Pre-conception Nutrition Care, Nutritional Knowledge, Nutritional Practices, and Cultural Belief Among Pregnant Women: A Qualitative Study in Aceh

ARTICLE INFORMATION Health care during pre-conception and pregnancy is one of the important factors that can improve pregnancy outcomes. This study aims to explore how pre-conception care, nutrition knowledge and practices, and the factors that influence it in pregnant women. This study used a cross-sectional design with a qualitative study approach. The subject was 11 pregnant women who were selected as well as 5 health workers. The data pre-conception of care and nutrition practices before pregnant, nutrition knowledge and nutrition practices, food taboo and suggestion, cultural belief influence, and data sources of information and nutritional information needs was carried out using the Focus Group Discussion. The results showed that most of the pregnant women did not get and done pre-conception nutrition care, had insufficient nutritional knowledge and the practice of balanced nutrition was still low. There is still an influence of cultural belief in the form of food taboos and food suggestions, and the lack of sources of information and nutritional information towards nutrition practice. It is necessary to develop media and nutrition educational methods to improve nutrition and health care during pre-conception and pregnancy, and further studies are needed specifically on the role of family factors, especially grandmothers, mothers in-laws, and family members on nutrition practices in pregnant women. Submitted: 09/11/2020 Revised: 17/11/2020 Accepted: 28/11/2020 Published Online: 30/11/2020


Introduction
Malnutrition in the first 1000 days of life, especially during pregnancy, affects the growth and development of the infant (Abu-Saad, 2010). Several nutritional problems that remain a problem in Indonesia are the high prevalence of pregnant women suffering from chronic energy deficiency (CED) and anemia. Basic Health Research (2018) shows one in five pregnant women suffer from chronic energy deficiency and 48.9% of pregnant women suffer from anemia in Indonesia. In Aceh, 12.3% of pregnant women suffered from CED and 46% suffer from anemia (Ministry of Health, 2018).
The high prevalence rate of CED and anemia in pregnant women is related to inappropriate nutrition practices, referring to the guidelines for balanced nutrition, there are ten nutrition practices that mothers must do during pregnancy, namely; consume three servings of carbohydrate sources, consume three servings of animal side dishes, three servings of vegetable side dishes, three servings of vegetables, three servings of fruits, consume two additional meals to meet energy needs and additional nutrients, consume 1 iron tablet a day, drink Sufficient water is at least eight glasses, implement a clean and healthy lifestyle, including washing hands with soap, and doing physical activity for at least 30 minutes every day (Ministry of Health, 2020). The application of the ten messages of balanced nutrition during pregnancy will ensure the fulfillment of energy and nutrient needs and avoid anemia and have a body that is fit and free from infection and disease.
Several studies have shown that the practice of balanced nutrition among pregnant women in Indonesia is still low, this is indicated by the low intake of energy and nutrients and low compliance of mothers in consuming the iron tablet. Data Indonesian Survey of Food Consumption in 2014 showed 49.6% of pregnant women in urban areas and 55.7% in rural areas have protein intake <80% RDA (Ministry of Health, 2014). The compliance of pregnant women consumed iron tablets of 90 tablets or more is still low, only 33.3% in 2013and 38.1% in 2018(Ministry of Health, 2013, Ministry of Health, 2018. Other studies on 203 pregnant women in Bogor showed more than 50% of pregnant women have inadequate intake of iron, zinc, calcium, vitamin A and vitamin C (Madanidjah et al. 2016).
Fulfillment of nutritional needs is one aspect important during pregnancy, according to the principle of nutrition during pregnancy, the nutritional intake of the mother should be able to meet the needs of mothers and needs of the fetus, so it takes the quality and amount of energy and nutrients balanced, fairly and have high bioavailability. For that, we need a good dietary pattern for pregnant women. Knowledge, attitudes, motivation, and factors related to health services such as nutrition education and the family environment, as well as the existing socioculture in the community will affect the nutritional behavior practiced by pregnant women.
Information on a scientific nature through a special study of the factors that influence the nutritional behavior of pregnant women in Aceh is still limited, therefore this study aims to explore Pre-conception care and nutrition practices before pregnant, nutrition knowledge and nutrition practices, food taboo and suggestion, cultural belief influence, and data sources of information and nutritional information needs.

Method
This study used a cross-sectional design with a qualitative study method to determine nutrition practices in pregnant women and the factors that influence it in the work area of the Darul Imarah Community Health Center, Aceh Besar District. The research sample was 11 pregnant women who were selected based on the inclusion criteria: 1). Pregnant women 1 st -3 rd trimester. Do not experience pregnancy complications (sick conditions or pregnancy disorders), 3). Willing to take part in research, as well as 5 health workers (nutrition workers and village midwives) who are responsible for the nutrition and maternal and child health program. The data collected includes; Preconception care and nutrition practices before pregnant, nutrition knowledge and nutrition practices, food taboo and suggestion, cultural belief influence, and data sources of information and nutritional information needs. Data collection was carried out using the Focus Group Discussion (FGD) method with stages, opening, clarifying, reflecting, motivating, digging for deeper information, blocking and distributing to provide opportunities for all respondents to provide information/voice, reframing, focus, break up the debate. if any and take advantage of the time lag and close the FDG. To facilitate the implementation of FGDs, the FGD guidelines are used, namely the FGD guidelines for pregnant women and staff who have been prepared according to the research objectives.
Data FGD results processing was carried out in six stages, namely 1). listen to the FGD recordings, 2). Making a transcript, 3). Rereading the transcript, 4). Determine the prominent and recurring topics that appear in the transcript, 5). Data grouping based on data classification (consensus, differences of opinion, different experiences, and specific or innovative opinions that emerged, 6) coded information. Furthermore, data analysis is carried out using the thematic analysis method carried out in 7 stages, namely recording all information systematically, making data outlines, comparisons and grouping data outlines, building themes and codes, building evaluations, interpreting results, and conclusions. Ethical Approval of this study has been received from The Ethical Committee of Health Polytechnic of Aceh with number LB.02.03/7144/2019.

Results
Focus group discussions (FGD) aimed to find nutritional practices, implementers of appropriate nutrition, and factors affecting maternal nutritional practices in the application during pregnancy. The FGD targets were 11 pregnant women and 5 health workers (nutrition workers and midwives) in charge of the nutrition and mother and child health program from the work area of the Darul Imarah community health center Aceh Besar District.

Pre-conception care and nutrition practices before pregnant
In general, pregnant women do not prepare specifically related to nutritional aspects before pregnancy (pre-pregnancy), some of the actions taken by pregnant women before becoming pregnant are increasing consumption of vegetables such as bean sprouts to increase fertility, some women do not do food consumption patterns. Specifically, namely consuming food such as normal days and what is available at home, some respondents stated that they had checked with a doctor, while the food was related to what was suggested by the doctor as stated by the respondent in box 1 below: Meanwhile, related to the early examination of the nutritional condition of the mother before pregnancy, no mother who checked before becoming pregnant, the examination of the state of nutrition was only carried out after it was found out that some of the women were pregnant, while some of the others if there were any visits to the officer or doctor, almost all of the respondents stated that they were not. know how to find out the condition of the mother's nutrition before pregnancy, as well as the practice of checking hemoglobin to find out anemia, most women stated that they had never checked before becoming pregnant and only did the examination after pregnancy (Box 2). The results showed that although pregnant women did not carry out Hb checks before pregnancy, some of them knew the signs of anemia, including dizziness, pallor, lethargy, pale/white eyelids, nausea, numbness, lack of desire, however, some pregnant women who identify signs of anemia with signs or symptoms of hypotension such as headaches and low blood pressure (Box 3). The results of the study related to the knowledge of mothers about the conditions of mothers at risk of becoming pregnant, based on the results of the FGD, showed that mothers at risk of becoming pregnant according to the knowledge of pregnant women were elderly, diabetics, myoma, acid reflux disease, hypertension and mothers with poor nutritional conditions (Box 4).

Sir "
Mrs. E " There is a regular myoma sir " Mrs. F " There is a disturbance with the stomach sir " Mrs. F " The one with high blood, Sir " Mrs. N " The one who is malnourished sir " Most pregnant women do not know how to assess whether a mother is malnourished or not, but generally, they know the impact of malnutrition on the mother and her fetus, among other things, effects are; the mother loses weight and is harmful to the fetus (Box 5).
Box 5 Bu Y " If the mother is pregnant and doesn't eat, then she will get sick so she will lose weight. So the risk to the baby ". Mrs.E " The danger to the fetus, Sir. Usually pregnant people find it difficult to eat, so they will lack nutrition ".

Nutrition knowledge and nutrition practices
The results showed that pregnant women did not know for sure about weight gain during pregnancy, some mothers said that between 2-3 kg and between 3-4 kg (Box 6).

Box 6
Mrs. E " About 2 kg Sir " Bu H " Usually according to our diet and body weight. For example, a bodyweight of 48 kg, you will increase 2 to 3 kg " Mrs. S " some are 3 kg, some are 4 k, Sir, depending on how much we eat " The results showed that generally pregnant women did not understand in detail balanced nutrition for pregnant women, overall in daily food consumption, pregnant women had mentioned the types of food ingredients, including balanced nutrition, which was consuming foods with vegetables and fruit sources, carbohydrate sources such as rice, Animal side dishes such as meat, eggs and milk, fish and foods that are 4 healthy 5 perfect, meaning that the understanding of pregnant women about balanced nutrition still refers to the 4 healthy 5 perfect diets (Box 7). Regarding the frequency of eating for pregnant women, it is recommended that between 3 to 5 times and some mothers stated that it depends on the presence of hunger, and it is generally uncertain, besides eating staples it is also interspersed with snacks (Box 8).

Box 7 Mrs. E "I don't know sir. But at first glance
Box 8. Mrs. H " 3 times a day, sometimes more than 3 and 5 times " Mrs. E " It depends on how hungry you are, sir. But it should be 3 times, just have to be on time and interspersed with other snacks ". Mrs. M " 3 times Sir. But sometimes 2 times sir " The application of a diet based on the contents of the recommended dinner plate during pregnancy shows that most of the respondents stated that each meal consisted of vegetables, vegetable side dishes, animal side dishes, but some respondents stated that not every meal consisted of various types of food sources, sometimes -sometimes just enough with rice and fish which is important a large amount of food (Box 9). doi: https://doi.org/10.35308/jns.v1i2.2762 While the types of food sources of animal protein (animal side dishes) mentioned include fish, meat, eggs. However, some respondents did not know. (Box 11).

JNS: Journal of Nutrition Science
Box 11. Bu Fd " Fish, meat, eggs " Mrs. S "I don't know sir " Mrs. A "Don't know Pa k" Meanwhile, for food sources of vitamin A, generally, the respondents did not know, only one mother mentioned sweet potato as a source of vitamin A, other than that she did not know (Box 12).
Box 12. Mrs. N "I don't know sir " Bu E " Sweet Potatoes " Bu F d "I don't know sir " Mrs. M "I don't know either sir " Furthermore, food sources of iron generally mention cassava leaves, spinach, corn broccoli, meaning that pregnant women only mention sources of iron from plant-based foods from the vegetable group, while no one knows the source of iron from animal foods (Box 13).

Mrs. Y " Corn "
Supplementary food during pregnancy, the results of research that explores the practice of mothers consuming additional food and the importance of supplemental food during pregnancy show that most pregnant women consume additional food besides the main food, the form of additional food consumed is in the form of snacks and fruits, peanut porridge. green beans, red bean porridge, bread and biscuits, and additional food sources purchased or made by yourself. The reason the respondents consume additional food is so that the mother and fetus are healthy. (Box 14).

Box 14. Mothers: Yes
Bu Y " Snack, fruits " Mrs. E " Most porridge, sir " Bu H " Yes, green bean porridge, sir. Red Bean " Mrs. N " Once, bread and biscuits sir " Bu A " Roti Pak " Mothers: Buy yourself Sir, who is for Sir Mrs. S "extra food so that mother and baby are healthy " The result of this study showed that most respondents already knew the importance of consuming blood-supplemented tablets, all respondents stated that iron supplemented tablets were obtained from Puskesmas. Some reasons pregnant women need to consume iron tablets by respondents are, to prevent the risk of bleeding during childbirth so that when giving birth there is enough blood so that there is no need for donors, so that pregnant women have strong energy during childbirth, but some of the perceptions of mothers about lack of hemoglobin were determined by blood pressure measurement (Box 15). Maternal confidence in the nutritional practices that have been carried out, the result of this study shows that some respondents are convinced of their diet and nutritional practices because they have followed the recommendations of health workers (midwives) and parents, but to find out whether nutrition practices have been implemented. Respondents stated that they were more certain by looking at the baby's weight at birth. Meanwhile, most respondents are not sure because so far they are still not consuming certain types of food, such as vegetables and fruits, so that their daily diet is not complete (Box 20).

Sources of information and nutritional information needs
Most of the respondents get information about nutrition and health during pregnancy from health workers, namely midwives, health centers, specialist doctors, and the surrounding community, besides that, it is also obtained from families at home. (Box 21). The results showed that respondents needed explanations and information related to; Good nutrition for pregnancy requires a more detailed explanation. The form of information media needed is in the form of a book, and respondents stated that so far there has been a Mothers and Child Health guideline book but the nutritional information is not too detailed in it. Besides, respondents expect structured and routine nutrition education every month on nutrition during pregnancy. Respondents also stated that so far they rarely received counseling, especially regarding nutrition for pregnant women (Box 23).

Mrs. F d. "Good nutrition for pregnancy " Bu Ft. "Good nutrition sir "
Based on the above results, it can be identified about nutrition practices in pregnant women, pre-conception care of mothers before pregnancy, application of balanced nutrition and maternal diet during pregnancy, as well as factors related to nutritional practices, namely the condition of maternal knowledge, socio-cultural eating, and the information required. by mothers, both from officers and other sources of information (Table 2). (pineapple, durian), coconut water, tape to prevent miscarriage.  Some types of food that are suggested for consumption are vegetables and fruits, tofu water, drinking lots of water, and coconut water, especially in late pregnancy.  The recommendation is to drink tofu water so that the baby is white and coconut water so that the baby is clean at birth  Most of the mothers stated that they were not sure about the diet that was applied during pregnancy because they still lacked consumption of certain types of food such as vegetables and fruits, and stated that their diet was incomplete. and detailed information  The information media needed is in the form of a book so that it can be read over and over again.  Nutrition education activities are needed with frequent frequency for pregnant women.

Pre-conception care and nutrition practices before pregnant
The results of this study (Table 2) show that most of the pregnant women do not have special readiness to face pregnancy, both from the nutritional aspects, namely examination of nutritional status and anemia status, this condition is caused by most mothers not planning a pregnancy, and do not know anything. that must be prepared to face pregnancy. The readiness of the mother before pregnancy affects the preconception of care practices that the mother uses in dealing with pregnancy. Tayden (2016) stated one of the actions preventive to improve the outcome of pregnancy is doing preconception care to know the condition before pregnancy, include; biochemical status, behavior, and social factors that can cause a high risk of pregnancy.
Several research results in various countries also show results that are almost the same as this research, the results of the study of Bortolus et al (2017) on pregnant women in Italy also show that there are several obstacles and still lack of attention to the preconception of health relating to women, health care professionals and policies. The low level of maternal attention to preconception care is influenced by various factors, including low knowledge, attitudes towards service, and examinations in the preconception phase (Bortolus et al. 2017).
Besides that, the result of a systematic review by Goossens et al. (2018) shows that some several obstacles and supporters that affect the preconception of health care by health workers, namely; less supportive attitude of officers, low knowledge of pre-conception care at the provider level, while the factors at the patient level are; not checking health workers, negative attitude, and lack of knowledge about preconception care. Another factor is the limited resources at the organizational and social levels, such as; lack of time, tools, guidelines, and reimbursement.

Nutrition knowledge and nutrition practices
The results of the study ( Table  2) that most of the pregnant women had low knowledge of nutrition, only some mothers knew the signs of anemia, risk factors for pregnancy, and the impact of malnutrition on pregnancy outcomes, weight gain during pregnancy, balanced nutrition, and the importance of iron tablets. The low knowledge of nutrition for pregnant women can be caused by various factors, both from the mother, the role of health workers, and health service institutions, as well as social factors. Wong et al. (2018) Saepul et al. (2019) and Sriwahyuni, et.al (2020) showed the majority of pregnant women (84.4%) had knowledge of nutrition with less category, as well as studies and Zema Nana (2018) (2015) in Abeokuta South Local Government Area of Ogun State shows that 75.5% of pregnant women know that malnutrition is a risk factor for pregnancy, as well as the results of the study by Wong et al. (2018) in Malaysia, showed that 63.3% of pregnant women have good knowledge of nutrition.
The results of the study (Table 2) show that the application of balanced nutrition in pregnant women is still low, which is indicated by the frequency of eating that is not according to standards, the diversity of consumption of types of food is not complete according to the diversity of food consumption standards, namely at least four types of food ingredients from different food groups, namely a source of carbohydrates, a source of non-animal protein, a source of vegetable protein, vegetables, and fruit. These results are the same as those of Tsegaye et al. (2020) in Ethiopia where many pregnant women have low nutrition practices. The study of Nana and Zema (2018) in Ethiopia also shows that 60.7% of pregnant women have poor dietary practices.
A meta-analysis study by Hidru et al. (2020) in Ethiopia showed 53% (95% CI: 44%, 62%) pregnant women inadequate dietary diversity, several factors that influence are food security, family size greater than four, rural residence, no formal educational status, and a lack. of counseling about dietary diversity. The study of Tsegaye et al. (2020) also shows that lack of nutrition practices in pregnant women is influenced by factors of education and family economic status.

Food
Taboos, foods suggestion, and cultural belief The results of the study (Table 2) show that there are still barriers to socio-cultural effects on nutrition practices in pregnant women, this condition can be seen from the presence of taboo on certain foods in early pregnancy, several types of dietary restrictions, among others; fruits (pineapple, durian), coconut water, cassava fermented or "tape". The prohibition against food is based on public belief to prevent miscarriage, on the other hand, at the end of pregnancy, there are recommendations to consume vegetables and fruits, tofu water, drink lots of water and coconut water in the belief that it helps clean the baby clean at birth. The results of this study also showed that pregnant women were not sure about the diet they applied because they had not consumed certain types of food such as vegetables and fruits.
The results of a similar study by Darmawati et al. (2020) in Aceh shows that one of the factors related to high anemia in pregnant women is associated with cultural beliefs, namely the existence of certain traditional food taboos. The results of other studies in Madura also show that many food taboos and food suggestions are still being applied to pregnant women Madura, several types of food that are considered taboo among pregnant women, including squid, shrimp, pineapple, Kedondong, cabbage, cold water, and instant noodles. On the other hand, some of the recommended foods are rice, corn rice, skipjack tuna, tilapia fi sh, milk fish, egg, moringa leaves, apples, and coconut water (Diana et al. 2018).
Various studies in several countries also show almost the same results, as the study of Chakona and Shackleton (2019) at Eastern Café, South Africa shows 37% of pregnant women have nutrition practices that are formed from one or more practices shape by local cultural taboos or beliefs, some of the taboos practices were learned or obtained from their mothers or grandmothers. In another study by Shahid et al. (2011) there is still a strong influence on food beliefs that affect the food intake of pregnant women.

Sources of information and nutritional information needs
The results of the study (Table 2) show that most pregnant women obtain information from health workers (midwives, health workers, and specialist doctors), from the local community where they live (family and doi: https://doi.org/10.35308/jns.v1i2.2762 P-ISSN : 2723-2867, E-ISSN : 2723-2875 24 neighbors), meanwhile the use of social media and media electronics as a source of nutritional information is still small. Research results have also shown the majority of pregnant women states require a source of information in book form with the contents of the message easy to understand, so it can be read again and again sat needed, but it requires a structured education with greater frequency by health care workers or others.

JNS: Journal of Nutrition Science
Several studies on pregnant women also show that the main source of information is obtained from health workers, the results of the study of Bortolus et al (2017) in Italy show that the main source of information from pregnant women is health personnel, namely obstetric-gynecologists. The results of the study by Scewejcer et al. (2008) show a different matter where the most favorite information media used by pregnant women apart from the pocketbook for pregnant women is the Internet.
Basically, during pregnancy, pregnant women need to be provided with various information related to pregnancy, according to the study of Kamali et al. (2018) partially expectant mothers information need about baby care, physical and psychological complication after birth, fetal growth and development, nutrition dive pregnant, and special examinations during pregnancy, however general, pregnant women need the information when they are experiencing illness or complications pregnancy. Another study by Almalik and Mosleh (2017) shows that pregnant women need a high degree of importance of specific learning topics that are closely relevant to their current period of pregnancy.
The need for pregnant women for information is influenced by many factors, the results of the study by Sharifi et al. (2020) in Iran shows that information needs during pregnancy are influenced by age, education level, husband's education level, length of stay and place of residence, number of children and previously obtained information, and routine prenatal care. The results of the study by Ferraro et al. (2011) most pregnant women do not get sufficient information about the specific needs of energy and nutrients to support the gestational weight gain target, most pregnant women get various information and get information from care providers. Sources of information are an important factor in the effort to deliver the various services and practices that mothers must do, both before, during pregnancy, and after delivery. The provision of information can be done through electronic media and social media, books, and other printed media such as posters, leaflets, and booklets, as well as through direct delivery by officers both in health services and in the community.

Conclussions and Sugestions
Most of the pregnant women did not get and done pre-conception nutrition care, had insufficient nutritional knowledge and the nutrition practices among pregnant was still low. There is still an influence of cultural belief in the form of food taboos and food suggestions, and the lack of sources of information and nutritional information towards nutrition practice. It is necessary to develop media and nutrition educational methods to improve nutrition and health care during pre-conception and pregnancy, and further studies are needed specifically on the role of family factors, especially grandmothers, mother in-laws, and family members on nutrition practices in pregnant women.