Midwife Support and Nutritional Adequacy
for the Prevention of Anemia During Pregnancy
Mira Triharini
1
, Nursalam
1
, Agus Sulistyono
2
and Merryana Adriani
3
1
Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia
2
Dr. Soetomo General Hospital Surabaya, Indonesia
3
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
94
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
Copyright
c
2018 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
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
AugustOctober 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
95
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 2535 years old. Most respondents (n = 89,
71.2%) had a parity of 13. 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.
No
n (%)
Energy
Carbohydrate
Protein
Vitamin C
Iron
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
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
2535 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
0
34 (27.2)
80.1 ± 30.6
79.9± 47.4
97.5 ± 46.2
136.5 ± 142.8
168.8 ± 78.4
13
89 (71.2)
77.2± 29.9
65.5± 28.6
104.3 ± 51.3
102.5 ± 158.5
169.6 ± 85.8
>3
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
96
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
1817.692079.65), carbohydrate was 239.97 gram
(95% CI 222.32257.62), protein was 78.36 gram
(95% CI 71.9484.78), Vitamin C was 94.68 mg
(95% CI 72.12117.23), Iron was 61.36 mg (95% CI
55.8566.88) (Table 4).
The mean score of midwife support was 26.75
(95% CI 26.227.3). The mean score of energy
adequacy was 78,16% (95% CI 72, 8283,46). 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 63,4075,79). 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 89,67146,56). 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 (%)
n (%)
n (%)
n (%)
n (%)
Gave me the opportunity to make
choices in a nutritious food setting
2 (1.54)
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
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
97
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.
No
Item
Mean
SD
1
Gave me the opportunity to make choices in a nutritious food setting
4.32
0.84
2
Gave me the opportunity to tell my problems
4.57
0.65
3
Feel confident in my ability to maintain healthy pregnancy
4.54
0.59
4
Gave me the opportunity to ask questions
4.50
0.62
5
Listen to my story about the consumption of food and iron tablets
that I take
4.48
0.70
6
Asked me what I had done before giving advice
4.39
0.78
Table 4: Nutritional intake among pregnant women.
No
Variable
Mean
SD
95% CI
1
Energy
1968.67 (kcal)
754.79
1817.692079.65
2
Carbohydrate
239.97(gram)
101.70
222.32257.62
3
Protein
78.36 (gram)
36.98
71.9484.78
4
Vitamin C
94.68 (mg)
129.96
72.12117.23
5
Iron
61.36 (mg)
31.77
55.8566.88
SD - standard deviation
Table 5: The relationship of midwife support with nutrition adequacy.
No
Variable
Mean
SD
95% CI
r
p-value
1
Midwife support
26.75
3.11
26.227.3
2
Energy adequacy
78.16%
29,96
72.8283.46
0.182
0.042
3
Carbohydrate adequacy
69.59%
34,99
63.4075.79
0.054
0.553
4
Protein adequacy
102.7%
49,92
94.09111.66
0.222
0.013
5
Vitamin C adequacy
118.29%
161,93
89.67146.56
0.061
0.502
6
Iron adequacy
171.81%
85,62
156.65186.97
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
98
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. 109118.
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. 155160.
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. 111.
Cario, W. R. and Haenel, H. (2006) ‘Nutrition in
Midwife Support and Nutritional Adequacy for the Prevention of Anemia During Pregnancy
99
pregnancy’, British Nutrition Foundation Nutrition
Bulletin, 31, pp. 2859.
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. 27. 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. 793796. 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. 19. 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. 324. doi: 10.1016/B978-0-08-100168-
4.00001-X.
Kemenkes (2014) ‘PMK No. 88 Tablet Tambah Darah’,
Kemenkes 2014, (1), pp. 15. 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. 230239. 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. 117.
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. 113.
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. 112. 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. 46.
Purwaningsih et al. (2013) ‘Kepatuhan Bidan Desa
Terhadap Standart Pelayanan Antenatal Di Jawa
Timur’, Jurnal Ners, 2(2), pp. 295300. 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. 7781. 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.
18.
Sharma, J. B. and Shankar, M. (2010) ‘Anemia in
Pregnancy’, JIMSA, 23(4), pp. 253260.
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. 624629. 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. 16. 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. 532541. 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.
149154. 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. 18. 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