Fish, Meat, Vegetable Food Expenditures are Contribute to
Haemoglobin Concentration among Pregnant Women in Sub-Urban
Areas of Indonesia
Triska Susila Nindya, Djazuly Chalidyanto, Diah Indriani, Hario Megatsari, Aida Nailil Muna
Faculty of Public Health, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia
Keywords: Haemoglobin Concentration, Fish, Meat, Vegetables, Food Expenditure.
Abstract: Low haemoglobin concentration during pregnancy remains a problem in developing countries. One of
contributing factors towards haemoglobin concentration is food intake to do with protein and high iron
sources. The intake of this type of food is affected by economy access that can be measured by food
expenditure. The objective of this research was to analyse the correlation of food expenditure and
haemoglobin concentration among pregnant women in sub-urban areas. A cross-sectional study was
conducted from August-October 2016 in Sidoarjo, East Java. The sample was selected by stratified
random sampling. The sample was 83 pregnant women who completed a blood sample collection and
home visit interview. The characteristics and food expenditure were assessed by way of a structured
questionnaire. The haemoglobin concentration was analysed by the cyan meth method. The Pearson
correlation was employed to analyse the data. The result showed that most of the pregnant women had
graduated from high school, were on their second pregnancy, and the majority were housewives. The
mean of the haemoglobin concentration was 14.5 (SD±0.958). There was a correlation of total food
expenditure, and fish, meat and vegetable expenditure towards haemoglobin concentration in pregnant
women. It can be concluded that the higher the proportion of expenditure on fish, meat and vegetables,
the more it contributes to a higher haemoglobin concentration.
1 INTRODUCTION
The problem of low haemoglobin level in pregnant
women is ubiquitous in developing countries due to
the changes in the physiology during pregnancy and
the low intake of iron source food. Low
haemoglobin level in pregnancy poses a higher risk
of foetal and neonatal morbidity as well prematurity
and low birth weight. Low haemoglobin level below
the cut off is depicted by anaemia. Based on an
Indonesia basic health survey in 2013, it indicated
that the proportion of anaemia in pregnant women
was 37.1%. The figure of anaemia in rural area was
slightly higher than that in urban areas, accounting
for 37.8%. The urban area proportion was 36.4%
(Balitbangkes RI, 2013). The Indonesian
government set up the target that anaemia among
pregnant women should be below 30%. Therefore,
anaemia remains a problem in pregnant women.
The cause of anaemia is due to multiple factors.
Among those factors are nutritional such as vitamin
and mineral deficiencies and non-nutritional such as
infection and haemoglobinopathies. The major
mineral deficiency linked to anaemia is iron, since it
has a role in oxygen transport and there is often a
low availability of iron source in daily consumption,
hence it is considered that iron deficiency is one of
the ten leading global risk factors of disease burden
(McLean et al., 2007).
Pregnant women in developing countries are
prone to having the higher risk of nutritional
problems due to several factors such as socio
economy, inadequate diet, the high burden of
physical demand due to household chores and
frequent reproductive cycles (Lee et al., 2013).
Moreover, women in low-income households are
more likely to eat a poor diet than their wealthier
counterparts due in part to an inadequate
understanding of nutritional requirements and the
limited ability to purchase healthy foods (Bhargava,
2004).
Based on previous research, it showed that
consumer motivations to purchase foods are mainly
influenced by the price of food, and also its taste and
convenience (Lennernas et al., 1997). Moreover, for
lower income families, price is the most important
and the decision made is based on the ability to
purchase the food item (Dachner et al., 2010).
248
Nindya, T., Chalidyanto, D., Indriani, D., Megatsari, H. and Muna, A.
Fish, Meat, Vegetable Food Expenditures are Contribute to Haemoglobin Concentration among Pregnant Women in Sub-Urban Areas of Indonesia.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 248-251
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

Therefore, a family with a low income often
perceive that a healthier diet such as a decent intake
of meat, vegetable, fruits and dairy product is
difficult to obtain.
Individual or family food access can be linked to
their health outcomes. The lack of family access to
healthy food is also known as household food
insecurity. A study in Bangladesh, a developing
country with similar social background to
Indonesia showed that food insecurity in the
household reduced maternal dietary diversity,
particularly with a reduction in all types of animal
source foods such as eggs, meat, fish and dairy
products (Na et al., 2016).
Identifying the link between particular food
expenditure and the haemoglobin level in pregnant
women may suggest an important intervention due at
the household level. The purpose of this study was
test the hypothesis as to whether total food
expenditure and expenditure on particular items are
inversely related to the level of haemoglobin among
pregnant women in sub-urban areas.
2 METHODS
2.1 Study design and setting
The cross-sectional survey study was conducted
from August -October 2016. The study was
conducted in an area with a high prevalence of
anaemia and chronic energy deficiency (CED)
among pregnant women in Sidoarjo, East Java.
Sidoarjo is sub urban area that is located near the
capital city of East Java Province.
2.2 Study participants
The study participants were 83 eligible pregnant
women who were randomly selected for the sample.
Stratified random sampling was done by looking at
the primary health care (PHC) centres with a high
prevalence of anaemia and CED, and dividing them
into three (3) stratum based on the village
characteristics. The sample size calculation found 21
PHC: 8 PHC in the urban area, 7 PHC in rural areas
and 6 PHC in industry areas. In each PHC, one
village was selected randomly. In each village, five
(5) pregnant women were selected randomly based
on the midwives’ register. Some pregnant women
did not complete the blood test for various reasons.
Therefore only 83 pregnant women’s data has been
possible to analyse in this research.
2.3 Measurements
The main outcome variable in this study was
haemoglobin level. The independent variables
include maternal characteristics, family income,
food expenditure, child sex, prematurity, family
type, maternal working status and maternal
education. The data collection instrument was a
validated structured questionnaire. Haemoglobin
Assessment at the time of enrolment, 5 mL of
venous blood was collected by a trained technician
using standard procedures. The haemoglobin
concentration was determined by the cyan-meth
method.
2.4 Data collection and analysis
The data was collected by trained study enumerators
during a home visit along with a face-to-face
interview. The enumerators were trained by the
research team and they did the trial interviews using
a standardised questionnaire in two of the pregnant
women before data collection in the research site.
Descriptive statistics included the frequencies and
proportions that were first performed. Following
this, a bivariate analysis was done by way of the
Spearman Correlation. A statistical association was
declared to be significant if the p-value was less than
0.05.
2.5 Ethical consideration
Ethical clearance was obtained from the Faculty of
Public Health of the Universitas Airlangga’s Ethical
Review Board with certificate number 504-KEPK.
Written informed consent was also obtained from
each respondent.
3 RESULTS
The results of this research showed that the maternal
characteristics of the majority of pregnant women
was that they had graduated from high school, were
non-employed and on their second pregnancy. The
detailed figure of the characteristics has been
summarised in Table 1. 1. Demography profile.
Table 1: Distribution of the percentage of participants
Back
g
round Characteristics n %
Education level
Elementary School 5 6.0
Junior high School 19 22.9
Senior hi
g
h school 46 55.4
Di
p
loma/Universit
y
13 15.7
Fish, Meat, Vegetable Food Expenditures are Contribute to Haemoglobin Concentration among Pregnant Women in Sub-Urban Areas of
Indonesia
249

Back
g
round Characteristics n %
Employment
Had employment 19 22.9
Non-em
p
lo
y
ment 64 77.1
Pre
g
nanc
y
First
(
1
st
)
25 30,1
Second (2
nd
) 43 51.8
≥ Third (3
rd
) 15 18.1
Drawn from several items of food expenditure,
the food expenditure items were then correlated to
haemoglobin concentration including fish, meat,
vegetable and pulse (nut/lentil) expenditures. The
detailed median of each food item and statistical
correlation is in Table 2.
Table 2: the Median of Each Expenditure and Statistically
Correlation
Food Expenditure
Item
p
er month
Mean±SD p-
value
Grain 205,000±105,470.41 0.309
Root/Tubers 10,000±42,112.79 0.115
Fish 120,000±131,969.81 0.000*
Meat 100,000±120,319.47 0.000*
E
gg
s and mil
k
80,000±236,058.19 0.477
Vegetable 80,000±62,317.37 0.016*
Pulse (nut, lentil) 80,000±47,837.64 0.523
Fruit 60,000±74,170.93 0.120
Instant noodle and
crackers
25,000±50,783.25 0.381
*statistically significant correlation
The higher proportion of food expenditure was
grain as the staple food. The mean of haemoglobin
concentration among pregnant women was 14.5
(±0.958). This haemoglobin concentration is relative
high.
4 DISCUSSION
Food prices pose a barrier to adopting a healthy diet.
This research findings show that certain food
expenditures, particularly fish, meat and vegetable
expenditures, were correlated to haemoglobin level.
Thus food which has a correlation to haemoglobin
level is well known as a source of iron. However,
sometimes the decisions to do with healthy food are
often affected by the price of the food. This study is
consistent with the previous finding that maternal
dietary diversity declines in relation to the level of
household insecurity which reported that animal
source food, especially meat, fish, dairy product was
consumed less by the pregnant women. There was
also a lower frequency of micronutrient-dense plant-
based food such as legumes and nuts (Na et al.,
2016).
From this research findings, it should be also
highlighted the contribution of food expenditure on
vegetable to haemoglobin level of pregnant women.
Since vegetable is considerable affordable for food
insecure family, it is also important to encourage the
pregnant women to include vegetable particularly
dark green vegetable in their daily consumption.
The average of haemoglobin concentration in
this research was at a good level. This reflects that
the iron status among pregnant women is adequate.
Iron plays a vital role in oxygen transportation and
storage, oxidative metabolism, cellular proliferation
and many other physiological processes. Dietary
iron requirements are the highest in the second and
third trimester of pregnancy (Lynch, 2007). The
importance of maternal iron sufficiency is for
ensuring an optimum supply for the developing
foetus.
Findings from this study should be viewed with
caution for several reasons. Although the food
expenditure is significant correlated to haemoglobin
concentration, it is not causal because of the nature
of the study design that was employed. This study
could not establish the causal effect. The
expenditure itself was not calculated based on an
individual basis, but instead on overall household
expenditure. This may not represent the pregnant
women’s food consumption since it is also depends
on the food distribution within the family.
5 CONCLUSION
The higher proportion of expenditure on fish, meat
and vegetables contributes to a higher haemoglobin
concentration. It has been suggested to the family to
improve the quality of their diet by increasing the
food expenditure in relation to iron-rich food.
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