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The effect of anemia among pregnant women to low birth weight babies:
A meta-analysis in various countries from 2015 to 2019
*
E-mail: aditianti@yahoo.com
Manuscripts for 9 September 2020; review 21 September 2020; approved to be published December 29, 2020
Abstract
Background: The prevalence of low birth weight (LBW) in Indonesia shows a decrease, but the risk factor for
anemia in pregnant women has increased sharply and this has an impact on increasing the prevalence of LBW.
Objective: This study aimed to determine the risk of anemia in pregnant women to the prevalence of LBW in
several countries.
Methods: This study was a meta-analysis using PRISMA. Eleven of the 122,000 studies met criteria for the
analysis. Presentation of the data used a forest plot with a random effect statistical model.
Results: The combined odds ratio (OR) showed that the effect of anemia in pregnant women on LBW was 1.49 times
higher than that of non-anemia mothers (95% CI: 1.26-4.60; p <0.001). The variance was 53.7%. The results of the funnel
plots from 11 studies were not evenly distributed so that the information obtained was homogeneous, focusing more on
the middle value.
Conclusion: There was an effect of anemia in pregnant women with the prevalence of LBW. Detection of anemia in
pregnant women needs to be done as early as possible by involving the role of health workers and cadres. Outreach
activities for young women at schools and Posyandu must be carried out regularly and continuously.
Abstract
Background: The prevalence of low birth weight (LBW) in Indonesia shows a decrease, but the risk factor for anemia in
pregnant women has increased sharply and this has an impact on the increase in the incidence of LBW.
Destination: This study aims to determine the risk of anemia for pregnant women to the incidence of LBW in several
countries.
Method: This study is a meta-analysis using PRISMA. Eleven of the 122,000 studies met the criteria for
analysis. Presentation of data using a forest plot with a statistical model random effect.
Result: Big odds ratio ( OR) combined showed that the effect of anemic pregnant women on LBW was 1.49 times higher than that
of non-anemia mothers (95% CI: 1.26-4.60; p <0.001). The amount of the variant is 53.7 percent. The results of the funnel plots of
the 11 studies are not evenly distributed so that the information obtained is homogeneous, focusing more on the middle value.
Conclusion: There is an effect of anemia in pregnant women with the incidence of LBW. Detection of anemia in pregnant
women needs to be done as early as possible by involving the role of health workers and cadres. Outreach for young
women in schools and posyandu must be carried out regularly and continuously
____________________________
*
Author correspondence
( aditianti@yahoo.com )
The same thing was expressed by Tabrizi and as well as several other countries. This
Barjesteh in a study in Iran in 2018, namely analysis aims to determine the risk of
that low blood Hb levels during pregnancy are maternal anemia during pregnancy for
associated with low birth weight. Maternal LBW babies in several countries.
blood hemoglobin has a positive relationship
with measurement of weight, length, and head
circumference in newborns. 14 While
According to a prospective study of anemia
METHOD
in pregnancy conducted by Kaur in 2015 in This article is prepared using a meta-analysis
India, the maternal hemoglobin level has a method, namely a quantitative, formal,
positive association with measurements of epidemiological research design that is used to
the weight, length and head circumference systematically assess using previous research. 16 In
of newborns. 15 Prevalence of anemia other words, meta-analysis is a quantitative
on mother pregnant show approach by combining several studies with the
A significant increase in the last decade, the same size of association, which aims to obtain a
results of the 2013 Riskesdas showed the combined size of association. This meta-analysis
prevalence of anemia in pregnant women study uses the method Preferred Reporting
was 37 percent and the 2018 Riskesdas
showed an increase to 48.9 percent. 8), (9)
Items for Systematic reviews and
Although LBW in infants has shown a decrease, MetaAnalyses ( PRISM). 17 This method is
the prevalence of anemia in pregnant women used because it is systematic and makes it
shows an increasing trend. The strong influence easier to extract data. There are 4 phases
between anemia of pregnant women on low birth carried out, that is identification, screening,
weight encourages the need for information on eligibility, and fall within the criteria as
how big the problem is in Indonesia described in Figure 1.
This analysis does not differentiate between I 2 below 50 percent, all research results are
sources of reference search sources ( database considered homogeneous. Conversely, if I 2 above
reference) and language. Article search strategy 50 percent, all research results are considered
using keywords: maternal anemia, low birth heterogeneous.
weight, upper 2014. Source database is google
scholar and pubmed. Once obtained The results of the meta-analysis are presented in forest plot,
a number of articles, then checked to see the same each study was shown the same effect, taken by size
or multiple articles. If the same article is found, then point estimate and convidence interval 95 percent
the article is excluded so that there is only one which corresponds to the size of the association.
article with the same title and content. The next step Reference bias test is carried out using funnel plot,
is to conduct a feasibility study on whether the
article matches the inclusion criteria that have been that is to see the distribution from effect size study
set, if it does not comply with the inclusion / by comparing between the research precision plots ( standard
eligibility criteria that have been set, then the article error) with effect size
is excluded or not included in the next analysis. The all studies analyzed. The data is said to be
inclusion criteria used were multiple pregnancy; biased when the value effect size not spread
association sizes are not the same; born with symmetrically in a triangle funnel plot. Data
congenital defects, and the baby is stillborn. analysis using software Stata version 12.0
Meanwhile, the exclusion criteria for this study were
not lab research and articles related to animal
subjects. Reference searches were conducted from
RESULTS
January 2019 to December 2019.
Based on keywords "Maternal anemia and
low birth weight upper 2014 ", Obtained
122,000 articles for further selection based on the
Methods are used to maintain reference year of publication. By choosing a publication
quality quorum by method checklist. year ranging from 2014 to 2019, 17,600 articles
There are 5 indicator that used were obtained. Further tracing was carried out by
depending on the subsections, namely (1) the selecting articles that matched the substance of
abstract includes: objectives, data sources, review the analysis, from 17,600 which were in
methods, results, conclusions; (2) introduction accordance with the topic of analysis, there were
includes: magnitude of the problem, rationalization, 82 articles that were relevant. Of the 82 articles,
expectations; (3) methodology includes reference eight of them were duplicated so that they were
search, reference selection, reference validity excluded from the article collection, henceforth
testing, abstraction
data, characteristics research, done filtering again
qualitative data; (4) the results include an overview based on the inclusion criteria (single birth,
of the analysis flow, study characteristics, normal birth, and the child is still alive),
quantitative analysis data; (5) discussion includes excluded the exclusion criteria (studies related to
conclusions from key findings. References that do experimental animals and clinical studies), which
not meet the quality are not included in the analysis. ended with the acquisition of 38 articles.
The results of the meta-analysis are presented in forest plot, Of the 38 articles, there were 15 articles that
namely the distribution description effect were included in the meta-analysis because
size of all the research results analyzed. The they had the same size of association, the size
statistical model used refers to its width of the association used was value. odd ratio
confidence interval ( CI), if the combined CI (OR). Most of the articles have no data outcome
cuts all the CIs of the analyzed study on exposure so it is not possible to calculate
results, the statistical model used is fixed OR. There were four articles that were
effect model, however, if the combined CIs excluded from being analyzed because confident
do not cut all the CIs from the analyzed interval which is not good or has an upper
study results then it will be used and lower limit of the width and has poor
random effect model. For look reference validity. The process of filtering
The homogeneity or heterogeneity of the research which is the articles can be seen in Figure 2.
source of the analysis is seen from the value I 2. When
Identification
122,000
17,600
82
Screening
8 duplications
74
36 excluding the inclusion criteria:
- not born twins
- born with stillbirth
- defects
Appropriateness
38
15
Enter criteria
11
Eleven articles that can be analyzed were three and two articles. Acquisition of articles
obtained from various reference sources from each journal is summarized in the Table
with the most journals coming from BMJ 1.
Global Health and PLOS ONE, namely
Table 2. Characteristics of articles on the effect of anemia in pregnant women with LBW
Birth weight
No. Author Title Year Location Sample Subject Design Study results
baby
1 Mitao M, et al 9 Risk factors and adverse 2015 Tanzania 37,799 Mother and baby Retrospective Number of samples LBW related factors:
168
perinatal outcome North born cohort ( data Normal: anemia, preeclampsia,
associated with low birth secondary) 33,792 premature birth, heavy
weight in Northern LBW: 4,007 pregnant mother's body
Tanzania: a registry-
based retrospective
cohort study
2 Bhaskar RK, et al 18 A case control study on 2015 Nepal 159 cases; Mother and baby Case control Average LBW related factors:
risk factors associated East 159 birth controls birth weight: iron supplementation,
with low birth weight Case group: illness during pregnancy,
babies in Eastern Nepal 2.126.73 grams The first ANC, and the number
Control group: ANC visit
3.083.65 grams
3 Zerfu, et al 19 Dietary diversity during 2016 Ethiopia 374 Mother and baby Retrospective Average The pregnant mother
pregnancy is associated born cohort birth weight: consuming more than 4
4 Nair M, et al 13 Association between 2016 Assam, 1,007 Mother and baby Retrospective Pregnant women
maternal anemia and India born cohort related to anemia
Pregnancy outcomes: a increased risk
cohort study in Assam, postpartum haemorrhage
India (PPH), LBW, and perinatal
mortality
Birth weight
No. Author Title Year Location Sample Subject Design Study results
baby
5 Kattula D, et al The first 1000 days of 2014 South India 497 Mother and Community- Percentage High morbidity in
20
life: prenatal and baby born based birth birth weight: poor areas of India in the
postnatal risk factors for cohort Normal: first 1000 days of life is
9 Anwar R 24 Impact of maternal 2019 Karachi, 643 Cohort A low maternal blood
169
Mother and Number of samples
anemia on perinatal Pakistan baby born LBW: 168 Hb level increases
outcome the risk of birth
preterm, infant LBW, APGAR
score <5 at 1 minute and the
IUD ( intrauterine fetal
death)
Birth weight
No. Author Title Year Location Sample Subject Design Study results
baby
10 Fajriana et al 25 Risk factors are 2018 Surabaya, 22 cases; Mother and Case control Pregnant women who gave birth to
associated with Indonesia 22 controls baby born premature babies had a 6.2 times
the incidence of low birth greater risk of experiencing LBW,
170
weight babies in Kecamatan while pregnant women who had
Semampir Surabaya KEK had a 6.6 times greater risk of
experiencing LBW.
11 Rajashree K, et al 10 Study on the factors 2015 Karnataka, 131 Mother and Cross- Percentage by weight The cause of LBW is
associated with low birth India baby born sectional born: multidimensional: age, number
weight among newborns ( hospital- Normal: 69% literacy, birth spacing, daytime rest
delivered in a tertiarycare based) LBW: 31% during pregnancy, maternal weight
hospital, Shimoga, gain during pregnancy, and Hb
Karnataka levels.
All study results in 11 articles stated that meaningful. Anemia in pregnant women is
anemia in pregnant women is a risk factor proven statistics cause LBW.
for LBW. A total of seven studies, namely While four studies other not
the Mitao study (2016) 9, shows a significant difference, namely the
Zefru (2016) 19, Nair (2014) 13, Enter the resume study of Bhaskar (2015) 18, Kattula (2014) 20 Adane
(2015) 21, Feresu (2015) 22, Anwar (2019) 24 and (2014) 23 and Fajriana (2018) 25. The results of this
Rajashere (2015) 10 yielded statistically study are detailed in Table 3.
significant or different results
% amount Representative
No. Studies Year OR 95% CI Study design
weight sample sample
1 Mitao M, et al 9 2016 1.70 1.40-2.20 17.91 Retrospective 37,799 Representative
cohort ( data
secondary)
2 Bhaskar RK, et al 18 2015 1.27 0.59-2.71 2.55 Case control 318 Not
representative
3 Zerfu, et al 19 2016 2.29 1.62-3.24 4.37 Prospective 374 Not
cohort representative
4 Nair M, et al 13 2016 1.26 1.04-1.53 47.47 Retrospective 1,007 Not
cohort representative
5 Kattula D, et al 2014 2.00 0.98-4.06 1.21 Community-based 497 Not
20
birth cohort representative
6 Masukume G et al 21 2015 1.34 1.01-1.78 19.33 Prospective 5,069 Representative
cohort
7 Feresu SA, et al 22 2015 3.51 2,10-5,84 0.82 Cross-sectional 3,110 Representative
(secondary data)
8 Adane, AA, et al 23 2014 1.49 0.79-4.74 0.73 Cross-sectional 481 Not
( hospital-based) representative
9 Anwar R 24 2019 2.48 1.80-3.30 5.09 Cohort 643 Not
representative
10 Fajriana et al 25 2018 2.31 0.62-9.03 0.16 Case control 44 Not
representative
11 Rajashree K, et al 10 2015 4.06 1.50-14.4 0.07 Cross sectional 131 Not
( hospital-based) representative
To see whether the number of samples Of the 11 studies included in the analysis, the
from each study can represent the largest contribution in calculating the combined
population under study, the minimum risk was from the Nair (2016) study. 13 that is
sample size that should be met is 47.47 percent and the smallest contribution
calculated. The sample calculation uses came from the Rajashere study (2015) 10 that is
the sample size formula estimating and 0.07 percent. The biggest risk factor for anemia
odds ratio with specified
relative precision, with in pregnant women to the incidence of LBW in
using by using Badshah research in 2008 3, namelybabies born comes from the study of Rajashere
the proportion of anemic pregnant (2015). 10 with 131 samples of pregnant women.
women who gave birth to LBW by From this study, it was found that the risk of
12.3 percent, while pregnant women who were not anemic gave pregnant women with anemia to give birth to
birth to LBW babies at 8.5 percent and an OR value of 1.5. With a LBW babies was 4.06 times compared to
precision value of 25 percent and pregnant women without anemia. While the
confidence level 95 percent, then the smallest OR value comes from the study of
recommended minimum sample size is 1,028. Nair (2016), 13 that is, the risk of anemia for
In Table 3, it can be seen that a representative pregnant women to have babies with low birth
sample size from each study is compared to weight is 1.26 times compared to pregnant
the number of samples that should be. women who do not have anemia.
This meta-analysis resulted in the magnitude anemia in pregnant women with LBW
of the risk of pregnant women with anemia cases in babies born. 9, 13, 20, 21, 22, 10,
24
affecting the occurrence of LBW in babies
born by 1.495 times compared to mothers
without anemia (95% CI: 1.36-1.66). This The quality of the data that constructs the combined
means that a mother who suffered from risk factors (combined OR) can be seen from
anemia during her pregnancy had almost 2 chi-squared heterogeneity ( Figure 3), which
times the risk of giving birth to a child with shows the results that the combined OR has a
low birth weight, compared to a mother who heterogeneous distribution (p = 0.017 below p
was not anemic during her pregnancy, with <0.05). This can also be seen from the width confidence
a significant difference in risk (p <0.001). As interval ( 95% CI) of the combined ORs that did
many as seven of the 11 journals studied not cut across the whole
stated that there was a significant confidence interval study (lower limit <1.33
relationship between events and> 1.66).
Information:
Heterogeneity chi-squared = 21.61 (df = 10) then p = 0.017
Variance I-squared (variation in OR attributable to heterogeneity) = 53,7%
Test of OR = 0; z = 17.31; p = 0.000
Figure 3. Distribution forest plot the effect of anemia in pregnant women with LBW
Apart from looking at the magnitude of the combined evenly, the value of all the risks is above 1.
effect of the 11 studies, reference bias also needs to be Reference more found in the center axis.
looked at. Figure 4 shows that the results funnel plot Studies with OR values above 1 and
of the 11 studies were not scattered below 0.5 are underrepresented.
Figure 4. Distribution funnel plot the effect of anemia in pregnant women with LBW
birth, 10 habit of resting during the day, 10 anemia. Anemia in pregnant women is
and weight gain during pregnancy. 10 mostly caused by iron (Fe) deficiency. Lack of
iron consumption can reduce hemoglobin
In this meta-analysis, there are also studies (Hb) levels in the blood of pregnant women
which reveal that there is no significant so that blood flow to the fetus becomes
relationship between anemia in pregnant obstructed and causes disruption of oxygen
women and the incidence of LBW. The flow and nutrient supply from the mother to
insignificant results of the study were due to the fetus. fetus. Thing this disturb
the fact that most mothers did not have fetal growth and leads to inhibition of fetal
anemia. This study was conducted in 2018 in weight gain. There is an inverse
Surabaya Indonesia using a case-control relationship between changes in maternal
design. 25 Study conducted by Enterume in blood Hb levels during pregnancy and
2015 21 also reported that the incidence of weight gain in babies born. The lower the
anemia in pregnant women did not affect outcome blood Hb level of the pregnant woman,
pregnancy, however the greater the risk of the mother giving
bad pregnancies are more common in birth to a low birth weight baby.
those who are anemic than in those who
are not.
SUGGESTION
A meta-analysis study on the relationship
between anemia and LBW pregnant women It is necessary to innovate intervention programs in
in children was carried out by Figueiredo. 35 This the management of anemia in pregnant women that
study did not limit the number of years of can be carried out by collaborating across programs
publication but limited the study design to and cross sector in a manner
the cohort and case-control study of 68 continuous, for example with
articles. The results of the study concluded detect anemia in pregnant women as early as
that anemia in pregnant women is a risk possible. Pregnant women who experience
factor for low birth weight in infants (OR: anemia must be monitored by health personnel
1.23; 95% CI: 1.06-1.43). Meanwhile, a and cadres so that the provision of Fe tablets and
meta-analysis study conducted by Rahmati local food ingredients sources of Fe can be given
in 2016 on 30 articles showed that anemia in freely routine During period pregnancy.
pregnant women in the first trimester Massive outreach to young women as
showed a significant relationship with low prospective mothers at schools and posyandu
birth weight (RR: 1.28, 95% CI: 1.10-1.50, p is a mustheld in a manner routine and
<0.01). 36 continuous.
Related to the incidence of low birth of the evidence. Albert Canada Inst Heal
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birth weight - What is really important? d + Prevention + of + Low + Birth + Weight +: +
Indian J Med Res. 2009; 130 (5): 600–8. A + Synopsis + of + the + Evidence # 0
27. Alen LiH. Biological Mechanisms That 33. Widya Larasati E. Relationship between
Might Underlie Iron's Effects on Fetal Deficiencies Energy Chronic (SEZ)
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131: 616–35. women at RSKDIA Siti Fatimah Makassar 2018. J
28. Novianti S, Aisyah IS, Study P, Society Health Pomegranate Pelamonia.
K, Health I, Siliwangi Tasikmalaya U. Relationship 2018; 2 (2): 131–4.
between anemia in pregnant women and pregnant 34. Rizki F, Lipoeto NI, Ali H. Relationship between Fe
women. 2018; 4 (1): 6–8. tablet supplementation and hemoglobin levels in
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