Introduction

The Republic of Indonesia is located in Southern Asia and is situated between the Indian Ocean and the Pacific Ocean. The flora is very rich, and this natural resource has contributed to better living conditions for many Indonesians. About 6000 species of plants are known to be used directly or indirectly by the people. Agriculture remains the most important sector of the country's economy (Department of Information, 1996). Because of the various ethnic groups and cultures, the Indonesian diet consists of food from all parts of the archipelago (Ministry of Health, 1995). Rice is consumed by most Indonesians (Sumarno et al, 1997; Ministry of Health & WHO, 2000).

A well-nourished woman who gains 12.5 kg and gives birth to an infant weighing 3.5 kg is estimated to require 71 700 kcal in addition to her non-pregnant energy balance. This extra requirement is needed by the mother to cover her increased basal metabolic rate and the synthesis of new tissue including foetal tissue, maternal fat deposits and maintenance (Prentice et al, 1993). The recommended extra protein intake is 1.3, 6.1 and 10.7 g/day, respectively, for each trimester (National Research Council, 1989). These additional requirements must be met primarily through increased food consumption. Further, an extra 30 mg of ferrous iron supplementation per day during pregnancy is recommended starting at about week 12 of gestation (Institute of Medicine, 1990).

Even though a multitude of nutritious foods exist in Indonesia, protein energy malnutrition (PEM), anaemia, iodine deficiency and vitamin A deficiency problems remain, especially among pregnant women (Kodyat et al, 1996). For example, in a study conducted in Bogor, Indramayu, Purwakarta, Gunungkidul and Madura Districts, mean maternal energy (1500 kcal/day) and protein intake during pregnancy were low in all these districts (Soekirman et al, 1992; Kardjati et al, 1994). This constitutes a serious public health problem in Indonesia as well as in many other developing countries (Huddle et al, 1998).

Further, National Survey of Social Economy data from 1999 on the nutritional status of reproductive-aged women showed that 24.2% had chronic energy deficiency (Ministry of Health & WHO, 2000). A study in West Java in 1992 reported that 43.5% of women had low serum ferritin levels, no women were vitamin A deficient, but 10% had marginal vitamin A status (Suharno et al, 1993). Iodine deficiency disorder (IDD) is one of the biggest nutritional problems in Indonesia (Ministry of Health & WHO, 2000). To eliminate malnutrition in Indonesia, nutrition policy programmes and activities have been developed in stages. In the long term, the most appropriate strategies for reducing malnutrition among pregnant women and children include improvement in dietary intake and fortification of foods (Kodyat et al, 1996). In addition, supplementing pregnant women with iron tablets on a periodic basis is the recommended short-term solution to iron deficiency (Ministry of Health & WHO, 2000).

In mid-1997 East Asia was faced by an economic crisis. Thailand, Korea and Indonesia were the first to suffer the impact of this crisis (World Bank, 2000). In Indonesia, due to sharp increases in food prices, people were unable to buy enough food (Suara Merdeka, 1998; FAO/WFP Special Report, 2000). However, the extent to which the population's health was affected, and whether certain groups were particularly vulnerable, were unknown. This paper evaluates the adequacy of nutrient intake before the crisis in comparison with the Indonesian Estimated Average Requirements (EARs) and investigates the short-term effect of economic crisis on nutrient intake and iron status of pregnant women in Central Java, Indonesia, before and during the crisis.

Conceptual model

As a conceptual model we chose the entitlement approach developed by Sen (1997), which suggests that starvation is not a consequence of a physical scarcity of food. The theory concentrates instead on the ability of people to command food. This theory was used to analyse which subgroups of pregnant Indonesian women had a higher risk of developing malnutrition during the economic crisis. This is further described in another article (Hartini et al, 2002), where we evaluated the effect of the economic crisis on the energy intake of these same women.

Economic crisis causes an increase in the price of food and other basic necessities as well as an increase in the cost of living, along with an increased unemployment rate. In Indonesia, although food and basic necessities were available in the market during the economic crisis, the poor were probably unable to buy enough food. In contrast, the rich were able to afford both food and basic necessities. A high proportion of rural pregnant women own or rent rice fields and thus probably had better opportunities to cope with the crisis. Hence, vulnerable groups in terms of food intake would be expected among landless agricultural labourers and those working in industrial and service jobs, whereas the people with access to land were expected to be in a better position as they could consume their cultivated food directly. Alternatively, due to the increase in food prices, they could increase their income through the sale of crops. Local and national authorities reacted in different ways to the possible effect the crisis had on health. One intervention implemented by the Indonesian Government was a food programme for the poorest people that was called the social safety net. In this programme, the Government sold cheap rice to poor households (National Development Planning Agency, 2000).

Based on Sen's entitlement approach, we classified the pregnant Indonesian women into four groups: first, rich pregnant women who obviously had greater possibilities to handle the crisis by redistributing their income; second, urban poor women; and third, rural landless women. Both the second and third groups worked for wages and were at high risk of becoming malnourished. The fourth group comprised rural poor women with access to rice fields, and these women had more direct access to basic foods such as rice.

Methods

Study site and sample

The site used for the study was Purworejo District, Central Java, located 60 km west of Yogyakarta Province. According to the 1998 census, Purworejo District had a population of 757 000 persons (372 000 men and 385 000 women, Figure 1). Eighty-seven percent of the people lived in rural areas, and 53% were farmers. The area used for rice fields totalled 30 600 hectares and the yearly production of rice was 283 400 tons (Development and Planning Board of District Level & Central Bureau of Statistics, 1999). Using data from the 1990 census, a crude death rate of 9.9 per 1000 was estimated. The infant mortality rate has shown a declining pattern in the past 5 y, and the current estimates are 52 per 1000 births (Wilopo, 2001). Infectious diseases still dominate the health condition of the population in Purworejo. The prevalence of PEM in children under 5 y of age is 5.43% (Purworejo District Health Office, 2000).

Figure 1.

Map of Purworejo District, Central Java Province, Indonesia.

Full figure and legend (69K)

Within a surveillance system conducted by Community Health and Nutrition Research Laboratories (CHN-RL), a sample of 13 094 women of reproductive age were followed over time. Monthly monitoring of new pregnancies took place between 1996 and 1998. The detection of pregnancy was based on recording the date of the last menstrual period (LMP) and this was confirmed with a -HCG pregnancy kit in the field. Gestational age was calculated from date of data collection minus the date of LMP. For cultural reasons, only married pregnant women were registered. In total, 846 newly pregnant women participated in a longitudinal study of maternal depletion that was part of a larger randomized trial of 2173 women on vitamin A and zinc supplementation during pregnancy. The aim of this study was to evaluate the interactive effects of pre-pregnant nutritional status and reproduction on women's energy stores during one full reproductive cycle. This study included a detailed evaluation of dietary intake during pregnancy and lactation. These data are here also used to evaluate the effect of the crisis, an opportunity that had not been planned for originally. However, 232 pregnant women were enrolled before the dietary study was implemented, 121 pregnant women were lost at the peak of the economic crisis because of difficulties in the field, 10 women were too shy, mentally ill or too sick to be interviewed, 11 refused, 12 had incomplete information, and 10 were lost for other reasons. In total, 450 women were interviewed in their homes by 22 trained female interviewers about dietary intake. Written informed consent was obtained from all women. The study was approved by the ethics committees of the Medical Faculties of Umeå University, Umeå, Sweden, and Gadjah Mada University, Yogyakarta, Indonesia.

Dietary intake

A structured 24 h recall questionnaire was used to estimate the dietary intake of individual women. There were six repeated recalls during the second trimester of pregnancy, spaced over the 5 days of the Javanese calendar (5 days within 1 week). Household measurements (eg plate, teaspoon, bowl, glass) and food models (eg banana, fish, meat, tomato, bread) were used to estimate the portion sizes. The interviewers collected the detailed descriptions of all foods, beverages, vitamin and mineral supplements consumed between 00:00 a.m. and 24:00 p.m. and recorded the cooking methods.

A computerized data analysis system (Inafood) was used to convert food intake to nutrient intake. The system is based on reported intake including portion sizes, food recipes and food composition tables. This programme was developed by Gadjah Mada University and the Nutrition Academy, Yogyakarta. The Indonesian nutrient composition tables were used in most cases (Mahmud et al, 1990; Briawan & Hardiansyah, 1990; Mukrie et al, 1995). However, in a few cases these were supplemented with nutrient composition tables from other countries (Siong et al, 1988). Vitamin A values were predominantly taken from the food composition table in de Pee and Bloom (1999). We used the standard conversion factor of 1 g retinol=3.33 IU retinol (Booth et al, 1997). We have previously shown that two or three repetitions of 24 h recalls are sufficient to measure most nutrients in our study (Persson et al, 2001). Further, the ratio of energy intake of pregnant women to basal metabolic rate was 1.55 and the proportion of under-reporters 16.2% (Winkvist et al, 2001). This indicates that underestimation was a minor problem in our study.

Blood samples

Nurses collected blood samples once during the second trimester. These were centrifuged in a field laboratory and analysed at the Pathology Department Laboratory, Faculty of Medicine, Gadjah Mada University. Serum ferritin was assessed by the IMX ferritin assay (Abbott Laboratories, IL, USA). Low iron stores was defined as serum ferritin <12 g/l (Cook & Skikne, 1989). Interviewers recorded any ingested iron supplements from the health care providers or purchased locally as well as symptoms of pregnancy morbidity during monthly visits at home.

Socio-economic and other data

Demographic and socio-economic information as well as information on ownership of rice fields was collected yearly during home visits by trained CHN-RL interviewers using pre-coded questionnaires. In West Java a motorbike may indicate relative wealth (Achadi et al, 1995). Also in our study area, prices were high for motorbikes and cars. Thus, a dichotomous variable indicating ownership of a car and/or a motorbike was used as a measure of wealth. 'Rich' was defined by ownership of a car or motorbike irrespective of whether the pregnant women lived in a rural or urban area and irrespective of access to rice fields. 'Urban poor' was defined as living in an urban area without fulfilling the criterion for 'rich'. 'Rural poor' was defined as living in a rural area without fulfilling the criterion for 'rich'. In the last step, 'rural poor' was divided according to access to rice fields.

Time periods in the crisis

There are nine essential commodities classified by the Indonesian government, ie rice, cooking oil, sugar, small salty fish, salt, kerosene, block soap, polyester cloth material and cotton cloth material. Unlike prices of rice, cooking oil and sugar, the prices of the others six essential commodities did not increase sharply. Thus, based on changes in the price of rice, cooking oil and sugar, and the value of the Indonesian rupiah, we defined three periods of time in order to investigate the course of the crisis. The first period is labelled 'before crisis' (up to August 1997), the second 'transition' (September to November 1997) when the crisis emerged, and the third 'during crisis' (December 1997 and onwards). Further, it was during the crisis that national food support programmes were organized, and hence possible signs of recovery could be expected only during the third period. The 450 women in the sample were grouped into these three time periods based on the date of data collection for each woman.

Statistical analysis

Mean individual intake of protein, fat, carbohydrates, calcium and iron was calculated from the repeated recalls during the second trimester of all women. These data were analysed cross-sectionally in relation to the time of data collection. Ninety-two percent of the women had six recalls, 5% had only five recalls, 1% had only four recalls and 2% had only three recalls. In total, only seven women consumed vitamin and mineral supplements obtained within the regular health care system or purchased locally. For these women, the supplements contributed 26% of their calcium intake and 21% of their iron intake. As the inclusion of these intakes led to large standard deviations around the group means, the main analyses of effect of the crisis excludes the intake of vitamin and mineral supplements. However, where the intake of supplements affect any conclusions, this is indicated in the text. Because the 450 women were a sub-sample of the 2173 women participating in a vitamin A and zinc supplementation trial, some of course also received such supplements. However, because this paper evaluates the natural diet of the 450 women, the vitamin A and zinc supplements are not included in the analysis.

Nutrient intakes of the 450 pregnant women were analysed based on the date of the interview in relation to the three different phases. In the second trimester, 90% of the pregnant women had six recalls. This means that the data from the second trimester were most complete. During the first trimester some women were detected late and during the third trimester, and some women had already delivered when the interviewers visited the women at home. During the second trimester, 235 pregnant women were interviewed 'before crisis', 104 during 'transition' and 111 'during crisis'. Further, to present the changes over time in greater detail, the women were also categorized into seven time periods, each representing a 3 month period of data collection (eg November 1997–January 1998).

The Estimated Average Requirement (EAR) is a nutrient intake value that is estimated to meet the requirement of half the healthy individuals in a life stage and gender group. The EAR is useful for evaluating the adequacy of nutrient intakes of population groups (National Academy of Sciences, 1997). Nutrient intakes before the crisis were compared with the Indonesian EAR for pregnant women. EAR correspond to 80% of Indonesian RDA (Muhilal et al, 1998). The Indonesian RDA are coordinated with ASEAN RDA (Muhilal, 2002). Nutrient intake per 1000 kcal or per 4187 kJ (nutrient density) was also calculated (Hansen & Wyse, 1980; Willet et al, 1997). Vitamin A intake and serum ferritin concentration did not exhibit a normal distribution, but were skewed to the right. Vitamin A intake and serum ferritin concentration are therefore presented as median values. Differences in mean nutrient intake between the three time periods were analysed for the four socio-economic sub-groups using Student's t-test or ANOVA. For vitamin A and serum ferritin concentration, the Kruskal–Wallis test and the Mann–Whitney U-test were used. Differences were considered statistically significant when the P-value was less than 0.05.

Potential confounding effects of maternal age, education and household size on nutrient intake by different subgroups were evaluated in multivariate analysis. No such effects were found and therefore analyses without adjustment for these factors are presented.

Statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS version 7.5).

Results

Characteristics of the subjects

The women in the sample (n=450) ranged in age from 16 to 47 y, with a mean age of 28.35.3 y, and a mean height of 150.35.0 cm. The mean gestational age at delivery was 37.94.6 weeks and birth weight was 3198.1488.7 g. The mean body weight was 50.27.3 kg. Overall, 56% had completed primary school. The majority of the working women (37.3%) were employed in the area of agriculture and 40% were housewives. Two-thirds (67%) of the women had access to rice fields. Among these, 144 (32%) were owners of rice fields, 8% were supported by their parents, and 14% rented their rice fields. Only five (1%) of the households owned a car and 74 (16%) owned a motor-bike.

The sample of 450 women in the dietary study did not differ significantly from the 13 094 women of reproductive age in the surveillance sample with respect to occupation, education and radio as well as television ownership. The mean age and height of the 13 094 women were 30.4+9.7 y and 149.1+5.1 cm (Nurdiati et al, 1998), respectively; both of which differed from the study sample (P<0.05). The differences were not large, but they were significant, probably because of the large size of the former sample. Thus, in general the dietary sample represents women of childbearing age in Purworejo District.

In order to compare the three samples in the different time periods, we evaluated the variables 'age' and 'height', which are not affected by the crisis. There were no significant differences among the three time periods, 'before', 'transition', and 'during crisis', in terms of age and height in any of the socio-economic groups. Thus these data suggest that the women in the three time periods were sampled without a bias that could affect our study objectives.

Nutrient intake

Average nutrient intakes in the period before the crisis are shown in Table 1. For all of the nutrients studied, mean intakes were lower than the Indonesian EARs. More than 40% of the pregnant women had inadequate protein and vitamin A intakes, and all women had inadequate calcium and iron intakes before the crisis. However, when intake of vitamin and mineral supplements were included for those 7 women who used them, mean iron intake equalled 17 (8) mg and mean calcium intake equalled 466 (304) mg.

Table 1 - Average nutrient intake per day before the crisis and percentage of pregnant Indonesian women with a nutrient intake below Indonesian EARs (n=235).

Full table (31K)

For the sample as a whole before the crisis, protein contributed to around 10% of the total energy intake, fat contributed to 21% and carbohydrates to 69%. During the crisis period the contributions of protein, fat and carbohydrate to the total energy intake were 10, 19 and 71%, respectively.

Before the crisis there was a higher intake of protein, fat, calcium and iron among urban as compared to rural pregnant women; this was significant (Table 2, second and fifth columns). Likewise, there was a significantly different intake 'before crisis' for these same nutrients for the different socio-economic groups, with higher values for rich and urban poor subgroups compared with rural, poor, access to rice fields and rural, poor, landless subgroups (P-values 0.00–0.04). During the transition period (Table 2, third and sixth columns) the urban poor experienced a significant decrease in their intake of protein, fat, carbohydrate and calcium compared with 'before crisis' (P-values 0.01–0.04).

Table 2 - Average nutrient intake of pregnant women according to socio-demographic characteristics and time of data collection in relation to the economic crisis.

Full table (71K)

During the crisis period (Table 2, fourth and seventh columns), rural pregnant women had a higher nutrient intake than urban pregnant women. Rich women experienced a significant decrease in fat 'during crisis', compared with 'before crisis' (P<0.05). Figure 2 presents nutrient intakes according to time of data collection and socio-economic group. A tendency toward a decrease in selected nutrients was observed in rich and urban poor women.

Figure 2.

Nutrient intake of pregnant women according to socio-economic groups and time of data collection.

Full figure and legend (42K)

Nutrient density

Before the crisis period rich women, in comparison with other socio-economic groups, were found to have the highest protein and fat densities (Table 3, P<0.05). During transition, a significant increase in protein density was observed for the rural, poor, access to rice field subgroup (difference between 'before crisis' and 'transition', P<0.01). In contrast, a significant decrease in protein and calcium densities was seen for the rural, poor, landless subgroup (difference between 'before crisis' and 'transition', P<0.05). Negative changes in fat density during crisis were experienced by all socio-economic groups, especially the rich and the rural, poor, access to rice field subgroups (difference between 'before crisis' and 'during crisis', P<0.01). Figure 3 illustrates that the density of most nutrients tended to decrease for the rich (except carbohydrate density), whereas nutrient densities for the rural, poor, and access to rice fields subgroup tended to remain stable.

Figure 3.

Nutrients density by pregnant women according to socio-economic groups and time of data collection.

Full figure and legend (44K)

Table 3 - Average nutrient density of pregnant women according to socio-demographic characteristics and time of data collection in relation to the economic crisis.

Full table (69K)

Iron status

The median serum ferritin concentration was 13.5 (8.1–21.4) g/l in the total sample. The total prevalence of low ferritin stores was 42%. In the period before the crisis the mean serum ferritin concentration was lowest for the urban poor (Table 4). During the 'transition' period, a significant decrease in serum ferritin concentration was experienced by the rural, poor, landless women (P<0.01). During the crisis, the serum ferritin concentration of the urban poor and the rural, poor, landless women decreased in relation to the serum ferritin concentration 'before crisis' (difference between 'before crisis' and 'during crisis' for the urban poor, P<0.05, and for the rural, poor, landless P>0.05). The rich experienced an increase in serum ferritin concentration during the crisis (P<0.05 for 'before crisis' vs 'during crisis').

Table 4 - Median serum ferritin concentration of pregnant women according to socio-demographic characteristic and time of data collection in relation to the economic crisis.

Full table (40K)

The statistical analyses of serum ferritin were adjusted for infection, iron tablet consumption, vitamin A and zinc supplementation, and gestational age. Serum ferritin exhibited a significant positive association with iron tablet consumption (P=0.04) and a non-significant positive association with maternal age, gestational age, BMI and vitamin A and zinc supplementation.

Discussion

The study was carried out in both urban and rural areas. Although the study design was cross-sectional, the results we report here demonstrate a significant short-term effect of the economic crisis on the nutrient intake and nutritional status of pregnant women in Indonesia.

The adequacy of nutrient intakes

The study revealed that more than 40% of the pregnant women were already at risk of inadequate intake of protein, vitamin A, calcium and iron before the crisis. Several previous reports also suggest that the usual dietary intake of many nutrients is inadequate for meeting the needs of pregnant Indonesian women (Kardjati et al, 1994; Soekirman et al, 1992; Latief et al, 1997).

The entire nutrient intake of more than 40% of the pregnant women was inadequate. This means that more than 40% of the pregnant women were at high risk of developing nutrient deficiency. Although foods are abundant in Indonesia, nutrient deficiency (chronic energy deficiency, vitamin A deficiency, anaemia, iodine deficiency disorders) remains a serious public health problem. The Government should not only continue promoting nutritious natural food, increase food production, distribute nutrient supplements to vulnerable groups and fortify some foods with nutrients, but it should also implement the social and economic measures necessary to achieve national and economic stability.

Nutrient intake

Protein intake among the pregnant Indonesian women in the present study was similar to that reported in pregnant Southern Malawian women (Huddle et al, 1998) and in a previous study of pregnant women in East Java, Indonesia (Kardjati et al, 1994). The mean consumption of carbohydrates 'before crisis' among the pregnant Indonesian women in the present study was higher than that for pregnant women in developing countries such as Mexico (Hunt et al, 1987), Malawi (Huddle et al, 1998) and Brazil (Vitolo et al, 1997).

Calcium intake in the present Indonesian study was lower than in pregnant women in other developing countries (Huddle et al, 1998; Prentice et al, 1993; Rad et al, 1998; Hunt et al, 1987; Vitolo et al, 1997). Iron intake was similar to that observed in the Malawian study (Gibson & Huddle, 1998), but lower than in the South Indian study (Sundararaj & Pereira, 1973). Overall, the daily intake of the nutrients studied was higher than reported in a previous study in East Java, Indonesia (Kardjati et al, 1994; Latief et al, 1997). In our study, vitamin and mineral supplementation contributed 26% of the calcium intake and 21% of the iron intake for those few women who consumed supplements. Overall, these studies indicate the importance of nutrient supplementation and/or improved diet for pregnant women in Indonesia as well as in other developing countries (Ladipo, 2000).

Similar conclusions have also been reached in other developing countries. Fifty percent or more of the pregnant women in Mexico were reported to have calcium, iron and vitamin A intakes of less than two-thirds of the RDAs (Hunt et al, 1987). Whiteford (1993) reported that 24% of pregnant Dominican women were at risk of protein deficiency. Even before the most recent economic crisis, 90% of the Dominican population consumed less than the recommended minimum of 60 g of protein per day. The nutrient intake of pregnant women in Haryana State, India, indicated an adequacy with respect to all nutrients except for fat, thiamine, riboflavin and niacin (Panwar and Punia, 1998). In our study, before the crisis the rich women had, as expected, the highest total intake of most selected nutrients as well as the highest nutrient density compared to that of the other sub groups. The urban poor had the highest carbohydrate, Vitamin A, calcium and iron intakes as well as densities. Perhaps there was a greater variety of food in the urban areas (Warta kesehatan perkotaan, 1992).

As the crisis was emerging, the urban poor experienced a significantly decreased intake of protein, fat and calcium and a close to significantly decreased intake of iron. The rural, poor, landless women also experienced lower intakes of iron during transition, but these changes were not significant. In contrast, nutrient intakes remained stable for the rich and the rural poor with access to rice fields. In the transition period the rural, poor, landless women predominantly experienced poorer protein and calcium density, perhaps indicating less milk intake. However, nutrient densities increased among the rural, poor, access to rice field subgroup.

Few tendencies toward decreased nutrient intake or nutrient density during the crisis were visible in our data, except that rich women experienced a significant decrease in fat intake, and both the rich and the rural, poor, access to rice fields subgroups experienced decreased fat density concurrent with increased carbohydrate density. The latter subgroup also experienced increased protein density, perhaps indicating a larger consumption of rice from their own fields. We have previously reported a higher rice consumption for this group, compared to the other subgroups, during the crisis (Hartini et al, 2002).

There was a tendency towards an increased intake of protein, fat, carbohydrate, calcium, vitamin A and iron for the two rural poor groups (rural, poor, access to rice fields and rural, poor, landless); P-values for change between 'before crisis' and 'during crisis' ranged from 0.09 to 0.95, perhaps indicating the existence of food support from relatives or neighbours. Densities of protein, fat, calcium and iron in the urban poor decreased during 'transition' and 'during crisis', although the differences were not significant.

This is supported by qualitative data collected in area of the study in 1999 (to be reported in a separate publication). Our results are supported by those of others. A study by the Ministry of Health in Indonesia (Latief et al, 2000) reported that mean intakes of carbohydrates and protein by Indonesians were not influenced by the economic crisis; on the other hand mean intakes of fat, vitamins (vitamin A, C and B₁) and minerals (calcium and iron) tended to decrease during the crisis.

During the 'crisis', a decrease in the contribution of fat and an increase in the contribution of carbohydrates to total energy intake was expected in all sub groups. Carbohydrates increase satiation and satiety whereas fat has a weaker effect on satiety (Blundell et al, l994, 1996; Rolls & Hammer, 1995). Perhaps the pregnant women in our study consumed carbohydrate-rich foods because these foods were cheaper than other foods and contributed better to satiety. The impact of eating carbohydrate rich food on cardiovascular disease and metabolism is unknown (Schneeman, 2001). Compared to the energy and protein intake of the Indonesian 'before crisis' and 'during crisis' (Kodyat et al, 1996; Latief et al, 2000; Ministry of Health and WHO, 2000), it appears that pregnant women's energy and protein intake 'before crisis' and 'during crisis' were lower. Although extra nutrient intake are needed by women during pregnancy, their nutrient intakes were insufficient for their needs.

Iron status

The rural poor with access to rice fields also experienced an increase in their serum ferritin concentration during the crisis. The serum ferritin concentration of the urban poor and the rural, poor, landless subgroups decreased 'during crisis'. The urban poor group also experienced lower iron intake during 'transition' and 'during crisis'. After controlling for vitamin A and zinc supplementation, number of iron tablets consumed, gestational age, serum ferritin and iron intake was still negatively associated to time period. Although our data showed that low iron intake was followed by a decreasing serum ferritin, except among the rural, poor landless women, there was a negatively associated effect on serum ferritin. Perhaps the adequacy of dietary iron depends on its bioavailability, and serum ferritin is influenced not only by iron intake but also by other variables such as parasitic infection, bleeding, and malaria.

However, the nutritional status of the vulnerable groups tended to be affected by the crisis. The results of our study are similar to those of the Helen Keller International study (HKI). In 1998 and 1999, the HKI study in Central Java, Surabaya and Jakarta reported an increased prevalence of anaemia, an indicator of iron deficiency among women of reproductive age, compared to data from June 1996 (Helen Keller International, 1999).

Since 1974, Indonesia has a programme of iron supplementation for pregnant women (Ministry of Health, 1998). Although pregnant women receive the iron supplements free of charge, we found that only seven women used any supplements. When included in the analyses, the vitamin and mineral supplements increased calcium and iron intake of these pregnant women to meet the needs of these nutrients. There is no doubt that supplementation is required for pregnant women. Several efforts are underway to improve the coverage and compliance of the iron supplementation programme (Yip & Ramakrishnan, 2002). The coverage of pregnant mothers who received their Third round distribution has increased from 42.7% (1994) to 64.9% (1998) (Ministry of Health and WHO, 2000). In our study, the coverage of pregnant women who received iron supplements was 84.7%.

Vulnerable groups

Further, our results are consistent with the theory developed by Sen (1997), in that the negative effect of the emerging economic crisis was most evident among the vulnerable groups: the urban poor and the rural, poor, landless women. In contrast, the pregnant poor women with access to rice fields are dependent on agricultural activities for their income. Because of rising prices for agricultural production, their incomes most likely increased, leading to a higher intake of nutrients. During crisis, the urban population will be at higher risk (Wasito et al, 2001).

In a long-term economic crisis, relatives and neighbours who help the poor may face the same problems in their efforts to fulfil their basic needs, as the prices of basic needs remain high. How long will these relatives and neighbours continue to help by supplying these poorer individuals with food? It is of vital importance to remember that poor people will not survive in the long run if the government does not continuously make serious efforts to alleviate this emerging problem. Although the government has responded to the crisis, the use of the funds and the cost effectiveness of the social safety net should be evaluated and be made more easily understandable.

Conclusions

In conclusion, the results of our study show that pregnant Indonesian women consume an inadequate diet. The high carbohydrate intake is characteristic not only of these pregnant women but also of the Indonesian people in general. Nutrient intakes among the urban poor and the rural, poor, landless subgroups were influenced by the emerging economic crisis. During the crisis the nutrient intakes of these vulnerable groups were higher, probably because of support from relatives and neighbours. This, however, is not sustainable. Thus, pregnant women, especially vulnerable groups, are at risk of developing nutritional deficiencies without food support programmes.

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Acknowledgements

We would like to thank all the women in Purworejo District who participated in the study and the staff of CHN-RL. We would also like to thank the following organisations for funding the project: Sida/SAREC (the Swedish International Development Authority/the Swedish Agency for Research Cooperation in Developing Countries), Mother Care, John Snow Inc., Washington, DC, USA, UNICEF, Jakarta, Indonesia, and STINT (the Swedish Foundation for International Cooperation in Research and Higher Education) and the World Bank through the Community Health and Nutrition Development Project of the Ministry of Health, Indonesia (IBRD Loan no. 3550-IND).