanadiancity.Inphasefour,theresearchteam
will inform the development of culturally appropriate visual tools for health promotion.
Results: Five themes were identified: (a) Perceptions of Health, (b) Social Support (c) Antenatal Foods (d) Postnatal
Foods and (e) Role of Health Education. These themes provide practitioners with an understanding of the cultural
differences that affect women’s dietary choices during pregnancy. The project identified building collaborations
between practitioners and families of pregnant immigrant women to be of utmost importance in supporting
healthy pregnancies, along with facilitating social support for pregnant and breastfeeding mothers.
Conclusion: In a multicultural society that contemporary Canada is, it is challenging for health practitioners to
understand various ethnocultural dietary norms and practices. Practitioners need to be aware of customary practices of
the ethnocultural groups that they work with, while simultaneously recognizing the variation within—not everyone
follows customary practices, individuals may pick and choose which customary guidelines they follow. What women
choose to eat is also influenced by their own experiences, access to particular foods, socioeconomic status, family
context, and so on.
The pilot study demonstrated the efficacy of the employed research strategies and we subsequently acquired funding
for a national study.
Keywords: Pregnancy, Food choices, Immigrant women, Perinatal
* Correspondence: gina.higginbottom@ualberta.ca
1
University of Alberta, Faculty of Nursing, 3rd Floor Edmonton Clinic Health
Academy, 11405 87th Avenue, Edmonton, Alberta T6G 1C9, Canada
Full list of author information is available at the end of the article
© 2014 Higginbottom et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Higginbottom et al. BMC Pregnancy and Childbirth 2014, 14:370
http://www.biomedcentral.com/1471-2393/14/370
Background
Immigrant women may be regarded as vulnerable pop-
ulations since challenges exist with respect to access
and navigation of health services and more specifically
maternity care services [1]. Difficulties may be encoun-
tered in terms of accessing culturally appropriate care in
addition to other challenges such as language barriers and
discriminatory policy and practices that may ultimately
impact upon maternal health. Without culturally appro-
priate health care delivery a negative trajectory of events
may occur that range from simple miscommunication
to life-threatening incidents [2,3]. For this research, we
utilize the Canadian Council of Refugees definition of
an immigrant as a person who has settled permanently
in another country. Immigrants choose to move whereas
refugees are forced to flee [4]. Immigrant women are a
diverse group that includes economic skilled workers,
refugees and asylum seekers, and those without legal
status [4].
Diversity and health in Canada
Global migration contributes to increasing diversity
within nation states resulting in diverse populations.
Immigrant populations in Canada are more diverse than
the Canadian-born population in terms of ethnic origin,
first language, culture, traditions and socio-economic
status [5]. As evidenced by the healthy immigrant effect
[6,7], relatively healthy immigrants enter Canada, yet
over time, many factors contribute to a decline in their
health. This phenomenon largely affects those communi-
ties whose immigration is planned. Immigration effects
include: health selection [6], acculturation and the stress
of relocation that may erode health advantage [7], and dis-
trust of Western medicine with a preference for seeking
out traditional health care providers. However, popula-
tions who relocate as refugees or asylum seekers are found
to have compromised health status, particularly women
who are often traumatized by war, rape and the transgres-
sion of their human rights [8]. Many have lived in refugee
camps for several years prior to immigration; this results
in deterioration of their health status including those
related to maternal health and maternity service provision.
While substantial diversity exists within immigrant women
populations, commonality may exist in terms of challenges
encountered during access to and navigation of maternity
care services and in experiences of migration, cultural
adaptation and acculturation.
Without culturally appropriate health care delivery, a
negative trajectory of events may occur ranging from
simple miscommunication to life-threatening incidents
[2,9]. Poor or inadequate initial health assessments and
communications between the caregiver and patient may
lead to unsatisfactory therapeutic encounters that in
turn result in multiple consultations or failure to comply
with treatment, thereby wasting time and resources for
both patient and caregiver. There is currently a growing
public health initiative which requires healthcare organiza-
tions to promote, protect and contribute to reducing health
inequalities and culturally appropriate communication can
be an important component to this aim.
Maternal and birth outcomes of immigrant women:
relevance of food choices and practices
Epidemiological research from Canada and elsewhere
has reported equal or more favorable birth outcomes for
migrants [10-13] supporting an “epidemiological paradox”
associated with the concept of the “healthy migrant ef-
fect”. Numerous other reports highlight serious problems
of equity in perinatal health outcomes [14-16] particularly
for refugees [17] and other immigrants after increased
lengths of stay (with the accompanying acculturation)
[18,19]. A recent Canadian study found higher rates of
low birth weight and full-term low birth weight (i.e., small
for gestational age or SGA) for infants born to recent
immigrant women [15] and immigrants living throughout
Europe have been reported to be at substantial risk for
pre-term delivery (24%), perinatal mortality (50%), and
congenital malformations (61%) [14]. Hospital costs for
preterm and SGA newborns are higher than those for
their normal-growth counterparts by nine and two times,
respectively [20].
Although there is no consensus that poor birth out-
comes are associated with immigrant women, the poten-
tial negative health outcomes include significantly higher
rates of gestational diabetes (predisposing the mothers
to preeclampsia and type 2 diabetes and their offspring
to obesity and type 2 diabetes) [21], low maternal weight
gain (compromising both newborn and maternal health)
[18], genetic anomalies such as neural tube defects due
to lack of folic acid intake [22], and maternal anemia
(increasing the risk of preterm delivery) [23]. All of these
outcomes relate to food choices and practices, and thus
food beliefs and behaviors could be important aspects in
encouraging good health practices (and address any un-
desirable ones) to avoid poor health outcomes. Evidence
suggests that everyday diets of immigrant women consist
mainly of processed foods and animal proteins as well as
foods high in fat, salt, or sugar [24,25]. It is reported that
prevalence of obesity post-migration is widening because
of the adoption of a Western diet [26]. Conversely, im-
migrant women reduce their dietary intake, even during
reproduction, to maintain or quickly return to their
hegemonic body ideals [18]. Successfully providing ap-
propriate prenatal nutritional and diet education re-
quires the legitimization of the pervasive traditional
beliefs and practices of immigrant women [27,28]. Des-
pite these observations, little attention has been paid
to the food consumption and choices of immigrant
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women in the perinatal period and research is needed
to elicit understanding of ethnocultural food choices
and practices and to improve culturally based compe-
tency of maternity care.
Study aim
The purpose of this project was to understand ethnocul-
tural food and health practices and how these intersect
in a particular social context of cultural adaptation and
adjustment in order to improve the care-giving capacities
of health practitioners (i.e. maternity nurses) working in a
multicultural perinatal clinic located within a hospital.
The funding stream awarded for this study has, as its
ultimate aim, a goal of enhancing services in the hos-
pital. As a secondary goal, this study aimed to assess
the feasibility of the study design, and in turn expand
the research with specific immigrant communities resid-
ing in different places.
Methods
We employed a case study design that incorporated a
participatory approach [29]. The case study is both de-
scriptive and explanatory in nature and is appropriate
to examine complex, real-life situations [29]. Our en-
deavour will acknowledge the complexity of everyday
lives and acknowledge the existence of multiple realities.
Decisions regarding health and illness prevention are
fraught with ambiguity as individuals strive to maintain
culture and traditions whilst integrating evolving modern-
ities and the influence of globalization in daily existence.
Food practices are an important component of marking
individual and group identity. How an individual repro-
duces or resists normative practices is a means of under-
standing their social location. Migration, whether between
countries or within Canada provides both opportunities
and challenges for maternal health practices, including
food practices. There is no question that social determi-
nants affect approaches to meeting the human need for
nutrients, but this research will provide a greater depth of
understanding as to why and how such food practices
develop.
Case studies also allow for multiple means of data col-
lection, data collection in different settings, and different
units of analysis. Our project was structured into four
phases: Phase One - A scoping review of the literature;
Phase Two - Pictorial representations of food choices
(photovoice/photo-elicitation); Phase Three –Semi-
structured photo-assisted narrative interviews of 10 im-
migrant women; Phase Four - Production of a culturally
appropriate visual tool for immigrant women. The de-
scription of the methodological approaches of the all four
phases is published, as are the findings from phase one
[1,30]. In this paper we present a brief overview of the
methodology and results of phases two and three.
Phase one: scoping review
A scoping review was performed to examine and outline
the extent, range, and nature of empirical evidence on
immigrant and Aboriginal women’s food practices during
pregnancy and childbirth. A framework for performing
scoping reviews published by Arksey and O’Malley in
2005 [31] and Levac, Colquhoun and O’Brien [32] was
used to conduct this review. This framework included:
identifying the research question; identifying relevant
studies; study selection; charting the data and collating,
summarizing, and reporting the results. Further details on
the methodology can be found in Higginbottom et al. [30].
Phases two and three –photovoice and photo-assisted
interviews
Photovoice is the process by which people identify, rep-
resent, and enhance their community through specific
photographic technique [33]. This approach is particularly
useful for individuals who speak English as an additional
language. The camera as a research tool is well docu-
mented in disciplines such as anthropology and sociology
[34-36]. Photography often leads to uncovering miscon-
ceptions and arriving at more reality-based understand-
ings of phenomena [37]. A combination of photographs
and accompanying narratives adds richness to data in
qualitative studies. The technique also acknowledges that
the participants’perspectives are valuable and necessary
to the understanding of a problem or event [38]. Through
small or large group discussion, community members
reflect on the images produced in a safe environment, and
dialogues on potential solutions may emerge. Therefore,
as a data collection method, photovoice serves the dual
process of engaging communities on a topic of concern
while providing valuable information about their current
life in relation to a topic.
Study setting: context of the study
Study participants were recruited from a Prenatal and
Obstetric Clinic in Edmonton, Canada. In 2006, Edmonton’s
population totaled one million, with 189,775 people iden-
tifying themselves as being foreign born [11]. The visible
minority group totaled 174,729 (17%) largely being of
Chinese, South Asian and Filipino origin [11]. Visible
minority is a term used in official discourse in Canada,
and speaks to the fact that minority groups with charac-
teristics that are evident to others (e.g. physical traits) may
have different everyday experiences (including potential
discrimination) than those who are members of hidden
minority groups (i.e. without traits marking their differ-
ence in the general population). South Asian is also used
in official discourse and by local community organizations
to include people whose ancestry originated in Pakistan,
India, Nepal, Bhutan, the Maldives and Sri Lanka. The
clinic in an area hospital was our recruitment site. This
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clinic provides consultation services for preconception
counseling, prenatal screening, diagnosis, and treatment
for women who are experiencing high risk conditions in
pregnancy. Many of the high risk conditions, including
obesity, diabetes, hypertension, intrauterine growth re-
striction, and oligohydramnios, are affected by women’s
behaviors including food practices. The region surround-
ing this clinic is home to many immigrants. The popula-
tion diversity of this area mirrors or exceeds the general
population of Edmonton. Moreover, data in 2006 (latest
available figures) indicated that interpretation services
at the unit responded to 849 requests representing 33
languages. The reasons for requesting interpretation
can be categorized in three broad groups: 1) to explain
procedures during clinical examination, treatment or
diagnostic tests; 2) to translate information about a
diagnosis, treatment options, outcomes and other in-
formation for informed decision-making by the client
with their health care provider[s]; and 3) to allow
clients to communicate their perceptions of their con-
dition, signs and symptoms, and general well-being to
the physician, nurse or other health care provider.
Since this time, interpretation services at the hospital
have been outsourced.
Considering these language interpretation challenges
and the needs for specialized education about nutrition
during pregnancy at our study sites, a team was gathered
in 2011 consisting of researchers from the university and
clinicians at the hospital. A concern that emerged during
these early meetings was the challenges maternity care
nurses may face when eliciting and conveying informa-
tion regarding optimum food choices during pregnancy
because of language difficulties and cultural differences
in reproductive health and food practices.
Recruitment
Because of the partnership between the clinicians and
researchers and the identified knowledge gap/issues
faced by clinicians, and the funders’focus on improv-
ing care and resources at the hospital, recruitment was
focused at the clinic. This clinic receives approximately
twenty requests for referral daily from local area doc-
tors and obstetricians-gynaecologists (there are no
self-referrals). A co-investigator (DG), or an informed
intermediary who worked daily in the clinic, provided
potential participants a brief description of the study
and indicated where they could sign and submit (into a
locked mailing box) a consent form allowing contact
by the research team. From this point, contact information
of the volunteers were referred to one of the investigators
(GH or HV), or their designated research assistant, who
would arrange for a meeting to gain informed written con-
sent and initiate the photovoice and photo-assisted inter-
view process.
Sample population
A total of ten immigrant women were recruited. Partici-
pants were purposively selected to represent a range of
migration experiences and ethnocultural communities.
The inclusion criteria for immigrants were years of resi-
dence in Canada—participating women lived in Canada
for at least two to four years—in the hope that they had
become somewhat familiar with the Canadian health
care system and had some familiarity with English if this
was limited prior to arrival in Canada. Of the ten women,
translators were used for two; in these cases, the women
had some English skills, but felt more comfortable
speaking in their native languages. A sample size of ten
is adequate for a pilot study, and served to reveal general
issues immigrant pregnant women face when adjusting
their food practices to the local food environment. When
this study was designed, we had also planned on conduct-
ing approximately ten interviews with Aboriginal women,
because the clinical partners had identified the need for
more information on cultural variation of food and health
practices amongst the Aboriginal pregnant women using
the hospital and clinic. Unfortunately, early in the re-
cruitment process the Aboriginal coordinator at the
hospital left the position, and this position was unfilled
for months—the time period corresponding to data col-
lection. Without a community collaborator who could
navigate cultural and other issues, the team decided to
not attempt to recruit Aboriginal women and to revive
this aspect of the study at a more opportune time for all
involved. Furthermore the research ethics framework in
Canada demands a specific skill set including collaboration
with Aboriginal community members [39].
Data collection
After obtaining informed consent, a short interview of
approximately thirty minutes using a topic guide was
undertaken and then disposable cameras were provided
to participants (the women received training on their
use if necessary). Participants were asked to take photo-
graphs of all meals and snacks (including drinks) during
a three-day period (including one weekend day) and
other foods they perceived to be healthy/unhealthy for
consumption during and after pregnancy. They were
asked to hand in their camera to the Clinical Nurse Spe-
cialist at their next visit to the clinic, who in turn handed
them over to the PIs for development. Subsequently, the
PIs or a research assistant conducted a semi-structured
narrative photo-assisted interview, where each woman
was asked to tell their story through the photos, to discuss
whether food choices represented are typical or not, what
factors influences their dietary choices, and what they
would like to change. This revealed not just what women
are typically eating but the kinds of everyday issues that
influence their food practices. Some questions addressed
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culturally normative practices surrounding maternal food
choices and consumption, including how women negoti-
ate normative practices within their own worldview and
experiences. A methodological approach of photovoice
known as photo-elicitation was also used to complement
interviews and better attain an understanding of taken-
for-granted beliefs and assumptions about food practices
during pregnancy and the postnatal period. Total time
commitment for the each participant was about four hours;
they were given a small honorarium in appreciation. The
pilot study was focused on the hospital partner setting and
consequently we focused on the users of the facility.
We were looking for common experiences of immigrant
women; however we recognize that there is heterogeneity
within and between various immigrant communities. The
large-scale national study that followed this pilot is investi-
gating variations in women’sexperiences[40].
Data management & analysis
Data was stored, managed, classified and ordered with
the aid of Atlas-Ti, a qualitative data analysis software
package. Atlas-Ti is useful for this study as the software
package facilitates analysis of visual representations. The
process of analysis is characterized by identification and
classification of data and progresses to abstract gener-
alizations and explaining patterns - it is not linear but
undulating and cyclical. We drew upon the analytic
framework of Miles and Huberman [41], which includes:
1) Familiarization with the transcript, 2) Identification of
open and in vivo codes, 3) Utilization of both theoretical
and commentary memos, 4) Funneling and rationalization
of redundant codes, 5) Creation of themes categories and
families, 6) Creation of graphic network views in Atlas-Ti
demonstrating relationships between the various codes
and categories, 7) Constant interrogation of the data and
the challenging of initial assumptions, 8) Identification
of outliers and non-confirming data, 9) Reflective team
meetings to achieve higher level of abstraction in the
analysis, 10) Creation of hierarchies, classifications and
typologies, and 11) Creation of a written narrative. This
characterizes the iterative process associated with quali-
tative data analysis as preliminary interpretations are
challenged and data are revisited in the light of further
data collections and new insights into the data.
Ethical considerations
Before commencing research, ethics approval was ob-
tained from the University of Alberta Health Research
Ethics Board and operational approval was obtained from
the Prenatal and Obstetric Clinic and the partner hospital.
Voluntary written informed consent was obtained from all
participants. As part of the consenting process, partici-
pants were assured that they did not have to answer every
question, could choose to be audio-recorded (or not), and
could withdraw at any time. To ensure that participants
were fully informed, a translator was used for both the
consenting and interviewing processes when necessary.
The principles of informed consent, confidentiality and
anonymity were observed at all times (including storage of
materials).
Results
Phase One
Detailed description of the scoping review and findings
are published elsewhere [30] consequently we briefly
summarize the major themes of the review here to com-
pare themes with those revealed from our interviews. All
qualitative studies highlighted the importance of under-
standing the diversity in cultural practices of immigrant
pregnant women when promoting healthy pregnancy
outcomes. Major themes included: 1) Cultural practices
and beliefs regarding the perinatal period:Studiesiden-
tified the importance of dietary or food-related cultural
practices during pregnancy. Topics included dietary prac-
tices, religious rituals, values and beliefs related to the
fetus, maternal health, and the role of family members
and support groups during pregnancy. 2) Family and
social support during pregnancy and delivery:Amajor
challenge for immigrant pregnant women can be the
roles played by partners, family members, and social
supports during pregnancy, especially since often immi-
grant women are away from their extended family and
communities [22,42-44]. Immigrant women expressed
feelings of loneliness and missed the social support which
they could receive in their own countries. Pregnant
women mainly received support from their husbands.
3) Healthy pregnancy: While all studies reviewed described
the importance of healthy foods and emotional wellbeing
to experience a healthy pregnancy, a few participants
reported craving harmful substances, such as alcohol, and
stated that one must be careful not to drink too much be-
cause it is harmful for the baby [45]. These food cravings
were viewed by the women to be part of a healthy preg-
nancy and their consumption thought good for their ba-
bies [46,47]. 4) Weight gain issues: Overall, immigrant and
Aboriginal women were concerned about the weight and
adequate growth of their baby. However, a few immigrant
women were purposefully not eating enough because they
believed that too much food would result in a large baby
and hinder a vaginal birth. On the other hand few immi-
grant women felt that need to eat more when they are
pregnant because “they’re eating for two now”[47:202],
some of them believed that mother weight gain will reflect
the baby’s’weight [47].
5) Concern for health of the baby: Immigrant women
were more worried about their unborn child’swell-being
than their own health. The ‘important’thing for women
was to have a healthy baby, and they were prepared to
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modify their lifestyle [47]. 6) Specific food items.Immi-
grant women also categorized the specific food item into
“good”or “bad”food during pregnancy. Good food in-
cludes foods such as fruits and vegetables and bad foods
include oily and fatty foods. Low income and the higher
cost of healthy foods were identified as major barriers
to healthy eating identified by these women [46]. Three
major themes derived from the quantitative studies in-
cluded in the review were nutritional assessment, cultural
practices, and seafood consumption and other environ-
mental exposures in the diet. While the first two themes
highlighted similar issues raised in the qualitative studies,
the latter theme focused on potential toxic contaminants
in foods, such as heavy metals in seafood. The review
indicates that there is a complex interplay of cultural,
social, and economic factors affecting food choices and
nutritional adequacy for pregnant immigrant women.
As a result, influencing food and health behaviors may be
particularly difficult in groups where the recommended
changes are perceived to clash with one’s own customs.
Phases two and three –photovoice and photo-assisted
interviews
The ten participants in this study were immigrant
women who migrated to Canada from a range of regions
in Africa and Asia, however most (6) had come from
Asia, predominantly from South Asia. Three participants
reported being employed, and only one of these worked
in a profession in which she had prior experience. All
participants were married, with an average age of 33.5 years,
gravida range of two to four, and an average of 1.6 children.
Only three participants had previously given birth in
Canada. Women who have larger numbers of children and
thus a greater range of prior reproductive experiences to
draw upon may have different food practices or adherence
to ethnocultural food practices than those reported here.
However this sample does provide a snapshot of relatively
recent immigrant women’s experiences, who had little prior
exposure to the Canadian health care system and repro-
ductive health (including nutritional) practices.
The study was constructed so that women’s ideals and
perceptions on healthy dietary practices during pregnancy
would be discussed in the first interview, while in the sec-
ond interview, through discussions of the photographs
each woman took, a better understanding of actual prac-
tices and everyday challenges would emerge. Interestingly,
the same themes emerged in the independent analysis of
the first and second interviews, which suggests these
themes are very salient for the participating women. Ana-
lysis of the interviews revealed five themes.
Perceptions of health
This theme incorporates participants’beliefs on physical
health, emotional/psychological health, and nutritional
health. Some participants focused on a specific indicator,
while others used a combination of factors with varying
degrees of importance placed on each. The meanings at-
tached to health affected what women ate before, during,
and after pregnancy as well as behaviors and practices
unrelated to food choices, such as exercise or attempting
to maintain a positive mental outlook. This includes per-
ceptions of what makes a person healthy in general, as
well as the pregnant body specifically, and is illustrated
with the following quotes:
Okay, eat healthy and the other thing, walk during
when you are pregnant, not be very lazy, like lie down
all the time and rest. That is not good during the
pregnancy. Drink milk, take your protein and
everything which is useful for the baby. [17:1]
Like being healthy in pregnancy eating well, sleeping,
sleeping well…you can feel your baby moving, you go
to the hospital, they check you and say baby’s okay…
But for pregnant women I think we have to take all
the veggies, yeah, and the banku and then the fish.
Fish and meat is also very good for us.[8]
Healthy foods are not just types of foods, such as “veg-
gies,”“proteins”or “milk”, but also reflect the quality of
foods, as illustrated by one participant’s description of
the importance of “fresh”foods: “Very important. Fresh,
not stay overnight, the one-week old, two days old. Every
time my mom give me fresh food and homemade. Don’t
eat outside a lot”[4:2].
The following image (Figure 1) was taken by one par-
ticipant to illustrate how cultural beliefs of healthy foods
affects her everyday eating behaviors. Important here is
Figure 1 Illustrates how one participants cultural beliefs about
colour of foods affected concepts of healthy pregnancy foods.
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not just what the food items are, but the combination of
foods and their colors: “in Chinese culture, people think
the black food, red food, are good for our body. Yeah,
especially for the blood”[27:2].
Considerations of how food choices and behavioral
practices can affect the health of one’s developing child
also affected the health and dietary practices of mothers,
and these understandings of how (un)healthy bodies were
maintained or developed are partly informed by custom-
ary cultural knowledge and practices.
Social support (family & community)
The role of family, partners, friends, and community
members in supporting and enforcing healthy eating and
healthy behaviors were highlighted by almost all immi-
grant women. There were a variety of kinds of support
described by participants, including those related to
pragmatic everyday activities (e.g. housework, cooking,
childcare), as explained by one woman, “Yeah. After deliv-
ering baby at least two or three week, traditionally the
family support everything. I don’t need to care about the
housework; I don’t wash dishes, laundry, anything. Just
stay relaxed, take care of your baby”[4:2]. Other women
described the intangible emotional encouragement that
contributes to the support they receive from others,
“When if it’s–let’s say if it’s your first pregnancy everybody
like, won’t let you get down from the bed. …they will be
very careful for you”[15:1]. There was a wide variety of ex-
periences within this theme, influenced by each woman’s
cultural background, socioeconomic status, and access
to support networks. Many had relatives living nearby, so
there was at least one adult the women could rely on, as
one woman noted, “And if my mom is not here, maybe
husband prepare everything. …even if he can’t do all but
he will have to help something and then leave while these
things were okay”[4:2].
Some women’s support networks were stretched across
space. This is exemplified by women receiving advice
from relatives over the telephone or internet. For ex-
ample, one woman from western Africa spoke with her
mom regularly via phone and Skype, noting that: “No,
she tell me every day, “Take care of you, don’t work too
much, don’t do something you don’t like it (?).”I say,
“Okay, mom.”I said, “Okay, mom.”She’s scared because
I’m here just with myself. My husband is not at home
sometimes and I have another two boys and this is not
easy”[14:1]. Based on the importance of the social sup-
port networks described by the women, it suggests that
for those without family or friends in Canada or who
were unable to speak English, social support may be low
or absent altogether. The absence of social support for
antenatal or postnatal women can be a significant factor
in their antenatal and postnatal choices, behaviors and
overall health status.
Antenatal food choices
This relates to the foods consumed and avoided before
and/or during pregnancy. These choices correlated with
cultural beliefs on what a healthy pregnancy entailed,
advice given by friends and family, and past pregnancy
experiences, as exemplified by: “During pregnancy, they
said that during pregnancy you should drink as much as
you can, so like it makes your uterus like really strong
and it makes it like, let’s say slippery so the baby can just
slip down, slip down easily”[15:1]. This South Asian
woman, pregnant for the second time, heeded the advice
of family, despite having lived in Canada for ten years.
Thus, not only biomedical health care providers, but also
family, are important sources of dietary knowledge.
In some cases, pregnant women continued eating
similar foods to what family members consumed, as
one participant explained, “We were all eating the
same thing, the pita, and chapatti during pregnancy”
[20:2]. However, in most cases, pregnant women ate
more frequently, consumed specific foods thought to
improve birth outcomes, and/or ate greater quantities.
For example, one South Asian participant [22:2] noted
that pregnant women were encouraged to have butter
in every meal. “Butter, butter, butter; every meal butter.
Even during pregnancy, like after seventh or eighth
month, they said if you eat more butter it will soothe
all your birth canal so the delivery will be easier.”This
echoes the South Asian woman’s comment on the import-
ance of drinking liquids above, so as to improve ease of
delivery. Clearly, these ideas are linked to women’scultur-
ally informed concepts of the body, and how bodies work.
Some cultural ideas of food and bodies are based on the
concept of balance, originating in various humoral med-
ical systems. For instance, pregnancy in many humoral
medical systems is viewed as a ‘hot’condition, thus ‘hot’
foods must be avoided. This is reversed after birth, where
‘hot’foods are consumed. This notion of balance is al-
luded to by this woman, “And I was not allowed to drink
water out of the tap because it was cold, so they always
give you warm water to drink, you know, for fear of catch-
ing a cold. That’s one thing. But of course, you know, I can-
not have water without ice so I’msousedtothecold
water”[20:2].
Other cultural ideas on the body also impact food
practices. For example, a participant described how
pregnant women were advised to drink a lot of milk
(and apples too) so that the baby would be fair-skinned.
This was important not only for aesthetic preferences, but
also for the health and wellness of the child: “‘white’or
have a lighter skin color, and lighter baby signified a
healthy baby: the baby will be whiter, the baby. Because
the skin color will be lighter, your baby will be healthy. But
the milk especially, they - every people, apples and milk”
[22:2].
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Food cravings were another common experience shap-
ing pregnant women’s food choices. Food cravings may
pose a dilemma for pregnant women, in terms of whether
to succumb or resist the craving, especially if the food they
were craving was viewed as unsafe or unhealthy during
pregnancy. For example, one South Asian woman admit-
ted that while “People say caffeine is not good during preg-
nancy….Iknowit’s not good but I just couldn’t, you know,
give it up. So I just have to”[20:2]. This participant also
noted the common experience of craving familiar foods of
home:
“Usually, you know, in India when women are pregnant
people do go ahead and make special pickles at home
because they have the craving. You know sometimes you
just want to go and have pickles. Pickles in the sense that
yeah, even here, you know, in North America people do
want to eat pickles, the bottled ones, you know, the dill or
whatever you call them, you know. …they crave for this
pickle because it’s a little sour and spicy”.
Food cravings cam become a complex matter for
women with an underlying health condition such as ges-
tational diabetes, as one participant [22:2] described; “So
craving is something. [laughter] But the diabetes was a
very big issue. Like my readings go very high during preg-
nancy, my hormones changes so much. For some people,
my doctor was saying, for some people it’s not that bad,
but for some people they just mess up all the hormones
and mine was one of those.”
Food aversions are also mediated through culturally in-
formed practices. One participant illustrated this through
the following image (Figure 2),
“noting: Yeah, but in our context when we say - let’ssay
somebody is going to eat banku and pepper, it means
you add pepper with tomatoes, with onions, or with
ginger and garlic or whatever. But ginger and garlic are
optional, so we take pepper, onions and tomatoes, add a
little salt to it. You grind them together and then take it
with banku, yeah, just to kill the nausea.”[8:2]
The ethno-cultural socialization and experiences of
women highly influenced their antenatal behaviors, es-
pecially in terms of food consumption patterns. For
some women, religious beliefs or health challenges lim-
ited their food choices, although most seemed aware
of possible dietary deficiencies and had alternatives
in place. Socioeconomic status was variable among the
sample and was not explicitly stated to be an issue
affecting the ability to make healthy choices; however, it
is worth considering that lower socioeconomic status
affects one’s ability to purchase nutritionally dense foods.
Geographical location was mentioned by some participants
as a factor in their ability to purchase certain seasonal
foods, or foods not readily available in Canada as they
are in their home countries.
In addition, at least one participant mentioned the
urban/rural location distinction affecting dietary choices.
In terms of availability, the existence of specialty ethnic
food stores or aisles in supermarkets allowed most women
to find cultural and religiously sanctioned foods, however,
some foods were simply not available or too expensive
in Canada. Lastly, all of the women in the sample were
experiencing high-risk pregnancies, and so they were deal-
ing with previous or developed medical conditions (such
as gestational diabetes) that affected their choices and
behaviors.
Postnatal food choices
Immigrant women were very concerned about the foods
that are consumed or avoided directly after and in the
forty days following birth. These choices correlate with
cultural beliefs surrounding health and healing, produc-
tion of breast milk, and advice from social networks. For
instance, “you eat some sweets, the sweets will give you
milk for the baby, and nuts. And we drink like hot tea
with cinnamon, cinnamon with ginger for cleaning the
blood after delivering the baby”[7:1]. Following such
beliefs often depended on having the social support, typ-
ically of a female kin, who would prepare these foods,
teach which foods ought to be consumed in the forty
days post-birth, and who could ensure the new mother
Figure 2 Illustrates how one participant’s food aversions were mediated through culturally informed practices.
Higginbottom et al. BMC Pregnancy and Childbirth 2014, 14:370 Page 8 of 13
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rested and followed these post-birth food traditions (see
social support theme). Women that had previous children
referred back to those experiences when making choices
regarding food practices, and her educational status was
an important factor in how post-birth food traditions were
adhered to.
The immediate postpartum food choices and practices
depended on the type and place of delivery. For medic-
ally assisted delivery (i.e. Caesarean section), the doctor
prescribed the meals for the first few days. However,
for a normal vaginal delivery in a hospital, regular light,
semi-liquid, energy rich foods were provided. But many
women also described the foods their female kin would
prepare: “So the palm fufu, if it’s in the afternoon your
mommy will bring fufu and soup and then you take for
you to replenish your energy that you spend during bearing
[child], and then the soup itself, you will drink it, for you to
get enough milk, yeah, to come”[8:2] (see Figure 3).
Breastfeeding affected women’s food consumption
practices, dictating the kinds of foods that would foster
milk production, but also be healthy and nourishing for
the newborn’s sensitive stomach: “Because they said if
you eat more of those starchy foods they will make you
more gassy and the baby will be more uncomfortable, so
try to avoid starchy food - rice, more pitas. Try to fill
your stomach with more proteins, even though nuts or
whatever you can”[22:2]. Another participant provided
images (Figure 4) of foods she avoided while breastfeed-
ing, explaining: “I breast feed my baby, that’s why also I
try to avoid any alcohol and coffee and spicy food …stay
as much as I can stay healthy, you know. Don’t eat any
junk food and not the fat, everything, you know. For my
health, also for my baby’s health. …If I eat any, you
know the unhealthy food, baby is going to be, you know,
take unhealthy milk from me. [laughs]”[4:2].
Role of health education
We also examined the sources of information and know-
ledge on healthy eating during pregnancy. Medical doctors
were a critical knowledge source, as illustrated here: “Be-
fore I eat it because I like hot sauce and I like chicken
wings. Yum, so good. [laughter] But this doctor is saying
that’s not very good for a baby”[14:1]. Another women
showed the following image (Figure 5) to explain, “I want
to show you, this food we are trying to avoid. …Yeah, I
heard it from my dietitian. I never heard of this before,
actually. I didn’t know”[27:2].
Another woman shared, “they tell me that don’t eat so
much cold things like cold water; those are not good. …
We avoid yogurt. …And they told me avoid rice too. …
But according to doctors, rice are good, I think so. That’s
why they are in their manual, give her rice”[17:2]. This
example illustrates how biomedical and customary advice
may sometimes be at odds, and women must make their
own decisions on which recommendation should be
followed. Thus, women incorporated other knowledge
sources as well, such as family members, friends, com-
munity members, media, and their own experiential
knowledge (where relevant). One woman noted,“mom
taught me like that and, yeah, she’s teaching me like
that. Also, I am going to do [i.e. teach] my daughter,
yeah”[4:2]. Women’s relatives are frequently the first
source of advice and ministrations, but many women
also rely on their experiential knowledge, as illustrated
in the following exchange:
P: I would say all of them, because that was the food I
was eating.
I: Why do you feel that those foods are healthy while
you’re pregnant?
P: Because I’ve been eating [these foods] since I was
born so I don’t see anything [wrong]. [10:2]
The foods this woman had consumed for her entire
life could not possibly be unhealthy, for in this woman’s
opinion, she would have previously suffered illness if
that was the case. This is an important consideration for
health care professionals, to navigate cultural norms and
individual experiences when advising on healthy dietary
practices.
Because all participants were experiencing high-risk
pregnancies and dealing with a variety of health issues,
many referenced these experiences when explaining their
food choices.
Through the process of immigration, some of the women
exhibited acculturation in the food choices and in the
acceptance of Western biomedical understandings of preg-
nancy. Furthermore, some women decided not to adhere to
“traditional”guidelines. However, the women in this sample
largely favored advice given by family members, continuing
to follow customary food practices of their foremothers.
Figure 3 Illustrates immediate postpartum food choices that
one participant’s female kin prepared for her.
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Discussion
The scoping literature review emphasizes the limited
amount of data on this topic. More studies are required
to elicit deeper understanding of ethnocultural food choices
and practices, in order to fully inform processes to improve
cultural competency of maternity care. Therefore our pilot
study using photovoice and photo-assisted interviews
had provided deeper understandings of ethnocultural
food choices and practices. Our findings from the photo-
assisted interviews validates the finding of the scoping
review that there is a complex interplay of cultural, social,
and economic factors exists to affect the food choices,
intake and nutritional adequacy for pregnant immigrant
women [33].
Family and social support during pregnancy was import-
ant for participants, especially when they are not with their
extended family post-migration, as has previously been
reported [22,43]. Immigrant women in our study reported
various experiences of how much they can rely on support
network during pregnancy [42]. Antenatal and postnatal
food choices of these women also confirmed that the mean-
ing of food in a particular life event such as pregnancy
couldnotbechangedevenwhenthesewomenwereliving
in the country of migration for longer period of time
[48,49]. Immigrant women may adhere to certain cultural
food beliefs and practices more rigidly than their friends
and family that have remained at home [14]. As a result,
influencing dietary behavior change may be particularly dif-
ficult in these groups, particularly when the changes are
perceived to clash with one’sowncustomsthatprovide
emotional connections to home. It is important to note that
these cultural food items may be more important in some
families and communities than in others, and the existence
of intracultural diversity—further research is required on
factors affecting dietary change amongst immigrant preg-
nant women, and the heterogeneity of practices within
various ethnocultural immigrant communities.
The role of health practitioners, especially medical doc-
tors were identified as an important source of information
Figure 4 Illustrates foods that one participant avoided while breastfeeding.
Figure 5 Illustrates food that one participant was advised by a
dietician to avoid.
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in our study. One possible reason we found health
personnel as important sources of dietary information is
the location and context of the study. The clinic is rec-
ognized for providing language interpretative services
for diverse cultural groups. Conversely a few studies
have reported that immigrant women experience diffi-
culty in following healthy diet advice during pregnancy
that is provided by health care personnel. Some studies
indicate this is most challenging when they are from
low-income groups [42,45,50], although cost of food
was not as salient for our participants. We suggest that
this may be due to the fact that most of our participants
(seven) were not employed outside the home, and were
cooking traditional foods prepared with basic ingredients.
For example, it is cheaper to purchase dried beans, grains,
and so on than to buy processed or partially prepared
products. Nevertheless, we recommend that clinicians
may need to spend additional time discussing dietary diffi-
culties with their patients when cost of food impacts ac-
cessibility. Additionally, nurses, physicians and dietitians
may benefit from discussing lifestyle factors with the preg-
nant women’s entire family because pregnant immigrant
women may not make food decisions in isolation; their
husbands or elder female kin may bear responsibility for
family food decisions and practices.
Our study provides a snapshot of relatively recent
immigrant women’s experiences, which had little prior
exposure to the Canadian health care system and re-
productive health (including nutritional) practices. The
thematic analysis emphasizes the importance of local
social milieus of immigrant women in providing the
context for healthy practices and behaviors. Sources of
nutritional knowledge include female family members,
but also health practitioners.Thisisanopportunityto
incorporate cross-cultural normative practices when
advising immigrant women on health dietary practices
during pregnancy. We suggest that honoring and re-
specting traditional knowledge will potentially make
it easier to explain biomedical dietary norms and
recommendations.
Based on our findings, we recommended that clinicians
working within our hospital partners’setting: (a) look for
intersections in cultural food practices during pregnancy
with biomedical recommendations and build upon these
when providing dietary advice; (b) infrastructure and
policy activities of the hospital should continue building
collaborations with various ethnocultural communities
beyond language translation services to support health
pregnancies, recognizing the particular constraints and
opportunities in various immigrant communities (e.g.
community outreach by hospital dieticians may be use-
ful); and, (c) Health care policies of the hospital need to
provide support for practitioners, particularly with re-
spect to cultural knowledge they may need to improve
their effectiveness, perhaps during some of the regular
training sessions.
Study limitations
Recruitment from the diverse ethnocultural group was
the key challenges in this research project. To recruit
women for the study, we relied on our hospital partners.
Although the study was initially conceived to include
Aboriginal pregnant women, this was not done because
the Aboriginal hospital coordinator left the position and
the team decided that without an Aboriginal coordinator/
liaison it was not appropriate to proceed. Although our
hospital partners working with immigrant women were
enthusiastic, recruitment proved to be time-consuming,
and recruitment involved additional time constraints on
our partners’schedules. To assist with recruitment, a brief
information sheet with permission to contact (i.e. poten-
tial participants gave consent for researchers to contact
them) was developed. It also seemed that women were
often in the latter part of their pregnancies when recruited,
and in a few cases this meant that they were no longer
pregnant by the time they were contacted. Furthermore,
the hospital setting arguably had stressful connotations for
potential participants which may have influenced their
willingness to participate. Consequently, of the twenty-one
women who indicated that they would be willing to be con-
tacted, only ten agreed to participate in the pilot study.
Clearly potential and actual participants had many stresses
to grapple with and participationinthisresearchstudy,
even for those who were interested, was not always pos-
sible. A high-risk pregnancy is stressful for anyone, but
particularly so for those who may have cultural and/or
linguistic barriers and limited social support networks.
Our study sample consisted of women mostly from
South Asia (six out of ten). Among our participants, shared
dietary experiences when pregnant post-migration centered
on the importance of support networks for pragmatic
and emotional support while pregnant, and as knowledge
sources for appropriate dietary practices (e.g. ethnocul-
tural beliefs on appropriate foods to consume or avoid
during pregnancy). Although this seemed salient for all
our participants, it ought to be kept in mind that immi-
grants from other places, particularly Latin America which
was not represented in our sample, may have other factors
shaping food beliefs and practices in pregnancy and in the
immediate post-natal period. Furthermore, all the partici-
pants were experiencing high-risk pregnancies, and this
may have influenced our results. Nevertheless, findings of
this pilot study did enable us to progress to a large
national study, in which we are currently examining
immigrant pregnant women’s food beliefs and practices
from select ethnocultural groups, to better understand
variations in beliefs and practices between and within
specific immigrant communities [40].
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Conclusion
In a multicultural society that contemporary Canada is,
it is challenging for health practitioners to understand
various ethnocultural dietary norms and practices. Prac-
titioners need to be aware of customary practices of
the ethnocultural groups that they work with, while simul-
taneously recognizing the variation within—not everyone
follows customary practices, or individuals may pick
and choose which customary guidelines they follow. It is
critical that health care providers recognize the complexity
in cultural food and health beliefs and practices, and how
socioeconomic status, age, ethnicity and family structure
and support may differentially shape these beliefs and
practices. Findings of this project are valuable for health
practitioners to recognize that not all women accept
customary dietary rules. What women choose to eat is
also influenced by their own experiences, their access
to particular foods, their socioeconomic status, family
context, and so on. Thus, it is important to not assume
that all people of a particular cultural group share the
same dietary notions and food practices. The project
team suggest that building collaborations between practi-
tioners and communities to support healthy pregnancies
and social support for pregnant and breastfeeding mothers
is of prime importance. Working with community organi-
zations will also be important in continuing to develop
culturally appropriate dietary recommendations that in-
corporate biomedical knowledge and customary practices.
The pilot study enabled us to establish the feasibility of
our approach in terms of methodology and recruitment
strategies for a larger study; in particular, we realized that
recruiting at the perinatal clinic was not the best ap-
proach, so for the larger study we partnered with com-
munity groups for recruitment of immigrant women
with normal pregnancies. For our hospital partner, we
recommended that policies and practices ought to
consider cultural food practices, building on traditional
strengths while addressing customs that may not be
ideal for the health of the mother or child. It cannot,
though, be forgotten that additional approaches such as
social and financial assistance programs addressing the
array of health determinants are also required. These
findings may be useful in other clinical settings providing
care for immigrant women.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
GH conceptualized the study and led the research team, contribution to
data analysis and production of the manuscript. HV contributed to
conceptualization of the study, data analysis and production of the
manuscript. JF and DG contributed to data collection, FM and RB
contributed to the scoping review and data analysis and manuscript
production. All authors read and approved the final manuscript.
Acknowledgements
We would like to thank the Royal Alexander Nursing Research Foundation
for generously funding our research.
We confirm our research and subsequent publication confirms to the
principles espoused in http://www.biomedcentral.com/authors/rats.
Author details
1
University of Alberta, Faculty of Nursing, 3rd Floor Edmonton Clinic Health
Academy, 11405 87th Avenue, Edmonton, Alberta T6G 1C9, Canada.
2
Department of Anthropology, University of Alberta, 13-15 HM Tory Building,
Edmonton, Alberta T6G 2H4, Canada.
3
Alberta Health Services, Lois Hole
Hospital for Women, 10240 Kingsway Avenue, Edmonton, Alberta T5H 3 V9,
Canada.
4
Department of Maternal-Infant and Public Health Nursing, University
of São Paulo at Ribeirão Preto College of Nursing, São Paulo, Brazil.
Received: 4 March 2014 Accepted: 15 October 2014
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doi:10.1186/s12884-014-0370-6
Cite this article as: Higginbottom et al.:Food choices and practices
during pregnancy of immigrant women with high-risk pregnancies in
Canada: a pilot study. BMC Pregnancy and Childbirth 2014 14:370.
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