A woman’s health is essential to the good health of her baby. Women who eat well and exercise regularly along with regular prenatal care are less likely to have complications during pregnancy, and also more likely to successfully give birth to a healthy baby. Eating a nutritious diet during pregnancy is linked to good foetal brain development, a healthy birth weight, and it reduces the risk of many birth defects. Anaemia is common problem during pregnancy due to haematological changes occur in pregnancy results in physiological anaemia, and also nutritional deficiency is one of the cause due to their poor economic status. ¹

Anaemia is a condition that develops when blood lacks enough healthy red blood cells or haemoglobin (< 10 grams). Haemoglobin is a main part of red blood cells and binds oxygen. If having too few or abnormal red blood cells, or haemoglobin is abnormal or low, the cells in the body will not get enough oxygen. Iron deficiency anemia this is the most common type of anemia worldwide. Vitamin deficiency anemia, anemia of chronic disease, aplastic anemia, anaemia associated with bone marrow disease, hemolytic anemias, Sickle cell anemia and Other anemia. There are a number of causes for each type of anaemia, Anemia occurs due to iron deficiency, B12 deficiency, folate  deficiency ,red blood cells prematurity, inadequate intake of diet, chemotherapy drugs, alcohol use and bone marrow diseases.² 

Anaemia during pregnancy is especially a concern because it is effect associated with low birth weight, premature birth and maternal mortality. Women who are pregnant are at a higher risk for developing anaemia due to the excess amount of blood the body produces to help provide nutrients for the baby. Symptoms of anaemia includes weakness, fatigue, irritability, dizziness, dysphagia, pale sclera, conjunctiva, shortness of breath, glossities, headache, palpitations, abnormal heartbeat, lethargy, tachycardia, heart murmur. Complications of anaemia, It includes, increases   neural   tube defects in foetus, congenital anomalies, foetal growth restriction. Maternal complications are, heart failure, pneumonia, urinary tract infections, preterm delivery, thalamesia, and pancytopenia.³

Anaemia during pregnancy can easily be treated by adding iron or daily supplements, to the daily routine. Pharmacological therapy for anaemia, intravenous, drug iron sucrose (200mg) , recombinant human erythropoietin (10,000 U) . However, in very rare cases, women with severe anaemia may need a blood transfusion. Some of the non pharmacological therapy includes combination  of jaggery and moringa powder extract. Moringa leaf powder is one of the local potential is widely used   in India. It contains iron and vitamin C which is quite high, Moringa leaf extract can improve haemoglobin levels and have equal ability with iron supplements of folic acid in preventing anaemia in pregnant women. Moringa leaf extract can be used as an alternative to prevention of anaemia in pregnant women.⁴

Moringa, is a natural as well as cultivated variety of the genus, moringa belonging to Family Moringaceae. It is one of the richest plant sources of vitamin A, B and C, D, E, K. The vital minerals present in moringa includes Iron, calcium, copper, Potassium, Magnesium, manganese and zinc. It has more than 40 natural anti-oxidants.   Moringa has been used since 150 B.C. by ancient kings and queens in their diet. Moringa provides excellent support of the body’s anti-inflammatory mechanism, enrich anaemic blood and support Immune system. It also improves eye sight, mental alertness and bone strength. It has potential benefits in malnutrition, general weakness. Lactating Mothers,  menopause, depression and osteoporosis .Moringa is an edible extremely safe plant. The tree could easily and cheaply be cultivated and grown. It is need to explore therapeutic, nutritional and benefits of this gift of nature reported to be one of the world’s most useful tree.⁵

Moringa Leaf extract can improve hemoglobin levels and have equal ability with Iron supplements of folic acids in preventing anemia among pregnant women.  Nutrient     deficiencies is a public health problem that is often found in pregnant women. Thus increasing the   risk of morbidity and mortality in mothers and infants. Iron deficiency has been known not only the cause anemia in pregnant women Iron substances also usually interact with other Micro nutrients in the body. In pregnant women with anemia was also found to have deficiencies of micro nutrient such as Zinc and Folic acid. Moringa leaf extract can improve hemoglobin levels and have equal quality, ability with iron supplements of folic acid and for anemia prevention in pregnant women.  Moringa contains astonishing iron compared to any other animalistic source that 100 grams of moringa powder contain 28 mg of iron, and might help a person’s body absorb more iron, therefore the red blood cell count. It is thought the moringa extract is very helping in treating and preventing anemia.⁶

NEED FOR THE STUDY

Anemia during pregnancy is a major cause of morbidity and mortality of pregnant women in developing countries and has both maternal and fetal consequences. Anemia during pregnancy is considered severe when hemoglobin concentration is less than 7.0g/dl, moderate when hemoglobin is from falls concentration is from 10.0-1 Nutritional, genetic, and infectious diseases are contributing factors for anemia. However, iron deficiency is the cause of 75% of anemia among mothers.⁷

More than half of the pregnant women in the world have less haemoglobin levels indicative of anaemia. Although only 15% of pregnant women are anaemic in developed countries, the prevalence of anaemia in developing countries is relatively high (33% to 75%). The Prevalence of anaemia among pregnant women in United States was reported at 16.2 % in 2016. Although the prevalence of anemia is estimated at 9% in counties with low development; the prevalence is 43%. Children and women of reproductive age are most at risk, with global anemia prevalence estimates of 47%in children younger than 5 years,42% in pregnant women, and 30% in non-pregnant women aged 15-49 years and with Africa and Asia accounting for more than 85% of the absolute burden in high risks groups.⁸

The prevalence of anemia was 98 % among the pregnant females in the region of rural India, out of these 41.71% had mild anemia, 37.05% had moderate anemia, and15.88% had severe anemia. The proportion of women experiencing anemia increased with the increase in gestational age (trimester 15.5% to 46.6% in III trimester).⁹

Anemia in pregnancy continues to be a health problem the overall prevalence of anemia was 99% among women in lab our who are attending the labour ward at Government maternity hospital, from   adjoining districts of Nellore, Chittoor, Kadapa, Ananthapuram. The study was conducted from January 2022 to November 2022,  revealed a high prevalence of anemia, among younger age group of pregnant women i.e. 21-25 years and the distribution of anemia was almost equal in urban and rural population. Most iron-rich nutritional sources are animalistic, such as meat and liver. Usually the content and bioavailability of iron from plant sources is lower. For this reason, Vegans and Vegetarians are at particular risk of anemia. ¹⁰

A  Randomized double blind   study conducted   with  Pre test-Post test design by using a sample of non-anaemic pregnant women, conducted in the coastal areas of Makassar, Mariso and Tamalate. Total sample  of 35 people per group. Pregnant women who meet the criteria (Gestagational age 5-6 months of pregnancy, haemoglobin (Hb) < 10.5 g/dL, and working as a housewife) divided into two groups by simple random sampling. The first group received the intervention of Moringa leaf extract and the second received supplementation of folic iron (60 mg Fe and 0.25 mg folic). Intervention performed during 12 weeks..Haemoglobin (Hb) level was measured by cyanmenthemoglobin method using a hemocue. Hb levels of pregnant women in a group of moringa leaf extract before intervention (11 283 ± 0777 g/dL) increased to 11 754 ± 1089 g/dL after intervention (p = 0.040). Hb levels of pregnant women in folic iron group also increased between before and after intervention (P = 0.002). ¹¹

It is known that the bioavailability of iron is increased in the presence of Vitamin C, Vitamin A and carotenoids, as well as reducing (antioxidizing) agents. Moringa leaves contain all of these compounds in high quantities. Several pregnant women suffering from anemia were given moringa and very quickly recovered from their symptoms.¹²

STATEMENT OF THE PROBLEM

A study to assess the effectiveness of moringa Leaves on anemia among pregnant women in Narayana Medical College Hospital, Nellore, Andhra Pradesh.

OBJECTIVES

1. To estimate the level of anaemia among pregnant women.
2. To assess the effectiveness of Moringa leaves on anaemia among pregnant women.
3. To find the association between effectiveness of moringa leaves on anaemia with their selected socio demographic variables.

RESEARCH HYPOTHESIS:-

• H₁: There is statistically significant effectiveness of moringa leaves on anaemia among pregnant women.
• H₂: There is statistically significant effectiveness of moringa leaves on anaemia between the experimental group and control group.

DELIMITATIONS

The study is limited to;

• Pregnant Women attending, Narayana Medical, College Hospital, Nellore.
• The pregnant women suffering from anemia.
• Sample size is 60.

Research Approach: A quantitative research approach was adopted for the present study. 

Research Design: Quasi experimental design

O₁ – Pre-test

X – Intervention   with moringa leaves extract.

O₂ – Post-test

Setting: The study was conducted in Obstetrics department in Narayana Medical College Hospital, at Chinthareddypalem, Nellore.

Population:-

Target population:-Pregnant women with anemia

Accessible Population:-Pregnant women were attending OPD and IPD in Narayana Medical College Hospital, Nellore.

Sample:- Pregnant women with anemia admitted at Narayana Medical College Hospital, Nellore and who fulfilled the inclusion criteria.

Sampling Technique: - The sample was selected by non-probability Purposive sampling technique.

Sample Size: - The Sample size for the Present study was 60 samples. 30 pregnant women was allotted to experimental and 30 allotted to control group.

Criteria for sample collection: -

Inclusive Criteria: -

• Pregnant women with anemia, admitted at Narayana Medical College Hospital.
• Pregnant women who are willing to participate in the study & who are available at the time of data collection.

Exclusion Criteria: -

• Pregnant women with anemia who are not willing to participate.
• Pregnant women who are suffering from other systemic illness

Variables: -

• Independent Variable: - Moringa powder.
• Dependent Variable: - Level of anemia.
• Demographic variables:- Age, gravida, trimester, body mass index, and number of children, education, type of diet, family income, iron supplementation, gap between pregnancy, nature of previous delivery, area of residence, family type and history of anemia.
• Extraneous Variables: -

Description of the Tool: -

• Part - I: It deals with the demographic data.
• Part - II: Measurement of Hemoglobin % by using clinical method by means of collecting 2ml of blood following aseptic techniques from the pregnant women and transport to central lab through messenger to evaluate the findings.
• Part - III: ICMR Grading of anaemia.

Grading of anaemia according to ICMR:

 Intervention protocol:-

 Introduction:-

Moringa oleifera is a plant that is often called the drumstick tree.  Moringa has been used for centuries due to its medicinal properties and health benefits. It also has antifungal, antiviral, antidepressant, and anti-inflammatory properties.

Moringa powder preparation:-

 Preparation of moringa leaves powder by collecting the dried moringa leaves into the bowl or sheet and grinding it. Adding 10-30 grams of powder in to the 200 ml luke warm water. It is administrated once in a day, after dinner for 25 days.

Mechanism of action:-

Total iron content in Moringa extract of the averages 14.67mg/ 100g extract. Moringa leaves, especially dried leaf powder, are known to be excellent sources of iron, compared to most plants.  Iron is part of the haemoglobin molecule, which is the main protein in red blood cells, and also it contains vitamin c, help to absorb more iron, and the red blood cell count. It is thought the moringa extract is very helping in treating and preventing anaemia by improving iron.

Pilot Study: -

After obtaining permission from the concerned authorities the pilot study was conducted at Narayana Medical College Hospital in antenatal OPD, IPD and antenatal ward for 7 days.

Data Collection Procedure: -

The data collection procedure was carried for a 6 weeks, after obtaining formal written permission from the concerned authorities the main study was conducted in Narayana Medical College hospital at antenatal ward OPD and IPD ward for a period of 6 weeks. 60 pregnant women were selected by using Non –probability purposive sampling technique. The pregnant women with anemia are informed by investigator about the nature and purpose of the study and then written consent was obtained.

At first demographic data was collected, followed by measurement of hemoglobin by clinical method was done. The intervention is given for each pregnant moringa powder 30gms in 200ml of luke warm water for 25 days from 8.00 p.m to 8:15 p.m. The participants had given the information about the intervention for 25 days according to admission in the antenatal ward. For the control group routine care was given after that post test was conducted by using same tool to evaluate effectiveness of moringa between two groups. The data was organized according to objectives and hypothesis of the study. The collected data was analyzed by using descriptive and inferential statistics.

Plan of Data Analysis:

FIG:1 SCHEMATIC REPRESENTATION OF RESEARCH METHODOLOGY

Data Analysis & DISCUSSION:

Table-1: Frequency and Percentage distribution of  anaemia  among  pregnant women in the experimental and control group in pre-test                                                     (N=60)                                                                                                                                                                                                                                                                                                                                                                                                                  

Fig-1: Frequency and percentage distribution of pregnant women based on grading of anaemia in pre-test.

Table-2:  Frequency and Percentage distribution of anaemia among pregnant women in the experimental group and control group in post-test                                                                             (N=60)    

Fig-2: Frequency and Percentage distribution of pregnant women on grading of anaemia in post-test among experimental group and control group.

Table-3: Effectiveness of moringa leaves on anaemia among pregnant women in experimental group 

                                                                                                                            (N=30)  

Table-4:  Effectiveness of moringa leaves on anaemia among pregnant women in control group                                                                                                                         (N=30)

Table -5: Comparison between effectiveness of moringa leaves on anaemia among pregnant women in experimental and control group.                                        (N=60)                                                                            

Table-6: Association between post test anaemia with demographic variables among pregnant women in the experimental group.                                                                               (N=30)                                                                                                                       

Table-7: Association between post test on anaemia among pregnant women in the control group with their selected socio demographic variables                                                 

                                                                                                                                  (N=30)

MAJOR FINDINGS OF THE STUDY:

1. Level of anemia in experimental and control group:

• Regarding grading of anaemia, in pre-test, in experimental group, 5(17%) had mild, 16(53%) had moderate, 6(20%) had severe and 3(10%) had very severe anaemia.  Whereas in control group, 1(3%) had mild, 16(53%) had  moderate, 12(20%) had severe and 1(3%)  had very severe anaemia.
• Regarding the grading of anaemia in post test in experimental group, 25(83%) had mild, and 5(17%) had moderate anaemia. Whereas in control group, 6(20%) had mild, 15(50%) had moderate, 5(17%) had severe and 4(13%) had very severe anaemia.

1. Effectiveness of moringa leaves on anaemia in experimental and control group:

• As per Paired ‘t’ test, In experimental group, post test mean was higher than the pre-test mean. It is evident that the calculated value is greater than the table value; hence research hypothesis (H₁) is rejected. There is significant effectiveness of moringa administration on anaemia. In control group, the calculated value is less than the table value. Hence the research hypothesis (H₁) is rejected. There is no significance difference in the post test.
• As per Independent “t” test, the calculated value is greater than table value, so there is a significant in improvement of haemoglobin level in post test among experimental group than post test in the control group. It can be concluded that moringa administration was found to be effective on anaemia among pregnant women. Hence the research hypothesis (H₁) is accepted.

III: Association between post test anaemia with demographic variables among women in the experimental and control group:

• In experimental group, demographic variables such as age, gravida, trimester, number of living children, education ,type of diet, family income, taking iron supplementation, gap between pregnancy, mode of previous delivery and family type had significant association with level of anaemia at P<0.05 level.
• In Control group, demographic variables such as gap between pregnancy, taking iron supplementation and history of anaemia had significant association with level of anaemia at P<0.05 level.

The study concluded that there is a significant improvement of haemoglobin on anaemia after moringa leaves administration. Since significant percent of pregnant mothers found to have anaemia in india, Moringa leaves is readily available and cost effective green leafy is very much helpful in improving the haemoglobin levels and reducing anemia related symptoms. Adequate education and awareness to be created among public regarding the moringa leaves consumption and its various health benefits.

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2. A text book of Harrison’s text book of clinical medicine 18^th edition 2012, Iron Deficiency and other hypo proliferative disorders published by mc graw – Hill.
3. A Hand book of food and nutrition by Dr M. Swaminatham fifth edition published by the Bangalore printing and publishing co ..Ltd Pg no 327-330.
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6. Journal on Phytochemicals of Moringa oleifera: a review of their nutritional, therapeutic and industrial significancev.6(2); 2016 Dec.
7. Shridevi (2018) A cross-sectional observational study was conducted on Prevalence of anemia based on peripheral smear findings at Maheshwara Medical College, Hyderabad,India.
8. Rajamouli Jet (2015) A Cross sectional study was conducted on the pregnant women attending in the Ante-natal Clinic in Rural Health Training Centre Annaram Karimnagar at Telangana^,
9. Totateja G.S (2007) A study conducted on prevalence of anemia among pregnant women and adolescent girl, New Delhi, India.
10. Abdul Munim (2016) A experimental study was conducted on leaves of Moringa which have been   empirically used as anti-anemia for pregnant woman in   Department of pharmaceutical care, Depok Indonesia.
11. Sri Rahayu (2016) A Quasi experimental study was conducted on low hemoglobin concentration during pregnancy with accidental sampling technique. Purwodadi Community Health Center, Pasuruan city of java, India.
12. Nadimin (2015) A randomized control study was conducted on pregnant women, aimed to determine the effect of Moringa leaf extract for anaemia prevention in pregnant women. Makassar, Indonesia.