| Abstract|| |
Background and Objective: Pregnancy and the period afterward are accompanied by major psychological and physiological changes. Stress in pregnancy can be associated with poor prenatal results and adverse repercussions for the health of the mother. Hence, the present study aimed to investigate the effects of physiological parturition training on stress and mental health of pregnant women. Methodology: As a two-group, randomized clinical trial, the present study was conducted on 50 pregnant women visiting Kermanshah-based health-care centers and Motazedi Hospital in 2015. The samples were randomly divided into the experimental and control groups. The experimental group was provided with eight 90-min training sessions, from which the control group was excluded from the study. For data collection, a researcher-made demographic questionnaire, the depression anxiety stress scale-21, and the general health questionnaire-28 were utilized. Moreover, the three questionnaires were distributed to both groups in the pretest and posttest. To analyze data, the Levene's test, analysis of covariance, and Kolmogorov–Smirnov test were employed in the which were filled out by the participants in a pretest-posttest design. Data analysis was performed in SPSS, version 20, using analysis of covariance. Results: Given the findings of the present study as well as the difference between the mean scores before and after receiving the physiological parturition training (measuring 13 and 7.4, respectively), it was concluded that the said training was efficacious in the alleviation of stress in pregnancy (P < 0.01). Furthermore, due to the mean scores before and after receiving the physiological parturition training (measuring 23.6 and 20.55, respectively), it was concluded that this training was effective in improving the general health of pregnant women (P < 0.01). it could be concluded that reduction scores after the training sessions was indicative of improved mental health and stress of the participants. Conclusion: According to the results of the present study, exploitation of physiological parturition training both promotes the mental health of pregnant women and lessens the accompanying stress and consequences. Accordingly, this training is thoroughly recommended for all eligible pregnant women.
Keywords: Mental health, physiological parturition training, pregnancy, stress
|How to cite this article:|
Ayoubi S, Bostan N, Sharifipour F. A study of the effects of physiological parturition training on pregnant women's stress and mental health. Ann Trop Med Public Health 2017;10:878-83
|How to cite this URL:|
Ayoubi S, Bostan N, Sharifipour F. A study of the effects of physiological parturition training on pregnant women's stress and mental health. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 19];10:878-83. Available from: http://www.atmph.org/text.asp?2017/10/4/878/215857
| Introduction|| |
The pregnant mothers' mental health has significant impacts on the health of the fetuses, and its disregarding can be accompanied by dire consequences. A prime example is when depression in pregnant women is accompanied by stillbirth, committing suicide, and the possibility of giving birth to low birth weight (LBW) infants. In addition, the mothers' dysfunctional mental health impedes full care of themselves and fetuses. Thus, all the aforementioned factors can impair women's ability to perform roles in daily life, affecting their mental health. On the one hand, in addition to the marked changes in the physical and mental health of women, it seems that their social functioning and vitality have been lessened by pregnancy as well. For this reason, it is expected that the quality of life and mental health is lower in pregnant women as opposed to nonpregnant women. On the other hand, plasma cortisol and anxiety have been found to correlate among pregnant women so that this hormone is more secreted in distressed mothers, immediately affecting the fetus and impairing the development process of the infant. The effects of anxiety and stress tend to become visible in the form of disorders, including intrauterine growth restriction (IUGR), gestational diabetes, preeclampsia, preterm delivery (also known as premature birth), faulty loop in the labor process, and even increased rates of postpartum depression. Most importantly, the effects become noticeable in the form of dysfunctions in maternal roles and mothers' normal attachments to their infants., Stress in pregnancy predisposes mothers to complications, including anemia, hyperactivity, excessive irritability, fastidious diet, abnormal patterns of the fetal heart rates, low Apgar score, increased mortality at birth, LBW, development of depression during pregnancy, anxiety, and reduced milk production during the postpartum. In addition, stress in pregnancy causes infants to be vulnerable to irritability, more crying, unstable states, and even decreased mental development at the age of two. Physical ailments can give rise to psychological disorders, and physical illnesses can frequently cause hormonal and chemical changes which lead to psychological disorders. For instance, with the incidence of hypothyroidism (also called underactive thyroid or low thyroid), low levels of thyroid hormone (thyroxine) lessen serotonin, resulting in depression. Furthermore, hyperthyroidism leads to anxiety, anger, and aggression symptoms. Brain diseases result in psychotic disorders, and brain tumors give rise to impaired functioning in terms of intelligence, memory, speech, and language. According to Oates, not only does the happening of stressful events during pregnancy affect the children's mental health in childhood, they witness mental health problems in adulthood, indicating the seriousness of the issue and its profound effects on the entire life.
Stress in pregnancy, childbirth, and breastfeeding can be accompanied by poor pregnancy results and horrific repercussions, including miscarriage, stillbirth, nausea and vomiting, preeclampsia, weight loss, preterm delivery, LBW, immune suppression, episiotomy and neonatal infections, and postpartum mental disorders. Some of the accompanying complications of stress in pregnancy include attention-deficit/hyperactivity disorder, particularly among boys, growing difficult temperaments among infants, higher likelihood of being affected by schizophrenia, and similar disorders among the children of women who lose one of their beloved ones during their first trimester of pregnancy (approximately 67%), stressful women's higher probability of being pregnant with girls (more or less 5%), eating disorders (anorexia and bulimia), increased corticotropin-releasing hormone production, premature delivery, IUGR, and behavioral disorders in childhood. Accordingly, to provide mothers-to-be with physiological parturition, training courses can be advantageous to reducing the side effects, unpleasant symptoms, stress, rectifying the wrong mentalities about labor pain, and preparing for better deliveries through relaxation and concentration training, physical exercise, massage, etc. The secretion of endorphins (antipain hormone) and adrenaline hormones can be increased and decreased though relaxation, respectively. Furthermore, relaxation creates harmony between mind and body, causing a deeper relationship with the fetus. Therapeutic massages reduce pain through either blocking impulses to the brain or the topical relief of endorphins. It also stimulates the blood flow, detoxifies the body, strengthens the immune system, and creates feelings of well-being. In the deep breathing technique, more oxygen is transferred to the mother and the infant, and with slow exhalation, the body becomes relaxed. Moreover, stress is naturally coped with through secreting more endorphins in the body. Exercise increases the level of serotonin hormone which is secreted in the brain, whereby one's mood is regulated and depression and anxiety are lessened. High social support is associated with reduced cortisol and reduced anxiety. Numerous studies have been conducted on the beneficial effects of such courses. For example, in a study performed by Teixeira et al., on 58 pregnant women, it was shown that anxiety was significantly lessened through pregnancy training. According to the results of a study conducted by Shakeri et al., physical activities that are proportional to the conditions of pregnancy help improve the health of the mother and the fetus, and mothers-to-be should be equipped with physical activities. Hence, the present study aimed to investigate the effects of physiological parturition training on stress and mental health of pregnant women. To this end, the following hypotheses were proposed.
- The stress of pregnant women can be affected by the physiological parturition training
- The mental health of pregnant women can be affected by the physiological parturition training.
| Methodology|| |
As a two-group, randomized clinical trial, the statistical population of the present study comprised both all women at their 20 weeks' pregnancy and above with health-care records in one of Kermanshah-based health-care centers as well as pregnant applicants for the physiological parturition training courses offered at Motazedi Hospital in 2015. A sample of 50 pregnant women was selected using the simple random sampling who were randomly divided into the experimental and control groups (25 in each group). The experimental group was provided with eight 90-min training sessions from which the control group was excluded from the study. For data collection, a researcher-made demographic questionnaire, the depression anxiety stress scale-21 (DASS-21), and the general health questionnaire-28 (GHQ-28) were utilized. Moreover, the three questionnaires were distributed to both groups in the pre- and post-test.
The validity of these instruments was assessed through the content validity. In addition, their reliability was assessed through the test-retest and Cronbach's alpha coefficient. To commence the study, the required permits were obtained from the Vice Chancellery for the Department of Research and Technology at Kermanshah University of Medical Sciences. The inclusion criteria were lack of high-risk pregnancies, lack of abnormal stress (based on Holmes and Rahe's adjusted five-item scale), not having anxiety and depression, and not taking mind-altering drugs before and during pregnancy. To this end, the objectives of the study, methods, and duration of the interventions as well as the exclusion criteria were explained to the target subjects, and they were assured that they could discontinue their participation at any time and for any reason while taking the courses. After assessing the experimental group based on the said criteria, they were included in the study, and their informed consent was obtained. Ten pregnant women attended each class and were provided with eight 90-min training sessions. In the first session, each participant was given a book and a CD about the prenatal education and childbirth preparation. The theoretical discussions were presented with an emphasis on the dynamics of classes and mothers' participation. Further, the practical exercises were taught in groups according to the protocol of the Ministry of Health, and even in some sessions, the educational videos or related posters were displayed to the participants to better understand the practical contents. Since the participants were issued with health certificates by their gynecologists and midwives, they were not banned from taking childbirth preparation classes and doing the pregnancy exercises. At the start of the classes, the fetal heartbeats were heard using a Sonicaid, and the blood pressures of the participants were checked. In each session, the mothers exercised for 20 min in a suitable place. Then, while they were lying down, the relaxation and breathing techniques were exercised, and they were recommended to perform the same techniques at home as well. The first questionnaire was completed in the first session before the start of classes, and the mothers attended the classes as scheduled. For those who were absent for one session, the theoretical contents were repeated in the next attendance. However, in the event of more than three repeated absences, they were excluded from the study while continuing the classes. Moreover, the second questionnaire was completed at the end of the eighth session. The assessment of the control group was simultaneous with that of the experimental group in the health-care centers. After the course termination (eight sessions), the pregnant women in the experimental group and their accompanying persons were issued with certificates of participation and completion of the course. To analyze data, the Levene's test, analysis of covariance, and the Kolmogorov–Smirnov test (K–S test) were employed in the SPSS Statistics Software Version 20 developed by IMDB cooperation, London, UK.
| Results|| |
According to the results of the present study, the pregnant women participating in both groups were homogeneous in terms of age, education, occupation, gestational age, number of deliveries, history of chronic mental illnesses, and exposure to stressful events in the past year. Based on the descriptive findings of the GHQ-28 questionnaire [Table 1], the mean scores measured 23.6 and 20.55 in the pretest (experimental) and posttest groups (control), respectively. In other words, following the physiological parturition training courses, the mean score of the mental health dropped by three points in the experimental group, suggesting that the intended training had positive effects on the mental health of the pregnant women. According to the results of [Table 1], the mean score of the pretest in the experimental group measured 13.0, which dropped to 7.4 after the physiological parturition training courses. This score declined by 6.5 units, indicating the positive effects of physiological parturition training on the stress of pregnant women.
Before hypothesis testing, the required presuppositions for employing the parametric tests were examined. This presupposition stated that the distribution of scores between the two groups was not significantly different from the normal distributions in the statistical population. To test this hypothesis, the K–S test was employed [Table 2]. As can be seen, the significant values exceeded 0.05 for both questionnaires in the pre- and post-test groups. Hence, their distributions can be normalized with confidence.
The equality of variances was another presupposition, for which the variance analysis was used. This presupposition stated that the variances of the scores of two groups were equal in the statistical population and were not significantly different. In addition, the Levene's test was exploited to test this hypothesis [Table 3].
|Table 3: The Results of the Levene's test in Depression Anxiety Stress Scale-21 and General Health Questionnaire-28|
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Based on the analytical results presented in [Table 4], it was demonstrated that there was a significant difference between the mean scores of the pre- and post-test in terms of stress (P < 0.05). Hence, the first hypothesis, stating that the stress of pregnant women can be affected by the physiological parturition training, was supported. The impact factor measured 0.287, which was indicative of the fact that the individual differences in the experimental and control groups were determined by group membership. In addition, the statistical power was 0.980, indicating the fact that the sample size was sufficient enough for examining this hypothesis.
|Table 4: The results of the analysis of covariance of the effects of physiological parturition training on reducing stress in the posttest|
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Based on the analytical results presented in [Table 5], it was revealed that there was a significant difference between the mean scores of the pre- and post-test in terms of mental health (P < 0.05). Accordingly, the second hypothesis, stating that the mental health of pregnant women can be affected by the physiological parturition training, was supported. The impact factor measured 0.306, which was indicative of the fact that the individual differences in the experimental and control groups were determined by group membership. In addition, the statistical power was 0.988, indicating the fact that the sample size was sufficient enough for examining this hypothesis.
|Table 5: The results of the analysis of covariance of the effects of physiological parturition training on mental health in the posttest|
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| Discussion and Conclusion|| |
The first hypothesis stated that the stress of pregnant women could be affected by the physiological parturition training. To this end, the scores of the experimental group were compared in the pre- and post-test on the DASS-21 questionnaire to see if there were any significant differences in terms of the scores of stress before and after training. Given the findings of the present study as well as the difference between the mean scores before and after receiving the physiological parturition training (measuring 13 and 7.4, respectively), it was concluded that the said training was efficacious in the alleviation of stress in pregnancy. Consistent with the results of the present study, the results of studies conducted in the UK and Sweden about the relationship between the social support, quality of life, and stress among the pregnant women indicated that the prevalence of stress in pregnancy was 33%–37% and 5%–7%, respectively. Research indicates that labor, as the most stressful physical and mental event, affects the physical and psychological indicators of pregnant women during childbirth, and nondrug therapies for reducing labor pain can be used as effective interventions to alleviate the stress of mothers during childbirth. Mulder et al. concluded that there was a direct relationship between the maternal anxiety and abnormal fetal brain developments. In addition, it was found that high levels of anxiety and stress were associated with increased premature birth, LBW, spontaneous miscarriage (also known as spontaneous abortion and pregnancy loss), and birth abnormalities. In a study conducted by Akbarzadeh et al., it was demonstrated that the anxiety of the mother, as the first person affecting the mental health of a child, was exceedingly important, and to adopt different approaches to mitigate the maternal anxiety played a significant role in lessening the mental problems of the mother and child. Hence, it is the responsibility of community health workers to enhance the provision of social protection for pregnant women and to improve the quality of physiological parturition training and quality of life toward reductions in both stress and its adverse consequences.
The second hypothesis stated that the mental health of pregnant women could be affected by the physiological parturition training. To this end, the scores of the experimental group were compared in the pre- and post-test on the GHQ-28 questionnaire to see if there were any significant differences in terms of the scores of mental health before and after training. Furthermore, due to the mean scores before and after receiving the physiological parturition training (measuring 23.6 and 20.55, respectively), it was concluded that this training was effective in improving the general health of pregnant women. Consistent with the results of the present study, the results of a study performed by Dalfrà et al. revealed that 2%–6% of pregnant women suffered from acute symptoms in terms of health and compared to 2 years before their pregnancies, they were 20 times more in need of hospitalization due to mental disorders.
In addition, Wang et al. showed that women tended to speak with their fetuses during pregnancy and were worried about their fetal growth and development. Therefore, pregnant women may feel that their personal control on solving problems has lessened, resulting in reductions in their social power owing to feelings of isolation and reduced social activities along with a reduction in their daily contacts which lay the groundwork for mental health problems in terms of social functioning during pregnancy. Khodabakhsh and Mardani concluded that pregnancy is perceived by women as a vulnerable period during which they are faced with new difficulties.
The above findings are indicative of the need for paying more attention to the mental health status of pregnant women. In a study conducted by Hosseininasab and Taghavi (2010), the results revealed that the prenatal education proved efficacious in lessening anxiety in such a way that the trained women witnessed less anxiety as opposed to the control group. In a study done by Melzer et al., it was concluded that some interventions should be designed by the health-care workers to promote exercise during pregnancy among the pregnant women. To prevent the occurrence of various complications and disorders to the fetuses during pregnancy and after birth to mothers, the results of the present study play vital roles in the measures taken by the health organization to stress the importance of the psychological aspects of physiological parturition training.
The present article was approved under the terms of the ethical codes of 19220701941020 and 2N2016100427633IRCT on August 19, 2015. In the end, our grateful thanks to all participants in the present work for their kind support and cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Psychology and Counseling, Faculty of Literature and Humanities, Islamic Azad University of Kermanshah, Kermanshah
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]