Highlights:
What is current knowledge?
Anemia during pregnancy may lead to serious maternal and fetal complications and some interventions had examined to prevent it.
What is new here?
Consumption of dates alone or combined with ferrous fumarate supplementation could be recommended to pregnant women in order to prevent or control anemia during pregnancy.
Introduction
 Maternal mortality is widely acknowledged as a general indicator of the overall health of a population, of the status of women in society, and of the functioning of the health system (1). According to the World Health Organization (WHO) report in 2015, the prevalence of maternal mortality was 239 per 114100 million live births in the least developed countries and 15 cases per 100 million live births in developed countries (2). According to the Indonesia Demographic and Health Survey, the MMR in Indonesia was 305 per 100,000 live births in 2015 (3). This high MMR in Indonesia is inseparable from complications that occur during pregnancy, childbirth and the puerperium. The most common causes of maternal mortality are thought to be bleeding (28%), eclampsia (24%) and infection (11%). Nutritional problems arising from anemia in pregnancy and chronic energy deficiency are some indirect causes of maternal mortality (4). Anemia during pregnancy remains an important public health problem in Indonesia as about 49% of pregnant women in the country experience anemia during pregnancy (4). Previous studies have well-demonstrated the increased risk of maternal morality associated with anemia in pregnancy (5, 6), highlighting the need for immediate and effective prevention programs against the condition (7). Daily ferrous fumarate supplementation is a commonly used pharmacological therapy for anemia during pregnancy, while consumption of dates (Phoenix dactylifera) is suggested as a non-pharmacological alternative owing to the high iron, vitamin B12, vitamin C and folic acid content (8-11). A study reported that Ajwa dates contain less iron (0.85 mg/100 g date), while Tunisian dates have the highest iron content (7.2 mg/100 g date) (12). In addition, 100 gr of date contain 5.2% crude fiber and minerals, such as calcium (65 mg), phosphorus (72 mg), potassium (521 mg), magnesium (20 mg) and selenium (0.34 mg). Dates also contain vitamin A (0.04 mg), vitamin B1 (0.08 mg), vitamin B2 (0.05 mg) and nicotinic acid (2.20 mg) (13).
Although numerous studies have investigated the effect of ferrous fumarate supplementation on hemoglobin levels in pregnant women, there is insufficient data on the effect of date consumption on hemoglobin levels, particularly in the third-trimester of pregnancy. Therefore, this study aimed to compare effects of ferrous fumarate supplementation alone and along with date consumption on hemoglobin levels of women in third trimester of pregnancy.
Methods
This was a quasi-experimental study with a pretest-posttest design. Study population consisted of all pregnant women in third-trimester of pregnancy who were referred to the Puteri Ayu Public Health Center in Jambi (Indonesia) for antenatal visits during April and November 2019.
Inclusion criteria were as follows: being in the third trimester of pregnancy, a minimum upper arm circumference of 23.5 cm and having no dietary restriction on iron sources (plant and animal protein). Those who consumed tea and coffee during the study, had serious diseases/infections and were active smokers were excluded from the study. Overall, 60 participants were enrolled in the study via convenience sampling. The subjects were then equally divided into two groups of ferrous fumarate supplementation alone and ferrous fumarate supplementation combined with date consumption.
Hemoglobin level was determined using the Sahli Haemometer at baseline and after consumption of dates. The subjects in the combined group consumed three pieces of Sukari dates a day for seven days. The type of date was selected based on the subjects’ preference.
Data were expressed as mean ± standard deviation (SD). Analysis of data was performed in SPSS 16 using the paired t-test and independent t-test and at significance of 0.05.

Results
 The mean age, mean gestational age and number of parity of subjects were 26.33±6.13 years (range: 18-38 years), 33.30±3.67 (range: 28-39 years) and 2.20±1.00 (range: 1-5), respectively.
As shown in table 1, hemoglobin level in pregnant women increased significantly after ferrous fumarate supplementation (P=0.000). The simultaneous use of ferrous fumarate and dates also resulted in a significant increase in hemoglobin level of pregnant women (P=0.000) (Table 2). Table 3 shows the effects of ferrous fumarate supplementation alone and combined with dates consumption on the hemoglobin level of pregnant women. Discussion

Funding source
The authors received no financial support for the research, authorship, and/or publication of this article.
 

Ethical statement
The study was approved by the Health Research Ethics Committee of Komisi Etik Penelitian Kesehatan Poltekkes Kemenkes Jambi (Reference number LB.02.06/2/31/2019).

Conflict of interest
The authors declare that there is no conflict of interest.

Author contributions
 IK and AGW were responsible for the study conception and design; YS performed the data collection; IK and AGW performed the data analysis; IK, AGW, and YS were responsible for the drafting of the manuscript; IK and AGW made critical revisions to the paper for important intellectual content.