CHAPTER 2

LITERATURE REVIEWS

This study aimed to examine factors influencing eating behavior among

pregnant women in Bangladesh. The theoretical perspectives and research findings
relevant to the study topic are reviewed and summarized into four sections as follows:
1. Nutrition in pregnant women
1.1 Nutritional needs during pregnancy
1.2 Nutritional guidelines for pregnant women in the Western world
1.3 Nutritional guidelines for pregnant women in Bangladesh
1.4 Effects of nutrition on maternal and infant health outcomes
2. Nutritional problems and eating behaviors in Bangladeshi pregnant
women
2.1 Maternal nutritional problems in Bangladeshi pregnant women
2.2 Eating behaviors in Bangladeshi pregnant women
3. Pender’s health promotion model and eating behavior in pregnant women
4. Factors related to eating behavior among pregnant women

Nutrition in pregnant women

Nutritional needs during pregnancy
Nutrition during pregnancy is a significant public health concern (Wen et al.,
2010) because pregnancy is a critical period during which good maternal nutrition is a
key factor influencing the health of both mother and child. During the prenatal period,
the developing fetus obtains all of its nutrients through the placenta, so dietary intake
has to meet the needs of the mother as well as the products of conception, and enable
the mother to lay down stores of nutrients required for the development of the fetus
(Williamson, 2006). According to WHO (2014), nutrition is the intake of food
considered in relation to the body’s dietary needs. Good nutrition, well balanced diet
combined with regular physical activity is a cornerstone of good health, whereas poor
nutrition can lead to reduced immunity, increased susceptibility to disease, impaired
physical and mental development, and reduced productivity (WHO, 2014). Therefore,
women of child-bearing ages should maintain good nutritional status through a
 12

lifestyle that optimizes maternal health and reduces the risk of birth defects,
suboptimal fetal growth and development, and chronic health problems in their
children. The key components of a health-promoting lifestyle during pregnancy
include appropriate weight gain, appropriate physical activity, consumption of a
variety of foods in accordance with the dietary guidelines for pregnancy, appropriate
and timely vitamin and mineral supplementation, avoidance of alcohol, tobacco, and
other harmful substances, and safe food handling (Kaiser & Allen, 2008).
Nutritional guidelines for pregnant women in the Western world
In order to address the needs of nutritionally demanding for pregnant
women, many developed countries have developed nutritional recommendations for
their pregnant women. In the USA, a system of Dietary Reference Intakes (DRIs) has
been devised which provides nutritional recommendations for North American
pregnant women (United State Department of Agriculture [USDA], 2010). For a
pregnant woman to meet recommended DRIs, she should eat according to the USDA
Food Guide My Plate. The Dietary Guideline for Americans, 2010, is the basis for
federal nutrition policy (USDA, 2010). The Food Guide My Plate provides guidelines
to help implement these guidelines and serve as a basis for dietary instruction and it
can be tailored to provide sufficient nutrients for a healthy pregnant woman (Ricci,
2013).
Guidelines for American pregnant women can be summarized as follows
(Ricci, 2013):
1. Total Energy: Energy is the chief nutritional determinant of gestational
weight gain. Recommendations for weight gain during pregnancy should be
individualized according to pre-pregnancy body mass index (BMI) to improve
pregnancy outcome, avoid excessive maternal postpartum weight retention, and
reduce risk of later chronic disease for the child. On average, expected weight gain
was 11.5-16 kilograms (25-35lb) by the end of pregnancy (Murray & McKinney,
2014). Most pregnant women need daily caloric intake of 2,200 to 2,900 calories
which vary by their BMI, age and activity. No additional calories are needed in the
first trimester of pregnancy, but an additional 340 calories per day and 452 calories
per day are needed in the second and third trimester of pregnancy respectively for fetal
 13

growth (Murray & McKinney, 2014; McKinney, James, Murray, Nelson, & Ashwill,
2013).
2. Protein: During pregnancy, the women need increased amounts of protein
to provide amino acids for fetal development, blood volume expansion, and growth of
fetal and maternal tissues, such as the breast and uterus. Protein also contributes to the
body’s overall energy metabolism (Davidson, London, & Ladewig, 2008). Protein
intake of approximately 71 grams/day is recommended during the second half of
pregnancy (Murray & McKinney, 2014). High-quality sources of proteins include
animal sources - meat, eggs, poultry, fish and dairy, and variety of plants (Brown,
2010).
3. Carbohydrate: The carbohydrate needs of the pregnant women increase,
especially during the last two trimesters. Carbohydrate intake promotes weight gain
and growth of the fetus, placenta, and other maternal tissues. Dairy products, fruits,
vegetables, and whole grain cereals and breads all contain carbohydrates. The
requirements for carbohydrate during pregnancy is 175 grams /day, increased from
130 grams/day for non-pregnant woman (USDA, 2010).
4. Lipids and Fats: Fats provide energy and fat-soluble vitamins. When
decreasing calories is necessary, a reduction but not elimination of carbohydrates and
fats is important. If carbohydrate and fat intake provides insufficient calories, the body
uses protein to meet energy needs. This use decreases the amount of protein available
for building and repairing tissue. Fat intake for pregnant women is 20% to 30% of
total calories, the same as for general women (USDA, 2010). However, pregnant
women are recommended to lower intake of saturated fats, trans fats, and cholesterol.
Essential fatty acid such as alpha-linolenic acid and linoleic acid, helps in the fetal
neurologic and visual development. Decosahexaenoic acid is also important for fetal
visual and cognitive development, particularly in late pregnancy. These fatty acids are
found in canola, soybean, and walnut oils, as well as some seafood such as bass or
salmon (Murray & McKinney, 2014; Williamson, 2006).
5. Fiber: Fiber is very important component of the prenatal diet. The
development of the fetus is not dependent on an adequate supply of fiber, but a high-
fiber diet significantly increases the comfort of the pregnant women by helping to
reduce constipation, hemorrhoids, and diverticulitis (Brown, 2010; Davidson et al.,
 14

2008; Murray & McKinney, 2014; Williamson, 2006). Fruits, vegetables, beans,
whole grain, seeds, and nuts are all good dietary sources of fiber.
6. Vitamins and Mineral Supplement: An adequate intake of all vitamins is
essential during pregnancy and several are required in larger than normal amounts to
fulfill specific needs. Extra vitamin A is required during pregnancy for growth and
maintenance of the fetus, for fetal stores of vitamin A and for maternal tissue growth.
Requirements are highest during the third trimester, when fetal growth is most rapid.
Daily requirements vitamin A is 770 micrograms which sources in dark green, yellow,
or orange vegetables; whole or fortified low-fat or nonfat milk; egg yolk and butter
(Davidson et al., 2008; Murray & McKinney, 2014; Williamson, 2006).
Thiamin (B1) and riboflavin (B2) are needed for the release of energy in the
body’s cells. Requirements for thiamin parallel the requirements for energy and are
subsequently higher for the last trimester of pregnancy, an increase of 0.1 mg to a total
of 0.9 milligrams per day during the last trimester. The increase for average riboflavin
intake is 0.3 milligrams per day to a total of 1.4 milligrams per day for pregnant
women. Good sources of riboflavin include milk, meat. fish, poultry, eggs, enriched
grain products, and dark green vegetables (Davidson et al., 2008; Murray &
McKinney, 2014; Williamson, 2006).
Before getting pregnancy women need to take a folic acid supplement of 400
micrograms/day and up until the twelfth week of pregnancy. The need for folic acid
increases during times of rapid tissue growth, increase in red blood cell mass,
enlargement of the uterus, and the growth of the placenta and fetus (Abu-Saad &
Fraser, 2010; Littleton-Gibbs & Engebretson, 2013; Williamson, 2006).
The requirement for vitamin C (Ascorbic acid) is increased in pregnancy
from 75 to 85 milligrams per day. The major function of vitamin C is to aid the
formation and development of connective tissue and the vascular system. Sources
include citrus fruit, peppers, strawberries, green leafy vegetables, and tomatoes
(Davidson et al., 2008; Murray & McKinney, 2014). Another crucial nutrient for
pregnant women includes vitamin D which found in milk, yogurt and juice, fortified
cereals and breakfast bars. Daily requirement vitamin D is 15 micrograms during
pregnancy (Anderson, 2010).
 15

The women can increase minerals needed for the growth of new tissue
during pregnancy by improving mineral absorption and increasing mineral intake
(Davidson et al., 2008). Calcium and phosphorus are involved in the mineralization of
fetal bones and teeth, energy and cell production. Calcium is absorbed and used more
efficiently during pregnancy. Some additional calcium and phosphorus are required
early in pregnancy, but most of the fetus’s bone calcification occurs during the last 2
or 3 months. Adequate intake for calcium for the pregnant women is 1000 milligrams
per day and sources in dairy products, salmon, sardines with bones, legumes, fortified
juice (Davidson et al., 2008; Murray & McKinney, 2014).
The sodium is essential for proper metabolism and the regulation of fluid
balance. The pregnant women can obtain moderate sodium intake (2-3grams) by using
fresh food lightly seasoned to taste during cooking. The use of extra salt at the table
should be avoided. Salty foods, such as potato chips, sausages, and sodium-based
seasonings, can be eliminated to avoid excessive intake. Iron requirements increase
during pregnancy because of the growth of the fetus and placenta and the expansion of
maternal blood volume. Daily requirements of iron is 27 milligrams and sources in
meats, dark green leafy vegetables, enriched bread and cereal, dried fruits, nuts.
7. Water and drink: A pregnant women should consume at least 8-10 glasses
of fluid each day, of which 4 – 6 glasses should be water. Other beverages such as
juices and milk can contribute water as well as other nutrients to the diet (Davidson et
al., 2008).
8. Food safety: Safe food cooking is an important aspect of good eating
behavior in order to prevent food-related diseases in pregnancy such as listeriosis and
toxoplasmosis. Thus pregnant women are suggested to avoid raw or undercooked
fresh meat and chilled ready-to-eat food. Raw fruit and vegetables should be peeled
and washed thoroughly before consumption to remove contaminating soil (Gilbert,
2002; Murray & McKinney, 2014). The first six weeks after conception are extremely
important for the most favorable development of the fetus. Therefore, the women must
be aware of and avoid nutritional risk factors and ingestion of teratogenic substances
such as alcohol, tobacco, and illegal drugs (Ferrari, Siega-Riz, Evenson, Moos, &
Carrier, 2013; Littleton-Gibbs & Engebretson, 2013).
 16

In summary, according to the USDA Food Guide My Plate, five groups of

food recommended for pregnant women include fruits, vegetable, grains, meat and
beans, and milk as details in the table 1(Ricci, 2013).

Table 1 Food guide for pregnancy daily requirement (Ricci, 2013 p. 328).

Food 1st 2nd and 3rd Counts as 1 cup Additional

Group Trimester Trimester or 1 ounce Recommendation
Fruits 2 cups 2 cups 1 cup fruits or Focus on fruits- eats
juice, ½ cup dried a variety of fruits
fruit
Vegetables 2 ½ cups 3 cups 1 cup raw or Vary vegetables - eat
cooked vegetables more dark-green and
or juice, 2 cups orange vegetables
raw leafy and cooked dry
vegetables beans.
Grains 6 ounces 8 ounces 1 slice bread; 1 Make half grains
ounce ready- to- whole- choose whole
eat cereal; ½ cup instead of refined
cooked pasta, rice grains
or cereal
Meat and 5½ 6 ½ ounces 1 ounce lean meat, Go lean with protein
beans ounces poultry, or fish; ¼ - choose low- fat or
cup cooked dry lean meats and
beans; ½ ounce poultry
nuts or 1 egg; 1
table spoon peanut
butter
 17

Table 1 (Cont.)

Food 1st 2nd and 3rd Counts as 1 cup Additional

Group Trimester Trimester or 1 ounce Recommendation
Milk 3 cups 3 cups 1cup milk, 8 Get calcium rich
ounces yogurt, 1 ½ foods- go low fat or
ounces cheese, 2 fat –free when
ounces processed choose milk, yogurt,
cheese and cheese.

Nutritional guidelines for pregnant women in Bangladesh

The nutritional guidelines in western or developed countries have been used
as international guidelines in many countries to ensure, in theory, that it will be the
most effective to the health of a pregnant woman and her developing fetus. Individual
nations should be developing their own nutritional guidelines in order to be more
context specific as some of the international guidelines may not be appropriate.
World Food Programme [WFP], (2014) in Bangladesh stated that during
pregnancy women have special nutritional needs. Pregnant women have a greater need
for energy and also for the nutrients that make their breast milk nourishing to their
babies. This is critical in situations where women are already malnourished before
pregnancy and do not receive certain vitamins or minerals (WFP, 2014). The
nutritional guidelines for Bangladeshi pregnant women have been developed as shown
in table 2 (Chowdhury, 2009).
 18

Table 2 Bangladeshi pregnant women daily nutrition requirements (Chowdhury, 2009

p. 61).

Nutrient element Quantity Food stuff Quantity

Calories 2,500 Rice 235 grams
Protein 1 gram/kilogram body Wheat 115 grams
weight + extra 10 grams
Calcium 1 gram Pulses 90 grams
Iron 40 grams Leafy 145 grams
Vitamin-A 750 micrograms Others vegetables 90 grams
Vitamin-B1 1.3 milligrams Potato or kachu 75 grams
Vitamin-B2 1.4 milligrams Seasonal fruits 90 grams
Niacin 1.7 milligrams Milk 235 grams
Vitamin-C 50 milligrams Oil 45 grams
Folic acid 150-300 micrograms Sugar 30 grams
Vitamin-12 1.5 micrograms Fish or meat 60 grams
Vitamin-D 120 micrograms Egg 1

In Bangladesh, to assess and reinforce dietary information at every prenatal

visit to promote good nutrition, nurses can play an important role in ensuring adequate
nutrition for pregnant women. During the initial prenatal visit, nurse conduct a
thorough assessment of a women’s typical dietary practices and address any
conditions that may cause inadequate nutrition, such as nausea and vomiting or lack of
access to adequate food.
Effects of nutrition on maternal and infant health outcomes
Intake of adequate and balanced diet before conception is required for
successful pregnancy outcomes. All women experience increased nutritional
requirements during pregnancy, and thus all women should ensure they are well
informed about and attempt to maintain a healthy balanced diet before and during
pregnancy. However, some women may find it harder to access or consume all the
necessary components of a healthy diet throughout their life and during pregnancy.
 19

Several studies found that inadequate nutrient intake of both macronutrients

(carbohydrate, protein, fat) and micronutrients (such as iron, calcium, phosphorus,
magnesium, zinc, vitamin A, thiamine, riboflavin, niacin, and vitamin C) appear to
affect maternal anemia, increasing the risk for other maternal morbidities and
mortality, fetal growth retardation and low fetal birth weight (Bhutta et al., 2013;
Darnton-Hill, 2013; Fowles & Feucht, 2004; Persson et al., 2012).
Under nutrition of mother during pregnancy created serious problem of low
birth weight or weighing of baby less than 2,500 grams at birth mostly occurred in
Asia (Muthayya, 2009). Low birth weight is an important indicator of the overall
health of the mother and the newborn (Muthayya, 2009; Williamson, 2006).
Intrauterine growth retardation (IUGR) and preterm birth are the two main causes of
low birth weight. In low-income countries, the majority of low birth weight infants are
born small but not premature. A study in rural Bangladesh reported that IUGR was the
major contributor to low birth weight (96.4%) while only 3.6% of babies were born
preterm (Nahar, 2004). The rates of low birth weight among Bangladeshi infants,
though reduced from 40%, are still among the highest in the world, ranging from 20%
to 22%. After controlling for the independent effects of other covariates, maternal
BMI and height were shown to be the powerful predictors of LBW in Bangladesh.
Study among 100 pairs of pregnant mother-newborn in urban and rural areas of Dhaka
city, Bangladesh found that there were associations between the mothers' body weight
and their newborns body weight indicating that well nourished mothers gave birth to
healthy babies (Ahmed et al., 2005).
A recent study among pregnant women in poor communities in Bangladesh,
Persson et al. (2012) demonstrated that giving prenatal multiple micronutrient
supplementation including iron and folic acid combined with early food
supplementation helped to increase maternal hemoglobin level and birth weight even
was not at statistically significant, but resulted in decreased infant mortality rate of
16.8 per 1000 live births as compared to 44.1 per 1000 live births in women receiving
a standard program that included treatment with iron and folic acid and usual food
supplementation usual invitation.
Micronutrient-related malnutrition is often termed ‘hidden hunger’ as the
consequences are not always visible. Inadequate intake of micronutrients during
 20

pregnancy predisposed women to multiple complications of pregnancy. Allen (2000)

has found that insufficient iron intake was associated with preterm delivery.
Insufficient calcium intake was associated with increasing maternal blood pressure
during pregnancy among women at risk of hypertension (Ritchie & King, 2000).
Micronutrient deficiencies also has a great impact on the long-term health
prospects of child. Inadequate nutrition, especially early in the pregnancy, may impair
fetal brain development and cause abnormalities in endocrine functioning, organ
development and the energy metabolism of child. Pregnant women whose foliate
levels were low because their diets lacked foods containing this B-complex vitamin,
increased the risk of defects in the neural tubes of their newborn babies (Juhasz,
2013). Prenatal deficiencies in vitamins D and E have been associated with increased
incidences of respiratory difficulties, including wheezing and asthma, in the baby
(Devereux et al., 2007). A recent study found that intake of prenatal vitamins may
reduce the risk of having children with autism (Schmidt et al., 2011).
Micronutrient deficiencies especially iron and folic acid deficiencies that
result in nutritional anemia in children and women and neural tube defects in
newborns remain a public health problem in Bangladesh. Poor intake of foods rich in
iron and folic acid and multiple infections have resulted in high rates of anemia among
pregnant women and children less than two years. Coverage of pre and postnatal iron
and folic acid supplements is very low (only 15% of pregnant women in rural areas
take at least 100 tablets during pregnancy) due, in part, to low compliance rates and
low coverage of antenatal services. Coverage of multiple micronutrient supplements
formulated to address iron and other micronutrient deficiencies is also very low
(Ahmed et al., 2012).
The prevalence of common childhood illnesses such as diarrhea and acute
respiratory infections continues to be a major cause of infant and child morbidity and
mortality in Bangladesh (Piechulek, Aldana, Engelsmann, & Hasan, 1999). It has been
proposed that inadequate intake of nutrients during pregnancy induces the fetus to
develop adaptations to a limited supply of nutrients, results in permanent alteration on
its structure, physiology, function, and metabolism. Such change is called “fetal
programming” which may activate a number of diseases later in life when individual
expose to dietary intakes and lifestyles diversed significantly from the scarcity
 21

experienced in uteroplacental insufficiency, cause the emerging the theory of “fetal

origins of adult disease”; endocrine and cardiovascular disease in adult life (Wu,
Bazer, Cudd, Meininger, & Spencer, 2004).

Nutritional problems and eating behaviors in Bangladeshi pregnant

women
Maternal nutritional problems in Bangladeshi pregnant women
In Bangladesh, maternal mortality rate remains high underpinned by the fact
most deliveries take place at home, away from emergency obstetric care and without a
skilled attendant; moreover, inappropriate consumption of food. Bangladesh continues
to struggle with levels of maternal malnutrition that are among the highest in the
world. Almost one-quarter women are considered to be undernourished with BMI of
less than 18.5 (National Institute of Population Research and Training, Mitra and
Associates, ICF International, 2013). In addition, anemia is a severe public health
problem in pregnant women due to lack of nutrition (UNICEF, 2007). World Food
Programme (WFP, 2012) in Bangladesh indicated that micronutrient deficiencies
particularly iron deficiency anemia and iodine deficiency is widespread and multiple
deficiencies are common. Iron deficiency anemia among pregnant woman is a serious
nutritional challenge; with one in two pregnant women is anemia. Pregnant women in
Bangladesh suffer most from under nutrition and underweight (WFP, 2012).
Micronutrient deficiencies especially iron and folic acid deficiencies result in
nutritional anemia during pregnancy. Poor intake of foods rich in iron and folic acid
and multiple infections have resulted in high rates of anemia among pregnant women.
Coverage of pre and postnatal iron and folic acid supplements is very low (only 15%
of pregnant women in rural areas take at least 100 tablets during pregnancy) due, in
part, to low compliance rates and low coverage of antenatal services. Coverage of
multiple micronutrient supplements formulated to address iron and other
micronutrient deficiencies is also very low in Bangladesh (UNICEF, 2007).
Thus, attention to appropriate eating behavior and proper nutrient intake will
supply adequate nourishment to achieve optimum health for both mother and child
(Wen et al., 2010).
 22

Eating behaviors in Bangladeshi pregnant women

Eating behavior is important for pregnant women to maintain a healthy life
and good birth outcomes. Eating behavior differs from other types of health behaviors
and its basic forms are essential for life. Some eating behaviors are not necessary to
sustain life, such as drinking alcoholic beverages. Eating behavior is an integral part
of individual, family, and community lifestyles.
Eating behaviors and practices during pregnancy in Bangladesh have been
widely studied. A study by Karim, Bhat, Troy, Lamstein, and Levinson (2002) found
that 40% of women indicating a belief that more food during pregnancy is optimal
however they did not, in fact, put this knowledge into practice during their last
pregnancy. Factors not significantly associated with food consumption during
pregnancy included number of antenatal visits, household size, and family type. A
study of dietary practices among pregnant mothers in a rural area served by a
reproductive health and nutrition program reported that despite high levels of
awareness of nutritional dietary requirements, half the pregnant women reported
unchanged or reduced food intake during pregnancy. Dietary taboos and food
aversions were widely practiced. Women consistently received the last and smallest
food shares during mealtimes. The findings highlight the need to address traditional
dietary taboos and preferences, and actively target key household decision makers,
namely, husbands and mothers-in-law, in nutrition behavior change communication
(Shannon et al., 2008).
The findings of Shom (2010) showed that pregnant women had a high level
of healthy dietary behaviors in the aspects of quality of diet and avoiding diet during
pregnancy, except supplementary diet during pregnancy needed to be improved. This
is consistent with a study by Islam and Ullah (2005) which found that about 75%
women believe that mother’s malnutrition is the main cause of child malnutrition.
Most of the pregnant women have positive opinion about taking food. Some
traditional disbelief exists about taking milk and certain fruits such as pineapple and
banana. From the study it was observed that pregnant women do not take milk (21%),
Pineapple (75%), Banana (10%) for various disbeliefs.
Results of a qualitative study among ultra-poor pregnant women found that
women usually considered pregnancy as a normal event unless complications arose,
 23

and most of them refrained from seeking antenatal care except for confirmation of
pregnancy, and no prior preparation for childbirth was taken. There were multiple
food-related taboos and restrictions, which decreased the consumption of protein
during pregnancy and post-partum period (Choudhury & Ahmed, 2011).
An ethnographic study in an urban slum in Dhaka, Bangladesh found that
women were aware of the importance of good nutrition and demonstrated accurate,
biomedically-based knowledge of healthy eating practices during pregnancy. The
normative gender rules that have traditionally constrained women’s access to
nutritional resources are relaxing in the urban setting; however, women are challenged
in accessing adequate quality and quantities of food due to the increase in food prices
at the market (Levay et al., 2013).
Findings of several studies demonstrated that maternal malnutrition in
Bangladesh is a persistent health issue and is the product of a number of complex
factors, including adherence to food 'taboos’ and a patriarchal gender order that limits
women’s mobility and decision-making (Levay et al., 2013; Shannon et al., 2008).
Eating down during pregnancy (i.e. consuming less food) in order to avoid
having too large a baby, and consequently a more difficult labor, is a commonly
reported phenomenon in Bangladesh and in other South Asian countries (Shannon et
al., 2008). This practice is counter to the western biomedical paradigm’s definition of
healthy eating while pregnant, which states that women should consume more calories
during this time. However, there is evidence to support the notion that Bangladeshi
women are not necessarily “eating down” during their pregnancies as a result of
traditional or cultural reasons. Rather, socioeconomic status has also been found to be
associated with whether or not a woman increases her food intake while pregnant
(Choudhury & Ahmed, 2011; Karim et al., 2002).

Pender’s health promotion model and eating behavior in pregnant

women
The HPM is a framework for integrating nursing and behavioral science
perspectives on factors influencing health behaviors which was developed by Pender
et al. (2011). The HPM guides for exploration of the complex bio-psychosocial
processes that motivate individuals to engage in behaviors directed toward the
 24

enhancement of health (Pender et al., 2011). The model describes that there are ten
determinants of behavior organized into three major components which included (1)
individual characteristics and experiences, (2) behavior specific cognitions and affect,
and (3) behavioral outcome (Pender et al., 2011).
Individual characteristics and experiences include the persons’ unique
characteristics and experiences that affect subsequent action. The individual
characteristics and experiences are divided into prior related behavior and personal
factors. Prior related behavior which is the best predictor of behavior is the frequency
of the same or a similar behavior in the past. Prior behavior is proposed as having both
direct and indirect effects on the likelihood of engaging in health promoting
behaviors. The direct effect of the past behavior on current behavior may be due to
habit formation. The indirect effect can influence health promoting behaviors through
perceptions of benefits, barriers, self-efficacy and activity related affect such as
positive behavior, engendering high levels of efficacy and positive affect through
successful performance of experience and positive feedback. Personal factors are
categorized as biologic, psychological and sociocultural characteristics. These factors
which are predictive of given behavior are shaped by the nature of the target behavior
being considered.
Behavior specific cognitions and affect include perceived benefits of action,
perceived barriers to action, perceived self-efficacy, activity-related affect,
interpersonal influences and situational influences. Perceived benefits of action can
improve health behavior by motivating behavior directly as well as indirectly (Pender
et al., 2011). Perceived barriers to action usually arouse motives of avoidance in
relation to a given behavior. Perceived barriers to action affect health promoting
behaviors directly by impeding action, and indirectly through decreasing commitment
to a plan of action. Perceived self-efficacy is a judgment of one’s abilities to
accomplish a certain level of performance, whereas an outcome expectation is a
judgment of the likely consequences (e.g. benefits, costs). Self-efficacy motivates
health promoting behavior directly by efficacy expectations and indirectly by affecting
perceived barriers and level of commitment or persistence in pursuing a plan of action
(Pender et al., 2011). Activity-related affect describes subjective positive or negative
feelings that occur before, during and following behavior based on the stimulus
 25

properties of the behavior itself. Activity-related affect influences perceived self-

efficacy, which means the more positive the subjective feeling, the greater is the
feeling of efficacy. In turn, increased feelings of efficacy can generate further positive
affect. Interpersonal influences are cognitions of the behavior, believes, or attitudes of
others. It includes norms, social support and modeling. These three interpersonal
processes result in individuals’ predisposition to engage in health promoting
behaviors. It also influences as determinants of health promoting behavior including
moderate support for the construct. Situational influences are personal perceptions and
cognitions of any given situation or context that can facilitate or impede behavior.
They include perceptions of available options, demand characteristics, and aesthetic
features of the environment in which health promoting behavior is proposed to take
place and situational influences may have direct or indirect influences on health
behavior (Sakraida, 2010).
The last component of the HPM is the behavioral outcome such as healthy
eating behavior. Health promoting behavior is directed by the commitment to a plan of
action, which is determined by the six behavior-specific cognitions and affect.
Immediate competing demands and preferences-competing demands are alternative
behaviors over which individuals have low control because there are environmental
contingencies such as work or family care responsibilities. Competing preferences are
alternative behaviors over which individuals exert relatively high control, such as
choosing a tasty, high-fat food instead of a healthier option. The components and
variables are related to each other, such as the individual characteristics and
experiences which influences the behavioral outcome through the second component
of the interrelationship among variables. All of these combined directly affect the
individuals commitment and ultimately the performance of the health promotion
behavior including healthy eating behavior (Pender et al., 2011).
The HPM has been applied to pregnant women's health promotion in many
studies (Lin et al., 2009; Thaewpia et al., 2012) including eating behavior among
pregnant women (Fowles & Feucht, 2004; Thaewpia et al., 2012)
 26

Factors related to eating behavior among pregnant woman

There are several factors that influence eating behavior among pregnant
women. This literature review will focus on selected factors according to the HPM
including family income, perceived benefits, perceived barriers, and perceived self-
efficacy.
Family income
Family income/ economic status is an important personal factor that
contribute to eating behavior during pregnancy. A woman with a firm financial
background will be able to seek the benefits of health care, get good food and high
quality service, and also find the right products and equipment for health promotion
behavior. A person with less income will have limits in finding things to improve
health. This agrees with the findings of a study by Walker et al., (1999) indicating that
lower family income was related to poorer health behaviors in the first trimester of
pregnancy.
Many studies have noted family income that women with low income have
more disturbed eating patterns. Financial instability creates hindrance in the
development of healthy eating patterns during pregnancy. As a result in such a
situation, women are at high risk of given birth to low birth weight infant (Sohail &
Muazzam, 2012). Murakami et al. (2009) mentioned that family income were
associated with nutrient inadequacy. Low income is associated with unhealthy eating;
moreover, low income mother is associated with low infant birth weight
(Ramakrishnan, 2004). Diet quality may be reduced in low-income women due to
limited finances to purchase nutrient-rich foods. Low income women might perceived
that they should eat a quality diet but could not afford to buy food to make up a
healthy diet (Dammann & Smith, 2009).Women with limited financial resources
unable to engage in healthy nutritional practice early in pregnancy , thereby placing
them at risk for perinatal complications. Low income pregnant women often have a
lower intake of fruits and vegetables, lean sources of protein, and whole grains- all
relatively high cost foods. This eating pattern can result in lower intakes of
macronutrients, vitamins, and minerals (Fowles & Fowles, 2008). In Bangladesh
results of several studies found that energy intake and nutritional status of Bangladeshi
women were influenced by socioeconomic status and monthly family income. It was
 27

also found different contributory sources in high and low income groups (Hossain et
al., 2013; Islam, Akhtaruzzaman, & Lamberg-Allardt, 2004; Panter-Brick,1993).
Perceived benefits of healthy eating
Perceived benefits are anticipated positive outcomes or reinforcing
consequences that will result from health behavior (Pender et al., 2011; Sakraida,
2010). It is the belief that changing one's behavior will reduce the threat. The build of
perceived benefit is a person’s opinion of the value or helpfulness of a new behavior
in decreasing the risk of developing a disease. Perceived benefits from good dietary
practices encourage individuals to select foods that are high in nutrients, low in animal
fat, and refined carbohydrates, high in fiber, and low sodium and food additives (
Pender et al., 2011). Perceived benefits of health promoting behaviors were found to
be a predictor of actual health promoting behaviors in mothers experiencing preterm
delivery (Thaewpia et al., 2012).
There are benefits pregnant women get from healthy eating behavior. The
healthy eating means eating a variety of food that provides nutrition for pregnancy as
well as gives energy and feeling better. Healthy eating tends to show better gain of
mother’s weight and is related to healthy birth result (Sohali & Muazam, 2012).
Benefits to healthy eating include weight control, disease prevention, fitness, higher
energy level, staying healthy, looking more attractive, feeling better and living longer
(Strolla, Gans, & Risica, 2006). One study survey reported that the most frequently
selected benefits to healthy eating were prevent disease (73.6%), stay healthy (69.4%),
have good quality of life (49.7%), have weight control (47.0%), be fit (39.4%), live
longer (28.7%) and have plenty of energy (28.2%) (Azpiazu, Gonzalez, Kearney,
Gibney, & Martinez, 1998). Greater perceived benefits to healthy eating have been
significantly associated with healthy dietary behaviors among women (Walker et al.,
2006). Perceived benefits related to positive outcomes of healthy eating for mother
were making look better, feeling better, preventing too much extra weight, and
reducing chances of having a baby that is too big (Gardner et al., 2012).
Perceived barriers to healthy eating
Perceived barriers are defined as factors that impede health promoting
behavior and include perceptions about the potentially negative aspects of changing
behavior (Pender et al., 2011). Perceived barriers are perceptions (real or imagined) of
 28

the obstacles to changing one's behavior, to engaging in action or to inhibiting

commitment to a behavior. Barriers may include time, cost, inconvenience, access,
and actual performance (Boland & Gibbons 2009; Lappalainen et al., 1997; Mirsanjari
et al., 2012; Reyes et al., 2013). In the HPM, barriers are modifying factors that
directly interfere with performing the health-promoting behavior (e.g., healthy eating
behavior) or indirectly interfere by reducing commitment to the plan of action for
changing behavior). For example, if the barriers to increasing fruit and vegetable
intake are lack of time and lack of access to affordable produce, then difficulty in
obtaining affordable produce directly reduces the likelihood of eating more fruits and
vegetables. Lack of time would interfere with commitment to a plan of action since
extra time would need to be expended to obtain fresh, affordable produce.
One study result indicated that barriers of healthy eating were time
constraints (24%), giving up foods that participants like (23%), busy lifestyle (17%),
resistance to change (21%), food preparation (19%), cost (15%), preferences of others
(13%), eating out (11%) and don’t want to change (15%) (Lappalainen et al., 1997).
On the other hand, a study in Bangladesh Shannon et al. (2008) found that barriers to
increasing dietary intake during pregnancy included discriminatory food allocation
(90%), lack of decision-making power (85%), lack of family support (67%),
economic/ access constraints (50%), illness (46%), not wanting the baby to be too
large (20%), large family size (7%), and not feeling comfortable to increase (7%).
Perceived dietary self-efficacy
Perceived self-efficacy is a judgment of personal capability and to organize
and execute a particular health behavior or self-confidence in performing the health
behavior successfully (Pender et al., 2011). In terms of health functioning, “efficacy
beliefs largely determine whether people consider changing their health habits and
whether they succeed in making and maintaining the change” (Bandura, 1997). Self-
efficacy is an individual’s confidence in his or her ability to maintain a healthy diet.
Specifically, dietary self-efficacy is the confidence one has to eat a healthy, balanced
diet under challenging circumstances, such as adhering to a diet or choosing healthier
food options at social functions (Sallis, Pinski, Grossman, Patterson, & Nader, 1988).
Perceived self-efficacy is a competence-based, prospective, and operative construct
that can be used to predict, explain, and change health behaviors (Schwarzer,
 29

Luszczynska, & Wiedemann, 2012).Therefore, an individual who feels capable and

efficacious in managing their health has a greater chance of engaging in more frequent
health promoting behaviors than an individual who feels unskilled. Greater perceived
self-efficacy leads to an increased probability of commitment and action to a health
promoting behavior (Pender et al., 2011). For that reason, perceived dietary self-
efficacy is an important construct that enhances the behavioral outcome associated
with commitment to healthy eating behavior among pregnant women.
One study found that the eating behavior scores of the experimental group
after receiving the self-efficacy and social support enhancement program were higher
than the control group (Tinamas, Panuthai, & Choowattanapakorn, 2008). Self-
efficacy significantly predicted the level of engagement in a health-promoting lifestyle
(Jackson, Tucker, & Herman, 2007). High dietary efficacy predicts increased ability to
lose weight (Abusabha & Achterberg, 1997). In addition, another study found that a
high self-efficacy score was significantly associated with high weight loss (Bas &
Donmez, 2009). A study among pregnant women in Bangladesh Shom (2010) found a
very high positive significant relationship between perceived dietary self efficacy and
dietary behavior during pregnancy (r = .92, p< .01).
In conclusion, eating behavior is one of the most important behaviors for
pregnant mothers. Moreover, research needs to be done in an attempt to identify
factors related to eating behavior which will in turn increase healthy eating behavior
in pregnant women. Through the review of literature, many factors related to eating
behavior in pregnant women were found. However, study in pregnant women in a
high prevalence of malnutrition as Bangladesh is limited. Among the above factors,
family income, perceived benefits of healthy eating, perceived barriers to healthy
eating and perceived dietary self-efficacy were found to have an association with
eating behavior. Therefore, effective modification eating behavior of pregnant woman
requires understanding such factors that determine eating behavior of pregnant woman
in Bangladesh.