RISK FACTORS FOR ANEMIA IN PREGNANCY

Nadia Arofah1, Anissa Ermasari2*, Neneng Siti Latifa3, Ledy Octaviani Iqmy4

1Mahasiswa Prodi Kebidanan Fakultas Ilmu Kesehatan, Universitas Malahayati, Bandar Lampung, Indonesia
2,3,4Prodi S1 Kebidanan Fakultas Ilmu Kesehatan, Universitas Malahayati, Bandar Lampung, Indonesia
Email: [email protected]

ABSTRAK: FAKTOR RESIKO ANEMIA PADA KEHAMILAN

Latar Belakang: Permasalahan ibu hamil yang mengalami anemia merupakan permasalahan mendasar
yang perlu mendapatkan penanganan yang lebih baik. Menurut data di PMB Bidan Ketut dani SST menunjukkan
ibu hamil yang berkunjung ke PMB Bidan Ketut dani SST berjumlah 485 orang. Berdasarkan observasi ada 42
(0,08%) ibu hamil yang mengalami anemia.
Tujuan: Mengetahui faktor-faktor yang berhubungan dengan kejadian anemia pada ibu hamil di PMB
Bidan Ketut Dani SST Tahun 2023.
Metode: Penelitian merupakan kuantitatif, desain penelitian cross sectional. Populasi ibu hamil di PMB
Bidan Ketut dani SST yang melakukan kunjungan dan pemeriksaan kehamilan pada Tahun 2023 sebanyak 485
orang. Sampel dalam penelitian ini adalah 87 responden. Tekhnik sampling random sampling, Analisa data
univariate dan bivariate menggunakan uji chi square.
Hasil: Hasil dari 87 responden dengan status anemia sebanyak 42 responden (48,3%) dan yang tidak
anemia sebanyak 45 responden (51,7%). Faktor yang berhubungan dengan anemia pada kehamilan adalah usia
kehamilan p-value 0,000 (<0,05), usia ibu p-value 0,000 (<0,05), paritas p-value 0,000 (<0,05), jarak kehamilan p-
value 0,000 (<0,05), Kekurangan Energi Kronis (KEK) p-value 0,000 (<0,05), dan Indeks Massa Tubuh (IMT)
0,491(>0,05).
Kesimpulan: Terdapat hubungan bahwa usia kehamilan, usia ibu, paritas, jarak kehamilan dan KEK
berpengaruh terhadap anemia pada kehamilan dan tidak ada pengaruh statistic antara IMT terhadap anemia
pada kehamilan.
Saran: Diharapkan bagi ibu hamil agar mencegah terjadinya anemia dengan mengkonsumsi makanan
yang tinggi energi atau kalori dan memahami faktor resiko maternal terjadinya anemia.

Kata Kunci : Anemia, IMT, KEK, Paritas, Usia

ABSTRACT
Background: The problem of pregnant women experiencing anemia is a fundamental problem that needs
better treatment. According to data from PMB Bidan Ketut Dani SST, there were 485 pregnant women visiting
PMB Bidan Ketut Dani SST. Based on observations, there were 42 (0.08%) pregnant women who experienced
anemia.
Objective: Knowing the factors associated with the incidence of anemia in pregnant women at PMB Bidan
Ketut Dani SST in 2023.
Methods: The type of quantitative research, cross-sectional research design. The population of pregnant
women at PMB Bidan Ketut Dani SST who made visits and pregnancy checks in 2023 was 485 people. The
sample in this study was 87 respondents. The sampling technique was random sampling, univariate and bivariate
data analysis using the chi square test.
Results: The results of 87 respondents with anemia status were 42 respondents (48.3%) and those who
were not anemic were 45 respondents (51.7%). Factors associated with anemia in pregnancy are gestational age
p-value 0.000 (<0.05), maternal age p-value 0.000 (<0.05), parity p-value 0.000 (<0.05), pregnancy spacing p-
value 0.000 (<0.05), Chronic Energy Deficiency (CED) p-value 0.000 (<0.05), and Body Mass Index (BMI) 0.491
(>0.05).
Conclusion: It was concluded that gestational age, maternal age, parity, pregnancy spacing and CED had
an effect on anemia in pregnancy and there was no statistical effect between BMI and anemia in pregnancy.
Suggestions: It is expected for pregnant women to prevent anemia by consuming foods high in energy or
calories and understanding maternal risk factors for anemia.

Keywords: Anemia, BMI, CED, Parity, Age

INTRODUCTION
The condition known as pregnancy is a physiological condition. The pregnancy process has certain factors
that can worsen the condition of the mother and child, In some cases even causing death. One of the factors is
anemia. Anemia in pregnancy is defined as pregnant women who experience iron deficiency in the blood. In
addition, anemia in pregnancy is defined as a condition of the mother with hemoglobin (HB) levels <11 gr / dl or
hematocrit (Ht) <33%. The Center for Disease Control and Prevention defines anemia as a condition with Hb
levels <11g / dL in the 1st and 3rd trimesters, Hb <10.5 g / dL in the 2nd trimester (Wibowo, 2021).
According to data from the World Health Organization (WHO) in 2018, the prevalence of anemia is still
quite high. The prevalence of anemia in pregnant women in Indonesia is 41.8%, in Asia it is 48.2%, Africa 57.1%,
America 24.1%, and Europe 25.1%. In Indonesia (Riskesdas, 2018) it was obtained as much as 48.9%, this
percentage increased from 2013 which was around 37.1%. Data from the Lampung Province Health profile
showed that 5.4% of anemia cases occurred during pregnancy, Bandar Lampung City had the highest cases of
anemia during pregnancy at 10% (Kemenkes RI, 2019 dalam Carolin, 2023; Dinas Kesehatan Provinsi Lampung,
2022).
The National Maternal Mortality Rate (MMR) is stated at around 307/100,000 in live births. The triggers for
death in mothers in labor include bleeding 58% with one of the triggers being anemia during pregnancy. While the
neonatal mortality rate is 987/100,000 live births. If the mother experiences anemia during pregnancy, it will have
a bad effect on her and the fetus. The mother will experience the risk of abortion, congenital abnormalities,
premature delivery, antepartum bleeding. The fetus will be at risk of growth disorders in the womb, intrauterine
asphyxia, LBW, gestosis and often infected, low IQ and can cause death (Lestari s, 2018; Priyanti, 2020).
Research conducted by Bansal, (2020) regarding the prevalence and risk factors for anemia in pregnancy,
the majority of pregnant women in this study were 26-30 years old. Based on obstetric history, the majority of
pregnant women were multigravida in the second trimester, 22.4% of mothers with a pregnancy gap of <2 years.
The assessment obtained from mothers with comorbid conditions during pregnancy showed that the mother had
a BMI> 24.9. As many as 74.8% were not compliant in consuming iron and folic acid tablets. Anemia occurs due
to repeated childbirth which makes pregnant women more susceptible to malnutrition which can result in anemia
and reduced iron reserves in pregnant women, so that pregnant women are at risk of losing a lot of blood during
childbirth. There are a number of factors that trigger anemia cases in pregnant women, including age, parity,
consumption of iron tablets, coffee and tea consumption, frequency of ANC visits, pregnancy spacing, CED
status, and Body Mass Index (BMI), education status, number of family members, income, gestational age, diet,
and vegetable and meat consumption habits (Amalia Djamil, 2023; Amanupunnyo, 2018; Bansal, 2020; Lugita
Sari, 2021; Rizki Fauzan, 2022).
According to WHO, the large iron requirement (1000 mg) during pregnancy is not sufficient if obtained
from food alone, therefore pregnant women must be assisted with iron tablet supplements. Iron supplements are
given for preventive efforts and to overcome anemia which is prioritized in pregnant women. Therefore, to prevent
anemia cases in pregnant women, iron supplements are given daily as much as 1 tablet (60 mg) of elemental iron
0.25 g folic acid for at least 90 days in sequence during pregnancy (Sulistyawati, 2019).
Based on PMB Midwife Ketut Dani SST, in 2023 there were 485 pregnant women who visited for antenatal
care and there were 42 (0.08%) mothers who experienced anemia during pregnancy. From this background, the
researcher aims to conduct a study on the risk factors for anemia during pregnancy at PMB Midwife Ketut Dani
SST Rajabasa Bandar Lampung in the period October-December 2023.

RESEARCH METHODOLOGY
This study is a quantitative study with an observational analytical approach using a cross-sectional design.
This study was conducted at PMB Bidan Ketut Dani, SST Rajabasa, Bandar Lampung City in 2023. This study
was conducted on June 6. The population in this study were all pregnant women who visited PMB Bidan Ketut
Dani SST to carry out ANC in 2023 as many as 485. The sample in this observation was 87 pregnant women who
underwent HB examination and 42 pregnant women with anemia were found: 45 normal pregnant women.
The independent variables in this study are gestational age, maternal age, parity, pregnancy spacing,
KEK, and BMI. Meanwhile, the dependent variable in this study is pregnant women with anemia. Secondary data
collection was carried out by looking at patient records to evaluate the risk factors experienced by mothers with
anemia. In addition, documentation was carried out using notes, transcripts, medical records.
Univariate analysis was applied in this study to understand the characteristics of pregnant women as a
whole. Bivariate analysis was used to show the risk factors for anemia in pregnancy at PMB Bidan Ketut Dani,
SST Rajabasa Bandar Lampung in 2023. The bivariate analysis applied in this study was the Chi-Square test.
The alternative hypothesis (Ha) is accepted if the p-value generated from the Chi-Square test is less than 0.05,
this implies that the observed variables have a significant relationship. Conversely, the null hypothesis (Ho) which
states that there is no significant relationship between the variables studied is accepted if the p-value is greater
than 0.05.
This study has received ethical eligibility information from the Malahayati University Health Research
Ethics Commission, with an ethical eligibility number: No.4330/EC/KEP-UNMAL/V/2024 which is valid from May
31, 2024 to May 31, 2025.

RESEARCH RESULT
Characteristics of Pregnant Women
Based on table 1. the results were obtained from 87 respondents with anemia status as many as 42
respondents (48.3%), and not Anemia as many as 45 respondents (51.7%). The most gestational age of trimester
I and III as many as 52 respondents (59.8%). Mothers with risk age as many as 26 respondents (29.9%), and the
majority of reproductive age as many as 61 respondents (70.1%). The majority of mothers with multiparity parity
as many as 50 respondents (57.5%) with the most pregnancy interval ≥2 years as many as 56 respondents
(64.4%). The nutritional status of the mother most did not experience KEK with normal BMI as many as 55
respondents (63.2%).
Tablel 1. Characteristics of Pregnant Women at PMB Midwife Ketut Dani SST Bandar Lampung in 2023

Variable n Percentage
Hemoglobin
Anemia 42 48,3%
Non-Anemia 45 51,7%
Gestational Age
Trimester I dan III 52 59,8%
Trimester II 35 40,2%
Mother's Age
<20 and >35 Years 26 29,9%
20-35 Years 61 70,1%
Parity
Multipara 50 57,5%
Primipara 37 42,5%
Pregnancy Spacing
<2 Years 31 35,6%
≥2 Years 56 64,4%
CED
CED 32 36,8%
Non-CED 55 63,2%
BMI
Abnormal 32 36,8%
Normal 55 63,2%
Amount 87 100%

Gestational Age, Maternal Age, Parity, Pregnancy Spacing, KEK and BMI on Anemia Incidence

Table 2. Relationship between Gestational Age, Maternal Age, Parity, Pregnancy Spacing, CED and BMI
to the Incidence of Anemia
Hemoglobin
Amount
Variable Anemia Non-Anemia p-value
n % n % n %
Gestational Age Trimester I and III 34 80,1 18 40 52 59,9 0,000
Trimester II 8 19,9 27 60 35 40,1
Mother's Age <20 and >35 Years 25 59,5 1 2,2 26 29,8 0,000
20-35 Years 17 40,5 44 97,8 61 70,2
Parity Multipara 33 78,6 17 37,8 50 57,4 0,000
Primipara 9 21,4 28 62,2 37 42,6
Pregnancy Spacing <2 Years 26 61,9 5 11,1 31 35,9 0,000
≥ 2 Years 16 38,1 40 88,9 56 64,1
CED CED 28 66,7 4 8,9 32 36,8 0,000
Non- CED 14 33,3 41 91,1 55 63,2
IMT Abnormal 16 38,1 16 35,6 32 36,8 0,491
Normal 26 61,9 29 64,4 55 63,2

Based on table 2. the results obtained respondents who experienced anemia were (48.3%), with the first
and third trimester gestational age of 34 respondents (80.1%), and the second trimester age of 8 respondents
(19.9%). While those who were not anemic were 45 respondents (51.7%) the first and third trimesters were 18
respondents (40%), and the second trimester gestational age of 27 respondents (60%). The results of the study
obtained a p-value of 0.000 (<0.05) which means that there is a relationship between gestational age and the
incidence of anemia in pregnancy at PMB Bidan Ketut Dani SST Rajabasa Bandar Lampung in 2023, with an
Odds Ratio of 6.375 which means that mothers who have a gestational age at risk have a risk of causing anemia
in pregnancy.
Pregnant women who experience anemia with maternal age <20 and >35 years were 25 respondents
(59.5%), and maternal age 20-35 years were 17 respondents (40.5%). Meanwhile, those who were not anemic
with maternal age <20 and >35 years were 1 respondent (2.2%), and those aged 20-35 years were 44
respondents (97.8%). The results of the study obtained a p-value of 0.000 (<0.05) which means that there is a
relationship between maternal age and the incidence of anemia in pregnancy at PMB Bidan Ketut Dani SST
Rajabasa Bandar Lampung in 2023, with an Odds Ratio of 64,706 which means that mothers who are <20 and
>35 years old have a risk of causing anemia in pregnancy.
The parity status of respondents who experienced anemia with multiparous parity was 33 respondents
(78.6%), and primiparous parity was 9 respondents (21.4%). Meanwhile, those who were not anemic with
multiparous parity were 17 respondents (37.8%), and primiparous parity was 28 respondents (62.2%). The results
of the study obtained a p-value of 0.000 (<0.05) which means that there is a relationship between parity and the
incidence of anemia in pregnancy at PMB Bidan Ketut Dani SST Rajabasa Bandar Lampung in 2023, with an
Odds Ratio of 6.039 which means that mothers who have multiparity have a risk of causing anemia in pregnancy.
Respondents who experienced anemia with a pregnancy interval of <2 years were 26 respondents (61.9%), and
a pregnancy interval of ≥2 years were 16 respondents (38.1%). While those who were not anemic with a
pregnancy interval of <2 years were 5 respondents (11.1%), and a pregnancy interval of ≥ 2 years were 40
respondents (88.9%). The results of the study obtained a p-value of 0.000 (<0.05), which means that there is a
relationship between maternal age and the incidence of anemia in pregnancy at PMB Bidan Ketut Dani SST
Rajabasa Bandar Lampung in 2023, with an Odds Ratio of 13,000, which means that mothers who have a
pregnancy gap of <2 years have a risk of causing anemia in pregnancy.
Pregnant women who experience anemia with CED are 28 respondents (66.7%), and not CED are 14
respondents (33.3%). While those who are not anemic with CED are 4 respondents (8.9%), and not CED are 41
respondents (91.1%). The results of the study obtained a p-value of 0.000 (<0.05), which means that there is a
relationship between CED and the incidence of anemia in pregnancy at PMB Bidan Ketut Dani SST Rajabasa
Bandar Lampung in 2023, with an Odds Ratio of 20,500, which means that mothers who have CED have a risk of
causing anemia in pregnancy.
Pregnant women who experience anemia with abnormal BMI are 16 respondents (38.1%), and normal
BMI are 26 respondents (61.9%). While those who are not anemic with abnormal BMI are 16 respondents
(35.6%), and normal BMI are 29 respondents (64.4%). The results of the study obtained a p-value of 0.491 (>
0.05) which means that there is no relationship between CED and the incidence of anemia in pregnancy at PMB
Bidan Ketut Dani SST Rajabasa Bandar Lampung in 2023, with an Odds Ratio of 1.115 which means that
mothers who have abnormal BMI do not have the risk of causing anemia in pregnancy.
.
DISCUSSION
Anemia in Pregnancy
The results of the study were obtained from 87 respondents with anemia status of 42 respondents
(48.3%), and non-anemia of 45 respondents (51.7%). The theory put forward by R. Y. Astutik & Fitriana, (2018)
states that anemia in pregnancy occurs because the body lacks erythrocytes in the blood circulation or
hemoglobin mass (HB) so that it is unable to fulfill its function as a carrier of oxygen to all tissues. HB
measurement is a way to determine the risk of anemia in pregnant women. Laboratory tests can be carried out
for, such as HB, Ht, RBC count, RBC shape, erythrocyte count determines the degree of anemia and iron
deficiency testing, which can be done using laboratory tests, determining the degree of anemia can be done
through routine blood tests.
According to the researcher's opinion, anemia in pregnancy is caused by iron deficiency, pregnant women
are very susceptible to iron deficiency anemia because during pregnancy the need for oxygen is higher, triggering
an increase in erythropoietin production. As a result, plasma volume increases and red blood cells (erythrocytes)
increase. However, the increase in plasma volume occurs in a greater proportion when compared to the increase
in erythrocytes so that there is a decrease in hemoglobin (Hb) concentration due to hemodilution.
Iron reserves in pregnant women can be low due to menstruation and poor diet. Pregnancy can increase
iron requirements by two or three times. Iron is needed for the production of extra red blood cells, for certain
enzymes needed for tissues, the fetus and placenta, and to replace the normal daily increase in losses. The
greatest fetal iron requirement occurs during the last four weeks of pregnancy, and this requirement will be met at
the expense of the mother's needs. Iron requirements during pregnancy are partially met because menstruation
does not occur and there is increased absorption of iron from the diet by the intestinal mucosa although it also
depends only on the mother's iron reserves. Iron contained in food is only absorbed by less than 10%, and the
usual diet cannot meet the iron needs of pregnant women. Unmet iron requirements during pregnancy can result
in iron deficiency anemia which can have a negative effect on both the mother and the fetus, this can cause
complications of pregnancy and childbirth. In this study, indirect factors that cause anemia are gestational age,
maternal age, parity, pregnancy spacing and KEK.
Gestational Age with Anemia Incidence in Pregnancy
The results of the study obtained a p-value of 0.000 (<0.05), which means that there is a relationship
between gestational age and the incidence of anemia in pregnancy. This is in line with research by Bansal,
(2020) which found that gestational age (p-value = 0.0001) is related to the incidence of anemia, then research
conducted by Yudhya Muliani, (2020) stated that gestational age (p-value = 0.000) is related to the incidence of
anemia. However, this study is not in line with Lestari, (2018) who explained that gestational age (p-value = 0.17)
is not related to the incidence of anemia. Hemoglobin examination to find anemia in pregnant women is carried
out in the first trimester (<3 months) and the third trimester (>6 months) of pregnancy.
Trimester III, in particular, is considered an important period where nutritional needs increase significantly.
Lack of iron in the blood can cause a decrease in hemoglobin levels, which in turn can interfere with fetal growth.
Several studies have shown that hemoglobin levels in pregnant women in the final trimester and high levels of
anemia in the third trimester can have an impact on the birth weight of babies. Although iron intake from daily
food is sufficient, additional iron tablets or vitamin supplements containing iron are still needed. Iron is not only
important for maintaining a healthy pregnancy, but also to prevent the risk of postpartum hemorrhage, infection,
fetal death in the womb, congenital abnormalities, and miscarriage in pregnant women who are iron deficient. In
this study, pregnancy, especially the third trimester, is a critical period where the need for nutrients increases. If
iron in the blood is lacking, hemoglobin levels will decrease, resulting in fetal growth disorders (Andyarini, 2018).
Based on the results of research conducted by Padma, (2017) regarding the factors that influence the incidence
of anemia in pregnant women, it states that trimesters 1 and 3 have a higher risk of experiencing anemia.
According to researchers, gestational age is more at risk in the first and third trimesters. The hemodilution
process that begins in the first trimester causes blood volume to increase in this trimester. During hemodilution,
Hb levels increase. However, because plasma volume increases by 25-30%, while the number of blood cells
increases by about 20%, it results in blood dilution called hemodilution. In the first trimester, pregnant women can
lose their appetite and experience morning sickness so that the amount of food that should be consumed also
decreases, accompanied by a lack of nutrients absorbed by the body, including iron. In the third trimester, the
need for high nutrition for fetal growth and sharing iron in the blood to the fetus will reduce the mother's iron
reserves. Therefore, pregnant women in the third trimester are at greater risk of anemia.
In this study, in the anemia group, 7 respondents were in the first trimester, 8 respondents were in the
second trimester, and 27 respondents were in the third trimester. While in the non-anemia group, 5 respondents
were in the first trimester, 27 respondents were in the second trimester, and 13 respondents were in the third
trimester. The majority of respondents in the anemia group were in the third trimester which is a risky gestational
age, while in the non-anemia group, the majority of respondents were in the second trimester, which is a non-risk
gestational age. It can be concluded that gestational age (trimesters I and III) is a risk factor associated with the
occurrence of anemia. However, there were 8 respondents who experienced anemia in the second trimester of
pregnancy (not at risk), possibly because they had other factors because even though the 8 respondents were in
a non-risk gestational age, some of them had poor age, parity, pregnancy spacing, and nutritional status so that
they still had risk factors for anemia in pregnancy. Meanwhile, there were 19 respondents who did not experience
anemia in the first and third trimesters of pregnancy (at risk), because even though they were at risk of
pregnancy, they were at reproductive pregnancy age, had a history of parity, safe pregnancy spacing and had
good nutritional status so that their pregnancy was safe and iron needs during pregnancy could be met, thus
reducing the risk of anemia and no anemia occurred in pregnancy. It was found that there were 4 respondents
who had very low levels (hemoglobin) of 8.3 to 7.0, it was known that 2 respondents had 5 risk factors of
gestational age, maternal age, parity, pregnancy spacing and poor nutritional status, and 2 of them had 3 risk
factors including parity, CED, and BMI at risk and gestational age, parity, and CED. 2 of these respondents had
an age at risk and 2 of them had CED, in this study it was found that maternal age was the most influential risk
factor 64 times and CED was the second highest risk factor, namely 20 times having a risk of causing anemia in
pregnancy.

Maternal Age with Anemia in Pregnancy

The results of the study obtained a p-value of 0.000 (<0.05), which means that there is a relationship
between maternal age and the incidence of anemia in pregnancy. This is in line with what was done by Sari S,
(2021) which found that maternal age (p-value = 0.001) is related to the incidence of anemia in pregnancy, then
research conducted by Amini, (2018) found that maternal age (p-value = 0.01) is related to the incidence of
anemia in pregnancy, However, this study is not in line with Sari & Romlah, (2019) who explained that maternal
age (p-value = 0.23) is not related to the incidence of anemia. The ideal age for a woman to get pregnant is 20-35
years, at that age women are less at risk of experiencing pregnancy complications and have healthy
reproduction. This is related to the biological and psychological conditions of pregnant women. Anemia in
pregnant women will be worse if pregnant under the age of 20, because young mothers need more iron for their
own growth and the growth of the baby they are carrying. The risk of death in the age group under 20 years and
over 35 years is three times higher compared to the healthy reproductive age group Astuti & Ertiana, 2018;
Priyanti, (2020)
According to the researcher's opinion, the younger and older the age of a pregnant mother will affect the
nutritional needs required. Lack of fulfillment of nutrients during pregnancy, especially at the age of less than 20
years and more than 35 years, will increase the risk of anemia. Pregnancy at the age of 35 years is at risk of
anemia. This happens because in pregnancy at the age of <20 years, biologically, human emotions are not
optimal and tend to be unstable and mentally immature. This results in a lack of attention to meeting nutritional
needs during pregnancy.
At the age of <20 years, a woman's body condition is not ready to accept pregnancy because it is still
growing. Therefore, nutrients are still needed by pregnant women for their growth and nutrition for their own
pregnancy is reduced so that they are susceptible to anemia. The age of pregnant women >35 years is also
related to the decline and decrease in immunity and the condition of the biological organs of pregnant women
experiences a decline which causes hemoglobin production to decrease so that they are susceptible to anemia.
In this study, in the anemia group, 7 respondents were aged <20 years, 19 respondents were aged >35 years,
and 16 respondents were in the reproductive age of 20-35 years. While in the non-anemia group, 1 respondent
was aged <20 years, and 44 respondents were in the reproductive age of 20-35 years. The majority of
respondents in the anemia group were at risk of <20 and >35 years, while in the non-anemia group, the majority
of respondents were in the reproductive age of 20-35 years, it can be concluded that maternal age <20 and >35
years is a risk factor associated with the occurrence of anemia. However, there were 16 respondents in the
reproductive age (20-35 years) who experienced anemia, possibly because they had other factors because even
though the 16 respondents were at a safe age, some of them had poor gestational age, parity, pregnancy spacing
and nutritional status so that they still had risk factors for anemia in pregnancy. Meanwhile, there was 1
respondent who did not experience anemia at a risky age <20 years, possibly because even though she was at
risk, she had a history of parity, pregnancy spacing and good nutritional status so that her pregnancy was safe
and her iron needs were met during pregnancy so that anemia did not occur in pregnancy.

Parity with Anemia in Pregnancy

The results of the study obtained a p-value of 0.000 (<0.05) which means that there is a relationship
between parity and the incidence of anemia in pregnancy. This is in line with the research of Lestari, (2018) et al.,
it is known that parity (p-value = 0.04) is related to the incidence of anemia. Then research conducted by (Yudhya
Muliani et al., 2020) stated that parity (p-value = 0,001) is related to the incidence of anemia.
According to the researcher's opinion, anemia has a greater risk in mothers who have high parity. the
more often a woman gives birth, the more. Pregnant women with high parity or frequent childbirth will experience
a greater increase in plasma volume, causing greater hemodilution. Mothers who give birth more than three times
are at risk of bleeding complications which can be influenced by anemia during pregnancy and the risk of
recurrent bleeding in subsequent pregnancies due to decreased hemoglobin levels. This is explained in a study
conducted by Edah, (2019) in Belo Ximenes. (2021) on literature studies on risk factors for postpartum
hemorrhage that mothers who have given birth >3 times are at greater risk of experiencing postpartum
hemorrhage than mothers with parity 1-3. At parity >3, reproductive function declines so that the possibility of
postpartum hemorrhage becomes greater. With increasing parity, there will be more connective tissue in the
uterus so that the ability to contract decreases, resulting in difficulty in applying pressure to blood vessels that are
open after the placenta is released. In addition, there is also regression and defects in the endometrium which
results in fibrosis in the placental implantation site so that vascularization can be reduced.
In this study, in the anemia group, there were 33 multiparous respondents and 9 primiparous respondents.
While in the non-anemia group, there were 17 multiparous respondents and 28 primiparous respondents. The
majority of respondents in the anemia group were multiparous, while in the non-anemia group, the majority of
respondents were primiparous. It can be concluded that multiparous parity is a risk factor for anemia in
pregnancy. However, there were 9 primiparous respondents who experienced anemia possibly because they had
other risk factors because even though the 9 respondents were in non-risk parity, some of them had a history of
gestational age, maternal age, pregnancy spacing and poor nutritional status so that they still had risk factors for
anemia in pregnancy. While there were 17 multiparous respondents who did not experience anemia because
even though they were in risky parity, they had a history of gestational age, maternal age, pregnancy spacing and
good nutritional status so that their pregnancy was safe and the mother's iron needs could be met during
pregnancy so that anemia did not occur in pregnancy.
Pregnancy Spacing with Anemia Incidence in Pregnancy
The results of the study obtained a p-value of 0.000 (<0.05) which means that there is a relationship
between pregnancy spacing and the incidence of anemia in pregnancy. This study is in line with research
conducted by Sari & Romlah, (2019), it is known that pregnancy spacing (p-value = 0.04) is related to the
incidence of anemia, then research conducted by Gusnidarsih, (2020) it is known that pregnancy spacing (p-
value = 0.003) is related to the incidence of anemia.
A woman is said to give birth too often if the spacing is less than 2 years. Birth spacing that is too close
can increase the risk of anemia. This is because the mother's condition has not fully recovered from the previous
pregnancy and the fulfillment of nutrients is not optimal, because the mother must meet the nutritional needs for
herself and the fetus she is carrying. birth spacing has a risk of 1,146 times greater risk of experiencing anemia
(Astuti & Ertiana, 2018).
According to the researcher, birth spacing that is too close (<2 years) will cause low fetal quality and will
also be detrimental to maternal health. Too close birth spacing causes mothers to not have the opportunity to
repair their own bodies where mothers need enough energy to recover after giving birth to their children. In this
study, in the anemia group, there were 26 respondents with a pregnancy spacing of <2 years and 16 respondents
with a pregnancy spacing of >2 years. While in the non-anemia group, there were 5 respondents with a
pregnancy spacing of <2 years and 16 respondents with a pregnancy spacing of >2 years. The majority of
respondents in the anemia group were respondents with a pregnancy spacing of <2 years, while in the non-
anemia group, the majority of respondents had a pregnancy spacing of >2 years. It can be concluded that a
pregnancy spacing of <2 years is a risk factor for anemia in pregnancy. However, there were 6 respondents with
a pregnancy spacing of >2 years who experienced anemia, possibly because they had other risk factors because
even though the 6 respondents had a risky pregnancy spacing, some of them had a history of gestational age,
maternal age, parity, and poor nutritional status so that they still had risk factors for anemia in pregnancy.
Meanwhile, there were 5 respondents with a gap of <2 years who did not experience anemia because even
though they were at risk of pregnancy spacing, they had a history of good pregnancy age, maternal age, parity
and nutritional status so that their pregnancy was safe and the mother's iron needs could be met during
pregnancy so that anemia did not occur during pregnancy.
CED with Anemia In Pregnancy
The results of the study obtained a p-value of 0.000 (<0.05), which means that there is a relationship
between CED and the incidence of anemia in pregnancy. This study is in line with research conducted by Lestari,
(2018) which found that CED (p-value = 0,002) is related to the incidence of anemia, Then research conducted by
Widya Larasati, (2018) found that CED (p-value = 0,003) is related to the incidence of anemia. While research
conducted by Supriyatun, (2022) explained that CED (p-value = 0,542) is not related to the incidence of anemia.
Pregnant women who experience CED are at 3 times greater risk of experiencing anemia. CED in
pregnancy is influenced by the mother's health condition before pregnancy, CED occurs due to insufficient energy
intake for a long time (Yudhya Muliani, 2020).
According to the researcher's opinion, this may be related to the negative effects of protein energy
deficiency and other micronutrient deficiencies. From the review of the theory, it can be seen that pregnant
women who experience CED are at risk of anemia. This occurs because CED describes the nutritional status of
pregnant women who are lacking. The fulfillment of pregnant women's nutrition that is still lacking causes
pregnant women with CED to be at greater risk of anemia. In this study, in the anemia group, there were 28 CED
respondents and 14 respondents who did not have CED. While in the non-anemia group, there were 4 CED
respondents and 41 respondents who did not have CED. The majority of respondents in the anemia group were
respondents who had CED, while in the non-anemia group, the majority of respondents did not have CED. It can
be concluded that CED is a risk factor for anemia in pregnancy. However, there were 14 respondents who did not
have CED who experienced anemia, possibly because they had other risk factors because even though the 14
respondents did not have CED, some of them had poor gestational age, maternal age, parity, and pregnancy
spacing so that they still had risk factors for anemia in pregnancy. Meanwhile, there were 4 CED respondents
who did not experience anemia because even though they experienced CED, they had a good history of
gestational age, maternal age, parity, pregnancy spacing, and BMI so that their pregnancy was safe and the
mother's iron needs could be met during pregnancy so that anemia did not occur during pregnancy.

BMI with Anemia Incidence During Pregnancy

The results of the study obtained a p-value of 0.491 (> 0.05) which means that there is no statistically
significant relationship between BMI and the incidence of anemia. In line with the opinion put forward by (Fitriah,
2018) During pregnancy, the growth process continues, namely the growth of the fetus and various growths of
body organs that support the growth process so that increased metabolism in pregnant women has an impact on
increasing the supply of vitamins and minerals in addition to energy, protein, and fat. If the increased need for
energy, protein, fat, vitamins, and minerals cannot be met through the food consumed by pregnant women, then
pregnant women will experience malnutrition which will result in low birth weight, premature birth (born
prematurely), and birth with various difficulties / to death, and for mothers, the mother's weight in the first trimester
<40 Kg, Body Mass Index (BMI) before pregnancy <17.0, Mother suffers from anemia.
Malnutrition in pregnant women not only has an impact on the fetus that will be born, but can also cause
problems for the pregnant woman herself. Nutritional problems in pregnant women are caused by the unfulfilled
nutritional needs from food, divided into macro-nutritional problems (chronic energy deficiency / KEK) and micro-
nutritional problems (lack of iron, iodine and calcium). During pregnancy, mothers need quality food in sufficient
quantities (not lacking and not excessive). To meet the needs of the mother's body during pregnancy, a balanced
diet is needed, where all the nutrients are needed by the body every day, although the amounts are not the same,
there are nutrients that are needed in small amounts and there are also nutrients that are needed in large
amounts. The comparison between carbohydrates, proteins, and fats in the daily menu must be in accordance
with the body's needs (Fitriah, 2018).
According to researchers, the statistical results are not significant because BMI is not at risk of having 3
levels, namely KEK, overweight and obesity. In line with the theory presented by Marlapan, (2013); Yudhya
Muliani, (2020) Pregnant women who experience KEK are at 3 times greater risk of experiencing anemia. In this
theory, it is emphasized that those at risk of experiencing anemia are pregnant women with KEK conditions, while
pregnant women with overweight and obese BMI are abnormal BMI but are able to have sufficient nutritional
fulfillment and are not at risk of experiencing anemia. Fulfillment of nutrition during pregnancy, food intake is the
main factor in meeting nutritional needs as a source of energy, maintaining body resistance in dealing with
disease attacks and for growth. To get an ideal BMI, pregnant women must pay attention to the food consumed,
not only the requirement to eat but the food must be healthy and nutritious by paying attention to the AKG, AKG is
used for planning national food consumption & provision, assessment of food consumption in aggregate (macro)
at the national level, and determination of nutritional components in the formulation of the poverty line and
minimum wage with adjustments to the level of activity. The level of energy and protein consumption are two
indicators of nutritional quality that are commonly used to measure nutritional status.
In this study, in the anemia group, there were 16 respondents who had abnormal BMI (4 KEK, 5
overweight, and 7 obese) and 26 respondents who had normal BMI. Meanwhile, in the non-anemia group, there
were 16 respondents with abnormal BMI (1 overweight, and 15 obese) and 29 respondents with normal BMI. The
majority of respondents in the anemia group were respondents who had normal BMI, while in the non-anemia
group, the majority of respondents also had normal BMI. It can be concluded that in this study, BMI is a risk factor
that is not related to the occurrence of anemia in pregnancy
.
CONCLUSION
There are risk factors that affect the occurrence of anemia in pregnant women such as gestational age, maternal
age, parity, pregnancy spacing and maternal nutritional status against CED which can be the cause of anemia in
pregnancy.

SUGGESTION
Pregnant women should prevent anemia by consuming foods that are high in energy or calories and iron such as
meat, chicken, fish, eggs, cereals, nuts, fruits and green vegetables and mothers can understand the risk factors
for anemia by making ANC visits at least 4 times during pregnancy 1 time in the first and second trimesters, and 2
times in the third trimester.

REFERENCE
Amalia Djamil, R., Eko Irianto, S., & Yulia Maritasari, D. (2023). GHIDZA : Jurnal Gizi Dan Kesehatan Analisis
Faktor-Faktor yang Berhubungan dengan Kejadian Anemia Pada Ibu Hamil Trimester III di Kabupaten Way
Kanan Provinsi Lampung Tahun 2022. https://doi.org/10.22487/ghidza.v7i1.750

Amanupunnyo, N. A., Shaluhiyah, Z., & Margawati, A. (2018). Analisis Faktor Penyebab Anemia pada Ibu Hamil
di Puskesmas Kairatu Seram Barat. Jurnal Aisyah : Jurnal Ilmu Kesehatan, 3(2), 173–181.
https://doi.org/10.30604/jika.v3i2.134

Andyarini, H. &, Hidayati, I., Andyarini, E. N., Psikologi, F., Kesehatan, D., Sunan, U., & Surabaya, A. (2018a).
Hubungan Jumlah Paritas dan Umur Kehamilan dengan Kejadian Anemia Ibu Hamil The Relationship
Between The Number of Parities and Pregnancy Age with Maternal Anemia. In Journal of Health Science
and Prevention (Vol. 2, Issue 1).

Astuti, R. Y., & Ertiana, D. (2018). Anemia dalam Kehamilan. Pustaka Abadi.
https://books.google.co.id/books?id=6tisDwAAQBAJ

Astutik, R. Y., & Fitriana, D. (2018). Anemia dalam kehamilan (1st ed., Vol. 1). CV. pustaka abadi.

Bansal, R., Bedi, M., Kaur, J., Kaur, K., Shergill, H. K., Khaira, H. K., & Suri, V. (2020). Prevalence and factors
associated with anemia among pregnant women attending antenatal clinic. Adesh University Journal of
Medical Sciences & Research, 2, 42–48. https://doi.org/10.25259/aujmsr_8_2020
Belo Ximenes, J., Sofiyanti, I., Alves, F. D., Pinto, E. A., Cardoso, D. S., D Amaral, E. F., De Jesus, H. M.,
SPereira, I. A., Reis, A. D., Morreira, A., Moniz, C. P., Soares, O., Md FSoares, A., & Da Costa, R. (2021).
Faktor Resiko Terjadinya Perdarahan Post Partum : Studi Literatur.

Carolin, B., Novelia Fakultas Ilmu Kesehatan, S., Nasional, U., Sawo Manila No, J., Barat, P., Minggu, P., &
Selatan, J. (2023). Penyuluhan Serta Pemberian Tablet Penambah Darah Dan Vitamin C Untuk Mengatasi
Anemia Pada Ibu Hamil. http://jurnal.globalhealthsciencegroup.com/index.php/JPM

Fitriah, A. H. (2018). Buku_Saku_Gizi_Ibu_Hamil_Full (1st ed.). media nusa creative.

Lestari, widia. (2023). asuhan kebidanan kehamilan (E. Rianty, Ed.; cetakan pertama, Vol. 1). 2023.
Lestari, S., Fujiati, I. I., Keumalasari, D., Daulay, M., Martina, S. J., & Syarifah, S. (2018). The prevalence of
anemia in pregnant women and its associated risk factors in North Sumatera, Indonesia. IOP Conference
Series: Earth and Environmental Science, 125(1). https://doi.org/10.1088/1755-1315/125/1/012195

Lugita Sari, L. (2021). Faktor-Faktor Yang Berhubungan Dengan Kejadian Anemia Pada Ibu Hamil The Related
Factosr to The Event of Anemia in Pregnant Mothers. In Jurnal Sains Kesehatan (Vol. 28, Issue 3).

Padma. (2017). Skripsi Faktor-Faktor Yang Mempengaruhi Kejadian Anemia.

Priyanti, S., Dwi, A., & Irawati, D. (2020). anemia dalam kehamilan (E. Kartiningrum, Ed.; 1st ed., Vol. 1). stikes
majapahit mojokerto.

Profil Kesehatan Kota Bandar Lampung, 2022. (n.d.).

Rizki Fauzan, M., Kaseger, H., Studi Kesehatan Masyarakat Fakultas Ilmu Kesehatan Institut Kesehatan dan
Teknologi Graha Medika, P., & Studi Keperawatan Fakultas Ilmu Kesehatan Institut Kesehatan dan
Teknologi Graha Medika, P. (2022). Hubungan Indeks Masa Tubuh Ibu Hamil Dengan Kejadian Anemia Di
Wilayah Kerja Puskesmas Motoboi Kecil. In Graha Medika Public Health Journal (Vol. 1, Issue 1).
https://journal.iktgm.ac.id/index.php/publichealth

Sari, A. P., & Romlah, R. (2019). Faktor yang Berhubungan dengan Kejadian Anemia pada Ibu Hamil Trimester
III. Journal of Telenursing (JOTING), 1(2), 334–343. https://doi.org/10.31539/joting.v1i2.982

Sari, S. A., Fitri, N. L., & Dewi, N. R. (2021). Hubungan Usia Dengan Kejadian Anemia Pada Ibu Hamil Di Kota
Metro. Jurnal Wacana Kesehatan, 6(1), 23. https://doi.org/10.52822/jwk.v6i1.169

Sulistyawati, W., Khasanah, N. A., Majapahit, S., Prodi, M., Kebidanan, D., & Id, W. C. (2019). Asuhan
Kebidanan Pada Ibu Hamil Dengan Anemia Dan Faktor Yang Melatarbelakangi.

World Health Organization (WHO). (2018). Prevalensi Kejadian Anemia pada Kehamilan.

Wibowo, N., Irwinda, R., & Hiksas, R. (2021). anemia defisiensi besi pada kehamilan (1st ed., Vol. 1). UI
Publishing.

Yudhya Muliani, E., Sa, M., Purwara Dewanti, L., Muh Asrul Irawan, A., Al Azhar, A., & Kec Kebayoran Baru
Jakarta Selatan, S. (2020). 1,2,3,4 Program Studi Gizi, Fakultas Ilmu-Ilmu Kesehatan Univesitas Esa
Unggul. Jl. Arjuna Utara, 4(2). https://doi.org/10.33757/jik.v4i2.289.g125