• Users Online: 3071
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Browse Articles Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2023  |  Volume : 14  |  Issue : 1  |  Page : 18

The impact of iron supplementation during pregnancy and change of consumption among stunting children aged 6-24 months during the COVID-19 pandemic in Indonesia

1 Doctorate Candidate of Faculty of Public Health, University of Indonesia, Departemen Gizi. Gedung G, Fakultas Kesehatan Masyarakat, UI, Depok; The National Research and Innovation Agency, Gedung B.J. Habibie Jalan M.H. Thamrin Nomor 8, Jakarta Pusat 10340, Indonesia
2 Department of Nutrition, Faculty of Public Health, University of Indonesia, Departemen Gizi. Gedung G, Fakultas Kesehatan Masyarakat, UI, Depok, Jawa Barat, Indonesia

Date of Submission06-Aug-2021
Date of Acceptance06-Jul-2022
Date of Web Publication18-Feb-2023

Correspondence Address:
Ratu Ayu Dewi Sartika
Fakultas Kesehatan Masyarakat, UI Depok, Jawa Barat
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpvm.ijpvm_354_21

Rights and Permissions

Background: During the COVID-19 pandemic, stunting is estimated to increase 2.4 times higher (It seems that some information is missing here because the usage of the word 'higher' hints at a comparison with some other statistic. Or please consider making the following changes in the statement: “…stunting is estimated to be 2.4 times higher than the normal trend.” which can increase mortality, morbidity, and cause economic losses in the future. This study aims to identify the risk factors for stunting during the COVID-19 pandemic. Methods: An unmatched case-control study was conducted to compare the exposure of stunted (cases) and non-stunted (controls) children. There were 127 children aged 6-24 months, 43 cases, and 84 controls. Results: The probability of stunting was two times greater in children who experienced good changes in the consumption of tofu/tempeh (p: 0.047; AdjustedOR (aOR): 2.296; 95% CI 1.013-5.205) and fourtimes greater in children who have a mother that did not receive iron supplementation during pregnancy (p: 0.030; aOR: 4.344; 95% CI: 1.154-16.355). Conclusions: Based on the above results, increasing access to nutritious food, and the delivery of services and information related to maternal and child health services during the pandemic needs to be intensified by using innovative low-risk platforms.

Keywords: Consumption, COVID-19, iron supplementation, stunting

How to cite this article:
Sari K, Sartika RA. The impact of iron supplementation during pregnancy and change of consumption among stunting children aged 6-24 months during the COVID-19 pandemic in Indonesia. Int J Prev Med 2023;14:18

How to cite this URL:
Sari K, Sartika RA. The impact of iron supplementation during pregnancy and change of consumption among stunting children aged 6-24 months during the COVID-19 pandemic in Indonesia. Int J Prev Med [serial online] 2023 [cited 2023 Oct 3];14:18. Available from: https://www.ijpvmjournal.net/text.asp?2023/14/1/18/369958

  Introduction Top

The incidence of stunting is estimated to increase 2.4 times during the pandemic, especially in children from poor families.[1] The target for reducing stunting, to be achieved under the 2030 Sustainable Development Goals, is predicted to be increasingly difficult.[2] Stunting can cause various diseases, economic losses, and can even endanger future generations.[3] In many developing countries, including Indonesia, stunting peaks at the age of 6-24 months.[4],[5]

In various parts of the world, COVID-19 causes an increase in food insecurity and malnutrition.[6] During the pandemic, changes in food consumption also occured.[7] The pandemic is believed to increase the risks of malnutrition in children, one of which causes a decrease in the quality and quantity of food consumption as well as limited access to health services for children.[1]

The lack of quality food consumption by children from poor families is almost double than that of children from well-off families.[1] Before the outbreak of COVID-19, the quality and quantity of food being consumed by children aged 6-23 months is quite apprehensive— only 29% of children aged 6-23 months achieve adequate dietary diversity, and only 53% meet the minimum eating frequency.[8] Meanwhile, the age of 6-24 months is a period that is quite vulnerable to malnutrition because children are introduced to complementary foods other than breastmilk.[9]

Children need to obtain good health services and a supportive environment (availability of clean water, hygiene, sanitation) else they become vulnerable to infection because of the stage of immunity development in their bodies.[10] During the pandemic, the quality of maternal and child health services has decreased due to the fact that many health workers who initially handled the health of pregnant women were diverted to take care of COVID-19 patients.[2] A study stated that during the first 3 months of COVID-19, the coverage of essential nutrition services decreased by 30% in lowand middle-income countries and further decreased to 75-100% during the lockdown.[11]

This study aims to determine the risk factors for stunting in children aged 6-24 months during the COVID-19 pandemic.

  Methods Top


This study was conducted in January - March 2021, after one year of the COVID-19 pandemic, using an unmatched case-control study design to compare exposure to stunted (cases) and non-stunted (controls) children. The case group is children aged 6-24 months who suffer from stunting (z-score index height for age z-score (HAZ) <-2 SD) and the control group is children who do not suffer from stunted (normal) with a HAZ ≥-2 SD based on WHO Anthro 2006.[12] HAZ calculation was carried out using software of WHO Anthro.[13]

Sample and data collection

The sample was children aged 6-24 months who were born and lived in Pasir Putih Village, Sawangan District, Depok City, West Java. This location is one of the stunting loci (out of the 10 loci) with a high stunting rate in Depok City. In 2018, compared to the national figure, West Java Province had a stunting prevalence that was higher than the national figure of 32%.[5]

Interviews with mothers from the selected sample using a structured questionnaire were conducted by five trained enumerators and the data collection process follows the health protocol. The data collected includes children's characteristics, health status, parent/family characteristics, socio-demography, environmental factors, children's eating frequency, and hemoglobin levels. Interviews were conducted with mothers from the selected sample using a structured questionnaire. The length of the children was measured using a baby length board with an accuracy of 0.1 cm. Hemoglobin (Hb) level was checked using the Hemocue device with the help of two health workers from the Pasir Putih Village Public Health Centre, Sawangan District, Depok City.


The variables analyzed were sociodemographic (gender of the child, mother's age, mother's education, household head occupation, income, number of under-five children, drinking water difficulty), children's health status (birth weight, birth length, exclusive breastfeeding, reported illness, anemia, iron), access to health interventions (iron supplementation during pregnancy, vitamin A supplementation, deworming), and changes in food consumption (red meat, white meat, eggs, tofu/tempeh, fruits, vegetables, processed foods, and dairy products).

Changes in food consumption were defined as 'good' and 'poor'. Changes in consumption were assessed by comparing the frequency before and after the pandemic [Table 1].
Table 1: The Food Consumption Category based on The Change of Consumption Frequency Before and After Pandemic

Click here to view

Data analysis

The data analysis was carried out using SPPS version 24.0. Bivariate analysis was carried out using Chi-square statistics to assess potential predictors of stunted, using a significance limit of P < 0.25.[14] Multiple logistic regression analysis was then performed to assess the correlation between risk factors and stunting with a significance limit of P ≤ 0.05.

Ethical approval

Ethical approval was obtained from the Research Ethics Committee and Community Service, Faculty of Public Health, University of Indonesia. Ethical approval no. 613/UN 2. F10.D11/PPM.00.02/2020. Written informed consent was obtained before data collection.

  Results Top

Sociodemographic characteristics

This study consists of 43 cases and 84 controls, a total of 127 children aged 6-24 months. The number of samples of boys and girls is almost the same as shown in [Table 2]. Most of the children have mothers aged 25 years and over (85%). The number of children is almost the same across categories in maternal education. Among the surveyed, most of the heads of households have an informal job (62.1%), earn less than 3 million per month (73.2%), have 1 under-five child (78.7%), and have never experienced difficulty accessing water (71.7%).
Table 2: Sociodemographic Characteristics

Click here to view

Children with mothers aged 25 years and over tended to have a significantly lower rate of stunting (p: 0.107; OR: 0.369 (0.147-1.065). In addition, children in households who sometimes had difficulty accessing water had significantly higher rates of stunting (p: 0.246; OR: 1.607 (0.723-3,570). There was no significant association between socio-demographic variables and stunting in the multivariate analysis.

Children's health status and access to health interventions

[Table 3] describes the risk factors for stunting related to the children's health status and access to health interventions. The results also showed that stunted children tend to have low birth weight, and low birth length, and are not exclusively breastfed. In addition, stunted children tend to be anemic, have mothers who do not receive iron supplementation during pregnancy, who do not receive vitamin A supplementation, and who do not receive deworming treatment. The multivariate analysis showed that stunting children were significantly more likely to have mothers who did not receive iron supplementation during pregnancy (p: 0.030; aOR: 4.344; 95% CI: 1.154-16,355) [Table 5].
Table 3: Health status of child and access to health intervention

Click here to view
Table 4: Food Consumption Status

Click here to view
Table 5: Risk factors for stunting among children aged 6-24 months in multivariable analysis

Click here to view

Changes in food consumption

During COVID-19, the majority of children surveyed had adverse changes in consumption of red meat and dairy products; while, the consumption of white meat, eggs, tofu/tempeh, and vegetables is mostly good. The number of children who experienced changes in consumption of good or poor quality of fruit was not much different.

[Table 4] shows the probability of stunting in children is 1.8 times greater in children who experience good changes in red meat consumption compared to children with poor red meat consumption, although the level of significance is close to significant (p: 0.256; OR: 1.877; 95% CI: 0.760-4.640). In multivariate analysis, the chance of stunting was 2 times greater in children who experienced good changes in tofu/tempeh consumption compared to children with poor consumption (p: 0.047; Adjusted OR (aOR: 2.296; 95% CI 1.013-5.205) [Table 5].

The summary statistical model presented that the Nagelkerke R-squared was 0.091 which implies that 9.1% of the variability in stunting at birth could be explained by iron supplementation during pregnancy and change in consumption of tofu/tempeh.

[Graph 1] shows the difference in frequency between stunted and non-stunted children. In stunted children, the frequency of consumption of dairy products remains good and increases but not in children who are not stunted. However, the frequency of consumption of tofu/tempeh, processed food, and red meat remained good and increased in children who are not stunted. The frequency of other types of food tends not to be too different between stunted and non-stunted children.

  Discussion Top

During COVID-19 in Indonesia, the government imposed Large-Scale Social Restriction (Pembatasan Sosial Berskala Besar/PSBB) which limited peoples' activities from and at home.[16] This had an impact on several sectors which resulted in a reduction in staff and a decrease in household income.[17] The pandemic disrupts health services, nutrition, and socioeconomic disorders that can lead to an increase in malnutrition in children.[11] The longer families suffer from limited access to basic health services and food insecurity due to COVID-19, the worse the impact will be on stunting.[2]

This study showed that the risk of stunting increased more than 3 times in children of mothers who did not receive iron supplementation during pregnancy compared to children of mothers who received iron supplementation. This is in line with the findings of previous studies.[18],[19] A retrospective cohort study showed that iron supplementation reduced the risk of stunting by 14% in children <2 years of age.[19] Children of mothers who consumed 120 iron supplements during pregnancy had a higher mean length for age (LAZ) than children of mothers who consumed <120 iron supplements.[18]

Giving iron supplementation to pregnant women is very necessary to prevent anemia, puerperal sepsis, low birth weight, and premature birth.[20] The results of this study confirm the results of previous studies[18],[19] which was that the provision of iron supplementation for pregnant women is necessary to prevent stunting children. Although the results of this study indicated that there was no significant relationship between anemia and stunting, the cross-tabulation results showed that the probability of anemia in children whose mothers did not consume iron during pregnancy was 2 times higher than in children whose mothers did not consume iron during pregnancy. Therefore, preventive services must be maintained and expanded by using innovative ways while minimizing risks.

During a pandemic, the quantity and quality of child and maternal nutrition can be affected. There was a 30% reduction in coverage of essential nutrition services in low and middle-income countries and a decline to 75-100% in the event of a lockdown.[11] There was also task shifting from maternity services to COVID-19 treatment.[2] A similar situation exists in Indonesia where the number of districts/cities that provide maternal and newborn health services reached 23.3%; only 11.7% of Integrated Health Posts (Posyandu) are actively providing services (health facilities for monitoring growth and development, immunization, supplementation, and counseling for children and pregnant women)[21] and this is very worrying, if this continues.

The results of the multivariable analysis also showed that tofu/tempeh consumption had a significant relationship in the stunting group. The consumption increase of tofu/tempeh may be due to the relatively cheap price of tofu/tempeh, making it more affordable to buy. The price of 500 gr tofu/tempeh is Rp. 7,500 ($0.5), while red meat is IDR 60,000 ($4-5). This shift to cheaper food sources is an adaptation to the declining purchasing power of the people.

Tofu/Tempeh is a food source of vegetable protein derived from fermented soybeans. Protein is found in animal and vegetable protein but is much lower in vegetable protein.[10] Consumption of animal protein can reduce stunting prevalence by 4.3 percentage points, the more combinations of animal protein consumed the higher the percentage point of stunting that can be reduced.[10] Therefore, although the frequency of consumption of tofu/tempeh as a source of vegetable protein is high, it is not sufficient enough to fulfill the protein needs of children for their growth and development, especially if tofu/tempeh is consumed as a substitute for animal protein sources.

To meet food security, the government prepares social safety net programs for basic needs, especially for low socio-economic families, ranging from cash (unconditional cash transfers) and food aid. One of the social safety net programs provides an unconditional cash transfer of 150 thousand rupiahs ($10) per month for children under 6 years old.[22] This is quite beneficial because a study found that one of the beneficiaries stated that “I never thought I could buy food regularly for my children such as eggs, fish, and vegetables because I did not have enough money”.

COVID-19 has changed patterns of maternal and child health service delivery and child consumption, and perhaps other practices. We suggest future studies on innovation and its impact on delivering maternal and child health services during the pandemic. In addition, we also suggest future studies on consumption impacts on children's nutritional status and development. Qualitative studies related to the experiences of mothers and children in maintaining health during a pandemic may also be of interest to support our findings.

There are several weaknesses of this study, such as children's consumption patterns were based on the memories and perceptions of parents, hence, bias might appear. In addition, data on food consumption before the pandemic was reported retrospectively which could lead to recall bias. However, we hope that respondents can distinguish between the time before and after the pandemicbecause of the contrasting conditions between normal life and a life spent staying just at home (during the pandemic).

Meanwhile, this study has the following strength— to our knowledge, this is the first study conducted to collect various risk factors for stunting including children's health status of maternal and child health services as well as changes in the frequency of children's consumption based on recall 24 hours the pandemic. (Phrase unclear/incomplete. Please consider revising.)

  Conclusions Top

The change of stunting is two times greater in children who experience good changes in tofu/tempeh consumption, and fourtimes greater in children who have mothers that did not receive iron supplementation during pregnancy. Increasing access to nutritious food as well as the delivery of services and information related to maternal and child health services during the pandemic needs to be intensified by using innovative low-risk platforms.


Thank you to the Public Health Centre (Puskesmas) and cadres in Pasir Putih Village, Sawangan District, Depok City, West Java, for their assistance in carrying out this study while still paying attention to health protocols, as well as the respondents who have participated in this study. The authors would like to thank the University of Indonesia for funding this research through PUTI Grant 2020-2021 Number BA-783/UN2.RST/PPM.00.03.01/2020.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Key messages

Health systems that support maternal and child health services must be more innovative and advanced so that they can cover the shortages that occurred during the pandemic. Social support systems should be maintained to help household food security.

Financial support and sponsorship

This study was supported by PUTI Grant 2020-2021 Number: BA-783/UN2.RST/PPM.00.03.01/2020 from the University of Indonesia.

Conflicts of interest

There are no conflicts of interest.

  References Top

UNICEF. COVID-19 and children. 2021. Available from: https://data.unicef.org/covid-19-and-children/. [Last accessed on 2021 Jun 04].  Back to cited text no. 1
Goalkeepers B and MGF. COVID-19: A Global Perspective. 2020. Available from: https://www.gatesfoundation.org/goalkeepers/downloads/2020-report/report_a4_en.pdf. [Last accessed on 2021 Jun 16].  Back to cited text no. 2
Dewey KG, Begum K. Long-term consequences of stunting in early life. Matern Child Nutr 2011;7:5-18.  Back to cited text no. 3
Prentice AM, Ward KA, Goldberg GR, Jarjou LM, Moore SE, Fulford AJ, et al. Critical windows for nutritional interventions against stunting. Am J Clin Nutr 2013;97:911-8.  Back to cited text no. 4
Indonesian Ministry of Health. 2018 Indonesian Basic Health Research (RISKESDAS) Survey. Indonesian. 2019.  Back to cited text no. 5
Sachs JD, Kroll C, Lafortune G, Fuller G, Woelm F. Sustainable Development Report 2021 Includes the SDG Index and Dashboards The Decade of Action for the Sustainable Development Goals. Cambridge University Press; 2021.  Back to cited text no. 6
Janssen M, Chang BPI, Hristov H, Pravst I, Profeta A, Millard J. Changes in food consumption during the COVID-19 pandemic: Analysis of consumer survey data from the first lockdown period in Denmark, Germany, and Slovenia. Front Nutr 2021;8:635859.  Back to cited text no. 7
UNICEF. Child nutrition and COVID-19. 2020. Available from: https://data.unicef.org/topic/nutrition/child-nutrition-and-covid-19/. [Last accessed on 2021 Jun 04].  Back to cited text no. 8
Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr 2008;4(Suppl 1):24-85.  Back to cited text no. 9
Headey D, Hirvonen K, Hoddinott J. Animal sourced foods and child stunting. Am J Agric Econ 2018;100:1302-19.  Back to cited text no. 10
Fore HH, Dongyu Q, Beasley DM, Ghebreyesus TA. Child malnutrition and COVID-19: The time to act is now. Lancet 2020;396:517-8.  Back to cited text no. 11
World Health Organization (WHO). Training Course on Child Growth Assessment: Interpreting Growth Indicators. Geneva: WHO; 2008.  Back to cited text no. 12
World Health Organization (WHO). 2020. WHO Anthro Survey Analyser. Available from: https://worldhealthorg.shinyapps.io/anthro/. [Last accessed on 2021 Apr 20].  Back to cited text no. 13
Zhang Z. Model building strategy for logistic regression: Purposeful selection. Ann Transl Med 2016;4:111.  Back to cited text no. 14
Gebreweld A, Ali N, Ali R, Fisha T. Prevalence of anemia and its associated factors among children under five years of age attending at Guguftu health center, South Wollo, Northeast Ethiopia. PLoS One 2019;14:e0218961.  Back to cited text no. 15
Coordinating Ministry for Human Development and Culture. imposed a large-scale social restriction 2020. Available from: https://www.kemenkopmk.go.id/pembatasan-sosial-berskala-besar. Indonesian. 2020. [Last accessed on 2021 Jun 07].  Back to cited text no. 16
Saliem HP, Agustian A, Perdana RP. Dynamics of Prices, Demand, and Efforts to fulfill staple food during the COVID-19 pandemic in Dampak Pandemi Covid-19: Perspektif Adaptasi Dan Resiliensi Sosial Ekonomi Pertanian; Indonesian. 2020:p. 361-79.  Back to cited text no. 17
Nisar Y Bin, Aguayo VM, Billah SM, Dibley MJ. Antenatal iron-folic acid supplementation is associated with improved linear growth and reduced risk of stunting or severe stunting in south Asian children less than two years of age: A pooled analysis from seven countries. Nutrients 2020;12:1-19.  Back to cited text no. 18
Nisar Y Bin, Dibley MJ, Aguayo VM. Iron-folic acid supplementation during pregnancy reduces the risk of stunting in children less than 2 years of age: A retrospective cohort study from Nepal. Nutrients 2016;8:67.  Back to cited text no. 19
World Health Organization (WHO). Daily iron and folic acid supplementation during pregnancy. WHO; 2018. Available from: http://www.who.int/elena/titles/guidance_summaries/daily_iron_pregnancy/en/. [Last accessed on 2021 Jun 22].  Back to cited text no. 20
Ministry of Health. Ministry of Health performance report 2020. Jakarta, Indonesian. 2021. Available from: https://e-renggar.kemkes.go.id/file2018/e-performance/1-131313-1tahunan-211.pdf. [Last accessed on 2021 Jun 23].  Back to cited text no. 21
UNICEF Indonesia. One Year on: COVID-19 through the Eyes of Children INDONESIA.; 2021.  Back to cited text no. 22


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Tables

 Article Access Statistics
    PDF Downloaded100    
    Comments [Add]    

Recommend this journal