How to cite:
Ririn Ariyanti, Selvia Febrianti, Ely Rahmawati. (2022). The
Relationship of Pregnancy Anemia with Primary Postpartum
Hemorrhage in Tarakan, North Kalimantan. Journal Eduvest. Vol (2):
698-703
E-ISSN:
2775-3727
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Eduvest(–(Journal(of(Universal(Studies(
Volume(2(Number(4,(April,(2022(
p-(ISSN(2775-3735-(e-ISSN(2775-3727!
THE RELATIONSHIP OF PREGNANCY ANEMIA WITH
PRIMARY
POSTPARTUM HEMORRHAGE
IN TARAKAN,
NORTH KALIMANTAN
Ririn!Ariyanti
!1
,!Selvia!Febrianti
!2,!
Ely!Rahmawati
3
!!
1.2
Midwifery!!Department,!Borneo!Tarakan!University,!Indonesia!
3
Midwifery!Department,!Poltekkes!Ministry!of!Health,!Eeast!Kalimantan,!
Indonesia!
Email:![email protected],![email protected],!
[email protected]
!
ARTICLE!INFO!!!!!!!!ABSTRACT!
Received:
March, 26
th
2022
Revised:
April, 16
th
2022
Approved:
April, 17
th
2022
!
!
!
Bleeding in childbirth is caused by anemia in pregnancy. This
happens because when the mother gives birth, there will be
adequate uterine contractions to be born. This study aims to
determine the relationship between anemia during pregnancy
and the incidence of primary postpartum hemorrhage. This
type of research is analytical survey research. The subjects in
this study were all pregnant women who suffered from
anemia. The research place of the Juata Community Health
Center in Tarakan City, North Kalimantan. From May to June
2020. The data used in this study is secondary data obtained
from medical record books at the Juata Community Health
Center. This study used a total sampling technique—data
analysis using chi-square analysis. The statistical tests showed
that pregnant women with anemia had an 11,253 times
greater risk of bleeding during childbirth than women who
gave birth vaginally. Pregnant women and their families
should take care of their pregnancy by routinely carrying out
antenatal care under antenatal care service standards
KEYWORDS!
anemia,!postpartum!hemorrhage,!postpartum!hemorrhage!
!
This! work! is! licensed! under! a! Creative! Commons!
Attribution-ShareAlike!4.0!International!
!
Ririn Ariyanti, Selvia Febrianti, Ely Rahmawati
The Relationship of Pregnancy Anemia with Primary Postpartum Hemorrhage in
Tarakan, North Kalimantan 699
INTRODUCTION
Maternal Mortality Rate is one indicator to see the success of maternal health
efforts. Mother death is the ratio of deaths during pregnancy, childbirth and the puerperium
caused by pregnancy, delivery and postpartum or its management but not due to other
causes such as accidents or falls in every 100,000 live births. In addition to assessing
maternal health programs, this indicator can also assess the degree of public health, because
of its sensitivity to improving health services, both in terms of accessibility and quality. In
general, there was a decrease in maternal mortality from 1991-2015 from 390 to 305 per
100,000 live births. Although there is a downward trend in the Maternal Mortality Rate, it
has not succeeded in achieving the MDGs target, which must be achieved at 102 per
100,000 live births in 2015 (Cameron et al., 2019)
Efforts to accelerate the reduction of maternal mortality can be made by ensuring
that every mother can access quality maternal health services, such as health services for
pregnant women, delivery assistance by trained health workers in health care facilities,
postpartum care for mothers and babies, special care and referrals. in case of complications
and family planning services, including postnatal family planning (Indonesian Health
Ministry, 2021)
According to the World Health Organization, the cause of maternal mortality is 81%
due to complications during pregnancy and childbirth, and 25% of maternal deaths are
caused by postpartum hemorrhage and an estimated 100,000 deaths each year. The
maternal mortality rate in Indonesia is relatively high. In Southeast Asia, Indonesia ranks
second after Laos. The causes of death in Indonesia are bleeding 28%, eclampsia 24%,
infection 11%, abortion 5%, prolonged labor 5%, embolism 3%, puerperal complications
8%, and the rest due to other causes (Indonesia, 2014). Meanwhile, in Tarakan, North
Kalimantan, bleeding is the most significant contributor to the maternal mortality rate,
which is 50% (Indonesian Health Ministry, 2021)
Postpartum hemorrhage is caused by anemia in pregnancy. This happens because
when the mother gives birth, there will be adequate uterine contractions to be born. In
pregnant women who are anemic with hemoglobin below 10, the risk of bleeding due to
hypotonia or atony is considerable, around 20-25 %—the more bleeding, the hemoglobin
level decreases. Making the uterus contract takes energy and oxygen supplied by the blood.
While the supply of these needs is getting thinner, the ability to contract is weaker (Watkins
& Stem, 2020). Not only causing maternal death, but anemia in pregnant women can also
increase the risk of premature birth, infant mortality, and infectious diseases. Iron
deficiency anemia in the mother can affect the growth and development of the fetus/infant
during pregnancy and after (Indonesian Health Ministry, 2021)
The 2018 Basic Health research results state that in Indonesia, 48.9% of pregnant
women experience anemia. As many as 84.6% of anemia in pregnant women occurred in
15-24 years. To prevent anemia, every pregnant woman is expected to get a minimum of
90 tablets for blood during pregnancy. The coverage of giving blood-added tablets to
pregnant women in Indonesia in 2018 was 81.16%. This figure has not yet reached the 2018
strategic plan target of 95%. The province with the highest coverage of giving blood
supplement tablets to pregnant women was Bengkulu (99.49%), while the province with
the lowest coverage was Banten (32.11%). The coverage of administration of blood-added
tablets in the province of North Kalimantan is 84.19%, this shows that the coverage of
blood-added tablets in North Kalimantan is above the coverage of blood-added tablets in
Indonesia (Indonesian Health Ministry, 2021)
Based on a preliminary study at the Juata Community Health Center, the incidence
of anemia in pregnant women throughout 2021 (January-February) was 11 cases, and 1
Eduvest – Journal of Universal Studies
Volume 2 Number 4, April 2022
700 http://eduvest.greenvest.co.id
case experienced primary postpartum hemorrhage. This study aims to determine the
relationship between anemia during pregnancy and the incidence of primary postpartum
hemorrhage.
RESEARCH METHOD
This type of research is analytical survey research. The subjects in this study were
all pregnant women who suffered from anemia. The research place of the Juata Community
Health Center in Tarakan City, North Kalimantan. From May to June 2020. The data used
in this study is secondary data obtained from medical record books at the Juata Community
Health Center. Sampling in this study used a total sampling technique. Data analysis using
chi-square analysis.
RESULT AND DISCUSSION
The subjects of this study were 271 pregnant women who checked themselves at
the Juata Tarakan Health Center, North Kalimantan, in 2020. The frequency distribution of
research subjects showed that most of 194 (71.4%) were pregnant more than once or
multigravida, most of the pregnant women were of reproductive age 20 -35 years 213
(78.6%), most of the pregnant women did not experience anemia 226 (83.4%), almost all
of the pregnant women gave birth typically 250 (92.3%), almost half of the respondents
gave birth at the Public health centre 151 (55,7%), a small proportion of respondents 17
(6.3%) had complications at the time of delivery, and 35 (12.9%) experienced bleeding at
the time of delivery.
Table 1. Characteristics of respondents
Variable
n
parity
Primigravida
77
multigravida
194
Age
20-35 years old
213
<20 years & >35 years
58
Anemia
No anemia
226
Anemia
45
Type of Delivery
Vaginal
250
Sectio Caesarea
21
Place of Delivery
Hospital
78
Public health center
Klinik
PMB
151
13
29
Labor Complications
No complications
254
complications
Postpartum Bleeding
No Bleeding
Bleeding
17
236
35
Ririn Ariyanti, Selvia Febrianti, Ely Rahmawati
The Relationship of Pregnancy Anemia with Primary Postpartum Hemorrhage in
Tarakan, North Kalimantan 701
Table 2. relationship between anemia and postpartum hemorage
Anemia
Postpartum Bleeding
Odd Ratio
CI 95%
No Bleeding
Bleeding
Anemia
No Anemia
211(93,4%)
15 (6,6%)
11,253
5,120-24,732
Anemia
25 (55,6%)
20 (44,4%)
1
The statistical tests showed that pregnant women with anemia had an 11,253 times greater
risk of bleeding during childbirth than women who gave birth vaginally.
Tabel 3. confounding variable
Variabel
Postpartum Bleeding
Odd Ratio
p-value
No Bleeding
Bleeding
parity
Primigravida
71(92,2%)
6 (7,8%)
2,080
0,159
Multigravida
Age (years)
20-35
<20 & >35
Type of Childbirth
Vaginal
Sectio Caesarea
165 (85,1%)
187(87,8%)
49 (84,5%)
215(86%)
21(100%)
29(14,9%)
26(12,2%)
9(15,5%)
35 (14%)
0 (0%)
1
1,321
1
0,860
1
0,511
0,134
The statistical tests showed that parity, age and type of delivery had no relationship with
maternal bleeding.
Discussion
The incidence of labor bleeding in pregnant women with anemia at the Juata Public
Health Center in Tarakan City throughout 2020 was 44.4%. Pregnancy anemia had a
significant effect on the incidence of postpartum hemorrhage with p-value = 0.00 and OR =
11.253. This means that mothers with anemia in pregnancy have a risk of postpartum
hemorrhage 11.253 times greater than mothers who are not anemic. wherefrom the research
he conducted showed a significant relationship between anemia and postpartum hemorrhage,
with anemia at risk of experiencing postpartum hemorrhage 17.6 times for postpartum
hemorrhage to occur compared to mothers who did not experience postpartum hemorrhage
anemia (Wardani, 2017).
Pregnant women with anemia are unable to meet the body's iron needs, so it can
cause interference and inhibition of body cells, including brain cells and cause health
problems for the mother and fetus (Suryanarayana et al., 2017). The following is the impact
of anemia in pregnancy according to various sources and experts, including anemia in
pregnancy can lead to miscarriage, premature birth, low birth weight, bleeding before and
after childbirth can even cause maternal and child death, the impact of anemia on pregnancy
varies from very mild complaints to disturbances in the continuity of pregnancy (abortion,
immature or premature labor), disorders of the delivery process (atonia, prolonged labor,
bleeding), disorders during the puerperium (sub involution of the uterus, resistance to
infection, stress, and milk production) low), and fetal disorders (dysmaturity, microsomes,
low birth weight, perinatal death, etc.) (Sataloff et al., 2020).
Mothers who suffer from anemia in pregnancy have fewer red blood cells than
needed. Without enough red blood cells or a reduced adequate number of red blood cells, the
Eduvest – Journal of Universal Studies
Volume 2 Number 4, April 2022
702 http://eduvest.greenvest.co.id
blood will not clot (Raisa Aringazina & Gulnara Kurmanalina, 2021). This means a person
can bleed excessively, even if only slightly injured. Mothers who enter labor with low
hemoglobin (Hb) concentrations may experience an even more rapid drop in Hb if bleeding
occurs, however small (Wardani, 2017).
Anemia occurs in 1/3 of women during the third trimester of pregnancy. Common
causes are iron and folic acid deficiency. The amount of blood in a pregnant woman's body
increases by 20-30%, thus requiring an increase in iron supply. It is crucial to do a
hemoglobin test to detect anemia in this period. Anemia in pregnant women significantly
affects the condition of the mother and fetus during the delivery process (Stephen et al.,
2018). Pregnant women who suffer from severe anemia can increase the risk of maternal and
infant morbidity and mortality, the chances of giving birth to babies with low birth weight
and premature are also greater (Hakimi & Helmyati, 2011).
There will be changes in hematological and biochemical values in progressive iron-
deficiency anemia. The first thing that happens is a decrease in iron stores in the tissues. This
decrease will be indicated by serum ferritin, a protein that binds iron in the body as storage.
Then the amount of serum iron will decrease, the iron-binding capacity of the serum (serum
transferrin) will increase, and transferrin saturation will drop below normal (Bata et al.,
2021).
As stores decrease, iron and protoporphyrin fail to form heme. Free erythrocyte
protoporphyrins (FEP) accumulate, and hemoglobin synthesis is impaired. At this point, iron
deficiency progresses to iron deficiency anemia. With reduced hemoglobin in each cell, the
red cells become smaller. These morphological changes most often appear in conjunction
with a decrease in the mean corpuscular volume (MCV) and the mean corpuscular
hemoglobin (MCH).
Changes in the size variation of red blood cells occur with the replacement of
normocytic cells with microcytic cells; this variation is indicated by the increase in red blood
cell distribution width (RDW). The number of red blood cells will also decrease. The
reticulocyte count will increase slightly or maybe be normal. A blood smear will show
hypochromic and microcytic red cells with constant cell variation. The elliptical or cigar-like
shape of the blood cells is often seen. Detection of increased transferrin receptors and
reduced reticulocyte hemoglobin concentration supports the diagnosis of iron deficiency
anemia (Fitriany & Saputri, 2018).
However, the variables of age, parity and type of delivery in this study did not have
an effect on the incidence of postpartum hemorrhage at the Juata Public Health Center,
Tarakan City; this was not following the research conducted by Wardani where the three
variables had a relationship with the incidence of postpartum hemorrhage. With many studies
proving that anemia of pregnancy affects the incidence of postpartum hemorrhage, it is a
particular concern for health workers, especially midwives, to always carry out hemoglobin
checks as a supporting examination in the first and third trimesters so that if anemia occurs
in pregnancy, it can be immediately detected and treated. In addition, pregnant women are
also required to consume a minimum of 90 tablets for blood during pregnancy (Kementrian
Kesehatan RI, 2020).
CONCLUSION
Anemia of pregnancy has a significant effect on the incidence of postpartum
hemorrhage with a value where mothers with anemia in pregnancy have a risk of
postpartum hemorrhage 11.253 times greater than mothers who are not anemic.
Suggestions for pregnant women and their families should be to maintain their pregnancy
with regular efforts to carry out prenatal care following antenatal care service standards.
!
Ririn Ariyanti, Selvia Febrianti, Ely Rahmawati
The Relationship of Pregnancy Anemia with Primary Postpartum Hemorrhage in
Tarakan, North Kalimantan 703
Health workers should prevent anemia in pregnancy to prevent postpartum hemorrhage.
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