Berita Kedokteran Masyarakat Volume x Nomor xx

(BKM Journal of Community Medicine and Public Health) Halaman xx-xx

ANEMIA FREE AND ANTENATAL CARE SERVICES IN

STUNTING PREVENTION
Afrina Mizawati1* , Nursyirwan Effendi2 , Delmi Sulastri3 , Rozi Sastra Purna4
(1 Departemen of Midwifery, Poltekkes Kemenkes Bengkulu; 1 Faculty of Medicine,
Doctoral Programme of Public Health, Universitas Andalas, Padang, Indonesia;
2
Faculty of Social and Political Science, Department of Social and Political Science,
Universitas Andalas, Padang, Indonesia; 3 Faculty of Medicine, Department of
Nutrition, Universitas Andalas, Padang, Indonesia; 4 Faculty of Medicine, Department
of Psychology, Universitas Andalas, Padang, Indonesia)

Abstract
Purpose: the purpose of this study was to evaluate the effectiveness of
interventions targeting anemia prevention and antenatal care (ANC) to reduce
the risk of stunting in children.
Method: a comprehensive search will be conducted in electronic databases to
identify investigating the impact of anemia prevention strategies on child
stunting. Studies will be included if they assess interventions in women focusing
dikirim: on iron supplementation, nutrition counseling, or a combination of both, and
diterbitkan:
report child stunting as an outcome measure.
Results: Anemia prevention is very effective in improving children's growth
outcomes, thus contributing to knowledge and ways of treating anemia in the
preconception and antenatal period in reducing the prevalence of stunting.
Conclusion: The importance of comprehensive interventions in improving the
health and well-being of future generations. Implementing health policies that
integrate blood supplementation interventions, nutrition education, and
quality antenatal care is highly recommended to ensure the creation of a
healthier and more qualified generation in the future
Keywords: Anemia; Antenatal Care; Stunting; Prevention

INTRODUCTION
Stunting is a chronic nutritional problem in toddlers developing countries. Stunting is a health problem because it is
which is characterized by shorter height compared to children of associated with the risk of morbidity and death, suboptimal brain
the same age. Children who suffer from stunting will be more development, resulting in delayed motor development and
susceptible to disease and when they become adults are at risk stunted mental growth. Globally, around 150.8 million children
of developing degenerative diseases. The impact of stunting is under five experience stunting problems. The data shows that
not only in terms of health but also affects the level of 55% of children under five in Asia are stunted, while the data on
intelligence of children (1)(2). The problem of stunting is a the prevalence of stunting under five collected by the World
nutritional problem facing the world, especially in poor and Health Organization (WHO), Indonesia is included in the third

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country with the highest prevalence in the South-East Asia affected if their mother is malnourished8 . Antenatal Care (ANC)
Regional (SEAR) (3). The average prevalence of stunting under is a health service provided by health workers for mothers during
five in Indonesia in 2005-2017 was 36.4% and in 2018 the pregnancy and carried out in accordance with the service
national prevalence of stunting was recorded at 30.8% and in standards set out in the Midwifery Service Standards (SPK) to
2019 it became 27.67% (2). detect the risk of pregnancy complications. ANC indicators that
Stunting, a form of chronic undernutrition manifested are in accordance with the MDGs are K1 (ANC at least once) and
by impaired linear growth and development, is closely ANC at least four times, and ANC indicators for evaluating
intertwined with anemia and often occurs concurrently in low- maternal health service programs in Indonesia are ideal
resource settings (4). Addressing stunting requires a coverage of K1 and K4 .(1) Care during pregnancy is very
comprehensive approach that encompasses both preconception important to note in order to prevent complications during
and postnatal periods. Anemia, a prevalent condition pregnancy and childbirth and to maintain the health of the fetus.
characterized by iron deficiency, is a significant risk factor for But in reality, people's behavior, especially in Indonesia, there
stunting in both prospective brides and pregnant women. are still many mothers who consider pregnancy as normal,
Anemia during pregnancy is a major public health concern, natural and natural. They feel that they do not need to routinely
affecting an estimated 27-32% of pregnant women globally [4]. check their pregnancies to health services, which in turn causes
This condition can lead to severe complications for both mothers the risk factors that may be experienced by the mother cannot
and babies, including preterm birth, low birth weight, and be detected early10. A study stated that mothers who had less
increased maternal mortality [5]. than three antenatal care and did not check their pregnancies
The prevalence of anemia among adolescent girls and with doctors, nurses or midwives could have a risk of stunting in
pregnant women in developing countries is alarmingly high, their children. ANC visits that are carried out regularly can detect
ranging from 15% to over 50% (5)(6).This is particularly early pregnancy risks that exist in a mother and her fetus,
concerning as anemia during pregnancy can lead to adverse especially those related to nutritional problems. (9)
outcomes for both the mother and the developing fetus, Stunting needs special attention and care from a
including increased risk of morbidity, mortality, postpartum variety of entities, including the government and families, as it is
hemorrhage, preterm birth, and low birth weight. Additionally, a national health concern. In light of these circumstances, Budi
maternal anemia has been shown to have a direct impact on the Gunadi Sadikin, the Republic of Indonesia's Minister of Health,
nutritional status of children, highlighting the importance of announced that three measures are being made to avoid
addressing this issue through comprehensive antenatal care stunting, which begins in the pre-pregnancy phase for women.
services (5)(7). Minister Budi Gunadi Sadikin stated that the Ministry of Health
ANC plays a crucial role in identifying and managing is responsible for bringing the stunting rate down from 24% to
anemia among pregnant women. ANC programs provide an 14% by 2024 during his remarks at the MURI Balanced Nutrition
opportunity for anemia screening, iron supplementation, and and Record Breaking Campaign event on Thursday, August 11,
nutrition counseling, which can effectively prevent and treat 2022. The intervention will therefore concentrate on mothers
anemia [6]. According to the 2018 basic health research before childbirth as a preventive (10).
(RISKESDAS), a study was conducted on ANC visits to pregnant Anemia affects not just young women but also
women and a comparison was made between 2013 and 2018, expectant mothers. It can stunt fetal development, result in an
that of all provinces in Indonesia the lowest percentage of ANC early birth, and compromise the health of the unborn child due
visits was on Papua Island, namely 71.7%. If it is divided to low iron stores. It can also become dangerous after childbirth.
according to the ANC examination at visit 1 (K1) and visit 4 (K4), mother, like passing out or even dying. One of the nutritional
the lowest percentage of K1 is in Southeast Sulawesi province, issues that toddlers face is stunting. Early-onset dietary issues
namely by 67% in 2013 while in 2018 it decreased by 3.5%. And are the cause of developmental delays in young children. A
the lowest K4 percentage was in the province of Papua, which nutrition journal reveals that genetic triggers from parents with
was 43.8% in 2013 while there was no definite data for 2018. (8) a history of anemia as well as a history of anemia during
Factors causing stunting according to WHO are pregnancy are risk factors for stunting. (11)
comprehensively broken down into factors direct and indirect.
The cause of stunting is a number of factors, both from parents,
METHODE
child factors, and household environmental factors. Parents
have a very important role in paying attention to children's Literature review is a description of theories, findings
development and supporting efforts to overcome nutritional and other research articles obtained from reference materials to
problems in children. Preventing malnutrition in children starts be used as the basis for research activities. Literature review can
with the mother. Mother's health is very important for the future be used to develop a clear frame of mind from the formulation of
the problem to be studied. Literature review can also be said as an
health of her child. The development of a child in the womb is

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analysis in the form of criticism from research that is being carried available in full-text form. Then the selection of articles through
out on specific topics in science. Literature review contains titles, abstracts, to full text is carried out according to the research
reviews, summaries, and the author's thoughts on several library objectives.
sources.
The inclusion criteria were research articles published in
journals within the last five years (2018-2023), in English and

RESULTS
Based on a search using predetermined keywords within screening for anemia prevention strategies and antenatalcare
the 2017-2023 publication period, 144 articles were found on services for stunting prevention. In the end, got.

Research identification using a database

Identification

Literature excluded before screening

Identification of literature through: because fulltext was not accessible (n
PubMed (n = 144 ) = 10)
Screening

Literature taken Literature excluded after screening of

(n = 134) titles and abstracts (n = 98)

Literature taken
(n = 36) Literature excluded after screening
of titles and abstracts (n =26)
Includ

Literature reviewed in the research

ed

(n = 10)

Figure 1. Flowchart of the literature selection process.

A review of the contents of the literature was then carried out detailed information from each of these literature can be seen in
on ten selected literatures, to find out the anemia prevention and table 1.
antenatal care instruments used and the results obtained. More

Table 1. Review of the contents of the literature

No Research Title Research purposes Method Sample Results
1 The effect of giving The study aimed to Quasi eksperimen The study involved The findings support the
blood supplement assess the impact 20 female junior importance of interventions like
tablets to adolescent of providing blood high school providing blood supplement
girls on increasing supplement tablets students in Cirebon tablets to prevent anemia,
haemoglobin levels to adolescent girls District who had promote healthy hemoglobin
in Cirebon District to on increasing experienced levels, and contribute to the overall
prevent stunting and hemoglobin levels menstruation and well-being of adolescent girls in
develop a quality to determine if were selected to Cirebon District. By addressing
generation in they were anemic receive the blood anemia and improving hemoglobin
Cirebon District or not . supplement tablets levels in adolescent girls, the study
The goal was to for the contributes to efforts aimed at
emphasize the intervention preventing stunting and fostering
importance of the development of a healthy and

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maintaining quality generation in Cirebon

anemia-free District for the future (12).
adolescents to
prevent stunting
and promote the
birth of healthy
generations in
Cirebon District.
2 An investment The research Quasi eksperimen The sample The Si NaNing application was
framework for objectives include consisted of 30 found to increase knowledge,
nutrition : reaching determining the pregnant women attitudes, and motivation to
the global targets for effectiveness of the from Independent prevent anemia and stunting,
stunting, anemia, "No Anemia No Practice of suggesting the need for further
breastfeeding, and Stunting" (Si Midwives in development and enhancement of
wasting NaNing) Tanjungpinang City the application (13).
application and .
module on stunting
prevention
3 Prevention of Evaluate the Quasi eksperimen All pregnant Provision of nutrition education for
Stunting through effectiveness of women attending pregnant women can effectively
Improving Maternal nutrition education classes at enhance their understanding of
Puskesmas stunting prevention, potentially
Parenting and Early in increasing Sidomulyo leading to improved health
Detection of knowledge about outcomes for both mothers and
Pregnancy Risk stunting infants (14).
Factors prevention among
pregnant women
at Puskesmas
Sidomulyo
4 The Influence of Pre- Investigate the Descriptive Include brides and pre-marriage classes play a crucial
Marriage Class on impact of pre- research design grooms attending role in educating brides and
Knowledge of Bride marriage classes on pre-marriage grooms about stunting prevention,
classes potentially contributing to
and Groom in the knowledge of improved health outcomes for
Prevention of brides and grooms future children (15).
Stunting Toddlers regarding the
prevention of
stunting in toddlers
.
5 Antenatal Care Visits This study aims to Cross sectional 174 mothers who There is a relationship between
With Incidence Of determine the have children aged antenatal care visits and the
Stunting In Children relationship 24-36 months incidence of stunting in children
Aged 24–36 Months between antenatal aged 24–36 months in Kec.
care visits and the Cigandamekar Kab. Brass year
2020 with a p-value = 0.000 (16)
incidence of stunting
in children aged 24–
36 months in Kec.
Cigandamekar Kab.
Kuningan
6 Antenatal Care Visits To identify the Cross sectional 100 children aged The results showed that there was
Associated with relationship 2-5 years who are a significant relationship between
Stunting Incidents between antenatal stunted antenatal care visits and the
care visits in incidence of stunting with a p
check their value of 0.000.
pregnancy with (p<0.05). With the closeness of the
health workers with relationship being marked by a
stunting incidents in correlation coefficient value of (r)
Kulon Progo Regency = 0.389 (17)
7 Quality & Quantity of This study aims to cross sectional 98 The results showed that there was
Antenatal Care (ANC) determine the a significant relationship between
History Visits with quality & quality ANC quality (p-value = 0.004) and
Stunting Toddler Age relationship
24-59 Months in ANC quantity (p-value
between history of = 0.003) with stunting (18)
Pujon District, ANC visits and
Malang Regency
stunting in toddlers
aged 24-59 years in
Pujon District,
Malang Regency
8 Description Of The purpose of this Descriptive 37 samples The results showed that of the 37
Antenatal Services In study was to find out children's height, the highest were
Stunting Children the description of very short, 21 people (56.8%) and
antenatal care for the lowest were short, namely 16

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stunting toddlers at people (43.2%). All stunted

the Karuwisi Health hildren get an examination weight,
Center Makassar city height, pressure blood, LILA,
uterine fundal height, TT
immunization, blood supplement
tablets, fetal heart rate, test
laboratory, and administration
communication, information and
education (19)
9 The Relationship Of The purpose of this Cross-sectional 100 The quality of antenatal care that
Antenatal Care To study was to is significantly related to the
Stunting Incidence In describe the incidence of stunting includes the
Toddlers Aged 24-59 relationship between frequency of antenatal care visits
Month the quality of ANC and the standard of antenatal care
and the incidence of services, but the quality of
stunting in toddlers antenatal care is not significantly
aged 24-59 months related to the incidence of
at stunting, namely (20)
10 Affecting Factors of The aim is to Case contol 128 There is a relationship between
Stunting Incidences determine the ANC (Antenatal Care) visits and
among Children relationship between the incidence of stunting in
Aged 12-59 Months antenatal care visits children aged 12-59 months
in West Nusa and the incidence of involving extraneous variables
Tenggara Province stunting in children such as mother's age at
Indonesia. aged 12-59 months pregnancy, family income level,
in North Lombok birth weight and body length (OR
Regency, West Nusa 2.13 (95% CI: 1.012 -4,494)).(21)
Tenggara Province,
Indonesia in 2016, by
involving foreign
variables such as the
mother's age at
pregnancy and the
mother's age at
pregnancy. family
income level

stunting prevention is not only beneficial for immediate

DISCUSSION health outcomes but also promotes long-term

Efforts to reduce stunting have profound social sustainability by creating a positive feedback loop where

impacts, extending beyond individual health to encompass improved health and productivity reinforce each other,

broader societal benefits. Addressing stunting can leading to sustained societal well-being and development

significantly boost economic development by improving (25).

cognitive development and physical health, which Efforts that will be carried out by public health in

enhances educational outcomes and workforce Indonesia to prevent stunting, including Conducting

productivity, thereby contributing to overall economic pregnancy checks, and providing supplementary food to

growth (22). Moreover, reducing stunting can lead to pregnant women to provide adequate nutrition and iron

substantial public health improvements by decreasing content in pregnant women; the stunting prevention

susceptibility to chronic diseases, thus lowering healthcare efforts mentioned above are urgent programs to

costs and enhancing population health (23). implement. So that with these efforts, it is expected to be

It also promotes social equality by tackling the able to have a good impact on reducing stunting rates in

socio-economic disparities that often underlie stunting, Indonesia. (26)(27)

fostering more equitable opportunities for children from Providing regular blood supplement tablets to 20

diverse backgrounds and helping to break the cycle of womens who were menstruating succeeded in increasing

poverty. Additionally, healthier children are more likely to hemoglobin levels, preventing anemia, and potentially

perform better academically and continue their education, reducing the risk of stunting in their offspring. These

contributing to a more educated and skilled workforce, findings emphasize the importance of blood

essential for national development (24). Investing in supplementation interventions as an effort to prevent
anemia and stunting from adolescence (28).

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Nutrition education for pregnant women effectively factor the risk of stunting whose value is not influenced by
increases their knowledge about stunting prevention, other variables. The study stated that access to ANC is
which has the potential to improve maternal and infant related to the incidence of stunting in children. It was found
health. Proper nutrition education helps pregnant women that access to antenatal care had a significant effect on
understand the importance of balanced nutritional intake reducing malnutrition in Colombia and Peru. However, in
during pregnancy to prevent stunting in their children. This Bolivia, research results state that there is no relationship
confirms that interventions that provide comprehensive between ANC and stunting. Differences in outcomes in
and practical information about nutrition are very these countries can be seen from the quality of antenatal
necessary (29). care.(31)
Regular and high-quality ANC visits are associated ANC visits during pregnancy that are carried out by
with a lower incidence of stunting in children. The quality a mother regularly can detect early risks of pregnancy,
and frequency of ANC visits plays an important role in especially those related to nutritional problems. Every
preventing stunting (Rahmawati, Utami, & Setiawan, 2021). pregnancy in its development has a risk of experiencing
Therefore, access and quality of ANC services must complications / complications. So according to the
continue to be improved to achieve optimal health standard, ANC must be carried out routinely in order to get
outcomes (28). quality antenatal care. Pregnant women who make ANC
The prevention and management of anemia during visits at least four times during the pregnancy period have
pregnancy and the provision of comprehensive antenatal the advantage of being able to detect early risks of
care services are essential components in the fight against pregnancy, prepare the delivery process for good birth and
stunting and malnutrition. By addressing the underlying maternal health, continue until the lactation and
causes of anemia, such as iron deficiency or folate puerperium. (32)
deficiency, and providing targeted interventions like iron ANC examination is very important for maternal
supplementation, healthcare providers can work to and fetal health that maternal and fetal mortality can be
improve the overall health and well-being of mothers by reduced with regular antenatal care (ANC) checks, because
reducing maternal mortality rates associated with severe every visit from K1 to K4 is an indicator to see the quality of
anemia-related complications while also benefiting their health services for pregnant women.(1)
children through a reduced risk of low birth weight or Quality examination for pregnant women will
preterm birth (30). prevent complications or defects in the mother and fetus
The ANC quality standards in the 2010 Integrated early, so that it can be a factor in preventing stunting in
Antenatal Service Manual are weighing, measuring upper children. This is in accordance with research that says
arm circumference (LILA), measuring blood pressure, antenatal care is to prevent obstetric complications
measuring uterine fundal height, calculating fetal heart rate whenever possible and ensure that complications are
(DJJ), determining fetal presentation, administering TT detected as early as possible and handled adequately. If the
immunization, administering blood supplement tablets antenatal care examination does not meet service
(iron tablets), laboratory examinations (routine and standards, then the welfare of the mother and fetus is not
special), case management and effective IEC. It is properly monitored so that there is a risk of having a stunted
categorized according to the standard if the "11T" above is child.(33)
carried out during pregnancy or during a pregnancy visit This research is also supported by research from
and not according to the standard if it is not carried out in Amini (2016) which states that mothers who make non-
its entirety. The implementation of ANC services is standard ANC visits have a 2.4 times the risk of having
influenced by several factors such as ANC service facilities stunting toddlers compared to mothers who make standard
and infrastructure, ANC service processes, midwives' ANC visits 15. In pregnant women examinations or ANC
compliance with ANC service standards and recording visits there is 10T as a standard examinations that are
devices or notebooks. Research conducted in three Latin mandatory for pregnant women, with quality 10T
American countries explains that ANC can be used as a examinations can be an early detection of complications in

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pregnant women to refer or treat pregnancy problems

CONLUSION
early.
A comprehensive approach is highly effective in improving the
The process of stunting is a long process, beginning
health and well-being of future generations. Giving blood
with failure to thrive both during pregnancy and after birth
supplement tablets to young women significantly increases
in the first two to three years of life. Thus examination at
hemoglobin levels and prevents anemia, which in turn can
Antenatal Care (ANC) is an important factor to prevent reduce the risk of stunting in their children in the future (Utami,
stunting. According to the Ministry of Health (2016), 10T of Puspitasari, & Anjani, 2023). In addition, nutrition education for
pregnancy checks consists of: measuring mother's height, pregnant women through applications such as "Si NaNing" as
measuring LILA, weighing mother's weight and measuring well as nutrition classes in health facilities effectively increases
mothers' knowledge and motivation to maintain their health
blood pressure, measuring TFU, calculating fetal heart rate,
and that of the fetus, thus contributing to the prevention of
TT immunization status, giving Fe tablets, lab tests,
stunting (Saraswati & Handayani, 2022; Setiawan , 2022). The
counseling, management / and medication. This 10T quality and frequency of antenatal care (ANC) visits have also
examination is an examination that must be given to been shown to be very important in reducing the incidence of
pregnant women for early detection in pregnant women so stunting in children. Regular, high-quality ANC visits ensure that
that they can be handled more if there are problems. pregnant women receive comprehensive health checks and
adequate nutritional information, which are essential for
Monitoring maternal nutrition during examinations of
healthy fetal development (Rahmawati, Utami, & Setiawan,
pregnant women or during antenatal care (ANC) visits is very
2021; Sari & Yuniarti, 2023). Apart from that, pre-wedding
important for the development of pregnancy and maternal
classes which provide education to prospective brides and
health, the fetus will experience growth and development grooms regarding the importance of nutrition and health during
very fast and what the mother consumes will affect the pregnancy and the early stages of a child's life also play a
baby's taste preferences for certain foods through the significant role in preventing stunting (Nugroho, 2023).
amniotic fluid so the quality of food, the rate of weight gain, Therefore, implementing health policies that integrate blood
supplementation interventions, nutritional education, and
the mother's health and lifestyle can affect the future of a
quality antenatal care is highly recommended to ensure the
child.
creation of a healthier and more qualified generation in the
future.

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