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"Allocation of economic resources for pregnancy care by pregnant women, Salatiga, Central Java, Indonesia"

"Target ambisius Pemerintah Indonesia, seperti tercermin dalam peta jalan Sistem JaminanSosial Nasional, untuk mencakup kepesertaan Jaminan Kesehatan Nasional JKN bagisemua penduduk Indonesia di tahun 2019. Salah satu kendala perbaikan indikatorkesehatan adalah terbatasnya akses pada pelayanan kesehatan. Kepesertaan BidanPraktek Swasta BPS pada program JKN di Kota Salatiga masih kurang, dimana hanya7 BPS 22 yang telah berjejaring dengan BPJS Kesehatan dari 32 BPS yang ada dikota tersebut. Penelitian ini bertujuan untuk mendapatkan faktor yang berhubungandengan keputusan BPS menjadi jejaring BPJS Kesehatan pada program JKN di KotaSalatiga. Desain penelitian kualitatif ini menggunakan informan pada BPS yang sudahmenjadi jejaring dan belum menjadi jejaring. Penelitian dilakukan pada bulan Februarisampai dengan Oktober 2017. Hasil penelitian menunjukkan bahwa keputusan BPSmenjadi jejaring dipengaruhi oleh aspek pengalaman dimana sebagian besar adalahpensiunan bidan di Puskesmas. Sementara BPS bukan jejaring mayoritas masih aktifbekerja di Puskesmas dan tidak mempunyai sisa waktu untuk praktek swasta. Besarnyaimbalan yang didapat perlu disesuaikan serta penyederhanaan alur klaim paling tidakseperti pada era Jaminan Persalinan. BPS belum menjadi jejaring tidak merasa dirugikanbila kunjungan pasien menurun mengingat telah ada tambahan dana jasa pelayanan dariJKN di instansinya bekerja. Perlu ditinjau kembali mekanisme kerjasama antara BPS danBPJS Kesehatan serta upaya sosialisasi dengan tujuan persuasif yang mengajak BPSmenjadi jejaring dalam program JKN.

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Ambitious target of the Indonesian government, as stated in the roadmap of NationalSocial Security System, aims to provide universal coverage to all Indonesians by 2019.One of the main obstacles to improve health development is the limited access to healthservices. Private midwives participants in the JKN program in Salatiga is still insufficient,only 7 out of the 32 private midwives 22 have been included in the BPJS Healthnetwork. This study aims to understand the issues in private midwives participancy inJKN program in Salatiga. Qualitative approach is used with case study using informan ofprivate midewives networked, as well as private midwives that are not yet networked withBPJS Kesehatan. The study was conducted from February to October 2017. The researchindicated that decisions of Private Midwives successfully networked with BPJS Health isheavily influenced by years of experience, where the majority of private midwivesnetworked is are retired. Meanwhile, the non network private midwives are still activelyworking in primary health care, and not time left for private practice. Another aspect isthat the amount of rewards earned is deemed insufficient and the flow of claims is morecomplicated when compared with Jampersal. Private midwives not in the network haveyet to feel the loss with the decrease in patient visits since their offices already receiveadditional funding services from JKN. A review of the mechanism of cooperationbetween private midwives and BPJS Health is necessary, as well as socialization ofbenefits to the private midwives not yet included."

"Prevalensi risiko kurang energi kronis (KEK) pada ibu hamil di Indonesia mengalami peningkatan berdasarkan data Riskesdas tahun 2007 dan 2013. Kondisi ini penting diperhatikan karena kurang energi kronis pada ibu hamil akan memberikan dampak yang buruk tidak hanya pada tubuh ibu namun juga janin yang dikandungnya. Proporsi risiko KEK memiliki sebaran yang berbeda-beda terkait karakteristik ibu hamil, misalnya pekerjaan, pendidikan, dan usia kehamilan. Selain itu, asupan nutrisi tentu menjadi faktor penting yang memengaruhi status nutrisi ibu hamil. Penelitian ini dilakukan untuk mengetahui hubungan antara prevalensi risiko KEK pada ibu hamil di Jakarta dengan pekerjaan, pendidikan, usia kehamilan, dan asupan makronutrien. Potong lintang merupakan desain penelitiannya dengan jumlah subjek sebanyak 56 orang ibu hamil usia 20-35 tahun di Jakarta. Pengukuran lingkar lengan atas (LiLA) digunakan untuk menilai risiko KEK (<23,5cm). Data asupan makronutrien diperoleh dengan menggunakan metode 24-hour food recall. Data pendidikan, pekerjaan, dan usia kehamilan diperoleh dengan menggunakan kuesioner. Hasil penelitian ini menunjukan bahwa prevalensi risiko KEK mencapai 10,7%. Berdasarkan uji fisher tidak menunjukan adanya hubungan yang signifikan antara risiko KEK pada ibu hamil di Jakarta dengan pekerjaan, pendidikan, asupan makronutrien, asipan energy, dan usia kehamilan. Terdapat beberapa faktor yang tidak diteliti pada penelitian ini antara lain usia saat hamil dan aktivitas fisik.

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The prevalence of chronic energy deficiency (CED) on pregnant women in Indonesia have increased based on data Riskesdas 2007 and 2013. This condition is important to note because chronic energy deficiency in pregnant women will have a negative effect for both mother and fetus. The proportion of CED has different based on occupation, education, and gestational age of pregnant women. In addition, nutrition is certainly an important factor affecting the nutritional status of pregnant women.

This study was conducted to determine the relationship between the prevalence of CED in pregnant women in Jakarta and occupation, education, pregnancy / trimester of pregnancy, and macronutrient intake. Is a cross-sectional study design with a number of subjects as much as 56 pregnant women aged 20-35 years in Jakarta.Measurement mid upper arm circumference (MuAC) is used to assess the risk of CED (<23.5 cm). Macronutrient intake data is obtained by using a 24-hour food recall. Data of education, occupation, and trimester of pregnancy obtained using a questionnaire.

These results indicate that the prevalence of CED reached 10.7%. Based fisher test showed no significant association between the risk of CED in pregnant women in Jakarta and her occupation, education, macronutrient intake, energy intake, and trimester of pregnanc. There are several factors which are not examined in this study include age and physical activity."

"ABSTRAKLatar Belakang: Angka Kematian Ibu AKI di Indonesia tergolong masih tinggi. Salah satu penyebabnya adalah komplikasi dalam kehamilan dan persalinan. Banyak komplikasi yang disebabkan karena masih banyaknya ibu hamil yang jarang atau tidak teratu dalam pemeriksaan kehamilan, sehingga ibu hamil kurang mengerti tanda-tanda bahaya dalam kehamilan dan persalinan. Tujuan: Penelitian ini dibuat untuk menilai ada tidaknya pengaruh edukasi prenatal terhadap pengetahuan, sikap, dan perilaku ibu hamil. Metode: Penelitian akan dilakukan menggunakan model penelitian eksperimental. Data didapatkan dari responden penelitian melalui kuesioner, yang akan membandingkan kelompok kontrol dan kelompok perlakuan yang diberikan edukasi. Hasil: Setelah dianalisis menggunakan uji McNemar, didapatkan p=0.041 untuk pengaruh pengetahuan, p=0.048 untuk pengaruh sikap, serta p=0.115 untuk pengaruh perilaku. Diskusi: Bahwa ditemukan peningkatan sikap dan pengetahuan yang bermakna antara kelompok kontrol dengan kelompok perlakuan setelah diberi intervensi, dimana pengetahuan dan sikap semakin baik setelah edukasi. Sedangkan, untuk perilaku, tidak terdapat hubungan yang bermakna.

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ABSTRACTBackground The immense number of mortality rate of mothers is still a heavy ongoing issue in Indonesia. One of the main reason of this situation is the complications during the pregnancy and labour. These complications can happen because of the lack of knowledge in the mothers regarding the signs of danger in the pregnancy and labour. Objective This research aim to evaluate the impact of prenatal education in knowledge, acts, and behaviour of mother during pregnancy. Methods This research was done using experimental research model. The researcher got the data by using questionnaire, which compare the control group and experimental group that has been given education. Results The researcher use McNemar test to evaluate the results. The results shows the p value of 0.041 for the impact of knowledge, p value of 0.048 for the changes in attitude, and finally p value of 0.115 for behavioural changes. Discussion The value shows that here are significant changes in the experimental group after given intervention regarding the changes of attitude and knowledge in comparison to the control group, where it was shown that a positive changes occurs in the experimental group. On the other hand, there is no significant differences for the experimental group regarding behavioural changes in comparison to the control group."

"Remaja mengalami perubahan biologis, psikologis, dan sosial. Kehamilan remaja merupakan fenomena pada usia remaja yang disebabkan faktor individu, orang tua, dan lingkungan. Penelitian ini bertujuan untuk menggambarkan pengetahuan ibu hamil usia remaja tentang kehamilan dan alasan hamil pada usia remaja. Penelitian menggunakan desain deskriptif sederhana. Subjek penelitian adalah 96 ibu hamil usia remaja di wilayah kerja Puskesmas Bruno menggunakan teknik non-probability sampling pendekatan quota sampling. Instrumen merupakan hasil pengembangan teori dan dianalisis menggunakan analisis univariat. Hasil penelitian didapatkan ibu hamil usia remaja memiliki pengetahuan kurang 44,8%, pengetahuan cukup 35,4%, dan pengetahuan baik 19,8%. Alasan hamil mayoritas berurutan karena faktor lingkungan (37,55%), faktor diri sendiri (36,6%), dan faktor orang tua (25,85%). Kehamilan remaja akibat pengetahuan yang kurang diperkuat kondisi lingkungan yang mendukung merupakan penyebab tingginya kasus tersebut. Penelitian ini memberikan rekomendasi kepada perawat untuk lebih memahami kehamilan remaja dan alasannya sehingga mampu memberikan intervensi berupa edukasi untuk menurunkan angka kehamilan remaja.

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Adolescent undergo biological changes, psychological, and social. Adolescent pregnancy is a phenomenon in adolescence due to individual factors, the elderly, and the environment. This study aimed to describe knowledge of adolescent mothers about pregnancy and the reasons of pregnancy in adolescence. This study using simple descriptive design. These subjects are 96 maternal adolescent in Puskesmas Bruno using non-probability sampling technique through a quota sampling approach. The instrument used was the results of theory development and analyzed using univariate analysis. The results showed maternal adolescent have less knowledge about pregnancy are 44,8%, 35,4% of sufficient knowledge, and good knowledge are 19,8%. The majority reason of pregnancy sequentially due to environmental factors 37,55%, followed by self factor 36,6%, and parental factors 25,85%. Adolescent pregnancy due to lack of knowledge reinforced by environmental conditions that support the cause of the high case. This study provides recommendations to nurses for better understand adolescent pregnancy and the reasons, so it can provide intervention in the form of education to reduce adolescent pregnancy rates."

"Angka kematian ibu di Indonesia masih tergolong tinggi. Penyebab langsung kematian ibu umumnya adalah trias pendarahan-infeksi-eklampsia yang berhubungan dengan rendahnya status gizi dan kesehatan ibu hamil yang diakibatkan berbagai faktor. Pelayanan antenatal merupakan komponen yang diperlukan bagi upaya mempertahankan kesehatan ibu yang perlu terus dimantapkan, bahkan lebih ditingkatkan baik cakupan maupun kualitas pelayanan dalam upaya akselerasi penurunan angka kematian ibu.  Oleh karena itu, diperlukan suatu penelitian  mengenai kualitas pelayanan antenatal yang kali ini dihubungkan dengan pengetahuan, sikap, perilaku ibu hamil mengenai nutrisi kemilan.  Penelitian ini menggunakan desain survei dengan pendekatan cross-sectiona lterhadap ibu hamil di Puskesmas Kecamatan Koja Kodya Jakarta Utara, pada Januari 2013 hingga Juli 2013, dengan menggunakan convenience sampling. Analisis korelasi Spearman digunakan untuk melihat keterkaitan antar variabel.  Hasil menunjukan tidak terdapat hubungan antara kualitas pelayanan antenatal dengan pengetahuan, sikap dan perilaku ibu hamil mengenai nutrisi kehamilan. Mayoritas ibu hamil (57,8%) belum mendapatkan pelayanan antenatal yang baik, namun demikian mayoritas ibu hamil (63,3%) sudah mendapatkan kualitas pelayanan antenatal yang baik mengenai nutrisi kehamilan. Tidak terdapat hubungan antara kualitas pelayanan antenatal mengenai nutrisi kehamilan dengan pengetahuan, sikap dan perilaku ibu hamil mengenai nutrisi kehamilan. Mayoritas ibu hamil memiliki pengetahuan, sikap, dan perilaku yang baik mengenai nutrisi kehamilan.

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Nowadays, Maternal Mortality Rate (MMR) in Indonesia is still high. The direct cause of maternal death is the triage haemorrhage-infection-eclampsia. Further findings show that this direct cause are related to the low nutrition and health status which caused by many factors. Antenatal care is a component needed to sustain maternal health must be established even improved. Therefore, a research on quality of antenatal care toward knowledge, attitude and practice of pregnant woman about nutrition during pregnancy is needed.This research used survey design and cross-sectional approach toward pregnant women in Puskesmas Kecamatan Koja Kodya Jakarta Utara, from January 2013 to July 2013 by using convenience sampling. Spearman’s correlation analysis is used to measurecorrelation between variables. The result shows that there is no correlation between quality of antenatal care toward knowledge, attitude and practice of pregnant woman about nutrition during pregnancy. Majority of the respondents (57.8%) do not get a good quality of antenatal care, but the majority of respondents(63,3%)have received a good quality of antenatal care about nutrition during pregnancy. Most of the respondents have good knowledge, attitude and practice about nutrition during pregnancy.

 

Keywords:  antenatal care, knowledge, attitude, practice, pregnant woman, nutrition, pregnancy

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"Gangguan perkembangan pervasif (GPP) merupakan kelompok gangguan yang ditandai dengan terlambatnya perkembangan keterampilan fungsional dalam sosialisasi, komunikasi, bahasa dan fungsi motorik.Prevalensi GPP dari tahun ke tahun semakin meningkat.Berbagai faktor diduga berkaitan dengan kejadian GPP termasuk faktor kehamilan ibu. Penelitian ini bertujuan untuk mengetahui hubungan antara faktor kehamilan dengan GPP. Penelitian ini menggunakan desain kasus kontrol dengan melibatkan 52 anak dengan GPP (44 laki-laki, 8 perempuan) dan 156 anak tanpa GPP sebagai kontrol (132 laki-laki, 24 perempuan) dengan umur rata-rata kelompok kasus dan kontrol 7,3 tahun, untuk menganalisis enam faktor kehamilan ibu yang mungkin berpengaruh terhadap kejadian GPP. Data diperoleh dari wawancara terhadap ibu kandung masing-masing anak. Hasil penelitian menunjukkan bahwa kebiasaan ibu merokok saat hamil berhubungan secara bermakna dengan GPP (OR = 6,417; 95% CI 1,140-36,12; p = 0,035). Demikian pula dengan riwayat infeksi (OR = 4,250; CI 3,319-5,443; p = 0.004) dan riwayat depresi ketika hamil (OR = 4,508; 95% CI 2,015-10,084; p = 0,001). Riwayat ibu sebagai perokok pasif, kebiasaan meminum alkohol, dan konsumsi obat-obatan selama hamil tidak berhubungan secara bermakna dengan GPP. Disimpulkan bahwa kebiasaan ibu merokok, riwayat infeksi, dan riwayat depresi saat hamil merupakan faktor risiko penting Gangguan Perkembangan Pervasif.

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Pervasive developmental disorder (PDD) is a group of developmental disorders that is characterized by delays in the development of functional skills in socialization, communication, language and motor function. Prevalence of PDD is increasing every year. Various factors are suspected to have correlation with PDD including maternal pregnancy factors.

This study aims to determine the relationship between pregnancy factors with PDD. This study used case -control design involving 52 children with PDD (44 males and 8 females) and 156 children without PDD as controls (132 men and 24 women) with an average age of cases and controls 7.3 years , to analyze the correlation between six maternal pregnancy factors that may affect the incidence of PDD. Data were obtained from interviews with the biological mother of each child.

The results showed that maternal smoking habits during pregnancy significantly correlate with PDD (OR = 6.417; 95% CI 1.140 - 36.12; p = 0.035). As well as a history of infection (OR = 4.250; CI 3.319 -5.443; p = 0.004) and a history of depression during pregnancy (OR = 4.508; 95% CI 2.015 -10.084; p = 0.001). Meanwhile, maternal history of passive smoking, alcohol drinking habits, and consumption of drugs during pregnancy was not significantly associated with PDD.

In conclusion, maternal smoking, history of infection and a history of depression during pregnancy have an important role as risk factors ofPervasive Development Disorders."

"[ABSTRAKIbu hamil risiko tinggi rentan mengalami kecemasan dan depresi yang berdampak pada kelekatannya dengan janin. Penelitian ini bertujuan untuk mengidentifikasi hubungan antara dukungan sosial dengan kelekatan ibu dan janin pada ibu hamil risiko tinggi. Penelitian cross sectional ini melibatkan 108 ibu hamil risiko tinggi yang dipilih menggunakan consecutive sampling. Hasil penelitian menunjukkan bahwa terdapat hubungan antara dukungan sosial dengan kelekatan ibu dan janin pada ibu hamil risiko tinggi (p=0.003). Ibu dengan dukungan sosial tinggi berpeluang 3,9 kali mempunyai kelekatan tinggi dengan janinnya dibandingkan ibu yang dukungan sosialnya rendah setelah dikontrol depresi (OR=3.9; 95% CI=1.66-8.99). Hasil penelitian ini menegaskan bahwa aspek psikososial perlu lebih diperhatikan dalam perawatan ibu hamil sehingga status sejahtera bagi ibu dan bayi dapat dicapai.

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ABSTRACTHigh risk pregnant women tend to experience anxiety and depression that occur prenatal attachment dismissed. This study aimed to identify the relationship between social support and prenatal attachment among high risk pregnant women. This cross sectional study involved 108 high risk pregnant women which selected by consecutive sampling. The result showed that there is relationship between social support and prenatal attachment among high risk pregnant women (p= 0,003). Pregnant women with high social support had prenatal attachment 3,9 times higher than women with low social support after controlled by depression (OR= 3,9; 95% CI=1.66-8.99). This finding confirms that the psychosocial aspects need to be considered in the antenatal care in order to achieve the wellness status for both mother and the baby.;High risk pregnant women tend to experience anxiety and depression that occur prenatal attachment dismissed. This study aimed to identify the relationship between social support and prenatal attachment among high risk pregnant women. This cross sectional study involved 108 high risk pregnant women which selected by consecutive sampling. The result showed that there is relationship between social support and prenatal attachment among high risk pregnant women (p= 0,003). Pregnant women with high social support had prenatal attachment 3,9 times higher than women with low social support after controlled by depression (OR= 3,9; 95% CI=1.66-8.99). This finding confirms that the psychosocial aspects need to be considered in the antenatal care in order to achieve the wellness status for both mother and the baby.;High risk pregnant women tend to experience anxiety and depression that occur prenatal attachment dismissed. This study aimed to identify the relationship between social support and prenatal attachment among high risk pregnant women. This cross sectional study involved 108 high risk pregnant women which selected by consecutive sampling. The result showed that there is relationship between social support and prenatal attachment among high risk pregnant women (p= 0,003). Pregnant women with high social support had prenatal attachment 3,9 times higher than women with low social support after controlled by depression (OR= 3,9; 95% CI=1.66-8.99). This finding confirms that the psychosocial aspects need to be considered in the antenatal care in order to achieve the wellness status for both mother and the baby., High risk pregnant women tend to experience anxiety and depression that occur prenatal attachment dismissed. This study aimed to identify the relationship between social support and prenatal attachment among high risk pregnant women. This cross sectional study involved 108 high risk pregnant women which selected by consecutive sampling. The result showed that there is relationship between social support and prenatal attachment among high risk pregnant women (p= 0,003). Pregnant women with high social support had prenatal attachment 3,9 times higher than women with low social support after controlled by depression (OR= 3,9; 95% CI=1.66-8.99). This finding confirms that the psychosocial aspects need to be considered in the antenatal care in order to achieve the wellness status for both mother and the baby.]"

"Masih banyaknya persalinan di rumah merupakan salah satu penyebab tingginya angka kematian maternal di Indonesia. Antenatal care merupakan sarana kontak pertama ibu hamil dengan tenaga kesehatan secara rutin. Melalui antenatal care tenaga kesehatan dapat memotivasi ibu hamil untuk mempersiapkan persalinannya dengan tenaga kesehatan di fasilitas kesehatan. Komponen antenatal yang lengkap dapat memotivasi ibu hamil untuk kembali memanfaatkan pelayanan tersebut untuk persalinan. Penilitian ini bertujuan untuk mengetahui seberapa besar peran antenatal care dapat mempengaruhi ibu untuk memilih melahirkan di fasilitas kesehatan. Penelitian cross-sectional ini menggunakan data sekunder Survei Demografi dan Kesehatan Indonesia 2012 dengan mengukur konten-konten ANC yang diterima ibu. Hasil penelitian menunjukkan ada asosiasi positif antara pemanfaatan antenatal care yang adekuat dengan persalinan di fasilitas kesehatan. Ibu dengan ANC adekuat berpeluang 6,6 kali untuk bersalin di fasilitas kesehatan (OR adjusted = 6,6, 95% CI: 4,8 - 9,1). Sedangkan ibu dengan ANC inadekuat berpeluang 2,8 kali lebih besar untuk bersalin di fasilitas kesehatan dibandingkan ibu yang tidak ANC (OR adjusted = 2,8, 95% CI: 1,9 - 4,0).

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The progress in reducing maternal mortality has been slow in Indonesia. Maternal mortality could be reduced if all women had a skilled institutional delivery. Antenatal care (ANC) is the first and regular contact between pregnant woman and health professionals. The adequate antenatal care may play an indirect role by motivating (encouraging) women to have a skilled institutional delivery.

The objective of this study is to investigate the role of antenatal care in motivating women to have a skilled institutional delivery. This cross sectional study measures the adequacy of antenatal care using Indonesian Demographic and Health Survey 2012.

This study shows a positive association between adequate ANC and skilled institutional delivery. Women with adequate ANC were significantly more likely to deliver in health facility rather than women with no ANC (OR adjusted = 6,6, 95% CI: 4,8 - 9,1). Meanwhile, women with inadequate ANC were also significantly more likely to deliver in health facility rather than women with no ANC (OR adjusted = 2,8, 95% CI: 1,9 - 4,0)."

"Saat hamil terjadi peningkatan kebutuhan berbagai mikronutrien salah satunya adalah seng. Asupan seng yang adekuat selama kehamilan berperan dalam kesehatan janin. Namun, defisiensi seng sebagai akibat dari asupan yang tidak adekuat atau bioavailabilitas seng yang rendah masih menjadi masalah bagi negara berkembang seperti Indonesia. Penelitian ini bertujuan untuk mengetahui bagaimana hubungan antara asupan seng dalam diet dengan kadar seng serum ibu hamil trimester satu dalam rangka menurunkan angka defisiensi seng di Indonesia. Penelitian ini menggunakan studi potong lintang dengan jumlah subjek penelitian adalah 62 ibu hamil trimester satu dipilih melalui simple random sampling. Dari penelitian ini diperoleh nilai media asupan seng pada ibu hamil trimester satu adalah 2.26 (0.3-51.8) mg/hari. Sebanyak 90.3% subjek penelitian tidak memenuhi asupan seng sesuai rekomendasi AKG. Nilai median kadar seng serum ibu hamil trimester satu dalam penelitian ini adalah 61.29 (39.0-102.0) ug/dL. Terdapat korelasi negatif lemah dan bermakna secara statistik antara kadar seng serum dan asupan seng dalam diet ibu hamil trimester satu (r = -0.266, p = 0.037). Dari penelitian ini dapat disimpulkan bahwa kadar seng serum perlu dipertahankan dalam interval normal, antara lain dengan kecukupan asupannya dari makanan dan suplementasi, khususnya selama masa kehamilan

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There is an increasing need in micronutrient including zinc as adequate zinc intake plays role in fetal health. Nevertheless, zinc deficiency as a result of insufficient intake or low bioavailability is a problem in developing countries including Indonesia. This research observe the association between zinc intake and the serum level of zinc in first trimester pregnancy with the goal to reduce zinc deficiency in Indonesia. There are 62 subjects of first trimester pregnant women and this study is done using cross-sectional design with simple random sampling.

It is found that the median of zinc intake in first trimester pregnant women is 2,26 (0,3-51,8) mg/day. This research found that 90,3% of subjects did not fulfill the recommended dietary allowances for zinc intake. The median serum level of zinc in first trimester pregnant women is 61,29 (39,0-102,0) ug/dL. There is weak inverse correlation that is significant statistically between zinc serum level and zinc intake in first trimester pregnant women (p = 0,037, r = -0,266). It is concluded that zinc serum level must be maintained in the normal interval, such as an adequate intake and supplementation, especially during pregnancy"