Health issue of maternal health in Indonesia:

Anaemia in pregnancy

Dr. Mira Triharini

Faculty of Nursing Universitas Airlangga
Background Information

Anaemia is a condition in which the number of red blood

cells (and consequently their oxygen-carrying capacity) is
insufficient to meet the body’s physiologic needs.
Anaemia in pregnancy is a significant global health
problem, with 38,2% of women worldwide affected
According to the World Health Organization (WHO), a
pregnant woman is considered to be anaemic if her
Haemoglobin concentration is <11 g/dL
Background Information
Anaemia in pregnancy remains a major health
problem worldwide, with an estimated 41.8% of
pregnant women being anaemia
Anaemia in pregnancy may result in adverse
maternal and fetal consequences. Adversely
impacts on pregnancy, childbirth and the post-
partum period.
Increases the risk of preterm delivery, low birth
weight and perinatal mortality
 Pathophysiology of iron deficiency
anaemia in pregnancy
Physiological changes occur in the second trimester,
increasing in red cell mass resulting in haemodilution
About 1000 mg of iron is required during pregnancy for
Red Blood Cell expansion, fetus, placenta and the
growing uterus.
The average woman of reproductive-age needs about
350-500 mg additional iron to maintain iron balance
during pregnancy.
Diet alone can not provide the extra iron and
stores, Approximately 600 mg of elemental iron
is required for the increase in red cell mass
during pregnancy and a further 300 mg for the
fetus
Pregnant women are advised to take iron tablets
for at least 90 tablets where 1 tablet is equivalent
to 60 mg ferrosus sulfate and 0.4 mg folic acid
(Ministry of Health RI, 2014).
 Incidence of Iron Deficiency Anaemia (IDA)
in developed versus developing countries

IDA remains the most common nutritional deficiency globally,

about 32 million pregnant women categorised as anaemic
A multicentre cross-sectional study in the UK estimated a
24.4% prevalence of maternal anaemia
About 53.0% of pregnant women in south Asia were
diagnosed with anaemia.
Insufficient quantity of iron-rich foods, poor environmental
sanitation, iron loss due to parasite and teenage pregnancies
and repeated pregnancies are the predominant causes
Anaemia during pregnancy in Indonesia

The results of the RISKESDAS (Basic Health

Research) 2013 : anaemia occurred in 37.1% of
pregnant women in Indonesia
36.4% of pregnant women in urban areas and 37.8%
of pregnant women in rural areas.

Effect of anaemia in maternal health ( prenatal,

intranal and postnatal) contributed to Maternal
Mortality Rate (MMR) in Indonesia
Effect of Anemia on Pregnancy & Mother

• Mild: anemia may not have any effect on pregnancy and labour
except that the mother will have low iron stores and may
become moderately to severely anemic in subsequent
pregnancies.
• Moderate anemia may cause increased weakness, lack of
energy, fatigue and poor work performance
• Severe anemia: palpitations, tachycardia, breathlessness,
increased cardiac output leading on to cardiac stress which can
cause de-compensation and cardiac failure.
• Increased incidence of pre-term labour (28.2%), pre-eclampsia
(31.2%) and sepsis have been associated with anemia.
 Effect of Anemia on Fetal & Neonate

Higher incidence of abortions

Pre-term and small-for-gestational-age babies
--- STUNTING
Neonate more susceptible for anaemia &
infections
Anemic infant with cognitive & affective
dysfunction
Anaemia and Maternal Mortality Rate
in Indonesia
 Indonesian Map

Indonesia is made up of more than 17.000 islands and 34 provincies

Consists of urban and rural areas with different socioeconomic that will
affect maternal health
Disparities among regions between urban centre like
Java and eastern Indonesian provinces like papua,
Nusa Tenggara
Each island is inhabitated by various ethnic groups
that have their own cultures
There are several ethnic cultures in Indonesia that can
decrease maternal health status
 What causes anaemia pregnancy
in Indonesia?

Cultural and socioeconomic: food

consumption, teenage marriage, level of
education
Non-compliance with iron supplementation
Irregular Antenatal care visits
Teenage married ( < 18 years)
Study of anaemia
Study collected 1202 samples in two private
hospitals in Jakarta.
The prevalence of anemia among pregnant women
in the third trimester was 33.7%.
Compared to women in the 21-35 year age group,
those with aged 16-20 years had 56% higher risk to
be anemic, however, those with aged 36-46 years
had the same risk to be anemic (opitasari, 2015)
Food consumption
One of the contributing factors to the prevalence of
anemia in Indonesia is food-related gender habits. low
socio-economic communities follow this practice.
This practice prioritizes nutritious food for the father as
head of the family, then boys, girls and finally the
mother.
This practice greatly contributes to the nutritional status
of women, especially for pregnant mothers which in turn
impacts the prevalence of Iron Deficiency Anaemia
Food consumption is affected by many economic and
cultural factors, including the availability of food,
education, lifestyle and others.
Rural Indonesia women’s traditional beliefs related anaemia

Low number of antenatal care in health center related

with relying on traditional birth attendants  rather
than midwife ( are kind, tolerant and patient and
have more experience than midwives; more
accessibility than midwives and encouragement of
natural birth)
Most people believed and followed the food taboos for
many generations. However, they did not know the
reason for doing it or the philosophy behind it.
Non adherence iron supplementation

There was still a belief among community that iron

tablets only need to be taken when a pregnant
mother had a complaint about her health
Bored
Side effects: Epigastric discomfort, nausea, faeces
may turn black
forgetness
Miss perceptions: hypertension and macrosomnia
Anemia prevention programs
Ministry of Health Republic Indonesia

1. Health promotion about the importance of nutrition in

pregnant women. To prevent anemia in pregnancy it
is necessary to have sufficient carbohydrates,
protein, iron and vitamin C.
Barriers :
- Adequacy of nutrition of pregnant women is related to
taboo on food
- The ability of the family to meet the nutritional needs of
pregnant women is related to the economic capacity
of the family
2. Iron supplementation
for pregnant women
Pregnant women are advised to
take iron tablets for at least 90
tablets during pregnancy.
1 tablet is equivalent to 60 mg
ferrosus sulfate and 0.4 mg folic
acid
 Barriers: availability in
community health centre ,
adherence to iron supplement
3. Iron supplementation for adolescent
girls
60 mg elemental iron and 0.4 mg folic acid , once
weekly for every week of the year
Decreased maternal and infant morbidity and
mortality for adolescents who become pregnant.
 Teachers distributed iron tablet to adolescent girls,
supervised, and recorded consumption, and
provided instructions on the prevention and
management of side effects.
4. Overcome diseases that can be related to anemia:
Chronic energy defisiency, parasitic worms, malaria, TB, HIV

Chronic energy defisiency and parasitic worms – problems

in poor area

Parasitic worms related to personal and environmental

hygiene
5. Improving Antenatal care

• At the first visit the pregnant woman will do a

hemoglobin examination to find out whether having
anemia
• Pregnant women need to receive an adequate
antenatal care
• Irreguler ANC visit related to knowledge and
culture
Antenatal care standard

1. Weight measurement
2. Upper arm circumference measurement
3. Blood pressure measurement
4. Fundal height measurement
5. Fetal heart rate measurement
6. Determine fetal presentation
7. Provide Tetanus Toxoid Immunisasion
8. Provide iron tablet
9. Provide laboratory test
10. Provide referral properly
11. Provide health education
7. Improving health promotion and family
empowerment
Target:
 Individual ( teenage girl, women of childbearing
age, women who will get married)
 Family (how the family is able to provide support
to mothers to prevent anemia)
 Community (the surrounding community )
Discussion
 Thank you
Terima Kasih