Kesmas

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TABLE OF CONTENT

Antenatal Care Provider and Cesarean Section in Urban Areas in Indonesia... 101-106 Terry Yuliana Rahadian Pristya, Milla Herdayanti, Besral, Dheni Fidyah Fika

Early Initiation of Breastfeeding and Vitamin A Supplementation with Nutritional Status

of Children Aged 6-59 Months... 107-113 Betty Yosephin Simanjuntak, Miratul Haya, Desri Suryani, Che An Ahmad

Family Support as a Factor Influencing the Provision of Exclusive Breastfeeding among Adolescent

Mothers in Bantul, Yogyakarta... 114-119 Maulida Lailatussu’da, Niken Meilani, Nanik Setiyawati, Sammy Onyapidi Barasa

Risk of Adolescent Pregnancy toward Maternal and Infant Health in Indonesia... 120-126 Anni Fithriyatul Mas’udah, Besral, Brimandra Adiputra Djaafara

Nutrition Counseling toward Knowledge and Attitude of Breastfeeding Mothers and Infant Growth

in Lubuk Pakam Subdistrict...127-133 Herta Masthalina, Zein Agustina

Exclusive Breastfeeding Intention among Pregnant Women... 134-141 Tria Astika Endah Permatasari, Ratu Ayu Dewi Sartika, Endang Laksminingsih Achadi,

Urip Purwono, Anies Irawati, Dwiana Ocviyanti, Evi Martha

The Risk Quotient of Sulfide Hydrogen toward Lung Vital Capacity of People Living Around

Landfill Area..... 142-147 Mohammad Zulkarnain, Rostika Flora, Novrikasari, Toto Harto, Dwi Apriani, Novita Adela

The Effect of Health Insurance on Institutional Delivery in Indonesia...148-152 Mazda Novi Mukhlisa, Pujiyanto

Nationally Accredited by Director General of Higher Education at Ministry of Research, Technology and Higher Education of the Republic of Indonesia No. 32a/E/KPT/2017 dated on April 26, 2017

National Public Health Journal

Volume 12, Issue 3, February 2018 p-ISSN 1907-7505

e-ISSN 2460-0601

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Kesmas

National Public Health Journal

Volume 12, Issue 3, February 2018 p-ISSN 1907-7505

e-ISSN 2460-0601 Kesmas: National Public Health Journal is a journal that contains both research articles and invited review

articles in the field of public health and published quarterly

Editor in Chief Dewi Susanna International Editorial Board

Dumilah Ayuningtyas (Faculty of Public Health Universitas Indonesia, Indonesia) Ahmad Syafiq (Faculty of Public Health Universitas Indonesia, Indonesia)

Zarfiel Tafal (Faculty of Public Health Universitas Indonesia, Indonesia) Doni Hikmat Ramdhan (Faculty of Public Health Universitas Indonesia, Indonesia) Ahmad Sulaeman (Faculty of Human Ecology Bogor Agricultural University, Indonesia) Upik Kusumawati Hadi (Faculty of Veterinary Medicine Bogor Agricultural University, Indonesia)

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Peter D Sly (Faculty of Medicine and Biomedical Science, University of Queensland, Australia) Budi Haryanto (Faculty of Public Health, Universitas Indonesia, Indonesia)

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Hidayatulfathi Othman (Faculty of Health Sciences, National University of Malaysia, Malaysia) Don Eliseo Lucero-Prisno III (Xi’an Jiatong-Liverpool University, China)

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Dear Editorial Team,

Of articles published in Volume 12 Issue 2, I am interested in the article titled “Increasing Use of Research Findings in Improving Evidence-Based Health Policy at the National Level”. This article shows a gap between the information needs of program and policy-makers and the information offered by researchers. However, research findings should be the basis for changes in national health policies and planning, even the Ministry of Health has raised the budget for evidence-based research. The article emphasizes how important the implementation of research findings, not mere- ly kept on the library shelves. Moreover, the related institutions need to work together, so they will understand how to apply the concept of ‘evidence-based research’ that has become the grounding for evidence-based health policy. I also agree that operations research variables have to be more specifically selected, so any programs made will be more effective and efficient. (Tri Gaya, Sukabumi)

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AUTHOR GUIDELINES

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Correspondence: Terry YR Pristya, Department Biostatistics and Population Studies Faculty of Public Health, Building A 2nd Floor, Kampus Baru UI Depok 16424, Phone: +6221-7863473, E-mail: [email protected]

Received: September 14^th2017 Revised: November 16^th2017 Accepted: December 07^th2017 Pristya et al. Kesmas: National Public Health Journal. 2018; 12 (3): 101-106

DOI:10.21109/kesmas.v12i3.1721 Kesmas: National Public Health Journal

Abstract

Trends of cesarean section trend in Indonesia (2007-2012) have doubled the risk of long-term and short-term health problems. This study was aimed to determine relation between antenatal care provider and cesarean section. This quantitative study used cross-sectional design with a total sample of 5,143 women aged 15-49 years who gave birth to the last child through cesarean section or not as in urban areas selected in samples of 2012 Indonesia Demographic and Health Survey. Logistic regression multivariate analysis was used to determine relation between antenatal care provider and section cesarean, which was controlled by maternal age, antenatal care facility, parity, and place of birth. Results showed that antenatal care at obstetrician was 6.6 times higher, while antenatal care at obstetrician and midwife was 2.1 times higher for cesarean section compared to women who had antenatal care at midwife after controlled by maternal age, antenatal care facility, parity, and place of birth. There is interaction between socioeconomic status and obstetrician for a cesarean section. Regulation on cesarean section by health authority, as well as protective and preventive labor applied towards on the high economic class community may reduce unnecessary cesarean section.

Keywords: Antenatal care, cesarean section, health provider, urban Abstrak

Tren persalinan sesar di Indonesia (2007-2012) mengalami peningkatan dua kali lipat berisiko pada munculnya masalah kesehatan jangka panjang maupun pendek. Penelitian ini bertujuan mengetahui hubungan tenaga kesehatan pemeriksa kehamilan dengan persalinan sesar. Penelitian kuantitatif ini menggunakan desain potong lintang dengan sampel penelitian 5143 wanita usia subur berusia 15-49 tahun yang melahirkan anak terakhirnya, baik melahirkan sesar maupun tidak di wilayah perkotaan yang terpilih dalam sampel Survei Demografi Kesehatan Indonesia tahun 2012. Analisis multivariat regresi logistik digu- nakan untuk mengetahui hubungan tenaga pemeriksa kehamilan dengan persalinan sesar, dikontrol oleh usia ibu, tempat periksa kehamilan, paritas, dan tempat melahirkan. Hasil penelitian menunjukkan bahwa pemeriksaan kehamilan pada spesialis kandungan 6,6 kali lebih tinggi, sedangkan pemeriksaan kehamilan pada spesialis kandungan dan bidan 2,1 kali lebih tinggi untuk melakukan persalinan sesar dibandingkan dengan ibu yang melakukan pemeriksaan kehamilannya di bidan setelah dikontrol usia ibu, tempat periksa kehamilan, paritas, dan tempat melahirkan. Terdapat interaksi antara spesialis kandungan dengan status sosial ekonomi untuk persalinan sesar. Implementasi peraturan dilakukannya persalinan sesar oleh institusi kesehatan, serta melakukan upaya protektif dan preventif persalinan pada kelompok masyarakat ekonomi tinggi dapat mengurangi terjadinya persalinan sesar yang tidak perlu.

Kata kunci: Pemeriksaan kehamilan, persalinan sesar, tenaga kesehatan, perkotaan

Antenatal Care Provider and Cesarean Section in Urban Areas in Indonesia

Tenaga Kesehatan Pemeriksa Kehamilan dan Persalinan Sesar di Wilayah Perkotaan di Indonesia

Terry Yuliana Rahadian Pristya, Milla Herdayanti, Besral*, Dheni Fidyah Fika***

*Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia, **School of Population Health, University of Western Australia, Nedlands WA, Australia

How to Cite: Pristya TYR, Herdayanti M, Besral, Fika DF. Antenatal care provider and cesarean section in urban areas in Indonesia. Kesmas: Public Health Journal. 2018; 12 (3): 101-106. (doi:10.21109/kesmas.v12i3.1721)

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Kesmas: National Public Health Journal, 2018; 12 (3): 101-106

Introduction

Trends of cesarean section in Indonesia have increased by two-fold from 2007 to 2012.¹In 2010, the cesarean section rate has also exceeded the standards World Health Organization.²High disparities in the population and in the health facilities causing more cesarean section in urban than rural areas. The number of elec- tive cesarean section requests without medical indication whether from pregnant women or the influence of antenatal care provider.³This condition is in contrasts with the number of pregnant women who check at the health providers who should not perform a cesarean section, such as nurse, midwife, or village midwife.¹ Medicalization has increased the rate of cesarean section.⁴The impact of increase in demand for cesarean section is mother and infant mortality-morbidity rate.⁵ Besides, problem with early breasfeeding initiation also implicated by of cesarean section.⁶

In Canada, mortality and morbidity rate due to cesarean section (2.7%) had impact three times higher than normal deliveries (0.9%).⁷Another study showed that mortality and morbidity rate of each section method increased to 9.2% in cesarean section and 8.6% in normal section.⁸ America is the region with the greatest number of birth (38%) in the world than other regions.⁹ One of countries in America region that has a high rate of cesarean section is Brazil. Trend from 1996 to 2012 al- ways increases from 36% to 56%.¹⁰The attitude of antenatal care providers becomes issue in reducing the rate of cesarean section. Several studies have shown how systematic use is most effective for cesarean section.¹¹

At present, the normal delivery is more herded toward medicalization, thus leading to pathologic labor.

Information gaps about delivery and technology also occur between doctor and patients is used by the health care providers to perform moral hazard with a profit- seeking motive, in case of interference from patients.¹²A qualitative study in Vietnam showed that attention and hostility of the antenatal care provider with the decision of women in choosing health facility and delivery method. Performance and interaction between antenatal care provider and pregnant women during antenatal care and delivery has a strong relation.¹³The aim of this study was to determine relation of antenatal care provider with cesarean section.

Method

This cross-sectional study used secondary data of Indonesia Demographic Health Survey (IDHS) 2012 which was conducted in 33 provinces in Indonesia.

Dependent variable of the study was cesarean section (cesarean and non-cesarean), and independent variable was antenatal care provider consisting of midwife, obstetrician, or obstetrician-midwife. The potential con-

founder variables were maternal age, maternal education, maternal occupation, socioeconomic, insurance, antenatal care facility, antenatal care frequency, parity, birth size, place of delivery, and complications. The population of this study was all of women aged 15-49 years who gave birth to the last child through cesarean section or not in urban areas in Indonesia. The sample of this study was women aged 15-49 years who gave birth to the last child through cesarean section or not in urban areas selected in the sample of IDHS 2012 that were 5143 respondents selected through complex sample design. The sample obtained was through a stratification process of 1840 census blocks, and selected on primary sampling unit which was supplemented with information on the number of households resulted from the 2010 population census listing. Data were collected through put questionnaire from IDHS 2012. The exclusion criteria were women of childbearing age who gave birth to their twin children, two or more. Multivariate logistic regression analysis was also used in this study.

Results

The results of characteristics of mothers who gave birth to the last child in urban areas in Indonesia were divided according to socio-demographic factors, antenatal care factors, birth records, and medical indications. The proportion of women who gave birth to the last child by cesarean section in urban areas in Indonesia had more of their pregnancies with obstetrician (39.5%) than in obstetrician and general doctor (10%). Women who had antenatal care only with the obstetrician had the highest odds of cesarean section compared to with the other antenatal care providers (Table 1).

In socio-demographic factors, women with higher education had the highest odds of cesarean section compared to the other educational background. Based on antenatal care factors, women whose antenatal care fre- quencies greater than or equal to 4 times had higher odds of cesarean section than women whose antenatal care fre- quencies 0-3 times. From birth records, especially based on size of birth, women with infant birth weight greater than 4000 grams had highest odds of cesarean section compared to the other baby size. Based on medical indication factors, women with complication had higher odds of cesarean section than no complication (Table 1).

In the first model of multivariable analysis, the selection of interaction variables that allegedly found sub- stantial interactions included socioeconomic, insurance, antenatal care frequency, and complication. While in the final model analysis multivariable, the variable that proved to interact was the examiner of pregnancy with socioeconomic. Four variables shown to be confounder variables were maternal age, antenatal care facilities, parity, and delivery facilities (Table 2).

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Pristya et al, Antenatal Care Provider and Cesarean Section in Urban Areas

Table 2 shows that women with antenatal care at obstetrician were 6.6 times higher (95% CI = 3.2-13.7) for cesarean section compared to women with antenatal care at midwife after controlled by maternal age, antenatal care facilities, parity, and delivery facilities. While women with antenatal care at obstetrician and midwife were 2.1 times higher (95% CI = 1.0-4.3) for cesarean section compared to women with antenatal care at midwife after controlled by maternal age, antenatal care facilities, parity, and delivery facilities. From socioeconomic status, women in quintile lower who checked their pregnancy at obstetrician was 6.6 times higher (95% CI = 3.2- 13.7) for cesarean section, at quintile middle was 2.6 times higher (95% CI = 1.5-4.6), and the quintile upper was 3.6 times higher (95% CI = 2.7-4.7) than checked at midwife. While women who checked their pregnancy at

obstetrician and midwife who were in quintile lower were 2.1 times higher (95% CI = 1.0-4.3) for cesarean section, in quintile middle was 2.8 times higher (95% CI

= 1.5-5.0), and in quintile upper was 1.7 times higher (95% CI = 1.2-2.4) compared to women who antenatal care at midwife after controlled by maternal age, antenatal care facilities, parity, and delivery facilities.

Four confounder variables influence cesarean section.

Women aged > 35 years was 1.4 times higher (95% CI=

1.1-1.9) for cesarean section compared to women aged 21-34 years, while women aged < 20 years was 0.4 times lower (95% CI=0.2-0.6) for cesarean section compared to women aged 21-34 years after controlled by antenatal care facilities, parity, and delivery facilities. Women who checked their pregnancy in private facilities was 1.8 times higher (95% CI = 1.3-2.5) for cesarean section

Tabel 1. Relation of Antenatal Care Provider and Mother’s Characteristic with Cesarean Section Section

Variable Catagory Non-cesarean Cesarean Total OR 95%CI p Value

n % n %

Antenatal care provider Midwife 2,669 85.2 465 14.8 3,134 Ref

Doctor 23 69.7 10 30.3 33 3.6 1.3 – 10.1 0.015

Obstetrician 768 60.5 502 39.5 1,270 4.0 3.2 – 5.0 0.000

Obstetrician and midwife 490 70.4 206 29.6 696 2.2 1.7 – 2.9 0.000

Obstetrician and doctor 9 90 1 10 10 0.1 0.0 – 1.4 0.098

Socio-demographic factors

Maternal age < 20 years 344 89.4 41 10.7 385 0.3 0.2 – 0.5 0.000

21-34 years 2,908 77.2 861 22.8 3,769 Ref

> 35 years 707 71.5 2 28.5 989 1.3 1.0 – 1.6 0.029

Maternal education Primary 689 84.4 127 15.6 816 Ref

Secondary 2,510 79.4 652 20.6 3,162 1.5 1.1 – 1.9 0.009

Higher 760 65.2 405 34.8 1,165 3.0 2.2 – 4.1 0.000

Maternal occupation Unemployed 2,130 78.8 572 21.2 2,702 Ref

Employed 1,829 74.9 612 25.1 2,441 1.3 1.1 – 1.6 0.008

Socioeconomic Quintile lower 856 84 163 16 1,019 Ref

Quintile middle 843 80.8 200 19.2 1,043 1.1 0.8 – 1.5 0.627

Quintile upper 2,260 73.4 821 19.2 3,081 1.9 1.5 – 2.5 0.000

Insurance No 2,225 80.9 526 19.1 2,715 Ref

Yes 1,734 72.5 658 27.5 2,392 1.6 1.3 – 2.0 0.000

Antenatal care factors

Antenatal care facilities Public 983 81.9 218 18.1 1,201 Ref

Private 2,976 75.5 966 24.5 3,942 1.3 1.0 – 1.7 0.070

Antenatal care frequency 0-3 times 197 86.0 32 14.0 229 Ref

> 4 times 3,762 76.6 1,152 23.4 4,914 2.1 1.2 – 3.5 0.005

Birth Records

Parity 1 1,449 75.5 470 24.5 1,919 Ref

2 2,043 77.3 601 22.7 2,644 1 0.8 – 1.3 0.860

>3 467 80.5 113 19.5 580 0.9 0.7 – 1.2 0.518

Birth size < 2,500 g 219 77.4 64 22.6 283 1.1 0.8 – 1.7 0.559

2,500 - 4,000 g 3,634 77.5 1,054 22.5 4,688 Ref

> 4,000 g 106 61.6 66 38.4 172 1.9 1.2 – 2.8 0.004

Delivery facilities Public 1,167 71.7 461 28.3 1,628 Ref

Private 2,792 79.4 723 20.6 3,515 0.6 0.5 – 0.7 0.000

Medical indication

Complication No 921 82.2 199 17.7 1,120 Ref

Yes 3,038 75.5 985 24.5 4,023 1.4 1.1 – 1.8 0.003

Notes:

n = Number of Sample, OR = Odds Ratio, CI = Confidence Interval

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Table 2. Final Model of the Relation of Antenatal Care Provider with Cesarean Section

Variable Catagory βb OR SE 95% CI p Value*

Antenatal care provider Midwife Ref

Obstetrician 1.9 6.6 2.5 3.2 – 13.7 0.000

Obstetrician and midwife 0.7 2.1 0.8 1.0 – 4.3 0.051

Mother’s age < 20 years -0.9 0.4 0.1 0.2 – 0.6 0.000

21-34 years Ref

> 35 years 0.4 1.4 0.2 1.1 – 1.9 0.012

Socioeconomic Quintile lower Ref

Quintile middle -0.0 1.0 0.2 0.7 – 1.5 0.953

Quintile upper 0.3 1.4 0.2 1,0 – 1.9 0.069

Antenatal care facilities Public Ref

Private 0.6 1.8 0.3 1.3 – 2.5 0.000

Parity 1 Ref

2 -2.6 0.8 0.1 0.6 – 1.0 0.037

> 3 -3.6 0.7 0.1 0.5 – 0.9 0.016

Delivery facilities Public Ref

Private -0.9 0.4 0.0 0.3 – 0.5 0.000

Interaction Obstetrician by quintile lower 1.9 6.6 2.5 3.2 – 13.7 0.000

Obstetrician by quintile middle 0.9 2.6 0.7 1.5 – 4.6 0.001 Obstetrician by quintile upper 1.3 3.6 0.5 2.7 – 4.7 0.000 Obstetrician and midwife by quintile lower 0.7 2.1 0.8 1.0 – 4.3 0.051 Obstetrician and midwife by quintile middle 1.0 2.8 0.8 1.5 – 5.0 0.001 Obstetrician and midwife by quintile upper 0.5 1.7 0.3 1.2 – 2.4 0.002 Notes:

*as interaction variables, a compared to midwife, SE= Standard Error, CI= Confidence Interval

compared to women who checked their pregnancy in public facilities after controlled by maternal age, parity, and delivery facilities. Women with parity of two children was 0.8 times lower (95% CI = 0.6-1.0) for cesarean section than women with parity of one child after controlled by maternal age, antenatal care facilities, and delivery facilities. Women with parity of > 3 children was 0.7 times lower (95% CI = 0.5-0.9) for cesarean section than women with parity of one child after controlled by maternal age, antenatal care facilities, and delivery facilities.

Women who gave birth in private facilities was 0.4 times lower (95% CI = 0.3-0.5) for cesarean section compared to women who gave birth in public facilities after controlled by maternal age, antenatal care facilities, and parity.

Discussion

Description of cesarean section in urban areas in Indonesia in this study was 1,207 deliveries from 5,239 total deliveries with cesarean rate at 23%. The cesarean rate was higher than national cesarean rate in Indonesia (16.8%) by IDHS 2012 report.¹The difference occurred because in this study, it was only in urban areas and only women who gave to the last child. This study also added several confounder variables to control independent variable. The missing data was excuse to reduce bias, so that it was the same with the study objectives.

Antenatal care providers in this study were catego- rized into five groups, namely midwife, doctor, obstetrician, obstetrician and midwife, obstetrician and doctor.

Antenatal care by doctor was only limited to general examination (blood pressure and weight). Antenatal care by midwife was by Leopold’s maneuvers. The purpose of Leopold’s maneuvers of pregnancy is to determine the fetus’ position and location of uterus, so as to ensure the gestational age. Inspection techniques use the hands of midwife to detect fetus’ position. In obstetrician, more detailed examination use ultrasound which can detect more the condition of pregnant women. Based on these differences, the division of health personnel of pregnancy examiner cannot be synchronized.

This study had similar results with those by Meiyetriani,¹²that mothers in Jakarta with antenatal care in obstetrician tend to have cesarean section 7 times higher (95% CI = 3.5-14) compared to mothers who performed antenatal care in other health providers after controlled by maternal age, maternal education, socioeconomic status, parity, records of complications, hypertension records, bleeding records, and pregnancy failure records.

In Shanghai, China, cesarean section proposed by a doctor increases 20 times higher (95% CI = 3.8-107.1) compared to other pregnancy examiners. The results also suggest that cesarean section is proposed by obstetrician during labor providers OR = 26 (95% CI = 6.26-105.8) after controlled by maternal age, education, and income.

Moreover, the rate of cesarean with medical indications is only 17%, while without medical indication is higher reach 40%. In Shanghai, cesarean section suggested by doctor has become a common.³

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Similar result was shown by Andree,¹⁴that the higher the economic status of the respondents, the higher the chances of undergoing cesarean section (dose response relationship). The lower the socio-economic status of the mother, the lower the chances of having a cesarean section.¹⁴

Attention and discomfort of the antenatal care is related to decision of the women in choosing health facilities and method of delivery. Performance and interaction between pregnant and maternity during antenatal care and delivery has a strong relation.¹³ Quality of counseling about hazard and benefits of cesarean section is also necessary when pregnant women perform a pregnancy check-up. The target of many patients every time the practice of making a pregnancy check up performed by an obstetrician is done in just a very short time. If pregnant women do not take the initiative to ask about pregnancy, then important information is not given. Study in Ireland finds that provision of personal counseling during pregnancy evidently has significant effect on reducing cesarean section.¹⁵

The increasing rate of cesarean section is also due to the medicalization of labor. The development of technology, the use of antibiotics in medicine especially obstetrics, and change in skill of health personnels cause a pat- tern of health care in process of delivery from natural birth to cesarean section.⁴

Regulations from health institution is one effort to reduce unnecessary cesarean section in Brazil. Regulations in health institutions need to be established, so that obstetrician convey information about risk of cesarean section, and ask the mother to sign the consent first. The obstetrician should also provide the reason for need for a cesarean section by filling out a form about the section process that will occur, and explain the steps to be taken.

Each mother also recieves a medical document containing her pregnancy records information clearly, so that it can be carried around when the doctor switches the examiner of pregnancy.¹⁶Increased risk of cesarean section by obstetricians is not caused by a single cause. This study explains that cesarean section is also caused by maternal age, pregnancy checkpoint, parity, and place of delivery.

Conclusion

Cesarean section occurs higher among women with antenatal care at obstetrician and obstetrician-midwife compared to women with antenatal care at midwife after controlled by maternal age, antenatal care facilities, parity, and delivery facilities. There is an interaction between antenatal care providers with socioeconomic status that cause the different effect in each level of socioeconomic levels. Implementation of rules was a cesarean section by health institutions, as well as efforts made to pre-

vent cesarean section in high economic communities in aim to reduce the occurrence of unnecessary cesarean section.

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Jakarta: Badan Pusat Statistik; 2012.

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Cesarean section in Shanghai: women’s or healthcare provider’s prefer- ences? BioMed Central Pregnancy Childbirth [Internet]. 2014; 14(1):

285. Available from: http://www.pubmedcentral.nih.gov/articleren- der.fcgi?artid=4148545&tool=pmcentrez&rendertype=abstract 4. Ghosh S. Increasing trend in caesarean section delivery in India: role of

medicalisation of maternal health. India: Institute for Social and Economic Change, Bangalore; 2010.

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6. Virarisca S, Dasuki D, Sofoewan S. Metode persalinan dan hubungan- nya dengan inisiasi menyusu dini di RSUP Dr. Sardjito Yogyakarta.

Jurnal Gizi Klinis Indonesia. 2010; 7(2): 92–8.

7. Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al.

Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term.

Canadian Medical Association Journal [Internet]. 2007 Feb 13 [cited 2017 Aug 13]; 176(4): 455–60. Available from: http://www.ncbi.nlm.

nih.gov/pubmed/17296957

8. Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. In: Hofmeyr GJ, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2011 [cited 2017 Aug 13]. Available from: http://doi.wiley.com/10.1002/14651858.CD006553.pub2 9. World Health Organization. Global heatlh observatory data repository

[Internet]. Women Data by World Health Organization Region. Geneva:

World Health Organization; 2015. Available from: http://apps.who.int/

gho/data

10. United Nation Children’s Fund. Caesarean section percentage. Geneva:

United Nation Children’s Fund; 2016. Available from: data.unicef.org.

11. American Collage of Obstetric and Gyneologist. Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology. 2014; 123(1): 693-711.

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Peran dokter ahli kebidanan dan kandungan. Kesmas: Jurnal Kesehatan Masyarakat Nasional. 2012; 7(1): 37–43.

13. Graner S, Mogren I, Duong LQ, Krantz G, Klingberg-Allvin M.

Maternal health care professionals’ perspectives on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam. BioMed Central Public Health [Internet]. 2010 Dec 14 [cited 2017 Aug 13]; 10(1):608. Available from: http://bmcpublichealth.bio- medcentral.com/articles/10.1186/1471-2458-10-608

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14. Andree A. Faktor-faktor yang berhubungan dengan persalinan melalui operasi sesar tahun 1997-2003 (Survei Demografi Kesehatan Indonesia 2002-2003) [Skripsi]. Depok: Universitas Indonesia; 2006.

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Available from: http://www.digitaljournal.com/news/world/new-brazil- rules-seek-to-cut-cesarean-craze/article/437671

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Kesmas: National Public Health Journal

Correspondence: Betty Yosephinm Simanjuntak, Department of Nutrition, Bengkulu Health Polytechnic of Health Ministry, Indragiri Street No.3 Padang Harapan, Bengkulu, Phone: +62736-341212, E-mail: [email protected] Received: Septemeber 20^th2017

Revised: October 30^th2017 Accepted: November 15^th2017

Abstract

Toddler period, especially the first two years of life is considered as golden age for children because of their rapid growth and development. Therefore, the occurrence of nutritional disorders in the period can be permanent and irreversible. This study tried to assess correlation between early initiation of breastfeeding and vitamin A with nutritional status. The total of samples analyzed in this study was 1,592 toddlers aged 6-59 months that were drawn from 2015 Indonesia Nutritional Status Monitoring Survey in Bengkulu. Data including age, sex, early initiation of breastfeeding, birth length, birth weight, vitamin A supplementation were collected by using questionnaire. Weight and height of children were obtained through anthropometric measurements. More than half of the toddlers (54.6%) did not get early initiation of breastfeeding. Based on multivariate analysis results, most dominant variables related to weight/age, height/age and weight/height indicators were early initiation of breastfeeding and Vitamin Asupplementation. Toddlers who did not get early initiation of breastfeeding are at risk of 1.555 times stunting compared to toddlers who got early initiation of breastfeeding. The most dominant variable related to height/age is vitamin A supplementation. Children who do not get vitamin A supplementation are at risk of stunting 2.402 times compared to children who get vitamin A supplementation.

Keywords: Early initiation of breastfeeding, nutritional status, vitamin A supplementation Abstrak

Masa balita, khususnya dua tahun pertama kehidupan merupakan usia emas bagi anak karena pertumbuhan dan perkembangannya yang cepat. Oleh karena itu, terjadinya gangguan nutrisi pada masa itu bisa bersifat permanen dan tidak dapat diubah. Penelitian ini mengkaji hubungan antara inisiasi dini pem- berian air susu ibu dan vitamin A dengan status gizi. Total sampel yang dianalisis dalam penelitian ini adalah 1.592 anak di bawah lima tahun (balita) berusia 6-59 bulan yang diambil dari Pemantauan Status Gizi Indonesia 2015 di Bengkulu. Data termasuk usia, jenis kelamin, inisiasi menyusui dini, panjang kelahi- ran, berat lahir, suplementasi vitamin Adikumpulkan dengan menggunakan kuesioner. Berat dan tinggi anak diperoleh melalui pengukuran antropometri. Lebih dari setengah balita (54,6%) tidak mendapat inisiasi menyusui dini. Berdasarkan hasil analisis multivariat, variabel yang paling dominan terkait dengan in- dikator weight/age, height/age dan weight/height adalah inisiasi menyusui dini dan suplemen vitamin A. Balita yang tidak mendapat inisiasi menyusui dini berisiko 1,555 kali me-ngalami stunting dibanding balita yang mendapat inisiasi menyusui dini. Variabel yang paling dominan terkait dengan height/age adalah suplementasi vitamin A. Anak yang tidak mendapatkan suplemen vitamin A berisiko mengalami stunting 2,402 kali dibandingkan anak yang mendapat suplemen vitamin A.

Kata kunci: Inisiasi menyusui dini, status gizi, suplementasi vitamin A

Simanjuntak et al. Kesmas: National Public Health Journal. 2018; 12 (3): 107-113 DOI:10.21109/kesmas.v12i3.1747

How to Cite: Simanjuntak BY, Haya M, Suryani D. Early initation of breastfeeding and vitamin A supplementation with nutritional status of children aged 6-59 months. Kesmas: National Public Health Journal. 2018; 12 (3):

107-113. (doi:10.21109/kesmas. v12i3.1747)

Early Inititation of Breastfeeding and Vitamin A

Supplementation with Nutritional Status of Children Aged 6-59 Months

Inisiasi Menyusui Dini dan Suplementasi Vitamin A dengan Status Gizi Anak Usia 6-59 Bulan

Betty Yosephin Simanjuntak, Miratul Haya, Desri Suryani*, Che An Ahmad**

*Department of Nutrition, Bengkulu Health Polytechnic of Health Ministry, Bengkulu, Indonesia, **Faculty of Nursing, Mhasa University, Kuala Lumpur, Malaysia

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108

Introduction

The Global Nutrition Report 2014 reported that Indonesia is listed in 17 countries among 117 countries that have three nutritional problems in toddlers.

Problems of nutritional deficiencies, such as being underweight, linear growth stunting, and wasting are still the main nutritional problems faced by developing countries in the world, including Indonesia. Prevalence of stunting in developing countries in 2011 reaches 28%, or 165 million children are suffering from stunting and 52 million children are suffering from wasting worldwide.¹ Results of National Basic Health Research 2013 show a decrease in the prevalence of underweight in toddlers (weight/age that is from 17.9% in 2010 to 13.9% in 2013 and a decrease in the prevalence of malnutrition weight/height that is from 0% in 2010 to 5.3% in 2013).²

Nutrition is one of the environmental factors which support growth and development for the process to run satisfactorily. This means that provision of food in good quantity and quality supports growth and development, so that toddlers can grow normally and healthy. Toddlers who do not get food in good quality and adequate quantity can be underweight, malnourished, stunted, and they can suffer from wasting.³

The anthropometric composite index is an anthropometric index that combines the three indexes, namely weight-for-age (weight/age), height-for-age (height/age), and weight-for-height (weight/height) to determine the nutritional status of toddlers. Nutritional status categories of the composite index are divided into failure to grow and normal. Failure to grow is a combination of six categories that are nutritional deficiency, stunting, thin, nutritional deficiency and stunting, nutritional deficiency and thin, and nutritional deficiency, stunting and thin.³Toddlers have normal status if they do not suffer from malnutrition, stunting, and if they are thin.²

A toddler period, especially the first two years of life is the golden age as it is critical for toddlers because they experience growth and development very rapidly.

Therefore, the incidence of nutritional disorders in those days can be permanent and irreversible even if the nutritional needs of the next period are met.⁴In addition, the nutritional problems found in toddlers increase because at this age, a child’s activities begin to increase, but food intake tends to decrease because they have difficulty in eating. Thus nutritional disorders are prevalent in children aged less than 2 years old or more than 2 years.⁵

In efforts to achieve optimal health status to improve the quality of life of a nation, good nutrition is one of most important elements. Malnutrition, high mortality and morbidity rates, especially in infants and toddlers will hamper the developmental process. Infant mortality rate (IMR) and under-five mortality rate are important

indicators of a child’s health. One effort to prevent infant mortality during this period is through breastfeeding.

Implementation of early initiation of breastfeeding, namely breastfeeding in the first hour after birth is one of the programs undertaken to improve the quality and quantity of breastfeeding. Early initiation of breastfeeding is important for both the mother and the child.⁶In Ghana, early initiation of breastfeeding can protect new- borns. A total of 22% of newborn mortality can be pre- vented by breastfeeding within one hour after birth.⁷

Breast milk can reduce morbidity and mortality because in addition to high nutritional value, it also contains immunological substances that protect infants and toddlers from various infections. Exclusive breastfeeding accounts for 13% in reducing child mortality.⁸Low levels of breastfeeding, both from breastfeeding in the first hour after birth and exclusive breastfeeding, result in stunted infant growth, especially weight gain and infant length.⁴

In Indonesia, micronutrient deficiency is quite high, as indicated by 54% of children with vitamin A deficiency, 50% iron deficiency anemia and 17% zinc deficiency.

Vitamin A is important micronutrient. Vitamin A deficiency affects protein synthesis, thus affecting cell growth and differentiation.⁹ In Indonesia, vitamin A that was given only a single supplementation has been reported to decrease mortality and morbidity. Therefore, children with vitamin A deficiency will get a failure of growth.^10,11 Study by Adhi,¹² in Surabaya found that among toddlers with retinol levels less than 20 µg/dL, stunting (height/age) was found at 33.3% and severe stunting 26.7%. This aim of study aimed to assess correlation between early initiation of breastfeeding and vitamin A supplementation with nutritional status (height/age, weight/height, and height/age).

Method

This study with cross-sectional design was conducted in ten districts in Bengkulu Province (Bengkulu, Rejang Lebong, Lebong, North Bengkulu, Muko-Muko, Seluma, South Bengkulu, Kaur, Central Bengkulu, Kepahyang) from May to September 2015. The population of study was mothers who had children aged 6-59 months.

Multistage cluster sampling was applied to select the study population. Eligible mothers were invited to inter- view using questionnaires for data collection.

The total of samples analyzed in this study was 1592 toddlers aged 6-59 months. Data including age, sex, early initiation of breastfeeding, birth weight, birth length, vitamin A supplementation were collected by using questionnaire. The weight and height of infants were obtained through anthropometric measurements. The weights and heights of the children were converted to z-score. Data were analyzed using the computer program. Chi-square

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Simanjuntak et al, Early Initiation of Breastfeeding and Vitamin A Supplementation

test was used for comparing proportions. Multivariate logistic regression analysis was used to determine factor of nutritional status (height/age, weight/height, and height/age) which age, early initiation of breastfeeding, birth length, birth weight and vitamin A supplementation. Statistical significance level was set with p value

<0.05.

Results

The total of samples analyzed in this study was 1,592 toddlers aged 6-59 months. Frequency distribution was based on toddler characteristics, such as age, sex, early initiation of breastfeeding, birth weight and length, getting vitamin A supplementation, and nutritional status of toddlers.

Based on the results of the study, most (81.6%) of 1,592 toddlers were at the age of 13-59 months. More than half of the toddlers (54.9%) were male. As much as 54.6% of the toddlers did not get early initiation of breastfeeding. Almost all (97.3%) of the toddlers were born with birth weight ≥ 2.5 kg. Majority (84.3%) of the toddlers were born with a birth length ≥ 48 cm. As much as 88.1% of toddlers got vitamin A supplementation on February and August. This study attempted to construct three nutritional status indexes. Almost all (89.1%) of the toddlers had a normal by weight/age nutritional status. A child whose height-for-age was less than 2 SD was considered stunted. As much as 26.8% the toddlers had a stunting by height/age nutritional status, and 89.8% of the toddlers had normal weight/height nutritional status.

Chi-square analysis was done to find the association between age, sex, early initiation of breastfeeding, birth weight, birth length, and vitamin A supplementation and nutritional status of toddlers (weight/age, height/age, weight/height).

Table 2 presents that variables which had significant association with weight/age nutritional status of the

toddlers were age, early initiation of breastfeeding and vitamin A supplementation. Meanwhile, variables that did not have significant correlation with the weight/age nutritional status of the toddlers were sex, birth weight and birth length.

Table 3 shows that variables which had significant association with the height/age nutritional status of the toddlers were early initiation of breastfeeding, birth length, and vitamin A supplementation (p value < 0.05).

Meanwhile, the variables that had no significant association with the height/age nutritional status of toddlers were age, sex, and birth weight.

From Table 4, variables that had significant association with the weight/height nutritional status of toddlers were early initiation of breastfeeding and vitamin A supplementation. This is indicated by p value < 0.05.

Meanwhile, the variables that did not have any significant correlation with the weight/height nutritional status of

Table 1. Distribution of Characteristics of Toddlers Aged 6-59 Months

Variables Category n %

Age 6-12 months 293 18.4

13-59 months 1,299 81.6

Sex Male 874 54.9

Female 718 45.1

Early initiation of breastfeeding Yes 722 45.4

No 870 54.6

Birth weight < 2.5 kg 43 2.7

≥ 2.5 kg 1,549 97.3

Birth length < 48 cm 250 15.7

≥ 48 cm 1,342 84.3

Vitamin A supplementation Yes 1,402 88.1

No 190 11.9

Nutritional status (weight/age) Underweight 174 10.9

Normal 1,418 89.1

Nutritional status (height/age) Stunting 426 26.8

Normal 1,166 73.2

Nutritional status (weight/height) Wasting 163 10.2

Normal 1,429 89.8

Notes:

n = The Number of Samples, % = Percentages Table 2. Variables Associated with Weight/Age Nutritional Status

Underweight Normal

Variables Category p Value OR (95% CI)

n % n %

Age 6-12 months 19 6.5 274 93.5 0.009 0.512 (0.312-0.839)

13-59 months 155 11.9 1,144 88.1

Sex Male 105 12.1 76.9 87.9 0.147 1.284 (0.931-1.771)

Female 69 9.6 649 90.4

Early breastfeeding initiation No 96 13.2 626 86.8 0.007 1.557 (1.135-2.137)

Yes 78 8.9 792 91.1

Birth weight < 2.5 kg 6 13.9 37 86.1 0.461 1.333 (0.554-3.205)

≥ 2.5 kg 168 10.8 1,381 89.2

Birth length < 48 cm 29 11.6 221 88.4 0.795 1.083 (0.709-1.655)

≥ 48 cm 145 10.8 1,197 89.2

Vitamin A supplementation No 162 11.5 1,240 88.5 0.041 1.938 (1.056-3.556)

Yes 12 63 178 93.7

Notes:

n = The Number of Samples, % = Percentages, OR = Odds Ration, CI = Confidence Interval

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Table 3. Variables Associated with Height/Age Nutritional Status

Stunting Normal

Variable Category p Value OR (95% CI)

n % n %

Age 6-12 month 61 20.8 232 79.2 0.140

13-59 month 365 28.1 934 71.9

Sex Male 238 27.2 636 72.8 0.680

Female 188 26.1 530 73.9

Early initiation of breastfeeding No 236 32.6 486 67.4 0.000 1.738 (1.390-2.174)

Yes 190 21.9 680 78.1

Birth weight < 2.5 kg 14 32.5 29 67.5 0.486

≥ 2.5 kg 41.2 26.6 1,137 73.4

Birth length < 48 cm 82 32.8 168 67.2 0.023 1.416 (1.058-1.894)

≥ 48 cm 344 25.7 998 74.3

Yes 27 14.2 163 85.8

Notes:

n = The Number of Samples, % = Percentage, OR = Odds Ratio, CI = Confidence Interval

Table 4. Variable Associated with Weight/Height Nutritional Status

Wasting Normal

Variables Category p Value OR (95% CI)

n % n %

Age 6-12 months 27 9.2 266 90.8 0.594

13-59 months 136 10.4 1,163 89.6

Sex Male 98 11.2 776 88.8 0.183

Female 65 9.1 653 90.9

Early initiation of breastfeeding No 90 12.4 632 87.0 0.010 1.555 (1.122-2.154)

Yes 73 8.3 797 91.7

Birth weight < 2.5 kg 4 9.3 39 90.7 1.000

≥ 2.5 kg 159 10.2 1,390 89.8

Birth length < 48 cm 31 12.4 219 87.6 0.265

≥ 48 cm 132 9.8 1,210 90.2

Yes 11 5.7 179 94.3

Notes:

n = The Number of Samples, % = Percentage, OR = Odds Ratio, CI = Confidence Interval

Table 5. Final Variables of Multivariate Analysis

95% CI for Exp(βb)

Anthropometric Index Variable p Value Exp(βb)

Lower Upper Weight/age Early initiation of getting breast milk 0.006 1.556 1.132 2.139

Height/age Vitamin A supplementation 0.000 2.402 1.573 3.668

Weight/height Early initiation of breastfeeding 0.008 1.555 1.122 2.154 Notes:

CI = Confidence Interval

the toddler were age, sex, birth length, and birth weight as shown by p value > 0.05.

The variable selection to be included in the multivariate analysis was analyzed using multiple logistic regression. The variable candidate for multivariate analysis can be seen in Table 5.

Based on multivariate analysis results, the most dominant variable related to weight/age and weight/height was early initiation of breastfeeding. This is indicated by p value = 0.06. The result of data analysis

obtained odds ratio (OR) = 1.556. On other hand, the most dominant variable related to height/age was vitamin A supplementation (OR = 2.402)

Discussion

Problems of malnutrition still occur in Bengkulu Province. National Basic Health Research 2013 reported that the prevalence of nutritional status of toddlers was based on weight/age, height/age, and weight/height.

In Indonesia, severe and moderate stunting prevalence in-

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creased from 2007 (36.8%) to 2013 (37.2%). The prevalence of poor nutrition and nutritional deficiency, moderate stunting also increased from 2007 (18.0%) to 2013 (19.2%). The prevalence of severe sunting fell by 0.8%

from 18.8% in 2007 to 18.0% in 2013. The prevalence of severe and moderate underweight (6.9% and 7.9% respectively) increased in 2013 compared to the prevalence in 2010 (9.7% and 8.1% respectively).²Malnutrition has significant health and economic consequences, which includes increasing risk of death, illness and lower cognitive development among others.¹³

Toddler age is an internal factor that determines the nutritional needs, so age is closely related to the nutritional status of toddler years. The toddler period is a fair- ly important period because in the toddler age group, the children experience the process of rapid development and growth. This determines the quality of life of the children in the future in producing human resources with good quality, thus requiring adequate nutrients for every kilo- gram of their weight.¹³ The selection of the right and proper food will ensure the adequacy of nutrition for their physical growth that will determine the nutritional status of toddlers.¹⁴ The results of this study showed that in Bengkulu Province, toddlers suffered from underweight (11.9%), stunting (28.09%) and wasting (10.46%) and these mostly occurred at between 13-59 months of age.

Stunting is the result of chronic undernutrition that re- tards linear growth, while wasting is the result of inadequate nutrition over a shorter period, and underweight encompasses both stunting and wasting.⁸

Based on the results of analysis on toddler age, there was no significant correlation between age and nutritional status of toddlers for height/age and weight/height (p value > 0.05), but there was a significant correlation between age and weight/age indicated by p value < 0.05.

This is in accordance with the theory stating that older the age of the children, the more weight gain they will have. A child whose weight/age is less than -2 SD is considered underweight, and one whose weight/height is less than -2 SD is deemed wasted. Growth faltering begins at about six months of age, as children transition to food are often inadequate in term of quantity and quality, and the exposure to the environment increases their vulnerability to illness.

Results of this study highlighted that sex was not associated with nutritional status of children (weight/age, height/age and weight/height). This indicates that both male and female toddlers had relatively similar chances of getting abnormal nutritional status. The birth weight re- portedly did not have significant corre