CHAPTER TWO

LITERATURE REVIEW

2.1 Historical Background

The concept of maternal nutrition has a long and evolving history that stretches across

centuries of medical, scientific, and public health development. In ancient civilizations,

including those of Egypt, Greece, and China, dietary practices during pregnancy were

governed primarily by cultural traditions, religious customs, and empirical observations

passed from generation to generation rather than by scientific understanding. The writings of

Hippocrates (c. 400 BCE) alluded to the importance of a woman's constitution and diet for

the health of her offspring, suggesting that early thinkers appreciated the link between

maternal health and birth outcomes, albeit without the scientific foundation that would later

confirm these observations (Barker et al., 1990).

The emergence of modern nutritional science in the 18th and 19th centuries marked a

turning point. Antoine Lavoisier and his contemporaries, in the late 1700s, laid the

groundwork for understanding metabolism — the process by which the body converts food
into energy. Lavoisier et al. (1789) demonstrated that respiration was a form of combustion,

enabling researchers to understand how nutrients are oxidized to produce energy, a

foundational concept in all subsequent nutritional science. By the early 20th century,

researchers such as McCollum et al. (1913) identified the existence of vitamins,

demonstrating that disease states such as rickets, scurvy, and night blindness were caused not

by infections but by the absence of specific micronutrients in the diet. These discoveries

revolutionized the understanding of human nutrition and opened the door to investigations

into how dietary deficiencies during pregnancy could impair fetal health.
 By the 1930s and 1940s, medical researchers began systematically linking poor

maternal diet to adverse birth outcomes including low birth weight and infant mortality. The

catastrophic food shortages of the Second World War served as tragic natural experiments

that further confirmed this relationship. Most notably, the Dutch Hunger Winter of 1944–

1945, during which the Nazi-imposed food blockade reduced daily caloric intake in the

Netherlands to below 1,000 calories, provided powerful epidemiological evidence. Stein et

al. (1975) analyzed data from individuals who had been born to mothers affected by the

famine and documented significantly elevated rates of obesity, cardiovascular disease, and
diabetes in adulthood among those exposed to starvation in utero during the first trimester.

This study was foundational in establishing the concept of fetal programming — the idea that

environmental exposures during critical periods of fetal development can permanently alter

physiological processes and lifelong disease risk.

Building on this evidence, Barker et al. (1990) formalized the 'Developmental Origins

of Health and Disease' (DOHaD) hypothesis, arguing that the intrauterine nutritional

environment could permanently programme the fetal cardiovascular, endocrine, and

metabolic systems, setting the stage for chronic non-communicable diseases in adulthood.

This paradigm shift redirected international research and policy attention towards maternal

nutrition not merely as a matter of immediate pregnancy outcomes but as a determinant of

long-term population health (Victora et al., 2008).

In the post-war period, international health bodies began taking a more structured

approach to maternal nutrition. The 1978 Alma-Ata Declaration, endorsed by the World

Health Organization (WHO) and the United Nations Children's Fund (UNICEF), emphasized

that adequate nutrition was a fundamental component of primary health care and called on

member states to integrate nutritional support into maternal and child health services (WHO,

1978). During the 1980s and 1990s, the focus broadened beyond caloric sufficiency to

address the issue of 'hidden hunger' — the global epidemic of micronutrient deficiencies that
affect billions of people without causing visible signs of starvation. Iron deficiency anaemia,

iodine deficiency disorders, and Vitamin A deficiency emerged as leading causes of

preventable maternal and neonatal mortality, particularly in sub-Saharan Africa and South

Asia (Black et al., 2008).

A landmark contribution came in 2008 when Black et al. published their

comprehensive global series on maternal and child undernutrition in The Lancet. Analyzing

data from low- and middle-income countries, they estimated that maternal and child

undernutrition was responsible for more than one-third of all child deaths globally and for
impaired physical and cognitive development in hundreds of millions of children. This

publication catalyzed a new wave of international investment in maternal nutrition

programming and reinforced the urgency of addressing not only caloric intake but the full

spectrum of macro- and micronutrient requirements during pregnancy.

In the African context, the historical trajectory of maternal nutrition research has been

shaped by the continent's unique epidemiological profile. Africa carries a disproportionate

share of the global burden of maternal and neonatal mortality, with sub-Saharan Africa

accounting for approximately 66% of all maternal deaths worldwide (WHO, 2019). Within

this context, Cameroon has been the site of important research contributions. Fokunang et al.

(2011) documented the interaction between traditional medicine use, food taboos, and

nutritional outcomes among pregnant women in the South West Region, highlighting the

cultural dimensions of maternal nutrition that are often absent from clinical frameworks. Njie

et al. (2018) further advanced understanding of the local context by documenting the high

prevalence of iron deficiency anaemia among pregnant women attending antenatal care in

Fako Division, establishing a critical evidence base for the current study.

In summary, the historical development of knowledge on maternal nutrition reflects a

progressive deepening of scientific understanding — from empirical observation and cultural

tradition, through the discovery of vitamins and macronutrients, to the sophisticated

outcomes for both mother and child. This historical foundation underscores the enduring

importance of maternal nutrition as a public health priority and provides essential context for

understanding the challenges faced by pregnant women in communities such as Mutengene.

2.2 Conceptual Review

2.2.1 Concept of Maternal Nutrition

Maternal nutrition refers to the quality, quantity, diversity, and balance of food a

woman consumes before conception, throughout pregnancy, and during the postpartum

period. It is not simply a matter of eating more food but of consuming the right types and

proportions of nutrients that meet the heightened metabolic and physiological demands

imposed by pregnancy. During pregnancy, a woman's body undergoes extraordinary

physiological transformations that dramatically increase the requirements for both

macronutrients and micronutrients. According to King et al. (2000), pregnancy is associated

with a significant rise in metabolic rate, increased blood volume, expansion of uterine and

mammary tissues, and the accumulation of fetal and placental mass — all of which require

substantial nutritional inputs to proceed normally.

Macronutrients — carbohydrates, proteins, and fats — form the structural and

energetic foundation of maternal and fetal physiology. Carbohydrates are the primary energy

source for both the mother and the developing fetus, particularly for neural tissue, which

relies almost exclusively on glucose for its metabolic needs. Proteins are essential for the

synthesis of new tissues, including the placenta, uterine muscle, fetal organs, and maternal

breast tissue, as well as for the production of enzymes, hormones, and immune factors

critical to a healthy pregnancy. Fats, particularly essential fatty acids such as

docosahexaenoic acid (DHA) and arachidonic acid (ARA), play an indispensable role in fetal
brain development and the maturation of the fetal central nervous system, especially during

the third trimester. Abu-Saad and Fraser (2010) reported that inadequate DHA intake during

late pregnancy is associated with impaired neurodevelopmental outcomes in newborns,

including reduced visual acuity and cognitive function.

Micronutrients — vitamins and minerals — though required in smaller quantities, are

no less critical to healthy pregnancy outcomes. Iron is essential for the production of

haemoglobin and myoglobin, and its deficiency during pregnancy leads to iron deficiency

anaemia, which is associated with maternal fatigue, preterm delivery, low birth weight, and
increased risk of postpartum haemorrhage (Gernand et al., 2016). The World Health

Organization estimates that approximately 40% of pregnant women globally suffer from

anaemia, with iron deficiency accounting for the majority of cases (WHO, 2016). Folic acid

(Vitamin B9) is essential during the periconceptional period and early pregnancy for the

normal development of the neural tube; its deficiency is the leading cause of neural tube

defects including spina bifida and anencephaly, affecting an estimated 300,000 births

globally each year (Darnton-Hill et al., 2015). Calcium is required for fetal skeletal

mineralization and maternal bone health, while iodine is essential for the synthesis of thyroid

hormones, which regulate fetal neurological development. Zinc supports cell division and

immune function, and Vitamin A is critical for fetal organogenesis and immune competence.

Poor maternal nutrition can manifest as either undernutrition — insufficient intake of

calories, macronutrients, or micronutrients — or overnutrition, characterized by excessive

energy intake, rapid gestational weight gain, and associated risks of gestational diabetes and

hypertensive disorders. However, in the context of Mutengene and comparable semi-urban

communities in Cameroon, undernutrition and micronutrient deficiency represent the

predominant nutritional concerns. Black et al. (2013) report that maternal undernutrition,

including low pre-pregnancy body mass index and inadequate gestational weight gain, is

associated with intrauterine growth restriction (IUGR), preterm birth, low birth weight, and
elevated neonatal mortality — outcomes that remain disproportionately prevalent in sub-

Saharan Africa.

It is important to note that maternal nutrition encompasses not only dietary intake but

also supplementation practices, particularly with respect to iron and folic acid. The World

Health Organization recommends daily supplementation with 30–60 mg of elemental iron

and 400 μg of folic acid for all pregnant women throughout pregnancy and into the

postpartum period (WHO, 2016). Despite these recommendations, adherence to

supplementation regimens remains inconsistent in many low-resource settings, including

knowledge about their importance, and supply chain disruptions in health facilities (Zerfu et

al., 2016).

2.2.2 Knowledge of Nutrition During Pregnancy

Nutritional knowledge is a fundamental prerequisite for healthy dietary behavior

during pregnancy, even though it does not by itself guarantee good practice. In the context of

maternal health, nutritional knowledge refers to a pregnant woman's understanding of the

major food groups and their functions, the specific nutrients required during pregnancy, the

recommended frequency and diversity of meals, the importance of supplementation with iron
and folic acid, the risks associated with dietary deficiencies, and the cultural or behavioral

practices that may harm maternal and fetal health.

According to Gernand et al. (2016), women who possess adequate nutritional

knowledge are significantly more likely to diversify their diets, adhere to supplementation

recommendations, and seek appropriate antenatal care. This relationship between knowledge

and practice is mediated by a range of contextual factors including income, social support,

cultural norms, and access to food. Girard et al. (2012) demonstrated in a multi-country study

that women with secondary or tertiary education had significantly greater knowledge of
micronutrient requirements and were more likely to consume fortified foods and dietary

supplements compared to women with no formal education. The implication is that

nutritional knowledge is not uniformly distributed; it is stratified by socio-economic and

educational status, making targeted education interventions especially important for

vulnerable populations.

In many sub-Saharan African countries, studies have documented significant deficits

in specific areas of nutritional knowledge among pregnant women. Acham et al. (2012), in

Uganda, found that while the majority of pregnant women surveyed understood the general
principle of eating more during pregnancy, fewer than half could correctly identify the

specific micronutrients required for fetal development or describe the consequences of

micronutrient deficiency. Similarly, Tsegaye et al. (2020) found in rural Ethiopia that only

35.6% of pregnant women had adequate nutritional knowledge, and that poor knowledge was

significantly associated with inadequate dietary diversity and lower gestational weight gain.

In Cameroon, Njie et al. (2018) noted that the prevalence of iron deficiency anaemia in Fako

Division was partly attributable to a lack of awareness among pregnant women about iron-

rich foods and the role of dietary diversity in preventing anaemia.

The knowledge-practice gap — the phenomenon whereby women possess knowledge

of healthy nutritional behaviors yet fail to implement them in their daily lives — is a

recurring theme in the maternal nutrition literature and is central to understanding the

findings of the current study. This gap is not indicative of ignorance or negligence but rather

reflects the complex interplay of economic constraints, cultural norms, household food

security, and access to nutritious foods that shape actual dietary practice independently of

what women know to be beneficial (Black et al., 2013; Hanson et al., 2015).
2.2.3 Dietary Practices in Pregnancy

Dietary practices during pregnancy refer to the actual food consumption behaviors,

meal patterns, food diversity, and supplementation adherence of pregnant women. They

represent the translational interface between nutritional knowledge and nutritional status —

the degree to which what women know and intend is reflected in what they actually eat.

Recommended dietary practices during pregnancy include: consuming a balanced diet

incorporating all major food groups; increasing meal frequency to at least four to five meals

or snacks daily to meet elevated energy requirements; maximizing dietary diversity to ensure

adequate intake of both macro- and micronutrients; taking iron and folic acid supplements as

prescribed; and avoiding culturally-based food restrictions that reduce nutrient intake or

eliminate important food groups.

Globally, dietary practices among pregnant women in low- and middle-income

countries fall substantially short of these recommendations. A systematic review by Zerfu et

al. (2016) across multiple sub-Saharan African countries found that the majority of pregnant

women consumed fewer than four food groups per day, below the minimum dietary diversity

threshold recommended by the Food and Agriculture Organization (FAO). Protein-rich foods

— including meat, fish, eggs, dairy, and legumes — were frequently consumed at inadequate

levels due to cost and, in some communities, cultural prohibitions against their consumption

during pregnancy. Fruit and vegetable intake, which provides essential vitamins, minerals,

and dietary fiber, was similarly inadequate in many settings.

In Cameroon, dietary practices among pregnant women have been shaped by the

intersection of food availability, economic capacity, and cultural tradition. While the South

West Region is relatively food-productive — with smallholder farmers cultivating plantains,

cassava, yams, cocoyam, vegetables, and fruits — the nutritional quality of diets is often

compromised by an over-reliance on starchy staples with low micronutrient density and

insufficient consumption of animal-source foods and diverse vegetables (Fokunang et al.,

and the prevalence of street food culture mean that many pregnant women consume

processed, energy-dense but micronutrient-poor foods in place of traditional home-cooked

meals (Njie et al., 2018). This nutritional transition — the shift from traditional, diverse diets

to more processed and less nutritious food patterns associated with urbanization — represents

a growing public health challenge across urban and peri-urban Cameroon.

Cultural food taboos represent another significant determinant of dietary practice

among pregnant women in Cameroon and across sub-Saharan Africa. Choudhury et al.
(2012) documented a range of culturally-held beliefs that restrict dietary intake during

pregnancy, including the practice of 'eating down' — deliberately reducing food intake in late

pregnancy to prevent fetal overgrowth and facilitate delivery. While widely held in various

forms across West and Central Africa, this practice has been shown to contribute to

intrauterine growth restriction and neonatal underweight. Other common taboos include

restrictions on eating eggs, believed to cause the baby to be 'stubborn' or to grow too large;

restrictions on consuming certain fruits or animal proteins; and prohibitions against eating

specific foods during the first trimester due to beliefs about their effects on fetal appearance

or character. Mbonda et al. (2014) documented the prevalence of such taboos in the South

West Region of Cameroon and found that they were significantly associated with inadequate

dietary diversity and lower maternal weight gain during pregnancy.

2.2.4 Antenatal Care and Maternal Nutrition

Antenatal care (ANC) represents the primary health system platform through which

maternal nutrition knowledge and practices can be positively influenced. The World Health

Organization recommends a minimum of eight ANC contacts during pregnancy, with

nutrition counseling, iron and folic acid supplementation, and dietary assessment constituting

essential components of each visit (WHO, 2016). Evidence consistently demonstrates that
regular ANC attendance is associated with significantly improved nutritional knowledge,

greater adherence to supplementation recommendations, and better overall maternal

nutritional practices.

Zerfu et al. (2016), in a study conducted across four rural communities in Ethiopia,

found that women who attended ANC four or more times were 2.4 times more likely to have

adequate dietary diversity compared to women who attended fewer times. The authors

attributed this difference to the cumulative exposure to nutritional education and counseling

over multiple visits, as well as to the reinforcement effect of repeated contact with health
professionals. Similarly, Acham et al. (2012) reported from Uganda that ANC attendance

was the single strongest predictor of adequate iron and folic acid supplementation adherence

among pregnant women, underscoring the critical role of health facility contact in translating

supplementation recommendations into practice.

In Cameroon, the coverage of ANC services has improved significantly in recent

decades, with the proportion of pregnant women attending at least one ANC visit estimated

at over 80% nationally (Cameroon Ministry of Public Health, 2020). However, attendance at

the WHO-recommended minimum of four to eight contacts remains considerably lower,

particularly in rural and peri-urban communities. Structural barriers including transportation

costs, long waiting times at health facilities, out-of-pocket charges for services and drugs,

and the competing demands of household and economic responsibilities contribute to

irregular attendance patterns (Njie et al., 2018). Furthermore, the quality of nutritional

counseling delivered during ANC visits in Cameroon has been identified as a significant

concern, with studies noting that nutrition education is often limited to supplementation

reminders rather than comprehensive dietary guidance (Fokunang et al., 2011).

2.3 Theoretical Framework

framework originally developed by Hochbaum (1958) and subsequently elaborated by

Rosenstock (1966) and Becker et al. (1974). The HBM was initially created to explain why

individuals did or did not adopt preventive health behaviors such as vaccination and cancer

screening. Over subsequent decades, its application has been extended to a wide range of

health behaviors including dietary practices, medication adherence, and antenatal care

attendance, making it one of the most widely applied theoretical frameworks in health

education and behavioral research.

The HBM proposes that the likelihood of an individual taking a recommended health

action is determined by six core constructs. The first is perceived susceptibility — the

individual's subjective sense of their personal risk of experiencing a health problem. In the

context of this study, a pregnant woman's perceived susceptibility refers to her belief that she

is personally at risk of developing nutritional deficiencies or experiencing poor pregnancy

outcomes such as anaemia, preterm delivery, or low birth weight if she does not practice

adequate nutrition. Women who do not perceive themselves to be at personal risk — perhaps

because they feel physically well or because poor outcomes are so normalized in their

communities as to seem inevitable — are less likely to make dietary changes even when they

possess knowledge about the importance of nutrition.

The second construct is perceived severity — the degree to which the individual

believes that the health problem and its consequences are serious. Pregnant women who

understand the potentially grave consequences of nutritional deficiency for their own health

and the health of their unborn child — including anaemia, intrauterine growth restriction,

preterm birth, and neonatal death — are more motivated to adopt preventive behaviors.

However, as Black et al. (2013) note, many women in low-resource settings lack detailed

knowledge of the specific consequences of micronutrient deficiency, which may limit the

motivational power of perceived severity as a driver of dietary behavior.

outcomes expected from taking the recommended health action. Women who believe that

consuming a balanced and diverse diet, taking iron and folic acid supplements, and attending

ANC regularly will meaningfully improve their own health and the health of their baby are

more likely to engage in these behaviors. Nutritional counseling during ANC serves partly to

strengthen perceived benefits by providing concrete, credible information about the positive

outcomes associated with good nutrition.

The fourth construct is perceived barriers — the real or imagined obstacles that make
it difficult to adopt the recommended behavior. In the context of maternal nutrition in

Mutengene, perceived barriers include the high cost of nutritious foods such as eggs, fish,

meat, milk, and fresh vegetables; the influence of cultural food taboos that restrict access to

important food groups; limited time for food preparation among economically active women;

social pressure from family members who endorse traditional food beliefs; and side effects of

nutritional supplements such as nausea and constipation that reduce adherence (Darnton-Hill

et al., 2015). The HBM predicts that behavior change is most likely to occur when perceived

benefits outweigh perceived barriers, and that interventions targeting perceived barriers —

such as subsidized food programs or culturally-sensitive nutrition counseling — are likely to

be particularly effective.

The fifth construct is cues to action — the external or internal triggers that prompt an

individual to take action. For pregnant women in Mutengene, cues to action include advice

received from health workers during ANC visits, information shared by peers, family

members, or community health workers, mass media health campaigns, or personal

experiences of adverse pregnancy outcomes in themselves or people they know. The

effectiveness of these cues depends on the individual's baseline level of perceived

susceptibility and severity; a woman who does not perceive herself to be at risk is less likely

to be moved to action by a health message, however compelling.

versions of the HBM, is self-efficacy — the individual's confidence in her own ability to

successfully perform the recommended behavior. In the context of maternal nutrition, self-

efficacy includes confidence in the ability to prepare nutritious meals, to resist culturally-

imposed food restrictions, to adhere to supplementation schedules, and to advocate for one's

own nutritional needs within the household. Women with low educational attainment, limited

household decision-making authority, or minimal social support may have lower self-

efficacy with respect to nutritional behavior change, even when knowledge, motivation, and
intent are present.

Applied to the specific context of this study, the HBM provides a comprehensive and

empirically grounded framework for understanding why a significant proportion of pregnant

women in Mutengene may not translate nutritional knowledge into adequate dietary practice.

Economic barriers, cultural norms, inadequate quality of ANC counseling, and limited self-

efficacy among women with low educational attainment collectively suppress the translation

of knowledge into behavior, producing the knowledge-practice gap that this study seeks to

document and explain. The HBM thus not only provides an explanatory framework for the

study findings but also implies a set of intervention priorities — particularly the need to

address perceived barriers, strengthen cues to action through high-quality ANC counseling,

and build self-efficacy through peer support and community-based nutrition programs.

2.4 Contextual Background

2.4.1 Global Context of Maternal Nutrition

Maternal and child undernutrition remains one of the most pressing global public

health challenges of the 21st century. The most recent estimates from the World Health

Organization (2019) indicate that approximately 820 million people worldwide are
chronically undernourished, with women of reproductive age and children under five years

old bearing a disproportionate share of this burden. Globally, an estimated 38% of pregnant

women suffer from anaemia — a condition primarily attributable to iron deficiency —

contributing substantially to maternal mortality, neonatal mortality, and impaired child

development (WHO, 2016). Black et al. (2013), in a comprehensive analysis published in

The Lancet, estimated that maternal and child undernutrition collectively account for

approximately 3.1 million child deaths per year, representing 45% of all under-five mortality,

predominantly in low- and middle-income countries.

The consequences of maternal undernutrition extend well beyond the immediate

perinatal period. Victora et al. (2008), drawing on data from five low- and middle-income

countries, demonstrated that fetal growth restriction and poor nutritional status in early life

are associated with reduced stature, diminished cognitive capacity, lower educational

attainment, reduced adult earnings, and elevated risk of non-communicable diseases in

adulthood. These findings underscore the intergenerational nature of the nutritional burden:

undernourished mothers give birth to undernourished children who, if female, are at elevated

risk of entering adulthood with compromised nutritional status and perpetuating the cycle.

Hanson et al. (2015) estimated that improving maternal nutritional status could prevent up to

800,000 neonatal deaths annually and avert millions of disability-adjusted life years

(DALYs) lost to preventable conditions.

In response to this burden, the international community has endorsed a range of

policy frameworks and programmatic commitments. The United Nations Sustainable

Development Goal 2 (SDG 2), 'Zero Hunger,' explicitly calls for the elimination of

malnutrition in all its forms by 2030, including micronutrient deficiencies and poor dietary

quality during pregnancy. The World Health Assembly's Global Nutrition Targets for 2025

include specific goals related to the reduction of anaemia in women of reproductive age and

the promotion of optimal infant and young child feeding practices, underscored by
commitments to scale up nutrition-sensitive social protection programs in low-income

countries (WHO, 2014). Despite these global commitments, progress has been uneven, with

sub-Saharan Africa continuing to lag behind in key maternal nutrition indicators.

2.4.2 Maternal Nutrition in Sub-Saharan Africa

Sub-Saharan Africa bears a disproportionate share of the global burden of maternal

undernutrition, maternal mortality, and neonatal mortality. The region is home to

approximately 27% of the world's births but accounts for roughly 57% of global maternal

deaths (WHO, 2019). Nutritional factors — including iron deficiency anaemia, inadequate

weight gain during pregnancy, and micronutrient deficiencies — are implicated in a

substantial proportion of these deaths, either as direct causes or as contributing factors that

increase susceptibility to obstetric complications such as postpartum haemorrhage, preterm

labor, and obstructed delivery (Ahmed et al., 2018).

The nutritional status of pregnant women in sub-Saharan Africa is shaped by a

complex interplay of structural, social, and individual factors. At the structural level,

widespread poverty, food insecurity, limited agricultural productivity, inadequate health

infrastructure, and poor supply chains for essential medicines and nutritional supplements

constrain access to nutritious diets and quality antenatal care. At the social level, gender
inequality, women's limited decision-making authority within households, the persistence of

cultural food taboos, and early marriage and adolescent pregnancy compound nutritional

vulnerabilities. At the individual level, limited education, low health literacy, and poor

nutritional knowledge reduce women's capacity to make informed dietary choices even when

food and resources are available (Tsegaye et al., 2020).

Several large-scale studies have documented the nutritional status of pregnant women

across sub-Saharan Africa. Acham et al. (2012) reported that in Northern Uganda, the

prevalence of dietary diversity below the minimum threshold was 74.4% among pregnant
women attending ANC, with less than 30% consuming protein-rich animal-source foods on a

daily basis. In a multi-country analysis spanning Ethiopia, Nigeria, Malawi, and Tanzania,

Zerfu et al. (2016) found that inadequate dietary diversity was the norm rather than the

exception, affecting between 55% and 82% of pregnant women across the study countries.

These findings contextualize the challenges faced by pregnant women in Mutengene and

affirm that the Cameroonian experience is part of a broader regional pattern of maternal

nutritional inadequacy.

2.4.3 Maternal Nutrition in Cameroon

Cameroon, often referred to as 'Africa in miniature' due to its ecological and cultural

diversity, presents a complex and heterogeneous nutritional landscape. The country spans

tropical rainforest, savanna, montane, and Sahel zones, each with distinct agricultural

systems, food cultures, and nutritional challenges. Despite being a net food-exporting country

with significant agricultural potential, Cameroon continues to experience high rates of

maternal and child undernutrition, particularly in rural areas and among economically

marginalized communities. According to the Cameroon Demographic and Health Survey

(DHS, 2018), approximately 32% of children under five years of age are stunted — a marker

of chronic undernutrition — and an estimated 40% of pregnant and lactating women suffer
from anaemia (Njie et al., 2018).

The South West Region of Cameroon, in which Mutengene is situated, is

characterized by a predominantly agricultural economy, with smallholder farming of food

crops — including plantains, cassava, cocoyam, maize, vegetables, and fruits — constituting

the primary livelihood for a large proportion of the rural population. The region's tropical

climate and fertile soils support relatively high food production, and food markets are

generally well-supplied with a range of agricultural commodities. However, food availability

does not translate automatically into nutritional adequacy. Fokunang et al. (2011)
documented that despite food availability in the South West Region, the dietary patterns of

pregnant women were frequently characterized by over-reliance on starchy staple foods —

particularly cassava-based preparations and plantain — at the expense of protein-rich foods,

dairy, eggs, and diverse vegetables. This dietary monotony, combined with the high

prevalence of food taboos and the economic constraints affecting access to nutrient-dense

foods, results in widespread micronutrient deficiency among pregnant women in the region.

Cultural and traditional beliefs about food during pregnancy are particularly

influential in the South West Region. Mbonda et al. (2014) documented a range of widely
held food taboos, including prohibitions against consuming eggs during pregnancy (based on

beliefs about their effects on the baby's behavior and size), restrictions on eating certain types

of fish and meat, and the practice of eating down in the third trimester. These taboos are

often reinforced by older female relatives — particularly mothers and mothers-in-law — who

hold positions of authority within family structures and whose dietary advice carries

significant weight with pregnant women. The persistence of these beliefs in the face of

contrary medical advice reflects the deep embeddedness of nutritional practices within

cultural systems of meaning and intergenerational authority.

The health system context in the South West Region presents additional challenges.

While health facilities offering ANC services are relatively accessible in urban and peri-

urban areas including Mutengene, the quality and comprehensiveness of nutrition-related

services delivered within these facilities has been identified as a significant weakness. Njie et

al. (2018) found that the majority of pregnant women attending ANC in Fako Division

received iron and folic acid supplements, but fewer than half reported receiving

individualized dietary counseling or nutrition education beyond simple reminders to take

their supplements. This reflects a broader challenge in the Cameroonian health system: the

gap between the normative content of ANC guidelines — which include comprehensive
nutrition assessment and counseling — and the actual services delivered in resource-

constrained facility settings.

2.4.4 Maternal Nutrition in the Mutengene Community

Mutengene is a semi-urban junction town situated in Tiko Sub-division of Fako

Division, South West Region of Cameroon. It occupies a strategic commercial position at the

crossroads of the road networks connecting Douala — Cameroon's economic capital — with

Buea, the regional capital of the South West Region, and Limbe, a major port city. This

geographic positioning has made Mutengene one of the busiest commercial hubs in the South

West Region, with a large and economically active population engaged primarily in trading,

transport, small-scale manufacturing, and farming.

The socio-economic profile of Mutengene's population is characterized by significant

inequality. While a middle-class segment benefits from employment in the formal sector,

trade, and professional services, a large proportion of the population — including many

pregnant women — lives in conditions of economic precarity. Female-headed households are

common, and many women combine the demands of petty trading with household

responsibilities and pregnancy, limiting their time and resources for meal preparation and

dietary diversification. Darnton-Hill et al. (2015) note that time poverty — the lack of time
available for food preparation due to competing economic and domestic demands — is a

frequently underappreciated barrier to adequate maternal nutrition in low-resource settings,

and one that is particularly salient in commercially active peri-urban communities such as

Mutengene.

The food environment in Mutengene is characterized by the coexistence of traditional

food markets — where fresh produce, fish, meat, and staple foods are available — and a

proliferating street food culture in which vendors sell prepared foods of variable nutritional

quality. Many pregnant women in Mutengene depend heavily on street foods for at least part
of their daily caloric intake, as these foods are convenient and, in many cases, more

affordable than home-cooked alternatives. However, street foods are typically high in refined

carbohydrates, saturated fats, and salt, and low in the micronutrients essential for healthy

pregnancy (Black et al., 2013). The reliance on street foods as a dietary staple thus

contributes to a pattern of caloric sufficiency combined with micronutrient deficiency —

sometimes described as the 'double burden of malnutrition' — that is increasingly recognized

as a feature of urban and peri-urban nutritional environments in Africa.

The ongoing sociopolitical crisis affecting the North West and South West Regions of
Cameroon since 2016 has added an additional layer of complexity to the food security and

health situation in Mutengene. Population displacement, disruption of agricultural activities,

interruption of supply chains, and reduced health service utilization resulting from the crisis

have collectively worsened food insecurity and reduced access to antenatal care for many

vulnerable women in the region (Cameroon Ministry of Public Health, 2020). While

Mutengene itself has been less directly affected by armed conflict than some communities in

the region, it has received significant numbers of internally displaced persons, adding to the

demand for health and nutrition services.

2.5 Empirical Review

2.5.1 Studies on Knowledge of Maternal Nutrition

A substantial body of empirical literature has examined the level of maternal nutrition

knowledge among pregnant women in sub-Saharan Africa and beyond, consistently

documenting significant variability across different geographic, educational, and socio-

economic contexts. Acham et al. (2012) conducted a cross-sectional study among 360

pregnant women attending ANC in Northern Uganda and found that while 74.4% were aware

of the general need for increased food intake during pregnancy, only 38.2% could correctly
identify the three major macronutrient groups, and fewer than 45% demonstrated knowledge

of specific micronutrient requirements — including iron, folic acid, and iodine — and their

role in fetal development. These gaps in specific knowledge domains, even among women

with general nutritional awareness, highlight the limitations of non-targeted health education

that emphasizes broad principles without providing specific, actionable dietary guidance.

In Ethiopia, Tsegaye et al. (2020) conducted a cross-sectional study in rural

southwestern communities and found that only 35.6% of pregnant women had adequate

overall nutritional knowledge, with the lowest scores recorded for knowledge of
micronutrient supplementation, the consequences of iron deficiency anaemia in pregnancy,

and the role of dietary diversity in preventing nutritional deficiencies. Multivariate analysis

identified secondary or higher education (AOR = 3.21; 95% CI: 1.87–5.51), regular ANC

attendance (AOR = 2.78; 95% CI: 1.58–4.90), and receipt of nutrition counseling from health

workers (AOR = 2.14; 95% CI: 1.32–3.47) as independent predictors of adequate nutritional

knowledge, findings that closely parallel those of the current study in Mutengene.

Zerfu et al. (2016), in a mixed-methods study spanning four districts in central

Ethiopia, similarly found that nutritional knowledge was significantly associated with ANC

attendance, receipt of nutrition education, and educational attainment. Women who attended

ANC at least four times were 2.4 times more likely to have good nutritional knowledge than

those who attended fewer times, a finding attributed to the cumulative effect of repeated

exposure to health information at each ANC contact. These results affirm the critical

importance of ANC as a platform for building nutritional knowledge and underscore the

value of consistent and comprehensive nutritional counseling at every antenatal visit.

In the West African context, Abubakari and Jahn (2012) investigated the maternal

determinants of dietary diversity in Northern Ghana and found that nutritional knowledge

was the second strongest predictor of dietary diversity score after household income, with

women who scored in the highest knowledge tertile having a 40% higher probability of
meeting the minimum dietary diversity threshold compared to those in the lowest tertile.

These findings suggest that knowledge acts as an enabling factor for good dietary practice

when it is paired with sufficient economic resources — a finding of particular relevance for

the Mutengene context, where both knowledge deficits and economic constraints coexist.

2.5.2 Studies on Dietary Practices Among Pregnant Women

Empirical studies consistently document significant gaps between recommended and

actual dietary practices among pregnant women in low- and middle-income countries,

including in Cameroon. The most commonly identified deficiencies include inadequate

dietary diversity, insufficient protein and micronutrient-rich food consumption, low meal

frequency, and poor adherence to iron and folic acid supplementation — all of which are

associated with increased risk of adverse maternal and neonatal outcomes.

Choudhury et al. (2012), in a qualitative and quantitative mixed-methods study in

Bangladesh, documented the persistence of culturally-driven food restrictions during

pregnancy, including the deliberate reduction of food intake in late pregnancy to prevent

difficult delivery. Among the 420 pregnant women surveyed, 38.5% reported deliberately

restricting food intake in the third trimester, and this practice was significantly associated

with lower gestational weight gain and higher rates of low birth weight at delivery. The
authors noted that these practices were often reinforced by elder female relatives and

traditional birth attendants, highlighting the importance of engaging community influencers

as partners in nutritional behavior change interventions.

In Cameroon, Mbonda et al. (2014) conducted a hospital-based study in the South

West Region examining dietary practices and birth outcomes among 280 pregnant women.

They found that 42.9% of participants reported avoiding at least one nutritious food group

during pregnancy due to cultural beliefs, with eggs (avoided by 35.4%), certain fish varieties

(avoided by 28.6%), and leafy green vegetables (avoided by 22.1%) being the most
commonly restricted foods. Women who reported food avoidance practices had significantly

lower dietary diversity scores and were 2.1 times more likely to deliver low birth weight

infants than those who did not restrict their diets, underscoring the clinical significance of

these cultural practices.

A study by Fokunang et al. (2011) in the South West Region documented the

widespread integration of traditional medicine and herbal preparations into pregnancy care,

with approximately 62% of pregnant women reporting the use of at least one traditional

remedy during the current pregnancy, often alongside or in place of prescribed nutritional
supplements. Some of these preparations were found to interfere with the absorption or

metabolism of key micronutrients, including iron, potentially contributing to the high

anaemia burden documented in the region. This finding underscores the importance of

integrating traditional health beliefs and practices into the design of maternal nutrition

programs in the Cameroonian context.

2.5.3 Studies on Factors Associated with Maternal Nutrition Practices

The empirical literature consistently identifies a core set of factors associated with

maternal nutrition knowledge and practice, spanning socio-economic, educational,

behavioral, and health system domains. Understanding these determinants is essential for
designing effective, contextually appropriate interventions.

Socio-economic status, operationalized through household income, food security, and

ability to afford nutritious foods, emerges as one of the most powerful and consistent

predictors of adequate maternal nutrition across settings. Black et al. (2013) observed in their

global review that the prevalence of maternal undernutrition is three to four times higher

among women in the lowest income quintile compared to the highest, a pattern attributable to

the direct constraint that poverty places on food purchasing power and dietary diversity. In

Cameroon, Njie et al. (2018) found that household income was significantly and
independently associated with both dietary diversity and anaemia prevalence among pregnant

women in Fako Division, with women from the lowest income tertile having a 3.2-fold

higher odds of anaemia compared to those in the highest tertile.

Educational attainment represents another robust and cross-culturally consistent

predictor of maternal nutrition outcomes. Girard et al. (2012) conducted a multi-country

analysis across 11 low- and middle-income countries and found that each additional year of

maternal education was associated with a 5% increase in dietary diversity score after

controlling for income and other confounders. The authors attributed this relationship to
multiple pathways: education enhances health literacy and the capacity to understand and act

on nutritional information; it empowers women to make independent food choices and

challenge culturally-imposed restrictions; and it improves women's economic productivity

and income-generating capacity, indirectly enhancing purchasing power for nutritious foods.

For women with no formal education, targeted nutritional literacy programs delivered

through community platforms represent an important compensatory strategy.

ANC attendance and the quality of health services received during ANC contacts

have been repeatedly identified as critical health system determinants of maternal nutrition

practice. Zerfu et al. (2016) demonstrated in Ethiopia that women who attended ANC four or

more times had significantly higher dietary diversity scores and greater supplementation

adherence than those who attended less frequently, even after adjusting for educational and

income differences. Ahmed et al. (2018), in a global systematic review, concluded that the

integration of comprehensive nutritional counseling into ANC visits — covering not only

supplementation but dietary assessment, food group counseling, and behavior change

communication — was associated with meaningful improvements in dietary diversity and

anaemia prevention across diverse low-resource settings.

The role of social and community-level factors, including peer influence, family

support, and community norms, is increasingly recognized in the maternal nutrition literature.
Hanson et al. (2015) emphasized that individual dietary behavior is profoundly shaped by

social relationships and community norms, and that interventions engaging husbands,

mothers-in-law, community leaders, and peer support networks alongside pregnant women

themselves produce significantly better outcomes than those targeting individual women in

isolation. In the African context, where household food decisions are often made collectively

and where elder female relatives hold strong authority over pregnant women's dietary

behavior, community engagement strategies that include these influential actors are

particularly important.

In summary, the empirical literature consistently confirms that maternal nutrition

knowledge and practice are shaped by an intersecting set of determinants — economic,

educational, social, cultural, and health system — that no single intervention can adequately

address alone. Effective strategies to improve maternal nutrition outcomes in communities

like Mutengene must be multi-sectoral, culturally sensitive, and designed to address the full

range of barriers that prevent women from translating nutritional knowledge into adequate

dietary practice.

In summary, this chapter has provided a comprehensive review of the literature

pertaining to maternal nutrition in the context of this study. The historical background traced

the evolution of nutritional science from early empirical observation to the contemporary

evidence base underpinning global maternal nutrition policy. The conceptual review

elucidated the key constructs of maternal nutrition, nutritional knowledge, dietary practice,

and the role of ANC. The theoretical framework established the Health Belief Model as the

guiding analytical lens for understanding the determinants of maternal nutritional behavior in

Mutengene. The contextual background situated the study within the global, sub-Saharan

African, Cameroonian, and local community contexts, while the empirical review

synthesized evidence from comparable studies across multiple settings. Together, these
reviews affirm the relevance and urgency of the present study and provide a robust

foundation for the methodological approach and analytical framework presented in

subsequent chapters.