Prevalence and consumption pattern of kolanut among pregnant women in Ibadan metropolis

Kolanut contains caffeine and it is widely consumed in various social contexts in Nigeria and other Sub-Saharan African countries. While some studies have suggested that kolanut is consumed by pregnant women, there is a dearth of information on the prevalence, consumption pattern and reasons for kolanut consumption among this group. This study investigated kolanut use among pregnant women in Ibadan, Oyo State, Nigeria. A cross-sectional study involving 478 consenting pregnant women in all trimesters of pregnancy was conducted. Semi-structured questionnaires were used to collect data. Associations between kolanut use and respondent characteristics were investigated using the chi-square test and logistic regression analysis. The mean age of the women was 28.7 ± 6.3 years. One hundred and sixty-two (33.9%) of women reported kolanut use during pregnancy, 140 (29.3%) in the current pregnancy. Fifty-five (39.3%) pregnant women reported frequent use and 46 (32.9%) used it in high quantities. Significant associations were found between current kolanut use and Hausa respondents (p = 0.014), educational level; secondary (p = 0.032), tertiary (p = 0.006), TBA (p = 0.005). The majority (93.7%) used kolanut to prevent spitting, nausea, and vomiting. This study showed that kolanut use is quite common among pregnant women and frequently used in large quantities.

The use of herbal plants, as part of complementary, alternate or traditional medicines during pregnancy has been on the increase [1][2][3] regardless of adequate scientific evidence about the safety of these substances 4 can cause harmful effects on the developing fetus 5,6 .The reported use of herbs and alternate medications, during pregnancy by pregnant mothers to suppress symptoms of morning sickness is on the increase, in various communities 1,2,4,7 .These herbal substances/ medications are believed by many to be cheaper than conventional medications, natural and safe, reasons that explain their increased use 8 .In addition to easy accessibility at very low cost and the assumption that they are safe, the proclamation by the WHO in 2019 9 encouraging traditional/herbal and/or alternate medications may have made their use more attractive.About 80.0% of the world population takes alternate medicines to treat a disease or alleviate the response of a disease 10 .
More than half of pregnant women experience morning sickness during pregnancy and this manifests as tiredness, dizziness, nausea and vomiting 11,12 .Although termed morning sickness, this group of symptoms can occur at any time of the day, depending on individual hormonal responses.Majority of pregnant women take different herbs, traditional and/or alternates substances 13,14 , to alleviate these symptoms which are more common in the first trimester.These substances can be in form of drugs prescribed by physicians or pharmacists, or self-prescription 15 , resulting from their observation of other pregnant women or practices passed down by their mothers or relatives 4 .The prevalence of consumption of herbal and alternate medicines by pregnant women is between 12.0% and 90.0% during pregnancy 8,14,16 .These alternate substances, which could be in the form of herbs or traditional plants 2,16,17 , include kolanut 17,18 .Kolanut, a plant and very common social snack, consumed by every gender and age group throughout tropical and equatorial Africa including Nigeria, is equivalent to tea, coffee, maté and cocoa [19][20][21] .Kolanut has 4 main different species and the most common one to the Southwest of Nigeria is the Gbanja which comes in two colors, white and red 19,22 .Kolanut is dark brown in color when bitten, acidic taste when fresh and bitter when dry, with an increase in nutmeg and aromatic aroma 23 .Kolanut contains different fractions like catechins, procyanidins, sugar, sterols, fatty acids, alkaloids, kolanin, theobromine and caffeine in large quantity 24 .Kolanut has numerous uses, apart from being a social snack, it has been documented to reduce labor pain, swellings, and accelerate the healing of fresh wounds 25 .Because kolanut contains caffeine, it is considered as a strong Central Nervous System Stimulant and increases sympathetic nervous system 26,27 .Caffeine overuse in pregnancy can cause death through ventricular fibrillation and cardiac arrest 21 .9][30] Kolanut also cause toxic effects such as delay in neuronal migration in the developing brain 8,31 .It has also been established that the effects of these uncensored substances are dose dependent, and the time of consumption could magnify its effects 32 .However, these results were not found in humans but could be potentially the same in humans.
Therefore, this research was designed to document the prevalence and consumption pattern of kolanut (onset of use, amount consumed, duration of use and trimester of use), common reasons for its use during pregnancy, the perceived and reported effects in pregnancy, factors associated with its use in pregnancy and its local geographical distribution.

Methods
Study area.The study was conducted in Ibadan, the most populous city in Oyo State, Nigeria with over 3 million people (National Population Commission, 2016).Ibadan is the third most populous city in Nigeria after Lagos and Kano, and the country's largest city by geographical area.The city has 11 local government areas (LGAs); five of these (Ibadan North, Ibadan North-East, Ibadan North -West, Ibadan South-East, Ibadan South -West) constitute the core Ibadan municipality and the other six (Akinyele, Egbeda, Ido, Lagelu, Ona-Ara and Oluyole) are the outlying areas which make up the rest of Ibadan city.

Study population.
Participants in this study were women attending antenatal care at formal or informal health care facilities in the study area.These women had pregnancies confirmed by an obstetric ultrasound scan.We excluded women who were unable to communicate in any of the common local languages and children under the age of 15 years.

Sampling technique. Two
LGAs were purposively selected for this study; Ibadan North due to its urban nature and mix of tribes (Ibo, Hausa, and Yoruba) and Akinyele as the peri urban LGA.A list of health care providers/facilities was obtained from the State Ministry of Health.One tertiary hospital, one secondary hospital, two primary health care centres and two TBA centres were selected in each LGA using simple random sampling techniques.The sample size was proportionally allocated across the selected facilities based on the number of registered antenatal attendees in the facility during the preceding year.At facility level, informed consent was obtained from adult respondents and guardians for individuals less than 21 years of age.Consenting women were recruited consecutively until the facility sample size was achieved.

Sample size.
The sample size for this study was determined to estimate a proportion using a prevalence of 10.0% with a two-sided alpha of 5.0%, a difference of 4.0% and a non-response rate of 20.0%.This yielded a minimum sample size of 271 respondents.We approached 500 women, and 22 questionnaires were unsuited to analysis due to grossly incomplete responses and these were excluded from analysis leaving us with 478 respondents.
Data collection.This cross-sectional study utilised a structured questionnaire developed by the researchers.
The content validity was ensured through extensive review of relevant literature on previous research reports to develop the relevant questions.The questionnaire was pre-tested with 30 pregnant women in two public and TBA facilities outside the selected LGAs.Following the pre-test, appropriate modifications were made to the instrument, ambiguous terms modified, and unnecessary items deleted.The questionnaire contained sixteen (16) questions on socio demographic characteristics, obstetric history, history of index pregnancy and pattern of kolanut consumption; with the frequency of use defined as high (every day), medium (thrice a week), low (≤ once a week) and quantity of use defined as high (≥ 1 nut at once), medium (half to < 1 lobe) and low (quarter to < half lobe).The questionnaire was interpreted and administered to the participants by four trained female research assistants.The assistants were trained to conduct initial entry/engagement on REDCap®, obtain informed consent and information on the required variables from interaction with respondents.The quality of information collected was cross-checked for any error and problems discovered were resolved by the supervisor on the field.All the questionnaires administered during the study were given code numbers and no names were recorded.The data collected from the pregnant women performed in accordance with relevant guidelines and regulations based on code of conducts from the ethical committee.Collection of data was carried out within a period of four months.

Mapping of geographical kolanut consumption. This was done by extracting the coordinates from
Google mapping of all the addresses of the respondents and these coordinates were entered into a Microsoft excel and saved as Comma Separated Values (CSV) alongside other variables and was exported into ArcGIS online to Prevalence of kolanut consumption.The study showed that 33.9% (55) respondents had ever used kolanut at different pregnancies while 29.3% (41) respondents were currently using kolanut.Out of the one hundred and sixty-two respondents that ever took kolanut, 40.1% (65) of them took kolanut during the first Pattern of kolanut consumption.The frequency of consumption of kolanut in the present pregnancy (n = 140) was, 39.3% (55) of the pregnant women consumed kolanut every day, 46.4% (65) consumed thrice a week, while 6.4% (9) consumed once a week and 7.9% (11) did not provide information on consumption frequency.The quantity of kolanut used in this present pregnancy showed that 32.9% ( 46) consumed up to one nut at once, 45.0% (63) consumed more than half but less than one lobe, while 11.4% (16) of the respondents consumed quarter to half lobe while 10.7% (15) were missing.For the ever use pregnancy (n = 162), 46.9% (76) consumed every day, 38.3% (62) consumed thrice a week while 6.8% (11) consumed once a week and 8.0% (13)  were missing.The quantity of use of the ever use kolanut was 42.0% (68) consumed up to one nut at once, 38.9% (63) consumed more than half but less than one lobe while 10.5% (17) consumed quarter to half lobe and 8.6% (14) were missing (Table 3).
Reasons for kolanut use.Over half, 56.8% (92) of the pregnant women used kolanut due to excessive salivation, 37.0% (60) due to nausea or vomiting, 3.1% (5) of women used it for cough and for recreation.A small Benefits and perceived usefulness of kolanut.Most women, 90.0% (146) reported that kolanut consumption helped in reducing excessive salivation, 71.6% (116) for nausea and 16.1% (26) for prevention of vomiting.3.7% (6) of the women claimed it helped in reducing cough, 2.5% (4) reported it refreshes their mouth while 3.6% (6) did not provide any benefit.
Sources of introduction to kolanut use in current pregnancy.Kolanut was introduced to the pregnant women, 40.7% (57) by friends, 37.0% (52) by relatives, 13.0% (18) decided to use it of their own volition and 1.8% (3) by a doctor or nurse while none heard from the media and 7.5% (10) did not provide an answer.
Association between kolanut use and variables.www.nature.com/scientificreports/facility of recruitment.Crude odds show Ibo women were significantly less likely to eat kolanut in current pregnancy compared to Yoruba women (OR = 0.16, 95% CI = 0.04-0.70,p = 0.015) in the analysis but after adjustment, Hausa women were now significantly less likely than Yoruba women to report kolanut use (AOR = 0.31, 95% CI = 0.12-0.79,p = 0.014).Higher levels of education were associated with reduced risk of kolanut use.Women with secondary or tertiary education were significantly less likely to report kolanut use (AOR = 0.32, 95% CI = 0.11-0.91 and AOR = 0.21, 95% CI = 0.07-0.63respectively) compared to women with no formal education.Respondents recruited from TBAs, or faith clinics had significantly higher odds of kolanut use compared to women who attended tertiary health facilities AOR = 3.17, 95% CI = 1.41-7.09.
Distribution of kolanut consumption.The distribution of kolanut consumption was shown in Fig. 1 and this signifies the respondents' residential addresses.The blue dots indicated the location of those that consumed kolanut in pregnancy and red dots showed those that did not consume kolanut in pregnancy within their residential Local Government areas.Higher percentage of kolanut consumption was more in the pregnant women as depicted as hotspots in Ibadan Northeast and Ibadan North Local Government Areas and followed by Akinyele Local Government area, while there is a low consumption rate at Ona Ara and Egbeda Local Governments areas based on the respondents' residential addresses (Fig. 2).The TBAs/Faith clinic and the primary health facilities had higher number of kolanut use attending pregnant women than other facilities.

Discussion
This study confirms that kolanut is frequently consumed at relatively high quantity by pregnant women.The current study showed a prevalence of 33.9% of kolanut consumption in previous pregnancy and 29.3% reported use in the current pregnancy, this shows a high consumption of kolanut in pregnancy.This is similar to the report from the study conducted in Jos, North Central Nigeria 33 , which reported a prevalence of 61.9%.Also, Ifesanya and Oke 18 reported a prevalence of 44.2% of kolanut/bitter kola consumption in pregnancy while looking at adverse gingival conditions among pregnant women in South-West Nigeria.However, other Nigerian studies that collected kolanut consumption data among pregnant women reported lower prevalence of kolanut use, this could be because kolanut consumption in pregnancy was not their primary focus or their geographical location and culture do not encourage kolanut consumption.Fawale and his colleagues 34 , investigated Restless Legs Syndrome in Hausa/Fulani women in Northern Nigeria and reported a prevalence of 8.4%.Also, a report on self-medication among women in South-South Nigeria found that only 1.0% of women reported kolanut intake in pregnancy 35 In Ghana, a neighboring West African country, Abu et., al 36 , in a study of pica use in pregnancy found that 3.6% of women reported kolanut use.The present study showed a higher rate of kolanut use compared to those studies in Northern and South-South Nigeria probably because our focus on this study was on kolanut consumption pattern unlike other studies who had other primary focuses.
Yoruba pregnant women had a higher percentage of kolanut consumption than another ethnic group.The reasons could include the availability of kolanut in some regions compared to others and cultural beliefs that could promote use in pregnancy.However, the ethnic differences found in this study must be interpreted with caution given the inadequate sample sizes for non-Yoruba ethnic groups.
The most reported reasons for use were for the prevention of excessive salivation, nausea, and vomiting, reported in about 56.0% and 37.0% respectively of women that reported ever using kolanut.And it has been established by different studies that these symptoms constitute the term morning sickness which usually occur in the first trimester but not limited to this period 11,12,37 and due to this, some pregnant women seek medications and/or herbs to mitigate these symptoms.This is why these women sought after kolanut especially because of its bitter taste which helps to stop the excessive salivation, nausea and vomiting.In support of the importance of nausea and vomiting warranting kolanut use, a study in North Central Nigeria reported that preventing nausea and vomiting was the reason mentioned by all women reporting kolanut use in pregnancy 33 .
Moreover, in other studies outside Nigeria focusing on caffeine use and not kolanut specifically reported that almost all women take caffeine containing foods for different reasons at different points of pregnancy 30,38,39 .For example, an Ethiopian study 39 investigated the consumption of caffeinated beverages and foods in a community sample of pregnant women and found that 98.2% of the beverages and foods had caffeine; with 17.6% of the women reporting excessive caffeine intake.These studies of caffeine use that are not restricted to kolanut alone highlight the possibility of greater caffeine consumption in pregnancy due to other sources such as coffee, energy drinks, soda such as Coca cola, and tea.
However, a significant number of studies have reported higher risk of adverse pregnancy outcomes such as miscarriages 28,38,[40][41][42] , among pregnant women consuming high levels of caffeine-containing substances in pregnancy like kolanut.Caffeine can cross the placenta into the amniotic fluid and the fetus, resulting in adverse pregnancy outcomes 43 , such as small for gestational age birth 29 , a delay in neuronal migration by retention of external granular cells in the cerebellum and neuronal toxicity which can affect posture, balance and vision 31 , and these effects can be elicited by kolanut due to its high content of caffeine.
Kolanut use in this study was most frequently reported in the first trimester (32.1%).Most women studied reported medium (thrice in a week) or high frequency (daily) kolanut use, while most women also reported www.nature.com/scientificreports/high (at least 1 nut at once) or medium (half to less than 1 lobe) quantity.These findings suggest that users tend to consume significant quantities at relatively frequently and highlight the need for efforts to identify these women and offer interventions that will get them to discontinue use.Health providers have a crucial role to play in this regard, especially given that history of kolanut use may not be routinely asked during antenatal care, a concern similarly shared by other authors 44,45 .Additionally, women who are managed for nausea and vomiting, have a greater chance of using kolanut for treatment and could be important targets for identifying those who may be using kolanut.Hämeen-Anttila et.al., 46 showed that the need for health information was significantly higher among pregnant women using herbal preparations, supporting the argument for the provision of health information to women who may be using substances like kolanut.However, this present study showed that 1.8% of pregnant women were advised by medical practitioners to consume kolanut to alleviate the symptoms of morning sickness.This act must stop and be discouraged.
Our study also noted that kolanut use was significantly higher among women with lower educational level, women attending primary health care centers and TBA clinics, after adjusting for other demographic characteristics and reproductive health related variables.The higher rates among women with lower education could be due to poor knowledge of foods safe for consumption in pregnancy 47 , compared to more educated women.It could also reflect poor socioeconomic status of women with lower education who may lack funds to seek healthcare for treatment of symptoms such as nausea and vomiting, thereby, visiting PHCs and TBA clinics, resulting in higher amount of kolanut use in these centers.In addition to women with excessive salivation and nausea and vomiting, interventions aimed at reducing kolanut use in pregnancy need to target women in PHCs or TBA clinics, Yoruba women, and those with lower education.
An understanding of patterns of kolanut use and associated factors as provided from our findings will support the design of interventions that could target pregnant women with kolanut, or caffein-containing foods use in pregnancy in Nigeria.Significant associated factors like ethnicity, with the highest use among Yoruba women, those with lower educational levels and those attending antenatal care at primary health care centers or TBAs especially within Ibadan Northeast and Ibadan North Local Government areas are to be included.
It is worthy of note to state that there is a limited number of studies on kolanut consumption in pregnancy, several studies have examined psychoactive substances use among secondary school students with lifetime use as high as 86.0% 48and 63.5% 49 in South-West and South-East Nigeria, respectively.Another study of students however reported 18.8% from the South-East 50 .Altogether, these studies of kolanut use in diverse populations suggest that kolanut use is popular in Nigeria and as stated by previous authors, some of the reasons for this include that it is cheap, readily available, and socially acceptable 33,48 .
Limitations of the study.The limitations of this study include the potential for recall bias concerning kolanut use in previous pregnancies.Additionally, some of the women studied in the first and second trimester could use kolanut later in their pregnancy, potentially underestimating kolanut use.However, majority of the women studied were in the third trimester and most current kolanut use would have been captured.In addition, the assessment of ever-use of kolanut is likely to capture most women that use the substance.Other limitations include the inability to quantitatively estimate the amount of the kolanut use as there are currently no guidelines for determining levels that are likely to result in adverse outcomes.This contrasts with caffeine-containing foods in the developed world such as coffee and soda that have been extensively studied.

Conclusion
This study has shown that kolanut use is quite common among pregnant women and frequently used in large quantities.Interventions need to focus on Yoruba women, those with nausea and vomiting, less educated women, and those attending lower levels of healthcare with education on the possible adverse effects of kolanut consumption in pregnancy.The results of this study justify research into consequences of kolanut use in pregnant women.

Recommendations
Studies designed with large sample sizes of the ethnic groups and including qualitative methodology are needed to understand kolanut use patterns in pregnancy by ethnicity.Also, multiple sources of caffeine in the Nigerian context and estimation of total caffeine intake through kolanut should be studied.Furthermore, health information about hazards of substances like kolanut or foods containing caffein should be included in routine counseling in ANC clinics and public awareness inclusive.Finally, further studies with a wider coverage within the country should be considered as this would give a better picture of kolanut consumption among pregnant women.

Table 4 .
Table 4 combines results of a crude and adjusted odds of kolanut use various sociodemographic variables and facility of recruitment of study participants.Odds are adjusted for age group, tribe, religion, employment, education experience, trimester at interview, parity and Bivariate and Adjusted Odds of factors associated with Kolanut use in current pregnancy -bivariate and adjusted odds.