Journal of Maternal and Child Health (2018), 3(4): 294-300

https://doi.org/10.26911/thejmch.2018.03.04.07
Prenatal Factors Associated with the Risk of Stunting: A Multilevel
Analysis Evidence from Nganjuk, East Java
Dewi Indriani​1)​, Yulia Lanti Retno Dewi​2)​, Bhisma Murti​1)​, Isna Qadrijati​3)
1)​
Masters Program in Public Health, Universitas Sebelas Maret 2)​
​ Faculty of Medicine, Universitas

Sebelas Maret
ABSTRACT
Background: ​Globally, one in four children under the age of five suffers from stunting. Stunting
is associated with an underdeveloped brain, with long-lasting harmful consequences, including
diminished mental ability and learning capacity, poor school performance in childhood, reduced
earnings and increased risks of nutrition-related chronic diseases, such as diabetes,
hypertension, and obesity in future. This study aimed to analyze prenatal factors associated
with the risk of stunting in Nganjuk, East Java, using a multilevel analysis. ​Subjects and
Method: ​This was an analytic observational study with a case control design. The study was
conducted at 25 posyandus (integrated health posts) in Nganjuk, East Java, from June 03 to
July 07, 2018. Posyandu was selected by stratified random sampling. A sample of 225 children
under five was selected by fixed disease sampling, consisting of 75 stunted children and 150
normal children. The dependent variable was stunting. The independent variables were birth
length, maternal height, and family size. The data were collected by questionnaire and analyzed
by a multilevel logistic regression run on Stata 13. ​Results: ​The risk of stunting increased with
maternal height <150 cm (b= 2.59; 95% CI= -0.75 to 4.42; p= 0.006), birth length <48 cm
(b=4.17; 95% CI= 2.19 to 6.15; p<0.001), and large family size (b= 2.31; 95% CI= 0.34 to 4.29;
p= 0.022). Posyandu had a contextual effect on stunting with ICC= 63.39%. ​Conclusion: ​The
risk of stunting increases with maternal height <150 cm, birth length <48 cm, and large family
size. Posyandu has a sizeable contextual effect on stunting.
Keywords: ​stunting, birth length, maternal height, family size, posyandu, multilevel
Correspondence: ​Dewi Indriani. Masters Program in Public Health, Universitas Sebelas Maret,
Jl. Ir. Sutami 36A, Surakarta, Central Java. Email: [email protected]. Mobile:
+6285735830730.
BACKGROUND ​Malnutrition in children under five is a direct consequence of a large
number of families, and lack of access to quality food and health services. Stunting is a
form of malnutrition that is often faced by deve- loping countries. Approximately 65% of the
deaths of children under five are due to some forms of malnutrition and malnutri- tion
representing one third of the burden of illness of children and mothers (Adeela and Seur,
2016). Indonesia is one of the deve- loping countries that has a high prevalence
294 e-ISSN: 2549-0257 ​of stunting, from 88 countries in the world, Indonesia is at the top five
of stunting cases (Unicef, 2013).
Basic Health Research (2013) shows that in Indonesia, the prevalence of stunting incidence
increased from 2010 to 2013 from 35.6% to 37.2%. WHO recom- mends a stunting target of
less than 20% so it would not cause problems. Nganjuk Regency is one of the provinces in
East Java which has a stunting prevalence of more than 20%. Nganjuk regency has
increased the prevalence of stunting events from 2016
Indriani et al./ Prenatal Factors Associated with the Risk of Stunting
to 2017 from 22.7% to 25.9% (Nganjuk Health Office).
Prenatal factors have an important role in the incidence of stunting. Biological factors
become a strong foundation in the growth of children. Growth failure is the main
manifestation of malnutrition during pregnancy and in childhood which is born with low birth
weight (Kramer et al, 2016). Studies in developing countries have shown that stunting
depends on the condition of the population of the region (Kinyoki et al, 2016). Stunting is
more common at the individual level in men than in women. Family and community levels
such as maternal education, employment, family income, and basic health services affect
the incidence of stunting (Hagos et al., 2017).
Stunting increases the global public health burden of contributing 45% of all under-five
mortality. More than two million children under five die each year from mal- nutrition
worldwide (Cruz et al., 2017). The other effects of stunting are disease, lack of intelligence
and productivity which are cer- tainly very beneficial for future generations (Yisak et al,
2015).
Stunting is a very important issue, so community-based interventions should be formulated
and implemented to improve children's health. At the individual level, interventions must
focus on educating mothers on the right basics of nutrition and the need to utilize available
health services. At the community level, health systems that facilitate public health
intervention include maternal and child health programs that need to be made accessible to
women in rural areas. This intervention will improve the nutritional status of children under
five so that the WHO global target of 2025 can be achieved (Akombi, 2017).
The foundation of the long-term food and nutrition program policy in Law No. 17 of 2007
concerns the Long Term Develop-
e-ISSN: 2549-0257 295 ​ment Plan (RPJPN) for 2005-2025. The multi-sector approach in the
development of food and nutrition includes production, processing, distribution to
consumption of food with sufficient nutrition, balanced and guaranteed safety. The focus of
the nutri- tion improvement movement is on the first 1000 days of life group at the global
level called Scaling Up Nutrition (SUN) and in Indonesia, it is called the national nutrition
awareness movement in order to accelerate nutritional improvement in the first 1000 days
of life. Integrated health post (Pos- yandu) is one of the interventions in the 1000 days of life
movement in monitoring the growth of children under five (Ministry of Health RI, 2012).
The researchers examined the pre- natal factors that affect the incidence of Stunting in
Nganjuk District, East Java Province. The purpose of this study to explain the influence of
prenatal factors that affect the incidence of stunting in Nganjuk regency.
SUBJECTS AND METHOD 1. Study Design ​This was an analytic observational study with
a case control design. The study was conducted at 25 posyandus (integrated health posts)
in Tanjunganom, Ngetos, Rejoso and Prambon sub-districts, Nganjuk district, East Java,
 from June 03 to July 07, 2018. Posyandu was selected by stratified random sampling. ​2.
Population and Samples ​A sample of 225 children under five was selected by fixed
disease sampling, com- prising 75 stunted and 150 normal children. ​3. Study Variables
The dependent variable was stunting. The independent variables were maternal height,
birth length, family size, and posyandu.
Journal of Maternal and Child Health (2018), 3(4): 294-300
https://doi.org/10.26911/thejmch.2018.03.04.07
defined as a short stature arising from the old
4. Operational Definitions ​Maternal height malnutrition that is characterized by short and
was defined as the height of the mother very short body circumstances by measuring
measured at the time of the study in height of age. The body length was measured
centimeters measured by micro- toise. The by microtoise. The measurement scale was
measurement scale was conti- nuous, but for continuous, but for the purpose of data
the purpose of data analysis, it was analysis, it was transformed into dichoto-
transformed into dichotomous, coded 0 for mous, coded 0 for normal children and 1 for
maternal height ≥ 150 cm and 1 for maternal stunting.
height <150 cm. 5. Data Analysis ​The data analysis included
Birth length was defined as infant’s univariate, biva- riate, and multivariate
body length measured (in cm) at the time of analysis. Multiva- riate analysis used a
birth. The data were taken from the maternal multilevel logistic regression run on Stata 13.
and child monitoring book. The measurement 6. Research Ethics ​The ethichal clearance
scale was continuous, but for the purpose of was obtained from the Research Ethics
data analysis, it was trans- formed into Committee at Dr. Moewardi Hospital,
dichotomous, coded 0 for birth length ≥48 cm Surakarta, Central Java, Indonesia, with N0:
and 1 for birth length <48 cm. 110 / UN27.6 / KEPK / 2018. Research ethics
of this study including inform consent,
Family size was defined as the number of
anonymity, and confidentiality.
household members who live and live together
which is the smallest unit in the community
consisting of husband and wife and their RESULTS 1. Univariate
children, wife and children or father and analysis ​The results of univariate analysis
children. The data were collected by were showed in Table 1. Table 1 shows that
questionnaire. The mea- surement scale was most of the stunted children was born with
continuous, but for the purpose of data birth length <48 cm (84%), maternal height
analysis, it was transform- ed into <150 cm (82.67%), and family size >4. ​Table
dichotomous, coded 0 for <5 and 1 for ≥5. 1. Study subject characteristics ​Variable
Stunting Normal
Posyandu activities are defined as all activities
​ n % n % Maternal Height
carried out at the posyandu. The measuring <150 cm 62 82.67 45 30 ≥ 150 cm 13 17.33
tool used was a questionnaire. The categorical 105 70 ​Birth Length <
​ 48 cm 63 84 37 24.67
measurement scale is using parameter 0 for ≥ 48 cm 12 16 113 75.33 ​Family Size ​≤ 4 23
score ≥4 and 1 for score <4. Stunting was 30.67 124 82.67 > 4 52 69.39 26 17.33
 birth length (OR= 16.03; 95% CI= 7.80 to
2. Bivariate analysis ​The results of bivariate 32.95; p<0.001), maternal height (OR= 11.13;
analysis on the effects of birth length, maternal 95% CI= 5.57 to 22.24; p<0.001), and family
height, and family size on stunting were size (OR= 10.78; 95% CI= 5.64 to 20.61;
showed in Table 2. Table 2 shows that the risk p<0.001).
of stunting in child under five increased with

296 e-ISSN: 2549-0257

Indriani et al./ Prenatal Factors Associated with the Risk of Stunting
Table 2. Chi-square analysis on the effects of maternal height, birth length, and
family size on stunting
Independent Variables
e-ISSN: 2549-0257 297
Yes (n=75) No (n=150) ​ 95% CI ​
Stunting status ​ OR ​ p n % n % Lower limit Upper limit Maternal
Height ​< 150 cm 62 57.94 45 42.06 11.13 5.57 22.24 <0.001 ≥ 150 cm 13 11.02 105 88.98 ​Birth Length
< 48 cm 63 63 37 37 16.03 7.80 32.95 <0.001 ≥ 48 cm 12 9.6 113 90.4 ​Family Size ​< 5 23 15.65 124
84.35 10.78 5.64 20.61 <0.001
≥5 52 66.67 26 33.33
3. Multilevel analysis ​The results of multilevel logistic regression was showed in Table 3.
Table 3 showed that there was association between maternal height and stunting. Maternal
height <150 cm increased the risk of stunting in children under five (b= 2.59; 95% CI= -0.75
to 4.42; p= 0.006). There was an association between birth length and
stunting​. Birth length <48 cm increased the risk of stunting ​(b= 4.17; 95% CI= 2.19 to 6.15;
p<0.001). There was an association between family size and stunting​. Family size ≥5
increased the risk of stunting ​(b= 2.31; 95% CI= 0.34 to 4.29; p 0.022). Posyandu had strong
contextual effect on stunting with ICC= 63.3%.
Table 3. The results of multilevel logistic regression analysis on the effects of
prenatal factor on stunting
95% CI ​
Independent Variable b ​Lower Limit ​ ​ Fixed Effect ​Maternal Height
Upper Limit p
(<150 cm) 2.59 0.75 4.42 0.006 Birth Length (<48 cm) 4.17 2.19 6.15 <0.001 Family Size (≥ 5)
2.31 0.34 4.29 0.022 ​Random Effect ​Posyandu Activeness N Observation = 225 N Posyandu
=25 Prob>chi2 <0.001 Likelihood Ratio = -25.20 ICC= 63.39
DISCUSSIONS 1. The effect of maternal height on
stunting ​The result of this analysis showed that there was an association between
maternal height and stunting, and it was statistically signi- ficant. Maternal height <150 cm
were more likely to have stunting than mother with normal height (≥150 cm) (b=2.59; 95%
CI= -0.75 to 4.42; p= 0.006).
The result of this study is consistent with a study by Indriyani ​et al​. (2018), which stated that
there was a relationship between maternal height and birth length. Maternal height <150 cm
was an indirect factor that increased the incidence of stunt- ing. Maternal height <150 cm
increased the likelihood of birth length <48 cm (b= 1.39; 95% CI= 0.55 to 2.24; p<0.001).
Journal of Maternal and Child Health (2018), 3(4): 294-300
https://doi.org/10.26911/thejmch.2018.03.04.07
The result of this study supported a study of Aguayo ​et al. ​(2016), which stated that
mothers who were <145 cm tall would increase the incidence of stunting in infants by 2.04
times than mothers who were ≥145 cm (b= 2.04; 95% CI= 1.46 to 2.81).
Maternal height was associated with children body height due to internal factors such as
genetic which contributed greatly to other internal factors such as ethnicity, family, and
gender (Ministry of Health RI, 2012). The result of this study was in line with a study done
by Setyaningrum et al. (2017) which stated that every enhance- ment of 1 cm of maternal
height, it would the growth of children nutritional status (height for age) (b= 0.43; CI 95%=
0.27 to 0.58; p<0.001).
A study by Amin and Hadi (2015) conducted on 252 study subjects and analyzed by a
multiple logistic regression showed that maternal height contributed significantly to stunting
among children aged 6-23 months. This study illustrated that genetic factors, especially
maternal height had a strong effect on the incidence of stunting. ​2. The effect of birth
length on
stunting ​The result of this analysis showed that there was an association between birth
length and stunting, and it was statistically signi- ficant. Infants with birth length <48 cm
increased the risk of stunting (b= 4.17; 95% CI= 2.19 to 6.15; p<0.001). The result of this
study is consistent with a study by Setyaningrum ​et al​. (2017), which stated that birth length
increased children nutri- tional status (height for age) (b= 0.21; 95% CI= 0.12 to 0.30;
p<0.001).
This study was in line with Rieger and Trommlerová (2016), which stated that children body
heigh was affected by birth length that would always increase along with the children’s age.
The result of a study
298 e-ISSN: 2549-0257 ​by Amaliah ​et al. ​(2016) stated that birth length was one of the
determinants of child growth and development. Children with short birth length were 3 times
more likely to have stunting​. ​3. The effect of family size on
stunting ​The result of analysis showed that there was an association between family size
and stunting, and it was statistically significant. Family size ≥5 increased the risk of stunting
(b= 2.31; 95% CI= 0.34 to 4.29; p= 0.022). The result of this study was in line with a study
by Wolde ​et al. ​(2015), which stated that the large number of family would increase the
incidence of stunting (b= 2.00; 95% CI=0.3 to 3.4).
Habyarimana ​et al. ​(2016) reported that malnutrition (stunting) determinants among children
under five in Rwanda was affected by birth order. This findings showed that children who
was born from large family size had higher risk to be stunted (OR= 1.65, p= 0.002).
The result of this study was in line with a study done by Cruz ​et al. (​ 2017), which stated that
children who live in a house with other family members (b= 17.3; 95% CI= 7.62 to 39.12; p=
0.001) and live in a house with other children for less than five years were more likely to
have stunting (b= 28.42; 95% CI= 11.93 to 67.70; p<0.001).
Children from large family size tend to get less nutrition intake, parental attention, and
health care (Proverawati and Wati, 2011). Large family size would spend more money to
fulfill their needs, and there would be competition and limitations in providing balanced
nutritious food (Amin and Julia, 2014). ​4. The effect of posyandu on stunting ​The result
of multilevel analysis showed the score of ICC= 63.39%. This indicator
Indriani et al./ Prenatal Factors Associated with the Risk of Stunting
showed that Posyandu had strong contextual effect on stunting.
The result of this study was in line with a study by Sinta ​et al. ​(2017), which stated that
Posyandu had a contextual effect on exclusive breastfeeding with ICC= 28.87%. Posyandu
with ​mandiri s​ tratifica- tion increased the likelihood of exclusive breastfeeding rather than
Posyandu with ​purnama a ​ nd ​madya ​stratification.
Ministry of Health RI (2012), stated that Posyandu has two activities, namely main activities
and optional or develop- ment activities. The main activities at the posyandu include
maternal and child health, family planning, immunization, nutrition, and prevention and
control of diarrhea, while the optional or development activities include the development of
toddler families (DTF), Family Medicinal Plants (FMP), elderly family development (EFD),
and early childhood education program (ECEP). With routine activities conducted at
Posyandu, health personnel and health cadres could share information about stunting to
the community, especially to the mothers.
Posyandu activities were closely related to Posyandu strata. Nganjuk has three Posyandu
stratification namely ​madya,​ ​purnama,​ and ​mandiri​. Posyandu was stratified by activeness
of organization and program achievement level.
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