Maternal Mental Health, Child Stunting, and Unintended Pregnancy in Developing Country: A Literature Review

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Yuni Hastutiningsih

yunihastuti81@gmail.com

 

ABSTRACT

The basic concept that is often used as the basis for stunting reduction interventions places the causes of stunting on two main factors, direct (nutrition) and indirect (maternal health status) causes. The question is, are there other important factors that can be used as the basis for intervention? These questions are the basis for why this research was conducted. This research was conducted by reviewing the literature, especially research results to identify other important factors causing stunting. The review was carried out with reference to articles published in the last 10 years, from 2012 – to 2022. The results showed that the problem of stunting was not only related to the physical health status of the mother, but also to mental health factors. Stunting is not only related to infant nutrition problems and maternal conditions that affect stunting but also maternal psychological conditions both before pregnancy and during the puerperium also affect stunting, which is 2 to 3 times higher risk in developing countries. Depression in the mother both when pregnant and postpartum can cause stunting in children. This is because the mother’s interest in parenting becomes reduced and the mother becomes not interested in studying health for both the mother and her child. This research also tries to give a little description of unintended pregnancy and stunting which is often overlooked. A pregnancy that is not properly prepared has a high risk of stunting, due to a lack of nutrition and nutrition for pregnant women and to close the distance between pregnancies. The best prevention that can be done is that future internal interventions should include women’s partners and raise the awareness of other family members. External intervention includes Therapeutic Group Therapy about nursing measures for infants and stunting health education about nutrition, parenting, and maternal depression. In addition, the government must also pay more attention to cases of unintended pregnancy to reduce stunting rates.

 Keywords: Stunting, Maternal Mental Health, Unintended pregnancy, Developing Country

 

BACKGROUND

Stunting is a condition of toddlers who are chronically malnourished resulting in toddlers; having developmental disorders so that toddlers’ height becomes abnormal and is very related to environmental and socio-economic conditions (World Health Organization, 1995 and The National Team for The Acceleration of Poverty Reduction, 2017). Stunting occurs when the toddler is 2 years old or during childhood, but stunting actually occurs when the baby is in the womb of his mother (The National Team for The Acceleration of Poverty Reduction, 2017).  Whereas malnutrition that occurs during the golden age of children in the first 1000 days of life cannot be corrected at a later stage of life and greatly affects the growth (Achadi, 2014).

Stunting is caused by insufficient nutrient intake in the long term, breastfeeding, and parenting (Ministry of the Health Republic of Indonesia, 2013). The impact of stunting is delayed neurological development, permanent cognitive impairment, a weakened immune system (Victoria et al, 2008), a high risk of diarrheal disease, upper respiratory infections, and delays in motor, cognitive, and social development during childhood. children (Moschovis et al, 2015), and are more at risk of suffering from high blood pressure, obesity, diabetes, and heart disease as adults (Dewey and Begum, 2011).

Globally, 178 million children as young as 5 years are stunted with most of them spread in South Central Asia and Sub-Saharan Africa (Bhutta, 2008). Data from the Research Agency of the Ministry of Health shows that the prevalence of under-fives experiencing stunting in Indonesia in 2019 was 27.7%. This figure in 2021 will decrease to 24.4% or a decrease of 3.3%. The World Health Organization states that stunting is at most 20% or one-fifth of the total number of children under five, so the number in Indonesia is still higher, so efforts are needed to reduce this number (WHO, 2021).

The Indonesian government takes the problem of stunting seriously and focuses on handling it. This is evidenced by the stunting rate in most of the 34 provinces showing a decline compared to 2019 and only 5 provinces showing an increase. This shows that the implementation of government policies to accelerate the reduction of stunting in Indonesia has given good results. This effort is a commitment to the implementation of Presidential Regulation no. 72 of 2021 concerning the acceleration of stunting reduction. The formulation of the acceleration program in reducing stunting leads to family-based interventions at risk of stunting by emphasizing preparing for family life, fulfilling nutritional intake, improving parenting patterns, increasing access and quality of health services, and increasing access to drinking water and sanitation (Rokom, 2021).

However, the acceleration formula for reducing stunting carried out by the Indonesian government only focuses on handling nutrition and maternal health. In fact, as mentioned in the previous section, the problem of stunting is more complex, one of which is related to maternal mental health, one of the factors causing stunting in toddlers is maternal pregnancy depression. The mental health of pregnant women is an important factor that is often neglected, even though Maternal pregnancy depression has a significant relationship with the incidence of stunted toddlers (p=0.044; r=0.170) (Apriliana et al, 2021).

Common mental disorders (CMD) of depression and anxiety are an important public health issue among mothers and toddlers in low-income countries (Fisher et al, 2012). Depression often occurs in women of reproductive age that adversely affects the psychological and intellectual development of the child (Rondóet al, 2013 dan O’hana and Swain, 1996).  This results in a disruption of the emotional quality of childcare (Cooper et al, 1991). Rapid physical growth and development occur early in life when infants and young children rely on primary parenting for their social and nutritional needs and it makes them vulnerable to the effects of their caregivers’ mental health problems (Wemakor et al, 2016). Depression and anxiety are thought to have a devastating impact on parenting practices, making mothers with mental disorders less involved (Goldsmith et al, 1997), less sensitive (Black et al, 2006), and more hostile when interacting with their child (Lovejoy et al, 2000), and damaging early childhood development.

Mothers who are depressed usually refuse to breastfeed their babies, are less responsive to baby cues, and are less likely to listen to the advice of health workers (WHO, 2015). Furthermore, when the mother is depressed, the mother pays less attention to her health and the development of the health of her children. This can be interpreted that mothers who are depressed can cause a lack of stimulation in children. Several studies show that depressed mothers who deliver low weight babies are 2.8 times higher than mothers who deliver babies with normal weight; mothers with a high level of anxiety and depression probably deliver a premature baby with low weight, and shorter in length than the average babies (O’Dellet al, 2013; Dasuki and Suryo, 2010). Maternal anxiety is associated with poorer early childhood outcomes including cognitive, motor, and socio-emotional development (Keim et al, 2011).  One of the risk factors that cause stunting in toddlers is maternal depression experienced during pregnancy. While stunting will affect the growth and development of toddlers (Budget Director for Human Development and Culture, 2018).

Both antenatal and postnatal depressive symptoms have been associated with poor early childhood health and development (Luoma et al, 2001). Depressive symptoms are recognized as common during pregnancy and are associated with postnatal (postnatal) depression (Lancaster et al, 2010). Postnatal depression has long been considered a syndrome in its own right that presents with no prior history (Cooper et al, 1991) and specific endocrine sensitivities (Bloch et al, 2003). Moreover, despite being one of the most common complications of pregnancy, perinatal depression remains a neglected global health priority (Wachs et al, 2019). Perinatal depression generally includes syndromes that present either during pregnancy or after birth (Gavin et al, 2005). Mental disorders before pregnancy are also recognized as important risk factors for perinatal depression (O’hara et al, 2014).

One of the people who have a high potential for experiencing maternal mental health is a mother who has an unintended pregnancy, either an unwanted pregnancy or a mistimed pregnancy. Whereas Unwanted pregnancy has a 2.2 times risk of stunting in toddlers by including family income variables, maternal age during pregnancy, birth weight, and gestational age. Therefore, the purpose of this study was to see whether maternal mental health during pregnancy or childbirth can affect stunting in children and how unintended pregnancy is related to stunting.

 

METHOD

This research is a literature review research method. This method is used to look at the results of previous studies related to maternal mental health, and stunting, as additional reference research related to unintended pregnancy and its relationship with stunting in developing countries. The results from the findings of previous studies are used as a reference in writing, especially in making recommendations for decision making that the Indonesian government can do in reducing stunting rates.

 

RESULTS AND DISCUSSIONS

Literature Search

The results of literature searches with stunting and mental health keywords were obtained from as many as 42 articles and using exclusion criteria in the form of a 10-year publication time, 2012-2022, 38 literature were obtained.  The final stage of the assessment is to remove journals that have the same article title or author, journals that discuss nutritional problems other than stunting, and journals that analyze developed countries so that the final journal is analyzed as many as 6 articles.

Figure 1. Flow chart illustrating the selection of study articles

Review Articles

The study examined 6 articles related to stunting and maternal mental condition in developing countries. Here are the results of the article review (Table 1):

Table 1. Article Review Results

Author Study Site, Sample Size, Method, Instrument Prevalence of Maternal Depression Prevalence of Stunting Conclusion
(Fisher et al., 2015) –   Ha Nam Province, Vietnam

–   234 of 255 eligible women (91.8%) for the baseline survey and 211 women (90.1%) for a follow-up survey

–   Cohort Study

Psychiatrist-administered Structured Clinical Interviews for Diagnostic and Statistical Manual Mental Disorders

CMD among women was 33.6% (baseline survey) and was 15.6% (follow-up survey when their children were aged approximately 15 months) Stunting Prevalence was 15.6% Maternal postnatal CMD is associated with child growth
(Wemakor & Mensah, 2016) –   Northern Ghana

–   All women (aged 15-45 years) and their children (0-59 months)

–   Cross-Sectionalal Study

–   Centre for Epidemiological Studies Depression Screening Scale (CES-D)

27.8% being maternal depression and 15.9% had scores corresponding to possible depression

 

 

16.1% of children being stunted

 

 

Children of depressed mothers were almost three times more likely to be stunted (p value=0.0011; OR= 2.48)
(Upadhyay & Srivastava, 2016) –   India

–   Cohort Study

–   All households with 5 – 21 months old child and 87 – 103 months old child

–   WHO-recommended tools of self-reported 20 items (SRQ20)

30% of mothers were postnatal depressive symptoms 27% among children aged 5 to 21 months being stunted Stunted children were also higher among women with high postnatal depressive symptoms (35%) and women who showed symptoms of postnatal depression were 1.53 times more likely to be stunted
(Apriliana et al, 2021) –   Indonesian

–   140 mothers of toddlers (aged 24-36 years)

–   Cross-Sectional Approach

–   Edinburgh Postpartum Depression Scale (EPDS) questionnaire

 71 (50.7%) of pregnant mothers suffer from depression

 

 

37 toddlers (26.4%) suffer from stunting

 

Note: Toddlers is at age of two or during childhood

 

 

Mother with pregnancy depression affecting children become stunting (33.8% with p-value 0.044)
(Girma et al., 2019) –   Western Ethiopia

–   234 mothers with children aged 6 -59 months

–   Case-Control Study

–   Self-Reporting Questionnaire (SRQ-20)

53.8% of cases mothers and 13.5% of controls mother were found to have a common mental disorder 38.4% prevalence of child stunting Children of mothers who had common mental disorders were found to be three times more likely of developing stunting
(Tome et al., 2021) –   Zimbabwe

–   4025 rural women with infants between 6 to 18 months

–   Experimental study

–   Edinburg Postnatal Depression Scale (EPDS)

8.7% of mothers are suffering from depression 33.4% of children stunted Although not statistically significant, depressed mothers were 35% less likely to have a low-birth-weight baby (p value=0.10)

 

Maternal Mental Health and Stunting

Based on the results study of the article conducted, depression in mothers both during pregnancy and postpartum greatly affects the incidence of stunting in children who are at risk of 2 times to 3 times experiencing stunting. Research explains that when mothers experience depression during pregnancy, mothers tend not to have an appetite and there is a decrease in hemoglobin which has an impact on reducing baby nutrition in the womb (Madlala and Kassier, 2018). Lack of nutritional intake in mothers who are depressed during pregnancy leads to stunting in toddlers.

Maternal depression can cause the mother to have an unhealthy lifestyle, bad behavior in terms of seeking health services, lack of physical and emotional care, and lack of psychosocial stimulation in infants; and aggravated by the low household socioeconomic status that can interfere with the growth and development of children (Sulaiman et al, 2019). Depression reduces the mother’s interest in parenting and caring activities. In addition, mothers who suffer from depression during pregnancy will increase the hormones norepinephrine and cortisone which causes babies to be born with low weight (Field et al, 2017). This statement is supported by research that states that high levels of anxiety and depression cause premature babies to be born prematurely with low weight and become the cause of stunting (The National Team for The Acceleration of Poverty Reduction, 2017). However, research from O’hara et al (2014) found that mental health orders before pregnancy is a major risk for depression.  Women who have mental health problems as teenagers and adults have the opportunity to have mental health disorders during the perinatal period (Patton et al, 2015).

The mother who has a diagnosis of depression will have a poor introduction to the hunger and satiety of the baby or practice in preparing food, as well as reduced interactions that can please the baby who is a supporter of the baby’s weight gain. Research from Fisher et al (2015) States that high-risk CMD exposure occurs when 15 months postpartum and mothers have a low mood and is associated with poorer toddler growth.

CMD that occurs when the mother cares for a toddler becomes an indicator of maternal difficulties including interpersonal violence to the child, lack of affection, and lack of special attention during the first 30 days of postpartum. This becomes very important as a consideration between maternal mental health and poor child growth. In addition, CMD is also on the rise among women who have a partner who is coercive, intimidating, and controlling. The couple’s attitude is also associated with the growth and development of the child and contributes to the low mood of the mother. In Vietnam, there is a unique traditional custom: women have at least 30 days of intensive care from other women and exercise social seclusion after childbirth (Fisher et al, 2015).

During pregnancy, maternal depression usually occurs in the 3rd trimester with symptoms such as anxiety and worries about pregnancy that will change the mother’s mood to become angry, bored, and sad for no reason that will interfere with the basic needs of the mother (Dasuki and Suryo, 2010). Moreover, mothers should prevent depression when pregnant to prevent the adverse effects on mother and child.

One of the maternal mental health cases that are often neglected is the case of unintended pregnancy, in which the unintended pregnancy actually tends to be more likely to experience maternal mental health problems. Unintended pregnancies are often overlooked when it comes to stunting, even though they are related. Unwanted pregnancy has a 2.2 times risk of stunting in toddlers by including family income variables, maternal age during pregnancy, birth weight, and gestational age.

 

Unintended Pregnancy and Stunting

Now, current issues of health care and welfare reform, and the new international focus on population are drawing attention to the consequences of unintended pregnancy. Unintended pregnancy including mistimed pregnancy (untimely pregnancy) and unwanted pregnancy is one of the important problems and needs to get attention, especially in developing countries. Unintended pregnancy will induce stunting. In unwanted pregnancy, the mother has the tendency not to check pregnancy to health workers who are competent, inadequate immunization, and inappropriate breastfeeding behavior.

World Health Organization (WHO) estimates 200 million pregnancies per year, and about 38 percent (75 million) is an Unwanted pregnancy in developing countries. In 2008, there was 208 million pregnancy in the world. As many as 185 million pregnancies of which occurred in developing countries, and 86 million (41%) of pregnancies in the world are unwanted pregnancies. Unwanted pregnancies are closely related to various aspects such as socio-demographic conditions of the family, culture, and beliefs in the community.

Babies of unwanted pregnancies are at risk of having an outcome worse health than a woman who wants to get pregnant. The results of several studies that have been carried out state that the proportion of higher unwanted pregnancies among unmarried women or still single compared to married women (Rahman, 2015).  Furthermore, the results of the study show that the highest number of unwanted pregnancies in a group of women with education is the low one. (Anggraini et al, 2008).

The resulting study by Rahman (2015) shows that in Bangladesh, compared with children whose conception had been intended, those whose conception had been unwanted were more likely to be stunted (46% vs. 39%), wasted (19% vs. 15%) or underweight (43% vs. 33%). In regression analyses, children who had been unwanted at the time of conception had an elevated risk of being stunted (odds ratio, 1.4), wasted (1.4), or underweight (1.3). In Peru, the odds of stunting were 15% greater if a pregnancy had been unwanted rather than wanted, although in Egypt the likelihood of stunting was lower if a pregnancy had been mistimed or unwanted than if it had been wanted (Marston and Cleland, 2003).

Data from 2015- to 2019 shows that of the total pregnancies that occurred in Indonesia, 36% were unintended pregnancies (Guttmacher, 2022). A pregnancy that is not properly prepared has a high risk of stunting, due to a lack of nutrition and nutrition for pregnant women and to close the distance between pregnancies. Maribeth and Syafiq (2018) show that from the 5 country studies reviewed (Bangladesh, Nepal, India, Northern Malawi, and Indonesia), it was found that unintended pregnancies can be the cause of stunting in the range of 1.25 to 2.19 times higher than the intended pregnancy. The National Population and Family Planning Agency (BKKBN) recorded a nationally unplanned pregnancy rate in 2021 was 20.3%. Cases of unwanted pregnancy were more common among mothers in the category 15-19 years (17.9%) and 45-49 years (21.4%). Meanwhile, in terms of age at first marriage, many cases of unwanted pregnancies were experienced by mothers with an age range of 15 to 24 years (Supriyadi, 2022).

Based on the data above, it can be concluded that it is important to make program interventions for the unintended pregnancy group. Mother’s feelings about having a child who is unwanted contribute to neglect of the child consciously or unconsciously reducing their ability to meet the child’s daily needs and reducing the quality of their parenting behavior, leading to consequences negative health for children and can increase the risk of stunting in children 1.4 times (Rahman, 2015). It is important to do this as an alternative strategy if the Indonesian government wants to reduce stunting rates because it has been proven that intent pregnancy is related to stunting rates.

 

Government Intervention to Reduce Stunting Rate

Maternal mental health should be a consideration of policymakers and public health experts whose goal is to improve the nutritional status of children. If women’s mental health can be overcome, then they are likely to be involved, responsive, and sensitive in applying the science of nutrition and child health and have ultimately a lot of knowledge about effective parenting, and feel confident (Fisher et al, 2015).

Efforts in caring for maternal mental health can be done by providing education in the form of stunting, nutrition, parenting, maternal depression, and receiving therapeutic groups because research from Oktaviana et al (2022) shows the reduction of mental health issues in mothers from 11.02% to 6.8%. Stunting can be prevented by providing good nutrition for mothers and children and mothers provide the best fostering style in the family. The Ministry of Health explained that prevention efforts that can be done by the government to overcome stunting in children are to provide health education related to nutrition improvement programs, pay attention to the menu on the plate such as carbohydrates, proteins, vitamins, and fiber, and the presence of additional foods (Ministry of the Health Republic of Indonesia, 2017).

Efforts that can be done to avoid depression in women during pregnancy are internally and externally. Internal efforts that can be done by the family can provide a sense of security and comfort to the mother when they experience changes both physically and psychologically. External efforts are with the direction and guidance both individually and in groups carried out by postal health workers, midwives, and other nearby health service places. Efforts from prevention efforts to avoid pregnancy depression can increase the mother’s acceptance of her pregnancy and the mother can get back on good terms with the environment (The National Team for The Acceleration of Poverty Reduction, 2017). Handling maternal pregnancy depression can help them reduce their psychological problems.

While efforts to reduce stunting from the unintended pregnancy group, the government can make effort by providing health education and discussion about the family’s readiness before planning to have children or not, as well as the factors, impact, and prevention of that decision. Policymakers should pay particular attention to factors (such as contraceptive failure) that directly or indirectly increase unwanted pregnancy. Efforts at reducing unwanted pregnancy may reduce not only child malnutrition but also the high fertility rate that contributes to population growth in developing countries. Therefore, the current policy needs to also focus on the group of unintended pregnancies, so that it will have an impact on reducing the stunting rate.

 

CONCLUSION

Common mental disorders (CMD) of depression and anxiety are an important public health issue among mothers and toddlers in low-income countries. A related research study in developing countries shows that; in Vietnam, CMD is associated with child growth; In Northern Gana, children of depressed mothers were almost three times more likely to be stunted; in India, stunted children was also higher among women with high postnatal depressive symptoms (35%) and women who showed symptoms of postnatal depression were 1.53 times more likely to be stunted; In Indonesia, a mother with pregnancy depression affecting children become stunting.

Especially in Indonesia, the prevalence of stunting is still higher than the threshold set by WHO. This means that although the Indonesian government pays more attention to handling stunting through various program interventions, there needs to be a deeper approach to reducing the prevalence rate. In addition to intervention programs with an emphasis on preparing for family life, fulfilling nutritional intake, improving parenting patterns, increasing access and quality of health services, as well as increasing access to drinking water and sanitation, the government also needs to put special emphasis on maternal mental health treatment programs and unintended pregnancy prevention programs.

Stunting is not only related to infant nutrition problems and maternal conditions that affect stunting but also maternal psychological conditions both before pregnancy and during the puerperium also affect stunting, which is 2 to 3 times higher risk in developing countries and also correlated with an unwanted pregnancy that has a 2.2 times risk of stunting in toddlers by including family income variables, maternal age during pregnancy, birth weight, and gestational age. Depression in the mother can make the child suffer from stunting nutritional problems and prevention efforts must be made starting from the mother’s young. Thus, prevention efforts that need to be carried out must also be started, before the mother decides to become pregnant. In addition, it is important to pay attention to the mother’s mental condition by maintaining the mother’s feelings in a critical condition during pregnancy and support from the closest people to health workers.

Based on the explanation, maternal mental health and unintended pregnancy should therefore be considered by policymakers and public health professionals who are working to improve child nutrition status. This study suggests that a more comprehensive approach, which takes women’s own needs for support and cares into account, is more likely to be effective. Future internal interventions should include women’s partners and raise the awareness of other family members about what a woman needs if she is to care well for a young child. External intervention, including Therapeutic Group Therapy about nursing measures for infants and stunting health education about nutrition, parenting, and maternal depression are highly recommended to prevent stunting risk factors: maternal depression (Oktaviana et al, 2022). Some related study results show the risk of stunting in early childhood is higher among women with unintended pregnancies and those with symptoms of postpartum maternal depression in India. Therefore, there is an urgent need to identify women with unwanted pregnancies during antenatal care visits and incorporate mental promotion health into their national reproductive and child health program (Upadhyay and Swati, 2016).

 

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