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The Correlation between Cultural Internalization and the Incidence

of Iron Deficiency Anemia on Pregnant Women

Darmawati

1,2

, Teuku Tahlil

, Hajjul Kamil

, Toungku Nizwan Siregar

, Williza Umami

Doctoral Program of Mathematic and Applied Sciences, Syiah Kuala University, Banda Aceh, Indonesia,

Department of Maternal Health Nursing, Faculty of Nursing, Syiah Kuala University, Banda Aceh, Indonesia

Department of Community Health Nursing, Faculty of Nursing, Syiah Kuala University, Banda Aceh, Indonesia

Department of NursingManagement, Faculty of Nursing, Syiah Kuala University, Banda Aceh, Indonesia

Faculty of Veterinary, Syiah Kuala University, Darussalam Banda Aceh, Indonesia

iza_williza@yahoo.com

Keywords: Belief, Culture, Iron deficiency anemia, Pregnancy, Taboo

Abstract: Unhealthy practices in community during pregnancy can cause complications during pregnancy, one of

them is iron deficiency anemia. Some pregnant women avoid some foods and adhering to certain beliefs.

This study aims to determine the relationship between cultural internalization with iron deficiency anemia

prevalence among pregnant women. This study used cross-sectional study design, involved 126 pregnant

women from working areas of a Community Health Center in the western part of Indonesia. The

participants were recruited using purposive sampling method. Data were collected by self-report

questionnaires developed by the researchers. Data analysis was done using chi-square test. Finding show

that there was a relationship between taboo in food and norm/belief with the incidence of iron deficiency

anemia among pregnant women. It is recommended that community health center should consider the use

of cultural practices in the community in their health education and information design and promote

positive cultural practices to reduce the negative impact on pregnant women..

1 INTRODUCTION

Maternal Mortality Rate (MMR) is one of important

indicators in upholding women's health status. MMR

was 305 per 100,000 live births in Indonesia and

was 30 per 100.000 live birth (23%) in Aceh

(Dinkes Aceh, 2016). In Aceh Besar, MMR was 88

per 100,000 live births in 2015 (Dinkes Aceh Besar,

2016). Factors affecting maternal mortality include a

history of illness, family planning history (named

keluarga berencana), history of complications and

anemia status (Jayanti, Basuki and Wibowo, 2016).

Anemia during pregnancy is a serious global

public health problem. It is estimated that more than

half of pregnant women have hemoglobin levels that

indicate anemia, which is <11.0 g / dL (Onyeneho et

al., 2016). The prevalence of anemic pregnant

women in Indonesia was 37.1% (Kemenkes RI,

2013). Iron deficiency anemia is one of the most

common disorders during pregnancy. Pregnant

women generally experience iron depletion. So that,

the iron in mother's body was given to the fetus. Iron

is needed for hemoglobin formation and blood

volume will increase due to changes in the pregnant

women's body and fetal blood supply. Iron

deficiency can cause disorders to fetal growth both

in body and brain cells, fetal death in the womb,

abortion, low birth weight and anemia in infants

(Kemenkes RI, 2014).

Iron deficiency anemia during pregnancy is

caused by nutritional deficiencies, one of them is

iron that can occurs due to inadequate intake of iron

and lack of availability of iron in food (Vir, 2011;

Silverberg, 2012). Other factors that cause iron

deficiency anemia was diet, socioeconomic,

environmental, health status, knowledge and culture

(Masrizal, 2007; Vir, 2011; Hartinah and Eswantii,

2017). The result of the study conducted by Kaphle,

Hancock, & Newman (2013) in Nepal found that

women in highland area considered tradition and

belief to be positive contributors to their safety and

survival and also their babies during pregnancy. The

behavior of the people in the village is based on their

belief in supernatural powers that directly oppose to

Darmawati, ., Tahlil, T., Kamil, H., Siregar, T. and Umami, W.

The Correlation between Cultural Internalization and the Incidence of Iron Deﬁciency Anemia on Pregnant Women.

DOI: 10.5220/0008396400002442

In Proceedings of the Aceh International Nursing Conference (AINC 2018), pages 199-204

ISBN: 978-989-758-413-8

199

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medical views, where they will not abandon the

tradition of seeking medical care during pregnancy.

Acehnese culture has several traditions during

pregnancy. First, there was a tradition named Ba

Boh Kayee (bringing fruit) to pregnant women by

mother in-laws after enter a 3-month pregnancy

period. Second, Me Bu (tradition of carrying rice)

was done when pregnant women enter 7-8 months of

pregnancy and the tradition of abstaining from food

during pregnancy (Puspitawati and Batubara, 2015;

Samad, 2015). The study conducted by Puspitawati

& Batubara (2015) in Aceh Utara found that many

pregnant women were still abstaining from certain

types of food, such as not being able to eat pineapple

because it can cause miscarriages, should not eat sea

fish such as cuttlefish, octopus or other types of

strange fish, and forbidden to eat eggplant, jackfruit

and gummy vegetable. Based on this phenomenon,

researchers want to assess "The Relationship of

Cultural Internalization with the Incidence of Iron

Deficiency Anemia in Pregnant Women in Aceh

Besar".

2 METHODS

This research was a quantitative research with

descriptive correlative method, carried out with a

cross sectional study approach. This study used a

questionnaire developed by researchers based on

theoretical objectives consisting of 3 parts, which

included demographic data, taboo in food, and

norms/beliefs about eating food during pregnancy,

as well as the use of Hb meters to measure maternal

hemoglobin levels.

The study population were all pregnant women

who visited a selected Community Health Center,

between September 2017 and February 2018. The

sample of this study was 126 pregnant women who

recruited by non-probability sampling, using 3

inclusion criteria as follow: (1) Acehnese pregnant

women; (2) pregnant women who did not experience

blood disorders, and; (3) pregnant women in their

second and third trimesters.

Data collection was started by asking for

approval from the research place/community, the

visited the respondents and explained them the study

purpose and objectives. Next, the researchers asked

the respondent's approval by signing an informed

consent sheet. Then, the researchers distributed

questionnaires and measured the respondent's

hemoglobin. Data were analyzed using Chi-Square

test. This study was approved by the Ethical

Committee of Nursing Faculty, Syiah Kuala

University.

3 RESULTS

3.1. Characteristic of Respondents

The distribution of respondents based on their

demographic characteristics is shown in Table 1.

Table 1: Demographic Characteristics of pregnant women (N=126).

Characteristics F (%)

Age

Risk age (<20 and >35 years old) 27(21.4)

Not risk age (20-35 years old) 99(78.6)

Education

Low 8(6.3)

Middle 79(62.7)

High 39(31.0)

Job

Not Working 110(87.3)

Work 16(12.7)

Gestational Age

trimester 78(61.9)

trimester 48(38.1)

Number of Deliveries:

Primiparous 32(25.4)

Multiparous 94(74.6)

Lived with

Parents 64(50.8)

Husband 62(49.2)

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Table 1 shows that most of the respondents were in

not at risk age (20-35 years), half of the respondents

have last education in the middle category, two

thirds of respondents did not work, and the

respondent’s gestational age was mostly in the

second trimester category. The majority of

respondents were multiparous and half of the

respondents lived with their parents

3.2. Distribution of Food Taboos,

Norms/Beliefs and Iron Deficiency

The distribution of food taboos, norms/beliefs and

iron deficiency is shown on Graph 1. The incidence

of iron deficiency anemia in pregnant women was

59.5%; 53.2% of respondents supported taboos in

food; and 52.4% of respondents supported

norms/beliefs during pregnancy.

Graph 1. Distribution of Food Taboos, Norms/beliefs and Iron Deficiency Among Pregnant Women.

3.3. Relationship between Food Taboos,

Norms/Beliefs and Iron Deficiency

The proportion of anemia among pregnant women

who supported food taboos (68.7%) differed

significantly with respondents who did not support

(49.2%) food taboos in food (p-value = 0.04). The

proportion of anemia among pregnant who

supported the norms and beliefs (69.7%) differed

significantly with respondents who did not

supported the norms/beliefs (48.3) food taboos in

food (p-value = 0.024). It can be interpreted that

there was a statistical relationship between food and

norms/ beliefs with the

incidence of iron deficiency

anemia. The Relationship between food taboos,

norms/belief and the Incidence of Iron Deficiency

Anemia in pregnant women is described in Table 2

as follows.

Table 2: The Relationship of Food Taboos and the Incidence of Iron Deficiency Anemia in Pregnant Women.

Sub-variables

Iron Deficiency Anemia

Total

p-value

Anemia f (%) Not Anemia f (%)

Food Taboos

0.041

Supported 46(68.7) 21(31.3) 67

Not Supported 29(49.2 30(50.8) 59

Total 75(59.5) 51(38.5) 126

Norms/beliefs

0.024

Supported 46(69.7) 20(30.3) 66

Not Supported 29(48.3) 31(51.7) 60

Total 75(59.5) 51(40.5) 126

Iron Deficiency Anemia Food Taboos Norms/Beliefs of Pregnant Women

Anemia Did not Anemia Supported Not Supported

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4 DISCUSSIONS

The results of this study were supported by the

research conducted by Martini dan Haryanti (2015)

and found that there was an effect of food taboos on

the incidence of anemia (p-value = 0.047). There

are still many cultural beliefs in the society that

potentially increase pregnancy complications.

Pregnancy complications had an impact on maternal

morbidity and mortality include anemia in

pregnancy.

Culture gives different roles and values for food.

There are certain foods that are considered taboo or

should not be consumed during pregnancy.

Community beliefs formed because of the meaning

or reason contained in every word of their parents

(Humaeni, 2015; Mubarak, 2011).

One factor that contributes to problems during

pregnancy in rural areas was food taboos during

pregnancy. In several studies, it seen that pregnant

women in various country of the world were forced

not to consume nutritious food as part of their

traditional eating habits (Ugwa, 2016).

Based on the results by respondents' answers, it

is known that pregnant women in this study were

still not consume shrimp (10.3%), did not consume

fish (21.4%), did not consume goat meat (28.6%),

did not consume vegetables (31.0%), did not

consume fruits (34.1%), did not consume iron

tablets (27.8%), and there were still many

restrictions on pregnant women in the surveyed

community.

This study result was similar with the result

conducted by Sholihah & Sartika (2014) in Suku

Tengger. From the interviews conducted on

traditional birth practitioners (named dukun

beranak), families and pregnant women, it is known

that bananas, pineapple, fish, cabbage, and others

are foods that often abstained during pregnancy.

Research conducted by Nurrachmawati &

Anggraeni (2010) in East Borneo found that

pregnant women were still prohibited to eat salty

fish, squid, shrimp, pineapple, durian and others.

The same results are also obtained by Zerfu, Umeta,

& Baye (2016)

in Arsi found that pregnant women

also abstinence from foods such as spinach,

cabbage, kale, meat, chicken and others. Research

conducted by Eram, Tamanna, & Humaira (2016)

mentioned that out of a total of 100 studied women

in India, 78 pregnant women avoided papaya, 43

avoided fish, 33 avoided badi foods (which caused

flatulence), 27 avoided citrus foods, and 8 avoided

peanuts and tea or brinjal.

Food abstinence by pregnant women in this

study is contradictory to the concept mentioned by

Gluckman, Hanson, Seng, & Bardsley (2015);

Almatsier (2001). This study found that the foods

they avoided were rich of such as fish, vegetables,

fruits, meat, chicken, ducks and others. The iron is

used to formed hemoglobin in red blood cells that

acts as an oxygen carrier from the lungs to the

tissues. In the condition of iron deficiency, the

hemoglobin in the body will also decrease. This

condition causes iron deficiency anemia in pregnant

women.

Researchers assumed that food taboos during

pregnancy occur due to a lack of information from

health workers regarding the importance of nutrition

during pregnancy, so that many pregnant women

avoided some foods which were needed during

pregnancy, especially iron. This research area still

has cultures and beliefs trusted by local community,

especially regarding food taboos that trusted by

their parents. The pregnant women still affected to

follow that beliefs because they were afraid to have

several dangerous condition for themselves or their

babies.

This study result was supported by a study

conducted by Zerfu et al., (2016)

in Arsi. It is

known that there were still many pregnant women

who believe that body weight should not be

increased during pregnancy; milk and eggs should

not be consumed because it can caused large babies.

They also belief that pregnant women should not

allowed to consume green leaf vegetables because it

was dangerous for themselves and their fetuses.

Results of research conducted by Zepro (2015)

found that from 49.8% of total respondents avoided

one or more foods during pregnancy. Honey and

milk/yogurt are usually avoided because they

believe it can make the baby were fat so it would be

difficult for giving birth, can cause abortion and

fetal abnormalities. More than 82.4% of

respondents believe that reducing food intake

during pregnancy was very important.

The recapitulation of respondents’ answers in

previous study found that pregnant women in the

surveyed area were still believed things that were

contrary to health during pregnancy. It was found

that 42.9% believed that consuming too much

food caused a large baby. Pregnancy is the most

important stage and requires adequate nutrition.

During pregnancy, the mother needs extra calories

and essential nutrients every day to support fetal

growth. Incorrect belief in avoidance of food can

drain important body nutrients that will affect the

mother and fetus growth (Ugwa, 2016).

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From total 26.2% of respondents believed that

consuming iron tablets can caused large babies. Iron

(Fe) is an essential mineral that is important in the

formation of hemoglobin, myoglobin and collagen

and has a good function for fetal growth and

development (Kemenkes RI, 2016).Without iron

therapy, pregnant women who consume adequate

nutrients would be experience iron deficiency

during pregnancy. Diet alone cannot replace iron

loss during pregnancy. Oral iron should be given for

at least 6 months to correct anemia and to replenish

iron reserves (Bobak, Lowdermilk and Jensen,

2005; Silverberg, 2012).

There was 34.1% respondents believed that eggs

can make a big baby, 47.6% trusted milk can cause

large babies and difficult to give birth. Milk and

eggs contained protein which was one of the factors

that can facilitate iron absorption (Adriani and

Wirjatmadi, 2012), 69.8% respondents believed that

pineapple can cause miscarriages. Pineapple is one

of the fruits that contain vitamin C. Vitamin C was

good to be consumed because iron from plants

cannot be absorbed effectively without it. So, the

pregnant women need to consume vitamin C to

helath iron absorption (Mariana, Wulandari and

Padila, 2018). There was 30.2% respondents

believed that consuming goat meat can cause

cramps in the stomach or miscarriage. Goat meat is

one of the foods that contain heme iron. Heme iron

has a small iron content, but it would be well

absorbed by the body (Gluckman, Hanson, Seng, &

Bardsley, 2015 ; Almatsier, 2001).

The beliefs held by pregnant women in this

study were still contradicted from the health sector,

the results above was the evidenced. Actually, what

they believe is about the nutrients needed during

pregnancy. Energy metabolism during pregnancy is

increases, therefore they need energy and other

nutritional that also increased for fetal growth and

development and the changes of the composition

and metabolism of mother's body. Basically,

pregnant women need all the additional nutrients,

but what often becomes deficiency was iron

(Sukarni & Margareth, 2013).

The beliefs about pregnancy can also change the

mother's eating habits so that nutritional intake is

not in balance with the needs, this can cause the

metabolism of hemoglobin formation is inhibited

and the body's need for nutrients cannot be fulfilled,

such as iron, vitamin C, protein and others. This

condition can cause iron deficiency anemia during

pregnancy (Widyawati et al., 2015; Mariana,

Wulandari and Padila, 2018).

Pregnant women in study who have different

beliefs from the medical concepts majority lived

with their parents. This makes the researchers

assumed that pregnant women who have these

beliefs were obtained from their parents.

Researchers also assumed that pregnant women feel

anxious and fear that something will happen to their

pregnancy if they did not obey what the other

people or who are more experienced about

pregnancy said. It caused the pregnant women tend

to obey or trust everything related to pregnancy,

whether that was true or contrary to health concepts.

Pregnant women in this study mostly in the middle

school level category. This condition can caused the

level of trust held by pregnant women was high,

because pregnant women tend to take information

without thinking about the effects of that good or

bad information.

This study also has limitation. It is very difficult

to find the respondent address because the selected

Community Health Center working area has a large

area, it consists of 47 villages and there are several

villages that are difficult to reach, so this study

implemented in a long time period.

5 CONCLUSION

Based on the results and discussion in this study, it

can be concluded that food taboos and

norms/beliefs were associated with the incidence of

iron deficiency anemia in pregnant women. It is

recommended that the community health center

providers must consider the cultural practices that

apply in the community for designing health

education and information. They should consider to

internalize positive cultural practices for health life

so it can reduce the negative impact on pregnant

women.

ACKNOWLEDGEMENTS

The authors thank the pregnant women for their

participation and enthusiasm, also for the health

workers and other personnel from Kuta Baro

Community Health Center and Aceh Besar Health

Office for the permission and support provided for

this research process.

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