The effect of nutrition and reproductive health education intervention on pregnant women in reducing stunting in Indonesia: A-quasi experimental study

Background: Almost one-third of children under ve suffer from stunting in Indonesia. Stunting can be prevented optimally since the period of pregnancy as the initial phase of the rst 1000 days of life. This study aims to determine the effect of nutrition education and reproductive health on 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 two different villages that were the stunting locus in Bogor Regency. The intervention group (n=97) received two hours of nutrition and reproductive health education in small groups (4-5 mothers per group) every two weeks for three consecutive months. This interactive education had been given by a facilitator using some techniques such as role-playing, lectures, simulation, and games. The control group (n=97) were to obtain 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 analyzed using t-test and chi-square analysis. Results: Pregnant women in the intervention group indicate a signicant increase in knowledge, attitudes, and practices regarding nutrition and health reproductive after being given an education. The pretest and posttest mean scores in the intervention group were 55.1 and 83.1; 40.2 and 49.0; and 36.2 and 40.2, for the overall mother's knowledge, attitudes, and practices, respectively. Whereas in the control group, there was no signicance between the pretest and posttest mean for these three variables. There was a signicant difference (p<0.05) in the posttest mean between the intervention group and the control group, but the di ﬀ erence was not signi ﬁ cant (p>0.05) at the pretest. 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 into large-scale implementation by optimizing collaboration between government, non-governmental organizations, and maternal and child health service providers.


Introduction
Reducing stunting is part of the Sustainable Development Goals (SDGs) [1]. In many countries, interventions to reduce stunting have been carried out since the pregnancy period [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 rst 1,000 days of a child's life strongly contribute to stunted growth and development [5,6]. Stunting re ects 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 2 standard deviations below the World Health Organization (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 an increased risk of degenerative diseases, and socio-emotional development [8][9][10][11]. These serious health problems have an impact on the high health care costs of a country, therefore effective prevention is needed in reducing its prevalence [12].
World Health Organization (WHO) reported that stunting is declining too slowly from 32.4% in 2000 to 21.3% in 2019. which of the three regions stunting affects 1 in every 3 children [13,14]. The slow progress of stunting is also happening in Indonesia in the last ve years, from 37.2-30.8% [15]. The stunting rate is relatively high based on WHO categories of public health signi cance for stunting (30-39%) [16]. The incidence of stunting in this country is in uenced by many factors consisting of characteristics of children (sex of the child, breastfeeding status, early initiation of breastfeeding, infectious diseases particularly diarrhea and acute respiratory infections, birthweight), household characteristics (family size and structure including mother education and her knowledge about nutrition and reproductive health, household and housing characteristics, and healthcare services, and community (environmental level characteristics) [4,[17][18][19]. According to these previous studies, harmoniously shows that maternal characteristics (health, nutrition, and, socio-demography) signi cantly in uence the occurrence of stunting among children under ve. In general, these studies recommended early integrated interventions to reduce stunting in Indonesia, one of them is through effective education to improve the knowledge, attitudes, and practices of pregnant women regarding nutrition and reproductive health using multisectorial approaches. Other scienti c evidence shows that more than one-third of mothers do not yet know about stunting, so health promotion and education to improve mothers' knowledge, attitude and practices need to be done [20].
The strategy to improve the mother's knowledge, attitude, 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, immunization, and health services [4,17]. Therefore, educational methods as an intervention to improve the mother's knowledge, attitudes, and practices have been carried out based on the theory of changes behavior [22,23]. Research about Knowledge, Attitude, and Behavior (KAB) has been able to assess the success of an educational method by applying a pre-test and post-test research design such as a quasiexperimental or randomized trial [23]. The interactions between knowledge, attitude, and behavior initiate a potentially reciprocal and dynamic relationship. The mother's knowledge regarding nutrition and reproductive health can inform her attitude about that topic, and how that attitude can in uence her behavior [23]. The improvement of these aspects is very important to do during the pregnancy period to determine the next quality of life for the mother and her babies. One of the scienti c evidence that is the success of early breastfeeding initiation and exclusive breastfeeding can be determined by the intention of mothers to breastfeed since the period of pregnancy [24][25][26].
Therefore, the purpose of this study was to assess the effectiveness of nutrition education and reproductive health on pregnant women in improving the mother's knowledge, attitudes, and practices regarding nutrition and reproductive health in Bogor District, in West Java Province, where the stunting rate in this province (about 31%) is higher than the national stunting prevalence [27]. The preliminary studies in this region showed there are 29.7% of children were stunted (19% stunting and 10.7% severe stunting). This study used interactive education methods that cover 3 topics namely parenting, balanced die and immunization, and reproductive health. Furthermore, each topic was given by different techniques, namely through role-playing, exercises, and, fun games which are supported by interesting props. Thus, the government and other health care providers can adopt or modify this educational method as an effort to reduce the prevalence of stunting early on.

Study Area and Period
The study was conducted in Bogor regency from August to November 2019. The district is demographically located close to the National Capital as the center of government, services, and trade, with fairly high development activities. The estimated population in this district reaches 5,715,009 people and occupies the highest rank in West Java Province. Of this amount, there are 49% of the female population, where the estimated number of pregnant women is 40,896 pregnant women.
Bogor District consists of 40 sub-districts with various types of regional morphology, namely the lowlands and highlands. Most of the population is poorly educated and in general, the residents' livelihoods in this district work as entrepreneurs, private employees/employees, and laborers, while the majority of mothers are housewives. Moreover, most mothers are the primary caregivers in childcare [28].

Design and Samples
A quasi-experimental with the two group's pretest-posttest design was conducted on pregnant women. The source population in this study were all pregnant women in Bogor District which are the focus locations for stunting consisting of 10 villages. Meanwhile, pregnant women selected from the four villages were the study population. Inclusion and Exclusion Criteria Pregnant women who lived at least 6 months in these villages were included in this study because it was related to homogeneity in access to information exposure and health services regarding nutrition and reproductive health. Another inclusion criterion is the mother's maximum gestational age of 27 weeks (end of the second trimester) so that this intervention can be used as early prevention of stunting before the delivery period. Meanwhile, the exclusion criteria were mothers who had been con rmed or diagnosed with 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 sample size for the two-sample test of proportions formulas with a one-sided alternative hypothesis, using the following assumptions: 95% con dence level, 82.6% of pregnant women whose improved knowledge regarding appropriate dietary practice after being given nutrition education in the intervention group (P 1 ), and 47.8% of pregnant women whose 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-up was added, and design effect 2. The calculated sample size was 97 pregnant women for the intervention group and the control group respectively, therefore the total sample was 194 pregnant women. Sampling Technique and Procedure The sampling procedure is illustrated in Fig. 1. Pregnant women living in four selected villages as stunting location focus from 10 villages in Bogor District identi ed from The Bogor District Health O ce data, and also recommended as priority areas for intervention. Furthermore, all eligible pregnant women were included in this study, and participants were selected by the simple random sampling method.

Data collection and measurements
This study consists of three stages, namely: 1) instrument development, 2) training for facilitators and, 3) nutrition and reproductive health education intervention on a pregnant woman (Fig. 2). The following are the stages of this study:

Instrument development
A Focus Group Discussion (FGD) was conducted to develop a research instrument including lea et, module, and questionnaire involving stakeholders, community leaders, cadres, and pregnant women. After that, nutrition and reproductive health expert judgment was carried out on the research instruments to ful ll the evidence based on the test content. This study also uses 'nutrition discs' that are educational tools developed and produced by Pergizi Pangan Indonesia (Indonesian Nutrition and Food Expert Association), which is an organization of nutrition and food experts. Furthermore, the facilitator uses the lea et, 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 sociodemographic characteristics, and other information such as obstetric history, nutrition, and reproductive health, and utilization of health services were collected only at baseline. Whereas knowledge, attitude, and practices regarding nutritional and reproductive health were collected both at baseline and end line by using 23, 16, and 12 questions, respectively. For knowledge, participants choose one of the four answer choices (A, B, C, or D), then were given a score = 1 if the answer is correct, and the score = 0 if the answer is wrong. Items of attitude 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 calculated the average. Similarly, items of practices regarding nutrition and health reproductive were collected using a four-point Likert scale (never = 1; through most of the time = 4). Then, each item was summed to get an overall score and calculated the average score.

Training on facilitators
The facilitators were cadres or community health workers that work in their local communities who give health education to the pregnant woman in the intervention group. They were given training about the health educational skills method and knowledge regarding nutritional and reproductive health. A pretest-posttest was applied to ensure the homogeneity of the facilitators' skills and knowledge. All facilitators had appropriate socio-demographics' characteristics. They are entirely housewives with low socioeconomic levels and served as a cadre for at least one year.

The nutrition and health reproductive education intervention on pregnant women in the intervention group.
Nutrition and health reproductive education only given for the intervention group. They were grouped into small groups (4-5 mothers per group) that received two hours of nutrition and reproductive health education from a facilitator every two weeks for three consecutive months. The education consists of three sessions that include theoretical (lectures) and practical sessions regarding: (1) parenting (psychoemotional and nutrition parenting) that complemented by role-playing; (2) Balance diet, immunity, and stunting. The education was reinforced by the simulation to assess nutritional status and nutritional requirements for the rst 1000 days of life. In this section, the facilitator uses nutrition discs, which are tools designed in two packages, namely: one packet consisting of 8 nutrition discs which function to determine the nutritional status of children based on age groups, and one other packet consists of 8 nutrition discs which made for mothers pregnant in knowing the gestational age and meeting the needs of balanced nutrition from the gestational period, aged 0-72 months period until adolescence (19 years); and (3) Health reproductive education, equipped with the games of myths and facts. While for the control group, nutrition education was given by cadres based on the general usual nutrition and reproductive health education that is provided in the health program regularly every month. In this routine health program, the pregnant women are informed about maternal and child health includes nutrition and health reproductive, measure the child's weight and height, and given primary immunizations.

Quality Assurance Of Data Collection
Four women nutritionists and two public health practitioners received as data collectors and supervisors have given two days of training. The questionnaire was pre-tested on ve percent of the representative sample assessed in other areas with characteristics approaching the study area. Data collectors administered the questionnaire through face-to-face interviews at the pregnant women's homes and were controlled by supervisors periodically. All questionnaires were veri ed for completeness and accuracy by data collectors.

Data Processing And Analysis
All data in the questionnaire were checked for missing values, included maternal characteristics and knowledge, attitudes, and practices. Furthermore, data were coded and inputted using SPSS version 20.0. Variables with continuous data, including knowledge, attitudes, and practices score, were analyzed for normality using the Kolmogorov-Smirnov test. Descriptive statistics consisting of the mean, standard deviation, and percentage analyzed by univariate analysis. While variables with categorical data were analyzed using the Chi-square test. A 95% con dence level and a value with P < 0.05 were used to assess the statistical signi cance. Independent t-test was used to see signi cant differences in pretest and posttest scores between groups in the intervention group and control group and paired t-test for continuous variables within groups at pretest and posttest 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 has obtained permission. The Health o ce of Bogor district, the national population and family planning board, and community health centers where the villages are located also approved this study. The comfort of pregnant women while being a participant is the main thing in the data collection process, and the con dentiality of their identity was well guarded.

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

a. Socio-demographic characteristics
Most of the participants belonged to the reproductive age (19-35 years) category. 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. One-third of participants in each group had short stature (height <150 cm), as much as 33.0% in IG and 28.9% in CG. Almost all participants were housewives in both IG (95.9%) and CG (94.8%). Nearly half of participants have graduated from elementary school, as much as 45.4% in IG and 42.3% in CG. Similarly, with a mother's education, most of the fathers have had an elementary education level in both the IG (79.4%) and CG (70.1%). Family income in two groups in the range ≥ of 1500000-3000000, as much as 59.8% and 62.9% for the GI and CG group, severally. Father and mother make decisions related to health problems together, in both the IG (85.6%) and CG (84.5%). Other than that, most of the participants are the original population, both in the IG (78.4%) and CG (79.4%).
b. Obstetric history, information on nutrition and reproductive health, and utilization of health services Of 194 participants, most of them have health insurance provided by the government that is about 68.0% and 71.1% in the GI and CG group, respectively ( Table 1). The majority of participants are multigravida (has been pregnant 2-4 times), that is 68.0% (IG), and 69.1% (CG) for each group. Two-thirds of them have been received information about nutrition and health reproductive both in the IG (69.1%) and CG (67.0%). They obtained general information on antenatal care, at least once in the trimester of pregnancy. Commonly, before the current pregnancy, they used hormonal contraceptive methods such as injection and pills, about 44.4% and 26.8%; and 45.4% and 24.7% for the IG and CG, sequentially. Nevertheless, there are still more than a third of participants who gave birth at home for her last child for both groups. About 35.1% and 30.9% of them were delivered by traditional birth attendance for the IG and CG, respectively. Table 2 presented that the overall mean nutritional and reproductive knowledge scores were highly signi cantly improved (P< 0.001) from 55.1 to 83.1 of IG. The paired t-test indicated that there was a highly signi cant difference (P<0.05) between pretest and posttest in IG. Similarly, the overall mean attitude score was a signi cant difference between pretest and posttest (P<0.05), which is from 40.2 to 49.0 in IG. The highest attitude score was an increase in nutritional parenting form (3.4) from 10.2 to 13.8 and the lowest in reproductive health (2.4) from 7.8 to 10.2. The paired t-test also represented that there increased overall mean practices score in IG (P<0.05), which is from 36.2 to 40.2. The independent test indicated that there was a signi cant difference in all aspects consisting of knowledge, attitude, and practices in the posttest between IG and CG (P<0.05), but there was no signi cant difference at pretest (P>0.05)

Nutrition and reproductive health knowledge of Pregnant Women
The knowledge of parenting consists of psycho-emotional parenting and nutritional parenting. In psychoemotional parenting knowledge, almost all of the participants (93.8%) in the IG knew the consequences of not providing psycho-emotional parenting since the pregnancy period towards the growth and development of the baby at the posttest (Table 3). While in the nutritional parenting knowledge, almost 100% of participants knew about the dietary source of macronutrients and micronutrients rich foods for babies more than six months old that is 95.9% and 96.9%, respectively. There was a signi cant difference between pretest and posttest in IG (P< 0.001) for each question in this aspect. The participant's knowledge of nutrition during pregnancy, stunting, and immunity improved after education. Almost 100% of participants (92.8%) knew the dietary source of macronutrients rich foods (92.8%), understanding of stunting such as sign and symptom (94.8%), and the bene ts of immunization in childcare (92.8%).
Similarly, their reproductive health knowledge also improves at the posttest. As much as 92.8% of participants knew the bene ts of antenatal care for maternal and babies' health. The paired t-test indicated that nutrition and reproductive health knowledge of participants were highly signi cantly (P< 0.001) increased after education in IG, but no signi cant difference in CG (P> 0.05) in all questions.

Discussion
The failure of fetal growth in the pregnancy period is signi cantly related to stunted child growth [30]. Pregnant women have central plays in achieve optimal growth since this critical period [4,30]. Of 194 pregnant women who participated in this study have a high risk of having stunted children, generally. They live in rural areas with low socioeconomic levels that are related to a lack of food availability in the household [31,32]. Another study among pregnant women in rural Punjab showed that education and parity were associated with knowledge, attitude, and dietary practices signi cantly [33,34]. World Health Organization (WHO) reported that mothers with low income and a low level of education experience more di culty affording adequate food that will provide a nutritious and diverse diet [35]. The ndings of this study also indicate that about one-third of them (33.0% and 28.9% in IG and CG, respectively) also have a short stature (less than 150 cm), which is at risk of having stunted children [36][37][38]. A 19-year-old woman with a height less than − 2 standard deviation (SD) (less than 150 cm) had short stature according to WHO provision [39]. Javid and Pu were showed the Pakistan Demographic and Health Survey of 2012-13 that short stature mothers (height less than 150 cm) were about 2.0 times more likely to have a stunted child compared to tall stature mothers [37]. They also have not utilized health services optimally. More than a third of participants who have given birth delivered their babies at home and helped by traditional birth attendants. They did not receive adequate health care in the early life of the baby as a crucial stage associated with pregnancy outcomes. This condition indicates a low quality of maternal health care, which may signi cantly affect child stunting [40,41].
The knowledge, attitude, and practices regarding nutrition and reproductive health are the main factors that can in uence pregnancy outcomes [42,43]. The nding of this study indicates that participants have a lack of knowledge, attitude, and practices regarding nutrition and reproductive at baseline. In this study, the knowledge, attitudes, and practices mean were highly signi cantly (P < 0.001) improve after education in the IG. In the CG, there was no signi cant difference (P > 0.05) improvement mean of knowledge, attitude, and practices regarding nutrition and health reproductive between pretest and posttest. This study also proves that education intervention effectively provides a signi cant (P < 0.05) difference between the mean knowledge, attitude, and practices 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 pretest and posttest. Similarly, a cluster randomized control trial study among pregnant women in Northeast Ethiopia shows that nutrition education improved signi cantly (P < 0.001) mean nutritional knowledge in the intervention group, about 6.9 at baseline to 13.4 after nutrition education. There was a signi cant difference (P < 0.001) in mean nutritional knowledge between the intervention group and control group at baseline. The study also shows that proportion of healthy dietary practices signi cantly 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 Adaba shows that nutrition knowledge improved after the nutrition education program from 53.9-97.0%, whereas dietary practice during pregnancy increased from 46.8-83.7% [44]. These studies reinforce the evidence that nutrition education has a positive effect in improving the knowledge, attitude, and practices of pregnant women.
Nutrition and health reproductive education is a speci c intervention in The Global Nutrition target in 2025 [7] to reach the target of 40% reduction in the number of children under-5 who 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]. A study in Bangladesh shows that maternal counseling using a framework of essential health care (EHC) can improve knowledge and dietary practices on child feeding to reduce the stunting prevalence effectively [2]. The study in West Gojjam Zone, Ethiopia, shows that pregnant women who had given nutrition education are 2.02 times more likely to improve their dietary practices than those who have not given nutrition education [45]. Furthermore, the proper knowledge and the dietary practices simultaneously in uence gestational weight gain, degrade the risk of anemia in the last trimester of pregnancy, improved the baby's birth weight, and reduce the risk of preterm birth [46]. This study strengthens scienti c evidence that nutrition and reproductive health education during pregnancy improved the knowledge, attitude, and practices of pregnant women, which contribute to increased maternal and neonatal health and reduce childhood stunting [29,30,47,48].
Nutrition and reproductive health knowledge on pregnant women that related to stunting improved signi cantly by education intervention [29,40]. A formative research study conducted in 10 provinces in Indonesia which 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 childbearing age women in Lagos State, Nigeria, reported that 61.89% and 86.89% of them had accomplished knowledge and positive attitude regarding nutrition, respectively [48]. The nding of this study shows that the number of participants who answered correctly for all questions increased signi cantly (P < 0.001) in IG. In parenting knowledge, almost 100% of participants knew the ways to improve 'bonding' between mothers, fetus, and fathers during pregnancy (90.7%), and the consequences of not providing psycho-emotional parenting since pregnancy period towards the baby's growth and development (93.8%). A previous study shows that maternal depression is associated with child stunting, psychological and intellectual development. The lack of psycho-emotional parenting since the pregnancy period weakens 'mother-child' attachment that affects the nutritional status and development of children [49,50]. In nutrition parenting, almost 100% of participants correctly answered the question about the timing of complementary feeding for babies (93.8%), a dietary source of macronutrients rich foods for babies > 6 months old (95.9%), and dietary source of micronutrients rich foods for babies > 6 months old 96.9%. Mistry et al. show that maternal counseling is associated with improving feeding practices in the early life of a child, which decreased stunting prevalence signi cantly [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 bene t of a balanced diet during pregnancy for fetus and mother (84.55%), the dietary source of macronutrients rich foods (92.8%), understood about stunting (94.8%), synergetic effect of nutrition and infection towards stunting (82.5%), and the bene ts of immunization in childcare (92.8%). A study in Dissie Town, Northeast, Ethiopia, shows 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 bene t of a balanced diet for fetus and mother (89.9%), and the synergetic effect between nutrition and infection (97.1%). Also, all participants (100%) knew about the dietary source of macronutrients and micronutrients 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 socioeconomic status, for example, education, occupation, family income. Other than that, this nding study also shows that the number of participants who answered correctly in reproductive health knowledge. As much as 92.8% of participants knew the bene ts of antenatal care for maternal and baby health after education. Similarly, a quasi-experimental study in Brebes District, Central Java in Indonesia, shows that reproductive health education improved the knowledge among brides and grooms [51]. Another evidence in Somalia shows that they have a lack of knowledge about reproductive health that con rmed the need for proper nutrition education [52].
Reproductive health during the pregnancy period is fundamental to ensuring all women have access to respectful and high-quality maternity care to increase maternal health and pregnancy outcomes [53].
This study contributes to increasing intensive nutrition and reproductive health education efforts implemented for the wider community. These provide scienti c evidence as consideration for policymakers, researchers, program practitioners and implementers, non-governmental organizations, health workers, community health workers, and the entire community to increase knowledge, attitudes, and practices regarding nutrition and reproductive health to reduce the prevalence of stunting from 27.7-14% in 2024 as the national target in Indonesia, and achieved The Global Nutrition target in 2025 to reach the target of 40% reduction in the number of children under-5 who stunted.

Conclusion
Nutrition and reproductive health education intervention by optimizing the role of community health workers as agents of behavior change is effective in improving knowledge, attitude, and practices regarding nutrition and reproductive health on 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, and immunity, also about reproductive health were strategic effort to accelerate prevalence of stunting reduction in the early 1000-day period of life.

Recommendations
Cross-sectoral cooperation, especially collaboration between the health o ce and the National Population and Family Planning Agency, and optimization 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, for helping community health workers to carry out health promotion and readily accepted by pregnant women to accelerate the improvement of knowledge, attitudes, and practices regarding nutrition and reproductive health. Also, the process of continuous supervising by health workers, such as midwives, nutritionists, public health workers, or other health practitioners, so that nutrition and reproductive health education programs continued until the rst two years of a baby's life, as a critical period of infant growth and development in preventing stunting.

Declarations
properly. Our thanks also go to data collectors and supervisors for their outstanding contributions. We are grateful to The Health O ce, The National Population and Family Planning Agency, and the Faculty of Medicine and Health, Universitas Muhammadiyah Jakarta for facilitating this research.
Authors' contributions TAEP: have study ideas, drafting, and design research, perform statistical analysis and interpretation of results, and drafting a manuscript. The author review and approved the manuscript. FRA: compiling and designed the study, perform statistical analysis and interpretation of the results, and prepare the manuscript. The author reviews and approved the manuscript. WKS: drafting and designed the study, conduct statistical analysis and interpretation of results, drafting a manuscript. The author review and approved the manuscript. IIS: compiling and design research, perform statistical analysis and interpretation of the results, and prepare the manuscript. The author reviews and approved the manuscript. ZHW: compiling and designed the study, perform statistical analysis and interpretation of the results, and prepare the manuscript. The author reviews and approved the manuscript.

Data of availability and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate
Ethical approval obtained from the 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. Also, the government in Bogor District and each village as the study area has obtained permission. Informed consent is ensured by the study participants. Con dentiality was maintained throughout the study by excluding personal identi ers from the data collection form. The pregnant women during data collection were also given priority during the data collection period. In this study the authors con rmed that all methods were carried out in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

Consent for publication
Not applicable. Tables Table 1 Maternal characteristics between intervention and control groups in two areas of community health centers in Bogor District (n 1 =n 2 = 97) Page Figure 1 Sampling procedure of pregnant women. SRS=Simple Random Sapling; n1 = sample size for intervention group; n2 = sample size for control group Figure 1 The stages of data collection and measurements