Anemia and Low Income of Preeclampsia Maternal Death in Jember District, Indonesian

Abstract
Background : Preeclampsia is a pregnancy complication that causes maternal morbidity and
mortality. This study aims to determine the effect of anemia and income on the incidence of
maternal death due to preeclampsia in Jember Regency.
Materials and Methods : Case control, using medical record data, in January 2016 – December
2019. 43 cases of mothers with maternal death due to preeclampsia, and 43 maternal controls
with live preeclampsia.
Results : Mothers who died from preeclampsia were more likely to have anemia (83.72%), and
being low income (86.05%). Women having anemia (OR 3,703, 95% CI p-value 0.009) and low
income (OR 4.032, 95% CI, p-value 0.007).
Conclusions : Maternal death from preeclampsia was associated with anemia and low income.
Keyword : Anemia, Low income, Preeclampsia, Maternal Mortality

Introduction
Preeclampsia is a contributor to 15% of pregnancy complications and 18% of maternal
deaths in the world, with an estimated 62,000 to 77,000 annually (1). Examination of blood
pressure and urine protein is a way to detect preeclampsia. Preeclampsia is characterized by an
increase in blood pressure ( mmHg systolic and mmHg diastolic pressure), starting after 20
weeks of gestation (2). Elevated blood pressure in preeclampsia reflects multisystem endothelial
dysfunction leading to vascular, renal, and hepatic damage (3).
Anemia is a risk factor for preeclampsia, with hemoglobin levels <11.0 g/dL in the first
and third trimesters of pregnancy and hemoglobin levels <10.5 g/dL in pregnancy.trimester
second pregnancy (4). Anemia causes the occurrence of hypoxia and causes endothelial
dysfunction and multiorgan injury (5). Income………………….
Based on the Indonesian Health Profile (2020), maternal mortality cases have increased by
406 deaths, which constituted 305 deaths per 100,000 live births (6) . Jember, a district in East
Java Province Indonesia, is the district with the highest maternal mortality, namely 61 cases or
173 per 100,000 live births in 2020 (7). In addition, preeclampsia (26.2%) was the second main
cause of death among mothers.
 This study was conducted to determine the effect of anemia and socioeconomics on the
incidence of maternal death due to preeclampsia in Jember Regency.

Materials and Methods

Study Design
This study uses a case control design conducted at the Jember District Health Office and
Public Health Center using a Maternal Verbal Autopsy (OVM) and the Mother's Register. The
study was conducted on March 17 – April 15, 2022. The research criteria used included pregnant
women at term, not with complications other than preeclampsia, and not with IUFD. The total
respondents were 86 mothers with preeclampsia consisting of 43 mothers with death due to
preeclampsia as cases using total sampling and 43 mothers with healthy preeclampsia as controls
using purposive sampling.
Research ethics comes from the Health Research Ethics Commission, Faculty of
Medicine, Universitas Brawijaya with the number: No.55/EC/KEPK-S2/02/2022.

Data Analysis
Variables have been categorized in terms of frequency and amount. The bivariate
analysis of this study used the Chi-Square test followed by Odds ratio (OR) with 95% confidence
interval (CI) to report the association from each type of risk factors and mortality. Statistical
analysis was performed using SPSS version 25.0 for windows.

Result
Table 1. Demographic and Risk factors for preeclampsia maternal mortality in Jember
district, Indonesia from January 2016 to December 2019

Risk factor Women who died Controls OR (95% CI) P-

from preeclampsia (N = 43) value
(N = 43)

Anemia
Yes 36 (83.72%) 25 (58.14%) 3,703 0.009
(1,347 – 10,179)
No 7 (16.23%) 18 (41.86%)
Low Income
Yes 37 (86.05%) 26 (60.47%) 4,032 0.007
(1,401 – 11,606)
No 6 (13.95%) 17 (39.57%)

The sociodemographic, characteristics of respondents are presented in table 1. The

sample size achieved was a total of 43 cases 43 controls. Percentage of women anemia who died
from preeclampsia was (83.72%%) among cases and (58.14%) among controls. The association
is statistically significant as p value 0.05, p 0.009 (OR 3,703, 95% CI: (1,347 – 10,179)).
Therefore, the null hypothesis is rejected and thus restated as; there is a significant relationship
between anemia and preeclampsia maternal mortality.
Low income 86.05% among cases and 60.47 among controls. The association is
statistically significant as p value 0.05, p 0.007 (OR 4.032, 95% CI : (1,401 – 11,606)).
Therefore, the null hypothesis is rejected and thus restated as; there is a significant relationship
between low income and preeclampsia maternal mortality.

DISCUSSION
Our study found that there was a significant effect between anemia and the incidence of maternal
death due to preeclampsia. This is in line with a study conducted in northern Ethiopia, which said
that women with anemia had a 3.23 increase in the incidence of preeclampsia compared to
women without anemia. A review study revealed that anemia causes a decrease in sufficient
oxygen levels in the blood, which leads to placental hypoxia. Placental hypoxia affects
trophoblast cell differentiation and spiral artery remodeling. Secretion of antiangiogenic and
inflammatory factors, sFlt-1 for example, can cause endothelial dysfunction and multiorgan
injury, which are hallmarks of preeclampsia (8). Other studies explain that anemia causes iron
deficiency, folate levels, or other metabolic disorders. This may be attributed to the associated
reduction of antioxidant micronutrients in anemia with the resulting vascular endothelial
oxidative stress, associated damage and preeclampsia (5).
In our study, it was found that there was a significant effect between low income and the
incidence of maternal death due to preeclampsia. This is in line with research
Conclusion
Overall, the results of our study have important implications for optimizing health services,
especially for pregnant women. We found strong evidence that anemia and income increased the
risk of death from preeclampsia. This finding can be one of the scientific references regarding
the factors that cause maternal death due to preeclampsia. In addition, these findings can be the
focus of government, health workers, communities and cross-sectoral collaboration to find
solutions and solutions to problems that increase the risk of maternal death caused by
preeclampsia through optimizing services, utilizing resources and providing community-based
social facilities.

DECLARATIONS
Ethics approval:
Research ethics comes from the Health Research Ethics Commission, Faculty of Medicine,
Universitas Brawijaya with the number: No.55/EC/KEPK-S2/02/2022.

Author Contribution:
(1) conceived of the research idea and carried out as well as analyzed the experiment. (2)
discussed the results and contributed to the final manuscript. (3) and (4) contributed to the final
version of the manuscript. (5) supervised the performance and findings of the study.

Competing interests:
The authors declare that they have no competing interests.

Funding:
None.
Acknowledgments:
None