The effect of nutrition and reproductive health education of pregnant women in Indonesia using quasi experimental study

Background Almost one-third of children under 5 years old in Indonesia suffer from stunting. Stunting can be prevented optimally during pregnancy as the initial phase of the first 1000 days of life. This study aims to determine the effect of nutrition and reproductive health education of pregnant women in Bogor Regency, Indonesia. Methods A quasi-experimental study was conducted among 194 pregnant women from August to November 2019. The pregnant women were randomly selected from four different villages in Bogor Regency. The intervention group (n = 97) received 2 h of nutrition and reproductive health education in small groups (four or five mothers per group) every 2 weeks for 3 consecutive months. This interactive education was given by facilitators using techniques such as lectures, role-playing, simulation, and games. The control group (n = 97) received regular health care services. A structured questionnaire was applied to collect data consisting of maternal characteristics, nutritional and reproductive health knowledge, attitudes, and practices in the intervention and control groups. Data were analysed using t-test and chi-square analysis. Results Pregnant women in the intervention group indicated a significant increase in knowledge, attitudes, and practices regarding nutrition and reproductive health after receiving education. The pre-test and post-test mean scores in the intervention group were 55.1 and 83.1 for overall knowledge, 40.2 and 49.0 for attitudes, and 36.2 and 40.2 for practices, respectively. In the control group, there was no significant difference between the pre-test and post-test mean scores for these three variables. There was a significant difference (P < 0.001) in the post-test mean between the intervention group and the control group, but the difference was not significant (P > 0.05) in the pre-test. Conclusion Providing nutrition and reproductive health education through small groups with interactive methods improves the knowledge, attitudes, and practices of pregnant women. This intervention has the potential to be replicated and developed for large-scale implementation by optimising collaboration between government, non-governmental organizations, and maternal and child health service providers.


Introduction
Reducing stunting is part of the World Health Organization (WHO) Sustainable Development Goals (SDGs) [1]. In many countries, interventions to reduce stunting have been implemented during pregnancy [2,3]. Poor maternal reproductive health and nutrition during pregnancy has lifelong impacts on the health of the offspring [4]. Furthermore, inadequate infant and child feeding practices, repeated infection, and inadequate psychosocial stimulation in the first 1000 days of a child's life strongly contribute to stunted growth and development [5,6]. Stunting reflects shortness for age, is a well-established risk marker of growth failure, and is measured by a height-for-age z-score of more than two standard deviations below the WHO Child Growth Standards median [7]. This chronic malnutrition is related to many indices of functional impairment, including cognitive and physical development, metabolic disorders that carry an increased risk of degenerative diseases, and socio-emotional development [8][9][10][11]. These serious health problems contribute to high health care costs of a country; therefore, effective prevention is needed to reduce the prevalence of stunting [12].
The WHO reported that stunting is declining slowly, from 32.4% in 2000 to 21.3% in 2019, and in some regions stunting affects 1 in every 3 children [13,14]. Slow progress in reducing stunting has been made in Indonesia, from 37.2 to 30.8% in the last 5 years [15]. The stunting rate is relatively high based on the WHO categories of public health significance for stunting (30-39%) [16]. The incidence of stunting in Indonesia is influenced by characteristics of the child (sex; breastfeeding status; early initiation of breastfeeding; infectious diseases, particularly diarrhoea and acute respiratory infections; and birth weight); the household (family size and structure, including mother's education and knowledge about nutrition and reproductive health, and household and housing characteristics), and the environment (healthcare services and community) [4,[17][18][19]. Previous studies show that maternal characteristics (health, nutrition, and socio-demography) significantly influence the occurrence of stunting among children less than 5 years old. In general, these studies recommended early integrated interventions to reduce stunting in Indonesia, such as effective education to improve the knowledge, attitudes, and practices of pregnant women regarding nutrition and reproductive health using multisectorial approaches. Other scientific evidence shows that more than one-third of mothers do not yet know about stunting, so health promotion and education to improve mothers' knowledge, attitudes, and practices is needed [20].
Strategies to improve mothers' knowledge, attitudes, and practices regarding nutrition and reproductive health have consistently contributed to reducing child stunting in Indonesia [20,21]. Most of the mothers in this country are the primary caregivers for their babies and decide on feeding patterns, immunisation, and health services [4,17]. Therefore, educational methods as an intervention to improve mothers' knowledge, attitudes, and practices have been implemented based on the theory of changes behaviour [22,23]. Research on knowledge, attitude, and behaviour has assessed the success of an educational method by applying a pre-test and post-test research design, such as a quasi-experimental or randomized trial [23]. The interactions between knowledge, attitude, and behaviour initiate a potentially reciprocal and dynamic relationship: knowledge regarding nutrition and reproductive health can inform attitude about that topic, which can influence behaviour [23]. Improving knowledge, attitude, and behaviour during pregnancy is important as it determines post-partum quality of life for the mother and her babies. For example, success of early breastfeeding initiation and exclusive breastfeeding can be determined by mothers' intention during pregnancy to breastfeed [24][25][26].
The purpose of this study was to assess the effectiveness of nutrition and reproductive health education of pregnant women in improving knowledge, attitudes, and practices regarding nutrition and reproductive health in Bogor District, in West Java Province, where the stunting rate (about 31%) is higher than the national prevalence [27]. Preliminary studies in this region showed that 29.7% of children were stunted (19% stunted and 10.7% severely stunted). This study used interactive education methods that cover three topics: parenting, balanced diet and immunisation, and reproductive health. Each topic was addressed using different techniques: role-playing, exercises, and fun games supported by interesting props. This educational method could be adopted or modified by the government and other health care providers in an effort to reduce the prevalence of stunting.

Study area and period
The study was conducted in Bogor Regency from August to November 2019. The district is located close to the National Capital as the centre of government, services, and trade, with fairly high development activities. The estimated population of this district is 5,715,009, the highest in West Java Province. The population is 49% female, with an estimated number of 40,896 pregnant women.
Bogor District consists of 40 sub-districts with varying regional morphology, namely lowlands and highlands. Most of the population is poorly educated, and in general, the residents of this district work as entrepreneurs, private or government employees, and labourers, while the majority of mothers are housewives. Moreover, most mothers are the primary caregivers for children [28].

Design and samples
A quasi-experimental study with a pre-test/post-test design was conducted on pregnant women. The source population in this study was pregnant women in Bogor District, in which the focus locations for stunting consist of 10 villages. Pregnant women selected from four villages were the study population. All eligible women were included in the study, and participants were selected by simple random sampling (SRS) method.

Inclusion and exclusion criteria
Pregnant women who lived at least 6 months in these villages were included in this study to maintain homogeneity in access to information exposure and health services regarding nutrition and reproductive health.
Another inclusion criterion was a maximum gestational age of 27 weeks (end of the second trimester), because the intervention is intended to be implemented before the delivery period. The exclusion criteria were confirmation or diagnosis of serious health problems requiring a special diet and nutritional needs, as well as premature delivery during the data collection period.

Sample size determination
The sample size was calculated using a formula for the two-sample test of proportions with a one-sided alternative hypothesis, using the following assumptions: 95% confidence level, 82.6% of pregnant women with improved knowledge regarding appropriate dietary practice after receiving nutrition education in the intervention group (P 1 ), and 47.8% of pregnant women with improved knowledge regarding appropriate dietary practice without nutrition education in the control group (P 2 ) based on previous study [29], 90% power, 10% contingency for loss to follow- Fig. 1 Sampling procedure of pregnant women. SRS = Simple Random Sapling; n 1 = sample size for intervention group; n 2 = sample size for control group up, and design effect 2. Therefore, using the following formula, the calculated sample size was 194 (97 for each group) pregnant women [30]: Sampling technique and procedure The sampling procedure is illustrated in Fig. 1. Pregnant women living in four villages, selected from the 10 villages in Bogor District identified as focus locations for stunting in The Bogor District Health Office data, and also recommended as priority areas for intervention, were identified and screened against the inclusion and exclusion criteria. Eligible participants were selected by the simple random sampling method.

Data collection and measurements
This study consists of three stages: 1) instrument development, 2) training for facilitators, and 3) nutrition and reproductive health education of pregnant women in the intervention group (Fig. 2).

Instrument development
A focus group discussion (FGD) was conducted to develop a research instrument including leaflet, module, and questionnaire involving stakeholders, community leaders, cadres, and pregnant women. After that, nutrition and reproductive health experts reviewed the research instruments to fulfil the evidence based on the test content. This study also used 'nutrition discs', which are educational tools developed and produced by Pergizi Pangan Indonesia (Indonesian Nutrition and Food Expert Association), an organization of nutrition and food experts. Facilitators used the leaflet, module, and nutrition discs to educate pregnant women in the intervention group. The structured questionnaire was applied to collect data on the intervention group and the control group. Maternal socio-demographic characteristics; other information such as obstetric history, nutrition, and reproductive health; and utilisation of health services were collected only at baseline. Knowledge, attitudes, and practices regarding nutritional and reproductive health were collected at both baseline and end line by using 23, 16, and 12 questions, respectively. For knowledge, participants chose one of four answer choices (A, B, C, or D), then were given a score = 1 if the answer is correct, and a score = 0 if the answer is wrong. Items of attitudes were measured using a four-point Likert scale (strongly disagree = 1 through strongly agree = 4). Then, the value of each Likert scale assessed by the participants for each question was summed and the average was calculated. Similarly, items of practices regarding nutrition and reproductive health were collected using a four-point Likert scale (never = 1 through most of the time = 4). Then, each item was summed to obtain an overall score and the average score was calculated.

Training for facilitators
The facilitators were cadres or community health workers in the local communities who provided health education to the pregnant woman in the intervention group. They were given training about the health educational skills, methods, and knowledge regarding nutritional and reproductive health. A pre-test/post-test assessment was used to ensure the homogeneity of the facilitators' skills and knowledge. All facilitators had appropriate socio-demographic characteristics. They are housewives with low socio-economic levels and served as a cadre for at least 1 year.

Nutrition and reproductive health education of pregnant women in the intervention group
This education intervention was designed according to the characteristics and information required by pregnant women based on the result of the FGD that involved stakeholders, community leaders, community health workers, and pregnant women (Fig. 2), who provided suggestions so that the educational methods used would be easy to understand and implemented during the pregnancy period to prevent stunting. The majority of pregnant women had low education and socio-economic level in the study area. Their literacy level might have been a barrier to access information regarding nutrition and reproductive health. They are generally housewives who have sufficient time to receive nutrition and reproductive health education for 2 h. These data are reinforced by data obtained from health profile reports and socio-demographics [28]. Advice from nutrition and reproductive health experts also confirms this method. Interactive education can increase participants' interest and concentration in receiving education. So this method can improve the knowledge, attitudes, and practices regarding nutrition and reproductive health, to prevent stunting since the pregnancy period. Nutrition and reproductive health education was only given to the intervention group. They were placed in small groups (four or five mothers per group) and received 2 h of nutrition and reproductive health education from a facilitator every 2 weeks for 3 consecutive months. The educational contents and special applied strategies can be seen in Table 1. The education consisted of three sessions that included theoretical (lectures) and practical sessions. The first covered parenting (psycho-emotional and nutritional parenting) and was complemented by role-playing. The second covered nutrition during pregnancy, stunting, and immunity. This session was reinforced by simulation to assess nutritional status and nutritional requirements for the first 1000 days of life. In this session, the facilitator used two packets of nutrition discs, one consisting of eight discs that determine the nutritional status of children based on age groups, and another consisting of eight discs focussed on the needs of balanced nutrition from the gestational period through adolescence (19 years). The third session covered reproductive health education, equipped with the games of myths and facts. The control group received from cadres the usual nutrition and reproductive health education that is provided in the health program regularly every month. In this routine health program, pregnant women are informed about maternal and child health including nutrition and reproductive health, children's weight and height are measured, and children are given primary immunizations.

Quality Assurance of Data Collection
Four women nutritionists acting as data collectors and two public health practitioners as supervisors were given 2 days of training. The questionnaire was pre-tested on 5% of the representative sample assessed in other areas with characteristics similar to those of the study area. Data collectors administered the questionnaire through face-to-face interviews at the pregnant women's homes and were overseen by supervisors periodically. All questionnaires were verified for completeness and accuracy by data collectors.

Data processing and analysis
All data in the questionnaire were checked for missing values, including maternal characteristics and knowledge, attitudes, and practices. Furthermore, data were coded and input using SPSS version 20.0. Variables with continuous data, including knowledge, attitudes, and practices scores, were analysed for normality using the Kolmogorov-Smirnov test. Based on the Kolmogorov test, all variables including knowledge, attitudes, and practices showed normal distribution. Descriptive statistics consisting of the mean, standard deviation, and percentage were analysed by univariate analysis, while variables with categorical data were analysed using the chi-square test. A 95% confidence level and a value of P < 0.05 were used to assess the statistical significance. Independent t-test was used to see significant differences in pre-test and post-test scores between the intervention group and control group, and paired t-test was used for continuous variables within groups at pre-test and post-test.

Ethical consideration
Ethics Commission of Health Research of the Faculty of Medicine and Health in Universitas Muhammadiyah Jakarta acceded this study with approval number 001/ PE/KE/FKK-UMJ/2019. The Government in Bogor District and each village as the study area also granted permission. The Health Office of Bogor District, the National Population and Family Planning Agency, and community health centres where the villages are located also approved this study. The comfort of pregnant women while participating in the data collection process was prioritised, and the confidentiality of their identity was well guarded.

Maternal characteristics
Maternal characteristics included socio-demographic characteristics, obstetric history, information on nutrition and reproductive health, and utilisation of health services as represented in Table 1. A total of 194 pregnant women participated (97 in each group).

Socio-demographic characteristics
Most of the participants were of reproductive age (19-35 years). Of 97 participants in each group, about 86.6 and 83.5% of participants were within the age range of 19-35 years in the intervention group (IG) and control group (CG), respectively. Approximately one-third of participants in each group had short stature (height <

Nutrition and reproductive health knowledge of pregnant women
The knowledge of parenting consists of psychoemotional parenting and nutritional parenting. In psycho-emotional parenting knowledge, almost all of the participants (93.8%) in the IG knew the consequences of not providing psycho-emotional parenting during pregnancy for the growth and development of the baby at the post-test (Table 4). In the nutritional parenting knowledge, almost 100% of participants knew the dietary sources of macronutrient-and micronutrient-rich foods for babies more than 6 months old (95.9 and 96.9%, respectively). There was a significant difference between pre-test and post-test in IG (P < 0.001) for each question in this aspect. The participants' knowledge of nutrition during pregnancy, stunting, and immunity improved after education. Almost 100% of participants (92.8%) knew the dietary sources of macronutrient-rich foods (92.8%), the signs and symptoms of stunting (94.8%), and the benefits of immunisation in childcare (92.8%).
Similarly, their reproductive health knowledge also improved at the post-test. As much as 92.8% of participants knew the benefits of antenatal care for maternal and babies' health. The paired t-test indicated that nutrition and reproductive health knowledge of participants were significantly (P < 0.001) increased after education in IG, but there was no significant difference in CG (P > 0.05) in all questions.

Discussion
The failure of foetal growth during pregnancy is significantly related to stunted child growth [31]. Pregnant women have central roles in achieve optimal growth during this critical period [4,31]. The 194 pregnant women who participated in this study have a high risk of having stunted children, generally. They live in rural areas with low socio-economic levels that are related to a lack of food availability in the household [32,33]. Another study among pregnant women in rural Punjab showed that education and parity were significantly associated with knowledge, attitude, and dietary practices [34,35]. The WHO reported that mothers with low income and a low level of education experience more difficulty affording adequate food to provide a nutritious and diverse diet [36]. The findings of this study also indicate that about one-third of pregnant women (33.0 and 28.9% in IG and CG, respectively) also have a short stature (> 150 cm), which may increase risk of having stunted children [37][38][39]. A 19-year-old woman with a height at least two standard deviations below the average (> 150 cm) has short stature, according to the WHO provision [40]. Javid and Pu showed in the Pakistan Demographic and Health Survey of 2012-13 that shortstature mothers (height > 150 cm) were about 2.0 times more likely to have a stunted child compared to tallstature mothers [38]. Participants in this study also have not utilised health services optimally. More than onethird of those who have given birth delivered their babies at home and were helped by traditional birth attendants. They did not receive adequate health care in the early life of the baby, which is a crucial stage associated with pregnancy outcomes. This condition indicates a low quality of maternal health care, which may significantly affect child stunting [41,42]. Knowledge, attitude, and practices regarding nutrition and reproductive health are the main factors that can influence pregnancy outcomes [43,44]. The finding of this study indicates that participants have a lack of knowledge, attitudes, and practices regarding nutrition and reproductive at baseline. In this study, the knowledge, attitudes, and practices mean scores were significantly (P < 0.001) improved after education in the IG. In the CG, there was no significant difference (P > 0.05) in mean knowledge, attitudes, and practices scores regarding nutrition and reproductive health between pre-test and post-test. This study also shows that education intervention effectively provides a significant (P < 0.05) difference in the mean knowledge, attitudes, and practices scores between the IG and CG at the end line: about 82.1 and 55.9, 49.0 and 40.5, and 40.2 and 36.3, respectively of the IG and CG between pre-test and posttest. Similarly, a cluster randomized control trial study among pregnant women in Northeast Ethiopia showed that nutrition education significantly improved (P < 0.001) mean nutritional knowledge scores in the intervention group, from 6.9 at baseline to 13.4 after nutrition education. There was a significant difference (P < 0.001) in mean nutritional knowledge scores between the intervention group and control group at baseline. The study also shows that proportion of healthy dietary practices was significantly different (P < 0.001) between pregnant women who were given nutrition education in  the intervention group compared to the control group at the end line [29]. A study among pregnant women in Addis Ababa showed that nutrition knowledge scores improved after the nutrition education program from 53.9 to 97.0%, whereas dietary practice scores during pregnancy increased from 46.8 to 83.7% [45]. These studies reinforce the evidence that nutrition education has a positive effect on improving the knowledge, attitudes, and practices scores among pregnant women. Nutrition and reproductive health education is a specific intervention in The Global Nutrition target in 2025 [7] to reach a 40% reduction in the number of children under 5 years old who are stunted. This intervention can be delivered effectively through community health workers who have a high potential to improve maternal and child health among the hard-to-reach population, particularly in rural areas [13]. According to the WHO recommendation, that method was applied in this study. The community health workers as facilitators delivered interactive nutrition and reproductive health education. They actively visited the homes of eligible pregnant women, formed groups, and conducted the education in small groups. This method has been proven to improve the knowledge, attitudes, and practices of pregnant women regarding nutrition and reproductive health. The intervention given in this study is different from the methods that have used done before both in educational content and applied strategies, although it has approximately the same effectiveness. The study in West Gojjam Zone, Ethiopia, showed that pregnant women who received nutrition education were 2.02 times more likely to improve their dietary practices compared with those who did not receive nutrition education [46]. The educational method used in the West Gojjam zone study was nutrition counselling provided by health workers, which would be difficult to apply in this study. The number of health workers such as midwives, nutritionists, or health promoters in rural areas is limited. There is more potential to optimise the role of cadres or community health workers as facilitators in providing nutrition and reproductive health education to pregnant women. This allows the intervention to be given continuously during the first 1000 days of life to prevent stunting. A study in Bangladesh showed that maternal counselling using a framework of essential health care (EHC) plus nutrition counselling could improve knowledge and dietary practices of child feeding to reduce stunting prevalence effectively [2]. However, with this method, education is given passively. The educator waits for participants to obtain EHC and nutrition counselling. Less interactive methods can lead to potential saturation for participants in obtaining an education. Furthermore, proper knowledge and dietary practices simultaneously influence gestational weight gain, degrade the risk of anaemia in the last trimester of pregnancy, improve the baby's birth weight, and reduce the risk of preterm birth [47]. This study strengthens scientific evidence that nutrition and reproductive health education during pregnancy can improve the knowledge, attitudes, and practices of pregnant women, which contribute to increased maternal and neonatal health and reduce childhood stunting [29,31,48,49].
Nutrition and reproductive health knowledge of pregnant women related to stunting improved significantly by education intervention [29,41]. A formative research study conducted in 10 provinces in Indonesia that implemented the National Nutrition Communication Campaign (NNCC) showed that only 2.1% of 3150 mothers had known about stunting, and about two-thirds of them assumed that stunting was caused by heredity [20]. Nevertheless, a study among women of child-bearing age in Lagos State, Nigeria, reported that 61.89 and 86.89% of them had accomplished knowledge and positive attitude regarding nutrition, respectively [49]. The finding of this study shows that the number of participants who answered correctly for all questions increased significantly (P < 0.001) in the IG. In parenting knowledge, almost 100% of participants knew the ways to improve 'bonding' between mother, foetus, and father during pregnancy (90.7%) and the consequences of not providing psycho-emotional parenting during pregnancy for the baby's growth and development (93.8%). A  previous study showed that maternal depression was associated with child stunting and psychological and intellectual development. The lack of psycho-emotional parenting during pregnancy weakens 'mother-child' attachment that affects the nutritional status and development of children [50,51]. In nutrition parenting, almost 100% of participants correctly answered the question about the timing of complementary feeding for babies (93.8%), dietary sources of macronutrient-rich foods for babies > 6 months old (95.9%), and dietary sources of micronutrient-rich foods for babies > 6 months old (96.9%). Mistry et al. showed that maternal counselling was associated with improving feeding practices in the early life of a child, which decreased stunting prevalence significantly [2]. The participants improved their knowledge about nutrition during pregnancy, stunting, and immunity after education. Most of the participants knew about a balanced diet (85.6%), the benefit of a balanced diet during pregnancy for foetus and mother (84.55%), dietary sources of macronutrient-rich foods (92.8%), stunting (94.8%), the synergetic effect of nutrition and infection towards stunting (82.5%), and the benefits of immunisation in childcare (92.8%). A study in Dissie Town, Northeast, Ethiopia, showed that the number of participants who answered correctly increased after nutrition education. Almost all of the participants knew about a balanced diet (95.7%), the benefit of a balanced diet for foetus and mother (89.9%), and the synergetic effect between nutrition and infection (97.1%). Also, all participants (100%) knew about the dietary sources of macronutrient-and micronutrient-rich foods [29]. Generally, the increase in the number of participants who answered correctly in Dissie Town is higher than in this study. The participants live in urban areas, so they get better access to health facilities. They also have a higher socio-economic status, including education, occupation, and family income. This study also shows an increase in the number of participants who answered correctly in reproductive health knowledge: 92.8% of participants knew the benefits of antenatal care for maternal and baby health after education. Similarly, a quasiexperimental study in Brebes District, Central Java in Indonesia, showed that reproductive health education improved knowledge among brides and grooms [52]. Additional evidence in Somalia shows that they have a lack of knowledge about reproductive health that confirmed the need for proper nutrition education [53]. Reproductive health during pregnancy is fundamental to ensuring all women have access to respectful and highquality maternity care to increase maternal health and pregnancy outcomes [54]. This study contributes to increasing intensive nutrition and reproductive health education efforts implemented in the wider community. Such studies provide scientific evidence as consideration for policymakers, researchers, program practitioners and implementers, nongovernmental organisations, health workers, community health workers, and the entire community to improve knowledge, attitudes, and practices regarding nutrition and reproductive health, in order to reduce the prevalence of stunting from 27.7 to 14% in 2024 as the national target in Indonesia and achieve The Global Nutrition target in 2025 of 40% reduction in the number of children under 5 years old who are stunted.

Conclusion
Nutrition and reproductive health education delivered by community health workers as agents of behaviour change was effective in improving knowledge, attitude, and practices regarding nutrition and reproductive health in pregnant women in the study area. The pregnant women had good knowledge, attitudes, and practices regarding psycho-emotional parenting, nutrition parenting, nutrition during pregnancy, stunting, immunity, and reproductive health. Similar strategic efforts could help to reduce the prevalence of stunting in the first 1000 days of life.

Recommendations
Cross-sectoral cooperation, especially collaboration between the health office and the National Population and Family Planning Agency, and optimisation of community empowerment are needed to strengthen education on nutrition and reproductive health of pregnant women sustainably. The education methods also need to be adapted to the local culture to help community health workers carry out health promotion and ensure it is readily accepted by pregnant women in order to accelerate the improvement of knowledge, attitudes, and practices regarding nutrition and reproductive health. Also, the process of continuous supervision by health workers, such as midwives, nutritionists, public health workers, or other health practitioners, to ensure that nutrition and reproductive health education programs continue through the first 2 years of a baby's life, as a critical period of infant growth and development, could help to prevent stunting.