INTRODUCTION:

The highest prevalence of iron deficiency anaemia occurs in young women, including pregnant women^1-3. The incidence of deficiency anaemia in pregnant women in Indonesia has increased from 37.1% in 2013⁴ to 48.7% in 2015⁵.

Iron deficiency anaemia in pregnant women, according to Baharini et al. (2017), can have a negative impact on outcomes such as intra-uterine growth retardation (IUGR), premature babies, miscarriages, and low body weight (LBW)⁶. Brannon and Taylor (2017) explain that iron is one of the important minerals in the formation of hemoglobin, which is used as a transport to circulate oxygen throughout the body⁷. Severe anaemia can lead to circulatory decompensation, increased cardiac output, increased bleeding risk, and decreased ability to tolerate blood loss, which can lead to hypovolemic shock and maternal death⁸.

The most common causative factor for anaemia is iron deficiency⁹. Iron deficiency in pregnant women occurs because of: 1) lack of iron intake in the mothers’ daily food; 2) the consumed food contains iron inhibitors to be absorbed by the body; 3) lack of family support that causes the distribution of nutritious food to not be a priority for the mother; 4) family economic conditions; 5) a lack of information about anaemia and its prevention¹⁰.

The government makes it a policy that every pregnant woman is obliged to consume iron tablets given by health workers in amounts up to 90 tablets, but this is still not enough to reduce the incidence of anaemia in pregnant women. Riskesdas reported that in 2014, the tablet coverage of blood for pregnant women in Indonesia amounted to 85.1% and did not experience an increase compared to 2015's 85.17%, even decreasing in 2017 and amounting to 73.2%¹¹.

Baharini et al. (2017) explained in their research that as many as 58 respondents felt the side effects of iron tablets, such as nausea (60.3%), constipation (31.1%), dizziness (17.2%), diarrhoea (10.3%), and stomach pain (1.7%)³. Likewise, another study reports that the most common complaint of pregnant women who regularly consume iron tablets is constipation. The most common side effect found in pregnant women after consuming iron tablets is constipation¹².

Consuming vegetables that contain high amounts of iron is one option for meeting the need for iron.Iron can be found in various types of vegetables, such as okra. Okra is extremely beneficial in alleviating the symptoms of pregnancy. Globally, studies regarding the benefits of okra for increasing haemoglobin have not been carried out. Therefore, researchers tried to do an exploration to test the benefits of okra as an alternative for increasing iron for pregnant women because it contains rich amounts of iron, folic acid, and vitamin C¹³. Vitamin C is very good for helping the absorption of iron tablets consumed by pregnant women every day. The results of previous studies have proven that absorption of iron in the body's organs will be more optimal if consumed with foods rich in vitamin C because they will provide acidic conditions that facilitate the reduction of ferric iron to ferrous^13-17. The fibre content in okra can maintain the digestive system and prevent constipation by increasing intestinal motility¹⁸. The addition of okra extract to food protects against gastric irritation and acts as an antimicrobial¹³.

For this reason, this study was conducted with the aim of knowing the effectiveness of okra as an alternative in overcoming anaemia through increasing haemoglobin levels in pregnant women in the midwife's clinical practice.

MATERIALS AND METHODS:

The increase in the Hb of pregnant women in this study was not only influenced by iron tablet supplementation without being separated from the food intake consumed by the respondents, one of which was the administration of infused Okra water. Okra, as a green vegetable, is a source of non-heme iron, which is rich in vitamin C as an enhancer¹⁹. Based on the literature, consuming sufficient vitamin C can increase the process of iron absorption²⁰. Okra is said to be very beneficial for genitourinary disorders, blood glucose levels, and working as an imbalance between antioxidants and reactive oxygen species (ROS) in the body causes oxidative stress, which can cause premature aging, atherosclerosis, and cancer^21-26.

This research is an experimental study with pre-test and post-test approaches. The intervention group in this study was given iron tablets plus okra, while the control group was given iron tablets without okra. At the beginning of the study, both groups measured Hb levels, then intervention was given. After the intervention, the Hb level was measured again by “Easy Touch Kit" Blood Hemoglobin Stick. The population in this study is all pregnant women with gestational ages of 16–32 weeks and Hb levels less than 30 who visit the midwife clinics from November 2021–March 2022, with an average of 10–15 respondents per month, for an estimated population of 50 respondents. The sampling technique was a purposive sample. The sample size was 100 people, with the control group consisting of 50 pregnant women who only take iron tablets and the intervention group consisting of 50 pregnant women who take iron tablets and drink Okra-infused water. Every day for 90 days, 150ml of infused okra water is given. After 90 days, the second Hb level was checked using the Hb test kit in the intervention group and the control group, and the checked data was analysed using a paired t-test.

This study is licensed by the ethics commission of the University of Muhammadiyah Sumatera Utara with ethical approval number 593/KEPK/FKUMSU/2021 dated August 26.

RESULTS:

Table 1: Mean and Standard Deviation of Hemoglobin Levels of Pregnant Women Before and After Administration of Okra and Iron in the Intervention Group

Variable	Mean	Standard Deviation	Difference	p-value
Pre-Intervention	10.208	0.5613	0.400	0.005
Post-Intervention	10.608	0.5576	0.400	0.005

Number of samples=100(N=100)

The results of the data analysis showed that the mean Hb level before giving infused Okrawater with iron tablets was 10.208mg/dL, and the mean after increasing it was 10.608mg/dL. There is a significant difference in Hb levels of pregnant women before (pre-test) and after being given infused Okra water with iron tablet administration (post-test) in the control group.

Table 2: Mean and Standard Deviation of Hemoglobin Levels of Pregnant Women Before and After Administration of Iron in the Control Group (Comparison)

Variable	Mean	Standard Deviation	Difference	p-value
Pre-Intervention	10.208	0.5356	0.338	0.005
Post-Intervention	10.546	0.5226	0.338	0.005

Number of samples=100 (N=100)

The results of data analysis showed that the mean Hb level before being given iron tablets was 10.208mg/dL and the mean after increasing was 10.546mg/dL. There is significant difference in Hb levels of pregnant women before (pre-test) and after iron tablet administration (post-test) in the control group.

DISCUSSION:

A paired t-test statistical test yielded a p-value of 0.0005 (p-value<α), indicating that there is a significant difference in Hb levels of pregnant women before (pre-test) and after iron administration (post-test) in the group of pregnant women given only iron tablets. The findings of this study are consistent with the findings of Hastuty and Khodijah (2017)²⁷, who discovered that the average Hb level in the measurement before treatment is 10.7 g/L with a standard deviation of 0.55g/L. In the measurement after treatment, the average Hb level was 11.3g% with a standard deviation of 0.37g%. The results of the statistical tests obtained a value of 0.001, so it can be concluded that there is a significant difference between Hb levels measured before treatment and after treatment. In line with Purba's research (2020)²⁸ which obtained results that there was a relationship between the act of consuming iron tablets and the incidence of anaemia in pregnant women (p = 0.000), pregnant women who did not comply with consuming iron tablets had 8,641 times the chance of experiencing anaemia compared to pregnant women who are obedient to consuming iron tablets.

Consumption of iron tablets containing up to 60mg of iron per day for 90 days is the result of a government programme aimed at lowering the rate of anaemia in pregnant women. Iron is a mineral that is needed in biological processes in the body and is an essential element for the synthesis of hemoglobin, where this haemoglobin functions as a carrier of oxygen and energy throughout the body⁷.

In the results of this study, there were also seven of the 50 respondents in the control group who did not experience an increase in Hb levels. The respondents whose haemoglobin levels did not rise were in their second trimester. At this gestational age, the respondent had just taken iron tablets because generally the consumption of these tablets was in the 2nd trimester, so the possible effect was not significant on increasing Hb levels. In addition, in the 2nd trimester of pregnancy, there is a higher increase in cardiac output (40%) than in the 1st trimester. Iron deficiency often manifests as a drastic decrease in haemoglobin concentration during the second trimester, so even though pregnant women consume iron tablets every day, it takes time to increase Hb levels²⁹.

Various factors can cause Hb levels to not increase in pregnant women despite consuming iron tablets. Based on the results of the study, anaemia can occur due to nutritional status, non-optimal absorption of iron, and insufficient iron content in daily foods. The consumption of foods that can encourage iron absorption is very important to note. One type of food that can help increase iron absorption is ascorbic acid and meat. Pregnant women are expected to consume as much as 25-250mg of vitamin C, with absorption increasing up to 2-5 times³⁰.

Administration of iron tablets together with other micronutrients (multiple micronutrients) is more effective in improving iron status compared to iron supplementation alone. Diversity of food consumption is very important in helping to increase the absorption of iron in the body. Animal proteins, vitamins C and A, and folic acid can increase iron absorption in the body. Vitamin C found in green vegetables can increase iron absorption^31,10.

Based on the research of Osman et al. (2020)⁹, apart from the characteristics of women who are at risk, anaemia can also be caused by a low intake of nutrients derived from animals and vegetables in the diet. while these two types of nutritional sources also support the absorption of iron. Red meat is rich in iron, which can increase haemoglobin levels, while vegetables are rich in vitamins that can increase iron absorption.

Sabina et al. (2015)³² explained that pregnant women need to be given an understanding of a diet with nutrients that can increase and inhibit iron absorption during pregnancy. Types of foods that block iron are tea, coffee, milk, and minerals that are high in calcium. As a result, it is critical to educate pregnant women about the importance of eating iron-rich foods and to broaden the variety and nutrition of foods consumed on a daily basis.

Based on data analysis using paired t-test statistical methods, a p-value of 0.005 was obtained in the intervention group (p-value < α), indicating that the administration of Okra + iron influenced increasing Hb levels in pregnant women in the intervention group.Consumption of infused Okra water along with iron tablets can help improve iron reserves in the mother's body.

Based on the results of the study, it was explained that the iron content in okra—as much as 1.20 mg—could possibly help iron reserves in pregnant women^13,15,17,18. Okra, as a source of nutrients that are important for health, contains many minerals needed to maintain homeostasis in cells. Okra contains 84 mg of calcium (Ca), 90 mg of phosphorus (P), and 1.20 mg of iron (Fe)^33,34,17.

Deficiencies of iron, folic acid, and vitamin B12 commonly occur in pregnant women and are exacerbated by inadequate intake of nutritious foods. Iron supplements are given during pregnancy as one strategy to treat and prevent complications that can occur at any time in the mother or fetus. It is currently important to prevent and treat nutritional anaemia in a way that is easy and inexpensive¹⁹, given that during pregnancy, about 1.000mg of iron is needed to meet iron needs and the formation of haemoglobin¹⁰. Giving infused Okra water in this study is an easy and inexpensive alternative therapy. It can be a solution for the prevention and treatment of anaemia in pregnant women. Okra with high iron mineral content can affect the haemoglobin of respondents.

Vitamin C, apart from being an antioxidant, can reduce non-heme iron so that the ferric form turns into ferrous. The need for vitamins during pregnancy is 85mg/dl. Okra contains 21.1mg of vitamin C, which means that it contributes to 40% of the needs of pregnant women. Besides being able to meet the needs of vitamin C, it can also help with iron absorption because it acts as an enhancer that forms iron ascorbate chains that can dissolve at a high pH in digestion¹⁹. The bioactive components of okra, such as amino acids, folic acid, and B vitamins, can also support the synthesis of globin because the interaction between heme and globin will produce haemoglobin^17,19.

LIMITATION OF THE STUDY:

The limitation in this study was that it did not inquire about food recall consumption for 24hours. However, researchers have observed respondents through interviews during visits only by asking the types of food that are often consumed daily and also genetic diseases and iron overload as well as family economic condition related to dietary habit is not considered in this study.

CONCLUTIONS:

The results of the study show that the administration of iron tablets alone or iron tablets combined with infused Okra water can significantly increase the haemoglobin level of pregnant women. Because Okra can be consumed as a drink and a vegetable, giving infused Okra water can help with the prevention and treatment of anaemia in pregnant women who take iron tablets.

ACKNOWLEDGMENTS:

The author would like to expresses deepest gratitude to Sari Mutiara Indonesia University for the moral and material support.

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Received on 03.11.2022 Modified on 31.12.2022

Research J. Pharm. and Tech 2023; 16(12):5808-5812.

DOI: 10.52711/0974-360X.2023.00940