Nutrition Knowledge During Pregnancy in Malnutrition Pregnancy

Women in Bandar Lampung City: A Qualitative Study

Dian Isti Angraini

, Merry Indah Sari

and Efriyan Imantika

Department of Community Medicine and Public Health, Faculty of Medicine, Lampung University, Indonesia

Department of Medical Education, Faculty of Medicine, Lampung University, Indonesia

Department of Obstetric and Gynecology, Faculty of Medicine, Lampung University, Indonesia

Keywords: Malnutrition, Nutrition Knowledge, Pregnant Women.

Abstract: The prevalence of malnutrition among pregnant women in Indonesia is quite high (17.3%). Knowledge of

good nutrition during pregnancy will shape the eating behavior of pregnant women so that they have adequate

food intake according to their needs and can prevent pregnant women from experiencing malnutrition. The

purpose of this study is to explore nutrition knowledge during pregnancy in pregnant women who experience

malnutrition in the city of Bandar Lampung. This research is a qualitative study with a phenomenological

approach that was conducted in the city of Bandar Lampung from June 2019 to February 2020. The informants

were 27 pregnant women who had an upper arm circumference <23.5 cm. Data collection was carried out

through in-depth interviews. Most of the informants were aged 20-35 years (70.38%) and were multiparous

(77.77%). Poor knowledge of nutrition during pregnancy consists of four themes, that were lack of

information about the impact of drinking tea during meals, allocation of income for fulfilling nutrition, the

impact of malnutrition on pregnancy, and information on nutrition during pregnancy. It is necessary to carry

out periodic counseling and assistance for pregnant women, especially regarding nutrition during pregnancy

to prevent maternal and child morbidity.

1 INTRODUCTION

One of the nutritional problems in Indonesia that has

a high prevalence is malnutrition in pregnant women.

The results of the 2013 Basic Health Research

(Riskesdas) show that in Indonesia, the prevalence of

malnutrition in pregnant women aged 15-49 years has

reached 24.2%, and has decreased by 17.3% in 2018.

This prevalence is still classified in the problem

severe category of public health by the world health

organization (WHO) (Ministry of Health Republic of

Indonesia, 2013; Ministry of Health Republic of

Indonesia, 2018).

Malnutrition in pregnancy is a problem that

occurs during pregnancy where there is an imbalance

between intake and nutritional needs. Malnutrition in

pregnancy is known by measuring the mid-upper arm

circumference (MUAC) of pregnant women which is

less than 23.5 cm or on the MUAC red band (Kpewou

et al., 2020). One of the effects of maternal

malnutrition is low birth weight (LBW) babies below

2500 grams (Arsyi & Besral, 2021).

Lack of food intake is the main risk factor for

malnutrition in pregnant women. The results of

Indonesian Nutrition Consumption Monitoring which

was carried out in conjunction with the collection of

nutrition status assessment data in 2016 showed that

only 26.3% of pregnant women met sufficient energy

and 29.3% of pregnant women met sufficient protein

in their daily consumption (Ministry of Health

Republic of Indonesia, 2016).

One of the factors that cause pregnant women to

experience malnutrition is the lack of knowledge of

pregnant women in determining good nutrition during

pregnancy. Nutritional intake in pregnant women

should contain energy, protein, vitamins, minerals,

folic acid, iron, and calcium which is very much

needed in the process of fetal development (Marshall

et al., 2022). Nutritional status during pregnancy

greatly influences the birth process of the baby later.

Mothers with malnutrition can increase the risk of

miscarriage, perinatal death (death of the fetus at 22

weeks gestation to 1 week after birth), and neonatal

(babies aged 0-28 days) (Lassi et al., 2021).

Angraini, D. I., Sari, M. I. and Imantika, E.

Nutrition Knowledge During Pregnancy in Malnutrition Pregnancy Women in Bandar Lampung City: A Qualitative Study.

DOI: 10.5220/0012898700004564

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 5th International Conference on Social Determinants of Health (ICSDH 2023), pages 49-55

ISBN: 978-989-758-727-6; ISSN: 2975-8297

Research conducted on pregnant women in the

Sungai Durian Health Center work area, Sintang,

West Kalimantan, Indonesia found that lack of

knowledge is related to the risk of malnutrition in

pregnancy, and 61.5% of malnourished pregnant

women have poor nutritional knowledge (Sinta,

2022). Other research on pregnant women in the

working area of the Batudaa Pantai Health Center,

Gorontalo, Indonesia also obtained knowledge that

was less related to malnutrition in pregnancy, and

94.1% of malnourished pregnant women had poor

knowledge (Retni & Puluhulawa, 2021).

The high level of knowledge that is lacking in

malnourished pregnant women needs to be

investigated in more depth regarding what knowledge

is wrong or not good so that this will later become the

basis for conducting nutritional knowledge

interventions for pregnant women so that the

nutritional needs of pregnancy are met and preventing

malnutrition in pregnancy.

2 SUBJECT AND METHOD

This research is qualitative exploratory research with

a phenomenological approach. In qualitative research

using descriptive phenomenological methods,

researchers try to explore meaning and meaning and

try to explore nutrition knowledge during pregnancy

in pregnant women who experience malnutrition.

This research was conducted in Bandar Lampung

City, Indonesia, from June 2019 to February 2020.

The target population for this study was all pregnant

women in Lampung Province. The case population in

this study were all malnourished pregnant women.

The inclusion criteria for this research informant were

having a mid-upper arm circumference <23.5 cm

(malnutrition).

Determination of samples/informants using

purposive sampling based on inclusion and exclusion

criteria. The number of samples is determined if the

data taken is saturated, that is as many as 27

malnourished pregnant women. The instrument used

was a qualitative research instrument, namely an in-

depth interview guide containing questions used in

data collection, field notes, and recording devices.

The data collection process in this study was carried

out by in-depth interviews with participants/

informants, that is malnourished pregnant women.

Data analysis is carried out simultaneously with the

process of collecting data, making interpretations,

and writing reports. Data validity is done by

triangulation and member checking. Data

triangulation was carried out using source

triangulation techniques (nutrition workers,

midwives, and doctors; that working at a community

health center) and theory.

3 RESULTS

The results showed that low knowledge of nutrition

during pregnancy consisted of four themes, which

were lack of information about the impact of drinking

tea during meals, allocation of income for fulfilling

nutrition, the impact of malnutrition in pregnancy,

and information on nutrition during pregnancy.

Figure 1: The Themes of Knowledge in Malnutrition of

Pregnant Women.

3.1 Knowledge About the Impact of

Drinking Tea During a Meal

The results of this research found that informants

(malnourished pregnant women) did not know the

impact of the habit of drinking tea together with

eating staple foods on health, which is a risk factor for

anemia in pregnancy. Informants stated that they had

never received this information from health workers

or from reading or hearing this information from

other people.

The informants stated that the reason they drank

tea along with eating rice was because of their habit,

and drinking can reduce the symptoms of nausea and

vomiting, and make the stomach feel warmer and

more comfortable so that pregnant women can eat

more. Quote from the informant's statement as stated

below:

Knowledge in

Malnutrition

Pregnant

Women

Impact of

drinking tea

during meal

Allocation of

income for

nutrition

Impact

malnutrition

in pregnancy

Information

on nutrition

during

pregnancy

ICSDH 2023 - The International Conference on Social Determinants of Health

"..... I don't know. I have never been informed that it

is not permissible to drink tea while meal ...”

“..... I don't know if that's possible, I drink tea because

it can reduce nausea, so when I eat I drink hot tea. To

be able to eat too because during pregnancy it

becomes difficult to eat ….”

"..... I don't know, I was never informed by the

midwife or others, so I drank hot tea at breakfast so

that it reduced nausea and I could eat more......"

''.... I do not know and have never been told or read

that it is not permissible to drink tea while a meal. I

eat rice and drink hot tea, so I can eat because the

stomach gets warm and reduces nausea too...”

The results of interviews with informants from

health workers (midwives, nutritionists, doctors)

found that health workers did not pay attention to the

habit of drinking pregnant women's tea together when

meal so that which is a risk of anemia. Health workers

stated that pregnant women who suffer from anemia

are caused by insufficient food intake and also low

socioeconomic conditions.

Health workers stated that they only focused on

giving blood supplement tablets and education on

food intake, but had not included nutritional

education regarding food enhancers and inhibitors

(inhibits) absorption of Fe. Quotations of health

workers' statements as stated below:

"..... all this time we have focused more on blood

supplement tablets, so the habit of drinking tea has

been forgotten......"

" ..... it was not noticed because there are already the

blood supplement tablets ....."

"...... because there are blood supplement tablets and

nutrition education, so the habit of drinking tea is not

asked about......"

"... the problem hasn't been explored yet, because

there is already an iron deficiency test and usually

those who are anemic eat less and have a low figure

....."

3.2 Knowledge About the Allocation of

Income for Fulfilling Nutrition

The results of interviews with malnourished pregnant

women informants found that knowledge regarding

the perception of the proportion of family income to

meet family nutrition was lacking. Informants stated

that 20-40% of the total family income was used to

buy food to meet the nutritional needs of the family.

According to the informant, the proportion of income

for spending on family food is sufficient, although

sometimes they can only buy vegetables and tempeh

or tofu.

Informants stated that it is difficult to increase the

proportion of income to fulfill family nutrition,

because considering that there are still many other

necessities to meet family life needs, such as

schooling for children, capital for trading, or

preparation for giving birth. Quote from the

informant's statement as stated below:

"..... I spend 10 thousand or 15 thousand (out of a

total income of 50 thousand per day), I think that's

enough...."

"..... Not sure... 20-25 thousand for food a day (out of

a total income of 60 thousand per day), in my opinion,

that is enough because there are other expenses...."

“..... I think about 20-30% is enough.....”

"...... approximately a day is around 30 thousand (2

million monthly income)......"

The results of interviews with informants from

health workers (midwives, nutritionists, doctors)

found that pregnant women's knowledge regarding

the proportion of income to fulfill family nutrition is

not good. This is because pregnant women do not

know the actual standard, what percentage should be

the proportion of income to meet the nutritional needs

of the family. The proportion of family income is also

mostly used for other purposes, for example for

school children, trading capital, medical expenses,

gas money, and so on.

Health workers also stated that the total income of

families of malnourished pregnant women was

indeed not large, because most of the malnourished

pregnant women came from families with middle to

lower socioeconomic status. According to health

workers, the most important thing is that the family

of pregnant women can eat 3 times a day, even with

simple side dishes or vegetables. Quotations of health

workers' statements as stated below:

".....pregnant women don't know, they spend for food

around 30% of the total family income for. They have

many necessities of life to fulfill, most of them come

from families with middle to lower socioeconomic

levels... ”

“....they are not sure how much they spend on food,

maybe around 25-30%, they don't know how much

should be, the important thing is enough to feed their

family.. not to mention the many other needs. ......”

"...... it seems they don't know how much they should

spend on food, they spend according to the finances

they have, and it is also divided with other needs

which are also many... I think maybe around 30% of

Nutrition Knowledge During Pregnancy in Malnutrition Pregnancy Women in Bandar Lampung City: A Qualitative Study

their income is spent on buying food, also shared with

other needs, for example, school fees and other

household expenses......”

Based on the results of interviews with

malnourished pregnant women informants and

triangulation with health workers, it was found that

the proportion of income for fulfilling maternal

nutrition in the pregnant women group was still

lacking/ below the recommended standard. The

proportion of family income for nutrition fulfillment

in the group of malnourished pregnant women ranges

from 20-40%.

The proportion of inadequate family nutrition

fulfillment can have an impact on pregnant women's

food intake both in quantity and quality. The low

proportion of fulfillment of nutrition from the amount

of family income is caused by many other needs that

must be met, large family members, and so on.

3.3 Knowledge About the Impact of

Malnutrition on Pregnancy

The results of this research state that knowledge about

the impact of malnutrition on pregnancy is still

lacking. Informants of malnourished pregnant women

stated that the effects of malnutrition were disorders

or illnesses during pregnancy, complications during

childbirth, and babies born underweight/abnormal.

Disorders or illnesses during pregnancy such as being

weak and not strong or having enough energy when

giving birth. Complications during childbirth such as

suffering from anemia there is a risk of experiencing

bleeding during childbirth, and also giving birth with

prolonged labor or late labor. Quote from the

informant's statement as stated below:

"..... later become weak and not strong when giving

birth......"

"..... information from the midwife that if you are thin

then it will be difficult when you give birth and the

baby will be small because you are underweight ....."

“……The baby will have a low weight……”

“……It can be difficult during labor and the baby is

small due to the lack of weight …. ”

"...... will have difficulties during pregnancy, can

become anemic, there are complications during

delivery so that it cannot give birth normally ....."

The results of interviews with health worker

informants found that pregnant women's knowledge

about the impact of malnutrition on pregnancy was

still lacking. Health workers stated that pregnant

women were informed of the effects of malnutrition

when pregnant women visited antenatal care (ANC).

The impact malnutrition that is informed to

pregnant women is a disorder or disease during

pregnancy and becomes a complication during

childbirth. Health workers stated that even though

they had been informed, it was very difficult for

pregnant women to change their behavior related to

food intake and anemia which are direct factors

causing malnutrition in pregnancy. Quotations of

health workers' statements as stated below:

"..... they already know because they were often

informed during ANC, but sometimes when asked

again the answer was when the birth was difficult and

had to be operated on, if asked further they don't

understand ...."

“..... if their answers when asked are usually the

answer will be experiencing difficulties during

childbirth and the body becomes weak, they don't

know the details. Even though they are always

reminded of malnutrition when pregnant ….”

“......we always inform pregnant women what are the

dangers of malnutrition during pregnancy, and when

asked again the answer is that they will often get sick

during pregnancy and experience difficulties during

childbirth. They don't understand..."

3.4 Knowledge About the Information

on Nutrition During Pregnancy

The research results found that knowledge regarding

nutrition and health information during pregnancy is

still not good. Informants of malnourished pregnant

women stated that the information they got during

pregnancy was regarding the schedule of antenatal

care (ANC) visits, food intake according to the needs

during pregnancy, consumption of vitamins,

attending classes for pregnant women, giving biscuits

giving additional recovery food.

This information was obtained from midwives,

doctors, and nutrition officers at the Community

Health Center. Access to information is also easy to

obtain. Excerpts from malnourished pregnant

women's informants as stated below:

“..... usually information about control schedules,

exercise for pregnant women, vitamins, and given

biscuits, from the midwife and nutrition officer.

Information is easy to get …..”

“..... Midwives often provide information, once also

doctors then nutritionists. The information provided

is about food that must be eaten, before that I had

anemia and because of that I was kept informed to

take the medicine regularly, then ANC information to

ICSDH 2023 - The International Conference on Social Determinants of Health

the health center, and others. Information is easy to

get, in fact, sometimes the midwives always remind

me...”

“...... usually informed about control schedules,

vitamins, nutritious food, exercise, and others.

Information from midwives and easy to get ….”

“..... information on food during pregnancy, control

schedule, taking vitamins, eating biscuits. Informed

the same midwives and nutritionist. Access to

information is not difficult or not and even always

reminded ....."

The results of interviews with health worker

informants found that pregnant women's knowledge

of nutrition and health information during pregnancy

was not good. The information provided, namely

regarding the schedule of antenatal care (ANC) visits,

food intake, consumption of vitamins, classes of

pregnant women, and weight gain during pregnancy,

is still lacking. Health workers stated that all this

information was always given when pregnant women

came to ANC or via telephone, SMS, and WhatsApp,

but indeed most pregnant women still did not

understand it, especially related to factors that are risk

factors for malnutrition. Quotations of health

workers' statements as stated below:

“..... All information about the ANC schedule, signs

of illness, nutritional needs during pregnancy, and

others is always given, but when asked again some

people don't know or forget. This may be due to young

age, lack of knowledge, and low education. We also

always inform via sms or Whatsapp or even by

telephone...” “….. Pregnant women are always

informed about weight gain during pregnancy,

healthy and nutritious food during pregnancy, ANC

schedule, etc. If asked again, some of them still don't

know even though they have been told many times,

sometimes we also discuss it in the WhatsApp group

..... "

“...... Every ANC is always informed about control

schedules, taking vitamins, nutrition, health checks,

etc. We are also always available if asked by

telephone or sms ..... ”.

4 DISCUSSION

Knowledge is the result of knowing and occurs after

people sense a certain object. Knowledge is a function

of human attitudes that have a basic urge to know,

seek reasoning, and any experiences. Knowledge of

nutrition will help in finding various alternative

solutions to the problem of family nutritional

conditions. Behavior-based knowledge will be better

than not based-on knowledge because it is very

important to shape one's actions (Adhiyati, 2013).

Inadequate food intake can be caused by a person's

low knowledge and eating behavior. Low nutritional

knowledge can lead to low food selection and have a

role in nutritional problems (Zychowicz & Plichta,

2022).

Pregnant women's knowledge about nutrition and

health during pregnancy is influenced by the level of

education of pregnant women. Knowledge of good

nutrition during pregnancy will shape the eating

behavior of pregnant women so that they have

adequate food intake according to their needs

(Mohammadi et al., 2022).

Education level is related to food intake. Low

education level tends to have low nutritional

knowledge, low food intake (including protein), and

poor nutritional status. Women with low levels of

education tend to have a higher probability of having

less food intake and suffering from malnutrition.

Women with higher levels of education have better

food consumption patterns than women with lower

education (Mulyadi, 2021). Education level is the

strongest factor that correlates with nutritional intake

in pregnant women. Pregnant women who have a

high level of education have a positive correlation

with nutrient intake, both macronutrients

(carbohydrates, protein, and fat) and micronutrients

(vitamins and minerals) (Mutalazimah, Wijaya &

Suswardany, 2020).

According to Adhiyati (2013), inadequate food

intake can be caused by a person's low knowledge and

eating behavior. Low nutritional knowledge can lead

to low food choices and have a role in nutritional

problems.

According to Stephanie and Kartika (2014), a

mother's low education can affect the risk of

malnutrition, this is because the education factor can

determine whether or not it is easy for a person to

absorb and understand the nutritional knowledge

obtained and influence one's eating patterns.

According to Muliawati (2012). the formal

education of housewives often has a positive

relationship with the development of consumption

patterns in the family. Education will affect a mother's

knowledge, especially related to health. Mothers who

have good nutritional knowledge will choose foods

that are more nutritious than those that are less

nutritious.

On average, pregnant women whose food intake

is insufficient due to unbalanced menu preparation

and lack of knowledge of pregnant women in paying

attention to fulfilling their food (Lugowska &

Kolanowski, 2019).

Nutrition Knowledge During Pregnancy in Malnutrition Pregnancy Women in Bandar Lampung City: A Qualitative Study

Informants had insufficient knowledge about tea

drinking as a risk factor for nutritional anemia in

pregnancy. The results of in-depth interviews with

health workers also stated that health workers did not

provide information about the risks of drinking tea as

a cause of anemia in pregnancy, because health

workers focused more on the prevention and

management of anemia on the blood supplement

tablet program.

The role of health workers in providing education

to pregnant women is very important in increasing

knowledge and forming healthy behavior, including

behavior in preventing anemia in pregnancy. The

health behavior of a person or society is influenced by

knowledge and attitudes. Good knowledge and a

positive attitude can support the behavior of pregnant

women in making efforts to prevent anemia.

Education about the prevention of anemia is one

effort that can increase knowledge and change

attitudes to be positive so that in the end pregnant

women can make various efforts to prevent anemia

(Sukmawati, Mamuroh, & Nurhakim, 2019).

Based on the results of in-depth interviews with

pregnant women informants, it was found that

knowledge about the effects of malnutrition was still

lacking. Informants only know that the impact of

malnutrition on pregnancy will cause disturbances

during pregnancy, become complications during

childbirth and give birth to babies with underweight.

The impact of malnutrition in pregnancy is

divided into 3, there were causing problems for the

mother, childbirth, and the fetus. Undernourishment

in pregnant women will increase the risk of

complications in the mother during pregnancy,

namely anemia, bleeding, the mother's weight does

not increase normally and contracting infectious

diseases (Karemoi et al., 2020). The effect of

malnutrition on the birth process can result in difficult

and long labor, preterm or premature delivery,

bleeding after delivery, and increases risk of

operative delivery. Malnutrition in pregnant women

can affect the growth process of the fetus, cause

miscarriage and, the fetus dies in the womb and is

born with a low birth weight (Zulhaida, 2013).

Based on the results of in-depth interviews with

pregnant women informants, it was found that

knowledge about nutritional information was still

lacking. Although in general, the informants stated

that they received information about ANC visit

schedules, food intake, vitamin consumption, class

schedules for pregnant women, and weight gain each

month; informants still do not fully understand the

amount, type, and frequency of food that must be

consumed during pregnancy, resulting in insufficient

food intake.

Informants still had insufficient knowledge

regarding the proportion of family income to meet

family nutrition, which ranged from 20-40% in

families of malnourished pregnant women.

Insufficient knowledge of the informants in this study

regarding the proportion of income to meet family

nutrition was influenced by the educational level of

the informants. Informants of malnourished pregnant

women in this qualitative study mostly had

insufficient knowledge (78%) and basic education

level (65%). According to Notoatmodjo (2012),

perceptions can be changed by increasing knowledge.

According to Ernest Engel, the percentage of

spending on food will decrease as income increases.

Therefore, the composition of household expenditure

can be used as an indicator of the welfare of the

population. The lower the percentage of spending on

food to total expenditure, the better the economic

level of the population. Based on the results of

Purwaningsih's research (2008) the average

proportion of food expenditure is at least 60% to

ensure household food security is included in the non-

food insecure category. Rosyadi & Purnomo (2012)

in their research stated that the proportion (share) of

household expenditure for food needs was much

higher than household expenditure for non-food

needs, namely an average of 78% for food needs,

while 22% for non-food needs.

5 CONCLUSIONS

Lack of knowledge about nutrition during pregnancy

is a risk factor for malnutrition in pregnancy so it can

increase maternal and child morbidity. It is necessary

to carry out periodic counseling and assistance for

pregnant women, especially regarding nutrition

during pregnancy.

ACKNOWLEDGEMENTS

Our gratitude is sent to the community health center

(Puskesmas) and the Health Office of Bandar

Lampung City who have permitted this research can

be completed. Do not forget to very thank to the

informants of this research.

ICSDH 2023 - The International Conference on Social Determinants of Health

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