The Relationship of Knowledge and Attitude of Pregnant Mothers Anemia Trimester III with Compliance with Fe Tablet Consumption in

According to 2019 World Health Organization (WHO) data, the Maternal Mortality Rate (MMR) in developing countries associated with anemia in pregnancy due to iron deficiency is 44.3%. One of the most common causes of pregnancy is iron deficiency. This study aims to determine the relationship between compliance to the consumption of Fe tablets in third-trimester pregnant women with knowledge, attitudes, motivation, frequency of ANC, family support, and the role of health workers. This study uses a quantitative method with a cross-sectional approach. Sampling by purposive sampling. The population in this study amounted to 100 respondents. Data collection was collected by distributing printed questionnaires to pregnant women. The research instrument consisted of a questionnaire about the compliance of pregnant women in consuming iron tablets, knowledge, motivation, attitudes, frequency of ANC, family support, and the role of health workers. The results showed that there was a relationship between pregnant women's compliance with knowledge of p-value (0.000), motivation (0.000), attitude (0.000), ANC frequency p-value (0.011), family support (0.002), and the role of health workers (0.000). There is still a lack of compliance among pregnant women in consuming iron tablets at Pasar Kemis Community Health Center, Tangerang Regency as many as 41 people (41.0%).

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INTRODUCTION
A serious and concerning problem in the health sector in Indonesia, particularly in the maternal and child health sector, is the high maternal and child mortality rates. This is an indication that shows the welfare of society in a country. Anemia in pregnancy is a national problem because it describes the economic value of society and has a major influence on the quality of human resources (Carolin & Novelia, 2021;Pratiwi, 2021).
According to 2019 World Health Organization (WHO) data, the Maternal Mortality Rate (MMR) in developing countries associated with anemia in pregnancy due to iron deficiency is 44.3%. Countries in Asia with the highest prevalence of anemia in pregnant women are India (50.1%) and Pakistan (44%), while in European countries the highest prevalence of anemia is (Bosnia 27.2%) and (Bulgaria 25.8%). Then in African countries, the highest prevalence of anemia is Mali (59%) and Benin (58.1%). Bleeding, hypertension during pregnancy, infections, complications of childbirth, and unsafe abortions account for around 75% of all cases of maternal death (WHO, 2019).
MMR in Indonesia in 2015 was 305 per 100,000 live births (KH). The number of maternal deaths in 2020 from the records of the family health program at the Ministry of Health shows 4,627 deaths. The 2024 National Medium Term Development Plan (RPJMN) AKI target is 183 per 100,000 KH and the 2030 Sustainable Development Goals AKI target is 70 per 100,000 KH. In Indonesia, the main causes of maternal death are 1,330 cases of bleeding, 1,110 cases of hypertension, and 230 cases of circulatory system disorders (Kemenkes Rl, 2021). The prevalence of anemia in pregnancy in Indonesia is still high and has increased in 2014 (41.5%), 2015 (42.1%), 2016 (42.7%), 2017 (43.2%), 2018 ( 43.7%), and 2019 (44.2%) (WHO, 2020).
In Banten Province, it was found that most of the anemia in the community was caused by iron deficiency, which could be overcome by regular iron supplementation and better nutrition. The prevalence of iron nutritional anemia in Banten Province in 2017 in pregnant women was 27.6%. Meanwhile, the prevalence of anemia in Tangerang Regency is 48.3% (Badan Penelitian dan Pengembangan Kesehatan, 2019).
According to data from the Maternal Health Annual Report from the Pasar Kemis Community Health Center Tangerang in 2017, there were 2,112 pregnant women, 243 of whom (11.5%) experienced anemia. The incidence of anemia has increased in 2018 from 2,140 pregnant women, 418 of whom (19.5%) experienced anemia. Whereas in 2019 there were 2,192 pregnant women, 440 of whom (20.1%) experienced anemia. The treatment that has been carried out by the Pasar Kemis Community Health Center Tangerang to treat anemia is giving Fe tablets (Profil Puskemas Pasarkemis, 2019).
Fe tablets distributed in the anemia prevention program seek to reduce the incidence of anemia in toddlers, pregnant women, postpartum women, young women, and women of childbearing age (WUS). Prevention of anemia in pregnant women is done by giving 90 Fe tablets during pregnancy or entering the 16th week of fetal age. Nationally the coverage of pregnant women receiving Fe tablets in 2022 is 84.2% This figure has increased compared to 2020 at 83.6% (Kemenkes RI, 2022). According to Banten Province data in 2019, 101.5% of pregnant women received 90 Fe tablets, an increase compared to the 2018 coverage rate of 93.73% (Dinkes Provinsi Banten, 2021). The results of the 2018 Riskesdas for Banten Province showed that 88.4% of pregnant women had taken iron tablets during pregnancy. As many as 43.6% of pregnant women took iron tablets during 90 days of pregnancy, 56.4% took iron tablets <90 days and 17.3% forgot to take iron tablets during pregnancy. The high number of pregnant women who forget or don't even take blood supplement tablets must be addressed immediately because the increasing number of non-compliance of mothers to take iron tablets will also increase the likelihood of abortion, premature delivery, hydatid mole, antepartum bleeding, premature rupture of membranes (PROM) (Badan Penelitian dan Pengembangan Kesehatan, 2019).
Pregnancy is defined as the fertilization or union of sperm and egg, followed by implantation or nidation. From the time of conception to delivery, the gestation period from ovulation to the birth of the baby is around 280 days (0 weeks) and no more than 300 days (3 weeks) (Prawirohardjo, 2016) In early pregnancy, pregnant women experience an increase in blood volume. At 12 weeks, the increase in blood plasma volume relative to prepregnancy levels is about 15%. As a result of an increase in plasma and erythrocytes, pregnant women experience an increase in blood volume. In the second trimester of pregnancy, the expansion of maternal blood volume increases rapidly and returns in the third trimester. The centralization of hemoglobin and hematocrit during pregnancy will also decrease due to the expansion of the flowing plasma. The normal hemoglobin level of pregnant women in the third trimester is 12.5 g/dl; the limit that is still considered normal is 11.0 g/dl, which can indicate iron deficiency (Sikoway et al., 2020).
Anemia during pregnancy is a public health problem, especially in developing countries, and is associated with poor pregnancy outcomes. WHO defines anemia in pregnancy as a hemoglobin concentration below 11 g/dl. According to WHO, anemia is considered a public health problem when population studies reveal a prevalence of 5% or more. The prevalence of anemia of 40% in the community is a major public health problem (WHO, 2019). Anemia that usually occurs in pregnant women is iron deficiency anemia or also known as iron nutritional anemia (Sulistyoningsih, 2011). According to Lawreen W. Green et al. (1980) behavioral and non-behavioral factors are the causes of health problems. Behavioral factors, especially health behavior, are affected by three factors, namely predisposing factors, enabling factors, and supporting factors.

METHODS
This study uses an analytic survey method, namely a survey or research that tries to investigate how and why health phenomena occur, in conjunction with a crosssectional approach. This research was conducted in June-July 2022. Determination of participants used a purposive sampling technique with inclusion criteria for thirdtrimester pregnant women with anemia in the Pasar Kemis Community Health Center work area, pregnant women who do not have comorbidities, single pregnant women, pregnant women who have books MCH and pregnant women who are willing to be respondents. In addition, researchers used a purposive sampling technique. The number of samples used for this study was 100 third-trimester pregnant women with anemia. The instrument used for this research is a questionnaire. The variables in this study were divided into 2, namely: The dependent variable used in this study was the incidence of LBW. The independent variables are knowledge, motivation, attitudes, frequency of ANC, family support, and the role of health workers. Then it is measured simultaneously with the dependent variable, namely the compliance of pregnant women in consuming Fe tablets. The data used in this research is primary data. To test the research hypothesis, researchers used statistical analysis, namely the chi-square test with SPSS version 22.0.
This research has received ethical approval from the health research ethics committee of the Faculty of Medicine and Health, University of Muhammadiyah Jakarta with number: 099/KE/FKK-UMJ/IV/2021. Informed consent was confirmed by the study participants. Confidentiality is maintained throughout the study by excluding personal identifiers from the data collection forms. During data collection, pregnant women were also given priority during the data collection period. The author confirms that all methods are carried out following the relevant guidelines and regulations. Based on Table 1, illustrates that out of 100 respondents, the majority of respondents based on age were in the age range of 20-35 years, namely 89 people (89.0%). According to occupation, it was found that the majority of mothers is housewife as many as 77 people (77.0%). It was found that the majority of respondents with multipara parity were 60 respondents with a percentage of 60.0%. The majority of compliance of third-trimester anemic pregnant women complied with consuming Fe tablets 59.0%. The majority of knowledge of third-trimester anemic pregnant women is a lack of knowledge in consuming Fe tablets 57.0%. The majority of pregnant women with anemia in the third trimester are motivated to take Fe tablets with a preset level of 55.0%. The majority of pregnant women with anemia in the third trimester are good at consuming Fe tablets, with a preset of 86.0%. The majority of ANC frequency of thirdtrimester anemic pregnant women is a complete ANC Frequency of 91.0%. The majority of family support for thirdtrimester anemic pregnant women is good in supporting pregnant women to consume Fe tablets 81.0%. Most of the role of health workers in supporting pregnant women to consume Fe tablets is 58.0%.

RESULTS AND DISCUSSION
Based on Table 2, shows the results of the analysis of the relationship between knowledge and adherence to Fe tablet consumption in anemic pregnant women in the third trimester, it was found that there were 33 (33.0%) pregnant women who lacked knowledge had less compliance to consuming Fe tablets. Meanwhile, there were 8 (8.0%) pregnant women with good knowledge but poor compliance in consuming Fe tablets. The Chi-square test obtained a pvalue of 0.000, so the conclusion is that there is a significant relationship between knowledge and compliance of pregnant women in consuming Fe tablets. With an OR value of 6.016, it indicates that pregnant women with less understanding are 6 times more likely to not consume Fe tablets.
The results of the analysis of the relationship between maternal motivation and adherence to the consumption of Fe tablets in third-trimester pregnant women found that there were 27 (27.0%) pregnant women with less motivation had less adherence to consuming Fe tablets. Meanwhile, there were 14 (14.0%) pregnant women with good motivation but poor compliance to consuming Fe tablets. The results of the chi-square test obtained a value of p = 0.000, so the conclusion was that there was a significant relationship between motivation and compliance of pregnant women in consuming Fe tablets. With OR = 4.393, mothers with less motivation are 4.4 times at risk for not complying with consuming Fe tablets.
Analysis of the relationship between maternal attitudes towards compliance to consumption of Fe tablets in thirdtrimester anemic pregnant women found that there were 38 (38.0%) pregnant women with less attitude had less adherence to consuming Fe tablets. While there were 3 (3.0%) pregnant women with good attitudes but poor compliance in consuming Fe tablets. The results of the chisquare test obtained a p-value of 0.000, so the conclusion is that there is a significant relationship between attitudes and compliance of pregnant women in consuming Fe tablets. With OR = 31.294, it means that mothers with less risky attitudes are 31 times less compliant in taking Fe tablets.
The results of the analysis of the relationship between ANC frequency and compliance to consumption of Fe tablets in third-trimester anemic pregnant women showed that 28 (28.0%) pregnant women with less or incomplete ANC frequency had poor adherence to consuming Fe tablets. While there were 13 (13.0%) pregnant women with complete ANC frequency but poor adherence in consuming Fe tablets. The results of the chi-square test obtained a p-value of 0.011, so the conclusion is that there is a significant relationship between ANC frequency and compliance of pregnant women in consuming Fe tablets. With OR = 2.929, it means that mothers with less frequency of ANC are 2 times at risk for non-adherence in taking Fe tablets.
The results of the analysis of the relationship between the role of health workers on compliance to consumption of Fe tablets in third-trimester anemic pregnant women, as many as 26 (26.0%) pregnant women with the role of health workers had less compliance in consuming Fe tablets. Meanwhile, there were 15 (15.0%) pregnant women with a good health worker role but poor adherence to consuming Fe tablets. The Chi-square test yields a p-value of 0.000, so the conclusion is that there is a significant relationship between the role of health workers and the adherence of pregnant women to consuming Fe tablets. With an OR = 4.658, it indicates that mothers with less risky health worker roles are 3 times more likely to not comply with consuming Fe tablets.
Analysis of the relationship of family support to adherence to consumption of Fe tablets in third-trimester anemic pregnant women, as many as 24 (24.0%) pregnant women with less family support had less compliance in consuming Fe tablets. Meanwhile, there were 17 (17.0%) pregnant women with good family support but poor compliance in taking Fe tablets. The results of the chi-square test obtained a p-value of 0.002, so the conclusion is that there is a significant relationship between family support and compliance of pregnant women in consuming Fe tablets. With OR = 3.794, it means that mothers with less family support have 3 times the risk of disobedience in taking Fe tablets.
The results of the analysis of the relationship between the role of health workers on adherence to consumption of Fe tablets in third-trimester anemic pregnant women, as many as 26 (26.0%) pregnant women with the role of health workers had less compliance in consuming Fe tablets. However, there were 15 (15.0%) pregnant women with a good role as health workers but their adherence was lacking in taking Fe tablets. The Chi-square test yields a p-value of 0.000, so the conclusion is that there is a significant relationship between the role of health workers and the adherence of pregnant women to consuming Fe tablets. With an OR = 4.658, it indicates that mothers with less risky health worker roles are 3 times more likely to not adhere to consuming Fe tablets.

Knowledge and Compliance with Consumption of Fe Tablets in Pregnant Women with Anemia in Trimester III
According to Notoatmodjo (2015), knowledge is the result of knowing, which occurs after someone senses a certain object. Knowledge will increase pregnant women's adherence to iron tablets (Subarda et al., 2011).
Mother's knowledge has a significant relationship with pregnant women's compliance at the Pasar Kemis Community Health Center, Tangerang Regency. This is in line with Misriani's research (2018) which was conducted on pregnant women at the Hamparan Perak Community Health Center in Deli Serdang Regency, which showed that there was a significant relationship between mothers' knowledge and adherence to taking Fe tablets.

Motivation and Compliance with Consumption of Fe Tablets in Pregnant Women with Anemia in Trimester III
Motivation in general is the encouragement or reason that becomes the basis for someone's desire to achieve something to achieve a goal. Motivation can also be said as something that arouses someone's encouragement or enthusiasm to do something (Winardi, 2012).
Maternal motivation has a significant relationship with the compliance of pregnant women at the Pasar Kemis Community Health Center, Tangerang Regency. This research is following research conducted by Yunita et al (2018) in the working area of the Tirtajaya Community Health Center, Bajuin District, and Yanti et al (2022) at the Blahbatuh Community Health Center which shows that there is a significant relationship between maternal motivation and compliance to Fe tablet consumption.

Attitudes and Compliance with Consumption of Fe Tablets in Pregnant Women with Anemia in Trimester III
The Theory of Attitudes and Behavior put forward by Triandis (1980) says that individual behavior is determined by attitudes related to what a person wants to do, including beliefs about the consequences of behavior, their behavior towards social rules, perceptions about them, and habits related of what is usually done. If the situation does not permit, the behavior is less likely to occur.
This study shows that there is a relationship between the mother's attitude towards compliance with the consumption of Fe tablets in pregnant women at the Pasar Kemis Community Health Center, Tangerang Regency. In line with Misriani's research (2018) which was conducted on pregnant women at the Hamparan Perak Community Health Center, Deli Serdang Regency. There is a significant relationship between the mother's attitude and consuming iron at the Hamparan Perak Community Health Center, Deli Serdang Regency.

Frequency of ANC and Compliance with Consumption of Fe Tablets in Trimester III Anemia Pregnant Women
According to Prawirohardjo (2016), antenatal care is a preventive effort in the obstetric health service system designed to maximize maternal and neonatal outcomes through a series of routine monitoring actions during pregnancy.
The results showed that there was a relationship between the frequency of ANC examinations and the compliance of pregnant women at the Pasar Kemis Community Health Center, Tangerang Regency. This study is following Ahmad and Kushermanto's research (2016) which was conducted on pregnant women at the Bojong Gede Community Health Center, Bogor Regency, which stated that there was a significant relationship between the frequency of ANC and compliance in consuming Fe tablets by pregnant women at the Bojong Gede Community Health Center, Bogor Regency.

Family Support and Compliance with Consumption of Fe Tablets in Pregnant Women with Anemia in Trimester III
Support is an action-oriented and accepting attitude towards group members. Family members are considered an inseparable component of the family environment. Family members and co-workers believe that a supportive individual is always willing to help when needed (Friedman, 2010).
The role of health workers is significantly related to the compliance of pregnant women at the Pasar Kemis Community Health Center, Tangerang Regency. This research is following research conducted on pregnant women at the Sikumana Community Health Center, Kupang City, showing that there is a significant relationship between attitudes, support from health workers, and family support with compliance of pregnant women in taking iron tablets (Dhone et al., 2022).

The Role of Health Workers and Compliance with Consumption of Fe Tablets in Pregnant Women with Anemia in Trimester III
According to Azwar (2013) as a client, communicator, facilitator, motivator, and advisor, the role of health workers is in maintaining and improving health. Health workers are expected to play these five roles in providing health services, especially in providing and supervising pregnant women to take iron tablets to reduce the incidence of anemia.
The results showed that there was a relationship between family support and compliance of pregnant women at Pasar Kemis Community Health Center, Tangerang Regency. This research is following Dara's research (2019) which was conducted on pregnant women at the Muaro Kiawai Community Health Center, West Pasaman Regency, showing that there is a significant relationship between attitudes, support from health workers and family support with pregnant women's compliance in consuming iron tablets at Muaro Kiawai Community Health Center, Pasaman Regency West.

LIMITATIONS OF THE STUDY
The limitation of this study is that pregnant women's adherence to taking Fe tablets was not measured through direct observation, but through filling out a questionnaire by pregnant women. This allows for recall bias, that is, the information provided relies on the mother's memory so that it does not give a real picture. To anticipate this, the interview process was carried out in comfortable conditions and sufficient time duration so that the mother could try to remember well about the Fe tablets she had consumed during her pregnancy.

CONCLUSIONS AND SUGGESTIONS
There is still a lack of compliance of pregnant women in consuming iron tablets at Pasar Kemis Community Health Center, Tangerang Regency. It is hoped that health workers will be more active, including posyandu cadres, in providing health information to pregnant women about the importance of tablets during pregnancy. In addition, the Community Health Center can provide pocketbooks or make posters, and banners containing short and interesting words in the form of health information, especially nutrition awareness for pregnant women.