The Maternal Mortality Rate (MMR) in Indonesia is still quite high, according to statistical data from the World Health Organization (WHO) which illustrated that Indonesia is in 7th place out of 11 countries in Southeast Asia, with MMR reaching 148/100,000 live births. Where the target of the Sustainable Development Goals (SDGs) is <70 per 100,000 live births. Although there has been a decline and increase in the MMR in Indonesia since 1991-2007 (42%), 2012-2015 (57%), 2015-2019 (15%), but the MMR in Indonesia is still less than 70 per 100,000 (305/100,000 KH) [1].

Anemia in pregnant women is associated with increased preterm birth, maternal and child mortality and infectious diseases. Iron deficiency anemia in pregnant women can affect the growth and development of the fetus/infant during pregnancy and afterward. It is estimated that 38.2/% of pregnant women worldwide are anemic. At least half of it is due to iron deficiency. Pregnant women are declared anemic if the hemoglobin is less than 11 g%/dL. Anemia in pregnancy, makes the mother unable to cope with blood loss and makes her more susceptible to infection. Anemia can also cause fetal hypoxia, prematurely and influence on maternal mortality. The incidence of anemia is investigated in order to detect anemia in pregnant women early, So that it can be handled properly. If anemia is not treated quickly, it will lead to serious consequences such as a bleeding. 

According to the Indonesian Ministry of Health, as many as 48.9% of pregnant women in Indonesia experience anemia. According to the DIY Ministry of Health, the causes of maternal death are various, such as heart disease, bleeding, eclampsia, sepsis/infection, but the majority are caused by bleeding. Bleeding is usually caused by anemia, because previous studies have found that the risk of bleeding is 5 times greater for mothers with anemia. Other factors that cause anemia in pregnant women, such as the age of pregnant women >20 years <35 years, parity of pregnant women, birth spacing, gestational age, maternal knowledge, economic factors, nutritional status of pregnant women, education level, antenatal care (ANC), compliance with Fe tablet consumption, medical history, how to consume blood-added tablets (TTD) [2]. The difference in the previous research is that the researcher will take a sample using a cohort and maternal medical records, as well as the research site that covers all health centers in Sleman Regency. Because of the COVID-19 pandemic, secondary data collection was carried out to avoid contact between individuals.

Efforts to reduce the prevalence of anemia in pregnant women have been carried out by the Indonesian Ministry of Health through the administration of Fe tablets. Fe tablets containing iron are minerals that the body needs to form red blood cells (haemoglobin). Lack of Fe tablets can cause anemia, especially in pregnant women. Anemia in pregnancy makes the mother unable to cope with blood loss and makes her more susceptible to infection. Anemia can also cause fetal hypoxia, premature delivery and influence on maternal mortality. The high rate of anemia in the second and third trimesters of pregnancy is associated with socioeconomic status [3]. In this study, the proportion of anemia in pregnant women in the second and third trimesters was greater in mothers with low economic status. In addition, the short birth spacing also causes anemia, because the mother's condition has not yet recovered and the fulfilment of nutritional needs is not optimal, but she must meet the nutritional needs of the fetus she is carrying. Pregnant women with a risk age of <20 years and >35 years can cause the incidence of anemia by 15 times [2].

The prevalence of anemia in pregnant women in Yogyakarta is still below the national target (102/100,000 live births) [4]. The prevalence of anemia in pregnant women in Kulonprogo is 12.88%, Bantul is 16.32%, Gunung Kidul is 16.77%, Sleman is 10.46%, Yogyakarta is 35.49% [4]. Compared to other districts in Yogyakarta, anemia cases in Sleman are lower than others. Although, previous studies have been conducted to observe the causes of anemia in pregnant women, iron deficiency is still the main cause of high morbidity and mortality in fetuses, including in Indonesia. Given the importance of the consequences that can arise from anemia during pregnancy, the authors are interested in researching "Determinants of the Incidence of Anemia in Pregnant Women in Sleman Regency". Therefore, researchers want to explore anemia in pregnant women in terms of maternal age, gestational age, gestational distance nutritional status and history of antenatal care (ANC) in pregnant women [5,6,7].

Research Method

This type of quantitative research with correlation studies is a study to determine whether there is a relationship between two or more variables. The study design used was nested-case control using cohort data on pregnant women in Sleman Regency, with 389 pregnant women as respondents. The data collection method in this study used a documentation study to obtain secondary data from the status of the mother and the cohort of pregnant women. The inclusion criteria in this study were pregnant women who had their pregnancy checked in all Public Health Centers of Sleman Regency. The exclusion criteria are missing data. 

The independent variables of this study were maternal age, nutritional status, gestational interval and parity in pregnant women, while the dependent variable was anemia in pregnant women. This research has passed research ethics before proceeding to the data collection and analysis stage. The ethics were issued by the Ahmad Dahlan University Research Ethics Commission with ethics number 012102014. 

This research was conducted in all Public Health Centers of Sleman Regency with a total sample of 389 pregnant women. Secondary data collection using medical records and cohort of pregnant women.

There were 104 pregnant women (26.7%) who were not anemic, but 285 pregnant women with anemia (26.7%). Based on table 1, it was found that the age of pregnant women at the age of 20-35 years was 280 people (72%), while those aged <20 years and >35 years were 109 people (28%). Based on table 1, it was found that the nutritional status of pregnant women who did not experience SEZ was greater as many as 253 people (65%) compared to pregnant women who experienced SEZ as many as 136 people (35%).

The parity of pregnant women who were not at risk was 304 people (78.1%) compared to 85 people who were at risk (21.9%). Based on Table 1, it was found that the interval of pregnancy among pregnant women who were not at risk of 2 years was greater by 318 people (81.7%) compared to pregnant women who were at risk of <2 years as many as 71 people (18.3%).

There were 109 respondents who were at risk of age, 101 were anemic and 8 were not anemic. While 280 respondents were not at risk, 184 were anemic and 96 were not anemic. Based on the Chi Square test, the person chi-square section shows a value of 0.000 (x2). Because of the value of 0.000 <0.05, it can be concluded that there is a significant relationship between maternal age and the incidence of anemia in pregnant women in Sleman Regency.

There were 136 respondents with SEZ nutritional status (Lila 23.5 cm), 131 were anemic and 5 were not anemic. Meanwhile, 253 respondents with nutritional status without SEZ (Lila > 23.5 cm) were 154 were anemic and 99 were not anemic. Based on the Chi Square test, the person chi-square section shows a value of 0.000 (x2). Because of the value of 0.000 <0.05, it can be concluded that there is a significant relationship between gestational distance and the incidence of anemia in pregnant women in Sleman Regency.

Respondents, which amounted to 71 with gestational interval <2, there were 66 who were anemic and 5 were not anemic. Meanwhile, 318 respondents with a pregnancy interval of 2 years, 219 were anemic and 99 were not anemic. Based on the Chi Square test, the person chi-square section shows a value of 0.000 (x2). Because of the value of 0.000 <0.05, it can be concluded that there is a significant relationship between nutritional status and the incidence of anemia in pregnant women in Sleman Regency.

There were 54 respondents with parity >2 years, 78 were anemic and 7 were not anemic. While 304 respondents with parity 2 there are 207 who are anemic and 97 are not anemic. Based on the Chi Square test, the person chi-square section shows a value of 0.000 (x2). Because the value of 0.000 <0.05, it can be concluded that there is a significant relationship between parity and the incidence of anemia in pregnant women in Sleman Regency.

Table 1: Distribution of the Frequency Anemia in Pregnant Women in Sleman District

Table 2: Frequency Distribution of Determinants of Anemia in Pregnant Women in Sleman District

Anemia is a condition in which the hemoglobin level is insufficient to meet the physiological needs of the body. Physiological needs are different for each person. Based on age, gender, altitude of residence, and also based on pregnancy. Iron deficiency is the most common cause of anemia in the world, including the most common cause in pregnant women. In addition to iron deficiency anemia, anemia can also be caused by deficiency of B12, folic acid, vitamin A, or the presence of acute and chronic inflammation, parasitic infections, and problems with red blood cell production or red blood cell survival [8].

Prevention and control of anemia in pregnancy are very important because mild anemia detected in early pregnancy does not cause serious adverse effects on the mother and baby. However, in severe anemia, the risk for adverse effects on the mother and baby will be even greater. Therefore, it is recommended for a complete blood count in early pregnancy to prevent the adverse effects of anemia in pregnancy [9].

The results of the research are:

The relationship between maternal age and the incidence of anemia in pregnant women in Sleman Regency

Based on the research results obtained using the chi-square test, it is found that in the person chi-square section, the Asymp value is seen. Sig 0.000 <0.05, it can be concluded that there is a significant relationship between maternal age and the incidence of anemia in Sleman Regency with the incidence of anemia at risky age of 101 people (26.0%), while the age of mothers who are not at risk is 184 people (47.7%).

From the research conducted in Sleman Regency, respondents with maternal age at risk (<20 and >35 years) there were 8 mothers at risk but not anemia and 101 pregnant women at risk who experienced anemia. After looking for the cause of the problem and in terms of the questionnaires distributed to the respondents, 1 of the 8 respondents did not comply in consuming blood-added tablets but the Hb level was 12 g% but the method of consuming Fe tablets was correct, namely not using coffee and tea. While the other 7 respondents obediently consume Fe tablets. Where pregnant women who received iron supplementation had higher hemoglobin levels than those who did or did not.

Biologically, the mental age <20 years is not optimal with emotions that tend to be unstable, mentally immature so that it is easy to experience anxiety which results in a lack of attention to meeting nutritional needs related to decreased body resistance and various diseases that often afflict this age. At the age of more than 35 years, the mother's health has begun to decline, the birth canal is stiff. In addition, several studies have shown that pregnancy complications, namely preeclampsia, abortion, and prolonged labor are more common for more than 35 years. Maternal mortality in pregnant women and giving birth at the age of under 20 years is 2-5 times higher than maternal mortality and increases again after the age of 30-50 years. Meanwhile, at the age of > 35 years, it is associated with a decline and decrease in body resistance and various diseases that often afflict this age [10].

The relationship between parity and the incidence of anemia in pregnant women in Sleman Regency

Based on the research results obtained using the chi-square test, it is found that in the person chi-square section, the Asymp value is seen. Sig 0.000 <0.05, it can be concluded that there is a significant relationship between maternal parity and the incidence of anemia in Sleman Regency with the incidence of anemia at risk parity >2 as many as 78 people (20.1%), while parity with no risk of 7 people (1.8%).

This study is in accordance with Astriana [10] which states that there is a significant relationship between parity and anemia, with the results of the Chi-Square statistical test obtained, namely a p value of 0.018. Pregnant women with parity have more risk of anemia than pregnant women who are not at risk. The number of parity more than 2 is a factor in the occurrence of anemia because too often pregnancy can deplete the nutritional reserves in the mother's body.

The Relationship Between Nutritional Status and the Incidence of Anemia in Pregnant Women In Sleman Regency

Based on the research results obtained using the chi-square test, it is found that in the person chi-square section, the Asymp value is seen. Sig 0.000 <0.05, it can be concluded that there is a significant relationship between maternal nutritional status and the incidence of anemia in Sleman Regency with the incidence of anemia in mothers with CED as many as 131 people (33.7%), while mothers who are not at risk are 5 people (1.3%).

This study is in accordance with Ismaini's theory which states that the relationship of nutritional status affects the incidence of anemia. Nutritional status is also defined as health status resulting from a balance between nutrient requirements and inputs and is a basic need for pregnant women. Measurement of nutritional status in pregnant women is carried out by measuring Upper Arm Circumference (LILA) where pregnant women are said to be good if LILA 23.5 cm. Pregnant women need protein, vitamins, calories and minerals as well as various types of other substances including iron which is very useful for maternal health and fetal growth.

The causes of anemia are lack of nutrition, lack of iron, blood loss during the last delivery, and chronic diseases. The decrease in hemoglobin levels found during pregnancy is due to the increased need for nutrients during pregnancy and changes in the blood such as the addition of plasma volume which is relatively larger than the addition of hemoglobin mass and red blood cell volume [11]. One way to measure the nutritional status of pregnant women is by examining the Upper Arm Circumference (LILA).

The relationship between pregnancy distance and the incidence of anemia in pregnant women in Sleman Regency

Based on the research results obtained using the chi-square test, it is found that in the person chi-square section, the Asymp value is seen. Sig 0.000 < 0.05, it can be concluded that there is a significant relationship between the distance of pregnancy and the incidence of anemia in Sleman Regency with the incidence of anemia at a distance of pregnancy at risk of <2 years as many as 66 people (17.05%), while the age of the mother who is not at risk a total of 5 people (1.3%).

This study is in accordance with the theory of Gusnidarsih [12] Pregnant women are at risk of experiencing anemia, namely in the group of mothers with pregnancies that are too close or less than 2 years. This is because the mother's condition has not recovered from the previous delivery, causing a decline in maternal health. Poor maternal health can cause the mother to experience anemia. Pregnancy spacing is one of the causes that can accelerate the occurrence of anemia in pregnant women. A good pregnancy distance of at least 2 years is very important to note so that the mother's body is ready to receive the fetus again [13]. According to Heriansyah, the distance of pregnancy in the mother greatly affects the hemoglobin level of pregnant women. This is because a pregnant woman requires physical and mental readiness during pregnancy. Birth readiness in question is the physical readiness of the reproductive organs, the longer the distance between a mother's pregnancy from her previous pregnancy, the more ready her reproductive organs will be for the next pregnancy.

The easiest way to prevent anemia is to eat a healthy diet and limit alcohol consumption. Doing regular hemoglobin checks can avoid the risk of anemia. Blood tests in the elderly are routinely recommended by doctors even though there are no symptoms. So that the symptoms of anemia can be detected [14].

The advantage of this study is that it can be used as a reference for future researchers who will take the theme of anemia in pregnant women, the drawback of this study is due to the COVID-19 pandemic, so the activities carried out are limited to avoiding contact from other people.

Based on the results of research and discussion of the determinants of the incidence of anemia in pregnant women in Sleman Regency, the following conclusions can be drawn:

• Pregnant women in Sleman Regency who experienced anemia were 285 people (73.3 %).

• There is a significant relation between maternal age and the incidence of anemia in pregnant women in Sleman Regency.

• There is a significant relationship between nutritional status and the incidence of anemia in pregnant women in Sleman Regency.

• There is a significant relationship between pregnancy distance and the incidence of anemia in pregnant women in Sleman Regency

• There is a significant relationship between parity and the incidence of anemia in pregnant women in Sleman Regency.

Suggestions 

For Ahmad Dahlan University

Is being requested to add some reference books, especially about anemia of pregnancy in the library, in order to facilitate researchers to finding information.

For Pregnant Women

It is expected that expectant are obedient in consuming blood-added tablets, pay attention to the nutritional intake consumed, and understand the risk factors of anemia based on age at risk and gestational age in each trimester to avoid the incidence of anemia in pregnancy.

For Midwives in all Sleman District Health Centers

It is expected to pay more attention to expectant who are at risk of anemia by looking at the register book to provide treatment by giving pregnant women biscuits according to the government program for mothers with SEZ, and providing nutritional counseling to prevent anemia.

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