A qualitative study on barriers in the prevention of anaemia during pregnancy in public health centres: perceptions of Indonesian nurse-midwives

Strengthening midwifery in the South-East Asian region: A scoping review of midwifery-related research

Improving sexual, reproductive, maternal, newborn, and adolescent health outcomes necessitates greater commitment to, and investments in, midwifery. To identify future research priorities to advance and strengthen midwifery, we conducted a scoping review to synthesise and report areas of midwifery that have been explored in the previous 10 years in the 11 countries of the World Health Organization's South-East Asia region. Electronic peer-reviewed databases were searched for primary peer-reviewed research published in any language, published between January 2012 and December 2022 inclusive. A total of 7086 citations were screened against the review inclusion criteria. After screening and full text review, 195 sources were included. There were 94 quantitative (48.2%), 67 qualitative (34.4%) and 31 mixed methods (15.9%) studies. The majority were from Indonesia (n = 93, 47.7%), India (n = 41, 21.0%) and Bangladesh (n = 26, 13.3%). There were no sources identified from the Democratic People's Republic of Korea or the Maldives. We mapped the findings against six priority areas adapted from the 2021 State of the World's Midwifery Report and Regional Strategic Directions for Strengthening Midwifery in the South-East Asia region (2020-2024): practice or service delivery (n = 73, 37.4%), pre-service education (n = 60, 30.8%), in-service education or continuing professional development (n = 51, 26.2%), workforce management (n = 46, 23.6%), governance and regulation (n = 21, 10.8%) and leadership (n = 12, 6.2%). Most were published by authors with affiliations from the country where the research was conducted. The volume of published midwifery research reflects country-specific investment in developing a midwifery workforce, and the transition to midwifery-led care. There was variation between countries in how midwife was defined, education pathways, professional regulation, education accreditation, governance models and scope of practice. Further evaluation of the return on investment in midwifery education, regulation, deployment and retention to support strategic decision-making is recommended. Key elements of leadership requiring further exploration included career pathways, education and development needs and regulatory frameworks to support and embed effective midwifery leadership at all levels of health service governance.

Factors associated with the completion of antenatal care in Indonesia: A cross-sectional data analysis based on the 2018 Indonesian Basic Health Survey

Background

The global incidence of maternal mortality remains high, including in Indonesia, and the utilization of antenatal care services can help reduce these rates. Despite numerous studies examining factors affecting antenatal care utilization, there has been limited focus on identifying factors related to the completion of these services.

Objective

This study aimed to analyze factors associated with the completion of antenatal care in Indonesia.

Methods

The study used a cross-sectional analysis of secondary data from the Basic Health Research conducted by the Indonesian Ministry of Health in March 2018. The sample consisted of 65,929 pregnant women aged 15 to 49. Descriptive statistics, chi-square tests, and multiple logistic regression were used for data analysis.

Results

The majority of respondents (75.2%) completed antenatal care. Factors significantly correlated with antenatal care completion were education level, occupation status, health insurance ownership, place of antenatal care services, travel time to health facilities, area of residence, history of pregnancy, parity, desired pregnancy, and pregnancy complications (p <0.05). The multiple logistic regression test showed that education level was the most dominant factor associated with antenatal care completion (p <0.001, OR = 2.023, 95% CI = 1.839-2.225).

Conclusion

Completion of antenatal care is influenced by various factors, including education, job status, health insurance ownership, antenatal care services' location, travel time to health facilities, residence area, previous pregnancy history, number of children, desired pregnancy, and pregnancy complications. However, education is crucial in determining a mother's understanding and approach toward using these services. The Indonesian government should enhance public education and awareness initiatives to increase utilization. Healthcare professionals, particularly nurses and midwives, play a vital role in educating pregnant women about the significance of utilizing prenatal care services consistently and facilitating their access to these services efficiently.

Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level

BACKGROUND

In LMICs, including Indonesia, there is a rising burden of non-communicable diseases (NCDs) with a prevailing burden of infectious diseases, including among pregnant women. The Indonesian health system faces significant challenges to provide effective care for infectious diseases, and even more so, NCDs. This is concerning due to the greater vulnerability of pregnant women to complications caused by concomitant illnesses (NCDs and infectious diseases), and the need for complex, integrated healthcare between maternal care and other health services.

METHODS

The objective of this study was to understand supporting factors and challenges of the health system to providing care for concomitant illnesses in pregnancy and how it may be improved. Semi-structured interviews were conducted with sixteen key stakeholders, including health providers and health service managers, involved in maternal healthcare for concomitant illnesses at a District level in Indonesia. The study was conducted in Kutai Kartanegara District of East Kalimantan. Analysis was conducted using framework analysis to identify themes from transcripts.

RESULTS

Supporting factors of the health system to provide care for concomitant illness in pregnancy included collaboration between health providers and health services, availability of screening and diagnostic tools, and access to universal healthcare coverage and financial subsidies. Common challenges included knowledge and awareness of concomitant illnesses among health providers, competency to diagnose and/or manage concomitant illnesses, and inappropriate referrals. Suggested improvements identified to address these gaps included increasing education and refresher training for healthcare providers and strengthening referrals between primary and hospital care.

CONCLUSIONS

The findings identified gaps in the health system to provide care for concomitant illnesses in pregnancy in Indonesia that need to be strengthened. More evidence-based research is needed to guide the implementation of policy and practice interventions for the health system to deal with a broader range of concomitant illnesses in pregnancy, particularly NCDs.

Fundamental Aspects of the Development of a Model of an Integrated Health Care System for the Prevention of Iron Deficiency Anemia among Adolescent Girls: A Qualitative Study

Iron deficiency anemia (IDA) in adolescent girls is a problem that has not been resolved. This study aimed to explore the critical aspects of an integrated health care system model for preventing IDA in adolescent girls in a rural area of Indonesia. This qualitative research employed a grounded theory approach in order to build a substantive theory. This study used in-depth interviews with adolescents, parents, teachers, health workers, and persons in charge of adolescent programs at the health office, education office, and ministry of religion. Purposive sampling was performed until data saturation was achieved. Codes, categories, and themes were generated through thematic data analysis to develop a substantive theory. Data analysis was performed using MAXQDA 2022 software. A total of 41 people participated in this study. This investigation generated twenty-two categories and seven themes. These themes relate to policymaker commitments, stakeholder governance, quality, adolescents' lifestyles, adolescents' self-factors, adolescents' access to health services, and social support. The themes identified become fundamental aspects of the integrated health care system model for preventing IDA in adolescent girls. The model of the integrated health care system consists of several essential points, which include awareness and efforts from policymakers and adolescent girls, supported by parents, teachers, and the community.

Food Consumption as a Risk Factor of Anemia among Indonesian Pregnant Women: A Cross-sectional Study among Javanese Ethnic Group

BACKGROUND: Anemia during pregnancy causes several adverse effects. Furthermore, in Indonesia, this leads to restrictions among pregnant women. The information on this situation is still limited, and more research needs to be conducted. AIM: Therefore, this study aims to investigate the association between food consumption and anemia among pregnant women. METHODS: This is a cross-sectional descriptive research that involved 424 pregnant women. Furthermore, written informed consent was obtained from respondents before data collection. A self-administered questionnaire was used to assess the food consumption and demographic data. Hemoglobin concentration was further measured using a haemoglobinometer, and data were analyzed using a descriptive statistical Chi-square, and a Multiple Logistic Regression test. RESULTS: It was found that half of the respondents suffered from anemia (46.5%). Furthermore, the Multiple Logistic Regression test showed that tea, liver, eggs, and iron consumption with values of (odds ratio [OR] = 5.075, p < 0.001), (OR = 4.128, p < 0.001), (OR = 3.590, p < 0.01), and (OR = 3.837, p < 0.05), respectively, had significant correlations with anemia among pregnant women. CONCLUSIONS: Anemia is commonly experienced by Indonesian pregnant women. Therefore, health-care providers should focus on preventing anemia in pregnant women by reducing their tea intake and increasing the consumption of iron-rich foods or supplements.

Incidence of concomitant illnesses in pregnancy in Indonesia: Estimates from 1990-2019, with projections to 2030

Background

‘Indirect’ causes of maternal death including concomitant illnesses such as infectious and non-communicable diseases (NCDs), accounted for 23% of maternal deaths in Indonesia in 2010. Reproductive-age women in Indonesia face a “double burden” of disease with increasing rates of NCDs and persisting rates of infectious disease. However, there is a lack of data on the burden of these diseases in pregnancy. The aim of this study was to estimate incidence of concomitant illnesses among pregnant women in Indonesia from 1990–2030.

Methods

Publicly available data was accessed including incidence of concomitant illnesses in Indonesian reproductive-age women, population data and crude birth rate data from 1990–2019, and formed basis for projections to 2030. A dataset of estimates for all variables was generated for each year and sampled from a binomial distribution. Using these estimates, pregnancy estimates and incidence in pregnant women were calculated. A cubic splines model was fitted to generate estimates of incidence of concomitant illnesses in pregnancy.

Findings

Past trends to 2019 show a decline in incident cases of infectious diseases except for HIV/AIDs, and an increase in most NCDs. In 2019, the most common disease was sexually transmitted infections. From 2020–2030, incidences of diabetes and lower respiratory infections are estimated to continue to increase.

Interpretation

With an increasing incidence of NCDs and high-incidence of infectious diseases in pregnancy, Indonesian policymakers and stakeholders should consider what evidence-based strategies and interventions are best to reduce potential impacts of concomitant illnesses on pregnancy outcomes.

Funding

Australian Government Research Training Program Scholarship.

Maternal Knowledge Associated with the Prevalence of Iron and Folic Acid Supplementation Among Pregnant Women in Muntinlupa, Philippines: A Cross-Sectional Study

PURPOSE

The World Health Organization advocates that all pregnant women in areas where anemia is prevalent receive supplements of iron and folic acid. However, owing to a myriad of factors, the uptake of iron and folic acid supplementation (IFAS) is still low in many countries. Therefore, this study was conducted to assess the prevalence of IFAS and its associated factors among pregnant women.

PATIENTS AND METHODS

A cross-sectional study was conducted at a hospital in Muntinlupa, Philippines, between March and August 2019 among 280 pregnant women. A systematic random sampling technique was used to select participants. Data were collected using interviewer-administered questionnaires. Multivariable logistic regression analyses were employed to identify factors associated with the prevalence of IFAS among pregnant women.

RESULTS

Among 280 pregnant women, a majority (85.6%, n= 238) took IFAS during pregnancy. Among the respondents, 128 (45.9%) women had knowledge about signs and symptoms of anemia, 126 (45.3%) had knowledge of the benefits associated with IFAS, and 42 (15.4%) had knowledge about side effects associated with IFAS. The main sources of information about IFAS were health care providers (41.8%), followed by community health workers (CHWs) (14.6%). Maternal knowledge concerning IFAS benefits (OR = 2.50, CI = 1.04-5.97, p=0.04) was positively associated with the prevalence of IFAS.

CONCLUSION

Maternal knowledge about the benefits of taking IFAS was significantly associated with the prevalence of IFAS among pregnant women in Muntinlupa, Philippines. There is a pressing need to improve health education on the benefits of IFAS among pregnant women to increase its prevalence. This emphasizes the necessity of increased involvement of health care providers and CHWs to increase women's knowledge of IFAS benefits and support them through pregnancy.

Indonesian antenatal nutrition education: A qualitative study of healthcare professional views

BACKGROUND

Early lifestyle intervention, including antenatal nutrition education, is required to reduce the triple burden of malnutrition. Understanding healthcare professionals' views and experiences is essential for improving future nutrition education programmes for Indonesian pregnant women. This study aimed to investigate the views of Indonesian antenatal healthcare professionals regarding nutrition education for pregnant women and the improvements required to provide more effective antenatal nutrition education.

METHODS

A descriptive qualitative study involved semi-structured interviews was conducted with 24 healthcare professionals, including nutritionists (n = 10), midwives (n = 9) and obstetricians (n = 5) in Malang, Indonesia, between December 2018 and January 2019. Data were analysed using thematic analysis.

RESULTS

The study identified four main themes. First, healthcare professionals were aware of the importance of providing antenatal nutrition education, which included supporting its targeted delivery. Second, there were differing views on who should provide nutrition education. Most midwives and obstetricians viewed nutritionists as the prime nutrition education provider. Nutritionists were confident in their capability to provide nutrition education. However, some nutritionists reported that only a few women visited primary health centres and received nutrition counselling via this pathway. Third, healthcare professionals revealed some barriers in providing education for women. These barriers included a limited number of nutritionists, lack of consistent guidelines, lack of healthcare professionals' nutrition knowledge and lack of time during antenatal care services. Fourth, participants expressed the need to strengthen some system elements, including reinforcing collaboration, developing guidelines, and enhancing capacity building to improve future antenatal nutrition education.

CONCLUSIONS

Healthcare professionals play a central role in the provision of antenatal nutrition education. This study highlighted the importance of educational models that incorporate various antenatal nutrition education delivery strategies. These methods include maximizing referral systems and optimizing education through multiple delivery methods, from digital modes to traditional face-to-face nutrition education in pregnancy classes and community-based health services.

Barriers to Health Workers in Iron Deficiency Anemia Prevention among Indonesian Pregnant Women

Background

Anemia is a global maternal health problem that commonly occurs in developing countries. During pregnancy, a woman will receive antenatal services to check her condition and prevent complications. This study aimed to explore barriers towards achieving eradication of iron deficiency anemia among pregnant women in Aceh Besar District, Indonesia.

Methods

This qualitative study was conducted on 18 health workers who were recruited through a purposive sampling method. Data were collected through in-depth interviews using open-ended questions to gain insight about participants' experiences in managing iron deficiency anemia among pregnant women. Data analysis was conducted by an inductive content analysis method to evaluate, encode, and analyze the interview's result.

Result

Three main themes emerged: (1) facilities, infrastructures, and supplement support; (2) sociocultural factors; and (3) health provider competency deficits and no developing guidelines.

Conclusion

Our findings provide understanding that there are many obstacles and barriers encountered by health workers in iron deficiency anemia prevention management. Thus, the management of anemia must be supported by a skilled health worker and quality facilities. Health workers and pregnant women must work together to achieve optimal management of anemia prevention.

Perception of childbirth experiences of Japanese women in Bali, Indonesia: a qualitative study

Background

Maternal healthcare services in Indonesia have seen dramatic improvements over the past 25 years and yet there is still room for improvement. The perception, by the women, of the perinatal care provided, is a vital input to further improving these services. This study examines how the perinatal care provided is experienced by Japanese women in Bali, using an interview survey.

Methods

We conducted semi-structured interviews, from August to October 2017, with 14 Japanese women living in Badung Regency and Denpasar City in Bali Province, Indonesia to report their perception of the perinatal care they experienced during their pregnancies. The interview guide included among others, the reasons for choosing specific (perinatal care) health facilities and their satisfaction with their experience of using the antenatal, delivery, and postnatal care services. The data were analysed using the qualitative content analysis method.

Results

From the interview data, 12 categories across five themes were extracted. Participants reported experiencing various concerns during their pregnancies such as difficulty in obtaining perinatal care related information. From the beginning of their pregnancies, participants gradually established trusting relationships with midwives, but in many situations, they were disappointed with their childbirth experiences, as they felt that the care provided was not woman-centred. Through their own efforts and with the support of family members and other Japanese residents, many women were able to eventually regard their childbirth experiences as positive. Nevertheless, some women could not overcome their negative impressions even years after childbirth.

Conclusions

Participants desired close attention and encouragement from nurses and midwives. Our results suggest that Japanese women in Bali expected a woman-centred perinatal care and active support from nursing/midwifery staff during their pregnancies and postnatal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03466-x.

Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage

BACKGROUND

Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy.

METHODS

Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role.

RESULTS

We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps.

CONCLUSIONS

Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

Animal-based food taboos during pregnancy and the postpartum period of Southeast Asian women - A review of literature

This paper gives an overview of the various taboos on animal products and the reasons behind such practices among women in the member countries of the Association of Southeast Asian Nations (ASEAN), while they are pregnant, during their postpartum period, and while breastfeeding. Three data search engines, Google® Scholar, PubMed and Scopus, were used one after the other, to generate the papers for this review. The online searches using the term food taboo, its synonyms, and truncations, in combination with the terms pregnancy, postpartum, and breastfeeding, and with the country name, were conducted from January to February 2017. In total, 28 papers were pooled and included in this review. The taboos and the justification for avoidance were collated and grouped per their occurrence, and according to the country where they are practiced. Nine papers provided information on the food taboos during pregnancy, 16 on postpartum food taboos, and six on breastfeeding. The food taboos included various river or seafood, meat from terrestrial animals, and derived products like fish paste, blood and internal organs. Healthcare providers should be aware of the food taboos being adhered to in the region to provide the right information and guidance to the women practicing them. There is a need to educate the public in general, and women, in particular, about the risk of malnutrition when food taboos are followed, and to support their nutritional requirements during pregnancy and the postpartum period by promoting dietary diversification. More research could be conducted to fill in the gap in information with regards to the food taboos and their impact in some of the ASEAN members. Culture-sensitive health interventions based on timely research work can contribute to the attainment of the sustainable development goal of reducing the maternal and under-five mortality ratios in Southeast Asia.

Plant-based food taboos in pregnancy and the postpartum period in Southeast Asia – a systematic review of literature

Purpose

Food taboos during pregnancy and the postpartum period have been linked to increased risk of maternal and neonatal death. This paper aims to present plant-based food restrictions on Southeast Asian women during pregnancy and after giving birth and the rationale behind such cultural practices.

Design/methodology/approach

Google® Scholar, PubMed and Scopus search using the term food taboo, its synonyms and truncations, in combination with the terms pregnancy, postpartum and breastfeeding, and with the name of the Southeast Asian countries, was conducted from January to February 2017. Articles were included in the review if their full texts were accessible online, in English, published from 2005 to 2016 and if they contained primary data from either quantitative or qualitative method.

Findings

A total of 281 articles were downloaded, and 28 were included in this review. The food taboos and the reasons for avoidance were collated and grouped per their occurrence and according to the country or countries where they are practiced. In total, 14 papers generated data on food taboos during pregnancy, 16 papers on postpartum food taboos and/or 6 on breastfeeding.

Research limitations/implications

This review pools together relevant information about plant-based food taboos Southeast Asian women adhere to during pregnancy and after giving birth. However, data are absent for some of the Association of Southeast Asian Nations (ASEAN) countries, and there is a need for more research to get up-to-date information on the local women’s adherence to these cultural practices.

Practical implication

The knowledge of these practices can support stakeholders who are contributing to the reduction of maternal and under-five mortality ratios in Southeast Asia.

Originality/value

This is the first review paper on food taboos covering all ASEAN members and highlighting the need for cultural sensitivity to properly address maternal and child health problems in the region.

Community midwives' acceptability in their communities: A qualitative study from two provinces of Pakistan

OBJECTIVES

this study was aimed to understand in depth how the community midwives (CMWs) in Pakistan perceive are the important factors for their acceptability and community related barriers to their practice of maternal and child health care services.

DESIGN

qualitative study design using in-depth interviews (IDIs) and focus group discussions (FGDs).

SETTING

two districts in Khyber Pakhtunkhwa and Punjab provinces in Pakistan.

PARTICIPANTS

we used qualitative study design and conducted 34 in depth interviews (IDIs) and 9 focus group discussions (FGDs) with 100 participants which included CMWs, lady health supervisors (LHSs) and managers in maternal neonatal and child health (MNCH) program of two provinces of Pakistan.

MEASUREMENTS

content analysis of the findings was performed manually and findings were arranged in relevant themes originating from the study.

FINDINGS

CMWs in our study experienced restrictions from their families, especially husbands and in-laws, to be independently available to attend to women during pregnancy and delivery. Communication between the communities and MNCH program was found to be weak therefore CMWs had to struggle to win the trust of and persuade pregnant women to use their services. Most CMWs attributed low utilization of their services to inherent taboos prevalent in the communities under which they relied more on unskilled traditional birth attendants (TBAs). Gender sensitivity and fears of insecurity in many conflict hit areas affected CMWs' mobility within their own communities which affected the access of rural women to skilled maternal and child care.

Prevalence and Sociodemographic and Lifestyle Determinants of Anemia during Pregnancy: A Cross-Sectional Study of Pregnant Women in China

OBJECTIVE

This study aimed to assess the differences regarding anemia among pregnant women with diverse characteristics and lifestyle factors.

METHODS

A cross-sectional study of pregnant women was conducted between June and August 2015 in 16 hospitals in five provinces of Mainland China. Self-reported doctor-diagnosed anemia was used in the study.

RESULTS

We included 2345 pregnant women. Of the participants, 1755 (74.8%) were pregnant women of first pregnancy (PWFP) and 590 (25.2%) were second pregnancy (PWSP). The mean age of the participants was 28.1 years (SD 4.1). Overall, the prevalence of anemia was 12.7% (13.4% and 10.7% among PWFP and PWSP, respectively). The prevalence for not eating breakfast was 11.0%. Compared with PWFP, PWSP was inversely associated with the risk of anemia (odds ratio (OR) 0.66, 95% CI 0.48-0.91). Compared with those being registered in a low ranking hospital, pregnant women who were admitted to a high (OR 0.40, 95% CI 0.28-0.57) or a medium ranking hospital (OR 0.58, 95% CI 0.37-0.92) were inversely associated with the risk of anemia. Compared with women of low income (<¥4,500), those with high income were less likely to have anemia (OR 0.68, 95% CI 0.50-0.94). Compared with women with non-manual jobs, women with manual jobs (OR 1.70, 95% CI 1.17-2.45) and unemployed women (OR 1.42, 95% CI 1.04-1.93) were associated with a greater likelihood of suffering from anemia.

CONCLUSIONS

Pregnant women not eating breakfast are of concern. Anemia is highly prevalent among pregnant women in China. Lower socio-economic status, manual jobs, PWFP, and those who attend a lower quality hospital have a greater likelihood of suffering from anemia. Tailored interventions are needed to address these issues.

Perceived Barriers and Facilitators of a New Model in Managing Pregnant Women With Iron Deficiency Anemia: A Qualitative Study

A new model of antenatal care to manage pregnant women with iron deficiency anemia at public health centers in Indonesia has been studied. This study aimed to explore the facilitators and the barriers of this new model introduction by using focus group discussions to nurse-midwives and nurse-midwife coordinators. Training and information booklets, the improved confidence in providing comprehensive care, and adequate support from supervisors were perceived as facilitators of the new model. Financial support and public transportation necessary to reach the optimum treatment according to the new model, limited health insurance coverage, and shortage of staff and iron tablets were the barriers. Similar barriers should be anticipated for further implementation. A lasting support of policy and decision makers therefore is essential.