Midwife Support and Nutritional Adequacy

for the Prevention of Anemia During Pregnancy

Mira Triharini

, Nursalam

, Agus Sulistyono

and Merryana Adriani

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Dr. Soetomo General Hospital Surabaya, Indonesia

Public Health Faculty, Universitas Airlangga, Surabaya, Indonesia

Keywords: Anemia, Iron Deficiency, Midwife Support, Nutrition Adequacy, Pregnancy

Abstract: Healthy nutrition is very important for fetal development during pregnancy. A pregnant mother is expected

to gain adequate energy, carbohydrates, proteins, vitamin C, and iron in daily food to prevent anemia. Many

factors inhibit the fulfillment of nutrients during pregnancy. Support from midwives is needed to help

mothers understand how to meet their nutritional needs. This study aims to observe the correlation of

midwife support with nutritional adequacy to prevent anemia during pregnancy. A cross-sectional study was

carried out on 125 pregnant women who had antenatal care at five community health centers in Surabaya.

Data were collected using questionnaires and food recall over 24 hours. There was a significant correlation

between the midwife support with energy adequacy (r = 0.182, p = 0.042), protein adequacy (r = 0.222, p =

0.013), and iron adequacy (r = 0.208, p = 0.020). Based on the Indonesian Recommended Dietary

Allowances (RDA), the recommended adequacy of energy is 78.16%, carbohydrates 69.59%, protein

102.87%, vitamin C 118.29%, and iron 171.81%. There was a significant correlation between midwife

support and energy, protein and iron adequacy to prevent anemia during pregnancy. Health education with

appropriate methods can improve mothers’ ability to meet nutritional adequacy during pregnancy.

1 BACKGROUND

Prenatal nutrition is essential for fetal development

and long-term health in infants. Malnutrition and

excess nutrients (obesity) during pregnancy, can

affect fetal development, growth, and development

of childhood and the risk of developing chronic

diseases in adults (Ministry of Health, 2006; Imdad

et al., 2017).

Weight gain during pregnancy indicates whether

pregnant women have good nutritional status. An

average weight gain of 12 kg is associated with

reduced risks of complications during pregnancy and

delivery and the risk of having low birth weight

(LBW). The UK Committee on Medical Aspects of

Food Policy (COMA) recommends that pregnant

women eat foods that contain lots of thiamin,

riboflavin, folate, vitamin A, vitamin C, vitamin D,

energy, and protein (Cario & Haenel, 2006).

Many factors affect the fulfillment of nutrition

during pregnancy. A study in Bangladesh found that

knowledge, self-efficacy, social norms, support from

husbands, and free supplements were associated

with maternal compliance of nutrition during

pregnancy (Phuong H Nguyen et al., 2017). A study

in Vietnam found that maternal compliance in

micronutrient supplementation was influenced by

ethnicity, occupation, parity, and support of health

workers in counseling regarding adherence to

supplemental consumption (Gonzalez-Casanova et

al., 2017)

Physical changes experienced during pregnancy

such as nausea, vomiting, constipation, and anemia

affect pregnant women's nutrition (Gonzalez-

Casanova et al., 2017). Anemia caused by iron

deficiency is a major nutritional problem in pregnant

women all over the world and is associated with low

iron reserves in the body. Anemia in pregnant

women can adversely affect the development and

health of the fetus. Research shows an association

between pregnancy anemia with prematurity, SGA,

and stillbirth (Tandu-umba & Mbangama, 2015).

The main cause of anemia is the lack of food

containing iron, multiparity, and worm infections

(Sharma & Shankar, 2010).

Eating habits during pregnancy can be influenced

Triharini, M., Nursalam, ., Sulistyono, A. and Adriani, M.

Midwife Support and Nutritional Adequacy for the Prevention of Anemia During Pregnancy.

DOI: 10.5220/0008321100940100

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 94-100

ISBN: 978-989-758-336-0

by the knowledge and perception of pregnant

women, so health education about healthy food is

required (Khoramabadi et al., 2015). Health

education on nutritional needs is very important

pregnant women, especially teenage pregnant

women who do not have the physical and

psychological readiness to manage the pregnancy. A

study shows that teenage pregnant women have

lower weight gain as well as higher health risks than

adult mothers (Phuong Hong Nguyen et al., 2017).

One's health behavior is related to interpersonal

relationships. Social support from families, peers,

and health workers affects the perceptions and

beliefs of a person if they are encouraged to act on

certain health behaviors (Pender, 2011). Physical

and psychological changes experienced by pregnant

women often cause anxiety, so emotional support is

required. Support from midwives provides a sense of

security and reduces the sense of rejection and

loneliness during pregnancy (Ekström et al., 2015).

Until now, there have not been many studies that

observe the relationship between midwife support

given to pregnant women and the anemia

prevention. This study aims to observe the

relationship of midwives’ support with nutritional

adequacy to prevent anemia during pregnancy.

2 METHODS

2.1 Design Research

This study used cross-sectional design conducted in

August–October 2017 on 125 pregnant women. The

population of this study were pregnant women who

attended antenatal care at five community health

centers in the city of Surabaya, namely Jagir,

MedokanAyu, Sidotopo Wetan, Asemrowo, and

Gundih.

2.2 Sample

Multi-stage Random Sampling was used in this

study. Samples were taken from five areas in

Surabaya, where one community health center in

each region was randomly selected. The sample size

consisted of 125 pregnant women who attended

antenatal care in community health centers and have

been receiving iron supplements.

2.3 Measurement Tools

The data collected in this research include midwife

support and nutritional adequacy. The demographic

characteristics questionnaire consists of several

questions that include age, parity, education level

income and gestational age. The questionnaires were

prepared by researchers based on the theory of

prevention of anemia of pregnant women and the

Health Promotion Model (HPM) (Sharma &

Shankar, 2010; Pender, 2011).

Midwife support was measured using a

questionnaire based on The Health Care Climate

Questionnaire (HCCQ) (Williams, Ryan & Deci,

1999). The six questions used a Likert scale with the

following options: never, rarely, sometimes, often,

and always. ‘Midwife support’ relates to the

perception of pregnant women regarding the support

given by health workers to pregnant women to

promote anemia-prevention behavior. The alpha

reliability was 0.945.

Nutritional adequacy consists of energy

adequacy, carbohydrate, protein, vitamin C, and

iron. Measurements were carried out with a

questionnaire with a 24-hour food recall method, of

which the results were measured in calories, grams,

and mg, and then compared with the Indonesian

Recommended Dietary Allowances (RDA),

categorized ≥ 100% = good; 80- <99% = medium;

70- <80% = less; <70% = deficit (Supariasa, Bakri,

& Fajar, 2002).

Research data was collected by the provision of

questionnaires regarding midwife support completed

by pregnant mothers and interviewing participant to

collect information about their nutrition over 24

hours through a food recall method. Data were

collected from pregnant women who had attended an

antenatal care visit in a community health center.

2.4 Ethical Considerations

Sampling was done after obtaining ethical approval

from the health research ethics committee of the

Faculty of Public Health Airlangga University,

Surabaya, Indonesia (No 123-KEPK). Informed

consent was carried out and pregnant women agreed

to participate in this research. Any information

obtained will only be used for research purposes and

confidentiality is guaranteed.

2.5 Data Analysis

Data analysis was conducted using Spearman's rho

to determine the relationship of midwife support

with nutritional adequacy for the prevention of

anemia.

Descriptive statistics used frequency, percentage,

mean, and standard deviation to identify

Midwife Support and Nutritional Adequacy for the Prevention of Anemia During Pregnancy

demographic characteristics, midwife support, and

nutritional adequacy. In all statistical analyses, a p-

value <0.05 was considered significant. All data

were analyzed using SPSS software.

3 RESULTS

3.1 Sociodemographic Characteristics

Table 1 shows sociodemographic characteristics and

the adequacy of energy, carbohydrate, protein,

vitamin C and iron. Most respondents (n = 85, 68%)

were 25–35 years old. Most respondents (n = 89,

71.2%) had a parity of 1–3. Most respondents (n =

114, 91.2%) had secondary education. Most

respondents (n = 86, 68.8%) had an income below 3

million rupiah per month. Most respondents (n =

108, 86.4%) had a gestational age below 37 weeks.

The greatest energy adequacy in age > 35 years

(83.9 ± 38.6), parity > 3 (86.9 ± 31.2), elementary

education (81.4 ± 24.1), income ≥ 3 million rupiah

(82.7 ± 35.9), and gestational age ≥ 37 weeks (79.8

± 32.7).

The greatest carbohydrate adequacy in age <25 years

(74.3 ± 51.1), nullipara (79.9 ± 47.4), secondary

education (70.6 ± 36.2), income ≥ 3 million rupiah

(74.9 ± 33.1), and gestational age ≥ 37 weeks (74.4

± 39.5).

The greatest protein adequacy in age > 35 years

(118.9 ± 67.8), parity > 3 (132.8 ± 17.5), elementary

education (108.4 ± 39.6), income ≥ 3 million rupiah

(107.7 ± 58.9), and gestational age ≥ 37 weeks (111.2

± 43.9).

The greatest vitamin C adequacy in age> 35

years (154.9 ± 288.9), parity > 3 (509.8 ± 164.6),

university education (188.9 ± 226.8), income ≥ 3

million rupiah (136.2 ± 176.1), and gestational age ≥

37 weeks (188.9 ± 150.8).

Table 1: Nutrition adequacy in pregnant women.

n (%)

Energy

Carbohydrate

Protein

Vitamin C

Iron

Mean ± SD

Age

< 25 years

29 (23.2)

74.8± 27.0

74.3 ± 51.1

90.9 ± 38.1

83.5 ± 92.8

169.9 ± 89.0

25–35 years

85 (68)

78.6± 29.9

68.1±.27.3

105.1 ± 50.3

125.9 ± 159.5

172.1 ± 86.7

> 35 years

11 (8.8)

83.9± 38.6

68.2± 36.3

118.9 ± 67.8

154.9 ± 288.9

174.7 ± 74.3

Parity

34 (27.2)

80.1 ± 30.6

79.9± 47.4

97.5 ± 46.2

136.5 ± 142.8

168.8 ± 78.4

1–3

89 (71.2)

77.2± 29.9

65.5± 28.6

104.3 ± 51.3

102.5 ± 158.5

169.6 ± 85.8

2 (1.6)

86.9± 31.2

73.5± 18.9

132.8 ± 17.5

509.8 ± 164.6

322.3 ± 112.8

Education

Elementary

16 (12.8)

81.4± 24.1

66.9± 29.2

108.4 ± 39.6

112.1 ± 189.1

160.9 ± 98.6

Secondary

98 (78.4)

77.6± 29.2

70.6± 36.2

102.1 ± 47.6

111.4 ± 148.6

172.2 ± 84.1

University

11 (8.8)

77.8 ± 44.2

64.6± 34.4

101.1 ± 78.4

188.9 ± 226.8

183.9 ± 85.7

Income

< 3 million rupiah

86 (68.8)

76.1± 26.9

67.2± 35.7

100.8 ± 45.1

110.5 ± 155.8

166.8 ± 81.4

≥ 3 million rupiah

39 (31.2)

82.7± 35.9

74.9± 33.1

107.7 ± 58.9

136.2 ± 176.1

183.3 ± 94.8

Gestational age

< 37 weeks

108 (86.4)

77.9 ± 29.6

68.8± 34.4

101.6 ± 50.5

188.9 ± 150.8

169.2 ±91.2

≥ 37 weeks

17 (13.6)

79.8± 32.7

74.4± 39.5

111.2 ± 43.9

108.9 ± 216.4

188.5 ±28.9

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

The greatest iron adequacy in > 35 years (174.7 ±

74.3), parity > 3 (322.3 ± 112.8), university education

(183.9 ± 85.7), income ≥ 3 million rupiah (183.3 ±

94.8), and gestational age ≥ 37 weeks 188.5 ±28.9).

Of the midwife support statements, the majority

of respondents stated that they always get support

from their midwife: “The midwife gave me the

opportunity to make choices in a nutritious food

arrangement” (n = 62, 47.69%); “the midwife gave

me the opportunity to express my problems” (n = 81,

62.31%); “midwives feel confident in my ability to

maintain healthy pregnancy” (n = 73, 56.15%); “my

midwife gave me an opportunity to ask about

nutrition and iron tablets” (n = 70, 53.85%); “the

midwife listened to my story about my food

consumption and iron tablets” ( n = 73, 56.15%);

“my midwife asked me about what I had already

done before giving advice” (n = 67, 51.54%) (Table

2).

Of the six midwife support statements, "Midwife

gives me the opportunity to tell my problems" had

the highest average score (4.57 ± 0.65) and

"Midwife gives me the opportunity to make a choice

in a nutritious food setting" had the lowest average

score (4.32 ± 0.84) (Table 3).

Nutritional intake among pregnant women. The

mean score of energy was 1968.67 kcal (95% CI

1817.69–2079.65), carbohydrate was 239.97 gram

(95% CI 222.32–257.62), protein was 78.36 gram

(95% CI 71.94–84.78), Vitamin C was 94.68 mg

(95% CI 72.12–117.23), Iron was 61.36 mg (95% CI

55.85–66.88) (Table 4).

The mean score of midwife support was 26.75

(95% CI 26.2–27.3). The mean score of energy

adequacy was 78,16% (95% CI 72, 82–83,46). There

was a significant correlation of midwife support with

energy adequacy (r = 0.182; p = 0.042). The mean

score of carbohydrate adequacy was 69,59% (95%

CI 63,40–75,79). There was no significant

correlation of midwife support with carbohydrate

adequacy (r = 0.182; p = 0.042). The mean score of

protein adequacy was 102,87% (95% CI 94,09-

111,66). There was a significant correlation of

midwife support with protein adequacy (r = 0.222; p

= 0.013). The mean score of vitamin C adequacy

was 118,29% (95% CI 89,67–146,56). There was no

significant correlation of midwife support with

vitamin C adequacy (r = 0.061; p = 0.502). The

mean score of iron adequacy was 171,81% (95% CI

156,65-186,97). There was a significant correlation

of midwife support with iron adequacy (r = 0.061; p

= 0.502) (Table 5).

Table 2: Midwife support statements.

Statements

Never

Rarely

Sometimes

Often

Always

n (%)

Gave me the opportunity to make

choices in a nutritious food setting

2 (1.54)

12 (9.23)

47 (36.15)

62 (47.69)

Gave me the opportunity to tell my

problems

0.00

1 (0.77)

8 (6.15)

35 (26.92)

81 (62.31)

Feel confident in my ability to maintain

healthy pregnancy

0.00

6 (4.62)

46 (35.38)

73 (56.15)

Gave me the opportunity to ask

questions about nutritious food and iron

tablets

0.00

1 (0.77)

5 (3.85)

49 (37.69)

70 (53.85)

Listen to my story about the

consumption of food and iron tablets

that I take

0.00

2 (1.54)

9 (6.92)

41 (31.54)

73 (56.15)

Asked me what I had done before

giving advice

1 (0.77)

2 (1.54)

11 (8.46)

46 (35.38)

67 (51.54)

Midwife Support and Nutritional Adequacy for the Prevention of Anemia During Pregnancy

4 DISCUSSION

Health workers have a role in promoting appropriate

health education to improve pregnant women’s

knowledge about anemia. Counseling techniques are

suitable because of the two-way interaction, meeting

the needs of pregnant women. The necessary

techniques are two-way communication, fostering a

good atmosphere, actively listening, asking

questions, and facilitating (Kementerian kesehatan

RI, 2013). Studies show that counseling techniques

significantly influence the prevention of anemia in

pregnancy (Triharini, Kusumaningrum and

Octaviani, 2017). In conducting health education at

community health centers, midwives often

experience barriers meaning that the provision of

health information does not achieve its potential.

The research shows there are communication

barriers between nurses and patients.

Communication barriers can be caused by nurses,

patients, and the environment (Norouzinia et al.,

2015).

The forms of support the midwives can provide

to improve pregnant women’s diet include giving

them opportunities to make choices in a nutritionally

motivated environment, providing opportunities for

complaints, confidence to maintain healthy

pregnancy, an opportunity to ask questions about

nutritious food problems and iron tablets, listen to

pregnant women's stories about the consumption of

iron foods and tablets, and asking what pregnant

women have done before giving advice on eating

nutritious food and taking iron. A study shows that

nutrition education in pregnant women effectively

increases knowledge about anemia, diet and

hemoglobin (Al-tell et al., 2010). Health workers

also need to develop appropriate forms of health

promotion for pregnant women. A study describes

interventions through group discussions and

individual interviews for pregnant women to

improve nutritional status (Setyowati, 2015).

Results of the research show that midwives

promoting good health provide opportunities for

pregnant women to ask questions and listen to the

stories of other pregnant women. Environmental

conditions such as heavy workload caused the

majority of respondent to state that midwives are

Table 3: Item analysis of midwife support.

Item

Mean

Gave me the opportunity to make choices in a nutritious food setting

4.32

0.84

Gave me the opportunity to tell my problems

4.57

0.65

Feel confident in my ability to maintain healthy pregnancy

4.54

0.59

Gave me the opportunity to ask questions

4.50

0.62

Listen to my story about the consumption of food and iron tablets

that I take

4.48

0.70

Asked me what I had done before giving advice

4.39

0.78

Table 4: Nutritional intake among pregnant women.

Variable

Mean

95% CI

Energy

1968.67 (kcal)

754.79

1817.69–2079.65

Carbohydrate

239.97(gram)

101.70

222.32–257.62

Protein

78.36 (gram)

36.98

71.94–84.78

Vitamin C

94.68 (mg)

129.96

72.12–117.23

Iron

61.36 (mg)

31.77

55.85–66.88

SD - standard deviation

Table 5: The relationship of midwife support with nutrition adequacy.

Variable

Mean

95% CI

p-value

Midwife support

26.75

3.11

26.2–27.3

Energy adequacy

78.16%

29,96

72.82–83.46

0.182

0.042

Carbohydrate adequacy

69.59%

34,99

63.40–75.79

0.054

0.553

Protein adequacy

102.7%

49,92

94.09–111.66

0.222

0.013

Vitamin C adequacy

118.29%

161,93

89.67–146.56

0.061

0.502

Iron adequacy

171.81%

85,62

156.65–186.97

0.208

0.020

SD - standard deviation; r = Spearman correlation coefficient; p < 0.05

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

unable to give adequate opportunities for promoting

healthy dietary choices for pregnant women.

Research shows that barriers to health promotion in

anemic pregnant women may come from midwives

who lack communication and clinical skills

(Widyawati et al., 2015). Counseling by midwives is

standard in antenatal care, but this has not been done

optimally. A study shows the correlation of antenatal

care with midwife knowledge and infrastructure in

the service. The development of midwifery skills

through training and improved infrastructure is

needed to improve antenatal care (Purwaningsih et

al., 2013)

Nutritious foods to prevent anemia need to

include adequate energy, carbohydrates, protein,

vitamin C, and iron. Several studies have proven that

there is a correlation between nutrients and

hemoglobin levels. Women with anemia show a

low-energy diet, protein, folate, B12, iron, vitamin C

and red meat (Thomson et al., 2011). Vitamin C is

associated with iron. This is supported by studies

looking at the correlation of hemoglobin levels with

iron and vitamin C in adolescent girls with iron-

deficiency anemia (Latheef & Vijayaraghavan,

2017). Many factors affect the fulfillment of

nutritional needs. A study shows that the traditions

of the Lombok Indonesian society influence

nutritional fulfillment in pregnant women, so

midwives need to take a cultural approach to health

education to change behavior (Armini, Pradanie &

Sudariani, 2008)

Several studies in various countries observe the

nutritional adequacy of pregnant women. Research

in Indonesia shows that 40% of pregnant women are

at risk of inadequate energy and protein intake and

70% of pregnant women are at risk of inadequate

vitamin A, calcium, and iron (Hartini, 2004).

Insufficiency of vitamin C and iron is shown by

research in the West North of Iran, but pregnant

women have consumed sufficient amounts of energy

and protein (Esmaillzadeh, Samareh & Azadbakht,

2008). Research in Western Rajasthan India shows

most pregnant women in the region have anemia.

The average nutritional intake suggests a deficiency

of protein, energy, and iron (Singh, Fotedar, &

Lakshminarayana, 2009)

The results of this study found that protein,

vitamin C and iron adequacy had an average above

100% compared with the Indonesian Recommended

Dietary Allowances (RDA). Adequacy of protein is

very important in pregnancy because it is needed for

fetal growth (Liberato, Singh, & Mulholland, 2013).

The high iron adequacy is supported by the

compliance of most pregnant women in taking iron

supplements. Each iron tablet contains the

equivalent of 60 mg of elemental iron (in the form of

ferro sulfate, ferro fumarate or ferro gluconate); and

0.400 mg of folic acid, which helps to prevent

anemia (Kemenkes, 2014). A study supports that

adherence to iron supplementation is associated with

the incidence of anemia in pregnant women, but

there are still pregnant women who are not

compliant in taking iron tablets. One study showed

that poor adherence to drinking iron supplements

was influenced by the level of education and use of

antenatal care services, so the role of midwives in

providing health education is very important (Nisar,

Dibley, & Mir, 2014; Mekuria et al., 2016).

Improving midwives' ability to promote health

promotion is essential. A study shows that midwife

training has increased the confidence and knowledge

of midwives in providing health promotion on

nutrition, physical activity, and weight management

in pregnant women (Basu et al., 2014).

5 CONCLUSIONS

There was a significant correlation between midwife

support and energy, protein, and iron adequacy to

prevent anemia during pregnancy. The practical

implications of this research are the sources of

information about the importance of social support

for pregnant women to improve diet to meet the

requirements of energy, carbohydrates, vitamin C,

protein, and iron. Health workers need to develop

techniques and health education materials to

improve prenatal nutrition. Social and cultural

values need to be given attention in providing health

education because pregnant women's behavior is

related to the beliefs held by the community. For

further research, the implications of this study are to

examine the internal and external factors that affect

the performance of midwives in providing health

promotion in pregnant women.

REFERENCES

Al-tell, M. A. et al. (2010) ‘Effect of Nutritional

Interventions on Anemic Pregnant Women ’ s Health

Using Health Promotion Model’, Med J Cairo Univ,

78(2), pp. 109–118.

Armini, N. K. A., Pradanie, R. and Sudariani, P. W.

(2008) ‘Community of Lombok ’ s Tradition Effects

the Nutrient Intake Behavior in Pregnant Woman’,

Jurnal Ners, 4(2), pp. 155–160.

Basu, A. et al. (2014) ‘Eating for 1 , Healthy and Active

for 2 ; feasibility of delivering novel , compact training

for midwives to build knowledge and confidence in

giving nutrition , physical activity and weight

management advice during pregnancy’, BMC

Pregnancy and Childbirth, 14(218), pp. 1–11.

Cario, W. R. and Haenel, H. (2006) ‘Nutrition in

Midwife Support and Nutritional Adequacy for the Prevention of Anemia During Pregnancy

pregnancy’, British Nutrition Foundation Nutrition

Bulletin, 31, pp. 28–59.

Ekström, A. et al. (2015) ‘Women’s Experiences of

Midwifery Support during Pregnancy A step in the

Validation of the Scale: “The Mother Perceived

Support from Professionals”’, Journal of Nursing &

Care, pp. 2–7. doi: 10.4172/2167-1168.1000241.

Esmaillzadeh, A., Samareh, S. and Azadbakht, L. (2008)

‘Dietary patterns among pregnant women in the west-

north of Iran’, Pakistan Journal of Biological

Sciences, pp. 793–796. doi:

10.3923/pjbs.2008.793.796.

Gonzalez-Casanova, I. et al. (2017) ‘Predictors of

adherence to micronutrient supplementation before

and during pregnancy in Vietnam’, BMC Public

Health. BMC Public Health, 17(1), pp. 1–9. doi:

10.1186/s12889-017-4379-4.

Hartini, N. S. (2004) Food habits, dietary intake and

nutritional status during economic crisis among

pregnant women in Central Java, Indonesia. Umea

University.

Imdad, A. et al. (2017) ‘Prenatal Nutrition and Nutrition in

Pregnancy: Effects on Long-Term Growth and

Development’, Early Nutrition and Long-Term

Health, pp. 3–24. doi: 10.1016/B978-0-08-100168-

4.00001-X.

Kemenkes (2014) ‘PMK No. 88 Tablet Tambah Darah’,

Kemenkes 2014, (1), pp. 1–5. doi: 10.1007/s13398-

014-0173-7.2.

Kementerian kesehatan RI (2013) Buku Saku Pelayanan

Kesehatan Ibu Di Fasilitas Kesehatan Dasar Dan

Rujukan, E-book. Jakarta: Kemenkes RI.

Khoramabadi, M. et al. (2015) ‘Effects of Education

Based on Health Belief Model on Dietary Behaviors

of Iranian Pregnant Women’, Global Journal of

Health Science, 8(2), pp. 230–239. doi:

10.5539/gjhs.v8n2p230.

Liberato, S. C., Singh, G. and Mulholland, K. (2013)

‘Effects of protein energy supplementation during

pregnancy on fetal growth: a review of the literature

focusing on contextual factors’, Food & Nutrition

Research, 57, p. 10.3402/fnr.v57i0.20499. doi:

10.3402/fnr.v57i0.20499.

Mekuria, A. et al. (2016) ‘Prevalence of anemia and its

associated factors among pregnant women attending

antenatal care in health institutions of Arbaminch town

, Gamo Gofa Zone , Ethiopia : a cross-sectional study’,

Hindawi Publishing Corporation, 2016(2016), p. 10.

doi: 10.1155/2016/1073192.

Ministry of Health (2006) Food and nutrition guidelines

for healthy adults: A background paper. Wellington:

Ministry of Health. doi: ISBN 978-0-478-19380-0.

Nguyen, P. H. et al. (2017) ‘Factors influencing maternal

nutrition practices in a large scale maternal , newborn

and child health program in Bangladesh’, pp. 1–17.

doi: https://doi.org/10.1371/journal.pone.0179873.

Nguyen, P. H. et al. (2017) ‘The nutrition and health risks

faced by pregnant adolescents: Insights from a cross-

sectional study in Bangladesh’, Plos one, pp. 1–13.

Available at:

http://journals.plos.org/plosone/article?id=10.1371/jou

rnal.pone.0178878.

Nisar, Y. B., Dibley, M. J. and Mir, A. M. (2014) ‘Factors

associated with non-use of antenatal iron and folic

acid supplements among Pakistani women: A cross

sectional household survey’, BMC Pregnancy and

Childbirth, 14(1), pp. 1–12. doi: 10.1186/1471-2393-

14-305.

Norouzinia, R. et al. (2015) ‘Communication Barriers

Perceived by Nurses and Patients’, Global Journal of

Health Science, 8(6), p. 65. doi:

10.5539/gjhs.v8n6p65.

Pender, N. J. (2011) ‘Heath Promotion Model Manual’, in.

Chichago: University of Michigan, pp. 4–6.

Purwaningsih et al. (2013) ‘Kepatuhan Bidan Desa

Terhadap Standart Pelayanan Antenatal Di Jawa

Timur’, Jurnal Ners, 2(2), pp. 295–300. doi:

10.1002/ejoc.201200111.

S, R., Latheef, F. and Vijayaraghavan, R. (2017)

‘Correlation of Level of Haemoglobin With Iron and

Vitamin C Among Adolescent Girls With Iron

Deficiency Anemia Undergoing Nutritional Support

Therapy’, International Journal of Research in

Ayurveda & Pharmacy, 8(4), pp. 77–81. doi:

10.7897/2277-4343.084219.

Setyowati (2015) ‘Improving the Nutrition of Pregnant

Village Women in Indonesia: The Important Roles of

Village Midwives and Cadres’, Jurnal Ners, 10(1), pp.

1–8.

Sharma, J. B. and Shankar, M. (2010) ‘Anemia in

Pregnancy’, JIMSA, 23(4), pp. 253–260.

Singh, M. B., Fotedar, R. and Lakshminarayana, J. (2009)

‘Micronutrient deficiency status among women of

desert areas of western Rajasthan, India’, Public

Health Nutrition, 12(5), pp. 624–629. doi:

10.1017/S1368980008002395.

Supariasa, I. M. N., Bakri, B. and Fajar, I. (2002)

Penilaian status gizi. Jakarta: EGC.

Tandu-umba, B. and Mbangama, A. M. (2015)

‘Association of maternal anemia with other risk

factors in occurrence of great obstetrical syndromes at

university clinics , Kinshasa , DR Congo’, BMC

Pregnancy and Childbirth. BMC Pregnancy and

Childbirth, 15(183), pp. 1–6. doi: 10.1186/s12884-

015-0623-z.

Thomson, C. A. et al. (2011) ‘Nutrient Intake and Anemia

Risk in the Women’s Health Initiative Observational

Study’, Journal of the American Dietetic Association,

111(4), pp. 532–541. doi: 10.1016/j.jada.2011.01.017.

Triharini, M., Kusumaningrum, T. and Octaviani, C.

(2017) ‘Counseling Improves Anemia Prevention

Behavior Of Pregnant Women’, Jurnal Ners, 4(2), pp.

149–154. doi: 10.20473/JN.V4I2.5027.

Widyawati, W. et al. (2015) ‘A qualitative study on

barriers in the prevention of anaemia during pregnancy

in public health centres: Perceptions of Indonesian

nurse-midwives’, BMC Pregnancy and Childbirth,

15(1), pp. 1–8. doi: 10.1186/s12884-015-0478-3.

Williams, G. C., Ryan, R. M. and Deci, E. L. (1999)

‘Health-Care , Self-Determination Theory Packet’.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

100