Comparison of the Effectiveness of Spinach and Tomato Smoothie
Consumptions with Fe Tablets to Increase Hemoglobin in Pregnant
Women
G. F. GustinaSiregar, Megawati Sinambela, Vitrilina Hutabarat, Stefany Anastasia,
Friska Ernita Sitorus, Husna Sari
Health Institute of Deli Husada Deli Tua, Medan-Indonesia
Keywords: Anemia, Smoothie, Hemoglobin.
Abstract: This study aims to determine the effectiveness of giving spinach and tomato smoothies with Fe tablets to
increase Hb in pregnant women. This type of research is quasi-experimental oquasi research with two pretest-
posttest design groups. Paired T-Test Test results stated that the value (r) in the higher group was 0.837 which
meant that it was stronger than by only providing Fe tablets, this group received a value (r) of 0.730 which
meant it had strong strength. The results of this study indicate that spinach and tomato smoothies are effective
against increasing levels of hemoglobin in pregnant women this is supported by the value of p-value, with a
value of {p (0,000) <α (0.05)}. The case group obtained higher effectiveness than the control group, indicated
by the results of the value (r). The correlation value in the case group was (r) = 0.837, meaning that the
effectiveness of Fe tablets, spinach smoothie with tomatoes on hemoglobin levels in pregnant women was
very strong while the correlation value in the control group was (r) = 0.730 meaning the effectiveness of Fe
tablets on hemoglobin in pregnant womenare stronger.
1 INTRODUCTION
Anemia is a condition where the body has too little
red blood cells (erythrocytes) or hemoglobin less than
11 gr / dL (Proverawati, 2013). According to the
World HealthOrganization, 40% of maternal deaths
in developing countries are related to anemia in
pregnancy and most are caused by deficiency iron and
acute bleeding, even not infrequently both of them
interact with each other. Iron deficiency anemia in
pregnant women is a health problem experienced by
women all over the world especially in developing
countries, for example Indonesia.
Anemia often occurs due to lack of iron content in
food, absorption of iron from food which is very low,
the presence of substances that inhibit iron
absorption. Iron anemia in pregnancy is a condition
where mothers with hemoglobin levels below 11
grams / dL in trimesters I and III and hemoglobin
levels less than 10.5 grams / dL in trimester II
pregnancies. Iron is very much needed to supply the
growth of the fetus and placenta in the womb and to
increase the number of red blood cells for pregnant
women.
In North Sumatera one of the efforts made to
reduce the prevalence of anemia is by administering
90 (Fe) iron tablets during pregnancy. The percentage
of coverage of pregnant women who received 90 iron
tablets in 2016 was 73.31%, this decreased compared
to 2015 which amounted to 80.13% or there was a
decrease of 6.82%. With the percentage of coverage,
the coverage of iron tablets in 35 pregnancies has not
been able to reach the national target set at 80%
(Dinkes. 2016).
Spinach is a green plant that is rich in various
nutrients, especially iron (Fe) which is quite high,
which is as much as 6.43 mg / 180 grams. And also
none of the substances contained in spinach can harm
the body. Iron is a substance that is difficult to be
absorbed by the body so that vitamin C is needed so
that iron can be absorbed optimally.
This is consistent with the results of research that
states that iron supplementation and vitamin C are
more effective in increasing hemoglobin levels and
red blood cell counts than the administration of iron
alone or vitamin C alone. One of the fruits that
566
Siregar, G., Sinambel, M., Hutabarat, V., Anastasia, S., Sitorus, F. and Sari, H.
Comparison of the Effectiveness of Spinach and Tomato Smoothie Consumptions with Fe Tablets to Increase Hemoglobin in Pregnant Women.
DOI: 10.5220/0009975305660572
In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 566-572
ISBN: 978-989-758-460-2
Copyright
c
 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

contain vitamin C and compounds for health is
tomatoes. The content of tomatoes in 180 grams is
24.66 mg of vitamin C, 0.49 mg of iron and 27 mg of
folic acid. Folic acid is needed by pregnant women
because they need for folic acid during pregnancy
will increase than usual. So that the combination of
spinach and tomatoes is considered very effective can
increase hemoglobin levels in pregnant women. This
will also be greatly helped by eating patterns on
mothers every day (Merinda, 2014).
According to research shows that in pregnant
women in the control group who did not consume
spinach juice and tomatoes, an average increase in
hemoglobin of 0.01 gr / dL by 15 respondents and in
the experimental group that consumed spinach juice
and tomatoes had an average increase in hemoglobin
of 0.47gr / dL. Based on research, the administration
of spinach and tomato juice to increase hemoglobin
in pregnant women with anemia can accelerate the
increase in hemoglobin and be a very effective
additional intervention.
The results showed that in pregnant women in the
control group who did not consume spinach juice and
tomatoes the average increase in hemoglobin was
0.01 gr / dL by 15 respondents and in the
experimental group who consumed spinach juice and
tomatoes had an average increase in hemoglobin of
0.47gr / dL.
The survey conducted by the author on pregnant
women at the Berta Naibaho Clinic which is often
carried out dizzy, limp, and pale, which is a sign of
anemia, said that none of the mothers had ever taken
a combination application of spinach juice and
tomatoes.
The purpose of this study was to determine the
effectiveness of spinach and tomato smoothies with
Fe tablets on increasing hemoglobin in pregnant
women.
Iron is an important nutrient for forming
hemoglobin, which is a protein in red blood cells that
carries oxygen to all tissues and organs of the body.
During pregnancy, the amount of blood in your body
increases to 50% more than the condition of the body
under normal conditions, so you need a lot of iron that
forms hemoglobin to compensate for the increase in
blood volume. Also to meet the needs of iron for fetal
and placental development.
To overcome anemia during pregnancy, you can
increase your intake of iron, folic acid, and vitamin
B12, both in the form of supplements given by your
doctor and in the form of food that you consume
daily. Examples of foods rich in iron, folic acid, and
vitamin B12 are red meat, dark green leafy
vegetables, eggs, beans, chicken, and fish.
The process of absorption of iron substance also
requires vitamin C, vitamin C can helpthe process of
absorption of iron substanceand help releaseing iron
substance from its storage. Vitamin C can play a role
in increasing the absorption of non-heme iron 4 times.
Vitamin C and ironsubstanceform complex iron
compound ascorbate which is easily soluble and
easily absorbed.
This is in line with Argana's research, namely that
there is an effect of giving vitamin C as a dominant
factor on haemoglobin levels. Previous research
conducted by Heltty 2008, proved that green beans
are effective in treating anemia in cancer patients with
chemotherapy, because consumption of 2 cups of
green beans can meet 50% of daily iron needs and
80% meet the daily needs of vitamin C and other
vitamins such as thiamine, riboflavin, and niacin.
One of the fruits that contain vitamin C and
compounds for health is tomatoes. The content of
tomatoes in 180 grams is 24.66 mg of vitamin C, 0.49
mg of iron and 27 mg of folic acid. Folic acid is
needed by pregnant women because the need for folic
acid during pregnancy will increase than usual. So
that the combination of spinach and tomatoes is
considered very effective can increase hemoglobin
levels in pregnant women. It will also be greatly
helped by eating patterns on mothers every day7.
2 RESEARCH METHODS
The research design (Figure 1) used was quasi-
experiment without a control group using the two
group pretest and posttest design approach. The
population in this research was pregnant women in
the Berta Naibaho's clinic with purposive sampling.
Assisted by the Slovin formula for determining
samples. The number of samples was 30 people.
Divided into 15 case groups and 15 control groups.
This study aims to determine the effectiveness of
giving spinach and tomato smoothies with Fe tablets
to increase Hb in pregnant women. In the experiment,
spinach and tomatoes are blended until smooth. The
juice is given to pregnant women every day for
several weeks. Measurement of Hb in pregnant
women was carried out before and after the juice
treatment. The next measurement data was used t-test
to see the correlation value between groups.
Comparison of the Effectiveness of Spinach and Tomato Smoothie Consumptions with Fe Tablets to Increase Hemoglobin in Pregnant
Women
567

SPINACH AND TOMATO
BLENDY
SMOOTHIE
PREGNANT DRINK
HEMOGLOBIN TOOL
ANEMIA YES/NO
Figure 1: Mechanism for making smoothies Spinach
and Tomato.
3 RESULTS
Table 1: Frecuency distribution of hemoglobinlevels of
pregnant women before and after in the control group and
casus group.
Identity
Pretest
Post-test
Total
Anemia
Not
anemia
Anemia
Not
anemia
N
%
N
%
N
%
n
%
n
%
Control
Group
12
80
3
20
9
60
6
40
15
100
Case Group
14
93.3
1
6.7
-
-
15
100
15
100
Total
30
100
3.1 Bivariate Analysis
Based on the age characteristics in the control group
the majority of pregnant women aged 20-35 years
(46.7%), minorities aged <20 years and> 35 years
each as many as 4 people (26.7%). 9 people (60%), 2
women (> 13.3%) in the minority case group aged>
35 years.
Based on the characteristics of maternal education
in the control group the majority reached 6 junior high
schools (40%), and the minority was at the tertiary
level as many as 2 people (13.3%). In the case group,
the majority of mothers with a high school education
were 7 people (46.7%) and the minority with tertiary
education was 2 people (13.3%). According to (4)
education is a form of changing knowledge, income,
concepts, changing attitudes, perceptions and
changing behavior that still uses customs to play an
active role in daily life into something new. The
higher a person's education, the more the information
obtained and insight.
Table 2: Comparasion of the effectiveness of giving Fe
tablets with Spinach and Tomato smoothies in increasing
hemoglobin in pregnant women.
Identity
Pretest
Post-test
Total
Anemia
Not
anemia
Anemia
Not
anemia
( r )
P
Value
N
%
N
%
n
%
n
%
N
%
Control
12
80
3
20
9
60
6
40
15
10
0
0.7
30
0.0
00
Case
14
93
.3
1
6.7
-
-
15
100
15
10
0
0.8
37
0.0
00
Total
30
100
Based on the characteristics of work in the control
group the majority of mothers work as entrepreneurs
as many as 7 people (46.7%) and the minority work
as civil servants and IRT where each number is 4
people (26.7%). In the case group, the majority of
mothers worked as IRTs by 8 people (53.3%) and the
minority worked as civil servants by 2 people
(13.3%).
At a pregnancy interval> 2 years, the number of
pregnant women with healthy reproduction is 13
people, while in the high-risk age group of 7 people,
none is found in the early age group. The results of
the above study indicate that anemia can occur in all
age groups due to many other factors that influence.
Based on the research results of the mothers in the
pretest control group the majority of anemia were 12
people (80%), and the minority were not anemic as
many as 3 people (20%) as Shown In the Table 1. In
the posttest control group, the majority of mothers
were anemic with 9 people (60%) and the minority
were not anemic with 6 people (40%). In the pretest
case group, the majority of pregnant women were
anemic with 14 people (93.3%) and the minority of
mothers were not anemic with 1 person (6.7%). And
after the experimental treatment was carried out
posttest, where all pregnant women who were given
treatment were not anemic with 15 people (100%).
Based on bivariate analysis (Table 2), it can be
seen that pregnant women in the control and case
groups experienced an increase in the number of
women who were not anemic before and after the
experimental treatment. This shows the influence of
Fe tablets, smoothie spinach and tomatoes in pregnant
women. Where the control group only consumed Fe
tablets while the case group consumed Fe tablets and
spinach and tomato smoothies.
This is strongly supported by conducting tests on
research with paired sample T-Test. This test strongly
supports the research analysis, especially in the
pretest and posttest research groups. From the results
of the table above it can be seen that there is an effect
of giving Fe tablets with spinach and tomato
ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology
568

smoothies on hemoglobin levels in pregnant women.
From the results of these tables, it can also be seen the
effectiveness of giving spinach and tomato smoothies
with Fe tablets on hemoglobin levels.
The control group can be seen as the value (r) =
0.730, meaning that there is a strong influence of
giving Fe tablets to hemoglobin levels. And the p-
value in the control group is 0.000 <0.05 meaning that
there is an effect of giving Fe tablets to hemoglobin.
Whereas in the case group the value (r) = 0.837,
means that there is a very strong influence, with a p-
value of 0.000 <0.05 meaning that there is an effect
of giving Fe tablets, spinach smoothies and tomatoes
to hemoglobin levels. From this description, it can be
concluded that the effectiveness that is very
supportive is the provision of Fe tablets, spinach
smoothies and tomatoes on hemoglobin levels in
pregnant women.
Among Southeast Asian countries, Indonesia is
listed as one of the countries with quite a lot of anemia
sufferers. According to data from the Basic Health
Research (Riskesdas) in 2017, the number of anemia
sufferers in Indonesia consists of 26.4 percent of
children, 12.4 percent of men aged 13-18 years, 16.6
percent of men over 15 years, 22.7 percent of women
ages 13-18, 22.7 percent of women aged 15-49, and
37.1 percent of pregnant women. The high number is
quite alarming. The reason is anemia is a health
problem that can reduce the quality of life.
In pregnant women are very susceptible to iron
deficiency anemia, the etiology of iron deficiency
anemia in pregnancy is hemodilution which causes
blood thinning, blood gain is not proportional to
plasma increase, lack of iron in the food and increased
need for iron as well as digestive and absorption
disorders5. Iron is not only needed for the formation
of hemoglobin which plays a role in oxygen storage
and transport, but it is also present in several enzymes
that play a role in oxidative metabolism,
neurotransmitters, and catabolism.
The results of this study stated that the greatest
increase in hemoglobin was obtained from the third
group who received iron supplementation, vitamin C
and nutrition education with p <α (0.05) so that Ho
was rejected. This is consistent with the theory that
vitamin C has a variety of important roles for iron
metabolism and one of them is as a factor for metal
reduction reactions such as iron and copper, so that
ferry ions are reduced to ferrous ions which are easily
absorbed in higher pH in the duodenum and small
intestine.
The results of this study also compare with the
research conducted by Wijayanti entitled "Test
Effectiveness of Spinach Juice in Increasing Blood
Hemoglobin Levels in White Rat
(RattusNorvegicus)". This type of research is a real
experimental study (True Experimental Design)
using a Completely Randomized Design (CRD)
consisting of 6 training and 4 replications. The sample
used is 24 white being front rats ± 2 months and with
BB ± 200 grams. Based on the results of the analysis
with the Anova test, one of the factors carried out by
the Duncan test is to prove the effectiveness of
spinach juice in increasing levels of hemoglobin,
white blood.
Organic acids such as ascorbic acid (Vitamin C)
can help the absorption of iron by reducing ferries to
ferrous materials that are easily absorbed 3-6 times.
Source of vitamin C is mostly derived from
vegetables and fruit. Based on research conducted by
Kailaku that tomato variety does not yet have a very
high nutrient that is 24.66 mg per 180 grams.
Therefore the combination of green spinach leaves
with high iron content and tomatoes with vitamin
content C which accelerates the absorption of iron in
the body can increase the production of red blood
cells so that hemoglobin levels also increase.
The process of absorption of iron also requires
vitamin C, vitamin C helps in the process of
absorption of iron and helps release iron from its
storage. Vitamin C can play a role in increasing the
absorption of non-heme iron 4 times. Vitamin C and
iron form complex iron ascorbate compounds that are
soluble and easily absorbed.
The results of previous studies by a team that
found lutein in food will reduce inflammation in the
immune cells of patients with coronary artery disease.
Chronic low-level inflammation is associated with an
increased risk of a heart attack. They also say lutein
can be stored in immune cells which is meaningful
but it builds up reserves of lutein in a person's body.
And it is also recommended that when consuming
spinach, you can add cream, milk or yogurt so that
you will increase your lutein and water expenditure.
According to a study conducted by Nasyidah
entitled "The Relationship of Anemia and
Characteristics of Pregnant Women at Alianyang
Pontianak Health Center", states anemia in pregnant
women does not depend on age, but there are other
factors that are more dominantly affecting, one of
which is the distance of pregnancy, which is at a
distance pregnancy <2 years, the highest number of
pregnant women suffering from anemia is 20
unhealthy reproductive ages.
The results of preliminary studies conducted at
Puskesmas Plus Perbaungan found various problems
causing the high maternal mortality rate (MMR)
especially in the Puskesmas Plus Perbaungan
Comparison of the Effectiveness of Spinach and Tomato Smoothie Consumptions with Fe Tablets to Increase Hemoglobin in Pregnant
Women
569

working area as a contributor to maternal mortality
rates with the highest maternal mortality rate and the
most causes of maternal death due to bleeding (43,
3%), eclampsia (23.3%), obstetric embolism (22.2%)
and other causes (11.1%).
Based on the 2015 MDG's target the health rate of
pregnant women is 102 per 100,000 live births.
Maternal mortality is still an indicator of the success
of health development in SerdangBedagai Regency
and nationally. The number of deaths in 2017 was 9
cases. The number of maternal deaths has increased
from the 2016 mortality rate of 7 cases. The maternal
mortality rate in SerdangBedagai Regency in 2015
was 8 per 100,000 live births. This number is indeed
far from the national mortality rate but when
compared with the MDG target it has already
exceeded the target.
This is following new research in Europe has
found raw spinach in the form of smoothies or juice
is the best way to get the antioxidant lutein.
Especially when healthy fat is added to help its
absorption.
As reported in the Malay Mail, Lutein is a natural
fat-soluble pigment found in plants. Dark green
vegetables contain very high levels of lutein. But like
many other nutrients, lutein levels decrease when
cooked. Spinach is one of the vegetables most often
used for research because spinach is one of the more
popular dark vegetables.
The findings, published in the food chemical
journal, also indicate that heating time and cooking
methods are equally important for maintaining lutein.
The longer the spinach is boiled, the less lutein is left.
The effect of heating spinach by microwaves is not
recommended because it wil increase the microwaves
which make more lutein released than it will
consume.
Research conducted in Sweden that spinach can
increase strength or immunity and prevent loss of
muscle mass in our body. This is done at the
Karolinska Institute in Sweden that in one serving of
spinach a day it will produce nitric acid which aims
to increase the efficiency of the body's muscles.
Based on reproductive age this is supported by the
normality of the reproductive period in women, both
in the control group and case group. Education in this
study did not affect the course of the study. And the
characteristics of this work are very supportive of the
research process, especially in the control group, the
mother who is a housewife is very helpful in the
process of making smoothies because mothers have a
lot of free time.
Fe tablets, spinach, and tomato smoothies are
effective against increasing hemoglobin levels in
pregnant women this is supported by the p-value, with
a value of {p (0,000) <α (0.05)}.
The case group obtained higher effectiveness than
the control group, indicated by the results of the value
(r). The correlation value in the case group is (r) =
0.837, meaning that the effectiveness of Fe tablets,
spinach smoothie with tomatoes on hemoglobin
levels in pregnant women is very strong while the
correlation value in the control group is (r) = 0.730
meaning the effectiveness of Fe tablets on
hemoglobin is strong in pregnant women.
Anemia in pregnant women can cause these needs
are insufficient, so oxygen is channeled to the body's
tissues and the fetus becomes limited. Apart from
supplements, iron deficiency can also be managed
through a healthy and regular diet. Increasing iron
food intake is one way to prevent and treat anemia in
pregnant women.
So it is recommended that if there are no blood
added tablets, pregnant women can consume spinach
and tomato smoothies regularly during pregnancy so
that the pregnant woman's hemoglobin is normal so
there is no bleeding during labor and post-delivery.
It is also recommended that midwives conduct
hemoglobin checks on pregnant women every ANC
visit and teach pregnant women to consume Fe tablets
combined with smoothies containing vitamin C even
though Fe tablets are a mandatory program from the
government. Midwives can provide health services on
giving pregnant women spinach and tomatoes to
increase hemoglobin so that pregnant women know
how to increase hemoglobin in addition to consuming
Fe tables.
Furthermore, this research can be used as
evidence-based and additional information to develop
further research on other benefits of spinach and
tomato smoothie combination therapy on health with
a larger number of samples and better research
techniques.
This research requires further development by
combining the main ingredients containing heme
substances to increase the absorption of substances in
the body.
4 CONCLUSIONS
The results of this study indicate that spinach and
tomato smoothies are effective against increasing
levels of hemoglobin in pregnant women this is
supported by the value of p-value, with a value of {p
(0,000) <α (0.05)}. The case group obtained higher
effectiveness than the control group, indicated by the
results of the value (r). The correlation value in the
ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology
570

case group was (r) = 0.837, meaning that the
effectiveness of Fe tablets, spinach smoothie with
tomatoes on hemoglobin levels in pregnant women
was very strong while the correlation value in the
control group was (r) = 0.730 meaning the
effectiveness of Fe tablets on hemoglobin in pregnant
women strong.
According to some experts who have researched
that anemia in pregnancy is defined as a decrease in
hemoglobin levels of less than 11 g / dL during
pregnancy during trimesters 1 and 3 and less than 10
g / dL during postpartum and trimester 2. Pregnant
women need more blood cells to support fetal
development.
ACKNOWLEDGEMENTS
This research was supported by Institut Kesehatan
Deli Husada Delitua Institut Kesehatan Medistra
Lubuk Pakam, Sembiring Hospital Foundation, and
GrandMed Hospital Foundation, Indonesia.
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