The formulation of Moringa leaf flour biscuit has followed the research results conducted by Dewi (2018) with Fe content 22.68ppm. Moringa leaf flour biscuits made with wheat flour 150g, Moringa flour leaves 100 g (40%), margarine 175 g, milk powder 30mg, sugar powder 125 g, salt 2 g kitchen, and one chicken egg. Then processed into biscuits (cookies) with a weight of 17 g/chip that has a content of moringa leaf flour 2.8g/chip and total nutrient content based on the calculation of FICL (food ingredient composition list) 1 piece of biscuit (cookies) Moringa leaf flour has energy 78.3kcal, 1.68g protein, fat 4.63g, carbohydrate 8.17 g, and Iron 0.99mg.

This research was conducted in the working area of Antang, Mamajang and Batua Public Health Center in Makassar and Clinical Pathology Laboratory of Hasanuddin University Hospital. The research took place in March 2020 to June 2020 after Ethical approval recommendation from the Medical Research Ethics Committee of the Faculty of Medicine of Hasanuddin University. The study used the quasi experiment research type, with the design of The Nonequaivalent control group Design in which the control and intervention groups were not randomly selected.10 The intervention Group is given the biscuit moringa leaves flour 2 pieces/day with a content of 2.8 grams of moringa leaf flour and a Fe tablet 2× 250mg and a control group given the tablet Fe 2× 250mg/day for 60 days. Sampling techniques with purposive sampling. Each group has 25 samples making it a total of 50 samples. The sample is a pregnant woman with anemia (Hb<11g/dl) in I and III trimester of a single fetus, does not have a history of diabetes, infection and genetic diseases and does not consume multivitamins and other minerals.

Data obtained directly from the respondents collected through a questionnaire sheet physical activity Baecke Index and Food recall 24h and 3 cc blood intake through the red vein that is assisted by laboratory officers at the research site then conducted hematology examination by using Sysmex hematology Analyzer in Clinical Pathology Laboratory at Hasanuddin University Hospital to know the value of erythrocytes index in blood.

Test Chi square to see the homogeneity of the respondents characteristics of both groups. Test data analysis of Paired Sample T-Test and Wilcoxon for a statistically significant average difference in two groups in pairs (average before and after each group). Then T-Test independent and Mann Whitney to see the statistically average difference between the two groups that are not paired (before and after between the biscuit moringa group and the control group).

Based on the results of the Wilcoxon test found the result that there is an average difference before and after the treatment of the group given biscuit moringa leaf flour from 27.55 to 28.00 with a mean difference value of 0.45 and p value=0.001, p<0.05 indicates that there is a difference in the value of MCH between before and after administration of the biscuit moringa leaf flour. The occurrence of increased MCH value in the biscuit moringa group makes the average value entered in the normal category than previously less than normal. In the control group the average change before and after treatment is from 26.85 to 26.87 with mean difference 0.02 and p value=0.584, p>0.05 means there is no significant difference before and after treatment in the control group.

The results of this study in line with the results of the research before by Idohou-Dossou et al., 2011 was found that a significant increase in the value of MCH in Moringa Oleifera group and control group, only different in the results of this research that control group increased but did not differ significantly from before and after treatment. This can occur due to the difference in the duration of administration and given dosage. In the study of Idohou-Dossou et al., 2011 Administration was conducted for 3 months and a given dosage of 100g of moringa leaves flour each week has consumed 3 times a day mixed in sauces or on slurries before they ate.11

Furthermore, the average intake of nutrients in the control group in the study is also still smaller than the intervention group and there is a meaningful difference in some nutrients such as protein, folic acid, zinc, iron, vitamin B1 and vitamin B2 which play an important role in the improvement of the indicator of anemia. However, it is not all nutrients that are fulfilled sufficiency needs each day, this can be caused most of the respondents have gestational age that is still in the I trimester because an estimated increase in Human Chorionic Gonadotropin (HCG) that occurs in the I trimester that leads to an increase in estrogen production is the cause of the emergence of nausea and vomiting symptoms that are very often encountered in about more than 70% of pregnant women.12 This is often what makes the pregnant women nutritional inadequate in I trimester.

Table 6 shows a significant difference in the mean difference value between the biscuit moringa group and the control group after The Mann Whitney analysis tested with p value=0.001, p<0.05. Moringa leaves contain a number of nutrients such as proteins, iron and vitamin C that could potentially prevent anemia more common in pregnant women.13 According to the conclusion of the results of the study conducted by Suzana et al., 2017 on the effect of Moringa leaf extract on hematology and biochemical values of patients with iron deficiency anemia that the water leaf extract supplementation of moringa as a natural supplement in addition to iron sulfate may help cope with iron deficiency anemia where the leaf extract of the moringa as an additional therapy provides an increase in the value of Hematocrit, MCH and MCHC.14

Based on the results of the test Paired T-Test found that there was no meaningful influence from before and after treatment in the biscuit moringa group and control group. However, both groups are both experiencing average value changes, seen in Table 4 in the biscuit moringa group occur the average value change from 33.27 to 33.41 with a difference of mean 0.14 and on Table 5 of the control group occur the average change from 33.28 to 33.36 with the mean difference of 0.08.

The need for red blood cells will increase because of the increase in physiological needs in the development of mothers and her baby. The mechanism of production of red blood cells is very complex and involves hormonal mediators such as erythropoietin, human placentals lactogen, estrogen and also progesterone. Although red blood cells are increased during pregnancy, the value of improvement differs from the increase in this plasma volume resulting in a rigid physiological anemia in pregnancy.15 so that after treatment the both groups have MCHC values persist in the normal state and increase but not significantly. Furthermore, the content of moringa leaves that have a multi-ingredient micronutrient substance that is needed by pregnant women such as: beta carotene, thiamin (B1), Riboflavin (B2), niacin (B3), calcium, phosphorus, magnesium, zinc those who maintain MCHC score have even fewer increase in biscuit moringa group.8

Difference with the research results of Suzana et al., 2017 where the study gained a significant increase in the MCHC value for the group that received Moringa Oleifera but decreased in the control group. Nutritional intake affects the results of this research. In research conducted by Hadju et al. (2015) for the administration of moringa leaf extract results in the erythrocyte value of both groups that also experienced an increase before and after administration but not significantly, and also no increase in differences between the two groups but able to increase hemoglobin levels significantly so that moringa leaves extract proved to prevent anemia in pregnant women.13

Based on the data on Table 4 occurs an average increase and differs significantly from before and after administration on the biscuit moringa group from 78.57 to 78.93 with a difference of mean 0.36 and p value=0.034, p<0.05. In the control group also experienced an average increase from 77.92 to 77.94 with a difference of mean 0.02 and p value=0.881, p>0.05 that means did not differ significantly from before to after treatment. This results in line with the research conducted Adegbite et al. (2016) where there was a significant increase in the MCV value after given food with the addition of moringa leaf flour. This can happen because Moringa Oleifera has been found to contain alkaloids, flavonoids, phytosterols and saponins that are known to have hematopoietic properties. In addition to this bioactive substance in the leaves of Moringa Oleifera, it is also said to be A source of vitamins A, B, C, minerals such as iron and proteins that all contribute to the formation of erythrocytes especially in the formation of hemoglobin in the blood.16 In addition, due to the high level of sensitive MCV erythrocytes to the change of erythrocytes to determine the likelihood of iron deficiency affects these differences are supported also by the difference in iron intake among the biscuits moringa group and control group.14

Based on the data in Table 6 test results the difference of the mean biscuit moringa group and control group get the value p=0.003, p<0.05 which means there is a significant difference to the increase in MCV between the both groups. This can be due to the iron content of the 22.68ppm moringa biscuit tested proximate on the research by Dewi (2018) which is known to be used in preventing anemia in pregnant women.9 In addition, a meaningful mean difference in protein nutrient intake, folic acid, iron, vitamin B1 and vitamin B2 between the biscuit moringa group and the control group supports this to occur. According to the research results many mention the high content of protein, vitamin B, vitamin C and iron in the moringa leaves. The iron on the leaves of the dried moringa or in the form of moringa leaf flour is equivalent to 25 times higher than that of spinach and also used as alternative to prevent anemia in pregnant women naturally.17 This proved by the feeding of extra biscuits (cookies) moringa leaf flour able to improve the value of the MCV erythrocytes in pregnant women with anemia.