APJCN

Perinatal and maternal mortalities in Java became of concern in the 1980s. Since some 90% of births took place at home, the Tanjungsari (TS) district of West Java was identfied as a locality where community-based risk management strategy might reduce this health burden. In 1987, traditional birth attendants (TBA) were trained to identify risk factors for unfavourable birth outcomes. From January 1st 1988 to December 1989, some 4,000 pregnant women in TS were followed and assigned either a trained or untrained TBA. In the first year, early neonatal, and maternal mortality rates (MMR) (32.9 per 1000 and 170 per 100,000 deliveries respectively) were reduced, but not sustained in the second year. Nationally, MMR was 446 in 2009 and 126 in 2015. Although possible to improve health worker performance, and community engagement, the most likely explanation for benefit attrition is that people and material resources ‘downstream’ of the TBA services were inadequate. Three decades later, Indonesian neonatal and maternal mortality rates of 14 per 1000 and 126 per 100,000 live births in 2015 (globally 16.2 in 2009 and 216 in 2015) according to UNICEF, still demanded improvement, despite more hospital-based births. The original 1988 cohort of women, their children and grandchildren, can now be interrogated for medium to long term health outcomes of nutritional, such as birth weight and growth, and other risk factors. The evolving TS cohort health and nutrition intermediates and endpoints are instructive. Maternal and early life factors predict adult energy metabolism and cognitive function.

Background and Objectives: Intrauterine growth retardation (IUGR) is related to mortality and morbidity. However, defining IUGR by suitable field methods remains a challenge. A maternal-child Risk-Approach-Strategy (during 1988-1989) and follow-on Tanjungsari Cohort Study (TCS) (1989-1990), aimed to generate a practical classification of IUGR and explore its usage in predicting growth, mortality and morbidity of infants in the cohort. Study Design: Some 3892 singleton live-birth infants were followed. IUGR was defined by birth weight (BW) and length (BL) classified as: acute, chronic, non-IUGR or ‘probably preterm’. Growth, mortality, and survival curve were calculated to prove that the classification identified the most vulnerable infants. Fever >3 days and diarrhoea were assessed based on IUGR classification, sex, exclusive breastfeeding, and environmental factors. Results: IUGR infant weight and length did not catch-up with the non-IUGR in the first year. Infant mortality rate was 44.7 per 1000 where some 61% died within 90 days. Using age specific mortality by BW, 23.6% of all deaths occurred when it was <2500 g compared to 66.2% from IUGR and preterm groups. Fever and diarrhoea rates increased over 12 months. Diarrhoea was associated with poor source-of-drinking-water and latrine. Conclusion: The IUGR classification predicted one-year growth curves and survival, besides age and sex. IUGR based on BW and BL identified a larger group of at-risk infants than did low BW. High morbidity rates were partly explained by poor environmental conditions. IUGR inclusive of BL has value in optimizing nutritional status in the first 1000 days of life.

Background and Objectives: Low birth weight leads to growth faltering, attributable inter alia to malnutrition and maternal health and literacy. Risk for growth faltering in rural children under five is studied. Study Design: The Risk Approach Strategy in Tanjungsari, West Java has been analysed for all pregnancies during 1988-1989 and 4,698 singleton infants born between 1 January 1988 and 31 April 1990. Weight and body length/height measurements were repeated over 60 months, and plotted against WHO standards. Weight-for-age and height-for-age z-scores were calculated using 2006 WHO growth as reference. The correlation between shortness (so-called stunting) and its presumptive risk factors was determined. A subset underwent DNA analysis for insulin-like growth factor-1 (IGF-1), and insulin receptor substrate-1 (IRS-1) polymorphism. Results: Weight and body length/height follow-ups were followed-up for 3795 infants; 14.2% of the cohort had low birth weight (<2500 g) (LBW) and 85.8% normal birth weight (NBW). LBW infants showed a similar velocity but tended to catch up more slowly (GEE; p<0.001). Relative to WHO references, the differential for stature increased with age, largely offset by reduced weight-for-age so that weight-for-height tracked close to the WHO reference; this contrasts with more divergence internationally. Birth length and weight, along with potable water access were correlated with stunting for children under 2 years. Neither the observed IGF-1, IRS-1 or combined gene polymorphisms were associated with LBW. Conclusions: The prediction by factors operative during pregnancy for early life stature ,with some adaptation for LBW infants, endures to 60 months.

Background and Objectives: Health status during adolescence may predetermine that during adulthood. Being short because of nutritional and health adversity, where stunting is indicative, is a global health concern, possibly in adolescence. This study assessed the prevalence of shortness (defined by HAZ <–2 SD) at age 12 and its determinants. Study Design: This Tanjungsari birth cohort of 1988/1989 was revisited in 2001–2002 with 3093 participating children, their parents and households. The cohort was tracked from birth, to ages 2 and 12 with anthropometry, with birth weight, then weight and height-for-age at 2 and 12, dietary history at age 2, health patterns at age 2 and 12, and environmental exposures. Results: The prevalence of adolescent shortness, presumed ‘stunting’, was 48.8% for which predictor Odds Ratios (OR) were low birth weight 1.64 (95% CI: 1.28-2.09), short height for age at 2-years 1.54 (95% CI: 1.33-1.80), limited maternal education 1.19 (95% CI: 1.01-1.41), unimproved source of drinking water 1.27 (95% CI: 1.08-1.49), unimproved latrine 1.18 (95% CI: 1.01-1.39) and presence of atopic disease at 12 years of age 1.29 (95% CI: 1.01-1.65). Smoking exposure, not breastfed, formula milk consumption and infectious disease at age 2 were not associated with shortness at age 12 on multivariable analysis. Conclusions: Adolescent shortness was found in almost half of this rural Javanese cohort followed from birth. It was associated with birth weight, and several individual, maternal and environmental factors evident at age 2, along with an atopic disposition at age 12. However, stature itself may not constitute a health risk over and above the associated socio-environmental conditions.

Background and Objectives: Resting metabolic rate and cognitive function may be associated with several factors, such as birth weight, growth, and fat-free mass in adulthood. The Tanjungsari Cohort Study (TCS) of 1988, to do with a maternal-child Risk Approach Strategy (RAS), provided the opportunity to determine the associations between birth weight, growth at 2 years, and body composition with adult resting metabolic rate and cognitive function. Methods and Study Design: In 2009 some 197 and, in 2017,144 of these representative participants from the TCS were assessed for energy intake, anthropometry, body composition, indirect calorimetry, and cognitive function in relation to low (ALBW, n=66) or normal (ANBW, n=78) birth weight. Associations were adjusted for basic demographic data. Results: Resting metabolic rate was positively associated with birth weight, body weight at 2 years of age, body mass index and fat free mass in adult life. Time to finish the Trail Making Test-A (TMT-A), a test of attention span, was significantly longer in the ALBW than the ANBW group (41.4±12.8 vs 37.8±15.6, p=0.005). In the ALBW group, weight catch-up improved TMT-A and logical memory test scores (29.5 vs 34.9.41, p=0.004; and 39.3 vs 29.4, p=0.04, respectively). Conclusions: Low birth weight was associated with poorer attention span in adult life; body weight gain at 2 years of age with better attention and memory function in adult life; a greater body mass index in adult life with better memory in adult life.