Research Article

Portuguese Journal
of Public Health Received: May 11, 2023
Port J Public Health 2024;42:6–14
Accepted: October 7, 2023
DOI: 10.1159/000534708 Published online: November 16, 2023

Anemia in Pregnancy: Study

Phenomenology
Rina Doriana Pasaribu a Evawany Aritonang b Etti Sudaryati b
Fikarwin Zuska c

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a
Student of Doctoral Program, Faculty of Public Health, Universitas Sumatera Utara, Medan, Indonesia; bFaculty
of Public Health, Universitas Sumatera Utara, Medan, Indonesia; cFaculty of Social Science and Political Science,
University Sumatera Utara, Medan, Indonesia

Keywords women. The policy of administering iron tablets to pregnant

Anemia · Iron tablet · Pregnancy · Preconception · women to prevent anemia is not effective in reducing the
Phenomenology prevalence of anemia. This government policy must be
accompanied by a community movement program because
the findings of this study show the problems that exist in the
Abstract individual factors of the mother.
Introduction: The prevalence of anemia in pregnant women © 2023 The Author(s). Published by S. Karger AG, Basel
in Indonesia remains high. This condition is concerning on behalf of NOVA National School of Public Health

because the government has run a program of giving iron

tablets to pregnant women since 1970. This study aimed to Anemia na Gravidez: Fenomenologia do Estudo
determine socioenvironmental factors that cause anemia in
pregnant women. Methods: This qualitative research used
phenomenological methods. In-depth interviews were Palavras Chave
conducted with 20 mothers with anemia and 12 focus group Anemia · Comprimidos de ferro · Gravidez ·
discussion (FGD) informants. Qualitative data analysis was Pré-concepção · Fenomenologia
applied to analyze the data. Results: The study found three
factors: anemia in the preconception period, diets that cause
a lack of iron consumption, and knowledge and con- Resumo
sumption of iron tablets in pregnant women. Anemia in Introdução: A prevalência de anemia em gestantes na
pregnant women is a continuous cycle of anemia which Indonésia ainda é alta. Essa condição é bastante pre-
begins in the preconception period. Adolescent eating ocupante porque o governo mantém um programa de
behavior and supplementation programs for pregnant administração de comprimidos de ferro para mulheres
women integrated with antenatal care are still problematic. grávidas desde 1970. Este estudo visa determinar os
Discussion and Conclusion: The findings of this study fatores socioambientais que causam anemia em mul-
provide important information for preventing anemia in heres grávidas. Métodos: Este estudo é uma pesquisa
pregnant women, increasing counseling, and evaluating the qualitativa com métodos fenomenológicos. Foram
implementation of iron supplementation in pregnant

karger@[Link] © 2023 The Author(s). Published by S. Karger AG, Basel Correspondence to:
[Link]/pjp on behalf of NOVA National School of Public Health Rina Doriana Pasaribu, rinadoriana @ [Link]

This article is licensed under the Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC) ([Link]
[Link]/Services/OpenAccessLicense). Usage and distribution for
commercial purposes requires written permission.
 realizadas entrevistas aprofundadas com 20 mães que
counseling [8]. Consumption of iron is needed by
tinham anemia e 12 membros de um focus group. A
pregnant women to prevent maternal and fetal anemia
análise qualitativa dos dados foi aplicada para analisar os
and other complications. Pregnant women are expected
dados. Resultados: O estudo encontrou três fatores,
to consume more than 90 iron tablets during pregnancy.
nomeadamente anemia no período pré-concepcional,
But in fact, 80.7 percent of pregnant women do not
dietas que provocam falta de consumo de ferro e con-
consume iron tablets [8–11].
hecimento e consumo de comprimidos de ferro em
A lack of iron consumption during pregnancy can lead
mulheres grávidas. A anemia em mulheres grávidas é um
to anemia in pregnant women. The prevalence of anemia
ciclo contínuo de anemia que começa no período pré-
in pregnant women in Indonesia in 2018 was as high as
concepcional. O comportamento alimentar de ado-
48.9 percent, which means that 5 out of 10 pregnant
lescentes e os programas de suplementação para ges-
women suffer from anemia. This condition is alarming
tantes integrados aos cuidados pré-natais ainda são um
because the government has run programs for iron tablet
problema. Discussão/Conclusão: Os resultados deste
supplementation in pregnant women since 1970. So-
estudo fornecem informações importantes para prevenir
ciocultural factors also contribute to anemia. The absence
a anemia em gestantes, aumentar o aconselhamento e
of certain food knowledge in pregnant women contrib-
utes to anemia. There are also suggestions that during

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avaliar a implementação da suplementação de ferro em
gestantes. A política de dar comprimidos de ferro às
pregnancy, pregnant women’s food should be reduced
grávidas para prevenir a anemia não é eficiente na re-
because, in case the fetus becomes large, there is a fear
dução da prevalência de anemia. Essa política governa-
about the labor [1, 8, 12–14]. Based on the above, the
mental deve ser acompanhada de um programa de
discussion of the concept of EMIC that causes anemia is
envolvimento comunitário, pois os resultados deste es-
interesting for studying the factors and finding an attempt
tudo mostram os problemas que existem nos fatores
to tackle the problem of anemia. This study aimed to
individuais da mãe.
determine the basics or factors that are contextual causes
© 2023 The Author(s). Published by S. Karger AG, Basel
which could contribute to maternal anemia and efforts to
on behalf of NOVA National School of Public Health combat anemia in pregnant women from the perspective
of pregnant women themselves. These findings will
provide a better understanding of anemia during preg-
nancy for the prevention and control of anemia in during
Introduction pregnancy.

Anemia is a major public health problem affecting

both developed and developing countries. According to
Materials and Methods
the World Health Organization, the prevalence of anemia
among pregnant women in developed countries is ap- This research is qualitative research using a phenomenological
proximately 14 percent, whereas it remains as high as 51 survey approach [15, 16]. This study uses phenomenological re-
percent in the developing world [1–4]. Anemia in search and ethnographic methods. Research on phenomenology
pregnancy is called a “potential danger to mother and and ethnographic methods is qualitative research that departs
from a phenomenon found in the field and reveals about culture
child” to be taken seriously by all parties involved in and people’s lives. Phenomenology is a qualitative research ap-
health care at the forefront line [3, 5–7]. proach that describes the meaning of the life experience of a
The results of basic health research conducted by the phenomenon in several individuals, which in this case is anemia
Indonesian government (Riskesda 2018) show that an- during pregnancy. Moustakas’ transcendental phenomenological
tenatal visits in Indonesia are still low at 86.6 percent for approach, adapted from Husserl, was applied in this study, namely
focusing on the descriptions given by the participants to produce
K1 (first antenatal visit to the midwife) and antenatal
the essence of life experiences. The ethnographic type is research
visits four times only 74.1 percent. Pregnant women who that is more about “portraits of people” about descriptions of
do not perform will not receive any antenatal visits (7T) particular cultures, customs, beliefs, and behavior.
or assistance that includes weight scales and iron tablets. The objective of this study was to understand the phenomenon
7T antenatal care includes weighing, measuring blood of anemia in pregnant women, which includes contextual factors
pressure, measuring the height of the fundus, providing that influence anemia in pregnant women, as seen in the cases that
have been studied in this research, as well as efforts to combat
complete tetanus toxoid immunization, provision of iron anemia in pregnant women. The study participants were 20
(Fe) tablets of at least 90 tablets during pregnancy, testing pregnant women with anemia and 12 with focus group discus-
for sexually transmitted diseases, and referral preparation sions. Pregnant women participants who met the requirements

Anemia in Pregnancy Port J Public Health 2024;42:6–14 7

DOI: 10.1159/000534708
were identified by first checking their HB (hemoglobin) levels. This Data Analysis: Tolley et al. [15] (2005) stated that qualitative
examination was conducted by a research team in collaboration data analysis began with spaciousness [15, 17]. Data analysis was
with the Tanjung Rejo Community Health Center. A total of 48 performed manually and simultaneously with data collection. The
pregnant women were examined, and 72.92 percent of pregnant interviews were transcribed word for word by all authors. The texts
women had anemia (35 women). were read several times to identify general ideas. Units of meaning
Informants were directly recruited, carried out on purpose, and were identified, related units of meaning were combined, and
designed to produce maximum varieties according to age, gravida, codes were generated. Similar codes were combined, and codes
educational level, employment status, economic social status, and that had related meanings were grouped into subcategories. After
residence. Variety in sampling is based on these factors, as they comparing the subcategories, the conceptually similar subcate-
affect maternal awareness and eating behavior during pregnancy. gories were combined to form the main category.
In addition, the inclusion criteria were pregnant women with Credibility was achieved by spending sufficient time on data
anemia; willingness to participate in research and provide in- collection (approximately 8 months), ensuring diversity of par-
formed consent; and the ability to understand, speak, and com- ticipants, and including member checking (in which transcripts
municate in Indonesian interviews. The exclusion criteria were were returned to the participants for comment or correction). To
pregnant women with severe anemia and reluctance to participate confirm the validity of the data, coded interviews were conducted
in any stage. The interview was conducted by the first author, a with six participants and their final opinions were determined.
female doctoral candidate in public health who is familiar with Members of the research team actively transcribed and analyzed
the results, a process that included reviewing interviews and codes,
qualitative research, has 20 years of work experience in the field of
discussing the findings, and compiling the final results. De-

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community nutrition, and is interested in this research topic.
pendability and conformability increased through external
Other authors are experts in qualitative studies. The second and checking and peer debriefing. Regarding transferability, purposive
third authors are professors and PhDs in public nutrition, and the sampling was used to obtain maximum variety. Authenticity was
fourth author is a doctor of anthropology familiar with qualitative evaluated through member checking, in which participants
research, especially ethnographic research. A combined method of compared the results documented by the research team to their
interviewing and sharing stories is applied. The interviewer pro- views.
vided open-ended questions and allowed time for participants to
tell their stories. In conducting the interviews, the researcher did
not use a list of questions, but the researcher asked the participants
to follow the storyline. This method aims to provide flexibility and Results
comfort for participants to express their opinions and under-
standing without the impression of patronizing/teaching and
directing them. The factors found were categorized into three thematic
In conducting the interviews, the researchers made home visits. groups in our article, namely:
The number of interview visits was different for each participant,
but the average number of interview visits for each person was 4–5 Anemia in the Preconception Phase
times. The first visit aimed to build relationships with participants All informants interviewed were married early aged
so that the interviewer had a close relationship with them. Since the
participants were generally housewives, the interview time was
16–20 years. During adolescence, they go on a diet that
adjusted according to their conditions. Interviews were conducted limits their food intake so that they do not become fat. Six
naturally, such as when the mothers cooked, cleaned the house, or informants experienced miscarriages due to anemia.
washed dishes and clothes. The interviews ranged from to 30–60 Eleven informants stated that before marriage, they had
min. To triangulate the data, the researcher interviewed the experienced symptoms compatible with anemia, such as
husbands of the participants and the parents of pregnant women weakness, lethargy, and pallor, but had never seen a
who lived with their parents. The list of questions for this tri- doctor. Six people were diagnosed by doctors with anemia
angulation was created based on the results of the interview with
the pregnant woman. in their teens due to fainting during menstruation. They
The interviews were recorded with the consent of all partici- stated that their anemia was normal, so it was not a
pants. Field notes were taken during the interviews. The researcher frightening problem.
also recorded observations of nonverbal behavior, encounters, and
interactions. The data collection procedure was carried out until P1: “. . . when I was pregnant I didn’t like to eat before I became
data saturation occurred, that is, no new data were found. After in- pregnant even when I was a teenager I didn’t like to eat, I liked
snacking on crackers and snacks. It’s normal like that until I was
depth interviews were conducted, Focus Group Discussions
pregnant.”
(FGDs) were conducted with key informants.
The results of in-depth interviews serve as the theme of the P12, who married at the age of 18, shared the same
FGD. Twelve FGD informants were involved with pregnant thing. Based on the results of the anemia screening, the
mothers at health centers amounted to 12 people. The FGD in-
formants consisted of one nutrition officer, two staff villages
mother was indeed suffering from anemia. She was
(village office), three midwives, a midwife coordinator, the head of pregnant with her second child at 5 months, but when she
the health center, two cadres, and two pregnant women. FGDs was pregnant with her first child, she had a miscarriage at
were conducted in the conference rooms of the PHC Tanjung Rejo. 4 months.

8 Port J Public Health 2024;42:6–14 Pasaribu/Aritonang/Sudaryati/Zuska

DOI: 10.1159/000534708
 P12: “I was pregnant with my second child, but my first child iron levels and consequently the concentration of ma-
when I was 4 months pregnant had a miscarriage. The doctor ternal hemoglobin, but ronggeng prawns are also not
said I was anemic. During pregnancy, I was indeed weak and
dizzy. But before I got pregnant I also often had sudden
consumed because they are bored with the taste of the
headaches. As a teenager, I’ve experienced symptoms like this prawns. A diet that illustrates the lack of intake of iron
a lot.” was also influenced by their favorite foods, such as in-
formants liked to eat instant noodles since the girl and
P20 is a mother aged 20 years and is pregnant with the
continued during pregnancy. Informants eat instant
first child at 5 months of pregnancy. She states that
noodles without a full meal, such as rice, vegetables, and
adolescents (before marriage) are already suffering from
side dishes.
anemia (what she calls anemia) but have never seen a
doctor. I know from the symptoms, namely, easily tired, P5: “......I usually eat small portions. As the girl, I also lazy to eat
weak, dizziness, and slight menstrual blood. vegetables. Eating fruit cannot be right during pregnancy. My
mother forbade me to eat fruit, especially when young and
P20: “I do not know that I am pregnant now lacking blood pregnant. Because it tastes sour fruits that can result in
because I felt when I was pregnant now I was healthier before heartburn during pregnancy. Fruit that can be eaten during
marriage. When I was a girl, I liked to diet. I often took slimming pregnancy is just bananas alone. And that’s not often.
drugs. When I was a teenager, I often experienced dizziness even Bored too.”
when I was a girl – suddenly fainted. Blood was a little. So when I

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was pregnant I never fainted again. Dizziness and fatigue are P8: “.... fish here a lot, but bored to eat the fish hold. Better to eat
common for pregnant women. The mother said that she often ate tofu or tempeh or eggs. Cheap and tasty. If you eat meat, it is
satay and ate the fruit to add blood. So, since this pregnancy, I expensive. It is difficult to find meat in the stall, must be ordered
have eaten satay almost every time, night.” first. When there is a party, then I eat meat.”

The anemia experienced by the informants at this time P15: “....I prefer to eat tofu, tempeh, and eggs. The fish here is
plentiful, but fish will cause the baby to smell fishy. If you eat
was probably related to previous medical history. From meat, it’s very expensive.”
the interviews, it was also found that the informant had
anemia. P17: “I do not like to eat anything if there is no instant noodle.
Every day I eat instant noodles.”
P4: “When I was pregnant with my first child, I had a Hb test. At
that time, there was also a free check in the village; he said I was Like the previous informant, this pregnant woman is
anemic.” also aware that prawn ronggeng can help to increase
P7: “When I was a teenager, I often got dizzy. I got tired easily
hemoglobin, but she also does not consume this food,
and even fainted when I was menstruating. I went to the doctor being cheap.
and the doctor said I was anemic.” “the ronggeng prawn also can blood added, but it can make you
feel dizzy when you eat it.” (P1, P9, P11, P13, P17)
Diets That Cause Lack Consumption of Iron
“the ronggeng prawn also can blood added, but it should not be a
From interviews with informants, we found that the
lot. Later his son fat times.”(P5, P8, P16)
pattern of consumption illustrates the lack of intake of iron
from the daily menu for pregnant women. The con- In addition to a favorite food, some drinks are also
sumption of green vegetables as a source of iron was also one of the possible factors causing the lack of iron
low. Fruits are a source of vitamin C, which aids the intake in the body, as some informants like coffee and
absorption of iron in the body is also very less. In addition sweet tea. From the interviews, several informants liked
to current eating habits, consumption of meat, vegetables, drinking hot tea while eating to prevent nausea and
and fruit is also influenced by economic factors and myths. vomiting. Advertisements on television also greatly
From the interview, the informant stated that they were affect the diet of pregnant women, such as instant
bored of eating fish, and some also stated that the fish was noodle advertisements that provide a lot of nutrition.
not consumed during pregnancy because of the stench The diet of the informants did not vary, and meal
which may have resulted in the birth of the baby being too portions were incompatible with the food portions
fishy. The consumption of meat is the best source of iron, recommended for pregnant women. Pregnant women
and in addition to being expensive, meat is also difficult to prefer to eat instant noodles and drink milk because
find in shops/markets. If there is a party, they eat meat. they believe that the nutrients they need have been met
The informant also stated that they know if shrimp or by this type of food. Daily consumption of pregnant
prawn ronggeng centipedes, which are found in the milk is believed to have adequate levels of nutrition
village, and their cheap price can contribute to increasing during pregnancy.

Anemia in Pregnancy Port J Public Health 2024;42:6–14 9

DOI: 10.1159/000534708
 P11: “I always eat with warm sweet tea to prevent nausea and P4: “I am pregnant with my fourth child. However, the midwife
vomiting.” never told me about the iron tablets. The midwife only gives
tablets which in my opinion are medicines for pregnant women.
P19: “... I have the habit of drinking coffee because the body feels The midwife just reminded me not to forget to take the medicine.
fresh coffee. This coffee drinking habits I have had since I was a That’s all.”
teenager.”
P7: “Every month I check with the midwife, the midwife will
Knowledge and Consumption of Iron Tablets in measure my blood pressure and listen to my baby’s heartbeat.
There is a device stuck in my stomach. The midwife declared my
Pregnancy child healthy. However, every checkup the midwife gave me
The informant did not know the function or benefits of medicine. I didn’t know what medicine it was, the midwife never
taking an iron tablet. Informants knew the Fe tablet given explained it. The midwife said, don’t forget to take medicine so
to the midwife every month as the blood booster, great that the baby is healthier. I just want to know it’s a blood booster,
shape, and the color red. Informants had a common right? Because it’s red and well-shaped. My friend said it was a
blood booster, even though I didn’t take it because my baby is
understanding of the lack of blood related to the blood healthy.”
pressure that is measured each month. The informant
states that if their blood pressure is good, then they are P8: “... every month I go to the midwife for antenatal care. When
I go to the midwife for antenatal care, I get 5 Fe tablets, but I
not anemic, so there is no need to take an iron tablet given

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never take them.”
by a midwife. Informants also argue that it is a blood
booster medicine. In large numbers, drugs are not con- The Phenomenon of Anemia in Pregnant Women
sumed by pregnant women. Informants do not consume Figure 1 illustrates the anemia cycle that occurs in
iron tablets because of the large tablet size, smell, nausea, pregnant women.
and fear because of the black stool.
The informant also stated that she never received an
explanation or clarification from the midwife about the iron Discussion
pills when they were given. The research team also found that
the number of iron tablets received by participants varied In our study, we found that dietary problems during
each month. However, some informants received only 10 adolescence persisted during pregnancy. This error in the
iron tablets from midwives during antenatal examinations. adolescent diet predisposes pregnant women to anemia.
Some of the informants received only five iron tablets. If the A balanced diet during childhood and adolescence is
informant did not examine the midwife, the informant did essential not only for a child’s well-being and growth but
not obtain an iron tablet. Lack of communication, education, also for the formation of healthy eating habits that will
and information from midwives to pregnant women causes a continue [18–20]. The results showed that the habit of
lack of knowledge about the importance of consuming iron limiting certain food intake during adolescence and fa-
tablets during pregnancy. Pregnant women stated that iron vorite foods during adolescence continued to become a
tablets given by midwives are drugs that are not good for habit during marriage and even during pregnancy.
consumption during pregnancy. Adolescents are one of the most vulnerable groups to
P12: “Every month I do a pregnancy check-up with the midwife. anemia and are the least explored area. The prevalence of
The midwife gave me 10 tablets of medicine. The midwife said anemia among adolescent girls in this category remains
the drug was for a blood booster. But I don’t take the medicine relatively high. Adolescence is a transition period between
because my blood pressure is normal, so why should I take the childhood development and childhood to adulthood
medicine?”
involving biological, cognitive, and socio-emotional
P5: “Fe tablets are medicine. I have heard information on changes. The iron requirement increases in adoles-
television that states pregnant women should not take much cence, both in young men and women. Young women
medicine. If a pregnant woman eats a lot of drugs while preg- require a high iron intake to replace the loss during
nant, it can cause her child to have a disability. That’s why I
never ate the Fe tablets given by the midwife. I am afraid my son menstruation. In addition, young women’s attention to
is deformed.” their ideal body shape is very high, so young women often
limit their food intake. An unbalanced diet with nutrient
P11: “I did not ever drink tablet that the red color bu. this requirements results in a lack of essential nutrients, such
medicine treatment. I’m fine really. Besides, taking medicine was
not good for a lot of pregnant women, right, Mom? Each month as iron [21–23].
midwife said indeed, do not forget to take his medication yes Adolescent girls are usually very concerned about body
ma’am, but that’s mom, not my ever eaten.” shape, which limits and restricts food consumption.

10 Port J Public Health 2024;42:6–14 Pasaribu/Aritonang/Sudaryati/Zuska

DOI: 10.1159/000534708
Fig. 1. Cycle of anemia.

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When food intake is less than iron stores, iron levels program for giving iron tablets to adolescents before
drop. Anemia can cause teens to quickly be tired, and pregnancy (preconception) based on the results of the
learning concentration decreases, resulting in low discussions (FGD) that have been conducted. Adoles-
learning achievement and decreased productivity. cence is associated with anemia and malnutrition during
Moreover, it lowers the immune system, making it sus- pregnancy. From the results of in-depth interviews and
ceptible to infection. If not treated properly, the high focus group discussions, it was found that unhealthy
prevalence of anemia among adolescents will continue eating patterns during pregnancy caused a lack of iron
and contribute greatly to the incidence of anemia at the intake. Lack of knowledge and skills of pregnant women
time of pregnancy [19, 23–25]. in providing healthy food during pregnancy is a major
Anemia in pregnant women is a health problem factor causing anemia, in addition to economic factors.
worldwide, especially in developing countries. The World Pregnant women are one of the groups most vulnerable to
Health Organization (WHO) reports that the prevalence of malnutrition because of the increased nutritional need to
pregnant women experiencing iron deficiency is around meet the needs of the mother and fetus. A wrong diet in
35–75% and increases with gestation. According to the pregnant women has an impact on the occurrence of
WHO, 40% of maternal mortality in developing countries nutritional disorders, including anemia [13, 24, 33].
is related to anemia during pregnancy, and most anemia in The sources of iron are animal foods, such as meat,
pregnancy is caused by iron deficiency and acute bleeding, chicken, and fish. Other good sources include eggs,
even less so in the two who interact [4, 26, 27]. mashed cereals, nuts, green vegetables, and fruits. In
Efforts to prevent anemia in pregnant women have addition to the amount of iron, the quality of iron in food
been made with iron supplementation during pregnancy; is also known as its bioavailability. In general, iron in
however, the results are unsatisfactory, which is low and meat, poultry, and fish has high bioavailability; iron in
cannot be replaced by a daily iron-based diet alone or by cereals and legumes has moderate bioavailability; and
taking iron supplements alone during pregnancy. In iron in most vegetables, especially those containing high
theory, iron supplements should be administered before oxalic acid, such as spinach, has low biological avail-
pregnancy to anticipate a decrease in body iron reserves. ability. It is necessary to pay attention to the combination
This failure may be due to low iron stores that are empty of a daily diet consisting of a mixture of iron sources from
before pregnancy (preconception), especially in devel- animals and plants as well as other sources of nutrients
oping countries. Therefore, iron supplementation during that can help absorb resources. The food menu in In-
pregnancy is insufficient to prevent anemia [28–32]. donesia should consist of rice, meat/chicken/fish, nuts,
Cases of anemia in adolescents and the phenomenon and vegetables and fruits rich in vitamin C [13, 34–37].
of increasing early marriage (married youth) in the The results of the study found that pregnant women
community affect the incidence of anemia in pregnant rarely consume meat because of the high price and lack of
women. For this reason, it is necessary to conduct a meat availability in food stalls.

Anemia in Pregnancy Port J Public Health 2024;42:6–14 11

DOI: 10.1159/000534708
 The results of in-depth interviews found that the daily Conclusion
intake of iron from food was very small, and the in-
formants also did not consume iron tablets provided by Pregnant women have anemia before they become
midwives; these are two factors to contribute to the pregnant. Adolescent eating habits (preconception),
occurrence of anemia in pregnant women. Based on the such as limiting food intake and favorite foods, continue
FGD and adjusted to the theory and research results of during pregnancy. The diet of pregnant women, which
Fatima (2011), Ojofeitimi EO (2008), and Soeliastio- does not reflect a varied and balanced diet, causes an iron
ningsih (2020), several things need to be done to deficiency. People often prefer to drink coffee and tea
overcome the problem of anemia in this research locus, when eating. Lack of knowledge and compliance of
namely [11, 34, 37]: The dose of iron supplementation is pregnant women in consuming iron tablets and lack of
adjusted according to the level of iron kinetics (ferritin health education by midwives when administering iron
and transferrin saturation); adjusting a balanced diet tablets to pregnant women exacerbate the problem of
based on the food pyramid so that macronutrient and anemia in pregnant women. Guidelines for adminis-
micronutrient needs can be met; increasing the con- tering iron tablets to pregnant women have not been
sumption of food sources of iron, especially from animal implemented, and there is a lack of evaluation and
protein; increasing the consumption of foods that can monitoring of the implementation of blood supplement

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increase the solubility and bioavailability of iron, such as tablets.
vitamin C; limiting the consumption of foodstuffs that Limitations of the study were as follows: the reference
can inhibit iron absorption, such as foods containing to anemia was only associated with anemia caused by lack
polyphenols or pitat; taking iron and folic acid sup- of iron, other causes of anemia were not considered, and
plements before pregnancy is planned for at least women could have anemia due to another etiology such
3 months and provision of nutrition education during as hemoglobinopathies or a deficit of other elements such
preconception. as folic acid. Conclusions were only drawn based on the
The results of in-depth interviews with informants given by the informants, which can be very limiting. Some
revealed that they did not know the benefits of consuming information may not be complete, and other limitations
Fe tablets, the number that must be consumed during that the study may have given are that it is a qualitative
pregnancy, and the side effects of consuming Fe tablets. analysis.
The informants also stated that the iron tablets received
were drugs, and they interpreted anemia as a measure a
blood pressure measurement that is checked during every Acknowledgments
antenatal care examination. If their blood pressure is We would like to thank the Ministry of Health of the Re-
normal, they do not have anemia. The results of the FGD public of Indonesia for funding this research. We also thank the
showed that midwives also lacked communication/health research informants who shared their stories so openly and
education for pregnant women when giving Fe tablets. frankly. The author comes from Indonesia and is a native
Indonesian, who is not familiar with Portuguese. If the author
According to the Ministry of Health (2002), iron sup- has many writing errors, we apologize and ask for help. Thank
plementation must be accompanied by information or you for your generosity. This issue is very important in In-
education about anemia [38]. This is to increase the donesia and also has an impact on the high number of stunting
knowledge of pregnant women about anemia and Fe cases. Prevention programs that have been carried out by the
government have not shown a significant impact.
tablets so that they want to consume iron (Fe) tablets.
Changes in a person’s behavior are based on knowledge
[24, 33].
Statement of Ethics
Many studies have indicated that factors such as ed-
ucation, age at marriage, socioeconomic status, poor Informed consent was submitted to the prospective infor-
knowledge, lack of birth spacing, and history of anemia mant. The researcher explains the aims and objectives of the
before pregnancy are significant determinants of anemia. research. Researchers ensure the confidentiality of all infor-
Another study on influence of awareness and attitude mation provided by informants and are only used for research
purposes. We confirm all personal/identifying information has
about anemia in South India found that, in women in been removed or disguised so that the person described cannot
rural areas misconceptions regarding oral iron intake and be identified and cannot be identified through the story details.
lack of counseling by health workers were significant Prospective informants who are willing have signed the con-
predictors of anemia [39–41]. sent form. And prospective informants are not willing;

12 Port J Public Health 2024;42:6–14 Pasaribu/Aritonang/Sudaryati/Zuska

DOI: 10.1159/000534708
researchers do not compel and respect the rights of prospective Author Contributions
informants. Before the implementation of the study, the re-
searcher had obtained ethical clearance approval from the All authors contributed equally to this work.
Medical Ethics Commission of the Politeknik Kesehatan RI
Medan, Indonesia.
Data Availability Statement

Conflict of Interest Statement All data generated or analyzed during this study are included
in this article. Further enquiries can be directed to the corre-
No potential conflict of interest was reported by the authors. sponding author.

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DOI: 10.1159/000534708