DATA-DRIVEN LESSON PLAN NATIONAL MATERNAL NUTRITION PROGRAMS COVERAGE IN INDONESIA: THE TRENDS, ASSOCIATED FACTORS AND INEQUITY

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1 DATA-DRIVEN LESSON PLAN NATIONAL MATERNAL NUTRITION PROGRAMS COVERAGE IN INDONESIA: THE TRENDS, ASSOCIATED FACTORS AND INEQUITY Authors Luh Ade Ari Wiradnyani (SEAMEO RECFON, Universitas of Indonesia) Aria Kekalih (Department of Community Medicine, Faculty of Medicine, Universitas Indonesia) Background Globally, 47.4% pregnant women are estimated to suffer from anemia (WHO, 2008). In Indonesia, the prevalence remains high across years (>40% from early 1990s until late 2000s) indicating a severe public health problem (Mason et al., 2004; McLean et al., 2007; WHO, 2008). Among multiple determinant factors of anemia, iron deficiency is known to be the predominant attributable factor. In addition to its effect on perinatal and maternal mortality in developing countries (WHO, 2002), anemia during pregnancy is associated with 30-45% less likelihood of good pregnancy outcomes (WHO, 2001). Iron-folic acid tablet supplementation/ifas is the most common strategy currently used to control iron deficiency in pregnant women in developing countries, where the iron may be difficult to obtain from diet alone (WHO, 2012, 2001). As indicated by findings of many clinical trials, impact of IFAS is related to the adherence of the women to consume the tablets (Lutsey et al., 2008; Mason et al., 2004; Sunawang et al., 2009). In line with the findings, low adherence of the women to the recommended number of IFA tablets to be consumed during pregnancy is suggested as one of the main constraints of IFAS effectiveness as a large-scale program (Deitchler et al., 2004b). Furthermore, Deitchler and colleagues (2004) found that the low adherence is found in most countries in their review and the adherence is estimated to be around 53% (Victora et al., 2012). In addition to iron deficiency anemia, another common nutrition problem among pregnant women is vitamin A deficiency/vad, known as a major contributor to high morbidity and mortality from infections. Indonesia is one of the countries with a moderate VAD problem among pregnant women (10-20%) (WHO, 2009). A study in Indonesia indicated that 51% lactating women had retinol concentration <1.05µmol/L in the breastmilk (Muslimatun et al., 2001), and one in two infants had marginal VAD (Dijkhuizen et al., 2001). Breastmilk is the best source of vitamin A for infants (WHO and Micronutrient Initiative, 1998). One study among Indonesian mother-infant pairs showed that the concentrations of vitamin A and β-carotene in breastmilk were closely related to those in the plasma of the infants (Dijkhuizen et al., 2001). Although several trials cannot show the effect of VAS for post-partum 1

2 women on functional health outcome in both mother and infants, the studies clearly demonstrated that the supplementation significantly improved maternal serum retinol, breast milk retinol and vitamin A liver stores (Oliveira-Menegozzo et al., 2010). Vitamin A content in the breastmilk is critical because infants are usually born with low body stores of vitamin A. In addition, if mothers have inadequate intake of vitamin A, the vitamin A reserves in their liver will be used to compensate the low vitamin A content in the breastmilk (WHO and Micronutrient Initiative, 1998) Both programs have been implemented for long time in Indonesia (MoH, 2005, 1999), especially the maternal IFAS program which has been started since Nevertheless, reports showed that only less than 50% post-partum women received the capsule. For IFAS program, although around 70% women in Indonesia reported to receive the IFA tablets during pregnancy, only around one-third who consumed the tablets by the recommended number (BPS et al., 2012, 2007, 2003). As impact of the nutrition intervention is associated with the program coverage and compliance, examining factors associated with the coverage and compliance is necesary. Moreover, since the supplements are mostly delivered through antenatal care (for IFAS) and postnatal care (for VAC po st-partum), there will also be necessary to examine whether there is an inequity issues to get the service, and thus the supplements, across socioeconomic as well as geographic factors. National-level survey, such as series of Indonesian Demographic and Health Survey/IDHS, is one of important data sources to provide pictures of the current status and trends of coverage of national maternal nutrition intervention program in Indonesia. The available variables in those datasets provide opportunities to examine factors associated with the program coverage as well as whether there is any inequity to have the services across socio-economic-demographic of the population. The analysis will focus on IFAS and VAS for post-partum women as example of national maternal nutrition programs in Indonesia. Learning objectives By the end of the lesson, participants: are exposed to IFAS and VAS for post-partum mothers as examples of national maternal nutrition programs in Indonesia are familiar with secondary data analysis in term of their uses and limitations are able to do analysis to assess trends and factors associated with maternal nutrition programs coverage, as well as inequity to get the service using Indonesian Demographic and Health Survey databases are able to present results of the analysis 2

3 Usage within the curriculum The lesson is designed as a part of Food and Nutrition Intervention Course of Master Program in Community Nutrition, Nutrition Study Program, Faculty of Medicine University of Indonesia. This lesson may be delivered as an independent lesson in nutrition and public health trainings. Eligibility of the participants The participants are the Master students, or those who have at least a bachelor degree, with nutrition or public health background. Participants should have a good proficiency in English, both oral and written. They also need to have basic skill for doing statistical analysis using SPSS. Materials and resources Materials and resources needed for the lesson: 1. Presentation Introduction to the lesson 2. Presentation National maternal nutrition program 3. Presentation Secondary data analysis, its uses and limitations 4. Presentation Example of secondary data analysis 5. List of variables used in Indonesia DHS data 6. Data IDHS Maternalnutrition Required Readings 1. Aikawa, R., Jimba, M., Nguen, K.C., Zhao, Y., Binns, C.W., Lee, M.K., Why do adult women in Vietnam take iron tablets? BMC Public Health 6, 144. doi: / Galloway, R., Dusch, E., Elder, L., Achadi, E., Grajeda, R., Hurtado, E., Favin, M., Kanani, S., Marsaban, J., Meda, N., Moore, K.M., Morison, L., Raina, N., Rajaratnam, J., Rodriquez, J., Stephen, C., Women s perceptions of iron deficiency and anemia prevention and control in eight developing countries. Soc. Sci. Med , Lutsey, P.L., Dawe, D., Villate, E., Valencia, S., Lopez, O., Iron supplementation compliance among pregnant women in Bicol, Philippines. Public Health Nutr. 11, doi: /s Seck, B.C., Jackson, R.T., Determinants of compliance with iron supplementation among pregnant women in Senegal. Public Health Nutr. 11, doi: /s Titaley, C.R., Hunter, C.L., Heywood, P., Dibley, M.J., Why don t some women attend antenatal and postnatal care services?: a qualitative study of community members perspectives in Garut, Sukabumi and Ciamis districts of West Java Province, Indonesia. BMC Pregnancy Childbirth 10, 61. doi: /

4 Facilitators The facilitators are the Course coordinator, Assistant Course Coordinator and/or the teaching team/expert of the course Food and Nutrition Intervention Course. The facilitators may also be experts in micronutrient intervention program or public health with advance skill of biostatistics. Duration This lesson is to be conducted for a total 8.5 hours (detailed scheduling available towards the end of this lesson plan). Directions of class activities The course is delivered in three parts, i.e introduction, data analysis, presentation of findings. Introduction The course is opened with Introduction to the course (objective, schedule, evaluation, required readings) maternal IFAS and vitamin A for post-partum women as example of national maternal nutrition programs in Indonesia and other countries secondary data analysis (their uses, limitations) Data analysis and interpretation In this part, participants are assigned to work in group to do analysis using IDHS datasets. The analysis will focus on two national maternal nutrition programs, i.e IFAS and vitamin A supplementation for post-partum mothers. Before starting the data analysis, participants will be given explanation on Indonesian DHS (its purpose, sampling, and available variables) examples of analysis on the program coverage using IDHS datasets The assignments for each group will cover, but not limited to: Trends of the IFAS and VAS post-partum program coverage across years (at national level, or by demographic factors) Factors associated with coverage of IFAS and women s compliance to consume the tablets Factors associated with coverage of VAS for post-partum women Inequity to get the service across socio-demographic and economic factors Presentation and discussion Participants are requested to present the results of their analysis, according to following points: 4

5 Presentation should be started with a short introduction and objective(s) of the analysis (3-4 slides) Each group may propose their own variables to be analyzed among the list of variables available in the IDHS database. It They should briefly describe the rationale/justification for using the variables. Putting references is strongly recomended. Where relevant, the findings should be presented as tables or figures, along with the interpretation. Presentation should not be more than 15 minutes for each group. There will be a discussion session after each presentation. Course schedule Time Activities Method File name PIC Introduction to the course Lecture Introduction to LAW, AK the course Introduction to Maternal Nutrition Lecture National LAW Problems and National Maternal maternal Nutrition Programs in Indonesia and other countries nutrition programs Break Introduction to Secondary Data: Its uses and limitations Explanation on Group Work Assignments Lecture Discussion Secondary Data Analysis: its uses and limitations Example of secondary data analysis AK LAW,AK List of variables used in Indonesia DHS data Data analysis Group work - LAW,AK Lunch Break Data analysis Group work - LAW,AK Presentation and discussion of data Presentation - LAW,AK analysis results and discussion Recap of the lesson Discussion LAW,AK PIC=person in charge, LAW=Luh Ade Ari Wiradnyani, AK=Aria Kekalih 5

6 Evaluation of the lesson and the participants Evaluation from participants about the lesson covers points similar to those applied in Food and Nutrient Intervention Course. The points are lecturer performance, teaching methods, increase of knowledge, relevance to the objective of the lesson, degree of difficulty, and time allotment. Participants will be evaluated based on results of group work (50%) and individual participation (during presentation and discussion)(50%). References 1. BPS, National Family Planning Coordinating Board, Ministry of Health, ORC Macro, Indonesia Demographic and Health Survey BPS and ORC Macro, Calverton Maryland. 2. BPS, National Family Planning Coordinating Board, Ministry of Health, ORC Macro, Indonesia Demographic and Health Survey BPS and ORC Macro, Calverton Maryland. 3. BPS, National Family Planning Coordinating Board, Ministry of Health, ORC Macro, Indonesia Demographic and Health Survey BPS and ORC Macro, Calverton Maryland. 4. Deitchler, M., Mason, J., Mathys, E., Winichagoon, P., Tuazon, M.A., 2004a. Lessons from successful micronutrient programs. Part I: program initiation. Food Nutr. Bull. 25, Deitchler, M., Mathys, E., Mason, J., Winichagoon, P., Tuazon, M.A., 2004b. Lessons from successful micronutrient programs. Part II: program implementation. Food Nutr. Bull. 25, Dijkhuizen, M.A., Wieringa, F.T., West, C.E., Muherdiyantiningsih, Muhilal, Concurrent micronutrient deficiencies in lactating mothers and their infants in Indonesia. Am. J. Clin. Nutr. 73, Lutsey, P.L., Dawe, D., Villate, E., Valencia, S., Lopez, O., Iron supplementation compliance among pregnant women in Bicol, Philippines. Public Health Nutr. 11, doi: /s Mason, J., Deitchler, M., Mathys, E., Winichagoon, P., Tuazon, M.A., Lessons from successful micronutrient programs. Part III: program impact. Food Nutr. Bull. 25, McLean, E., Egli, I., Cogswell, M., de Benoist, B., Wojdyla, D., worldwide prevalence of anemia in preschool aged children, pregnant women and non-pregnant women of reproductive age, in: Kraemer, K., Zimmermann, M. (Eds.), Nutritional Anemia. Sight and Life Press, Switzerland, pp MoH, Iron-folic acid tablets and iron syrup distribution: A guideline for health staff (Pedoman pemberian tablet besi-folat dan sirup besi bagi petugas), Third. ed. Jakarta. 11. MoH, Vitamin A: What and Why (Pr actical Guideline for Health Personnel)/Apa dan Mengapa tentang Vitamin A: Panduan Praktis untuk Praktisi Kesehatan. Jakarta. 6

7 12. Muslimatun, S., Schmidt, M.K., West, C.E., Schultink, W., Hautvast, J.G., Karyadi, D., Weekly vitamin A and iron supplementation during pregnancy increases vitamin A concentration of breast milk but not iron status in Indonesian lactating women. J. Nutr. 131, Oliveira-Menegozzo, J.M., Bergamaschi, D.P., Middleton, P., East, C.E., Vitamin A supplementation for postpartum women. Cochrane Database Syst. Rev. CD doi: / cd pub2 14. Sunawang, Utomo, B., Hidayat, A., Kusharisupeni, Subarkah, Preventing low birthweight through maternal multiple micronutrient supplementation: a clusterrandomized, controlled trial in Indramayu, West Java. Food Nutr. Bull. 30, S Victora, C.G., Barros, F.C., Assunção, M.C., Restrepo-Méndez, M.C., Matijasevich, A., Martorell, R., Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues. Food Nutr. Bull. 33, S WHO, Iron deficiency anemia: Assessment, prevention and control. A guide for program managers. Geneva. 17. WHO, The World Health Report Reducing risks promoting healthy life style. Geneva. 18. WHO, Worldwide prevalence of anaemia : WHO Global database of anemia [WWW Document]. WHO. URL (accessed ). 19. WHO, Global prevalence of vitamin A deficiency in population at risk: WHO, Guideline: Daily iron and folic acid supplementation in pregnant women. 21. WHO, Micronutrient Initiative, Safe vitamin A dosage during pregnancy and lactation. Recommendations and report of a consultation. 7