ANTENATAL CARE AND IRON DEFICIENCY ANEMIA AMONG …

Antenatal Care and Iron Deficiency Anemia among Pregnant Women

13 Proceeding of The 8th AIC: Health and Life Sciences 2018 – Syiah Kuala University

ANTENATAL CARE AND IRON DEFICIENCY ANEMIA AMONG

PREGNANT WOMEN

Darmawati1,2*, Teuku Tahlil3, Toungku Nizwan Siregar4, Hajjul Kamil5, Fithria6, and

Masyithah Audina7

1Maternity Nursing Department, Faculty of Nursing, Syiah Kuala University Darussalam 23111

Banda Aceh, Indonesia 2Doctoral Student of Mathematic and Applied Science Syiah Kuala University Darussalam 23111

Banda Aceh, Indonesia 3Community Nursing Department, Faculty of Nursing, Syiah Kuala University Darussalam 23111

Banda Aceh, Indonesia 4Faculty of Veterinary, Syiah Kuala University Darussalam 23111 Banda Aceh, Indonesia

5Management Nursing Department, Faculty of Nursing, Syiah Kuala University Darussalam 23111

Banda Aceh, Indonesia 6Family Nursing Department, Faculty of Nursing, Syiah Kuala University Darussalam 23111

Banda Aceh, Indonesia 7Student of Nursing Faculty, Syiah Kuala University Darussalam 23111 Banda Aceh, Indonesia

*Corresponding author e-mail: [email protected]

ABSTRACT

Anemia in pregnancy is one of the contributor factors to the increasing of maternal mortality rate, cause

hemorrhage and sepsis during labour. Infants who born from anemic mothers can also be premature, immune

system weakness, and developmental disorders. Globally, the most common cause of anemia during pregnancy is

iron deficiency. Indonesian Ministry of Health try to solve this problem with integrated antenatal service program

with the standards offered are middle upper arm circumference (MUAC) measurement, weight measurement, and

laboratory examination. This study aims to find out the relationship between integrated antenatal service with iron

deficiency anemia. This study is applied using cross sectional study with non probability and purposive sampling

method. The measuring instrument was checklist and questionnaire sheets. The sample of this study was 102

pregnant women and data analysis was done using Chi-Square test. The relationship between MUAC and iron

deficiency anemia has p-value = 0.008. MUAC is a standard in measuring nutritional status of pregnant mother

that has consistent result, so it can be used to identify the change of maternal nutritional status including iron. The

laboratory examination and iron deficiency anemia relationship has p-value = 0.005. The blood type and

hemoglobin examination is part of laboratory examination. The blood type examination provides information

about the type of blood group that susceptible to anemia, so that it can be used to detect and prevent anemia, while

hemoglobin examination also recommended by WHO to diagnose anemia in pregnancy. This study find out that

there is no significant relationship between body weight measurement and iron deficiency anemia (p-value =

0.808). Weight measurement in pregnancy is not always a step to detect nutritional status in pregnancy because

the weight gain in pregnancy may also caused by other factors. This study above indicates that anemia in pregnancy

is relate with integrated antenatal care service, especially middle upper arm circumference measurement and

laboratory examination. It is recommended to antenatal care providers to improve the quality of service that

offered, so it can make many health problems during pregnancy especially iron deficiency anemia can be detected

and handled quickly.

Keywords: anemia, antenatal, laboratory, weight

INTRODUCTION

One of the health problems that contributes to maternal mortality is anemia in pregnancy

(Silverberg, 2012). Anemia is a risk factor that contributes to 50% of maternal deaths

(Khaskheli et al., 2016). In Indonesia, the prevalence of pregnant women with anemia in 2013



was 37.1% (Kemenkes RI, 2013). Based on data from Aceh Besar Health Office in 2017, this

regency has a high prevalence of anemia in pregancy, which was 37.1%.

Anemia in pregnancy can increase the incidence of sepsis and hemorrhage during

labour. Infant who born from anemic mother can be premature, Low Birth Weight (LBW),

immune system weakness, and developmental disorders. In more severe conditions, anemia in

pregnancy can cause fetal death (Bivolarska et al., 2015). Inadequate intake of iron-containing

foods may cause the pregnant women’s body unable to meet the needs of this nutrition and

cause Iron Deficiency Anemia (IDA) (Khalafallah & Dennis, 2012). In addition to inadequate

nutrition, other things that contribute to iron deficiency anemia during pregnancy are the

antenatal services provided (Ikeanyi & Ibrahim, 2015).

The implementation of integrated antenatal care (ANC) is a program that can be a way

for pregnant women to look into their conditions to health workers so that it must be ensured

that health workers have provided a good quality service in accordance with the standards. In

ANC services, there are several standards to measure nutritional status in pregnant women and

detect anemia in pregnancy, which are: measurement of Middle Upper Arm Circumference

(MUAC), Body Weight (BW), and Laboratory Examination (Lab) (Kemenkes RI, 2010).

Midle upper arm circumference is a measurement of arm circumference for screening

the risk of chronic energy deficiency. Middle upper arm circumference less than 23.5 cm should

be a concern because this condition can be a predisposing symptoms that mothers give birth to

Low Birth Weight Babies (LBW). This examination is carried out at the first visit. Weighing

body weight at each antenatal visit is done to detect any fetal growth disorders. Weight gain

less than 9 kilograms during pregnancy or less than 1 kilogram each month indicates a

disturbance in fetal growth (Kemenkes RI, 2010) Laboratory examination on integrated

antenatal services performed include: Blood type examination and the examination of

hemoglobin levels carried out at least once in the first trimester and once in the third trimester.

Evaluation of hemoglobin (Hb) levels is the most reliable indicator for detecting anemia

(Punter-Villagrasa et al., 2015).

MUAC measurement is an examination standard to detect Chronic Energy Deficiency

(CED), while BW measurement is a standard that has performed every antenatal visit to detect

fetal growth disturbances. In addition, antenatal services also have a standard for anemia

screening through laboratory tests. This study aims to determine the relationship between the

implementation of ANC services especially the measurement MUAC, BW, and laboratory

examination with iron deficiency anemia at the Darul Imarah Community Health Center in

Aceh Besar Regency.



MATERIALS AND METHODS

The type of research used in this study was correlation study with cross sectional study

design that has been done in Darul Imarah Subdistrict, Aceh Besar. Methods of data collection

was through a guided interview to find out the description of MUAC measurement and

laboratory examination implementation, and the method of observation for the BW

measurement.

The population in this study was all of the pregnant women who came to the ANC

service at Darul Imarah Community Health Center in 2017, which was 1.285 pregnant women.

The sampling technique that used was non probability sampling with purposive sampling

method. The studied samples were selected with the following inclusion criteria: pregnant

women who agreed to participate in this study, more than once visited to ANC service at Darul

Imarah Community Health Center, second or third trimester of pregnancy, and did not

experience circulatory or blood disorders. The participant in this study were 102 pregnant

women. The data collection tool in this study was a hemoglobin measuring device (Hb Meter)

named Easy Touch; questionnaire sheet to examine the measurements of MUAC and laboratory

examination; and the checklist sheet as a guide in observation to examine the BW

measurements.

The collecting data start with asked the respondent's approval to be participated in this

study, followed by an explanation of the purpose and objectives of the study. Next, the

researcher asked the respondent's signature on the informed consent letter. After that, the

researchers conducted guided interviews with respondents related to the implementation of the

MUAC examination and laboratory examination that has been received by respondents from

the health workers. Furthermore, the researchers observed the implementation of BW

measurement carried out by health workers in a non-participatory manner and referred to the

checklist provided. The data analysis was using Chi-Square test with α 0.05. This study was

approved by the Ethical Committee of Nursing Faculty, University of Syiah Kuala (approval

number: 111002040418).

RESULTS

Table 1 describes the frequency distribution of pregnant women visiting ANC service

at Darul Imarah Community Health Center in Aceh Besar Regency. Sociodemographic

characteristics of the respondents demonstrated that nearly two-thirds of pregnant women were

mothers with a second pregnancy (multiparous), half of the respondents had a third trimester

pregnancy, and nearly half of the respondents had an antenatal visit on re-visit.



Table 1. Frequency Distribution of Pregnant Women Visiting ANC at the Darul Imarah Community Health

Center

Characteristics F %

Parity

a. Primiparous

b. Multiparous

c. Grandemultiparous

26

72

4

25.5

70.6

3.9

Gestational age

a. Second trimester

b. Third trimester

49

53

48.0

52.0

ANC visit

a. First visit

b. Second visit

c. Third visit

d. Fourth visit

e. Re-visit (> 4 times)

1

20

17

17

47

1.0

19.6

16.7

16.7

46.1

Total 102 100

The incidence of iron deficiency anemia at Darul Imarah Community Health Center,

Aceh Besar Regency was 30.4%. The implementation of integrated antenatal care services

describes as follows: The implementation of MUAC and BW measurement mostly not

implemented comprehensively (70.6% and 67.6% respectively) and the implementation of the

laboratory examination mostly implemented comprehensively (82.4%). Finally, the

implementation of antenatal care services was carried out comprehensively as much as 57.8%

(Figure 1).

Figure 1. Frequency Distribution of the MUAC, BW, and laboratory examination at Darul Imarah Community

Health Center, Aceh Besar Regency.

0

10

20

30

40

50

60

70

80

90

Iron Deficiency

Anemia

MUAC

Measurement

Implementation

BW Measurement

Implementation

Laboratory

Examination

Implementation

Integrated Antenatal

Care Service

Pre

gnan

t W

om

en (

%)

Anemia Did not Anemia

Implemented in an integrated manner Did not implemented in an integrated manner



The study found that from total 30 respondents who received a comprehensive MUAC

measurement, 27 respondents (90%) did not had anemia, and 28 of 72 respondents (38.9%)

who received an uncomprehensive MUAC measurement had anemia. The hypothesis test

obtained p-value = 0.008 so it can be interpreted that there was a statistical relationship between

the implementation of middle upper arm circumference measurement and iron deficiency

anemia in Darul Imarah Community Health Center, Aceh Besar Regency (Table 2).

Table 2. The Relationship between MUAC Measurement and IDA at Darul Imarah Community Health Center,

Aceh Besar Regency

No. MUAC Measurement

Implementation

Iron Deficiency Anemia

Total α p-value Anemia Did not Anemia

f % f %

1 Implemented comprehensively 3 10 27 90 30

0.05 0.008 2

Did not implemented

comprehensively

28 38.9 44 61.1 72

Total 31 30.1 71 69.6 102

The result of this study found that from total 33 respondents who received a

comprehensive BW measurement, 24 respondents (72.7%) did not had anemia, while 22 of 69

respondents (31.9%) who received an uncomprehensive BW measurement had anemia. The

result of the hypothesis test was p-value = 0.808 so it can be interpreted that there was no

statistical correlation between BW measurement implementation and iron deficiency anemia at

Darul Imarah Community Health Center, Aceh Besar Regency (Table 3).

Table 3. The Relationship between Body Weight Measurement and Iron Deficiency Anemia at Darul Imarah

Community Health Center, Aceh Besar Regency

No BW Measurement

Implementation



F % f %

1 Implemented comprehensively 9 27.3 24 72.7 33

0.05 0.808 2

Did not implemented

comprehensively

22 31.9 47 68.1 69

Total 31 30.4 71 69.6 102

Table 4 illustrates that from total 84 respondents who received a comprehensive

laboratory examination, 64 respondents (76.2%) did not categorized to anemia, while 11 of 18

respondents (61.1%) who received uncomprehensive laboratory examination were anemic. The

hypothesis test results obtained p-value = 0.005 so it can be interpreted that there was a

statistical relationship between the implementation of laboratory examination and iron

deficiency anemia in Darul Imarah Community Health Center, Aceh Besar Regency. Based on



Table 5, from 59 respondents who received integrated antenatal care, there were 52 respondents

(88.1%) did not had anemia, while 24 of 43 respondents (55.8%) who received antenatal service

comprehensively had anemia.

Table 4. The Relationship between Laboratory Examination Implementation with Iron Deficiency Anemia in

Darul Imarah Community Health Center, Aceh Besar Regency

No Laboratory Examination

Implementation



f % f %


0.05 0.005 2

Did not implemented

comprehensively

11 61.1 7 38.9 18

Total 31 30.4 71 69.6 102

Table 5. Relationship between the Implementation of Integrated Antenatal Care Services and Iron Deficiency

Anemia at Darul Imarah Community Health Center, Aceh Besar Regency

No Antenatal Care Service

Implementation



f % f %


0.05 0.005 2

Did not implemented

comprehensively

24 55.8 19 44.2 43

Total 31 30.4 71 69.6 102

DISCUSSIONS

The Indonesian Ministry of Health has developed an integrated antenatal service that

recommended all of the health workers to measure pregnant women's MUAC as a standard

performed at the first contact of antenatal visit (Kemenkes RI, 2010). MUAC measurement is

a simple anthropometric measurement than body mass index measurements because it does not

use expensive tools and complex calculations. This measurement is performed to determine the

nutritional status of pregnant women and prevent Chronic Energy Deficiency (CED) in the

pregnancy. The nutritional deficiencies condition experienced by pregnant women can caused

anemia condition (Fakier et al., 2017).

The results show that there was a statistical correlation between the implementation of

MUAC measurements and iron deficiency anemia supported by previous studies conducted by

Laghari et al. (2017). That study who found that there was a significant relationship between

MUAC and hemoglobin levels in female students (p<0.05). Another study conducted in

Westmoreland, Jamaica also found that pregnant women with MUAC less than 25 cm would

be more likely to have anemia. This finding showed that there was 18.6% of pregnant women



with anemia had a MUAC < 25 cm compared with 6.8% non-anemic women (Charles et al.,

2011). Similar studies also been conducted in Gombong, Kebumen by Novyriana et al. (2016)

and found out that there was a relationship between MUAC and the incidence of anemia in

pregnancy.

The decrease in the MUAC size of an individual indicates a reduction of nutritional

status. When a pregnant woman has a low nutritional status, she will not be able to meet the

nutritional needs of her body and fetus, so that it can be a predisposing factors to anemia in

pregnancy (Novyriana et al., 2016).

Middle upper arm circumference measurements should be accompanied by giving

information regarding the examination results in antenatal care given to the pregnant women.

It is intended to make the pregnant women understand about her condition and obedient to

follow the advices given by the health workers to improve their condition. This study obtained

that 51 respondents (50%) said that the measurement of MUAC was not included with giving

information about the interpretation of the measurement results.

The implementation of body weight measurement in pregnant women is one of the

standards that aims to detect any disturbance of fetal growth. The ideal weight gain is 9

kilograms during pregnancy or 1 kilogram every month (Kemenkes RI, 2010). Maternal body

weight is measured at every antenatal visit, any weight gain should be recorded and

documented. The result of weight gain should be communicated to the patient, as well as if the

mother does not experienced an appropriate weight gain (Addo, 2010).

This present finding was contrasted with the results found by Garcia-Valdes et al (2015)

who found that there were differences in iron status among obese pregnant women with normal

body weight. Pregnant women with excessive body weight have less iron status. Hepcidin levels

in the late pregnancy were also higher in obese women than women with normal weight (p

<0.05). This hepcidin level is an indicator that can identify maternal iron status (p = 0.025). The

differences between these researches can be due to differences indicators of anemia

examination used. In this study, the diagnostic indicator used was hepcidin level which also can

be influenced by the inflammatory process that occurs in the body of obese women, while our

study used hemoglobin level as a diagnostic indicator of anemia in pregnancy.

The absence of a relationship between BW measurement and iron deficiency anemia as

one of the greatest nutritional problems experienced by pregnant women could because of the

weight measurement in pregnant women was not always able to identify their nutritional status.

In the late pregnancy, weight gain can be caused by many conditions such as gestational

hypertension or congenital abnormalities (Department of Health Western Australia, 2016) .The



main cause of weight gain in pregnancy is due to fluid retention (edema). This situation is very

common and affects 65% of pregnant women. Edema may occur as a result of portal venous

suppression along with infant development. This condition reduces the ability of the blood

pump back to the heart effectively (Pickles, 2017).

As previously mentioned, body weight measurement should be accompanied by giving

informations about the interpretation of results and advices that should be done by the pregnant

women in their daily lifestyle. Today, society believes that weight gain during pregnancy is

considered a good condition because they believe that the baby grows and develops well.

However, pregnant women may not know that there were other situation that also contribute to

the body weight gain in pregnant women. This study found that from the total respondents who

got the weight measurement in the antenatal service, only 33 respondents (32.4%) received

information about the interpretation of the measurement results, while other respondents

(67.6%) did not receive it.

Laboratory tests for pregnant women which is implemented are blood type and

hemoglobin levels examination that performed at least once in the first trimester and once in

the third trimester of pregnancy. Blood type examination is needed to determine the maternal

blood group type and in case to prepare blood donor candidate if any time needed, while the

examination of maternal hemoglobin level is aimed to find out whether or not the mother is

anemic (Kemenkes RI, 2010).

This present study found similar result with other study obtained by Kumar & Kaushik

(2013) who found that there was a relationship between the blood type with the incidence of

anemia. A person with A, B, or AB blood type is relatively more susceptible to anemia than

someone with O blood type. This is because the A, B, and AB blood type have alpha and beta

antigens that are relatively more susceptible to anemia. So that, the researchers assume that the

blood type examination is not only a precautionary measure if any time the mother needs a

blood donor, but also as a preventive examination for pregnant women with anemia-susceptible

blood group to be more motivated and supported to maintain their intake of diet and more

obedient in taking irom tablets as a preventive steps to anemia.

In addition, our study also found a relationship between hemoglobin levels examination

and anemia. Hemoglobin levels are one of the laboratory indicators to diagnose anemia

although there also many other indicators to diagnose it that recommended, such as ferritin

levels. However, ferritin levels examination require more complicated equipment and steps

where the examination requires venous blood taking and it must sent to the laboratory to be

processed. If any symptoms occur leading to the signs of anemia (such as fatigue, headache,



vertigo, leg cramps, and pallor), the individual will be given laboratory tests directly (Api et al.

2015). The Indonesian Health Ministry recommends the hemoglobin examination as a

diagnostic examination to detect iron deficiency anemia in pregnancy (Departemen Kesehatan

RI, 2007; Kemenkes RI, 2010).

One other hemoglobin measurement tool that fast and easy to be used is Hb meter. It is

an automated tool to check hemoglobin levels by taking venous or capillary blood samples

(Adam et al., 2012). This tool has been sufficiently accurate and has passed the test to be used

for inspection (Purwanti & Maris, 2012).

Laboratory examination without the provision of information related to the results

interpretation is also wasted. Pregnant women should know about the results of the

examination, so they know what to do in the future. From total 73 respondents (71.6%) who

received blood type examinations, only 26 respondents (35.6%) were given information related

to the type of blood group; and 29 respondents (28.4%) did not receive blood type examination.

It may happened because the pregnant women already knew the type of blood group so they

did not need to be re-examination. Furthermore, from the 97 respondents (95.1%) who received

hemoglobin examination, 41 respondents (40.3%) were given information related to the

examination result and 5 respondents (4.9%) never received hemoglobin examination from the

community health center.

Laboratory tests as a first step or prerequisite in detected anemia should be performed

to all pregnant women, so this condition can be treated or prevented earlier and does not caused

worsening conditions in pregnant women and the fetus. Short interviews that researchers

conducted on several respondents revealed that pregnant women entrusted all the examinations

to the health workers because they felt that the health workers must know the best for them.

Claims for various checks were rarely submitted to health care workers because they believe in

the health workers.

Antenatal care is one of the complete packages of education and examination procedures

offered to the pregnant women population to improve health and detect pregnancy problems

earlier. This service is intended to prevent the occurrence of further risks of pregnancy, to

diagnose and provide appropriate treatment for various problems, so the potential infant and

maternal mortality can be prevented (Nogueira & Oliveira, 2017).

The results in this study has similar results conducted by (Mishra et al., 2016). The study

found that out of 307 anemic women studied, the incidence of anemia was significantly higher

in women who did not receive antenatal care service (95.6%) than women who received

antenatal care (62.2%). This analysis used statistical test and obtained p-value <0.0001. Similar



association was also observed in a study conducted by Fatimah & Ernawati (2016) in

Yogyakarta where the incidence of anemia is more prevalent in pregnant women who got poor

antenatal care service (63.6%) than the one who got good antenatal care service (15.2%).

Antenatal care service given to pregnant women with iron deficiency anemia is related

because the health workers can identify the condition of anemia, give iron supplementations,

and provide nutritional counseling to pregnant women through this antenatal care service. The

outcome of this implementation is to ensure that pregnant women's hemoglobin levels can be

monitored to prevent complications from iron deficiency anemia. An antenatal service that does

not work in an comprehensively or a mother who does not attend antenatal care regularly will

not get a very useful iron supplementation to increase her hemoglobin levels, nor she will get

any information about good nutrition to prevent severe condition of anemia that can actually

occur physiologically.

This study has limitations where the researcher did not do interrater reliability on

checklist sheets between researcher and enumerators. But, this limitation has been minimized

by the validity of content test for by experts in nursing maternity and enumerators have also

studied about antenatal care examination techniques. It can be ascertained that the researchers

and enumerators already have the same perception.

CONCLUSION

Based on the results and discussion in this study, it is concluded that the implementation

of integrated antenatal services was associated with iron deficiency anemia with related

standards was the examination of MUAC and laboratory examination, while the standard that

not related to anemia was body weight measurements. It is recommended for antenatal care

providers to improve the quality of services provided, so the problems in pregnancy especially

iron deficiency anemia can be detected and treated quickly. It is hoped for all of the health

workers to be more able to provide information related to the results of examination.

ACKNOWLEDGEMENTS

The authors thank the pregnant women for their participation and enthusiasm, also for

the health workers and other personnel from Darul Imarah Community Health Center and Aceh

Besar Health Office for the permission and support provided for this research process.



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