Antenatal care utilization on low birth weight children among women with high-risk births

Introduction

One of the focuses of the National Mid-Term Development Plan (RPJMN) in 2020–2024 was reducing the maternal mortality rate (MMR) and infant mortality rate (IMR).¹ Neonatal mortality rate (NMR) and IMR are indicators of child mortality, this figure shows an improvement since 1990. NMR decreased from 20 per 1,000 live births in 2002 to 15 per 1,000 live births in 2017 and IMR from 35 per 1,000 live births in 2002 to 24 per 1,000 live births in 2017.² However, this figure still has not reached the 2024 target, where NMR is expected to decrease to 10 per 1,000 live births and IMR to 16 per 1,000 live births.¹

The main causes of neonatal death in developing countries include low birth weight (LBW) and premature birth. Data showed that LBW and premature births were 19% in 2016.³ Babies with LBW are defined by WHO as babies born less than 2,500 grams regardless of gestational age.⁴ In Indonesia, the percentage of LBW has decreased slowly, from 11.2% in 2000 to 10.2% in 2012 then to 10.0% in 2015.⁴

Babies with LBW have a higher risk of stunting, low intelligence (IQ), and death in the first 28 days of life.^4,5 In addition, the risk of death at the age of under 1 year is 17 times greater than that of infants with normal birth weight.⁶ In adulthood, infants with LBW are at risk for obesity, heart disease, and diabetes.⁴

LBW can be caused by premature birth (<37 weeks), babies with small gestational age (SGA), or a combination of both.^4,7 The lower the gestational age, the lower the baby’s birth weight automatically because physiologically and anatomically the fetal organs have not grown and developed perfectly, and the risk of illness and death will increase.⁸

Premature births and fetuses that fail to thrive in the womb are influenced by four maternal factors, namely maternal malnutrition, maternal health problems during pregnancy, maternal characteristics, and other factors.⁴ In addition, obstetric factors such as maternal age, both too young and too old, significantly affect LBW.^9,10

Pregnancy in women with “4T,” namely “too young (gave birth <20 years), too old (gave birth >35 years), too close (short birth gap), and too many (a large number of children)” can have a positive effect on both the mother and the fetus being born.^8,11–15 This risk can be prevented or minimized by performing qualified antenatal care (ANC). ANC is important to prevent, detect and treat maternal and fetal health problems.^{3,8,11,12,16–18}

Since 2016, WHO has recommended pregnant women to have a minimum of eight pregnancy check-ups.¹⁹ WHO provides guidance for pregnant women to have a healthy pregnancy (positive pregnancy) through five interventions and 19 recommendations as well as several recommendations for specific cases.

Since 2020, it is agreed in Indonesia for pregnant women to make ANC visits at least six times, with at least two contacts with doctors in the first trimester to screen for risk factors/pregnancy complications; and in the third trimester for one-time delivery risk factor screening. Based on IDHS in 2017, National Family Planning stated that the coverage number of ANC visits (>4 times) in Indonesia was 90.6% and as many as 75% carried out pregnancy checks by health workers.²

The difference between this study and other similar studies is to look at the effect of ANC on women with 4T with the incidence of LBW. Therefore, this study aimed to determine the effect of ANC on women with 4T on the incidence of LBW. The hypothesis that is built is that qualified ANC in women of childbearing age with 4T reduces the risk of LBW events.

Methods

Results

The results of the univariate analysis presented a description of social, economic, and demographic characteristics as shown in Table 1. Descriptively, women in this study were relatively more middle-educated in each category (69% “too young”, 52% “too close”, 49% “too many”, and 45% “too old”). Based on the area of residence, the majority of women in the “too young” and “too many” categories are rural dwellers (66% and 53%), almost equal proportions of women in the “too close” category are urban and rural dwellers, and the majority of women in the "too old" category are urban dwellers.

Based on the wealth index, most of the women were in a low wealth index category: women who were “too young” (60%), “too many” (44%), and “too close” (47%). Based on employment status, more than half of the women were not working, namely, women who were “too young” (69%) and “too close” (52%). In addition, more than half of the women underwent pregnancy checks at health facilities, namely women with “too old” (79%), while “too young”, “too much” and “too close” were 77% each. The results of the descriptive analysis also showed that four out of five women had relatively more ANC check-ups with health workers in each 4T category. Table 1 also shows that women who perform qualified antenatal care in each 4T category have a percentage of less than 15%.

Based on the birth status of the children, almost all of them were born at term (normal) with a percentage above 90% in each 4T category. Likewise in all 4T categories, more children were born with non-LBW status (above 90%).

Discussion

Indonesia has tried to reduce infant mortality. One of the strategies is to prevent the incidence of babies with LBW. The results of this study showed that the birth incidence of LBW babies was almost the same in each 4T category, which is around 6 to 7%. This figure is lower than other Asian country, such as India.¹⁸ Also, comparing it to African country, the LBW in Indonesia is lower.¹⁷

The results indicate that ANC quality only affects LBW births in the category of too many children. Even so, previous studies also showed a significant relationship between ANC utilization and mothers who were too old (>35 years), whereas mothers who were too old were higher in using ANC.²⁰ However, mothers who were too young had higher knowledge than mothers who were too old.²¹ A previous study showed that most adolescent births were from mothers with a low education level.²²

Women with too many children and non-qualified ANC will have a 1.47 times higher chance of giving birth to LBW babies than women with too many children and qualified ANC. This was in accordance with research conducted in Padang, mothers with less than four ANC visits were more likely to give birth to LBW babies compared to mothers with four ANC visits.²³ Similarly, studies conducted in India¹⁸ and China⁸ also stated that a comprehensive antenatal examination was associated with a reduced risk of LBW in infants. Studies conducted in Rwanda,²⁴ Ethiopia,^12,16,17,25 and Sri Lanka¹¹ found that lack of ANC visits was associated with low infant weight. In a comprehensive ANC, including a complete number of visits, pregnant women carry out regular checkups, practice healthy living habits and obtain iron intake during pregnancy. Thus, they can detect problems, diseases, or complications during pregnancy early, including reducing the incidence of babies with LBW.^{12,13,16–18,24,25}

The results of this study showed that the age of childbirth has a significant effect on infants with LBW. Premature birth had the most significant impact on infants with low birth weight in the four 4T categories, namely “too young”, “too old”, “too many”, and “too close”. The World Health Organization (WHO) stated that premature birth is the cause of about one-third of LBW babies. Studies conducted in Yemen¹⁵ and Ethiopia²⁶ showed the same. Likewise, in Abu Dhabi, babies born prematurely have an 18 times higher risk of becoming LBW.⁷ This happens probably because fetal growth and weight gain mainly occur in the late period of pregnancy, so premature babies receive less nutrition which causes low birth weight.

Several socioeconomic and demographic characteristics such as education level, wealth index, and area of residence were significantly associated with the incidence of infants with LBW. The education variable has a significant relationship with the incidence of LBW in all four categories, except for women with births too young, which does not have a relationship with LBW incidence. In line with research conducted by Nuryani and Rahmawati, 2017 in Gorontalo Regency, there was a significant relationship between education level and the incidence of LBW (p=0.017).²⁷ This finding is in agreement with several studies conducted in other developing countries such as India,¹⁸ Ethiopia,²⁵ and Ghana.²⁸ Generally, women with higher education were more informed about the risks of not receiving health care during pregnancy and paid more attention to nutritional intake during pregnancy,^18,28,29 On the other hand, women with low education generally had less access to health facilities, especially economically.²⁵ However, the research conducted by Sharma et al. (2015) in Nepal and by Rahim FK and Muharry A (2018) in Kuningan showed different things, where maternal education was not associated with the incidence of LBW.^30,31

Regarding the wealth index in this study, among women with too old and too many, it is seen that low wealth index are more at risk for giving birth to babies with LBW compared to high wealth index. Studies in India¹⁸ and Sri Lanka¹¹ showed similar results, where the incidence of LBW decreases with an increasing wealth index.

The residence variable is seen only in the category of too many children, which has a significant effect on LBW births. Women with too many children who live in urban areas are 1.37 times more likely to give birth to LBW babies than women in rural areas. In line with research conducted by Mohammed S et al. (2019), the probability of giving birth to an LBW baby was significantly higher in urban residents.³² This is different from the results of the study by Kaur et al. (2019) that found that LBW was more common in rural areas than in urban areas (9.8% vs. 2.0%, p=0.03)³³ and some studies conducted in Ethiopia.^16,17 This may be related to the education level of women who generally have low and middle education in this study.

Conclusion

Based on bivariate testing or together with other variables, qualified ANC only has a significant effect on the incidence of LBW in women with the “too many” criteria. It is known that the most influential variable on LBW in women with 4T is premature birth. Besides that, it is known that with a low level of education women who give birth too close have the highest chance of giving birth to LBW compared to the other “4 too” criteria. Likewise, women who are “too old” and “too many” with a low wealth index and women who are “too many” who live in urban areas have the highest chances of giving birth to LBW.

The findings show that the recommendations for qualified ANC according to WHO standards have not been fully implemented. In the case of qualified ANC including ANC visits of at least eight times, it is hoped that ANC with health workers at health facilities can be increased. It is also necessary to increase the monitoring of pregnant women with the risk of 4T to continue making ANC visits to reduce the risk of preterm and reduce LBW births. Moreover, increasing education and counseling related to maturing the age of marriage, reproductive health, family planning (spacing), and the dangers of 4T to reduce the risk of LBW events in women with 4T in various information media.