The Effect of Hypnobirthing on Maternal Anxiety Levels and Length of Labor in Independent Practicing Midwives in the Panyabungan Area, Mandailing Natal Regency

ABSTRACT


INTRODUCTION
Childbirth is a phenomenon that every married couple looks forward to.However, as the birth process approaches, pregnant women will feel mixed feelings.Apart from being impatient to see the baby being born, the mother will also feel fear and anxiety when facing the birth according to Maryunani (2015).[1].The anxiety experienced by a birthing mother can have an impact on both the birthing process and the fetus in the womb.
Anxiety is believed to be a common mental problem in pregnant women, including more often in the third trimester of pregnancy.According to Silva et al., (2017), higher levels of anxiety in the third trimester of pregnancy may be related to the closeness of delivery, which is felt by some pregnant women as a vulnerable moment and capable of triggering feelings of fear.The number of cases of postnatal depression, one of which is caused by the unidentified psychological condition of pregnant women, is increasing.[2] Based on what Slade, et al., (2021) said, some pregnant women are not honest about the psychological conditions they are experiencing.They feel happy and enjoy their pregnancy, but actually they have big problems that can affect their pregnancy.Anxiety that is not identified during pregnancy can have an impact on the birth process and can even cause the mother to experience postpartum depression.[3] The level of anxiety greatly affects the well-being of pregnant women and the fetus in the womb.Low levels of anxiety in pregnant women can reduce the complications they cause so that they can indirectly reduce maternal and Int Jou of PHE  472 infant mortality rates, while high levels of anxiety can worsen complications in maternal and infant mortality rates according to Siallagan & Lestari (2018).[4] Research in Indonesia shows that pregnant women who experience high levels of anxiety can increase the risk of premature birth and even miscarriage.If this is allowed, the death and morbidity rates for pregnant women will continue to increase.[5] [6] Hasim (2018) also expressed the same thing in his research, where anxiety during pregnancy, if not addressed immediately, will have a negative impact on the mother and fetus.[7] Anxiety during pregnancy does not have a direct impact on death.However, anxiety can result in a decrease in uterine contractions so that labor takes longer, an increase in the incidence of uterine atony, bleeding lacerations, infections, maternal fatigue and shock, while in babies it can increase the risk of premature birth.and LBW.Previous research by Sariati, et al., (2016) showed that a history of mental health disorders, lack of social support, negative experiences of previous births, and Mood of Delivery (MOD) were correlated with Fear of Childbirth (FOC) and Post Traumatic Stress Disorder (PTSD).[8] This research confirms previous research where the results showed that the level of anxiety of the respondents was moderate anxiety as many as 14 respondents (43.8%), severe anxiety as many as 10 respondents (31.3%), mild anxiety as many as 6 respondents (18.8%)., and did not experience anxiety in 2 respondents (6.3%) from research data by Fazdria et al., (2016).This research aims to determine maternal anxiety during pregnancy, especially when facing childbirth.After knowing the phenomenon of anxiety experienced by birthing mothers, midwives can intervene so that the birthing mother can be more relaxed so that the birth takes place smoothly, naturally and normally without any trauma.[9] Identifying anxiety through instruments to measure maternal anxiety during pregnancy can help pregnant women so that their anxiety does not get worse and has an impact on the mother and baby.The results of the preliminary study obtained data on normal deliveries for 20 patients.Of the 20 patients, 15 (75%) experienced anxiety before giving birth.The high level of anxiety experienced by mothers giving birth can have an impact on the birthing process.
This is what prompted researchers to conduct research on the phenomenon of maternal anxiety before childbirth in order to identify the anxiety experienced by mothers giving birth so that appropriate interventions can be carried out as a solution to overcome anxiety in mothers giving birth.

RESEARCH METHODS
This research method uses a descriptive method with a cross-sectional approach to the research design.Crosssectional design is research to study the dynamic correlation between risk factors and their impacts, and all data can be taken over a certain period of time.The population in this study were all mothers giving birth normally who gave birth at the Independent Practice Midwives in the Panyabungan Area, Mandailing Natal Regency.The sampling technique in this research used a total sampling technique using all respondents.
Considering that research results can be generalized and the calculation does not require a sample size table, the sample size must be made representative.Thus, sampling in this study used the Slovin formula to obtain samples that could represent the condition of the object as a whole.This study used 40 subjects in physiological labor with an active phase of 4 cm to ≤ 7 cm who were willing to be respondents and follow research procedures.
The tool for measuring anxiety in mothers giving birth uses the Y-1 STAI scale (The Spielberger State and Trait Anxiety Inventory) containing 20 items, of which 10 items contain statements about anxiety (favorable) and 10 items do not contain statements about anxiety (unfavorable).The variable in this study is a description of the mother's anxiety before giving birth at the time of delivery.

RESEARCH RESULTS AND DISCUSSION
The results of the research subject characteristics showed 40 research subjects based on characteristics, frequency and percentage.Based on table 1, it can be seen that the characteristics of respondents according to age in the Independent Practicing Midwives in the Panyabungan Region, Mandailing Natal Regency, were mostly aged 20-35 years, namely 34 respondents (85%).The education level of respondents in the Independent Practice Midwives in the Panyabungan Region, Mandailing Natal Regency, was mostly low education, namely from elementary to middle school with a total of 21 respondents (52.2%).Characteristics of respondents according to work in the Independent Practice Midwives in the Panyabungan Region, Mandailing Natal Regency, showed that the majority did not work, namely 27 respondents (67.5%).Characteristics of respondents according to parity or number of pregnancies in the Independent Practicing Midwives in Panyabungan, Mandailing Natal Regency, most of whom were multiparous, namely 31 respondents (77.5%).The relationship between age and the level of anxiety in facing childbirth turns out to be quite closely correlated.The first pregnancy for a prospective mother is a new journey marked by physical and psychological changes resulting in various psychological problems [10] .In this study, the results showed that the majority of participants aged 20-35 years experienced severe anxiety, 25 respondents (62.5%).This means that the age of the birthing mother, whether in the risk category (>35 years) or non-risk category (20-35 years), does not have a significant influence on the anxiety level of the birthing mother.

Cross
However, this is supported by the results of research conducted by Komariah (2017) which found that a mother's readiness to give birth does not depend on age, so age is not a factor that influences the anxiety of a mother giving birth.Whether a person is mature or not is not only based on age.Some are still young, but they are ready to become a mother so they don't experience anxiety.[11] The results of a similar study conducted by Musahib, et al., (2015) also strengthen the results of this study where the factor of the age of pregnant women before giving birth at the Mabelopura Health Center Mabelopura Maternal and Child Health Clinic was not statistically related to anxiety levels. .This may be caused by uncontrolled interference factors that influence anxiety levels, namely knowledge.[12].
Meanwhile, regarding the relevance of education level to anxiety during childbirth, it has quite a large influence.The level of education of the respondents determines their ability to understand the knowledge and processes they have acquired.Thus, as the gestational age approaches the delivery process, the mother can prepare herself psychologically and mentally so as to reduce the burden on her mind.[13] The research results showed that 16 respondents (60%) with higher education experienced severe anxiety.These results are certainly not in line with the results of research conducted by Kotimaki et al., (2020) which shows that women with low education tend to have worse health status and habits and a higher risk of experiencing health problems during pregnancy, which can also cause health problems and contribute to anxiety and depression.[14] Mothers who are pregnant and have less knowledge will view the birthing process as something scary.However, this does not mean that highly knowledgeable mothers will not experience anxiety during pregnancy.The higher a person's level of education, the better they will be able to search for or receive information so that they can quickly understand the conditions and risks they face.However, this situation will cause the person to become more anxious.[15] The research results from Ni'mah (2018) also strengthen the results and theory used in the results of this research that third trimester pregnant women with low and high education have the same opportunity to experience anxiety when facing childbirth.This is because of the anxiety they experience in facing the birth.This does not depend solely on their education, but also depends on knowledge, interpersonal relationships, and also family history.[16] Meanwhile, the correlation between the work of pregnant women and anxiety in facing the birth period is quite close.Regarding job characteristics, the majority of mothers who do not work have a much lighter sense of anxiety compared to mothers who work, with 11 respondents (27.5%).The anxiety of people who work and don't work or as housewives certainly has different influences.Individuals who do not work tend to have a much heavier mental burden compared to individuals who work.
For mothers who are working, anxiety tends to be caused by work load and household chores.People who work tend to experience stress from the workload they bear.[17] This is reinforced by the results of Suyani's research (2020), where research shows that the majority of pregnant women who work experience anxiety.In the sense that there is an element of necessity, so it could be that the anxiety comes from the work itself and not from the process of preparing for childbirth.[18] This is also in line with research conducted by Mayasari (2018) which shows that one of the anxiety factors for pregnant women is work.The workload that a person has, such as feelings of incompetence in the world of work or feelings of not being able to provide maximum work results, will trigger feelings of anxiety in the individual.[19] The correlation between parity and the level of anxiety when facing childbirth has a close relationship.The parity level is able to attract the attention of researchers related to maternal and infant health.In general, it is said that Int Jou of PHE  476 there is a tendency for mothers who have high parity or have given birth more than once to be mentally prepared and also have a fairly good psychological condition.This is compared to mothers who have just had children or have given birth only once.[20] However, in fact the results of this study show that respondents who have experienced more than 1 birth have a tendency to feel severe anxiety with 23 respondents (57.5%).This is different from the theory from Manuaba (2012) that in maternity homes, mothers with primigravida parity have no idea about what will happen when they give birth.And we often find feelings of fear and anxiety because we often hear stories from mothers who have given birth before.As your pregnancy gets closer to the time of delivery, you will of course continue to imagine the frightening process of giving birth.[21] However, the results of this study are still in line with the theory expressed by Devi et al., (2018) that previous birth experiences have a role in influencing the mother's anxiety level in facing the birth process.[22].
It is very likely that mothers who have given birth before or are multigravidas can experience anxiety due to images they have experienced in bad birth experiences in the past.And this can also be influenced by birth abnormalities experienced by multigravida mothers.This statement is reinforced by the results of research from Harahap (2014) which shows that anxiety will increase with risk factors such as being too young and/or too old during pregnancy.The higher the parity, the more anxious the mother will experience when facing childbirth.[23] Then regarding the phenomenon and also the impact of anxiety on pregnant women when facing childbirth, there are factors that influence it.Childbirth is a phenomenon that is of course awaited by every married couple.Therefore, it is necessary to provide moral and material support from the family, especially the husband, to the community for the welfare of the mother and the fetus in her womb.However, when the birth process approaches, pregnant women can of course feel mixed feelings.There is a feeling of impatience to see the baby born, mothers can also feel fear and anxiety in facing their birth.
The theory most often associated with childbirth anxiety is the pain felt by the mother during the birthing process.The relationship between pain and anxiety is a positive correlation that is interconnected like a spiral with widening ends.The effects of anxiety are in the form of pain in a spiral pattern whose ends enlarge.The further along the labor process, the more anxious the mother will feel, and this anxiety causes more intense pain, and vice versa.[24] When a mother in labor feels anxious, the body will spontaneously release catecholamine hormones.An increase in this hormone will cause vasoconstriction of blood vessels, which can increase maternal blood pressure, reduce blood flow to the uterus, reduce uteroplacental flow, and reduce uterine activity, which can cause prolonged labor.[25].Maternal psychopathological symptoms during pregnancy are a significant risk factor for the well-being of the newborn.In particular, prenatal anxiety and depression negatively impact clinical aspects of the birth experience and, indirectly, the APGAR index.[26] A prospective cohort study conducted by Shao et al., (2020) showed that excessive anxiety experienced by pregnant women can trigger ADHD in boys (Attention Deficit Hyperactivity Disorder) through increasing C-reactive protein activity in the placenta.In his research, he explained that boys whose mothers experienced excessive anxiety during pregnancy at least in the last 2 trimesters tended to have significant mRNA expression in MCP-1, CRP, and HO-1 compared to the group of boys whose mothers did not experience excessive anxiety.experiencing excessive anxiety during pregnancy.The reason is also stated because the fetoplacental "connection" in male babies tends to be more sensitive to exposure to maternal cytokines and inflammation than in female babies.[27] Not only that, the negative impact of excessive anxiety on pregnant women when facing childbirth was also revealed by Ramos et al., (2022) that pregnant women who experience excessive anxiety tend to have a shorter gestational age due to the activity of the corticotropin-releasing hormone in the womb.placenta.It was explained that an increase in pCRH occurred between the second and third trimesters compared to early pregnancy.In addition, a sharper increase in pCRH from early pregnancy to the third trimester of pregnancy can be triggered by excessive anxiety.High levels of pCRH in the placenta can systematically "ripen" all products of conception and cause the gestational age to be shorter.Generally this event is called the pregnancy hour.[28] Therefore, when the mother who is giving birth is comfortable and relaxed, all the muscle layers in the uterus will work together in harmony as they should.That way, labor will run smoothly, easily and comfortably.If the body and mind can feel comfortable, then more constructive and positive thoughts can emerge.A positive surge in a birthing mother's self-confidence is very necessary during the birthing process because it can foster self-confidence.Confidence and mentality are needed to create the possibility of an uncomplicated birth.[29] The presence of a birth companion can provide a sense of comfort, security, encouragement and emotional support and can provide encouragement to the mother.Companions should play an active role in supporting mothers during birth.Supportive treatment measures include rubbing the mother's back or holding the mother's hand, maintaining eye contact, and reassuring the birthing mother that she will not leave it alone.[30] The presence of a birth companion can cause feelings of joy which will become impulses to neurotransmitters in the limbic system, then transmitted to the amygdala and then to the hypothalamus, resulting in excitation in the ventromedial nucleus and its surroundings.which can create a feeling of calm and ultimately reduce anxiety so that the mother feels comfortable.

CONCLUSION
There were 34 respondents (85%).The education level of respondents in the Independent Practice Midwives in the Panyabungan Region, Mandailing Natal Regency, was mostly low education, namely from elementary to middle school with a total of 21 respondents (52.2%).Characteristics of respondents according to work at PMB Lutfiana showed that the majority did not work, namely 27 respondents (67.5%).The characteristics of respondents according to parity/number of pregnancies at PMB Lutfiana were mostly multipara, namely 31 respondents (77.5%).Suggestions for health workers, especially midwives, in carrying out services, should always measure anxiety during childbirth so that interventions can be carried out to reduce maternal anxiety during childbirth.It is hoped that midwives will improve their skills in an effort to help give birth without anxiety.Future researchers are encouraged not only to use this research as a reference source but are expected to conduct further research using different variables so that other anxiety level factors can be identified that can influence the birthing process.The sample can also be increased so that the research is more valid.The data collection process can also be carried out using different techniques

Table 1 .
Characteristics of Respondents

Table 2 .
Anxiety Levels of RespondentsBased on table 2, it shows that the phenomenon of anxiety of pregnant women in facing labor during the active phase of labor in Independent Practice Midwives in the Panyabungan Region, Mandailing Natal Regency, the majority experienced severe anxiety, 30 respondents (75%).

Table 3 .
Correlation of Age and Anxiety Level of RespondentsBased on table3, it shows that the majority aged 20-35 years experience severe anxiety as many as 25 respondents (62.5%).

Table 4 .
Correlation of Education and Anxiety Level

Table 5 .
Correlation of work and anxiety levels

Table 6 .
Correlation of Number of Children/Delivery with Level of Anxiety Based on table 6, it shows that multiparous parity respondents are more likely to experience severe anxiety than others, as many as 23 respondents (57.5%)