Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11180 The correlation between family role and anemia prevention in pregnancy Mira Triharini,1 Ni Ketut Alit Armini,2 Sekar Ayu Pitaloka3 1Advance Nursing Department, Faculty of Nursing Universitas Airlangga, Surabaya, Indonesia; 2Basic Nursing Department, Faculty of Nursing Universitas Airlangga, Surabaya, Indonesia; 3Nursing Profession, Faculty of Nursing Universitas Airlangga, Surabaya, Indonesia Abstract Introduction: It is important to reduce the high incidence of anemia in pregnancy globally. Pregnant women need the support of their families to face any difficulties in order to prevent anemia. Design and Methods: This study aims to determine the corre- lation between family role and anemia prevention in pregnancy. This cross-sectional study was conducted in August 2021 among 60 pregnant women who went for check-ups at two primary healthcare centers in Surabaya, Indonesia, and received iron sup- plements. Additionally, it was discovered that family role and ane- mia prevention in pregnancy were evaluated using questionnaires. Result: The Spearman test was used as a test for significance and the results showed that there was a correlation between family role and anemia prevention in pregnancy (r = 0.318; P = 0.013). Also, it was found that informational, emotional, and affirmational support, as well as having a role model were significantly corre- lated with anemia prevention at (r = 0.311; p = 0.015), (r = 0.265; p = 0.041), (r = 0.400; p = 0.002), and (r = 0.353; p = 0.006), respectively. Conclusions: There was a relationship between family role and anemia prevention in pregnancy, as well as adequate nutrition, adherence to iron supplements, and prevention of worms. Therefore, there is the need for health promotion to the families of pregnant women in order to increase the understanding of anemia prevention in pregnancy. Introduction Anemia is a major problem for pregnant women all over the world, which is mostly characterised by iron deficiency. Furthermore, it is mostly associated with iron deficiency, which occurs when there is an insufficient balance of iron intake, storage, and loss from the body to support normal erythrocyte production.1 One of the leading causes of maternal morbidity and mortality is anemia during pregnancy.2 During pregnancy, mothers are consid- ered anemic when their hemoglobin (Hb) level is less than 11 g/dL.3 There is a high prevalence of anemia in a number of coun- tries, specifically in pregnant women, which ranged between 20% to 50% based on previous report from WHO in 2017. Meanwhile, the prevalence of anemia in Indonesian pregnant women was 41.98%, where more than half of the mothers were anemic.4 There was a slightly lower mean birth weight in babies born to anemic mothers compared to those born to nonanemic mothers.5 Subsequently, there is a relationship between anemia during pregnancy and poor maternal and child health, as well as an increased risk of maternal and perinatal mortality. The negative effects of anemia in mothers include fatigue, reduced work capac- ity, impaired immune function, an increased risk of heart disease, and death. Several studies showed that anemia in pregnancy accounts for 23% of all indirect causes of maternal death in devel- oping countries.6 According to the previous study conducted in Karnataka, India by Rajashree in 2015, there are multiple factors that contribute to the Low Birth Weight (LBW) in babies, such as blood hemoglobin (Hb) levels.7 Furthermore, a 2016 study in India found that anemia in pregnant women was associated with low birth weight and perinatal mortality.8 Anemia can be influenced by several factors, which may be both internal and external to the mother. Several studies found that family factors have a significant impact on the prevention of anemia in pregnant women.9,10 However, prospective fathers play an important role in ensuring maternal health and a safe delivery. The involvement of husbands in health education should be recognized and addressed due to its potential benefits to maternal and child health. This has significant implications for health policy and practice since health systems and maternal health interventions must be modified to ensure appropriate and effective inclusion of prospective fathers.10 The social support of the husband is the most important factor that affects the occur- rence of anxiety in pregnant women from the time of conception until delivery. Pregnant women require good service, transporta- tion, funds or consulting fees, and accompaniment during consul- tations with doctors or midwives. Husbands should also be aware of pregnancy complications and must pay attention to the needs of their pregnant wife.11 There is no study concerning the relationship between family role and methods of anemia prevention, such as nutritional adequacy, adherence to iron supplements, and intestinal worm prevention. Therefore, this study aims to deter- mine the relationship between family role and anemia prevention during pregnancy. Design and Methods The study was conducted using a descriptive cross-sectional approach in August 2021. The respondents were pregnant women Significance for public health The role of the family is an important factor that can increase the willingness of pregnant women to prevent anemia. This can be developed through health education delivered to families and pregnant women. This study aims to explain the relationship between the role of the family and the prevention of anemia in pregnancy. Article [page 70] [Healthcare in Low-resource Settings 2023; 11(s1):11180] Non -co mmerc ial us e o nly who attended antenatal care at two primary healthcare centres (Puskesmas) in Surabaya, East Java, Indonesia. The sample popu- lation included 60 women based on the inclusion criteria, which included those who received iron supplementation from primary healthcare centres. Meanwhile, the exclusion criteria included pregnant women with complications or severe concomitant dis- eases that required specific medical treatment. The data was col- lected using a questionnaire on sociodemographic characteristics, family roles, and anemia prevention. The questions on sociodemo- graphic characteristics were based on age, gestation age, parity, education, and income. However, the family role was focused on four areas, which included informational support, emotional sup- port, affirmational support, and possession of a role model. There were eight questions on the questionnaire and each item was con- verted into a Likert scale with the following options: always, fre- quently, occasionally, rarely, and never. The total scores for this section ranged from 0 to 32, with higher scores indicating higher levels of family role. The validity of the questionnaire in this study had a Cronbach’s α of 0.951. The questionnaire on anemia preven- tion was divided into three sections, which included nutritional adequacy and adherence to iron supplementation with five ques- tions each, as well as intestinal worm prevention with six ques- tions. Also, each item was converted into a Likert scale with the following options: always, frequently, occasionally, rarely, and never. The correlations between family roles and anemia preven- tion were determined using Spearman’s rho values. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to describe sociodemographic characteristics, family roles, and anemia prevention. In all statistical analyses using SPSS, a p-value < 0.05 was considered significant. Results and Discussions Table 1 showed that most women in the population (n = 43, 71.7%) were aged between 26-35 years. Also, most respondents (n = 27, 45%) were between their second and third trimester, while others (n = 2, 33.3%) were multigravida. The majority of the women (n = 42, 70%) have completed secondary education, while others (n = 50, 83.3%) were from families with incomes below Rp 4,300,000, as shown in Table 1. The results in Table 2 showed that the highest score among the eight items in the questionnaire was ‘My husband promotes me to always eat nutritious food’ at a sig- nificance of 3.82 ± 0.43), while the lowest score was observed in ‘My husband compliments me if I take iron supplements regularly’ at a significance of 2.98 ± 1.16. There was a significant correlation between anemia prevention in pregnancy and Informational sup- port, emotional support, affirmational support, and role model at significance values of (r = 0.311; p = 0.015), (r = 0.265; p = 0.041), (r = 0.400; p = 0.002), and (r = 0.353; p = 0.006), respectively, as shown in Table 3. As shown in Table 4, of the five nutritional ade- quacy questions, ‘eat meat, chicken liver, or eggs every day’, received the lowest score (2.85±0.99). Of the five items on iron supplementation adherence, ‘I take iron supplements before going to bed’, received the lowest score (2.43±1.49), and of the six items on worm prevention, ‘When I leave the house, I wear footwear.’ Article Table 1. Sociodemographic characteristics in participants (n=60). Indicator Category n (%) Age < 25 years 9 (15.0) 26-35years 43 (71.7) >35 years 8 (13.3) Gestation age First Trimester (1-13 weeks) 6 (10) Second Trimester (14-27 weeks) 27 (45) Third Trimester (28-40 weeks) 27 (45) Parity 1 15 (25) 2 20 (33.3) 3 18 (30.0) 4 7 (11.7) Education Elementary 7(11.7) Secondary 42 (70) University 11 (18.3) Income < Rp 4,300,000 50 (83.3) > Rp 4,300,000 10 (16.7) Table 2. Item analysis of family role. Parameter Questions Mean (SD) Percentage of women choosing strongly agree Informational support My husband reminds me to take iron supplements regularly 3.27 (1.01) 32 (53.3) My husband reminds me to eat nutritious food 3.77 (0.43) 46 (76.7) Emotional support My husband takes the time to listen to my health complaints 3.67 (0.60) 44 (73.3) My husband encourages me to always eat nutritious food 3.82 (0.43) 50 (83.3) Affirmational Support My husband compliments me if I want to eat nutritious food regularly 3.12 (0.99) 28(46.7) My husband compliments me if I take iron supplements regularly 2.98 (1.16) 26 (43.3) Role model My husband gives an example of healthy living by eating nutritious food 3.53 (0.75) 40 (66.7) My husband gives an example of healthy living by always maintaining personal and environmental hygiene 3.65 (0.61) 43 (71.7) *Range 1–4; SD: standard deviation. Table 3. Correlation matrix among the parameters of family role and the prevention of anemia during pregnancy. Variable Mean SD Min-max r p Informational support 7.03 1.15 4-8 0.311 0.015 Emotional support 7.48 0.81 5-8 0.265 0.041 Affirmational support 6.10 2.06 1-8 0.400 0.002 Role model 7.18 1.21 4-8 0.353 0.006 Anemia prevention 66.78 15.49 44-92 - - [Healthcare in Low-resource Settings 2023; 11(s1):11180] [page 71] Non -co mmerc ial us e o nly received the lowest score (3.25±1.37). (Table 4). The mean score for the role of family was 27.80, and the mean score for anemia prevention was 66.78. The role of the family (r = 0.318; P = 0.013) was found to be significantly related to the prevention of anemia during pregnancy, as shown in Table 5. The role of the family has a strong influence on the behaviour of pregnant women in preventing anemia. The promotion of health practices by health workers should be directed toward families in order to increase their role in providing support for pregnant women. This study found that the role of family in the prevention of anemia during pregnancy is significantly related to information- al support, emotional support, affirmational support, and tangible support. The highest score based on family role was observed when husband promoted their pregnant wives to always eat nutri- tious food. This demonstrated that the family was aware of the importance of eating nutritious foods while pregnant. Adequate maternal nutrition is important for the progression of a normal pregnancy, optimal foetal development, and normal foetal birth weight. Therefore, a proper diet should be consumed during preg- nancy in order to provide the mother and child with the necessary amount of energy as well as all of the essential nutrients such as protein, fat, carbohydrates, vitamins, and minerals.12 Enough ener- gy is required for optimal growth during pregnancy. Protein is also crucial because it serves as the structural foundation for all new cells and tissues in the mother and foetus. Meanwhile, vitamins and minerals participate in biochemical reactions that result in the formation of amino acids, which are then used to create new pro- teins and maintain the structural and functional properties of cells.13 Iron supplementation is widely used to prevent iron defi- ciency and anemia in at-risk populations (e.g., pregnant women and young children), as well as to improve the haemoglobin status of people who already have anemia. For oral supplementation, four different iron preparations are commonly used: ferrous sulphate, ferrous gluconate, and ferrous fumarate. Iron supplementation may benefit populations at high risk of anemia, for example, supple- mentation during pregnancy may reduce the risk of maternal ane- mia and iron deficiency, however, the benefits to the baby, such as a lower risk of being born prematurely or with low birth weight, are less clear.14 The CDC recommends that all pregnant women start taking 30 mg of iron per day at their first prenatal visit, while the World Health Organization recommends 60 mg of iron supple- ments per day for all pregnant women.15 The lowest score based on family role was observed when the husband complimented the pregnant mother concerning the regular intake of iron supplements, which could be due to his lack of understanding on the importance of taking iron supplements. Several studies demonstrated the importance of iron supplements in pregnant women with anemia, which is caused by a dramatically increased need for iron in pregnancy to cover the additional needs of the mother (expansion of erythrocyte volume) and the foetus (skeleton formation, CNS, and foetal erythrocyte mass). In cases of mild IDA and iron deficiency without anemia, oral iron adminis- tration is the recommended first line of treatment in pregnancy.16 However, it was difficult for pregnant women to find the right balance when it comes to iron intake since too little or too much iron can be harmful. High doses of iron supplements can cause adverse effects in the gastrointestinal tract (stomach and intestine), such as constipation, nausea, vomiting, and diarrhea, even though the body can store extra iron. Additionally, they can cause stomach lining damage when high doses of iron are taken on an empty stomach. It is widely assumed that oral iron supplements cause unpleasant GI side effects, which are somewhat similar to the physiological changes in pregnancy. However, some pregnant women attribute these complications to iron compounds and dis- continue its use.17 Many pregnant women do not take their iron supplements on a regular basis due to the side effects and difficul- ties that they women experience. Subsequently, this has led to a high incidence of anemia in pregnant women around the world. Furthermore, emotional support from husbands is essential for pregnant women in order to promote them to take iron supple- ments on a regular basis. The side effects that are feared by preg- nant women include nausea and vomiting. They think it will be dif- ficult for them. In addition to the discomfort caused by nausea, vomiting will also cause the food they have eaten to be wasted, so that the baby’s nutrition will be reduced. The husband’s role in preventing anemia includes providing information, emotional support, affirmational support, and serving as a role model. The prevention of anaemia in pregnancy through informational support involves the provision of the needed infor- mation to pregnant women in order to avoid the condition, such as eating an iron-rich diet, taking iron supplements on a regular basis, and avoiding intestinal worms. The addition of an iron-containing substance to a food prod- uct’s recipe, either as an isolated compound (for example, iron salts or chelates) or as an iron-rich ingredient, is referred to as for- tification (for example, meat or its derivatives). Because the dosage used in iron fortification is lower than in supplementation, the body’s iron level rises much more slowly, however, fortifica- tion may be a safer intervention.17 Ferritin is a protein that can absorb large amounts of iron and can be used by plants and animals as a natural reservoir for iron. Phytoferritin is found in protein-rich foods such as legumes (beans, lentils, etc.).18 Iron is found in two forms in foods: heme and non-heme. Heme iron is primarily obtained from the consumption of meat, poultry, and fish, while non-heme is obtained from cereals, beans, nuts, fruits, and vegeta- bles.19 Preventing worm infection is also important in preventing anemia in pregnant women. According to study, there is a link between worm infections and anemia. Most hookworm loads result in extracorporeal iron loss, and interventions to treat hookworm infections have resulted in significant haemoglobin improvements. Article Table 4. Lowest score in item analysis of anemia prevention. Parameters Items Mean (SD) Nutritional adequacy Eat meat or chicken liver or eggs every day 2.85 (0.99) Adherence to iron supplementation I always take iron supplements at night before going to bed 2.43 (1.49) Prevention of worms Always use footwear when going out of the house 3.25 (1.37) Table 5. Correlation matrix among the role of family and anemia prevention variable. Mean SD Min-max r p Family roles 27.8 3.98 18-32 0.318 0.013 Anemia prevention 66.78 15.49 44-92 [page 72] [Healthcare in Low-resource Settings 2023; 11(s1):11180] Non -co mmerc ial us e o nly Iron deficiency anemia is a common cause of long-term morbidity due to chronic intestinal blood loss caused by hookworm infection. Blood loss is caused primarily by the parasite’s release of coagu- lase, which causes persistent blood loss in the stool, rather than the parasite’s actual ingestion of blood.20,21 One of the factors that con- tribute to intestinal worm infection in pregnant women is their lack of knowledge about the cleanliness of the food they consume. For example, how to clean, wash, and cook food. The greater pregnant women’s awareness of the importance of hygiene, the lower their risk of contracting intestinal worms.22 Pregnant women who want to avoid anemia need their hus- bands’ help. Emotional support, affirmational support, and role model support are all forms of assistance that can be provided. In terms of emotional support from the husband, this can be provided by listening to the mother’s health complaints during pregnancy. Pallor, shortness of breath, palpitations, hair loss, headache, verti- go, leg cramps, cold intolerance, dizziness, and irritability are all symptoms of iron deficiency anemia in pregnant women. IDA can also cause postpartum hypothermia, fatigue, poor concentration, decreased work capacity, decreased maternal milk production, and depletion of maternal iron stores.23 As a result, emotional support from the husband can be beneficial because he can recognize the warning signs if his pregnant wife exhibits any of the above-men- tioned symptoms. Affirmational support can be provided by the husband by expressing gratitude when their pregnant wife consumes nutritious foods, takes iron supplements, and maintains personal hygiene. Appreciation is important because it boosts the mother’s confi- dence in her ability to accomplish difficult tasks. Good self-effica- cy increases the mother’s ability to practice good self-care during pregnancy, as a result, the mother’s pregnancy process can proceed smoothly until delivery.24 The husband can serve as a role model by demonstrating good behaviour such as eating habits and person- al hygiene. Pregnant women will mimic the positive behaviour of their husbands. In addition, the husband can consume nutritious food on a daily basis and maintain good personal and environmen- tal hygiene. This will be able to motivate the mother to imitate her husband’s good habits. The best way to avoid pregnancy anemia is to eat well, take iron supplements, and avoid worms by practicing good personal and environmental hygiene. The results on nutri- tional adequacy showed that the habit of eating meat, chicken liver, or eggs every day produced the lowest mean score. This can be influenced by a lack of knowledge about iron-rich foods, as well as a low income. According to the data, most of the respondents had an income less than Rp 4,300,000 and completed secondary school. Pregnant women who take iron supplements at night before going to bed had the lowest mean score on the iron supplement adherence questionnaire, which could be due to a lack of knowl- edge about how to drink properly. The purpose of drinking at night was to reduce the side effects. According to previous studies, the most common side effects of iron supplements are problems with the gastrointestinal tract (stomach and intestines), such as consti- pation, nausea, vomiting, and diarrhea. The lowest score on the questionnaire about preventing intestinal worms was on ‘If I go out of the house, I use footwear.’ This can be caused by pregnant women who are still accustomed to their pre-gestation behaviours. Personal hygiene had a close relationship with intestinal infections caused by worms, and was also important in preventing the trans- mission of worms that could cause anemia in pregnant women.22 Evidence suggests that the severity of hookworm infection is relat- ed to lower hemoglobin levels in pregnant women. Chronic intesti- nal blood loss caused by hookworm infection results in iron defi- ciency anemia. Intestinal parasitic infection in pregnant women is common and has a negative impact on hematological profiles. Some hematological profiles of pregnant women infected with intestinal parasites deteriorated, leading to anemia. Therefore, it is important to deworm before pregnancy, as well as to maintain good personal and environmental hygiene in order to reduce maternal anemia during pregnancy.25 Conclusions Anemia prevention in pregnancy was associated with informa- tional support, emotional support, affirmational support, and the presence of a role model. Also, there is the need for the develop- ment of health education in order to raise awareness of the role of families in anemia prevention in pregnant women. Families must continue to educate themselves about anemia in pregnancy to pro- vide the necessary support for pregnant women. Pregnant women can prevent anemia through diet, adherence to iron supplements, and maintaining good personal hygiene. Article Correspondence: Mira Triharini, Faculty of Nursing, Universitas Airlangga, Jl. Ir Soekarno, Surabaya, East Java 60115, Indonesia Tel.:+62315913754, Fax +62315913257. E-mail: mira-t@fkp.unair.ac.id Key words: Anemia prevention; family role; pregnant women; maternal health. Acknowledgment: The author would like to thank the Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia for their kind sup- port and motivation during this study. Contributions: All authors contributed equally to this study. Conflict of interests: The authors declare no conflict of interest. Funding: This study was financially supported by ministry of higher education. Clinical trials: This study has been approved by the Health Research Ethics Committee of Faculty of Nursing, Universitas Airlangga, Surabaya. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Informed consent: Written informed consent was obtained from a legal- ly authorized representative(s) for anonymized patient information to be published in this article. Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 3 December 2021. Accepted for publication: 21 May 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11(s1):11180 doi:10.4081/hls.2023.11180 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2023; 11(s1):11180] [page 73] Non -co mmerc ial us e o nly References 1. Miller JL. Iron deficiency anemia: A common and curable dis- ease. Cold Spring Harb Perspect Med 2013;3:1–13. 2. Daru J, Zamora J, Fernández-Félix BM, et al. Risk of maternal mortality in women with severe anaemia during pregnancy and post partum: a multilevel analysis. Lancet Glob Heal 2018;6:e548–54. 3. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva, Switz World Heal Organ 2011;1–6. 4. WHO. Prevalence of anaemia in women of reproductive age (aged 15-49) (%). Glob Heal Obs 2021;23:2021. 5. Kumar KJ, Asha N, Murthy DS, et al. Maternal Anemia in Various Trimesters and its Effect on Newborn Weight and Maturity: An Observational Study. Int J Prev Med 2013;4:193– 9. 6. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle- income countries. Lancet 2013;382:427–51. 7. Rajashree K, Prashanth H, Revathy R. Study on the factors associated with low birth weight among newborns delivered in a tertiary-care hospital, Shimoga, Karnataka. Int J Med Sci Public Heal 2015;4:1287. 8. Kaur M, Chauhan A, Manzar MD, et al. Maternal Anaemia and Neonatal Outcome: A Prospective Study on Urban Pregnant Women. J Clin Diagn Res 2015;9:QC04. 9. Wiradnyani LAA, Khusun H, Achadi EL, et al. Role of family support and women’s knowledge on pregnancy-related risks in adherence to maternal iron-folic acid supplementation in Indonesia. Public Health Nutr 2016;19:2818–28. 10. Triharini M, Nursalam, Sulistyono A, et al. Adherence to iron supplementation amongst pregnant mothers in Surabaya, Indonesia: Perceived benefits, barriers and family support. Int J Nurs Sci 201;5:243. 11. Diani LPP, Susilawati LKPA. Pengaruh Dukungan Suami ter- hadap Istri yang Mengalami Kecemasan pada Kehamilan Trimester Ketiga di Kabupaten Gianyar. [The Effect of Husband’s Support on Wives Experiencing Anxiety in the Third Trimester of Pregnancy in Gianyar Regency.] J Psikol Udayana 2013;1:1–11. 12. Maqbool M, Dar M, Gani I, et al. Maternal Health and Nutrition in Pregnancy : An Insight. World J Pharm Pharm Sci 2019;8:450–9. 13. Elango R, Ball RO. Protein and Amino Acid Requirements during Pregnancy. Adv Nutr [Internet] 2016;7:839S. 14. Lopes K da S, Takemoto Y, Garcia-Casal MN, et al. Nutrition�specific interventions for preventing and control- ling anaemia throughout the life cycle: an overview of system- atic reviews. Cochrane Database Syst Rev 2018;2018:1–14. 15. Achebe MM, Gafter-Gvili A. How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood 2017;129:940-949. 16. Jafarbegloo E, Tehran HA, Tehrani TD. Gastrointestinal Complications of Ferrous Sulfate in Pregnant Women: A Randomized Double-Blind Placebo-Controlled Trial. Iran Red Crescent Med J 2015;17:15001. 17. Prentice AM, Mendoza YA, Pereira D, et al. Dietary strategies for improving iron status: balancing safety and efficacy. Nutr Rev 2017;75:49–60. 18. Abbaspour N, Hurrell R, Kelishadi R. Review on iron and its importance for human health. J Res Med Sci 2014;19:164. 19. Lubis R, Panggabean M, Yulfi H. Pengaruh Tingkat Pengetahuan dan Sikap Ibu terhadap Penyakit Kecacingan Pada Balita. J Kesehat Lingkung Indones. [The Effect of Mother’s Knowledge Level and Attitude on Worm Disease in Toddlers.] J Indonesian Environmental Health 2018;17:39. 20. Feleke BE, Feleke TE. The Effect of Pregnancy in the Hemoglobin Concentration of Pregnant Women: A Longitudinal Study. J Pregnancy 2020:2020:2789536. 21. Mahadea D, Adamczewska E, Ratajczak AE, et al. Iron defi- ciency anemia in inflammatory bowel diseases—a narrative review. Nutrients 2021;13:4008. 22. Mutalazimah M, Mustikaningrum L. Knowledge about intesti- nal worm infection and helminthiasis in pregnant women. Electron J Gen Med 2020;17:1–5. 23. Shaw JG, Friedman JF. Iron deficiency anemia: Focus on infectious diseases in lesser developed countries. Anemia 2011;2011:1–10. 24. Sumiati S, Nurhidayati E. Relationship Between Family Support and Self- Efficacy among Pregnant Women in Yogyakarta. In Masters Program in Public Health, Sebelas Maret University November 2020 p. 1–141. Accessed 2021 September 14. 25. Demeke G, Mengistu G, Abebaw A, et al. Effects of intestinal parasite infection on hematological profiles of pregnant women attending antenatal care at Debre Markos Referral Hospital, Northwest Ethiopia: Institution based prospective cohort study. PLoS One 2021;16:1–13. Article [page 74] [Healthcare in Low-resource Settings 2023; 11(s1):11180] Non -co mmerc ial us e o nly