Are anemia,gastrointestinal disorders,and pregnancy outcome associated with pica behavior?

1 Introduction

Adequate nutrition during pregnancy is important to maintaining mothers’ and fetuses’ health because a person’s health largely depends on receiving nutrients. Nutritional status in the fetal period is particularly essential. Most women change their diet, which may not be good for their health as well as their infants’. Pica is the practice of craving substances with little or no nutritional value and is practiced by all cultures around the globe [1, 2]. Studies suggest that the prevalence of pica during pregnancy is much more than it is reported and has adverse health effects on mothers and infants [3 –5]. The reason that pica is underreported in studies is probably that women feel embarrassed to talk about this behavior or consider it as unimportant [2]. Statistics on the prevalence of pica vary considerably. This may be explained by geographical differences. According to Ngozi, 74% of pregnant women in Kenya practiced some form of pica during pregnancy [5]. In a study by Mikkelsen et al., pica rate among Danish pregnant women was reported as 0.02% [6]. In another study, Saunders et al. reported a 50% rate of pica in pregnant women in Rio de Janeiro [7]. And in Iran, the prevalence of pica among the studied population was 15–22.3% [8, 9].

The causes and origins of pica remain unknown. Proposed risk factors for pica include race (black women are affected four times as much as white women), rural life (rural women are affected two times as much as urban women), low socioeconomic status, maternal age, impaired nutritional status (vitamin and mineral deficiencies), and positive childhood and family history of pica [2]. Iron deficiency can be one of the most important reasons of pica during pregnancy [10]. Yet, the relationship between pica and iron deficiency remains unknown. Some researchers claim that pica causes iron deficiency or inhibits iron absorption, while there is evidence suggesting that pica is caused by iron deficiency [11]. Pica is an eating disorder that can cause serious problems depending on the amount and duration with which it is practiced [12]. Medical consequences of pica for mothers’ health include tooth erosion, constipation, ileus, parasitic infections, poisoning, interference with absorption of minerals, lead poisoning, and hyperkalemia. The fetus also suffers from some negative outcomes such as premature birth, prenatal mortality, low birth weight, irritability, small head circumference, and prenatal exposure to toxic substances like lead [3 , 14]. Both men and women in all ages are infected by pica. However, it is more prevalent among children and pregnant women [15].

Studies reveal a significant relationship between pica during pregnancy and gastrointestinal disorders, such as nausea, abdominal pain, and constipation [2 , 16]. Geophagia is claimed to be a response to gastrointestinal disorders. In other words, it has a soothing effect on diarrheal disease (by reducing the speed of fluids’ passage in the digestive system). This seems for geophagia since some types of clay soil have substances (kaolin) that are effective in controlling diarrhea [17 –19]. A probable explanation for the sudden increase in pica practices during pregnancy is that, due to hormonal changes, pregnant women are more sensitive to parasitic infections. However, this is just a hypothesis. Pica may cause gastrointestinal distresses, such as constipation [15].

Considering the importance of mothers’ and infants’ health and scarcity of studies on the relationship between pica and mother-fetus outcomes, and the high prevalence of anemia (The prevalence of anemia in Iranian pregnant women has been reported at 21.5% [20]) and pica in Iranian pregnant women, the present study was designed.

2 Method

This study was a prospective study carried out between January 2016 and June 2017 in the city of Urmia in Iran. A sample of 230 pregnant women in their first trimester was selected. The inclusion criteria were as follows: 1) being in the first trimester, 2) maternal age of 18–40, and 3) no history of gastrointestinal disease before pregnancy.

3 Results

It should be noted that 4 pregnant women were excluded from the study due to abortion. 226 women were included in the study. The average age of the participants was 26.10±6.27, ranging from 14 to 40. 47.3% of the participants were nulliparous, and 17.7% had a history of miscarriage (Table 1). The prevalence of pica in pregnant women in the first (0–14 weeks of pregnancy), second (15–28 weeks of pregnancy), third trimesters (29 weeks of pregnancy until delivery), and postpartum were 9.3% (22 cases), 8% (18 cases), and 2.1% (5 cases), 0.4 % (1 case) respectively. The most common pica craving among pregnant women was for ice and frozen materials. The frequency of pica practices and the substances eaten are presented in Tables 2 and 3 based on pregnancy trimesters.

The gastrointestinal problems in pregnancy trimesters and postpartum was significantly higher in women with pica practice (p < 0.001). The frequency of gastrointestinal disorders is given in Table 4 according to the pregnancy trimesters. Pregnancy complication in the second trimester (p = 0.002) was significantly higher in women with Pica practice. The complications during first, second, and third pregnancy trimesters in women with and without pica practices are given in Table 5.

The average birth weight of infants born to women with pica practices during pregnancy was 309 grams lower than other infants, which was a significant difference (p = 0.005). However, no significant difference was observed in birth height and head circumference between the infants born to women with and without pica practices (Table 6).

Association between pica behavior with anemia among trimesters of pregnancy and postpartum in pregnant women is shown in Table 7. Hemoglobin was less than 10.5 in the second trimester and less than 11 in the first and third trimesters, and after delivery (known as anemia).

The findings of the present study indicated that prevalence of pica in pregnant women who attended health care centers in their first, second, and third trimesters was 9.3%, 8%, and 2.1%, respectively. As discussed earlier, statistics on the prevalence of pica is quite controversial, which may be due to different geographical locations. Prevalence of pica in Iran was reported 22.3% [19]. Khoushabi et al. (2014) reported a 17.5% prevalence of pica practices among pregnant women in Zahedan, Iran [20]. In another study by Lin et al. (2015) on Mexican women, 29% of participants reported pica practices during pregnancy [21]. In another study, Saunders et al. reported a 14.4% of pica practices in pregnant women, and 46.7% of these women displayed pica behavior every day. In 46.7% and 30% of the cases, pica practices started from second and third trimesters [7]. Kariuki et al. reported that 74% of pregnant women reported some form of pica practices. These practices were observed more in the second trimester and were at their lowest in the third trimester [22]. In the present study, pica practices decreased in pregnancy trimesters and were at their lowest after delivery. This may be explained by potential effects of advice by healthcare practitioners against pica practices.

In the present study, the most common pica cravings among pregnant women were for ice and frozen materials. In a study conducted by Rezavand et al., the most common pica craving was for ice and the least common craving was for burned matches [19]. In the study conducted by Babayi, the most common cravings among pregnant women were for sugar and starch [23]. According to Abdullahi, the most common pica craving among pregnant women was soil [24]. In another study by López et al. in Argentina, ice was the most common craving among pregnant women [3]. Young et al. reported that geophgia was the most common pica craving (37%) among pregnant women [16]. As in the present study, most studies indicated that ice and frozen materials were among the most common pica cravings of pregnant women.

There was a significant relationship between anemia levels in each trimester with the pica practice in that trimester. In the study conducted by Rezavand et al., 4.47% of pregnant women with pica also had anemia, which showed a significant relationship between pica and anemia [19]. In another similar study, Saunders et al. showed a significant relationship between pica and anemia during pregnancy [7]. Many other studies indicate a relationship between anemia and pica practices [25, 26]. The results of the study conducted by López et al. indicated that although hemoglobin levels in women with pica were lower than normal women, there was not a significant difference between them [10]. By consuming pica, fewer nutrients can be absorbed into the body, which reduces hemoglobin levels and anemia.

In the present study, a significant relationship was observed between gastrointestinal disorders and pica (p < 0.001). In a study conducted in Tanzania, Young et al. demonstrated a significant relationship between gastrointestinal disorders, such as stomachache, nausea, and constipation, with pica practices in pregnant women [16]. López et al. found that pica practices of pregnant women led to gastrointestinal disorders, such as constipation and ileus [3]. In another study, Saunder et al. found no reason for pregnant women’s pica practices in 65% of the cases. However, in 15% of the cases, the pregnant women had pica practices to relieve nausea and heartburn, and in 10% of the cases to reduce stress [7]. However, in the study conducted in Sudan, gastrointestinal disorders, such as nausea and vomiting, were less frequent among women with pica as compared to those without pica practices, which was statistically significant [24]. Several reasons have been mentioned as the source of pica practices, including gastrointestinal symptoms, reducing stress, and reducing hidden hunger. In addition, ice and frozen materials create a cold sensation. On the other hand, in many different occasions of pica practices no specific reason was reported [24]. In the present study, pregnant women were not questioned about the origin of their pica practices.

This paper found a significant difference between average weights of infants born to mothers who practiced pica during pregnancy as compared to normal mothers. Nevertheless, no significant relationship was observed in their birth height and circumference head. In a study in Brazil, pica did not have an effect on health parameters such as infants’ birth weight, birth height, and gestational age at the time of delivery [7]. In addition, in the study by López, no significant relationship between pica practices and infants’ birth weight and gestational age was observed [3]. A comparison of the pregnancy outcomes in Khoushabi et al. study indicated that the average weight, height, and head circumference in infants born to mothers with pica did not have a significant difference with those born to normal mothers [20].

Pregnancy complications in the second trimester (p = 0.002) were significantly higher in women with pica practice. However, due to scarcity of similar studies in this area of research, it is not possible to compare the results with other studies. The present study has a number of limitations. The main limitation of this study was the lack of a similar prospective study to provide further discussion of the issue. Moreover, dietary habits, eating behavior, and feed frequency of pregnant women were not evaluated. Thus, it is recommended that more prospective studies be conducted on pica in different areas with different cultures and eating habits.

5 Conclusion

Pica in pregnant women had a significant relationship with gastrointestinal disorders and anemia during pregnancy and pregnancy outcomes. Thus, in addition to providing healthcare services, health care professionals should consider patients’ pica practices and make the necessary interventions.

Financial disclosure

“None declared.”

Conflicts of interest

“None declared.”

Conflict of interests

The authors declare that they have no conflicts of interest.