scholarly journals Optimal Ambulatory Vital Sign Targets in Pulmonary Hypertension Pregnant Women via Time-Dependent Survival Analysis

2022 ◽  
Author(s):  
renhuai liu ◽  
ziyu zheng ◽  
binxiao su
Keyword(s):  
Heart Rate ◽  
Pulmonary Hypertension ◽  
Maternal Mortality ◽  
Pregnant Women ◽  
Cox Regression ◽  
Vital Signs ◽  
Right Heart Failure ◽  
Time Dependent ◽  
Dynamic Features ◽  
Pregnancy And Postpartum

Abstract Background: Pulmonary hypertension (PH) can cause complications in pregnant women due to significant hemodynamic fluctuation or right heart failure as well as death during pregnancy and postpartum. Those in critical condition would be sent to the intensive care unit (ICU) for observation and treatment. However, evidence to suggest the safe target vital signs is limited and none specific to pregnancy with PH.Methods: This retrospective study of consecutive obstetric patients with PH admitted to ICU of the First Affiliated Hospital of Air Force Military Medical University of China, from January 2011 to May 2020, consisted of 92 cases analyzed using time-dependent Cox regression to consider the dynamic features of vital signs. Results: 7/92 maternal deaths occurred. Most of these deaths occurred within the first three days of admission to the ICU. The vital signs for survival were stable and normal compared to death. Three vital signs were identified as risk factors in the maternal in-hospital mortality model via backward selection: SpO2（HR，0.93；95%CI，0.88-0.97；P=0.003）, heart rate（HR，0.94；95%CI，0.90-0.99；P=0.027）, and mean arterial pressure (MAP) （HR，1.09；95%CI，1.00-1.18；P=0.045）. Log of relative hazard ratios of mortality is linearly negatively related to SpO2 value with a U-shaped correlation with heart rate and MAP (both lower and higher values were associated with high mortality). The optimal range of SpO2 <73%, MAP was 65–95 mmHg, and heart rate was 59–125 beats per minute (bpm). Further exploration showed that the cumulative and the longest consecutive time of abnormal vital signs also affect the outcome. For example, SpO2<73% accumulated for 5 h or continuously up to 2 h increases mortality.Conclusions: Pregnant women with PH who died in the hospital experienced long-term abnormal fluctuations in MAP, heart rate, and SpO2 during ICU stay. Maintaining SpO2>73%, MAP at 65–95mmHg, and heart rate at 59–125 bpm can significantly reduce in-hospital maternal mortality. The effects of the abnormal SpO2, heart rate, and MAP on in-hospital maternal mortality should be combined with the cumulative time and the longest duration.Trial Registry: ChiCTR2100046637.

scholarly journals Analysis of Prognostic Relevance based on Ambulatory Vital Signs Among Pregnancy with Pulmonary Hypertension in the ICU

2021 ◽  
Author(s):  
Renhuai Liu ◽  
Ziyu Zheng ◽  
Chen He ◽  
Chong Lei ◽  
Yu Chen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Pulmonary Hypertension ◽  
Cox Regression ◽  
Vital Signs ◽  
Model Performance ◽  
Mean Blood Pressure ◽  
Dynamic Features ◽  
Prognostic Information ◽  
Maternal Deaths

Abstract Purpose: The study seeks to utilise the extensively monitored data to explore the prognostic information in the continuous ambulatory vital signs of the pregnant women with pulmonary hypertension in the ICU, aiming to bring insights to physicians on evaluation and management of these specific patients. Methods: This is a retrospective study of consecutive obstetric patients with PH admitted to ICU of the First Affiliated Hospital of Air Force Military Medical University of China, from January 2011 to May 2020. 92 cases are analysed via time-dependent Cox regression to take account of the dynamic features of vital signs. Results: Seven out of 92 maternal deaths occurred, with most maternal deaths occurring within the first three days of admission to the ICU. The vital signs for the survived are more stable and normally ranged comparing to the death. Three vital signs are identified as risk factors in the maternal in-hospital mortality model: SpO 2 (OR,0.93;95%CI,0.89-0.98), Heart rate(OR, 0.95 ; 95%CI, 0.92-0.99), Mean blood pressure(OR, 1.1 ; 95%CI, 0.98-1). The model performance is justified by the ROC curve with AUC being 0.84. Further exploration showed that the total and the longest consecutive time ratios also affect the outcome. Conclusions: Pregnancy women with PH who dead in hospital experienced long-term abnormal fluctuations in blood pressure, heart rate and blood oxygen during ICU stay. Both dynamic and time ratios reported impacts relating to SpO 2 , heart rate and blood pressure. In general SpO 2 mitigate the hazard. Effects of the heart rate and mean blood pressure should be described combining the time ratios of hypotension and tachycardia.

scholarly journals Efektivitas Terapi Rendam Kaki Air Hangat terhadap Perubahan Penurunan Tekanan Darah Ibu Hamil Preeklampsia

2021 ◽  
Vol 8 (1) ◽  
pp. 24-31
Author(s):  
Maslahatul Inayah ◽  
Tri Anonim
Keyword(s):  
Blood Pressure ◽  
Maternal Mortality ◽  
Pregnant Women ◽  
Diastolic Blood Pressure ◽  
Blood Pressure Reduction ◽  
Intervention Group ◽  
Warm Water ◽  
Bivariate Analysis ◽  
Control Group ◽  
Pregnancy And Postpartum

Maternal Mortality Rate (MMR) can be a measuring tool to determine the quality of health services both during pregnancy and postpartum. Pregnant women with preeclampsia can cause complications that lead to increased maternal mortality and perinatal mortality. There are several attempts to control high blood pressure. This method can use pharmacological or non pharmacological.  The purpose of this study was to determine the effectiveness of warm water foot soak therapy on changes in blood pressure reduction of preeclamptic pregnant women. This type of research is a quantitative study with aresearch quasi-experimentaldesign, with adesign approach pre and post test in the intervention group and the conMtrol group. The sample for each group is 10 people, so that the total number of samples is 20 respondents.Bivariate analysis was performed using the Wilxocon test because the data distribution was not normal and the Mann-Whitney Test to determine the difference before and after the intervention was given.The results of the bivariate analysis showed that there was an effect of giving warm water foot soaking therapy to changes in the decrease in systolic and diastolic blood pressure of preeclamptic pregnant women with a value of p = 0.004 and p = 0.011 and there were differences in changes in the decrease in systolic and diastolic blood pressure between the intervention group and the control group. p = 0.001 and p = 0.007.

scholarly journals Heart Rate Recovery at 1 Min after Exercise Is a Marker of Disease Severity and Prognosis in Chronic Thromboembolic Pulmonary Hypertension

Respiration ◽  
2021 ◽  
pp. 1-10
Author(s):  
Qi Jin ◽  
Xin Li ◽  
Yi Zhang ◽  
Zhihui Zhao ◽  
Qing Zhao ◽  
...  
Keyword(s):  
Heart Rate ◽  
Pulmonary Hypertension ◽  
Disease Severity ◽  
Cox Regression ◽  
Heart Rate Recovery ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Peak Oxygen Consumption ◽  
Heart Catheterization ◽  
Thromboembolic Pulmonary Hypertension ◽  
Clinical Worsening

<b><i>Background:</i></b> Attenuated heart rate recovery at 1 min (HRR1) was demonstrated to correlate with poor prognosis in patients with pulmonary arterial hypertension, whereas its role in patients with chronic thromboembolic pulmonary hypertension (CTEPH) remains unclear. <b><i>Objectives:</i></b> The aim of this study was to investigate the correlations between HRR1 and functional status, echocardiography, hemodynamics, and prognosis of CTEPH. <b><i>Methods:</i></b> We retrospectively enrolled patients with CTEPH who underwent right heart catheterization and cardiopulmonary exercise test between June 2014 to October 2020 in Fuwai hospital. The primary outcome was clinical worsening. Linear regression was performed to assess the association between HRR1 and established markers of CTEPH severity. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff of HRR1. Cox regression models were used to assess the association between HRR1 and clinical worsening. <b><i>Results:</i></b> A total of 211 patients with CTEPH were included in the study. After adjusting for confounders, HRR1 positively correlated with 6-min walk distance, mixed venous oxygen saturation, and peak oxygen consumption, and negatively correlated with NT-proBNP, pulmonary vascular resistance, and ventilatory equivalent of carbon dioxide. Compared with patients with HRR1 ≥16 beats, patients with HRR1 &#x3c;16 beats had approximately a 3-fold risk of experiencing clinical worsening and the risk escalated with time. <b><i>Conclusion:</i></b> HRR1 could reflect disease severity and was independently associated with prognosis in patients with CTEPH.

scholarly journals Beta-Blocker Treatment in Ventilated COVID-19 patients – A Cox Regression with Time Dependent Covariate Analysis

2021 ◽  
Author(s):  
Dipesh Mistry ◽  
Anower Hossain ◽  
Jianxia Sun ◽  
Tonny Veenith ◽  
Ranjit Lall ◽  
...  
Keyword(s):  
Heart Rate ◽  
Critically Ill ◽  
Beta Blocker ◽  
Cox Regression ◽  
Prospective Trial ◽  
Time Dependent ◽  
Beta Blockade ◽  
Covariate Analysis ◽  
Risk Of Death ◽  
Immortal Time Bias

Abstract Background: Patients with co-morbidities are particularly vulnerable to severe COVID-19 disease. Critically ill patients with COVID-19 frequently experience severe tachycardias and avoidance of these is important in some co-morbidities, for instance cardiovascular disease. There is growing interest in beta blockade in critical illness as their use been associated with improved outcomes in a variety of conditions. We report the real-world use of heart rate management in patients during the first wave of the COVID-19 pandemic. As retrospective data are prone to an Immortal Time Bias, we created a Cohort Trial such as might be used for a future prospective trial and used Time Dependent Covariate Analysis for its analysis. Methods: Data for all PCR-proven COVID-19 patients ventilated in the Intensive Care Unit (ICU) were extracted from the hospital databases. To compensate for the risk of immortal time bias, we restricted analysis to 144 patients who achieved a heart rate (HR) of 90 beats per minute for more than 12 hours and were treated with norepinephrine. We recorded time from these ‘entry criteria’ to first beta blocker dose. Those patients who did not receive a beta blocker were given a nominal time to beta blocker beyond the censor day. Outcome was mortality censored at 28 days.Results: In the study group, 83/144 patients (57.6%) received a beta blocker. The median interval from entry criteria to beta blocker was 7.91 days (IQR 3.89, 13.15) and median duration of treatment was 7.00 days (IQR 4.00, 14.00). Twenty-four beta blocker patients (28.9%) died within 28 days compared with 29 (47.5%) who did not (adjusted OR 0.43; 95% CI 0.20-0.95, P=0.036). Cox Regression with time-dependent covariate analysis revealed there was an increased, but not significant, risk of death with beta blocker delay (Hazard Ratio 1.42 p=0.264). Mortality was also reduced for each day treated with beta blockade (adjusted Odds Ratio 0.76, 95% CI 0.64-0.91; P=0.002).Conclusions: In a retrospective analysis of critically ill ventilated patients with COVID-19 who developed a tachycardia >90 beats per minute and were treated with norepinephrine, beta blockade was associated with reduced mortality.

scholarly journals Exercise Induced Changes of Vital Signs in Adults with Sickle Cell Disease

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 59-60
Author(s):  
Solomon Johnson ◽  
Victor R. Gordeuk ◽  
Roberto Machado ◽  
J Simon R Gibbs ◽  
Mariana Hildesheim ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Pulmonary Hypertension ◽  
Systolic Blood Pressure ◽  
Vital Sign ◽  
Research Funding ◽  
Systolic Pressure ◽  
Vital Signs ◽  
Left Ventricular ◽  
Sign Change

The six-minute walk test (6MWT) is a well-established assessment of the cardiopulmonary function of sickle cell disease (SCD) patients. The test is used for people with SCD who are suspected of having hypoxia or an elevated estimated pulmonary arterial systolic pressure, which increases the risk for early death. Low 6MWT distances are associated with cardiopulmonary compromise. Six-minute walk distance examination has been proposed as a screening test, used in conjunction with plasma levels of brain natriuretic peptide and Doppler-echocardiography, through which to identify high-risk patients. Post-exercise tachycardia or lack of heart rate recovery following a 6MWT has been shown to be a predictor of pulmonary hypertension and mortality in people with pulmonary fibrosis. A rise in blood pressure after exercise is associated with impaired capacity for vasodilation in ischemic heart disease. The prognostic significance of patterns of vital sign change in adult SCD patients completing the 6MWT is currently unknown. In this study, we aimed to assess the distribution and predictors of vital sign change during 6MWT in adult SCD patients and test the association of these changes with patient survival. Data from a multinational observational study of SCD patients (Walk-PhassT), was used to calculate the change in vital signs (heart rate, O2 saturation, systolic blood pressure, diastolic blood pressure, pulse pressure) normalized for walk distance, after a 6MWT. Bivariate and LASSO regression analyses were performed to ascertain the significant predictors of change in each vital sign, in addition to Cox proportional hazard analysis to assess the impact of vital sign change and time to death. The median age of the 630 adult SCD patients was 37 years. 47% were male, 77% had the HbSS phenotype, and 22 (3.7% of 592 with follow-up data) died during a median time of follow up of 29 months. The most frequent changes in vital signs identified were increases in the heart rate (90%) followed by increases in systolic blood pressure (77%, Table 1b). Bivariate analysis revealed significant but weak positive correlations between tricuspid regurgitation velocity (TRV) and increases in both heart rate (r= 0.08; p&lt;0.05) and systolic blood pressure (r=0.13; p=0.002), as well as decreases in O2 saturation (r=-0.09; p=0.03). Significant positive correlations were also identified between increases in pulse pressure and TRV (r=0.14; p=0.001), left ventricular mass index (r=0.10, p=0.02), and a composite index of hemolysis (r=0.09; p =0.03). Pulse pressure increased more during 6MWT in patients with self-reported pulmonary hypertension than patients without pulmonary hypertension (median 1.6 vs. 1.3 per 100-meter walk, p=0.04); while heart rate increased less (median 3.4 vs. 4.3 per 100-meter walk, p=0.04). LASSO models selected TRV and markers of hemolysis as predictors of O2 desaturation, while higher left ventricular ejection fraction and non-SS genotypes were predictors of lesser O2 desaturation, during the 6MWT. Both older age and higher left ventricular volume were associated with reduction of diastolic blood pressure during 6MWT (Table 1a). In survival analysis, after adjusting for TRV and N-terminal pro-brain natriuretic peptide concentration, any increase in systolic blood pressure during the 6MWT was associated with better survival (hazard ratio=0.3, p=0.019, Table 1b). These findings support links between changes of vital signs during the 6MWT and established markers of hemolysis and cardiovascular dysfunction in SCD patients. Evidence of a protective effect of increased systolic pressure is a novel finding. This might indicate that the ability to increase systolic pressure during submaximal exercise relates to cardiac output and conveys a physiological advantage for SCD patients. These findings could be used as the basis for future mechanistic studies of exercise effects on cardiovascular function in SCD patients. Disclosures Gordeuk: Imara: Research Funding; Global Blood Therapeutics: Consultancy, Research Funding; Novartis: Consultancy; CSL Behring: Consultancy, Research Funding; Ironwood: Research Funding. Gibbs:Pfizer: Consultancy; United Therapeutics: Consultancy; MSD: Consultancy; GSK: Consultancy; Complexa: Consultancy; Bayer: Consultancy; Actelion: Consultancy; Acceleron: Consultancy. Little:BioChip Labs: Patents & Royalties: SCD Biochip (patent, no royalties); GBT: Membership on an entity's Board of Directors or advisory committees; NHLBI: Research Funding; Hemex Health, Inc.: Patents & Royalties: Microfluidic electropheresis (patent, no royalties); Bluebird Bio: Research Funding; GBT: Research Funding.

Quantifying Pregnant Women’s Knowledge of Educational Components of Antenatal Care in Lesotho

2019 ◽  
Vol 21 (1) ◽  
Author(s):  
Tabeta Seeiso ◽  
Mamutle M. Todd-Maja
Keyword(s):  
Antenatal Care ◽  
Maternal Mortality ◽  
Pregnant Women ◽  
Rural Areas ◽  
Geographic Location ◽  
Sub Saharan Africa ◽  
World Health ◽  
Cross Sectional ◽  
Danger Signs ◽  
In Pregnancy

Antenatal care (ANC) literacy is particularly important for pregnant women who need to make appropriate decisions for care during their pregnancy and childbirth. The link between inadequate health literacy on the educational components of ANC and maternal mortality in sub-Saharan Africa (SSA) is undisputable. Yet, little is known about the ANC literacy of pregnant women in SSA, with most studies inadequately assessing the four critical components of ANC literacy recommended by the World Health Organization, namely danger signs in pregnancy; true signs of labour; nutrition; and preparedness for childbirth. Lesotho, a country with one of the highest maternal mortality rates in SSA, is also underexplored in this research area. This cross-sectional study explored the levels of ANC literacy and the associated factors in 451 purposively sampled women in two districts in Lesotho using a structured questionnaire, making recourse to statistical principles. Overall, 16.4 per cent of the participants had grossly inadequate ANC literacy, while 79.8 per cent had marginal levels of such knowledge. The geographic location and level of education were the most significant predictors of ANC literacy, with the latter variable further subjected to post hoc margins test with the Bonferroni correction. The participants had the lowest scores on knowledge of danger signs in pregnancy and true signs of labour. Adequate ANC literacy is critical to reducing maternal mortality in Lesotho. Improving access to ANC education, particularly in rural areas, is recommended. This study also provides important recommendations critical to informing the national midwifery curriculum.

The impact of statin therapy after surgical or endovascular treatment of cerebral aneurysms

2020 ◽  
Vol 133 (1) ◽  
pp. 182-189
Author(s):  
Tae-Jin Song ◽  
Seung-Hun Oh ◽  
Jinkwon Kim
Keyword(s):  
Statin Therapy ◽  
Coil Embolization ◽  
Primary Outcome ◽  
Cox Regression ◽  
Cerebral Aneurysms ◽  
Time Dependent ◽  
Lipid Lowering ◽  
Surgical Clipping ◽  
The Impact

OBJECTIVECerebral aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Statins are lipid-lowering agents that may expert multiple pleiotropic vascular protective effects. The authors hypothesized that statin therapy after coil embolization or surgical clipping of cerebral aneurysms might improve clinical outcomes.METHODSThis was a retrospective cohort study using the National Health Insurance Service–National Sample Cohort Database in Korea. Patients who underwent coil embolization or surgical clipping for cerebral aneurysm between 2002 and 2013 were included. Based on prescription claims, the authors calculated the proportion of days covered (PDC) by statins during follow-up as a marker of statin therapy. The primary outcome was a composite of the development of stroke, myocardial infarction, and all-cause death. Multivariate time-dependent Cox regression analyses were performed.RESULTSA total of 1381 patients who underwent coil embolization (n = 542) or surgical clipping (n = 839) of cerebral aneurysms were included in this study. During the mean (± SD) follow-up period of 3.83 ± 3.35 years, 335 (24.3%) patients experienced the primary outcome. Adjustments were performed for sex, age (as a continuous variable), treatment modality, aneurysm rupture status (ruptured or unruptured aneurysm), hypertension, diabetes mellitus, household income level, and prior history of ischemic stroke or intracerebral hemorrhage as time-independent variables and statin therapy during follow-up as a time-dependent variable. Consistent statin therapy (PDC > 80%) was significantly associated with a lower risk of the primary outcome (adjusted hazard ratio 0.34, 95% CI 0.14–0.85).CONCLUSIONSConsistent statin therapy was significantly associated with better prognosis after coil embolization or surgical clipping of cerebral aneurysms.

FAKTOR– FAKTOR YANG BERHUBUNGAN DENGAN KEJADIAN ANEMIA PADA IBU HAMIL DI PUSKESMAS TALANG RATU PALEMBANG TAHUN 2014

2019 ◽  
Vol 4 (2) ◽  
Author(s):  
Yuhemy Zurizah Yuhemy Zurizah
Keyword(s):  
Mortality Rate ◽  
Health Service ◽  
Maternal Mortality ◽  
Pregnant Women ◽  
Health Center ◽  
Significant Relationship ◽  
World Health ◽  
Chi Square ◽  
Cross Sectional ◽  
Maternal Mortality Rate

  ABSTRACT Maternal Mortality Rate is a barometer of mother health service in a country. At this time maternal mortality rate in Indonesia is still very high. Indonesia Demography Survey on 2007, maternal mortality rate is about 28 per 100.000 of live births. The direct cause of maternal mortality in Indonesia as well as in the other country is hemorraghe (25%), sepsis (15%), eklampsia (12%), abstructed labor (8%). World Health Organization (WHO), 35-37% of pregnant women in developing coutries get anemy. Causing factor’s of anemy on pregnant women is age of pregnant, parity, economi socio, job, education, and nutritional status. Purpose of this research is to know the associated factors with incidence of anemy on pregnant women at the Health Center Talang Ratu Palembang in 2014. This research use analytic survey method with “cross sectional” approach. Population in this research is all of preganant women in medical treatment at Talang Ratu Palembang in 2014. Sample taking in this research with non random samplingmethod and accidental sampling technic. Analysis with univariatly and bivariatlywith Chi Square Statistic test with significant level α 0,05. The result of this research show that from 35 respondent there is (48,6%) respondent with anemy, high–risk age (28,6%), high parity (60,0%) and low economi socio (37,1%). This result show that there is significant relationship between age with incidence of anemy on pregnant women at the health center Talang Ratu Palembang in 2014 with p value0,027, there is significant relationship between parity with incidence of anemy on pregnant women at the health center Talang Ratu Palemabang in 2014 with p value0,023, and there is significant relationship between economi socio with incidence of anemy on pregnant women at the health center Talang Ratu Palembang in 2014 with p value0,026. Of the result, the author hope that health service worker at Talang Ratu health center can improve health service to pregnant women and often giving information about anemy on pregnant and nutritional for pregnant women during pregnancy.     ABSTRAK Angka Kematian Ibu (AKI) merupakan barometer pelayanan kesehatan ibu di suatu negara. Pada saat ini angka kematian ibu di Indonesia masih sangat tinggi. Menurut Survey Demografi dan Kesehatan Indonesia (SDKI) tahun 2007, angka kematian kematian ibu adalah 28 per 100.000 kelahiran hidup. Penyebab langsung kematian ibu di Indonesia seperti halnya Negara lain adalah perdarahan (25%), sepsis (15%), eklampsi (12%), partus lama (8%). Menurut World Health Organization (WHO), 35-37% ibu hamil di negara berkembang dan 18% di negara  maju mengalami anemia. Faktor penyebab terjadinya anemia pada ibu hamil secara tidak langsung adalah umur ibu, paritas, sosial ekonomi, pekerjaan, pendidikan, jarak kehamilan, dan status gizi.Tujuan penelitian ini adalah untuk mengetahui faktor - faktor apa saja yang berhubungan dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014. Penelitian ini menggunakan metode survey analitikdengan pendekatan cross sectional. Populasi dalam penelitian ini adalah seluruh ibu hamil yang berobat di Puskesmas Talang Ratu Palembang Tahun 2014. Pengambilan sampel pada penelitian ini dengan metode non random sampling dengan teknik Accidental sampling. Analisis dilakukan secara univariat dan bivariat. Dengan uji statistik chi square tingkat kemaknaan α 0,05. Hasil penelitian menunjukkan dari 35 responden terdapat (48,6%) responden yang anemia, umur yang beresiko  tinggi (28,6%), paritas tinggi (60,0%), dan sosial ekonomi rendah (37,1%). Hasil penelitian ini menunjukkan ada hubungan yang bermakna antara umur dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014 dengan  p value0,027,  ada hubungan bermakna antara paritas dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014 dengan p value0,023 dan ada hubungan yang bermakna antara sosial ekonomi dengan kejadian anemia pada ibu hamil di Puskesmas Talang Ratu Palembang Tahun 2014 dengan p value0,026. Dari hasil penelitian ini penulis berharap petugas kesehatan di Puskesmas Talang Ratu Palembang meningkatkan pelayanan kesehatan pada ibu hamil dan lebih sering melaksanakan penyuluhan anemia pada kehamilan dan nutrisi yang baik bagi ibu hamil.    

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