The Paradox of Stunting: Differences in the Perception of Health Workers in Community Health Centers and Experts in Hospitals on Low Birth Weight and Stunting Data

Abstract

Objective

This study aims to identify differences in the perception of health workers in Community Health Centers (CHCs) and hospital experts regarding Low Birth Weight (LBW) and Stunting, derived from community-based nutrition reporting (e-CBNRR).

Methods

The design was mixed-methods. Quantitative data uses secondary data from e-CBNRR for the years 2020 to 2024. Starting in 2022, LBW data are collected retrospectively through 2020 and prospectively through 2024 for subjects who meet the inclusion criteria. A total of 715 subject data were obtained. This consists of 287 LBW and 428 non-LBW in 141 sub-districts. Quantitative results were then used for qualitative exploration. Qualitative data was collected through in-depth interviews and analyzed thematically.

Results

Stunting at birth in the LBW and non-LBW groups reached 40.30% and 10.60%, respectively. Stunting in the LBW group decreased to 14.30% at 6 months of age. In contrast, the stunting rate rose again, reaching 51.20% at 48 months in the non-LBW group, which was higher than in the LBW group (49.30%). Health workers (HW) at CHC have never conducted advanced data analysis from e-CBNRR. HCWs fail to understand the relationship between the available data and the interventions needed for LBW and stunting cases.

Conclusion

LBW babies suffered from stunting 4 times higher than that of the Non-LBW group. The stunting can decline during the breastfeeding period, especially in the LBW group. Ironically, it increased again as the children grew in both groups. Health workers’ perceptions of stunting and LBW information differ between health workers in CHC and experts in secondary health services. e-CBNRR data can be used to dig deeper into valuable information and develop appropriate interventions for stunting and LBW cases.

Video Abstract

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Introduction

Stunting is still a global health problem, especially in developing countries.¹ WHO estimates the prevalence of this problem worldwide at 22% or as many as 149.2 million people in 2020.² Stunting is a form of chronic malnutrition marked by low height-for-age.³ Stunting is characterized by a height-for-age z-score of <-2 standard deviations (SD) relative to the WHO median, occurring mainly during the first 1000 days of life. It has a long-term impact on children’s cognitive and physical health. Most of these stunted toddlers come from Asia.⁴ Asia and Africa have the largest burden of child stunting at 55% and 39% of global stunting cases, respectively.⁵

More than half of deaths occur in children who are stunted.^6,7 Nearly one in four newborns is reported to be underweight in Pakistan.⁶ This is similar to research in sub-Saharan Africa, which found that low birth weight (LBW) has been identified as a risk factor for child morbidity and mortality, especially among children under five years of age in sub-Saharan Africa.⁸ Similar findings in South Asia and sub-Saharan Africa show that suboptimal breastfeeding caused 3.1 child deaths per year or 45% of all child deaths in 2011.⁹

Children who suffer from stunting may never reach their maximum height, and their brains may never develop to their maximum cognitive potential.¹⁰ They experience learning difficulties in school, lower income as adults, and barriers to participating in their communities.² The problem of stunting was exacerbated by the COVID-19 pandemic in 2020.⁴ Before the emergence of COVID-19, stunting affected about 21.3% of children under 5, or 144 million children.⁴ In Indonesia, stunting prevalence remains high at 21.6% in 2022. However, the case rate decreased from the previous year (2021), when it was 24.4%.¹¹

Low Birth Weight (LBW) of less than 2.5 kg is considered a major public health problem and a leading cause of neonatal mortality.^6,12 Every year, out of 20 million births worldwide, it is estimated that 15–20% of babies are born with LBW.^3,6 The target of reducing LBW by 2025 must reach a 30% reduction from the current data.⁶ Babies with LBW are not only at risk of dying in the first month of life, but are also at risk of developing other health problems, such as stunting problems.^6,13

The reduction in the LBW rate has become a global focus, as stated in the Sustainable Development Goals (SDGs).^14,15 Therefore, attention to LBW and stunting is actually a concern of the government and the community. LBW is related to the welfare of the baby during pregnancy. Monitoring the baby’s growth from the fetus should be a tool for early intervention.^6,16

In Indonesia, there are 2 massive ways to monitor children’s nutritional status nationally: 1) Surveys conducted once a year by the Ministry of Health; and 2) Electronic Community-Based Nutrition Recording and Reporting (e-CBNRR, namely e-PPGBM in the Indonesian language), including for LBW and stunting. The first method is conducted through an annual survey, which is released the following year.¹⁷ Secondly, it was particularly evident through the mass weighing of toddlers at the Integrated Service Post (ISP) in all villages every February and August. The result of this data is recorded in the e-CBNRR. All data from the ISP is sent in stages to the central government via Community Health Care (CHC, namely Puskesmas). The information can be accessed by both the district and provincial governments.^18,19

These two monitoring methods consistently yield different results, including for stunting and LBW data. This is, of course, due to differences in methodology and sample.²⁰ Some scientists do not trust e-CBNRR due to the possibility of bias in data collection by cadres and other factors. However, in the context of policy, such information is available and can be leveraged for decision-making.^18,21

Empirical data from e-CBNRR at this time are treated and used superficially. Indeed, e-CBNRR data is a potential source that has not been fully utilized or properly leveraged. After that, there is also no desire or action to interpret information and use it for decision-making. The information produced, on the other hand, will also depend on the perception of the stakeholders who use it. Information can vary depending on the stakeholder’s background and position.

The research aims to use these public raw data sources (e-CBNRR) to generate knowledge on LBW and stunting, and then deliver it to stakeholders. The purpose of the study is to identify differences in the perceptions of health workers in health centers and hospitals regarding LBW and Stunting data and information, based on e-CBNRR results and their use.

Study Context

Indonesia is an archipelagic country with 38 provinces. West Java is the province with the largest population, at 49 million (in 2022), or 20% of the national population. This province comprises 27 regencies/cities and 627 sub-districts. Indonesia’s government system comprises four levels: Central, Provincial, District/City, and Village/Urban Village. A Subdistrict is a government unit under the District/ City and consists of Villages. In this study, the research analysis unit is at the Subdistrict level.

Materials and Methods

Research Design

The research design was a sequential exploratory mixed-methods. The first step began with a quantitative method using secondary data from e-CBNRR. The period of quantitative exploration started from February 2020 to February 2024. In the next stage, the quantitative results are presented to stakeholders to elicit their perceptions through qualitative methods. So, the output of the qualitative method would explore and explain, at once, the perception of the quantitative results.

Subjects

The quantitative research dataset is secondary data from e-CBNRR for February 2020. The subject data was followed and explored in the same 2 months, February and August, every year until February 2024. The qualitative component involved 19 respondents from three categories: (a) Health Office Officials, (b) Community Health Center Personnel, and (c) Hospital Experts.

Data Collection

Quantitative Studies

The research began in 2022, with secondary data (e-CBNRR) retrospectively utilized in February 2020. LBWs were identified, resulting in 1,625 cases. The data were then explored through August 2022 and prospectively followed every February and August through February 2024. Inclusion criteria were LBW infants who were weighed and recorded at least 9 times, every 6 months, for 9 toddler weighings. Exclusion criteria were LBW data that were left blank.

After 9 observations and nearly 5 years, a total of 287 LBW cases that met the criteria were identified in 141 of 627 existing sub-districts. Then, we searched for non-LBW data from 141 sub-districts as a control group, using the same inclusion criteria and matching the same sub-districts. A total of 428 non-LBWs were identified. The total sample of LBW and non-LBW subjects recruited was 715.

Qualitative Studies

This qualitative research was conducted by interviewing all informants mentioned above. This qualitative research was conducted through unstructured interviews conducted by researchers. The interviews yielded 440 pages of verbatim transcripts.

Data Analysis

Quantitative Studies

Bivariate analysis was performed to examine the association between LBW and Stunting cases. The Pearson Chi-Square test was employed to determine statistical significance. The magnitude of risk was estimated using the Risk Ratio (RR) with 95% Confidence Interval (95% CI). All statistical analyses were conducted using SPSS version 18, and p-values < 0.05 were considered statistically significant. Univariate analyses were performed to prepare data and information for the second stage, the qualitative studies.

Qualitative Studies

The data was analyzed thematically using ScreenQ, a computer-assisted qualitative data analysis software (CAQDAS). The coding process results in 16 codes, 7 categories, and 4 themes.

Ethical Consideration

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and received ethical approval from the Universitas Padjadjaran Ethics Committee (No. 674/UN6.EP/EC/2024). Written Informed consent was obtained from all participants prior to their involvement in the study. Participants’ identities were kept confidential, and anonymity was ensured throughout the publication process, including the use of anonymized quotations.

Results

Quantitative Studies

Table 1 shows that the projected number of children under 5 in West Java province for 2020 was 3,450,106. However, the number weighed in February 2020 was only 1,828,214, or 53% of families with toddlers contributed to the mass weighing program. This data set included 51,510 newborn babies, of whom 1,625 (3.2%) were LBW.

Table 1.

Number and Percentage of Toddlers Weighed, LBW and Stunting in February and August 2020–2024 in West Java Province, Indonesia

West Java Province	2020		2021		2022		2023		2024
	FEB	AUG	FEB	AUG	FEB	AUG	FEB	AUG	FEB
Number of Toddlers (projection)	3,450,106		3,943,890		3,969,930		3,983,080		3,985,870
Number of Toddlers weighed	1,828,214	2,356,111	2,302,029	2,480,443	2,629,899	2,737,999	2,766,982	2,813,317	2,927,230
Percentage of Toddlers Weighted	53%	68%	58%	63%	66%	69%	69%	71%	73%
Number of 0-month-old babies weighed	51,510	55,096	50,932	53,116	48,329	50,462	43,615	41,636	30,717
Number of Babies Born in February with LBW	1,625	1,105	923	1,113	1,549	1,623	2,877	1,611	1,646
Percentage of Babies Born with LBW	3.2%	2%	1.8%	2%	3.2%	3.21%	6.5%	3.8%	5.3%
Number of children 0–60 months Stunting and Stunted	218,146	222,183	200,918	177,666	178,223	170,151	276,047	161,923	179,788
Percentage of children 0–60 months Stunting and Stunted	12%	9%	9%	7%	7%	6%	10%	6%	6%
SSGI/SKI Stunting Data	NA		24.40%		21.60%		21.60%		NA

From 2020 to 2024, the number of babies weighed and recorded in e-CBNRR increased. There was an increase in the percentage of toddlers weighed from 53% (February 2020) to 68% (August 2020) to 73% (February 2024) at the end of observation. The average annual percentage of toddlers weighed and recorded on e-CBNRR is 65.5%. Despite the COVID-19 pandemic occurring from 2020 to 2023, 65.5% of toddlers still contribute.

Figure 1 presented LBW babies born in February 2020 have a stunting proportion of 40.30%. The Non-LBW infant group obtained a stunting proportion of 10.60%. There were about 4 times more stunting cases in the LBW group compared to the non-LBW group. In both groups, stunting appears to decline in 6 months until August 2020, with a larger decline in the LBW group (jump to 14.30%) than in the non-LBW group (6.50%).

Figure 1.

Incidence of stunting in LBW and non-LBW infants.

In contrast, from the age of 6 months onwards, stunting was increasingly evident in both groups. The proportion of stunting cases in the LBW group increased every 6 months of observation, as seen in Figure 1. Ironically, at the age of 48 months, the stunting proportion of the non-LBW group of 51.20% became higher than that of the LBW group of 49.30%. At this point, there was a phenomenon of reversal of the proportion of stunting in both groups.

The incidence of stunting at 0 months between those born with BBLR and those without BBLR shows a significant difference. Further analysis, the risk of stunting at birth in the LBW babies was significantly 3 to 4 times higher compared to non-LBW babies (Table 2). The risk ratio of stunting in the LBW babies then became 2 times at 6 months old and is still significant. After that, the risk ratio approached 1 and was insignificant at 48 months of age.

Table 2.

The Relative Risk of Stunting in Children Born Low Birth Weight in West Java for the Period of February 2020 - February 2024

Age (m.o)	RR (95% CI)	P value
0	3.728 (2.741–5.070)	<0.001
6	2.049 (1.167–3.598)	0.011
12	1.405 (0.940–2.102)	0.097
18	1.338 (1.079–1.660)	0.012
24	1.154 (0.939–1.419)	0.182
30	1.100 (0.903–1.341)	0.349
36	1.119 (0.926–1.352)	0.250
42	1.028 (0.850–1.243)	0.774
48	0.955 (0.798–1.142)	0.614

Qualitative Study

This phase aims to explore perceptions of two groups of healthcare workers in CHC and hospital experts regarding LBW and stunting cases. The quantitative research data were then used as material during the interview.

Interview results showed that CHC workers are unaware of failures in ANC programs, complementary feeding (MPASI), and supplementary feeding (PMT). This differs from the perception of hospital experts, who have successfully identified the root causes of problems related to handling ANC, the exclusive breastfeeding period, complementary feeding (MPASI), and supplementary feeding (PMT). The qualitative results are shown in Table 3.

Table 3.

Differences in Views Between Health Center Officers and Hospitals In Providing Services to Pregnant Women to Children Aged 48 Months

No	Life Cycle	Construct	Health Worker at Community Health Center (CHC)	Ekspert at Hospital
1	Pregnant Women	Capacity of officers to conduct ANC	Not all officers understand the importance of the ANC Have been able to do ANC according to the standard even though it is different in carrying out the number of T, some do only 6T- but there are those who do 10 T. It is rare to find LBW Immediately refer to the hospital, if find a pregnant woman with complications without explanation Most state that it is rare or never to find/diagnose IUGR Body length measurements were only carried out by 1 person so the validity of the measurement results was doubtful Weak counseling for pregnant women Have ANC achievement data but are not compared to LBW’s findings in hospitals	CHC officers do not understand the importance of ANC At the time of ANC, not all health center officers do ANC according to standards and vary in doing 6T – 10T and do not explain the dangers of toxoplasma, hypertension, anemia and malnutrition in pregnant women PHC officers have not been able to diagnose IUGR, many IUGR cases are not detected CHC officers have not been able to carry out the 12 T’s which are ANC standards CHC officers have not been able to accurately measure the height of the Uteri Fundus Rarely get referrals from IUGR linked health centers Body length measurements should be done by 2 people so that the results are more valid Have LBW baby handling data
2	Breastfeeding Mothers (Infants aged 0–6 months)	Education for Breastfeeding Mothers (Exclusive Breastfeeding)	Rarely provides education about the importance of exclusive breastfeeding Rarely provide education on the correct way to breastfeed No exclusive breastfeeding coverage data Not understanding the content of breast milk Normal and LBW babies get the same breast mil Not looking at data on exclusive breastfeeding coverage with a decrease in the magnitude of stunting	Educate on proper breastfeeding Strive Exclusive breastfeeding for breastfeeding mothers up to 6 months, Specialist doctors do Catch up weight gain in LBW babies They knew there is a relationship between the achievement of exclusive breastfeeding and the magnitude of stunting Knowing the success of exclusive breastfeeding will support the reduction of stunting
3	Infants 6–24 Months	Supplemental Nutrition	Most of them have suggested giving complementary foods Not understanding the complementary food delivery model Not knowing the budget from the government for the provision of complementary foods Not all do education on making complementary foods Not monitoring complementary foods Complementary feeding education is given to the class of mothers of toddlers in general Not monitoring growth velocity Not providing the correct complementary feeding that is tailored to the problem Not aware of any failures in the MPASI program	Already suggested the provision of complementary foods Knowing the complementary food delivery model Not getting information from the health center level regarding the Complementary food budget Suggest that the feeding meets the nutrition needed by toddlers Education is provided on a person-to-person basis Monitoring velocity growth Provide complementary feeding according to the child’s needs and problems Knowing that there is a failure in the MPASI program
4	Age 24–48 months	Supplementary feeding (Breastfeeding Food, namely PMT in Indonesia Language)	Most of them know the importance of giving supplementary food Knowing the provision of supplementary food using Health Operational Assistance funds carried out by a third party (outsourcing) Not monitoring the impact of supplementary feeding Unaware of any failures in the supplementary feeding program	Fully understand the importance of Supplementary feeding Hospitals do not have supplementary feeding programs Getting a referral for toddler growth that is not in accordance with what it should be in condition Knowing that there is a failure in the supplementary feeding program

Perceptions in Both Groups of ANC Examinations During Pregnancy

Respondents from healthcare workers at the CHC did not compare and analyze quantitative results data with the achievements of the ANC, Exclusive Breastfeeding, complementary feeding programs (MPASI), and supplementary feeding programs (PMT). Even though they have the data, they admit that they rarely find cases of Intra Uterine Growth Retardation and LBW.

In contrast, hospital experts can analyze quantitative data and compare the outcomes of ANC, exclusive breastfeeding, complementary feeding (MPASI), and supplementary feeding programs (PMT). It is assumed that healthcare workers in CHC do not fully understand ANC. Factors that cause LBW cases are so high in hospitals, according to respondents is mentioned below.

On average, health workers at health centers and general practitioners who have been trained in ultrasound do not all perform ANC according to standards and there are still variations in the implementation of 6T-10T and rarely explain the possibility of toxoplasma infection, hypertension in mothers, anemia in mothers and malnutrition in mothers So that is one of the factors why LBW cases are very high.

It is necessary to be certain when ANC measures the correct height of the Uterine Fundus, which does not include the mother’s fat and must empty the urinary bladder first, not just measuring just like that, also thinking about the thickness of the mother’s fat.

Expert respondents argue that healthcare workers at CHCs still need to improve the quality of ANC and have the ability to perform ultrasounds to detect IUGR properly. This illustrates the ANC program’s failure. The expert is of the view that CHCs are not yet capable of providing proper ANC.

The diagnosis of IUGR cannot be done with a simple examination of the height of the uterine fundus and weight by health workers at the Health Center. It would be nice if it were equipped with an ultrasound examination by a general practitioner who can see that the comparison of Biparietal diameter (BPD) and abdominal circumference is enough to be able to diagnose the possibility of IUGR.

According to hospital experts, the procedures for measuring body length and height performed by health workers at the CHC are inadequate. This situation will introduce bias into the measurement value and the recording on the growth chart.

It is recommended that in measuring body length, it is ideally done by 2 examiners (health workers at the Health Center) and by using a body length measurement tool with an infantometer. When these 2 things are not implemented properly, the body length obtained is not the actual body length. It could be that the result is as if the baby has a shorter body length, when it could be the real thing; maybe the length of the body is normal.

With many LBW still being born and many being referred to the hospital, this illustrates the low quality of ANC and the feeding program for pregnant women. It can be said that the ANC program is not successful.

Perception of Babies at the Age of 0-6 Months (Exclusive Breastfeeding Period)

According to expert respondents at the hospital, the group of babies aged 0–6 months is a period where exclusive breastfeeding is very important. Exclusive breastfeeding is generally not done until the baby is 6 months old, because babies aged 4–5 months have received additional complementary feeding (MPASI). The perception at health centers does not have an understanding of the importance of supervision at the age of 0–6 months, especially special attention to LBW babies, so that they provide the same treatment as normal babies. Experts at the hospital usually provide formula milk for LBW babies so they can catch up and reach the ideal weight and body length. Hospital experts perceive that community health centers have not been successful in the Exclusive Breastfeeding program.

When a baby with LBW is caused by nutritional disorders while in the womb or born prematurely and accompanied by low body length, usually the medical team, either from the pediatrician or the awareness of the parents’ awareness, will try to catch up on the weight gain quickly. Usually given high-calorie formula milk, which in the market is known as LBW formula milk it does have above average calories with the aim that the babies can catch up and catch up so that it is hoped that later at the age of 2 years, he has reached the ideal weight and length, this factor should be looked for whether the type of formula is indeed used and whether or not it affects the development of the child at the time 6 months of age.

There should be a difference in treatment in the management of LBW and Non-LBW babies.

Exclusive breastfeeding is sometimes not in accordance with its exclusivity (up to 6 months) because it is not yet 6 months, it should be 4-5 months, it has been assisted by complementary foods, and rarely is it purely exclusive.

According to respondents from the health center, they do not understand the composition of breast milk, which is supported by specialist doctors’ opinion that Fe content in breast milk decreases after 4 months, so it requires additional nutrients from outside.

Not many people know that the breast milk will decrease from the age of 4 months so it requires additional support from the outside.

Here is a difference in perception between health workers at community health centers and hospital experts regarding the quantitative data on the sharp decline in LBW stunting from 40.30% to 14.30% at 6 months of age. Health workers at community health centers do not see the decline as being due to exclusive breastfeeding coverage. The experts at Hospitals perceive that high levels of exclusive breastfeeding are a key factor in stunting reduction, in addition to other measures.

Perception of Babies at the Age of 6-24 Months

According to the respondents, hospital experts, health center health workers, and general practitioners rarely pay attention to the acceleration of a baby’s growth. Even though the baby will increase in length as they age. Respondents who are experts at hospitals rarely get information from health workers at the community health center. At the health center level, they have provided counseling to mothers of toddlers and their families on complementary feeding (MPASI) to ensure the nutritional content meets toddlers’ needs. There should be continuity of information and services between the community health center and hospital levels. Hospital experts perceive that community health centers have been unsuccessful in the supplementary feeding program.

Health workers at CHC and General Practitioner do not pay attention to monitoring the growth velocity or growth speed of a child who experiences different growth rates according to a certain age range, for example, newborns born 0 - 1 year old, per year the increase in body length can reach up to a maximum of 45 cm per year if divided by approximately 3 - 4 cm per month in body length, When a child reaches an age above 1 - 2 years old, the increase in body length can decrease by almost half between 7 - 10 cm per year.

There should be a continuity of information about the condition or achievement of complementary foods at the health center level, so that experts in hospitals can follow up on problems that may arise in connection with the problem of complementary foods whether they have met the nutrition needed by toddlers.

According to the respondents of health workers at the community health Center, the CHC does not have a model for complementary foods, as a result of which the complementary feeding given by families is only based on their knowledge and abilities, currently complementary foods do not have guidelines on the form, frequency, texture and stages ranging from crushed to the same as family food. Although according to the respondents, the CHC staff said that complementary feeding (namely MPASI in Indonesian Language) education has been carried out in the class of mothers under five.

The age of 0–24 months is a golden period that if LBW and Non-LBW who experience stunting are not immediately intervened, they will fall into stunting and will have an impact on their future.

Currently, there is no pattern/model about complementary foods, so every breastfeeding mother provides complementary foods according to her knowledge and ability to make complementary foods (MPASI) for their babies.

So far, the administration of complementary foods has not had guidelines for both the form and frequency of feeding, the frequency of main feeding 3x, 2x snacks or interludes, and the texture is adjusted to the age and acceptance of the child to food. Age 6-7 months puree/filtered food, 8-9 months finely chopped food, 9-11 months coarsely chopped, 1 year and above as food usually eaten by the family.

Complementary food is given after the child is 6 months old. Complementary feeding at the health center is conducted in the class for mothers under five, once a month. The content of the activity is education about making complementary foods, providing a schedule for giving complementary foods, and gathering together to eat complementary foods.

Perception of Children Aged 24-48 Months (Supplementary Feeding Period)

According to the hospital’s expert respondents, they rarely received feedback reports or information about the provision of additional food to toddlers, including its impact. This was necessary because of the experts’ role as a referral point and as a resource person at quarter meetings. In addition to paying attention to food intake, monitoring toddlers’ growth should also consider that, after age 2, their growth rate decreases by almost half, to about 5 cm per year.

So far, there has been no reporting on the provision of additional food to the age group of 24-48 months, both the provision of counseling and the provision of rehabilitation supplementary feeding, so far there are also no guidelines on the content of supplementary feeding for recovery and supplementary feeding for counseling and there is no information on which stunted toddlers receive assistance in providing additional feeding for counseling and supplementary feeding the recovery.

So far, it seems that health workers at the CHC and general practitioners who have been trained in ultrasound do not pay attention when the toddler is over 2 years old, the growth rate decreases again, almost half, approximately 5 cm per year.

So far, obstetricians and pediatricians rarely get information about giving additional food to toddlers from the CHC level, including rarely getting information on the impact of giving these additional foods.

Similarly, health workers at the CHC have never monitored the impact of providing additional food. In fact, the provision of additional food is a government program funded by the Health Operational Assistance fund, so the CHC should provide a report on the impact of this provision to the Regency/City Health Office, according to its work area. So far, the process of providing additional food at the CHC level has been carried out using a third party (outsourcing).

So far, additional food has been provided at the CHC level with a budget source from the health operational assistance fund, which is made by 3rd party organizers; there has never been monitoring of the impact of providing additional food for counseling and additional food for recovery.

There is a difference in perception between the health worker at the CHC and the expert at the hospital regarding the quantitative data on stunting, which is increasing rapidly, as shown in Figure 1. There is an increase in the magnitude of stunting, LBW, and non-LBW even at the age of 48 months; the magnitude of stunting in non-LBW exceeds the magnitude of stunting in LBW. During this period, there is actually a supplementary feeding program (PMT). The CHC does not see a correlation between the provision of supplementary feeding and the increase in the magnitude of stunting. The hospital sees the data on the magnitude of stunting with the PMT it provides, so they see it as a failure in the PMT program. Given the failure of the PMT program, strong and strict monitoring and immediate intervention are required.

Other differences in opposite perceptions can be seen from the non-uniformity in the implementation of ANC because some have done it 4 times but some have done it 10 times, and vice versa the low findings of babies who have been ultrasound by general practitioners who have been trained at the health center accompanied by low referrals to hospitals, while experts get many referrals of babies with LBW.

Another difference in perception is that there is no uniform provision of companion basic necessities in terms of form, type, and frequency at the CHC level; so far, the provision is only based on ability, knowledge, and funding from families. Experts’ perceptions of the role at the CHC level are very important because contact with mothers and babies is much greater there than with experts. They think that socialization at the CHC level has provided information about the procedure for feeding old companions. At the CHC level, the Complimentary Feeding Program provides general counseling to those who attend, while individual counseling is provided by experts based on the problems they encounter during consultations.

Discussion

The national digital platform e-CNBBR for recording and reporting nutritional status remains open to exploration and the generation of various knowledge. The results of the quantitative study above show the importance of the desire, along with the ability of health care workers at CHC to analyze data. Loss of opportunities for potential knowledge leads to limited decision-making and/or improper intervention. Paradoxically, that knowledge is available in both hands.

In this exploration, it was found that stunting in newborns with LBW was 4 times higher than in non-LBW, Babies born with 40.30% LBW are already stunted. This illustrates the failure in the Antenatal Care (ANC) nutrition program for pregnant women. Figure 1 depicts the events behind the scenes related to the performance of Antenatal Care, Exclusive Breastfeeding, Complementary Feeding, and Supplementary Feeding. This phenomenon is in line with research conducted in Pakistan, which found that children born with LBW will be more prone to stunting.⁵

Even with e-CNBBR’s weaknesses, the Local Government and its stakeholders should focus more on the data available to them. The existing data includes a wide range of information, such as trends in LBW magnitude and the communities most affected, which is very important to consider. The program’s awareness is not limited to stunting.

The Indonesian government has designated “focus location of stunting” within subdistricts as a priority for addressing stunting. The determination of the “focus location of stunting” is based on the large number of stunting cases and risk factors in a village. The intention is to provide a sharp, integrated intervention.

This exploratory research offers an alternative method for identifying the focus location for stunting, using public cohort data owned by the CHC and the government. Additionally, it highlights LBW cases, which are also a hidden nutritional issue for babies during the antenatal period. Taking a further step in data analysis reveals much more knowledge, allowing many root causes to be uncovered.

The occurrence of LBW is the result of the condition of the mother and baby at the time of pregnancy. The role of antenatal care (ANC) is very important in the prevention of LBW and stunting. ANC is a key indicator of the improvement of maternal and child health services globally.²² Monitoring the mother’s nutritional condition and pregnancy during ANC will identify nutritional abnormalities and the baby’s health in the womb. Identifying the incidence of LBW and the interventions carried out are very important in preventing stunting in infants and children in the future.

ANC is expected to be able to detect the presence of pregnant women with chronic energy deficiency and the possibility of babies with low birth weight. On observations at the research site, ANC’s performance is quite high. However, this contradicts the relationship between high ANC coverage and LBW occurrence. ANC results may not necessarily identify pregnant women at risk of delivering LBW infants.

Actually, pregnant women have received additional food nationally to prevent nutritional disorders in babies.^23,24 However, there are still many pregnant women who experience chronic energy deficiency, which is one of the risk factors for LBW. This high LBW is in line with the theory that LBW can occur in babies who have been malnourished for a long time or whose mothers are infected.²⁵ Similarly, a 2022 study in the United States found an increase in LBW to 8.60%.²⁵ Similar to research conducted in Iran in 2024, which found a relationship between ANC and LBW.²⁶

The next contradiction is the unequal number of visits to ANC K4, K6, and K10, resulting in unequal detection rates.²⁵ This is in contrast to the number of ANC visits in Kenya, where the number of visits is determined by the proximity or distance of access to health facilities; the closer they are to the means of service, or because they have mobile phones, they will make more frequent ANC visits.²⁷ A study found that knowing the nutritional status of pregnant women at the time of ANC can prevent premature birth.²⁴

The paradox of the stunting situation occurred later. The percentage of stunting in both the BBLR and non-BBLR groups increased until the age of 48 months. Here, there is a failure to prevent stunting in a period of 6–12 months, where the intervention that may be carried out is complementary feeding (MPASI). Then, failure to prevent stunting in the 12–24 months period, where the intervention required is the provision of additional food. So local governments and stakeholders, including health workers, in these 141 sub-districts failed to use information from their e-CBNRR to detect an increase in stunting cases and intervene as they should.

This period of giving complementary foods (MPASI) indicates that the failure of this complementary food program (MPASI) must be corrected, including factors such as the mother’s education level, socio-economic policies, adaptive social protection, and poverty, all of which can lead to poor food quality and insufficient food intake. In contrast to the study in Poland, which provides a reference for food input information and macro- and micro-calculations of selected nutrients, adapted to the local culture using this food reference method, and can be used to evaluate its validity and reproducibility in estimating nutrient intake.²⁸

The golden period for growth and development from 0 to 24 months is widely known by stakeholders, and nutritional surveillance tools are also available. However, the incidence of stunting in these 141 sub-districts persists in the long term, creating a paradox in the government’s approach to stunting. Local governments and stakeholders are actually using the data and information at their disposal to deliver appropriate responses and interventions. The failure to provide supplementary feeding programs (PMT) at the same time as the results in Guatemala carried out by Martorell, who said that chronic malnutrition and poor nutritional quality show the existence of stunted babies.²⁹

In the non-LBW infant group at the age of 48 months, there was an increase in stunting compared to children with LBW. This shows the existence of the reversal phenomenon. This is consistent with Martorell’s research, which found that stunting is not only a manifestation of short stature but also reflects a history of more severe and prolonged malnutrition. Such chronic malnutrition can occur in children without LBW.^29,30

Although the LBW and Non-LBW groups aged 24–48 months both increased, and even at the age of 48 months, the Non-LBW group exceeded LBW. Until now, the increase in stunting has been higher in the Non-LBW group. It’s unclear why at the age of 48 months, the amount of stunting in Non LBW becomes greater than the stunting rate in LBW. They do not even realize that the data illustrate the failure of the ANC, complementary foods (MPASI), and supplementary feeding programs (PMT).

On the other side, there are differences in perception between health workers at CHC and experts at hospitals regarding LBW and stunting data. It appears that there are periods of ANC, exclusive breastfeeding, complementary foods (MPASI), and supplementary feeding (PMT). This aligns with research findings that identified differences in perceptions of equality in health services between health centers and partnership networks.³¹

Health workers in hospitals can identify and follow up on IUGR cases and other stunting-related cases. They and hospital institutions have sufficient guidelines and governance. However, it is different from the CHC. Indeed, health workers at CHCs do not have special instructions or regulations. In fact, they do not have guidelines for analyzing data and acting on it. CHC tends to refer directly without analyzing IUGR and LBW cases. This is feared to happen because knowledge at the CHC level is still low, as well as research in Africa showing that 45% of sick toddlers are taken to hospitals rather than to public services.³² Even though it is known that LBW has a higher risk of stunting and inhibits growth.³³

Another difference in perception is that compliance is not the same when entering the data from the examination results. At the CHC level, not everything is recorded in the book of pregnant women, so there is complete data, and some are incomplete, such as data on records of giving Fe tablets, immunization records that are still not filled, not including medical history, lack of recording the results of ultrasound examinations by general practitioners at health centers, the number and types of cases referred to obstetricians or pediatricians. This does not describe the progress of growth, unlike the hospital experts who directly enter it into the medical record.³⁴ Therefore, it is necessary that “Quality” has many dimensions,³⁵ including structural quality, delivery aspects, and technical or professional content of the treatment, all of which may affect the use of the service.^2,36

Both groups, both health workers at the CHC and experts at the hospital, are still paying little attention to the high level of LBW and stunting. This can happen because of a lack of monitoring of performance achievements at the CHC and hospital levels, including uniformity, guidelines, integration monitoring, and service sustainability performance achievements from the CHC level to the hospital level, so that they are integrated. Monitoring can be used for various purposes, such as assessing performance, clarifying the flow of performance achievement reporting, identifying problems, and seeking immediate improvements.³⁷ A solution was found as to why the target was not achieved and discussed together with experts to participate in finding a middle way, especially with the high number of babies born with LBW with stunting, which should have been a common concern from the beginning.

The low rate of toddler visits to ISPs was 56%. This condition is similar to research in Nyamira, where the number of toddlers visiting weighing posts is also low; only 21.1% regularly take their children there.³⁷ Another difference in perception concerns complementary feeding (MPASI) and supplementary feeding (PMT).

The Limitation of the Study

The quantitative data used is from 2020, and the study followed for 5 years. It is also necessary to explore the database in the following years. Qualitative data are limited to the included participants. Variations in the sides can produce different perceptions.

Conclusion and Suggestion

The results of public data exploration on stunting indicate that there are stunting focus areas the government has not identified, but that need to be addressed. At the location of the stunting focus, cases were found in LBW babies 4 times more than in non-LBW. Then there was a decrease in stunting among babies 0–6 months, estimated to be due to the success of Exclusive Breastfeeding. Ironically, stunting cases increased again in the LBW and Non-LBW groups up to the age of 48 months. Health workers’ perceptions of stunting and LBW, and of information and management, differ between primary health service providers and secondary service experts.

The government, stakeholders, and health workers, especially in CHC, need to improve the technical capabilities of data analysis from the stunting reporting recording system and its KIA (maternal and child health) program. Then they need to provide appropriate responses and interventions based on the information generated by the system. There is a need to reduce the knowledge gap among healthcare workers in both primary and secondary care regarding LBW and stunting.

Implication for Policy

1. With the findings of high LBW with Stunting and Non-LBW with Stunting, it is very important information for policy makers starting from the Central, Provincial, Regency/City levels to immediately improve policies related to LBW and Stunting, as well as the relationship between ANC, Exclusive Breastfeeding, complementary and supplementary feeding programs.

2. The perception between Health Workers in Community Health Centers and Experts in Hospitals must be equalized, in terms of the availability and utilization of LBW and Stunting data.

3. A guideline or reference is needed for Health Workers in CHC, and Experts in hospitals in terms of the sustainability and linkage of LBW and stunting data starting from the Village, District, Regency/City, Province, and Central levels.

4. Implications include: Food intake, Water conditions used by children, Water conditions provided by mothers, Infection and malnutrition, Pollutants, Diet during pregnancy, Other conditions during pregnancy (obesity, diabetes, hypertension), Intergenerational stunting.

5. Monitoring the attendance of toddlers to be weighed and recorded completely and correctly.

6. Paying attention to toddlers, not only those at risk of low birth weight but also those who are not.

7. Strict monitoring of ANC, exclusive breastfeeding, complementary feeding, and supplementary feeding programs.

Funding Statement

This publication charge is funded by Unpad (Universitas Padjadjaran) through the Indonesian Endowment Fund for Education (LPDP) on behalf of the Indonesian Ministry of Higher Education, Science and Technology and managed under the EQUITY Program (Contract No. 4303/B3/DT.03.08/2025 and 3927/UN6.RKT/HK.07.00/2025).

Disclosure

All authors have no conflicts of interest in this study.