A contributing factor of maternal pregnancy depression in the occurrence of stunting on toddlers.

BACKGROUND: Toddlers are a vulnerable population to nutritional problems including stunting. Stunting can have negative impact on toddlers' health. One of the factors causing stunting in toddlers is maternal pregnancy depression. This study aims to determine the relationship between maternal pregnancy depression and the incidence of stunting in toddlers. DESIGN AND METHODS: The research design employed a descriptive correlative with quota sampling technique. The research respondents were 140 mothers of toddlers in Indonesia such as West Java, East Java, Jakarta, Yogyakarta, Bali, North Sumatra, Riau, South Kalimantan, West Kalimantan, North Sulawesi, NTT, NTB, Maluku, Papua. The data were collected by using demographic method and the Edinburgh Postpartum Depression Scale (EPDS). The statistical tests employed correlation tests.
RESULTS: The analysis reveal that 26.4% toddlers in this study are stunted and 73.6% were not stunted. Maternal pregnancy depression has a significant relationship with the incidence of stunted toddlers (p = 0.044; r = 0.170).
CONCLUSIONS: The results of this study are expected to underlie the development of mental health promotion to prevent stunted toddlers against maternal depression and preventive programs. In addition, the research is expected to underly provision of curative and rehabilitative programs for stunted toddlers.

Introduction

Stunting is a condition of which a toddler experiences impaired growth due to chronic malnutrition, causing the abnormal height of the common toddler.[1] Stunting is obvious when a toddler is at the age of two or during childhood, but stunting has actually occurred since the baby is in the mother’s womb.[1] Stunting is regarded as a severe condition if it occurs during a child’s golden period, or the first 1000 days of a child’s life.[2,3] Malnutrition occurring during a child’s golden age period cannot be repaired in his next life stages.[2] This becomes crucial because stunting is regarded as a nutritional problem impeding toddlers’ growth.

The Indonesian Basic Health Survey stated that the prevalence of Indonesian toddlers experiencing stunting in 2013 reached 37.2 %; its 2018 updated data showed that stunting prevalence decreased from 6.4% in 2013 to 30.8% in 2018.[4] The prevalence of stunting illustrates the society’s health problems if the prevalence reaches 20% or more.[5] This means that the prevalence of stunting in Indonesia still exceeds the world’s limit.

One of the risk factors causing stunted toddlers is maternal depression experienced by mothers during pregnancy. A research states that the cause of stunting in toddlers is a mothers’ depression during the early period of child’s growth and development.[6] A depressed mother during pregnancy will affect the baby’s health.

Several studies show that depressed mothers who deliver low weight babies is 2.8 times higher than mothers who deliver babies with normal weight; mothers with high level of anxiety and depression probably deliver a premature baby with low weight, and shorter in length than the average babies.[7-9] The baby’s below normal weight and length are highly related to the risk factors of stunting on toddlers.[10,11]

Furthermore, maternal pregnancy depression may contribute to the occurrence of stunting in toddlers. Meanwhile, stunting in toddlers will affect their growth. The process of a child’s growth is certainly cantered on good brain development. A child’s brain cells development will be impeded due to stunting, and the child will face difficulties in reaching a maximum growth aspect.[12,13] No previous study has been done in Indonesian women. This study was conducted to determine the relationship between stunting and depression in pregnant women in Indonesia.

Design and Methods

The design of the study was descriptive - correlative using a cross-sectional approach. The cross-sectional design is a research design that analyzes the relationship between the independent variable and the dependent variable in one unit of time. A retrospective approach was also used by researcher to measure pregnancy depression. The study used the quota sampling technique because this technique only focuses on fulfilling the desired sample quota, making it easier for the researcher to take samples. The sample size used is determined by the Lameshow formula. This study managed to get 140 respondents’ mothers who are willing to take part in the study. The research was carried out in early April - July 2020 online through social media in the territory of Indonesia. Respondents who filled out came from 15 provinces such as West Java, East Java, Jakarta, Yogyakarta, Bali, North Sumatra, Riau, South Kalimantan, West Kalimantan, North Sulawesi, NTT, NTB, Maluku, Papua. The sample used in this study were all mothers with children living in Indonesia who met the inclusion criteria are mothers who had children aged 24-36 years, able to communicate well, caregiver, and willing to be respondents. Meanwhile, exclusion criteria are mothers who had children aged under 24 or upper 36 years. This study has met the ethical considerations and was approved by the Ethics Committee of the Faculty of Nursing, Universitas Indonesia (Permit ID: SK-140/UN2.F12.D1.2.1/ ETIK2020).

The data were collected by using the Edinburgh Postpartum Depression Scale (EPDS) questionnaire. This questionnaire was adopted from Ratu Kusuma’s dissertation at 2017 with the title “The Effectiveness of the Ratu’s Postpartum Depression Prevention Model on Prevention of Postpartum Depression” which has been tested for validity and reliability.[14] This questionnaire is not only used to measure postpartum depression but also pregnancy depression with 10 statements in which each statement has 4 answer choices with a score range of 0-3 then the scores from each statement are added up and categorized <10 = not depressed, and 10 = depression. The fulfilment of the questions follows the instruction that the respondents must reminisce the condition of their pregnancies.

The data were analyzed using statistical software Univariate analysis in the form of proportional distribution was carried out on all variables. Bivariate analysis was performed to determine the association between social support and self-management using the Chi-square test.

Results

The result of the research showeds that the average maternal age is 30 years old. Whereas the average of family income is 5,000,000 rupiah (351-352 USD) (Table 1). The research results showed that the majority of mothers hold college/university education, have occupations, and do not have history of pregnancy with anemia (Table 2). The research result shows that the majority of toddlers have normal birth weight, were exclusively breastfed, were introduced to solid foods as complimentary food to breast milk after the age of 6 months, never have history of infection, and were immunized (Table 3). The research result shows 37 toddlers (26.4%) suffered from stunting and 103 toddlers (73.6%) did not suffer from stunting (Table 4). The research result shows that more than 50% of pregnant mothers suffer from depression (Table 5).

Table 1.

Characteristics of mothers.

Variable	Median	Min-Max
Age	30	22-62
Family income	5,000,000	500,000-40,000,000

Table 2.

Other characteristics of mothers.

Variables	N.	%
Education
No education	9	6.4
Elementary	1	0.7
Junior High School/Equal	4	2.9
High School/Equal	54	38.6
College/University	72	51.4
Occupation
Not working	66	47.1
Working	74	52.9
History of pregnancy anemia
Without anemia	119	85
With anemia	21	15

Table 3.

Characteristics of toddlers.

Variables	N.	%
Gender
Male	86	61.4
Female	54	38.6
Birth weight
<2500 gram	8	5.7
≥2500 gram	132	94.3
History of exclusive breastfeeding
Without exclusive breastfeeding	26	18.6
With exclusive breastfeeding	114	81.4
History of solid foods
Before 6 months	20	14.3
After 6 months	120	85.7
History of Infection
With any infection	99	70.7
Without infection	41	29.3
Immunizations
Without immunizations	15	10.7
With immunizations	125	89.3

Table 4.

Illustration of stunting on toddlers.

Variables	N.	%
Unstunting	103	73.6
Stunting	37	26.4

Table 5.

Pregnancy with depression.

Pregnancy depression	N.	%
Without depression	69	49.3
With depression	71	50.7

The research result shows that stunted toddlers are found more in mothers with pregnancy depression than without pregnancy depression (33.8%) and unstunted toddlers are found more in mothers without pregnancy depression than with pregnancy depression (81.2%). The significant relationship value between depression pregnant mothers and stunted toddlers (0.044). Such a value indicates the existence of consequential relation between pregnancy depression and stunting in toddlers (Table 6).

Table 6.

Relation between stunting on toddlers and pregnancy depression.

Pregnancy depression	Stunting		P value	Correlation coefficient
	No	Yes
Depression	47 (66.2%)	24 (33.8%)	0.044	0.170
No depression	56 (81.2%)	13 (18.8%)

Discussion

This research found that 26.4% of 140 toddlers aged of 2-3 years old suffered from stunting. This result is not much different from the 2018 Indonesian Basic Health Survey data, which states that the prevalence of stunting reaches 30.8%. This percentage is obtained from different samples of the national prevalence calculation. Moreover, this percentage is considered large because it exceeds the limit of the world’s percentage, 20%.[15] One of the predominant causes of death on children under 5 years old is nutritional problems; children are vulnerable population, and therefore they are prone to stunting.[16] If toddlers with stunting are left alone, the condition will cause a huge impact on the children’s future.

The Government must give serious attention and necessary efforts to deal with stunted children. The curative effort is necessarily performed by providing health education related to stunting, child’s nutrition, and child’s care. Such education must inform i) diet improvement program, ii) feeding based on the ‘what’s in my plate’ pattern that emphasizes nutrition, such as carbohydrates, protein, vitamin, and fibers, and iii) supplementary foods.[16] Besides, continuous education consists of knowledge aspects informing children’s health and nutrition.[17] The Government conducted such measures to prevent detrimental effect of stunting in toddlers.

The percentage of mothers with pregnancy depression is more dominant (50.7%) than without pregnancy depression. A national survey supporting this result states that 23% of 700 new mothers in Indonesia suffer from depression, and 55% of them show depression symptoms and anxiety during medical care before and after delivering.[18] Maternal pregnancy depression more commonly occur during the 3rd trimester pregnancy with symptoms, such as anxiety, restlessness, and worry about pregnancy.[9] Maternal depression triggers hormonal changes that can affect mothers’ mood, such as anger, boredom, and sadness without reasons; these emotions disturb the mothers’ basic needs.[19] Therefore, mothers necessarily prevent pregnancy depression to prevent detrimental effects on mothers and children.

Performable promotional and preventive efforts to avoid pregnancy depression are improving a mother’s acceptation on her pregnancy and reestablishing good relation with the environment; Antenatal Care (ANC) service can monitor a mother’s emotional health can be through so that mothers can consult their conditions regarding their grievances.[20-22] The surrounding environment also plays a crucial role for the emotional health of pregnant women, like, positive supports from the closest relatives, especially their husbands.[23] Family supports can improve pregnant women’s welfare, self-control, and positive feelings, and assist them to adjust with the changes during their pregnancy. If preventive measurements have been conducted adequately, mothers can avoid pregnancy depression.

Curative efforts to handle pregnancy depression are internal and external assistance. Pregnant women greatly need internal assistance from the family to perform their daily tasks to feel safe and comfortable in dealing with their physical and psychological changes. Health care workers in Posyandu (Integrated Healthcare Center), post-natal health center, village midwives, midwives of Health Care Center, and public figures in health care sectors can provide external assistance for pregnant women of–through guidance and counseling by using direct or indirect methods individually or in a group.[24] Individual guidance method includes direct-private conversation through home visit, while group guidance method consists of direct communication with clients through a group discussion and group teaching. Maternal pregnancy depression handling can help mothers reduce their psychological problems.

Pregnancy depression commonly has strong correlation with the occurrence of stunting on toddlers. Such a correlation has a positive direction, which means that the more severe the pregnancy depression is, the higher the occurrence of stunting on toddlers is. This statement agrees with a study in Ghana stating that maternal depression has correlation with stunting on toddlers.[25]Whereas, another study states that the cause of stunting on toddlers is mothers’ depression throughout the early period of the child’s growth and development.[6] Another study explains that mothers who experience depression during pregnancy are prone to experience a lack of appetite and a decrease of hemoglobin that reduces nutritional intakes of the baby in the womb.[26] This statement is supported by a study proving that pregnancy depression leads to poor nutritional status for the fetus.[27] Lack of nutritional intake for the fetus in depressed mothers during pregnancy causes the occurrence of stunting in toddlers.

Chronic malnutrition since infancy in the womb is the primary cause of stunting in toddlers.[1,28] It occurs because malnutrition of fetus in the womb will inhibit fetal growth. Malnutrition disease is firstly indicated by a slowdown or retardation of fetal growth, also known as Intra Uterine Growth Retardation (IUGR). Retardation of fetal growth is obvious in a baby’s birth length. A baby’s birth length describes his linear growth in the womb.[29] Furthermore, low measurement of baby’s birth length indicates malnutrition due to lack of energy and protein previously suffered.[30] The baby’s birth length affects his growth his following ages. Furthermore, his low birth length possibly creates 2.8 times as many risks of suffering from stunting as babies with normal length birth.[31] Nutritional problems result in low measurement of baby’s birth length, which generates the risk of stunting in toddlers.

The risk of stunting caused by pregnancy depression is related to not only pregnant women’s nutritional problems but also hormones balance. The norepinephrine and cortisol hormones of pregnant women with depression will increase.[32] The increase of norepinephrine hormone causes low birth weight infants, whereas high level of cortisol hormone causes premature born.[32,33] This results are supported by other studies asserting that a mother’s high level of anxiety and depression may cause a prematurely birth with low birth weight and low birth length.[7,8] In addition, low birth weight and premature birth are risky factors in stunted toddlers.[1] Hormonal changes caused by maternal pregnancy depression affect stunting in toddlers.

Furthermore, the effects of maternal pregnancy depression can endanger the baby’s health in the womb. A study states that depression can affect the bonding between the mother and the fetus.[34] This bonding known as Maternal Fetal Attachment (MFA) or an emotional relation that psychologically helps women adapt with their pregnancy and readiness to become a mother.[35] This readiness is crucial because during pregnancy, women will face all changes that require adjustments, and thus, a positive energy is required to adapt. The emotional bonding between a pregnant mother and her unborn baby is related to her awareness of health pregnancy practices, such as willingness to receive health care during pregnancy, and her awareness of pregnancy care.[35] If pregnant women suffer from depression, they will ignore their own health and the future baby’s health.

Conclusions

The research result shows a correlation between pregnancy depression and the occurrence of stunting in toddlers. The results of this study are expected to be the basis for developing mental health promotion, preventive programs related to pregnancy depression and rehabilitative programs for stunting toddlers.