The Combination of Spinach, Tomato Juice and Honey to Improve the Levels of

Hemoglobin on Pregnant Women Anemia

Wilda Wahyuni Siregar

, Dwi Handayani

, Raisha Octavariny

, Diah Evawanna Anuhgera

Nikmah Jalilah Ritonga

, Supran Hidayat Sihotang

Institut Kesehatan Medistra Lubuk Pakam, Sumatera Utara, Indonesia

Universitas TJut Nyak Dhien, Sumatera Utara, Indonesia

Keywords : Pregnant Women, Anemia, Spinach , Tomatoes Juice, Honey

Abstract : Anemia on pregnancy will adversely affect the mother, whether in pregnancy,childbirth and during

childbirth and subsequent periods. Anemia management in pregnancy can be in the form of non-

pharmacological therapy. Namely by consuming a combination of spinach juice, tomatoes and honey.

The purpose of this study was to find out the effect of the combination of spinach juice, tomatoes, and

honey on the handling of anemia in pregnant women. This research used quasy experimental with a non

equivalent control group design which was divided into experimental and control groups. The

population in this study were all pregnantwomen in Merbau health center at Merbau fence district 2019,

average 78 people. Samples taken as many as 20 people, obtained used non-probality techniques with a

purposive sampling. The results showed that the effect of giving a combination of spinach juice,

tomatoes, and honey to improving hemoglobin levels on pregnant women anemia with a mean

difference of 0.54 and p value of 0.015. So, it could be concluded that the combination of spinach,

tomatoes juice and honeyhas been proven to increase hemoglobin levels in pregnant womenanemia 5

times better, compared to pregnant women anemia without juice combination intervention.

1 INTRODUCTION

Maternal Mortality Ratio (MMR) is a sensitive

indicator on describing the welfare of the people in a

Country. Maternal death by definition of the World

Health Organization (WHO) is death during

pregnancy or in the 42-day period after the end of

pregnancy, due to all causes related to or

exacerbated by pregnancy or treatment, but not

caused by accident or injury (WHO, 2012). In 2015,

the ratio of maternal mortality ratio (MMR) was

defined as the number of maternal deaths per

100,000 live births.

Maintaining pregnancy is a phase in the growth

of the child because the prospective mother and the

baby she is carrying requires considerable nutrition.

Nutritional deficiencies in the mother and fetus can

result serious problems. The risks of complications

for mothers include anemia, bleeding, low birth

weight, and contracting infectious diseases. This risk

if left unceasing can lead to death (Riskesdas, 2010).

Anemia on pregnancy is blood hemoglobin

level <11g / dL in the first and third trimesters, and

<10.5g / dL in the second trimester. Physiologically,

maternal blood circulation during pregnancy will

change, namely an increase in blood volume where

the amount of blood serum is greater than the

growth of blood cells, resulting in blood thinning

(hemodilution) starting at 16 weeks 'gestation and

peaking at 32-36 weeks' gestation (32-36 weeks

gestation) Novie, 2014).

According to the World Health Organization

(WHO) (2012) the prevalence of anemia in pregnant

women in the world reaches 41.8%. Asia is ranked

second in the world after African continent with a

percentage of the prevalence of anemia sufferers in

pregnancy reaching 48.2%. Pusponegoro's research

and Anemia World Map, in 2012 Indonesia was one

of the countries in Asia with a high incidence of

anemia in pregnancy of 51% (Lampost, 2013).

Anemia prevalence of pregnant women in Asian

countries is Myanmar as much as 33.3%, Philippines

32.3%, Thailand 30%, Indonesia 29.6%, Singapore

Siregar, W., Handayani, D., Octavariny, R., Anuhgera, D., Ritonga, N. and Sihotang, S.

The Combination of Spinach, Tomato Juice and Honey to Improve the Levels of Hemoglobin on Pregnant Women Anemia.

DOI: 10.5220/0009469702030210

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 203-210

ISBN: 978-989-758-460-2

203

28.5%, Brunei Darussalam 28.0%, Malaysia 26.6%,

and Vietnam at 23.5% (

Mothers during pregnancy, really need a lot of

nutrition, especially the need for iron, the need for

iron plays an active role in the formation of

hemoglobin in the mother's blood, this is closely

related to growth and health between mother and

fetus (Sulung, 2018).

Anemia on pregnancy which is most often

found is due to too few healthy red blood cells

because too little iron levels in the body (iron

deficiency) and acute bleeding are not even rare both

are interrelated (Leveno, 2009). Anemia that occurs

during pregnancy is a nutritional disorder as a result

of incorrect eating patterns in pregnant women

(Ojofeitimi, 2008). Handling is usually done to

overcome anemia in pregnant women is to give 60

mg of Fe tablets and 50 nanograms of folic acid

during pregnancy (Dinkes Sumut, 2013).

A mother who is often pregnant has the risk of

anemia in subsequent pregnancies if he does not pay

attention to nutritional needs. A mother with a first

pregnancy can also be at risk of anemia because they

do not have experience so that it impacts on

behavior related to nutritional intake (Madhavi,

2011).

During pregnancy, there is an increase in iron

requirements to 1000 mg. As much as 300 mg is

used for the fetus and placenta, 500 mg for Hb

production and 200 mg is lost through the digestive

tract, urine and skin. Hemoglobin is very important

in the transport of oxygen, because it has the ability

to bind with oxygen to form oxyhemoglobin. This

bonding ability is influenced by blood pH and

temperature. Iron is the main element in the

formation of hemoglobin. An adult's body contains

about 50 mg of iron per 100 ml of blood. The total

requirement for iron is between 2-6 grams,

depending on body weight and hemoglobin levels.

The hormone that is important in the formation of

red blood cells is the erythropoietin hormone. Iron

absorption occurs in the stomach, duodenum and

upper jejunum. Erosive esophagitis, gastric,

duodenal ulcer, cancer and colonic adenoma will

affect iron absorption (Tanto, 2014).

Anemia prevention program carried out by the

government is to give blood-added tablets, which are

Fe preparations which aim to reduce the number of

anemia in infants, hamill mothers, postpartum

mothers, adolescent girls, and WUS (Fertile Age

Women). Prevention of anemia in pregnant women

is carried out by giving 90 Fe tablets to pregnant

women during the pregnancy period. The target of

giving Fe as many as 90 tablets does not reach

100%. The difficulty faced by the government is the

compliance of pregnant women in consuming blood-

boosting tablets (North Sumatra Health Office,

2013). This could be due to the ignorance of

pregnant women about the importance of Fe tablets

during pregnancy. This iron therapy can be

combined with herbal therapy which is usually very

popular with the public (Nuraysih, 2015).

Iron is part of the hemoglobin molecule, with the

reduction of iron, the synthesis of hemoglobin will

decrease and result in decreased hemoglobin levels.

Decreased hemoglobin levels affect the ability to

deliver oxygen to all body tissues so as to reduce

work productivity or reduce the ability to

concentrate (Depkes RI, 2010)

Iron is a substance that is difficult for the body to

absorb. Therefore, the administration of Fe tablets

alone is less effective in increasing hemoglobin

levels, especially if the mother is not compliant to

consume Fe tablets. Complementary therapy is an

alternative therapy used together or in addition to

conventional medicine (Vitahealth, 2006).

Iron is a substance that is difficult to be absorbed

by the body so vitamin C is needed so that iron can

be absorbed optimally. This is consistent with the

results of Zulaekah's research which states that

supplementation with iron and vitamin C is more

effective in increasing hemoglobin levels and red

blood cell counts than administration of iron alone

or vitamin C alone. One of the fruits that have

vitamin C and compounds useful for health is

tomatoes. . The content of tomatoes in 180 grams is

24.6 mg of vitamin, 0.49 mg of iron, and 27 mcg of

folic acid (The George Mateljan Foundation, 2010).

In additiontomatoes, spinach also contains iron

to prevent anemia. Iron content in green spinach.

Iron is important for the formation of hemoglobin.

hemoglobin to carry oxygen throughout the body,

including the placenta. Red spinach and green

spinach do not differ in terms of nutritional quality,

only red spinach has anthocyan pigment that is not

found in green spinach. There are differences in iron

content in red spinach and spinach which is 2.2 mg /

100 grams and 3.9 mg / 100 grams (Lingga, 2010).

At present, there are 14T in MCH services at

ANC, one of which is anemia examination. This

program has the support of the government to

provide additional iron for pregnant women, in the

form of Fe tablets, but in fact in the field, there are

still many pregnant women who are still lazy to

consume it, even many who do not know. With this,

herbal alternatives might be more able to replace

iron nutrients and more attractive to mothers

(Sulung, 2018).

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Others ingredient that is often used in making

juice is honey. Honey is a snack containing iron

(Fe), vitamin C, vitamin B complex and folic acid

which can help the formation of red blood cells. The

combination of spinach, tomatoes, and honey which

all have high Fe content will be able to increase Hb

levels in pregnant women with anemia. In addition

as a natural sweetener, honey is also efficacious for

pregnant women, namely as a treatment for nausea

felt by pregnant women. Honey also has other

benefits when mixed with other herbal

ingredients(Nuraysiah, 2015).

According to Bakta, iron deficiency anemia can

be caused by low iron intake, impaired iron

absorption in tissues and organs, and iron loss due to

bleeding for a long time. Iron loss as a result of

relatively long bleeding can originate from:

1. Gastrointestinal tract: as a result of peptic

ulceration, use of salicylates or NSAIDs, gastric

cancer, diverticulosis, hemorrhoids, and hookworm

infections.

2. Genital tract (female): in women the menstrual

cycle causes bleeding every month.

3. Urinary tract: hematuria.

4. Airway: hemoptysis.

5. Nutritional factors, namely due to lack of total

iron in food (lack of intake) or low quality of iron

(bioavailability) of iron.

6. The need for iron increases, as in prematurity,

children in infancy, and pregnancy.

7. Impaired absorption of iron, as in gastrectomy and

chronic colitis, or consumed together with phosphate

(vegetables), tannins (tea and coffee), polyphenols

(chocolate, tea and coffee), and calcium (milk and

milk products).

The purpose of this study was to find out the

effect of giving a combination of spinach juice,

tomatoes and honey to increase hemoglobin levels

on pregnant womenanemia.

2 RESEARCH METHOD

This study used a quasy experimental research

design with a non equivalent control group design.

Pregnant women with mild / moderate anemia who

agree to be respondents in this research willbe

examined first to find out initial hemoglobin levels.

After thatdivided into two groups, namely the

experimental group and the control group. The

population of this rsearch were 78 people, while the

sample amounted to 20 respondents. Samples were

taken using a purposive sampling technique with

inclusion criteria for trimester II and III pregnant

women with mild / moderate anemia with

hemoglobin levels of 8-10 mg / dl. Each respondent

also had to consume Fe tablets regularly from the

first trimester. Direct data collection was obtained

from respondents by measuring hemoglobin levels

by using the Easy Touch digital measuring device to

see the changes that occurred. Measurements were

made using the pretest and posttest techniques in the

experimental group while those in the control group

were only for comparison without any treatment.

2.1 Research Sites

This research conducted at Pagar Merbau Health

Center, Deli Serdang District, 2019.

2.2 Tools and Material Used

In this study the tools and materials used include:

1) Blender

2) Cup / glass

3) Knives, scales

4) 180 grams of clean green spinach leaves

5) 180 gr tomatoes

6) 500 cc of boiled water

7) 2 tablespoons of honey.

Figure 1: Tools dan Material for Making Tomato, Spinach

dan Honey Juice

2.3 Implementation Procedure

A. Attitudes and Behavior

1) Greet and introduce yourself

2) Explain the intent and purpose

B. Content

1) Asking and reviewing complaints

2) Eye contact with patients

3) Provide an explanation to patients and

families how to consumed spinach juice,

tomatoes and honey at a dose of 180 grams or ±

The Combination of Spinach, Tomato Juice and Honey to Improve the Levels of Hemoglobin on Pregnant Women Anemia

205

5 strands of spinach leaves, 1 medium-sized

tomatoes and 2 tablespoons of honey once a day.

4) Explain how to process or how to make spinach

juice and tomato juice, namely:

a) Choose fresh spinach and tomato leaves.

b) Equal the spinach and tomato leaves.

c) Washing spinach leaves and tomatoes with

running water.

d) Boil spinach in boiling water for 5 minutes,

then drain. But for the tomatoes directly drained

without boiling first.

e) All ingredients are blended and added with 2

tablespoons of honey and 500 cc of mineral

water then filtered into a glass.

f) Spinach juice and tomato juice are ready to be

served.

g) Providing opportunities to ask the questions

C. Technique

1) Systematic and sequential actions

2) Response to the patient's reaction

D. Termination

1) Evaluate the action

2) Say hello

3 RESULTS AND DISCUSSION

The Data collection was performed using direct

measurements to study respondents to know changes

hemoglobin levels. Hemoglobin levels on pregnant

women are measured by pretest and posttest using a

digital hemoglobin meter (Easy Touch brand).

Statistical analysis was used through two stages,

namely using univariate and bivariate analysis using

dependent T-test and independent T-test.

3.1 Univariate Analysis

The majority of respondents in the study were

aged 20-35 years as many as 11 people (55%) with

the most gestational age being trimester 2 namely 12

people (60%). According to Gravida, the most

respondents are multigravida, 11 people (55%), and

the most education is high school education, 13

people (65%).

Table 1. Frequency distribution of respondent

characteristics

Characteristics

Eksperiment dan Control

Group

N %

Age

- <20 year 6 30

- 20-35 year 11 55

- >35 year 3 15

Total 20

Gestational Age

- Second Trimester 12 60

- Third Trimester 8 40

Total 20

Gravida

- Primigravida 9 45

- Multigravida 11 55

Total 20

Education

- Senior High

School 13 65

- PT 7 35

Total 20

Prior to the intervention of the patient, the

researcher took HB measurements in the control

group and the experimental group. This is done to

determine the changes that occur in HB pregnant

women with anemia after being given an

intervention. hb pregnant women before the

intervention can be seen in table 2.

Table 2. The Results of Hemoglobin Level Measurement

on Pregnant Women Anemia Before Intervention

Resp

onden

Control Group

Eksperiment

group

Hb Levels Hb Levels

1 Px 1 8,6 mg/dl 9,7 mg/dl

2 Px 2 9,2 mg/dl 10,2 mg/dl

3 Px 3 8,8 mg/dl 8,5 mg/dl

4 Px 4 9,0 mg/dl 9,0 mg/dl

5 Px 5 8,7 mg/dl 8,7 mg/dl

6 Px 6 9,9 mg/dl 10,0 mg/dl

7 Px 7 8,9 mg/dl 9,9 mg/dl

8 Px 8 8,6 mg/dl 8,6 mg/dl

9 Px 9 8,8 mg/dl 9,0 mg/dl

10 Px 10 9,7 mg/dl 9,4 mg/dl

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206

After the intervention, an increase in

hemoglobin in each respondent was obtained. The

increase in hemoglobin can be seen in table 3.

Table 3. The Results of Hemoglobin Level Measurement

on Pregnant Women Anemia After Intervention

Responden

Control

Group

Eksperiment

group

Hb Levels Hb Levels

1 Px 1 8,7 mg/dl 10,5 mg/dl

2 Px 2 9,1 mg/dl 11,1 mg/dl

3 Px 3 8,8 mg/dl 11,7 mg/dl

4 Px 4 9,2 mg/dl 10,8 mg/dl

5 Px 5 8,8 mg/dl 9,5 mg/dl

6 Px 6 10,1 mg/dl 11,2 mg/dl

7 Px 7 8,9 mg/dl 10,9 mg/dl

8 Px 8 8,4 mg/dl 9,1 mg/dl

9 Px 9 8,8 mg/dl 10,2 mg/dl

Px 10

9,8 mg/dl 11,4 mg/dl

The average hemoglobin level of pregnant

women before being given a combination therapy of

spinach juice, tomatoes and honey is 8.42 in the

experimental group and 8.54 in the control group.

Table 4 Averages hemoglobin levels of pregnant women

before intervention in the experimental and control groups.

Variable Amount Mean SD

Hb Levels

- Eksperiment

Group

- Control

Group

8,42

8,54

0,4

Total 20 100,0

The average value of hemoglobin levels on

pregnant women after the intervention, namely 9.10

in the experimental group and 8.56 in the control

group.

Table 5 Average hemoglobin levels after intervention in

the experimental and control groups

Variable Amount Mean SD

Hb Levels

- Control

Group

- Eksperiment

Group

8,56

9,10

0,42

0,45

Total 20 100,0

3.2 Bivariate Analysis

All respondent characteristics between the

control group and the experimental group were

homogeneous with p (0.376-0.702)> α (0.05).

Table 6 Homogeneity of Respondent Characteristics

Characteristics p value

- Age 0,376

- Gestational age 0,618

- Gravida 0,702

- Education 0,667

Table 7. Mean hemoglobin levels of pregnant women in

the experimental group before and after the combination

therapyspinach juice, tomatoes and honey

Variable Amount Mea

SD P

- Control

Group

- Eksperiment

Group

8,56

9,0

0,42

0,45

0,015

Total 20 100,0

Anemia is a condition where the erythrocytes

and / or circulating hemoglobin do not fulfill their

function to provide oxygen for body tissues. The

most common anemia is anemia caused by iron

deficiency. Iron deficiency anemia is anemia arising

from empty body iron reserves, so that the supply of

iron to erythropoesis is reduced, which in turn

results in reduced hemoglobin formation.

Iron is one of the important elements that are

included in one of the forming of blood hemoglobin.

The function of hemoglobin is to transport oxygen

and circulate it to all body tissues. If it is not met, it

will cause interference with various organs of the

body. So that it takes sufficient iron content to adjust

the iron needs in various organs.

Green spinach leaves (Amaranthus hybridus L)

contain iron (Fe) of 6.43% mg per 180 grams. The

function of substances that form red blood cells,

resulting in the production of red blood cells in the

body so that hemoglobin levels will be normal

(Arisman, 2007). Iron is a mineral that is needed in

the process of hemopoiesis, but iron is a substance

that is difficult to be absorbed by the body. In the

digestion process, continue the process of reduction

from the ferry form (Fe3 +) to ferrous (Fe2 +) so

that it is easily absorbed (Winarno, 2004).

As explained by ARAB (2009) that organic acids

such as ascorbic acid (vitamin C) can help the

absorption of iron by reducing ferries to ferrous

The Combination of Spinach, Tomato Juice and Honey to Improve the Levels of Hemoglobin on Pregnant Women Anemia

207

materials that are easily absorbed 3-6 times. Source

of vitamin C mostly comes from vegetables and

fruit. One of the fruits that have vitamin C and

compounds useful for health is tomatoes. Besides

containing lots of vitamin C, tomatoes are also a

delicious fruit for consumption. Therefore the

combination of green spinach leaves and tomatoes

with high iron content and tomatoes with vitamin C

which accelerates the absorption of iron in the body

can increase the production of red blood cells so that

hemoglobin levels also increase.

Madhavi & Singh's research (2011) with the title

"Nutritional status of rural pregnant women" also

found that pregnant women with anemia were most

prevalent in multigravidas as much as 79.48% and in

primigravidas as much as 20.52%. A mother who is

often pregnant has the risk of anemia in subsequent

pregnancies if he does not pay attention to

nutritional needs. A mother with a first pregnancy

can also be at risk of anemia because they do not

have experience so that it impacts on behavior

related to nutrition intake. A mother with a first

pregnancy can also be at risk of anemia because they

do not have experience so that it impacts on

behavior related to nutrition intake.

This study is also in line with the research of

Luluk, et al (2018) which states that the influence of

Hb levels in pregnant women before and after being

given spinach juice, tomato juice. This is because,

the combination between the two is very good,

where spinach contains iron which is a mineral that

is needed by the body in the process of hemopoiesis.

While tomato juice that contains Vitamin C can help

the process of absorption of iron by reducing ferries

to ferrous materials that are easily absorbed 3-6

times.

According to the analysis of researchers the

influence of HB levels of pregnant women with

anemia before and after being given spinach juice,

tomato juice and spinach and tomato juice

combinations because spinach contains a lot of iron,

which is a mineral that is needed in the process of

hemopoiesis. Vitamin C can help the absorption of

iron by reducing ferries to ferrous materials that are

easily absorbed 3-6 times.

The results of this study are also in line with

research conducted by Wijayanti (2006) entitled

"Test the effectiveness of spinach juice in increasing

blood hemoglobin levels in white rats (Rattus

norvegicus)." This type of research is a true

experiment (True Experimental Design) by using a

Completely Randomized Design. (CRD) consisting

of 6 treatments and 4 replications. The sample used

was 24 female white rats aged ± 2 months and with

BB ± 200gr. Based on the results of the analysis

with the Anova test one factor followed by the

Duncan's test showed that there was effectiveness in

the administration of spinach juice in increasing

blood hemoglobin levels in white rats. Based on the

results of statistical tests in this study it can be

concluded that the administration of combination

therapy of spinach and tomato juice is effective in

increasing hemoglobin levels in pregnant women

with anemia.

Results of research conducted by S Mehnaz et al

research titles on Iron, Folate and Vitamin C

supplementation on the prevalence of iron

deficiency anemia in women who are not pregnant

with anemia in the suburbs of Aligarh. The results

show that the woman experienced an increase in iron

after being given Vitamin C, folic acid, and iron.

As we know honey is a cure for all types of

diseases. Its contents are good for the body so honey

can be consumed as a supplement in daily life.

Honey contains many minerals such as sodium,

calcium, magnesium, aluminum, iron, phosphorus,

and potassium. The vitamins contained in honey are

thiamin (B1), riboflavin (B2), ascorbic acid (C),

pyridoxine (B6), niacin, pantothenic acid, biotin,

folic acid, and vitamin K. One way of using honey is

by add or mix herbs that have certain health benefits.

These properties can be to maintain health, treat

illnesses and care for the body. The mixture of

honey and herbs is called herbal honey. Herbs are

medicinal herbs, a mixture of certain types of herbs

and honey in the treatment of a disease will have a

good impact. The combination of herbs and honey

will increase strength in treating the disease.

Therefore, there is no doubt that besides being used

as a flavoring (sweetener) for honey juice, it can also

be utilized for pregnancy benefits.

Honey is a snack containing iron (Fe), vitamin C,

vitamin B complex and folic acid which can help the

formation of red blood cells. So by consuming

honey in pregnant women who suffer from anemia

can help increase the formation of red blood cells.

According Bogdanov (2015) said that dark

chestnut type honey has a strong effect on blood

circulation which can prevent anemia and prevent

infection in urinary tractus. honey). Mice that

received dark honey supplements were able to

maintain hemoglobin levels equivalent to

hemoglobin levels at the start of the experiment.

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

208

4 CONCLUSION

The combination of spinach juice, tomatoes and

honey has been showing to increase levels of

hemoglobin on pregnant women with anemia 5

times better, compared to pregnant womenanemia

without juice combination intervention.

5 SUGESTION

The Public Health Center (puskesmas) are expected

to continue to improving and maintain promotive

and preventive efforts, especially in antenatal

services. Promotive and preventive efforts can be in

the form of a routine supplementation of iron (Fe)

tablets every month and provide health education

about complementary therapies that can be used to

help increase hemoglobin levels on pregnant

women, one of which is a combination therapy of

spinach juice and tomatoes.

For educational Institutions, it is expected to be

used as evidence based practice in efforts to develop

knowledge.

Pregnant women are expected to continue to

increasing awareness and motivation of the

importance of health during pregnancy and to

prevent complications both during pregnancy and in

the labor process. The trick is to regularly check her

pregnancy in antenatal care services and consume

iron tablets as well as a combination of spinach and

tomato juice as a complementary therapy to increase

hemoglobin levels in the mother's blood.

Further researchers can make this research as

evidence based and additional information to

develop further research on the other benefits of

combination therapy of spinach juice, tomatoes and

honey on health with a greater number of samples

and better research techniques.

ACKNOWLEDGEMENTS

The Researcher would like thank you to all those

who have helped during research process, all staff of

Health Institute Medistra Lubuk Pakam and Pagar

Merbau Health Center, Deli Serdang District Nort

Sumatra.

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