i

College of Nursing

National Taipei University of Nursing and Health Sciences

Doctoral Dissertation

Effect of Prenatal Childbirth Program on Maternal Anxiety,

Maternal-Fetal Attachment, Childbirth Self-Efficacy and Marital

Satisfaction: A Randomized Controlled Trial Using Roy’s

Adaptation Model

Endang Koni Suryaningsih

Advisor: Professor Meei-Ling Gau, PhD

January 28, 2021

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iii

Acknowledgement

All praises to Allah and His Blessing to completion this dissertation. My humble gratitude to the holy Prophet Muhammad (Peace be upon him) whose way of life has been a continuous guidance for me. First and foremost, I would like to sincerely thanks my supervisor Prof. Meei-Ling Gau, PhD for her guidance, understanding, patience and most importantly, she has provided strong and positive encouragement to finish this dissertation. It has been a great pleasure to have her as my supervisor in this PhD journey in which so many against all odd. I would also like to thank my committee members, DR. Chien-Huei Kao, PhD. (NTUNHS), Professor Chieh-Yu Liu (NTUNHS), Professor Shu-Yu Kuo (Taipei Medical University), and Professor Jian-Jiuan Liaw (National Defense Medical Center) who provide me an incredible comments and suggestions and for letting my defense be an enjoyable moment . A special thanks go to my husband, Ns. Wantonoro, S.Kep., M.Kep., Sp.KMB., PhD . for his support and understanding in my up and down. I would also like to thank you to my family. Words cannot express how grateful I am to my father-in-law and mother-in-law for all of the sacrifices that you have made on my behalf, and take care of my son. Thanks to my niece Septi Widya Sari, to help me take care of my children in the last critical moment I almost complete the journey, you come to me in the right time. I dedicated this dissertation and Ph.D title to my beloved son, Muhammad Azam Suryaputra and my beloved daughter Azima Aqilatunnisa, thanks for being such a good boy and girl always cheering me up. My love is never ending for both of you dear. I would especially like to thanks my project manager, Ms. Peggy and Ms. Eunice, my friend Yanuan Ben Olin,. All of you have been there to help me bring my Ph.D title come true. I also would to extend my thanks to Ms. Stefany Preifer for her editing service, thank you for sharing incredible experience. I would especially like thanks to Midwives in the primary health center Mlati II, Midwives in the primary health center Jetis Kota, Midwives in the primary health center Mantrijeron, as the facilitator in the standard childbirth education program. Special thanks also to Siti Nurhayati and Sarah who have been assisted me to recruited participants and collected data for my Ph.D dissertation. For all my participants, thank you for your contributions in this study. I offer my special thanks to all my colleagues in Aisyiyah University of Yogyakarta in Midwifery Diploma III, for my superior, structural management in the health faculty, and my top leaders, for their support, motivation and their sincere help during my study. Finally, thank you for all every single person who involved in this Ph.D journey without I could not mention one-by -one in person, I thank them wholeheartedly. May God shower the above cited personalities with success and honor in their life.

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Abstract

Background: As the multifaceted changes during women’s life cycle, pregnancy, is the most crucial period that can affect to her further life process.

Purposes: The aim of this study was to test the effectiveness of childbirth education based on the Roy Adaptation Model through four modes: physiology, self-concept, role function, and interdependence.

Methods: A randomized controlled trial was applied to invite the participant who met the criteria including nullipara pregnant women and their husband, gestational age ranged 24-32 weeks, and married. High-risk pregnancy condition and miscarriage was excluded. The researcher used computer block size to allocate the participants into groups. To measure the potential outcomes of four modes, the following instruments were used: Demographic Data Set, Pregnancy-Related Anxiety Questionnaire Revised, short form of the Childbirth Self-Efficacy Inventory, Prenatal Attachment Inventory, and ENRICH Marital Satisfaction Scale. To produce the Indonesian version of each instruments, the researcher conducted translation and back translation following WHO guideline and measure its reliability using Cronbach’s Alpha. To describe demographic characteristic, a descriptive statistic was calculated. To test the efficacy of the program, general linear model was analyzed.

Results: The mean age of couple were 23.92/ 26.75 (wife/ husband) in the experimental group, and 29.14/ 30.86 (wife/ husband, respectively) in the control group. The mean gestational age week were 29.83 in the experimental group and 31.04 in the control group. In both groups, mostly couple graduated from high school and more than 50% mothers go to work. We loss more than twenty percent of total participants in our study that may due to the pandemic COVID-19 just ran into Indonesia. Consequently, the significance difference between two groups on demographic data include couple’s age, gestational week, husband education level, and wife’s occupation were found. After a-four week intervention, the mean score of maternal anxiety was significantly lower, and the mean score of maternal-fetal attachment, childbirth self-efficacy were significantly higher in the experimental group than that in the control group (p < .001). However, there were no significantly different mean score of marital satisfaction in the two groups. Conclusion and Implications to Nursing Practice: the implemented program in current study was potentially effective in promoting maternal-fetal attachment, childbirth self-efficacy, and decreasing maternal anxiety during pregnancy. Therefore, the modified traditional childbirth education program need to be considered. Recommendations: For the midwife, the flexible intervention may could increase response rate for couple to join the class. For the next researcher, the culture issue need to be consider to establish the feasibility of marital satisfaction tool. Keywords: maternal anxiety, childbirth self-efficacy, maternal-fetal attachment, marital relationship, Roy Adaptation Model, childbirth education, randomized controlled trial

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TABLE OF CONTENTS

Page

Abstract Iv

Table of Content v

Figures viii

Tables ix

List of Appendices x

CHAPTER I INTRODUCTION

1-1. Background 1

1-2. Conceptual framework: Roy Adaptation Model 3

1-3. Problem statement 7

1-4. Statement of purposes 9

1-5. Research question 9

1-6. Significant of the study 9

CHAPTER II LITERATURE REVIEW

2-1. Description of Roy’s Adaptation Model 11

2-2. Critique of Roy’s Adaptation Model 12

2-3. Roy’s Adaptation Model as a framework 13

2-4. The effectiveness of childbirth education classes 22

2-3. Childbirth education in Indonesia 32

CHAPTER III RESEARCH METHODOLOGY

3-1. Study Design 36

3-2. Study Setting 36

3-3. Population and sample 36

3-4. Data Collection 38

Intervention group 41

Controlled group 42

3-5. Research tools 44

3-6. Data analysis 48

3-7. Ethical consideration 49

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CHAPTER IV RESULTs

4-1. Demographic information of the Respondents 51

4-2. Comparison the baseline of the maternal anxiety,

maternal-fetal attachment, childbirth self-efficacy and

marital satisfaction

57

4-3. The relationship among maternal anxiety, maternal-fetal

attachment, childbirth self-efficacy and marital

satisfaction

58

4-4. The effect of childbirth education program on maternal

anxiety, maternal-fetal attachment, childbirth self-

efficacy and marital satisfaction

61

CHAPTER V DISCUSSION

5-1. Descriptive statistic of demographic characteristic of the

participants

68

5-2 The effect of childbirth education program on prenatal

anxiety, childbirth self-efficacy, maternal-fetal

attachment, and marital satisfaction

70

5-2.1 The effect of childbirth education program on

prenatal anxiety

70

5-2.2 The effect of childbirth education program on

maternal-fetal attachment

72

5-2.3 The effect of childbirth education program on

childbirth self-efficacy

73

5-2.4 The effect of childbirth education program on

marital satisfaction

74

CHAPTER VI CONCLUSION and RECOMMENDATIONS

6-1. Conclusion 77

6-2. Study implications 77

6-3. Suggestion for future research 80

REFERENCES

81

vii

APENDIXS 120

viii

Figures

Page

Figure 2.1 The Roy’s Adaptation Model (RAM) 12

Figure 2.2 Model, concept, and operational structures of efficacy on

childbirth education based on Roy’s Adaptation Model

31

Figure 2.3 Scheme of childbirth education class in Indonesia provided by

public sector

33

Figure 3.1 Research design 35

Figure 4.1 CONSORT flow chart 52

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TABLES

Page

Table 2.1. The application of RAM for childbirth education classes curriculum 28 Table 3.1 Comparison childbirth education program between experimental and

control group 43

Table 3.2 Reliability of the research instrument 48 Table 3.3 Statistical method 49 Table 4.1 Comparison of the demographic data between missing and non-

missing participants 53

Table 4.2 Comparison of the demographic data between missing and non-missing participants in the control group

54

Table 4.3 Comparison of the demographic characteristics between the

experimental and control groups

56

Table 4.4 Comparison of the baseline pretest test scores between two groups 57 Table 4.5 Pearson correlation for pretest scores within outcome variables 59 Table 4.6 Pearson correlation for posttest scores within outcome variables 60 Table 4.7 Effect of childbirth education program on maternal anxiety 62 Table 4.8 Effect of childbirth education program on maternal-fetal attachment 63 Table 4.9 Effect of childbirth education program on childbirth self-efficacy 64 Table 4.10 Effect of childbirth education program on wife marital satisfaction 65 Table 4.11 Effect of childbirth education program on Husband marital

satisfaction 66

x

APPENDICES

APPENDIX A Random Allocation APPENDIX B Draft of Flyer and Standing Banner APPENDIX C The Plan Curriculum of Childbirth Education Classes Based On Roy’ Model APPENDIX D Instruments APPENDIX E Grant Permission APPENDIX F Institutional Review Board

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CHAPTER I

INTRODUCTION

This chapter presents a brief summary of the background, the problem statement, and

aims of this study. The chapter also present the research question and addresses the

significance of the study. The conceptual framework of the study, which uses the Roy’s

Adaptation Model, will be explained.

1-1. Background

Changes that come with each stage of women’s lives are commonly accompanied by

anxiety, such as first menstruation, marriage, as well as pregnancy, childbirth, and the

postpartum period up to menopause. Pregnancy is a crucial period in the lives of women with

both short and long-term impacts. Marriage and child bearing bring multifaceted changes

requiring adaptations that are not only physical, but also psychosocial, marital, spiritual, and

financial (Chang, Yu, Chen, & Chen, 2015). Difficulty adapting to those changes may lead to

ineffective reactions such as pregnancy-related anxiety. Anxiety is a common and normal

response to change and is part of normal human experience, but it can also become mental

health problem (Deklava, Lubina, Circenis, Sudraba, & Millere, 2015; Goodman et al., 2014;

June, 2003; Maxson, Edwards, Valentiner, & Miranda, 2016; Wenzel, 2011; Wergeland &

Strand, 1998; Wright & Halfon, 2010). Anxiety during pregnancy is widespread. According

to one study, only seven percent of expectant women do not suffer from anxiety during

pregnancy, particularly in the last trimester (Madhavanprabhakaran, D’Souza, & Nairy,

2015).

Pregnant women with high levels of anxiety are at increased risk of adverse perinatal

outcomes (Abasi, Tahmasebi, Zafari, Gholamreza, & Takami, 2012; Clemens, 2014; Yuksel,

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Akin, & Durna, 2013) including postpartum depression, preterm birth, low birth weight

(O’Donnell et al., 2012), and fetal growth restriction which in turn, are risk factors for

impaired cognitive and social development children (Buss, Davis, Hobel, & Sandman, 2011;

Fishell, 2010; Qiao, Wang, Li, & Wang, 2012). Another negative effect of anxiety during

pregnancy its effect on the sleep quality (Jamalzehi, Omeidi, Javadi, & Dashipour, 2017).

Anxiety can lead to problem such as sleeping disturbances (Skouteris, Wertheim, Rallis,

Milgrom, & Paxton, 2009), nightmare (Furber, Garrod, Maloney, Lovell, & Mcgowan,

2009), and fatigue (Andersson, Nilsson, & Candidate, 2012). Shortness of breath,

hyperventilation, palpitations, and tremors have also been reported (O’Donnell et al., 2012).

Furthermore, studies have documented the complicated impact of pregnancy-related anxiety,

highlighting somatic complaints such as stomach pain, problems during sexual intercourse,

headaches, dizziness, and pains in the heart or chest, as well as gastrointestinal discomforts,

such as nausea and vomiting (Andersson et al., 2012). Anxiety during pregnancy may

manifest as maladaptive responses to stress, such as denial, self-blame, and self-distraction

(Gourounti, Anagnostopoulos, & Lykeridou, 2013). Anxiety due to fear of specific events,

such as labor, may also contribute to mood swings, short temperedness, panic and discomfort

about the feeling of having a baby living inside (Bayrampour, Ali, McNeil, et al., 2016).

Pregnancy is a period of adaptation to prepare for a new role as a mother (Niska, 1996).

Maternal competence is an important foundation for fulfilling the maternal role which

involves incorporating a set of mothering behaviors into her established identity (Niska,

1996). Mothering behavior include interaction or communication with her unborn baby, such

as calling the unborn baby by name, and preparing things for the baby before giving birth.

Such behaviors are characteristic of maternal-fetal attachment (Muller & Ferketich, 1993).

By contrast, anxiety behavior in women has been shown to have unfavorable impact on the

relationship between mother and fetus. It includes detachment, withholding attachment to the

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unborn baby, the newborn baby, and later, the child (Fishell, 2010). Manifested problems in

the maternal-fetal relationship manifest as difficulty expressing love and affection towards

the infants, as well as raising the possibility of neglect, rejection, neglection and impulses to

harm the infants (Edhborg, Hogg, & Kabir, 2013). Changes in the marital satisfaction

are frequently reported during pregnancy and the transition to parenthood (Perren, Wyl,

Burgin, Simoni, & Klitzing, 2005). The quality of the marital relationship is recognized as a

significant contributor to maternal mental health during the process of adaptation in

pregnancy (Mutlu, Erkut, Yildirim, & Gundogdu, 2018). A good marital relationship also

contributes to a healthier pregnancy and birth, and creating a supportive family environment

for the new child (Hohmann-marriott, 2009). Consequential characteristics of the marital

relationship include its quality, communication, the intention to get pregnant, and marital

status at the beginning of the pregnancy (Hohmann-marriott, 2009). Previous studies have

reported, the keys to establishing quality of parental relationships are figuring out how to

support one another and to communicate effectively (Mealing, 1991).

1-2. Conceptual framework: The Roy Adaptation Model

Roy Adaptation Model (RAM) has been widely used to help nurses and midwives

provide better care, including developing interventions to overcome physical and

psychological problems such as nausea and vomiting, hypertension, gestational diabetes, and

lack of self-concept as well as impaired body image (Amanak, Sevil, & Karacam, 2019;

Arcamone, 2005; Badr Naga & Al-atiyyat, 2013; Black, 2004; Blake & Beard, 1999; Blamer,

1999; Boucher, 1996; Chou, 2001; Erol Ursavas, Karayurt, & Iseri, 2014; Isbir & Mete,

2013, 2010; Kruszewski, 1999; Lee, Tsang, Wong, & Lee, 2011; Mohammadpour, Najafi,

Tavakkolizadeh, & Mohammadzadeh, 2016; Yaghoubinia, Navidian, Yousefian, & Chaji,

2017; Zhegner, 2003). Roy’s model, focuses on the concept of adaptation, specifically, how a

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person responds to the stimuli (Alligood & Tomey, 2010). The adaptation model identifies

two subsystems: cognitive and regulation mechanism. Since it is not possible to directly

observe the process of those two subsystems, observable behavioral responses are manifested

through four critical modes: physiology, self-concept, role function, and interdependence

mode (Alligood & Tomey, 2010). The goal of nursing care using the Roy adaptation model is

to promote adaptation in each of those modes (Amanak et al., 2019; Guarino, 1990; Isbir &

Mete, 2010; Jennings, 2017; Mohammadpour et al., 2016). Using Roy’s Adaptation Model as

the conceptual framework, this study will explore behaviors manifested through the four

modes and will be identified as adaptive or ineffective responses to pregnancy.

Ineffective defense mechanisms in one or more of the critical modes affected to a

person’s adaptation level. This adaptation level, will, in turn impact the individual’s ability to

respond effectively to stimuli. Situational demands, as well as previous levels of functioning,

have been noted to affect the ability to adapt the stimuli(Roy, 2009a). Roy uses stimuli as a

way to describe the pregnant woman’s environment, which consists of complex patterns of

interaction, feedback, growth and decline. For instance, expectant pregnant women who feel

well-prepared and who have a good quality marital relationship will respond adaptively

during pregnancy (Cody, Olga, Luciane, Richard, & Paul, 2012). Research has found that

low maternal-fetal attachment, and lack of childbirth self-efficacy are linked to non-adaptive

or ineffective responses to pregnancy (Salomonsson, Berterö, & Alehagen, 2013).

Many projects have shown that prenatal outcomes can be enhanced by reducing

pregnancy-related anxiety and improving childbirth self-efficacy, maternal-fetal attachment,

and marital relationships (Akbarzadeh, Dokuhaki, Joker, Pishva, & Zare, 2016; Arcamone,

2005; Broussard & Weber-Breaux, 1994; Chang, Park, & Chung, 2004; Deave, Johnson, &

Ingram, 2008; Dokuhaki, Akbarzadeh, Pishva, & Zare, 2017; Howharn, 2008; Larsen & Plog,

2012; Suto, Takehara, Yamane, & Ota, 2017). Childbirth education programs are one kind of

5

resource for helping expectant women prepare for the changes they will experience (Larsen

& Plog, 2012). Researchers around the world report interventions that target specific

problems with adapting during pregnancy using different approaches based on the needs of

particular populations. For instance, mindfulness interventions have been used to accomplish

different goals. Two studies in the United States conducted mindfulness-based interventions

to reduce maternal anxiety and depression (Duncan & Bardacke, 2010; Goodman et al.,

2014). In Taiwan, Pan and colleagues developed mindfulness training to enhance the

physiological health of pregnant women (Pan, Gau, Lee, Jou, & Liu, 2018). Larsen and Plog,

2012). In Minnesota, Larsen and Plog developed childbirth classes to enhance self-efficacy

for pregnant women and their support persons (Larsen & Plog, 2012). Dokuhaki and

colleagues (2017) in Iran provided training skills focused on fostering fetal attachment in

mothers and fathers (Dokuhaki et al., 2017). Toosi and colleagues (2017) in Iran conducted

an intervention to increase maternal-fetal attachment using relaxation techniques. In Korea,

Sue, Hee-Sook and Ha-Yoon (2011) used a coaching-based childbirth program to decrease

anxiety and increase childbirth self-efficacy.

Several studies have advocated using Roy’s adaptation model as a guide for

developing antenatal education programs. A project conducted by investigators in Turkey in

2010 tested the effectiveness of prenatal education for promoting maternal prenatal and

postpartum adaptation using Roy’s framework (Sercekus & Mete, 2010). In that study, the

investigators employed only those variables related to two Roy’s adaptation modes: self-

concept and interdependence. The classes consisted of seven weeks with different

educational contents based on women’s needs. The result of that study showed that antenatal

education had a positive effect on prenatal adaptation, but it had no effect on postpartum

adaptation. Therefore, they recommended conducting a review of contents in antenatal

educational that may beneficially impact postpartum adaptation (Sercekus & Mete, 2010).

6

The effectiveness of prenatal education on adaptation to motherhood after vaginal childbirth

in primiparas women following Roy’s four adaptive modes have been also reported

(Arcamone, 2005).

Through the four critical modes described by Roy, it is possible to understand women

who are maladaptive responses to pregnancy (Abasi et al., 2012; Akbarzadeh, Toosi, Zare, &

Sharif, 2011; Cody et al., 2012; Hwang, 2013; Saastad, Israel, Ahlborg, Gunnes, & Frøen,

2011; Yarcheski, Mahon, Yarcheski, Hanks, & Cannella, 2009). For example, physiological

changes contribute to the mother’s complaint and discomfort during pregnancy which may

lead in turn to maternal anxiety (Bayrampour, Ali, McNeil, et al., 2016; Borodulin et al.,

2010; Karaçam & Ançel, 2009). Negative self-concept in pregnancy can decrease a mother’s

childbirth self-efficacy (Bhattacharjee & Banik, 2016; Stern, 1998). Functioning in the

maternal role affects maternal-fetal attachment (Yarcheski et al., 2009) and interdependence

mode can provide insight into improving the marital relationship (Cody et al., 2012; Jang,

Kim, & Lee, 2015; Whisman & Davila, 2011). This phenomena support the hypothesis of the

RAM regarding the four critical modes. Nursing practices informed by Roy’s model promote

adaptation in each of the four modes leading to a more integrated level of functioning (Roy,

2009b).

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1-3. Problem statement

In the world, in 2017, approximately 810 women died from preventable causes

related to pregnancy and childbirth (World Health Organization, 2019). Two years earlier, in

2015, Indonesia had a 126/100,000 maternal death rate and 25/1,000 neonatal death rate.

These two rates compare unfavorably to other Asian countries such as Singapore (6/100,000),

Thailand (44/100,000), and Malaysia (39/100,000). The majority direct cause of Maternal

Mortality Rate (MMR) in Indonesia is dominated by bleeding (30.3%), pregnancy

hypertension (27.1%), infection (7.3%), prolonged labor (1.8%), abortus (1.6%), and others

(40.8%). To foster knowledge for pregnant women and couples on risk signs of pregnancy

and birth, Indonesia government implemented the national program, provides childbirth

education for free offered by midwives villages. The mother necessary to attend the

childbirth education for three meeting, aimed to acquire mother’s knowledge and skills on the

pregnancy, birth, postpartum, family planning, newborn care and postpartum exercise

(Minsitry of Health, 2014). However, the information on the effectiveness of existing

childbirth education program include learning method as well as the theoretical guidelines,

remain unclear (Fata & Rahmawati, 2016; Lucia, Purwandari, & Pesak, 2013; Nursofyanto &

Cahyanti, 2017).

In 2013, one study reported, roughly 76.8% pregnant women in Indonesia experience

anxiety in their last trimester consist of 80% were nulliparas and 20% were multiparas

(Setyaningsih, Setyowati, & Kuntarti, 2013). Manifested pregnancy-related anxiety among

Indonesian pregnant women affected their childbirth self-efficacy that may lead to prolonged

labor which in turn causing maternal death (Rofi’ah, 2015). Prolonged labor also recognized

as the main cause asphyxia which contribute to the infant mortality among Indonesian

newborn (Prime Minister of Health, 2014).

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Many Indonesian researchers developed childbirth education on decreasing anxiety

during pregnancy (Aryani, Raden, & Ismarwati, 2016; Fata & Rahmawati, 2016; Lucia et al.,

2013; Nursofyanto & Cahyanti, 2017; Setyaningsih et al., 2013). However, the studies to

investigate the effectiveness of childbirth education to increase maternal-fetal attachment,

childbirth self-efficacy and marital relationship are scarce (Galina & Risti, 2015; Sukriani &

Suryaningsih, 2018). Researchers from other countries emphasized that the method as well as

the content of material of childbirth education contributes on decreasing maternal anxiety,

increasing maternal-fetal attachment, childbirth self-efficacy and marital relationship

(Dokuhaki et al., 2017; Duncan & Bardacke, 2010; Larsen & Plog, 2012; Toosi, Akbarzadeh,

& Ghaemi, 2017). To reach the ultimate purposes of childbirth education, the classes should

be conducted in a sufficient period and appropriate curriculum. The conceptual framework

applied in the childbirth education is also important to be considered (Nichols & Humenick,

2000). Best on our knowledge, there is no study investigated the effectiveness of childbirth

education to addressed four modes outcome based on the Roy Adaptation Model in Indonesia

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1-4. Statement of purposes

The aim of this study is to explore the effectiveness of a four-week prenatal

childbirth program on prenatal anxiety and childbirth self-efficacy, maternal-fetal

attachment, and marital satisfaction.

1-5. Research questions

Based on the specific aims, the research questions of this study were the following:

1. How the descriptive statistic of demographic characteristic of the participants?

2. Are there any significant differences on the demographic characteristics

between the two groups?

3. How the effect of childbirth education program on prenatal anxiety and

childbirth self-efficacy, maternal-fetal attachment, and marital satisfaction?

1-6. Significance of the study

There are two reasons why using Roy’s Model approach as a framework to

develop the childbirth classes is essential in this study. First, nurses and midwives play

major roles in health-promotion activities. To achieve this critical goal of health

promotion, the nurse and midwives needs an accurate and complete data base. At

present in Indonesia, there is scarce concept of childbirth education class which is

applied the Roy’s Adaptation Model to provide the intervention. Using this model

approach, the appropriate contents and teaching methodology in the prenatal education

will be available as the practice-based practice (Arcamone, 2005). Second, during

pregnancy and preparation for childbirth, pregnant women and spouse seek out

information from various source. Nurse and midwives, in both professional and

personal, encounters, also encourage and interact daily with pregnant women and

10

husband. Therefore, nurse and midwives are in special position to give information to

these couples. Knowledge will gained from this study may afford nurses and midwives

an increased understanding of the physiological aspects of pregnancy and birth. An

increased knowledge base can help mother and husband to optimize the adaptation

during pregnancy and childbirth.

In conclusion, this study will focus on promoting on four modes; prenatal

anxiety, childbirth self-efficacy, maternal-fetal attachment, and marital relationship

during their third trimester of pregnancy in response to gap in existing research and

conflicting theoretical prepositions.

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CHAPTER II

LITERATURE REVIEW

To address the purposes of this study, researcher has been conducted the

literature review in where includes the Roy Adaptation Model include the major

concept and it is in adaptive response to the pregnancy. Roy’s Model critique and

reason why the researcher choose this framework, as well as the conceptual, theoretical

and empirical practices for this approach also has been described.

2-1. Description of Roy’s Adaptation Model

According to Roy (2009), people as part of adaptive system, the environment,

health, and the goal of nursing are the major concepts of her model. People as an

adaptive system defined as a whole with parts that function as a unity for a purpose.

Environment as a stimuli is defined as the condition or surrounding that can affected to

the human as an adaptive system. Health or outcome of adaptation is a state and process

of being and becoming integrated and whole (Roy, 2009b). Adaptation is realized when

an individual shows a positive reaction to stimuli. Roy defined adaptive modes as

physiological and physical, self-concept, role function, and interdependence to evaluate

responses to stimuli as described in the Figure 2.1. The physiological mode refers to

physical maintenance of the integrity of the adaptive system, while the self-concept

mode consist of belief, thought and feeling held about one’s self. The role-function

mode refers to the roles that a person has in her life, and the interdependence mode

consist of establishing and maintaining relationship with significance other. Behavior in

the context aforementioned are classified as adaptive or non-adaptive. Adaptive

12

responses are those that promote the integrity of the human system whereas non-

adaptive modes hinder this purpose (Roy, 2009b).

To derived her adaptation theory, Roy also uses other theory and concept

outside the discipline of nursing. She synthesized her theory from Helson’s

psychophysics theory, who is developed the concept of focal, contextual, and residual

stimuli (Alligood & Tomey, 2010). Roy redefined those concepts within nursing to

form an analysis of factors related to adaptation levels of person. Roy conducted studies

and nursing practice experience of herself, her colleagues, and her students to build her

four adaptive modes. Roy developed a step-by-step model on her conceptual

framework of adaptation and tested its theory to administer nursing care to promote

adaptation in health and illness situation (Roy, 1970).

2-2. Critique of Roy’s Adaptation Model

INPUT CONTROL PROCESS

EFFECTORS OUTPUT

Physiological and physical functions Self-concept Role function Interdependence

Stimuli adaptation level

Coping mechanism Regulator Cognator

Adaptive

Ineffective response

Figure 2.1. The Roy Adaptation Model

13

As grand theory, Roy’s Adaptation Model consist of major concept, sub concept,

and relational statement, therefore it is considered as a complex model. However, this

complexity assist to improve its empirical precision. Researcher has analyze and

criticize the Roy Adaptation Model (Abu & Al, 2012). According to them, in term of

the arrangement, the concept of Roy’s Model is logic, but in term of the word and

concept, inadequate to reflect nursing discipline was remain (Abu & Al, 2012). This

may decreases the clarity of the model when applied in any particular area of practice.

In fact, Roy Adaptation Model is broad in scope, widely accepted and inspired the

development of middle range nursing theories (Abu & Al, 2012). This theory

generalizable to all approaches in nursing practice, education field, and practice-based

research (Abu & Al, 2012; Alligood & Tomey, 2010; Dobratz, 2003).

2-3. Roy’s Adaptation Model as a conceptual framework

Many researchers have used Roy’s model to guide their studies. In this paper,

we have selected following childbearing studies to show their use of that model.

Kiehl and White (2003) conducted the study to test the relationship of maternal

adaptation during pregnancy following Roy’s Model. They invite pregnant women in

the third trimester and complete the questionnaire both during the first recruitment and

again at 6 weeks postpartum. The result reported mother with greater adaptation during

pregnancy have greater adaptation during postpartum. This finding supported the Roy’s

preposition that effective adaptation during pregnancy related with the adaptation after

birth (Kiehl & White, 2003). Serc¸ekus and Mete (2010) also measure the differences

between mother’s adaptation during pregnancy and postpartum, using the same

framework-based quasi experiment. The result in line of previous study that women in

the experimental group were better adapted in the prenatal compared with those in the

14

control. However, in term of prenatal adaptation, that no difference was found in

postpartum adaptation between the groups (Sercekus & Mete, 2010).

Fawcet (2006) used four adaptive modes of Roy’s Model as a guideline to

combined a qualitative and quantitative content analysis of responses to open-ended

interviews. She categorized the word, phrases, and/ or sentences that represent

women’s responses to the five questions which refer to the four adaptive modes

(Fawcet, 2006). Unfortunately, the researcher did not provide clear information on the

quantitative method she calculated.

Isbir and Mete (2010; 2013) followed the Roy’s Model as a framework in their

combined quantitative and qualitative study to explore expectant women with nausea

and vomiting. In 2010, they conduct a quantitative study and provide guidance for

nurse who want to use the model while offering nursing care and conducting research.

Then in 2013, they continued the qualitative study used the four mode to analysis the

content of categories based on transcribed verbatim. They found that the stimuli

causing nausea vomiting during pregnancy differed for each individual (Isbir & Mete,

2013). This result has completely supported the Roy’s Model in which the stimuli can

affecting individual’s adaptation as well as their behavior (Isbir & Mete, 2010, 2013).

A randomized controlled trial study conducted by Mohammadpour and colleagues

(2016) emphasized on self-concept mode in Roy’s Model. They invite expectant

women in the third trimester and join to participate in this study voluntary during four

weeks program. There was a significant self-concept adaptation in both groups before

and after the study. This result completely support that Roy’s Model has positive effect

on primigravida women’s physical and interpersonal self-concept adaptation in

pregnancy (Mohammadpour et al., 2016).

15

In the same way, Amanak, Sevil and Karacam (2019) used the Roy Adaptation

Model to manage mother with gestational hypertension and enhance their adaptation

through prenatal education class. The curriculum was prepared following the four

modes and has been proven effectively to manage the hypertension and promoting

levels of adaptation (Amanak et al., 2019).

Based on some of consideration above, in this study, the Roy Adaptation Model will

also be applied. Researcher will use Roy’s Model to develop the prenatal class based on

four modes to enhance expectant women’s adaptation and will measure each possible

outcome behavior for each modes. In this study, the four modes will be described as

below.

1. Physiological and physical Mode

In this mode, Roy emphasizes the maintenance of physiologic integrity of the

person (Roy, 2009a). The following nine components in physiological mode include:

oxygen, nutrition, elimination, protection, activity and rest, senses, fluid-electrolyte and

acid-base balance, and neurological and endocrine function. According to Roy (2009),

these nine components form the basis of nursing assessment and determined what the

appropriate intervention based on needed. Moreover, a comprehensive physiological

assessment is, indeed, necessary as pregnancy-related physiological changes happen in

almost all the body system. During the third trimester, the physiological changes to the

women’s body become noticeable as she finds its more difficult to find comfort on her

pregnancy. At this point, maternal circulatory system change and raise the physical

complaint and the literature indicates that the following symptoms were experienced by

a significant percentage of women: nausea, heartburn, breast tenderness, shortness of

breath, back pain, sleep disorder, fatigue, and frequency of urination (Beddoe, Lee,

Weiss, Kennedy, & Yang, 2010; Borodulin et al., 2010; Duncan & Bardacke, 2010;

16

Garland, 2017; Greenwood & Stainton, 2001; Milliano, Tabbers, Post, & Benninga,

2012; Yikar, 2019; Zsamboky, 2017).

A review of the related literatures has demonstrated a relationship between

discomfort during pregnancy due to physiological adjustment and pregnancy-related

anxiety as in effective response. For some women who have insufficient knowledge on

her physiology system change, these condition can be assumed as the high pregnancy

risk that can generate anxiety by creating uncertainty about pregnancy and pregnancy

outcome (Bayrampour, Heaman, Duncan, & Tough, 2013; Dako-gyeke, Aikins,

Aryeetey, Mccough, & Adongo, 2013). Through childbirth education program,

midwives could enhance mother’s physiological mode to increase their adaptation

during the transition by providing sufficient information and insight about pregnancy

such as the education of anatomical and physiological adaptation, which in turn, can

help mother to reveal their anxiety during pregnancy (Harpel, 2008). Some best

intervention to reduce maternal anxiety includes relaxation technique such as yoga,

Coping Anxiety trough Living Mindfully (CALM), and hypnotherapy (Baxter,

Hastings, Law, & Glass, 2008; Goodman et al., 2014; Rasouli, Pourheidari, & Gardes,

2019; Tragea, Chrousos, Alexopoulos, & Darviri, 2014).

Pregnancy-related anxiety is defined as worries, concerns and fears about

pregnancy, childbirth, and health of infant and future parenting. The attributes of

pregnancy-related anxiety includes affective response such as emotion: cognition, being

preoccupied with various thoughts; and somatic symptoms such as; physical complaint

(Bayrampour, Ali, Mcneil, et al., 2016). Pregnancy-related anxiety may increase

nausea, poor psychological adaptation, negative perspective of motherhood as well as

the predictor of low birth weight and preterm birth (Glover, 2014; Nicoloro-

SantaBarbara et al., 2017). In Indonesia, out of 15.5/100 live birth newborn were

17

preterm and contribute to the number of infant mortality rate (World Health

Organization, 2019). The deleterious effect of pregnancy-related anxiety has well-

documented in many studies in Indonesia (Alza & Ismarwati, 2017; Eka Roisa

Shodiqoh & Syahrul, 2014; Hayati, Herman, & Agus, 2017; Setyaningsih et al., 2013;

Trisiani, Hikmawati, Bhakti, & Bandung, 2016), and the intervention to decrease the

anxiety in the antenatal class has been developed such as pregnancy exercise (senam

hamil), Dhikr1, belly dance, and counseling to the mother and spouse (Aryani et al.,

2016; Mardhiyah & Khaerani, 2017; Nasir, 2015; Ranita & Hardjanti, 2016;

Setyaningsih et al., 2013). There are number of measures in current use for pregnancy-

related anxiety (Sinesi, Maxwell, Carroll, & Cheyne, 2019), the most appropriate one

for this study is Pregnancy-related Anxiety Questionnaire-revised (PRAQ-R2) consist

of 33 item is designed as screening scale with higher scores indicative of greater

pregnancy-related anxiety. The instrument developed by and characterized by a

pregnancy, the wellbeing of the mother and baby and impending motherhood.

2. Self-concept Mode

The self-concept is defined as the individual’s mixture of beliefs and feeling about

herself or others at a certain time (Roy, 2009b). The variables related to the self-

concept mode in the prenatal period were concern about well-being of self and baby,

fear of helplessness and loss of control during childbirth (Sercekus & Mete, 2010). As

the multidimensional construct, self-concept refers to an individual self-efficacy in

relation any number of characteristics, for instance knowledge, experience, culture,

religion, and belief. Self-efficacy is the antecedent for all motivated behavior (Bandura,

1998). According to Bandura, people with a positive self-efficacy have high motivation

1 are devotional acts in Islam in which short phrases or prayers are repeatedly recited silently within the mind or aloud (Wikipedia, 2019).

18

to accomplish the goal that they have been set up, while people with low self-efficacy

will less effort to fulfill required behavior to achieve the goal. Therefore, women who

predicted has high score on childbirth self-efficacy as low used more epidural analgesia

compared to women with high childbirth self-efficacy (Carlsson, Ziegert, & Nissen,

2014). Similarly, William, Povey and White (2008) also found the level of self-efficacy

was affecting to the intention to use pain relief medication during childbirth (Williams,

Povey, & White, 2008). However, women who planning to have section cesarean (SC)

option reported has lower scores of birth self-efficacy rather than those who are

planning to have vaginal mode (Schwartz et al., 2015; Williams et al., 2008). Obstetric

and psychological factor have been noted as the factor associated with childbirth self-

efficacy (Carlsson et al., 2014; Dilks & Beal, 1997; Drummond & Rickwood, 1997;

Lowe, 1993).

World Health Organization (WHO) determined for cesarean section (CS) indicator

range 10 to 15 % for each country (World Health Organization, 2017). In 2010,

Indonesia has 9.8% delivery birth with CS (Suryati, 2012) and, unfortunately in some

urban area such as Yogyakarta and Jakarta, the number of CS was rather high about

15% and 19.9%, respectively. Bleeding, pre-eclampsia, and infection have been known

as the complication of SC and mostly contribute to the maternal and mortality death in

Indonesia (Ministry of Health, 2018). The evidence on intervention to enhance

maternal self-efficacy for childbirth in Indonesia is lack (Ramie, Afiyanti, & Pujasari,

2004; Sriwenda, 2014). Some are discussed self-efficacy for breastfeeding (Fata &

Rahmawati, 2016; Wardani, Rachmawati, & Gayatri, 2017) hence the reference on the

issue is limit. Senior researcher from China who focus on childbirth self-efficacy

develop the educational intervention to enhance childbirth self-efficacy based on

Bandura’s framework. Out of 110 pregnant women have been recruited to participated

19

in his study. The content includes the biopsychological phenomena of childbirth and

the strategies of coping with childbirth discomfort. Demonstration of coping behavior

including breathing and relaxation techniques to control emotional tensions and pain

during labor have also been applied (Ip, Tang, & Goggins, 2009). They developed the

short form of Childbirths elf-efficacy inventory (CBSEI) to measure the childbirth self-

efficacy.

3. Role function Mode

According to Roy, the role function mode covers the individual’s to her Secondary

roles: different roles (mother, spouse, etc.), and 3. Tertiary roles (as a director or

supervisor in the hospital, etc.). Mercer (2004) reported the first pregnancy task of

prenatal transition to motherhood is commitment which is includes positive and

negative pregnancy effect. However, the positive pregnancy will result the commitment

regarding secondary role; relationship with the unborn baby, spouse and changes in the

women’s daily life (Nichols, Roux, & Harris, 2007). Maternal-fetal attachment is the

concept that can be used to explain the process of bonding (Muller, 1993). Based on the

definitions of maternal and fetal attachment, it could be understood that attachment is

key element in the successful psychological adjustment to pregnancy experience

(Cranley, 1981; Cunningham Facello, 2008; Muller, 1989). According to Muller, this

acquire behavior of attachment includes mimicry or role play such as calling baby with

his name, imagine the baby’s face, communicate with the baby, share her thought and

activity to the baby, and prepare the thing for the baby. Ask the spouse to put his hand

on the belly, as well as ask him to communicate with the baby have been also

recognized as the characteristic of maternal-fetal attachment (Muller, 1993). Evidence

indicate if the mother who have good quality of attachment to their unborn baby, more

engage to take care of their baby after birth, and optimized their interaction (Siddiqui &

20

Hägglöf, 2000), which in turn can enhance the physical, mental, and social health

development of their child (Ainsworth, 1969; Muti’ah, 2009). Mother who performed

high score in maternal-fetal attachment will have positively to their role as the mother

include attend the antenatal care (Lindgren, 2001).

There is a growing studies on maternal-fetal attachment in Indonesia since the

translation of its instrument to measure maternal-fetal attachment: Prenatal Attachment

Inventory (PAI) (Alvianty & Suryaningsih, 2016; Nosrati et al., 1994; Sukriani &

Suryaningsih, 2018; E.K. Suryaningsih, 2015). However, the scarce of intervention to

promote maternal-fetal attachment remain exist in Indonesia, while some

recommendation have been proposed by previous researchers during decade in others

countries (Abasi, Tafazzoli, Esmaily, & Hasanabadi, 2013; Akbarzadeh et al., 2016,

2011; Chang et al., 2004, 2015; Dokuhaki et al., 2017; Nishikawa & Sakakibara, 2013;

Saastad et al., 2011; Toosi et al., 2017) such as mindfulness-based therapy, fetal

movement counting, Leopold’s maneuver, and relaxation techniques. In Japan, a

program to improve maternal-fetal attachment has been selected as the grant project in

2015. The content material includes education on pregnancy, post-partum, relaxation

skills, and communication skill. The opportunity for women to interact with other

pregnant women and allowing them to build their social network also include the

program (Grant, McMahon, & Austin, 2008).

4. Interdependence

According to Roy, this mode is focused on interactions related to love, respect,

giving and receiving value (Roy, 2009a). During pregnancy, different perspective from

men and women in viewing developmental task as a parent can lead conflict, however,

if they can adjust that adaptation process and avoid or resolve conflict sufficiently from

both, so the spouse feel satisfied with the marriage (Ayub, 2014; Mealing, 1991).

21

Interdependence defined as the moment when spouse reach the resolution of parental

relationship conflicts in marital relationship and in turn, couple experience dependence

each other that keep them together. The higher level of couple’s ability to promote their

togetherness and interaction activities include sharing and spend more time together,

the higher level of their interdependence (Mealing, 1991). According to Mealing

(1991), this ability may be change during pregnancy, since upcoming roles as a parent

has been develop. There are two significant indicators in marital relationship: effective

communication, and marital satisfaction. Studies reported, the marital satisfaction as a

predictor of maternal mental health wellbeing during pregnancy, which in turn, affected

to the postpartum mental health such as postpartum stress, anxiety and depression

symptom (Clout & Brown, 2016; Dimitrovsky, 2002; Henriksen & Thuen, 2015). In

line, the latest systematic review reported, studies conducted ranged from 2000 to 2016

have been consistent in result on the relationship between marital satisfaction as well as

quality of marital communication and maternal mental health (Alipour, Kheirabadi,

Kazemi, & Fooladi, 2018).

A longitudinal study in Norway found expectant women who satisfied with their

marriage were more satisfied with their 3 years life after postpartum rather than those

who were less satisfied (Dyrdal & Nes, 2011). This study also found that marriage

satisfaction as a predictor of a future happy life. The intervention includes preparatory

classes or public message is recommended by Dyrdal and Nes (2011). The class aiming

to promote a robust and satisfactory relationship during pregnancy. Classes focus on

the importance of nurturing their relationship and building social support may also can

be considered as the content material of preparation class (Dyrdal & Nes, 2011).

Similarly, other study also recommend productive communication as targeted couple to

22

promote their relationship adjustment during pregnancy (Heyman, Baucom, Katherine,

& Trillingsgaard, 2014).

A mixed method study conducted in Virginia explore the effectiveness of

mindfulness-based relationship education for couples (Gambrel & Piercy, 2015). They

developed the class to improve participant’s relationship satisfaction by inviting 66

expectant parents. The intervention were couple activities and a 15-minute formal daily

mindfulness practices included body scan, mindfulness of breath, and open awareness.

The mindfulness program applied focus on Mindfulness-based Relationship

Enhancement, and Mindfulness-Based Childbirth and Parenting. Mindfulness activities

such as mindful touch, mindful communication, and mindful eye contact also have been

applied. The result findings based on statistical measure that there is a significant

improvement for those in treatment group in relation satisfaction rather than those in

control group. In qualitative result shown men and women have difference of

experience in term of social support, program enrollment, and identity and relational

processes during pregnancy. For men, the program give positive impact for them such

as more deeply connected with their partners. The researcher directed for the future

research to include measure of social support, program expectation, and connecting

with baby (Gambrel & Piercy, 2015).

2-4. The effectiveness of childbirth education classes

The studies on the reducing maternal anxiety, increasing childbirth self-

efficacy, maternal-fetal attachment and marital relationship trough childbirth education

classes are described as below.

Goodman and colleagues (2014) tested the effectivity of Coping with Anxiety

through Living Mindfully (CALM) to the anxious pregnant women during the

23

childbirth classes. They recruited twenty four pregnant women with anxiety symptoms

and conduct interview to test the feasibility of this pilot study. The interviewed

conducted by psychologist to determine the final eligibility of the participants using

Beck Anxiety Inventory (BAI), severity score of ≥ 11 indicating elevated level of

anxiety symptom. The content material of the class include psycho-education

knowledge, mindfulness practices, and cognitive exercises, continued by home practice

for about 30-45 minutes 6 days a week during five weeks. Additionally, the participants

in the experimental group have to read the material which is provided by researchers

from a variety of sources on aspects of mindfulness practices. Goodman and team

found if Mindfulness-Based Cognitive Therapy (MBCT) on form of the CALM

pregnancy intervention holds potential to provide effective treatment for pregnant

women with anxiety (Goodman et al., 2014). This intervention can be considered as the

non-pharmacological treatment and as the promising method to reduce anxiety during

pregnancy, however, the lack of participants is acknowledge as the limitation in this

study.

Larsen and Plog in 2012 developed the childbirth classes aims to enhance self-

efficacy for women and support person. They recruited one hundred fifteen expectant

women and 109 support persons in the small Midwestern hospital who participates in

childbirth education classes. The program conducted during 6 weeks class offered 2.5

hours once a week (Larsen & Plog, 2012). To measure the outcome, initially the

investigators considered using the Childbirth Self-Efficacy Inventory (CBSEI) because

its established reliability and validity (Lowe, 1993). However, they want to evaluated

the impact of the content of these specific classes, therefore they developed the

instrument by themselves: childbirth SE instrument consist of 18-item Likert-type

scale. Before the content of material is pilot tested, initially the investigators invited the

24

experts to review and scored it by rating from 1 (completely lacking in confidence) to 4

(very confident) in performing behaviors associated with communicating needs,

coping, relaxation, working with support person or expectant women, knowledge of

labor and delivery, and overall confidence in coping with labor.

Larsen and Plog (2012) found if both expectant women and support person had

significantly increase in self-efficacy after the childbirth education classes. The

interesting finding result from their study is that additional external hours of

preparation in fact did not significantly affect SE scores for the expectant women but

did not significantly affect SE scores for the expectant women but did have an impact

on support person’s SE. support persons had significantly less outside preparation than

expectant women, which may explain why SE scores were higher following the

childbirth preparation for support person. Therefore, Larsen and Plog recommend for

the childbirth educators to continue to offer various classes to support the learning

needs of expectant families and continue to evaluate both curriculum and pedagogy of

the classes (Larsen & Plog, 2012).

Akbarzadeh and team from Iran in 2016 develop the prenatal class focused on

teaching attachment behavior to pregnant women. In total, 190 pregnant women in their

last trimester, were randomly into two groups (experiment and control group). The

participants in the experiment group attended the six educational class each lasting for

60-90 minutes (Akbarzadeh et al., 2016). The content material includes physiology of

pregnancy and childbirth, awareness of the feelings and perceptions of the embryo, the

concept of attachment, attachment behavior to control the anxiety and negative thought

and patterns of proper sleep, exercise and nutrition during pregnancy. In two

educational sessions in this study, the investigators focused about maternal-fetal

25

attachment, the effects such as attachment on the mother, fetus and baby, and way to

promote trough group discussion and role playing.

The action of maternal-fetal attachment includes: speaking to the fetus, looking

at and caressing the stomach, giving the fetus a name, encouraging other family

members to talk to the fetus, visualizing the face of the fetus, visualizing breastfeeding,

and hugging the baby (Muller, 1993). However, the women in the control group

received routine care delivered by the staff midwife, including assessment of fetal heart

rate and the measurement of uterine growth at each visit. In this group, the women took

public classes in the form of lecturers about prenatal care and breastfeeding. The

investigator found the significance difference of fetal development between mothers

who have poor maternal-fetal attachment and mothers who have good attachment

during pregnancy.

Akbarzadeh and team (2016) provide recommendation for further study to

educate mothers on attachment skilled will encourage the attachment between the

mothers and their unborn babies and reduced anxiety in the babies which, in turn,

improved their mental health at birth and at the age of three months old. Additionally,

they also suggested that educational programs on attachment skills for pregnant women

to be incorporated into routine prenatal care. Tahmabesy et al. (2013) conducted

intervention on prenatal attachment among forty two pregnant women while non-

intervention set up for forty one pregnant women with routine prenatal care. Both

groups of participant were asked to complete a maternal-fetal inventory (Cranley, 1981)

and interview from prior to and after the intervention. The investigators reported that

there is different mean score on attachment between two groups. Therefore, they

concluded that the maternal-fetal attachment intervention lead to an increase in the

mother’s attachment with their fetus, further motivating them to meet the child’s need.

26

Ultimately, this attachment affected in the social, emotional, ad cognitive growth of the

child (Akbarzadeh et al., 2011).

The study confirms the efficacy of childbirth education of mindfulness-based

program on the psychological health such as self-efficacy, self-perceived stress and

depression (Pan et al., 2018). The eight-week program has been effective to increase

childbirth self-efficacy in the intervention group and decreased self-perceived stress

and depression significantly. The content material has been summarized on the paper,

include yoga, physiology of childbirth from a mind-body perspective, comfort measure

during birth, physiology of breastfeeding to coping breastfeeding challenge.

Childbirth education offers multiple opportunities to reach expectant mothers

with information related to pregnancy, labor, and delivery and as a way of promoting

delivery with the assistance of a skilled health-care provider (Anonymous, 2008).

Based on large study in China (Shi, Wang, Yuan, Jiang, & Zeng, 2015), which is

involved 604 pregnant women to participate in prenatal education curriculum. This

cross-sectional study was collect data on the format of the curriculum: lecture (92.6%),

promotional materials (64.6%), followed by video (60.0%), demonstration and practice

(58.3%) and group discussion (54.3%). In term of the effect of the prenatal education

curriculum provided by the hospitals, the majority of surveyed mothers who

participated in it said they know more about prenatal examination, health care

knowledge during pregnancy, roles of doctors and nurses during delivery, benefits and

approaches of breastfeeding. Therefore, they recommend to should be advocate the

childbirth education for mother and father.

Particularly, childbirth education take place as part of routine prenatal care

based on recommendation from World Health Organization (WHO), and has long been

acknowledged as a crucial component of prenatal care (Bahrami, Simbar, & Bahrami,

27

2013). The goal of childbirth education classes are to help expectant parents become

knowledgeable mothers and fathers, make them actively take part in maintaining health

during pregnancy, delivery, and parenting (Giurgescu & Templin, 2015; Endang Koni

Suryaningsih, 2016). However, the investigators have no provide the information on the

content of the material as the curriculum of the class.

In 1996, Beger and Beaman conducted the evaluation of childbirth education

classes to address the particular issue as the foundation for further researcher who want

to develop curriculum for childbirth education classes (Beger & Beaman, 1996). They

underlined if the timing of an educational interest survey also affects the result of

project. Additionally, expectant parent requested more demonstration and practice, and

breathing, and relaxation techniques to prepare for labor. However, commonly

techniques in childbirth education such as music, imagery, and effleurage have not been

reported useful (Beger & Beaman, 1996).

Based on those literature reviews, using RAM as the guidelines, the researcher

has been developed particular intervention to address the specific behavior that

manifest from the four modes as described in the Table 2.1. The goal of those

interventions are to promote mother’s adaptation for each modes and its outcomes can

be measured as the evaluation of the intervention

28

Table 2.1. The application of RAM for childbirth education classes curriculum based on literature

Modes Specific behavior

Stimuli Diagnosis Goal Intervention Evaluation Focal Contextual

Physiological Discomfort due to some changes

Type of childbirth education class

Maternal demographic characteristics

Adaptive response/ in adaptive response

Enhance maternal adaptation on physiological changes

- Relaxation - Provide

counseling for mother and spouse, information and education about physiological change

- Provide care for enhance comfort during pregnancy

Measure maternal anxiety

Self-concept Personal self-concept on pregnancy and childbirth

Type of childbirth education class

Maternal demographic characteristics

Adaptive response/ in adaptive response

- Enhance maternal confidence to cope with the preparation for childbirth

- Enhance maternal childbirth self-efficacy

- Provide information on maternal self-concept and maternal self-confidence

- Provide information and practice for childbirth preparation

- Measure maternal childbirth self-efficacy

Role function - Playing role as a mother

- Playing role as the spouse

Type of childbirth education class

Maternal demographic characteristics

Adaptive response/ in adaptive response

- Enhance the role function as the mother

- Provide maternal-fetal attachment skills

Measure maternal-fetal attachment

29

- Practice the maternal-fetal attachment skills

Interdependence - Relationship

with husband

- Relationship with unborn baby

Type of childbirth education class

Maternal demographic characteristics

Adaptive response/ in adaptive response

- Enhance the quality relationship between mother and spouse

- Provide skill how to communication with husband

- Empower husband to practice comfort measurement during pregnancy and childbirth

Measure marital relationship

30

Since Roy’s Adaptation Model is the complex concept, we need to translate the grant

theory into the practices. Figure 2.2 is the evidence that Roy’s Model can be accepted in this

study in which the gap between theory and empirical indicator can be measured. Adaptive

system in this study is the pregnant women in their third of pregnancy and will be recruited in

this study as the participant. The focal stimuli is childbirth education class that follow Roy’s

Model, and contextual stimuli is the demographic characteristic that may affect to the

mother’s adaptation level. The physiological mode resulted the physic and physiology change

during pregnancy and may lead some discomfort. This condition may resulted either adaptive

or maladaptive response. The indicator of this mode is pregnancy-related anxiety and will be

measured using Pregnancy-Related Anxiety Questionnaire Revised-2 (PRAQ-R2). The self-

concept is the mother’s efficacy to have their childbirth process, therefore the behavior will

be measured using the short form of Childbirth Self-Efficacy Inventory (CBSEI). Role

function mode refers to role function as the mother in which the degree the expectant women

attach to her unborn baby. The indicator behavior will be measure using Prenatal Attachment

Inventory (PAI). Finally, the interdependence mode defined as mother’s relationship with

their husband. Since the indicator variable of marital relationship is marital satisfaction and

communication, therefore ENRICH Marital Satisfaction Scale will be applied to measure the

behavior.

31

Grant theory Roy’s adaptation model

Adaptive system

Empirical stimuli

Adaptation modes

Concept

Pregnant women

Physiological Mode

Role function Mode

Self-concept Mode

Interdependence Mode

Focal

Contextual Nine physiological

change

Operational indicator Participants Experime

nt and control groups

Demographic data sheet

Pregnancy-related anxiety questionnaire (PRAQ-R2)

Short form of

Childbirth Self-

Efficacy Inventory (CBSEI)

Prenatal Attachment Inventory

(PAI)

Developed childbirth education

Maternal demographic characteristic: age, marital status, education, occupation

Discomfort

Adaptive/maladaptive response

Confidence in ability to cope with childbirth process

Role as a mother

Relationship with husband

Figure 2.2 Model, concept, and operational structures of efficacy on childbirth education based on Roy’s Adaptation Model

ENRICH Marital

satisfaction scale (EMS)

32

2-5. Childbirth education in Indonesia

In Indonesia, the program of childbirth education classes has been provide as a part of

midwifery care in the community since 2009 to accelerate the decreasing number of maternal

and infant mortality. The aim of this class is to enhance mother’s knowledge regarding

physiological adjustment and complaint that may rise during pregnancy and post-partum.

Family planning after birth, newborn care, local myth, belief and culture, infection disease as

well as birth certificate, also includes as the major topic of this program (Ministry of Health

Indonesian Republic, 2011). The childbirth educator for this program is the midwives, or

someone who certified as the childbirth educator. Indonesian health authority recommend for

pregnant women after 20 weeks of pregnancy may participate in this program. However,

partner or husband is expected to be involve in the class for at least one time. The participant

limited up to ten person for each class.

In Indonesia, both public and private sector are allowed to provide the childbirth

education class, yet the non-government organization and society. Prior to determine the

content material, need assessment will be conducted by midwives to addressed community’s

demand on the childbirth program. The content of material includes: anatomy and

physiological change during pregnancy, pregnancy care, birth and post-partum. Family

planning after birth, newborn care, local myth, belief and culture, infection disease as well as

birth certificate. The class consist of three time meeting and the number of content based on

the appointment between childbirth educator and the group of pregnant women. After the

program finish, then midwives will report and document the activity as the monitoring

process, and evaluate its effectiveness. The scheme of childbirth education class program in

Indonesia can be seen on the Figure 2.3. Many studies in Indonesia indicate the efficacy of

this program to enhance maternal mental and physical well-being(Agustiningsih, 2017; Faiza,

33

Notobroto, Trijanto, & Soedirham, 2016; Fata & Rahmawati, 2016; Fibriana & Azinar, 2016;

Lucia et al., 2013; Novitasari, Budiningsih, & Mabruri, 2013; Nursofyanto & Cahyanti, 2017;

Septerina, Hastuti, & Fitria, 2014; Setyaningsih et al., 2013).

Figure 2.3 Scheme of childbirth education class in Indonesia provided by public sector

The program has 120-125 minutes for each session, consisted of average four to five

topics. The method delivered by childbirth educator through lecturing, practicing, discussion,

brainstorming, and simulation. Midwives or childbirth educator should made documentation

in the end of the program as the monitoring and evaluation effort that have to be submitted to

ministry of health. Nowadays, the childbirth education class program becoming popular and

provided from private clinic, or hospital, and work independently. One of the most famous

childbirth education training center in Indonesia is Bumi Sehat foundation. As the non-profit

organization, Bumi Sehat, located in Bali, was founded by Robin Lim in 1995 provide a

comprehensive range of allopathic and holistic medicine, as well as pre and post-natal care,

breastfeeding support, infant, child and family health services, nutritional education, pre-natal

yoga and gentle, loving natural birth services (Bumi Sehat, 2019).

Need assessment from society, content material based on demand

Preliminary class

Team is created

Childbirth education class and report

Monitoring

Evaluation

34

Since its development, there are a huge number of facilitator of childbirth prenatal

yoga and gentle birth classes across the province who achieve their certification from this

foundation. They were, then, back to their place and provide childbirth education classes.

One of the private clinic which is provide childbirth education classes is Bidan Kita in Solo,

Center Java. As the one recommended clinic in central Java, Bidan Kita (in English mean:

Our Midwives), provide childbirth education classes for couple and expatriate as well. The

program includes: gentle birth, prenatal yoga, hypnobirthing, childbirth support and healing,

parenting and newborn care (Aprilia, 2019).

35

CHAPTER III

RESEARCH METHODHOLOGY

This chapter describes the research design, study setting, population, sampling and

sample determination, inclusion and exclusion criteria, data collection, childbirth education

curriculum development, data analysis, and ethical considerations.

3-1. Study design

This study was conducted using a randomized controlled trial with pretest-posttest

repeated measurement of pregnancy-related anxiety, maternal-fetal attachment, childbirth

self-efficacy, and the quality of marital relationships in the intervention and control groups.

Allocation concealment was assured by using a sequentially numbered, opaque, sealed

envelopes (SNOSE). This study has covered three aims, some following instruments were

used to measure the outcomes: Demographic questionnaire, Pregnancy-Related Anxiety

Questionnaire Revised (PRAQ-R2), Prenatal Attachment Inventory (PAI), Short Form of

Childbirth Self-Efficacy Inventory (CBSEI), and ENRICH Marital Satisfaction Scale (EMS).

E O1 X O2

Random allocation

C O1 X O2

Note: E= experimental group; C=Control group

O1= pretest Demographic questionnaire, Pregnancy-Related Anxiety Questionnaire

Revised (PRAQ-R2), Prenatal Attachment Inventory (PAI), Short Form of Childbirth

Self-Efficacy Inventory (CBSEI), and ENRICH Marital Satisfaction Scale (EMS)

O2= post PRAQ-R2, PAI, CBSEI, EMS

Figure 3.1 Research design

36

3-2. Study setting

Five health centers (bahasa: puskesmas) have been chosen based on the availability of

regular childbirth education classes. The intervention group, the classes were conducted at

the childbirth education room of health college of Aisyiyah University, Yogyakarta. For the

control group, the classes were conducted at the puskesmas in Yogyakarta Province.

3-3. Population and sample

The study population were pregnant women who attend antenatal care at primary health

care centers in Yogyakarta. Using a G-Power software, repeated measures, between factor,

set effect size = .25 and power= .80. The researcher calculated a sample size of 98 would be

needed for meaningful results (Faul, Erdfelder, Lang, & Buchner, 2007). Assuming a 20%

attrition rate, raises the total number of participants to 122. The researcher was produce a

random allocation list using a computer random allocation block (sequence 4, 6, 8) at five

health centers to ensures equal in size and treatment allocation within each block. The

allocation software using Microsoft Visual Basic 6 version 1.0.0 developed by Saghei from

Anesthesia Department in Isfahan University of Medical Sciences, Iran. This software

installed in the ordinary windows software such as running setup.exe and following on

screen instruction(Saghaei, 2004).

In this study, the inclusion criteria for participation were:

1. First time pregnancy (nullipara)

Prior experience giving birth affects mothers’ anxiety related to pregnancy and

childbirth self-efficacy. Therefore to minimize the threat to internal validity, the

researcher only invited nullipara women for the current study.

37

2. Pregnant women ages 20 to 35

Based on recommendations from the Ministry of Health in Indonesia, the ideal

reproductive range age for a healthy pregnancy is between 20 and 35 years old (Ministry

of Health, 2018). The four most common non-obstetric causes of maternal mortality in

Indonesia are summarized as the 4T conditions: Too young (pregnancy under age 20),

Too old (pregnancy above age 35), Too often (parity of greater than three), and Too close

(pregnancy spacing of less than two years) (Aeni, 2011).

3. Gestational age of 28 to 35 weeks

This program will be conducted during classes held once a week for a period of four

weeks. To prevent the possibility of high-risk pregnancy such as: preterm and posterm

birth, the researcher will invite pregnant women at 28 to 35 weeks of gestation to

participate.

4. Married

This study will invite husbands to accompany their wives during the childbirth

education classes. The classes will enhance the quality of the couples’ marital

relationships through counseling, verbal communication, and touching communication.

Unmarried couples having children are rare in Indonesia and to include marital status in

the model would require a larger number of such couples than are likely to be available.

5. Residents of Yogyakarta

The participants must be residents of Yogyakarta to decrease the possibility of

attrition due to distance from the study setting.

6. Singleton pregnancy

Multiple pregnancies are one of the high-risk pregnancy categories. Women with

multiple pregnancy tend to have shorter average gestation and more complications, such

38

as preterm birth, preeclampsia, diabetes mellitus, and placental problems, than women

with singleton pregnancies. (American Society for Reproductive Medicine, 2012;

Lazarov, Lazarov, & Lazarov, 2016). To minimize risk during this intervention, the

researcher will only invite women with singleton pregnancies.

The exclusion criteria:

Mothers who miss the classes more than two times is considered to be excluded in the

study. The mothers those who miscarry, and those whose pregnancies become high-risk, will

be automatic excluded from the study.

3-4. Data Collection

The researcher was prepare the curriculum, enroll participants, and allocate them into

groups.

1. Curriculum preparation

After a literature review, the researcher selected and modified possible material for

childbirth education based on a Roy’s Adaptation Model approach. The content has been

reviewed by thesis committee members during the proposal defense to get suggestions and

recommendations regarding its content and sequence. Next the researcher invited experts

from Indonesia to evaluate the curriculum. These experts were midwives who have provided

midwifery care for more than two years and who are teaching prenatal classes. They asked to

rate each topic in the curriculum as “not needed,” “a very minor topic,” “a minor topic,” or “a

major topic.” The survey form were open-ended, allowing the experts to add supplementary

topics or to make comments

The researcher recruited two research assistants with a bachelor degrees qualification.

They were participated in a one-day training session to discuss the aims of the study, as well

39

as the procedures and protocols they should use. The rationale for content of the childbirth

education class and the potential outcomes of the intervention also were discussed. The

training were also included a quality control issues relating to biases, fabrication of data,

missing data, and ethical issues, in order to ensure the consistency of the recruitment and data

collection process.

2. Enrolment and allocation

After approval from the Ethical Committee of ‘Aisyiyah University of Yogyakarta

Institutional Review Board, the researcher was prepare materials to approach pregnant

women attending antenatal care clinics for participation in the study. For recruiting purposes,

the researcher was create colorful flyers and standing banners promoting the benefits of

joining the study to put in the waiting rooms of antenatal care clinics in puskesmas. The

program were free of charge and mothers were given incentive for their participation. That

information was provide on the flyers and standing banners. The researcher and the two

trained assistants worn ID cards that include a photo, name, title, and job position for the

current study, along the affiliations name. Name tags for participants also has been provided

by the researcher.

The researcher and assistants were distributed flyers to the mothers who are potential

participants while they are waiting their turn to enter the antenatal care clinic. We were

explained the purpose of the study to all potential participants, as well as the benefits of

participation and the low risk of harm. The confidentiality of results and the right to withdraw

from the study at any time without any consequences will be guaranteed. Additionally,

potential participants also has been allowed to ask questions about the study. Once a

participant agrees, the researcher or a trained assistant will ask them to fill out the informed

consent form and include their cell phone number. The research assistant will give the

40

mothers a card in an opaque and sealed envelope containing a randomly assigned number for

the purpose of allocating them to groups. The research assistants were opened the sealed

envelope and record the number while the women are in the antenatal care room.

There were five intervention group classes and five control group classes held on

different days of the week. Participants were encouraged to choose a class time that is

feasible for them by providing their preferred and second-best available times through

WhatsApp meeting scheduler. The researcher were conducted two classes at a time, repeating

the recruitment and teaching process once the participants were completed due to it was not

possible to recruit enough participants to run five classes simultaneously. Participants who

are randomized to the intervention group were attended a four-week class lasting three hours

each time. Participants randomized to the control group were attended a four-week class

consisting of the existing antenatal education program offered at the puskesmas. The women

were informed of their final assignment to a childbirth education class schedule through

WhatsApp or by phone. The researcher were inquired about how each midwife instructor

normally sets up class times and were provided with a list of participants who have been

allocated to the control group.

The mothers were asked to complete the study questionnaire to establish a baseline

measurement for all instruments, whilst the husbands were asked to complete the

demographic information and the Enrich Marital Satisfaction (EMS) Scale . After four weeks

of classes, the participants were self-administer the same questionnaire again without the

demographic portion. Completing the questionnaire was estimated 15 to 20 minutes.

Intervention group

The participants in the intervention group are pregnant women and their husbands. The

instructors employed teaching methods such as a group discussion, watching videos, and

41

brainstorming, as well as questions and answer periods, demonstrations, childbirth

simulation, and practice. The primary investigator (PI) taught particular sessions, including

maternal-fetal attachment skills, parenting skills, comfort measures, childbirth positions, as

well as knowledge about anatomy and physiology during pregnancy and birth. The prenatal

yoga facilitator were taught pregnancy and relaxation exercises. The materials and learning

methods as the control process are expected to influence the four modes as the effectors that

can reduce maternal anxiety and increase maternal-fetal attachment, childbirth self-efficacy,

as well as marital satisfaction as the outcomes of adaptation level.

The study setting for the intervention group were conducted at antenatal care laboratory

of ‘Aisyiyah University of Yogyakarta. For safety and protocol concern during pandemic

COVID-19 situation, the class was set up in a big classroom and an adequate ventilation that

can accommodate 12 couples and is equipped with yoga mats and pillows, as well as

convenient access to a restroom. The couples and researcher team were required to wear

mask and wash their hand before and after enter the class. The distance from the university to

the five puskesmas or private clinics will range from 2 to 5 km.

Research assistants printed hand outs and lead the group through WhatsApp application to

following up practicing skills at home and also respond the question from the participant at

any time. During the intervention, the health workers from the participating puskesmas have

been invited to observe the intervention. Classes consisted of 180-minute sessions held once

a week for four weeks. Detailed class plans based on RAM are described in Appendix.

Control group

The control group participants in this study have attended standard childbirth education

classes during the same period as the intervention group. The control group classes were

conducted at the puskesmas where they were recruited, not at the university. The facilitators

42

of the control groups were midwives who are already providing prenatal education classes at

the clinics. The classes followed the government curriculum, which consists of three classes

per month and does not invite husbands to participate. However, in this study, participants in

the control group have four classes over a one-month period to better match the program of

the intervention group.

The material for the standard curriculum includes anatomical and physiological changes

during pregnancy, pregnancy care, birth and post-partum care. The classes also address

family planning after giving birth, newborn care, preventing infectious disease, and

procedures for obtaining a birth certificate. The midwives also discuss and debunk unhealthy

local myths, beliefs and cultural practices surrounding pregnancy, childbirth and the post-

partum period. For the fourth class, the control group have a half hour to fill out the

questionnaires and a half hour for feedback and discussion. Then the researcher and assistants

have provided the control group participants with a condensed two-hour class of prenatal

yoga, comfort measures, and maternal-fetal attachment activities.

We conducted online briefing sessions with midwives who are the childbirth education

program facilitator at five health centers. The briefing was discuss about the objectives of the

study, the administration of the questionnaire, and the quality control issues relating to biases,

fabricated data, missing data, and ethical issues. These were established in an effort to ensure

consistency in the process of data collection.

Table 3.1 Comparison childbirth education program between experimental and control group

Experimental group Control group

Content anatomical and physiological

changes during pregnancy and birth,

maternal-fetal attachment skills,

anatomical and physiological

changes during pregnancy,

pregnancy care, birth and post-

43

parenting skills, comfort measures,

childbirth positions, pregnancy and

relaxation exercise during

pregnancy and labor, as well as

couples communication issue.

partum care, family planning

after giving birth, newborn care,

preventing infectious disease,

and procedures for obtaining a

birth certificate.

Learning method Lecturing, round table discussion,

demonstrating, practicing, and

watching the video. Following up

the practical suing group online

discussion.

Lecturing and discussion

Hour 3 hours for each session 2-3 hours for each session

Instructor Researcher Midwives in the health center

Participants Mother and husband or relative Mother

Place Childbirth education room Health center

44

3-5. Research Tools

In this study, researcher applied five different instruments: Demographic

questionnaire, Pregnancy-Related Questionnaires Anxiety Revised-2, Short Form of the

Childbirth Self-Efficacy Inventory, Prenatal Attachment Inventory, and ENRICH Marital

Satisfaction Scale.

Demographic questionnaire

The researcher has developed a demographic data sheet to gain information about

participants’ backgrounds, such as maternal age, religion, ethnicity, education, gestational

week, occupational status, marital status and duration, and monthly income.

Pregnancy-related anxiety questionnaire revised (PRAQ-Q2)

The original instrument, the PRAQ-R1, consisted of 34-items developed by Van Den

Bergh (Bergh, 1990). The revised questionnaire, PRAQ-R2, is shorter and consists of a 10-

item self-report for multipara women, and an 11-item self-report for nulliparas. The scores on

each item range from 1 (definitely not true) to 5 (definitely true) (Huizink, Mulder, Robles de

Medina, Visser, & Buitelaar, 2004). The 10-items consist of three subscales: items 1, 2, 6 and

8 are related to “fear of giving birth,” items 4, 9, 10, and 11 are related to “worries about

bearing a physically or mentally handicapped child,” and items 3, 5, and 7 are related to body

image or “concern about own appearance.” In the revised version, Huizink explains the

awareness for calculate the new version of PRAQ-R2 which is only addressed to measure

pregnancy-anxiety for nulliparous, while PRAQ-R applicable for all pregnant women

regardless of parity. The item 8 (“I am anxious about the delivery because I have never

experience one before”) will apply in this study since all the proposed participant are

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nulliparous, instead of item 1 (“I am anxious about the delivery”) which is applicable for all

parity. Thus, the minimum and maximum total score are 11 and 55, respectively (Huizink,

Delforterie, Scheinin, & Tolvanen, 2016). The assumption is that, the higher the score, the

higher the level of anxiety in pregnancy. The PRAQ-R2 items are all structurally positive

statement and the questionnaire has no cut-off point. Huizink and team (2016), then tested for

its validity and reliability in a longitudinal study with a large sample size (1144 pregnant

women). The result showed the Cronbach’s Alpha for the total score was good, ranged from

.71 to .85 for the multiparous, and .75 to .84, for the primiparas based on values measured at

different weeks of gestation (Huizink et al., 2016).

Short Form of Childbirth Self-Efficacy Inventory (CBSEI)

Childbirth Self-Efficacy Inventory (CBSEI) was developed by Lowe (1986) to

measure maternal confidence in coping abilities during childbirth. Based on Bandura’s Self-

Efficacy Theory (1977), Lowe create the tool as a self-report instrument consist of 60 items

divided to four subscales; OAL, ESS, OSS and ESS. A total Childbirth Outcome Expectancy

Score (Outcome-Total) is computed by summing the Outcome-AL and Outcome-SS scale

scores. A Total Self-Efficacy Expectancy Score (Efficacy-Total) is computed by summing

the Efficacy-AL and Efficacy-SS scale scores (Lowe, 1989). The example item: “ Relax my

body”, “ tell myself that I can do it”, and “listen to encouragement from the person helping

me.”

Lowe measure the internal consistency ranged from .86 to .95 for all subscales (Lowe,

1993). Many studies reported high validities and reliabilities of CBSEI from different

languages around the world, the Cronbach’s Alpha range were 0.86 -0.93 (Abujilban,

Sinclair, & Kernohan, 2012; Carlsson et al., 2014; Eleonora Björk, Mari Thorildsson, 2007;

46

Gourounti et al., 2013; Gourounti, Kouklaki, & Lykeridou, 2015; Ip, Chan, & Chien, 2005;

Khorsandi et al., 2008; Tanglakmankhong, Perrin, & Lowe, 2011).

In 2005, Ip and colleagues developed the short form of CBSEI consist of 32 items

(OE= 16, and SS=16). They deleting the two repetitive expectancy subscale to producing the

responses across the two stages of labor and reduce the lengthy structure of the original

CBSEI (Ip et al., 2005). In different studies, the short form of CBSEI demonstrates high

internal consistency (á= .90- .96) (Gao, Ip, & Sun, 2011; Ip, Chung, & Tang, 2007;

Khorsandi, Jafarabadi, Farzaneh, & Mohammad, 2013).

Prenatal Attachment Inventory (PAI)

This instrument developed by Muller (1993) to measure the unique relationship

between mothers with their unborn babies. The instrument consist of 21 Likert-type items

ranging from 1 (‘almost never’) to 4 (‘almost always’). All items are summed for a single

score, and the possible range of scores is 21-84 (Muller, 1993). The 21-item PAI was

validated in a Swedish sample of 171 pregnant women by Siddiqui et al (1999), Cronbach’s

alpha coefficient was .86, and the mean was 57.22 (SD = 5.916) (Siddiqui & Hägglöf, 2000).

In 2003, Gau and Lee tested the construct validity of the instrument by using confirmatory

factor analysis (CFA) on a sample of 344 pregnant American women in their third trimesters.

Cronbach’s alpha coefficient was .89 and the mean were 63.7 (Gau & Lee, 2003). The author

have culturally translated, produce the Indonesian version of PAI, and demonstrates high

internal reliability (á= .93) (E.K. Suryaningsih, 2015).

47

ENRICH Marital Satisfaction Scale (EMS)

Evaluation and Nurturing Relationship Issues, Communication and Happiness

(ENRICH) Marital Satisfaction Scale (EMS) was developed by Fower and Olson (1993)

consist of a 15-item comprising the Idealistic Distortion (5 items) and Marital Satisfaction

Scales (10 items). This scale is a Likert-type ranging from 1 (strongly disagree) to 5 (strongly

agree) which is consist of positive and negative statement that indicate items scored direction

(Fowers & Olson, 1993). Items scored in negative direction would be reverse-scored (i.e if it

is mark 5, it would be scored 1; it is marked 4, it would be scored 2; a 3 remain unchanged).

The example item on Idealistic Distortion scale such as: “ My partner and I understand each

other perfectly”, “ My partner completely understands and sympathizes with my every

mood”. The example item on Marital Satisfaction scale such as : “ I am not pleased with the

personality characteristics and personal habits of my partner”, and “ I am very happy with

how we handle role responsibilities in our marriage”.

The EMS Scale provides a score for each partner. The complete scoring procedures

are available in Appendix D. EMS has been tested and performed high reliability in replica

studies across the countries range between .88 to .92 (Az & Caninsti, 2016; Fowers & Olson,

1993; Handayani & Harsanti, 2017; Salehi & Shahhosseini, 2017).

Translation and back-translation

The researcher will conduct translation and back translation method following

guideline from WHO, to produce the Indonesian version of Pregnancy-Related

Questionnaires Anxiety Revised-2, the Indonesian version of short form of Childbirth Self-

Efficacy Inventory, and the Indonesian version of ENRICH Marital Satisfaction Scale. The

four steps include: forward translation, back translation, pre-testing and cognitive interview

48

and final version (World Health Organization, 2018). The researcher will invite an

independent professional translator to adapt the instruments into Indonesian. Once the

researcher and translator approved a draft of the Indonesian version, another independent

translator will translate the draft back into English. Both the translator and back-translator

obtained their master’s degrees in Taiwan and neither was otherwise involved in the study.

To identify any discrepancies between the two versions, the researcher will conduct a

committee review. After gaining ethical approval, a pilot testing on 10 eligible subject will be

carried out to test the logistic concern in the feasibility of the study. They will be asked to

state their understanding on each items. The internal consistency reliability of Indonesian

version of PRAQ-R2, Short Form of CBSEI, and EMS were calculated as Table 3.2. The

reliability of pretest EMS scores were below .70. However, all Cronbach’s Alphas level for

the posttest were acceptable.

Table 3.2 Reliability of the research instrument Variable Pretest Posttest

Mean± SD Α Mean± SD α

Maternal anxiety 31.27±8.22 .83 23.75±99.36 .93 Maternal-fetal attachment 50.51±7.06 .75 61.22±8.72 .84 Childbirth self-efficacy 177.47±46.66 .95 236.79±57.50 .95 Wife marital satisfaction 47.95±4.51 .48 58.05±6.84 .84 Husband marital satisfaction

58.23±4.40 .61 64.11±6.54 .85

SD= Standard Deviation

3-6. Data analysis

To conduct data analysis, researcher established six progressive steps: evaluate and enhance

the quality of data, assess the psychometry properties, and assess the potential for bias. The

data were analyzed using Statistical Package for Social Science (SPSS) 20.0 program. To the

49

descriptive statistics, the comparison of quantitative data was performed using different

statistical method as described in Table 3.2. The researcher tested the effect of childbirth

education classes on four outcomes: pregnancy-related anxiety, childbirth self-efficacy,

maternal-fetal attachment, and marital relationship.

Table 3.3 Statistical method

No.

Research question

Independent/Dependent Variable

Types of data Analysis method

1. Describe the demographic statistic

Descriptive Percentage Descriptive statistic

2. Compare the demographic characteristic

Maternal age Interval Independent t-test Religion Nominal Chi-square Ethnicity Nominal Chi-square Educational background Ordinal Chi- square Gestational week Interval Independent t-test Occupation Nominal Chi-square Marital duration Interval Independent t-test Monthly income Nominal Chi-square 3. Tested the effect of

childbirth education to the 4 modes in the intervention group

Pregnancy-related anxiety Maternal-fetal attachment Childbirth Self-Efficacy Marital relationship

General Linear Model Per-Protocol

3-7. Ethical consideration

The researcher has obtain grant permission from instruments developers (see

Appendix E). Ethical approval was granted by ‘Aisyiyah University of Yogyakarta

(No.1303/KEP-UNISA/XI/2019). Informed consent from the pregnant women, anonymity

and the administration of questionnaire was conducted privately in the specific room and the

researcher assures the respondents that their information was limited as strictly confidential.

The researcher and assistance research have explained the nature and purpose study to the

respondents, and emphasized that participation was voluntary, and that they can the right to

50

withdraw from the study at any time without penalty. For the publication issue, only the

researcher and those directly involved with the study have access to the data.

51

CHAPTER IV

RESULTS

This chapter contains the result of this study. The contents will be divided into three

sections. The first section described the demographic information of the respondents. The

second section compared the baseline data of the maternal anxiety, maternal-fetal attachment,

childbirth self-efficacy, and marital satisfaction between two groups. The third section

presented the effectivity of the childbirth education program on the maternal anxiety,

maternal-fetal attachment, childbirth self-efficacy, and marital satisfaction between two

groups.

4-1. Demographic Information of the Respondents

The participants for this study were drawn from five public health centers in Yogyakarta,

Indonesia. The places were Mlati II, Jetis Kota, Mantrijeron, Kraton, and Godean I. In total,

there were 122 couples participated in this study consisting of 61 couples belonged to the

experiments group and 61 couples belonged to the control group. In such cases, some

participants were dropped out from the program. The final analysis after 4-weeks intervention

resulted 87 participants consisting of 52 couples in experiment group and 35 couples in

control group (see Figure 4.1).

52

Assessed for eligibility (n=152)

Randomized (n = 122)

Allocated to intervention childbirth education classes

(n=61)

Allocated to standard childbirth education class (n=61)

Enrollment

Allocation

Figure 4.1 CONSORT flow chart

Excluded (n = 60) Refused to participate (n = 15) Concern date and time (n=6) Other reasons (n=9)

Move to other area or cannot afford the schedule (n=12)

Loss of contact (n=14)

Move to another area before the class start (n=2) Premature labor (n=1) Move to other area(n=1) Loss of contact (n=5)

Analyzed (n=35)

Analyzed (n=52)

Analysis

Post-test after 4 weeks

Follow up

Post-test after 4 weeks

53

The missing subjects was about 28.6%. Independent t tests or Chi Square tests was

used to compare the demographic characteristics of the participants and missing subjects. The

results showed that these two groups were quite similar in couple’s occupation, education,

and maternal age. However, the participants had a lower maternal age than the missing

subjects (24.29 vs. 26.17, p<.05, Table 4.1).

Table 4. 1 Comparison of the demographic data between missing and non-missing participants (n=112)

Variables Attrition (n=35) Subject (n=87) Statistics (p) n % n %

Wife’s age (Mean, SD) 24.29 3.61 26.17 3.34 -2.76b (.007) Husband’s age (Mean, SD) 27.46 3.00 28.45 3.11 -1.61b (.110) Gestational week (Mean, SD) 30.23 2.39 30.20 1.76 0.08b (.933) Wife’s Occupation 1.95a(.162)

Unemployed 26 74.3 53 60.9 Employed 9 25.7 34 39.1

Husband’s Occupation Employed 35 100 87 100 ------

Wife’s Education 5.29a(.071) Elementary 15 42.9 23 26.4 High School 11 31.4 47 54.0 College 9 25.7 17 19.5

Husband’s Education 5.29a(.071) Elementary 6 17.1 6 6.9 High School 25 71.4 58 59.2 College 4 11.4 23 19.3

a= Chi Square; b= t test; SD= standard deviation According to table 4.2, there were a significant different in term of wife’s age, gestational

weeks, and couple’s education level in the control group. Mothers who complete the

program were older compare to those mother who missed the program (p < .05). Mothers

with older gestational age have complete the program compare to those mothers in the same

group (p < .001). Mother who graduated from high school were dominantly join the

complete program compare to those mothers who withdrawn from the program (p < .05).

Husband who graduated from high school were dominantly discontinued from the program

compare to those husband who complete the program (p < .05).

54

Table 4. 2 Comparison of the demographic data between missing and non-missing participants in the control groups (n=61)

Variables Attrition (n=26) Subject(n=35) Statistics (p) n % n %

Wife’s age (Mean, SD) 22.35 29.40 -17.07b (.007) Husband’s age (Mean, SD) 26.08 30.86 -9.47b (0.64) Gestational week (Mean, SD) 29.38 30.83 -.0.508b (<.001) Wife’s Occupation 1.95a(.162)

Unemployed 25 10 60.9 Employed 1 25 39.1

Husband’s Occupation Employed 26 100 35 100 ------

Wife’s Education 12.10(.002) Elementary 14 6 High School 6 23 College 6 6

Husband’s Education 4.30(.038) Elementary 2 5 High School 24 17 College 0 13

a= Chi Square; b= t test; SD= standard deviation

The baseline assessment for the demographic information such as couples’ gestational

week, couples’ education level, and couples’ occupation were also presented (Table 4.3).

Husbands were invited in this study since the curriculum address the couple topic including

the maternal-fetal attachment skill and marital relationship. To examine the difference of the

demographic variables between two groups, an independent t-test and Chi Square test were

applied. There was no significant difference mean score for gestational week, couple’s

education level, and couple’s occupation between two groups. However, there was a

significant difference mean score of the mothers’ age in the experiment and control groups (

p<.001). The participant’s age ranged from 20 to 35 years old, mean (SD)=23.92 (1.89) in

the intervention group and 20 to 28 years old, mean (SD)=28.40 (3.07) in the control group.

Husband’s age ranged from 22 to 36 years old in the intervention group and from 24 to 31

age in the control group. The gestational week ranged from 28 week to 33 week in the

intervention group, and from 28 week to 34 week in the control group. The age of the

55

participants and their partners significantly differed between two groups, and there was no

significant different in term of gestational week between two groups.

The Table also compared the frequency and percentage of couples’ education and

occupation across the groups. In the intervention group, almost 50% of the mothers graduated

from elementary-junior high school and senior high school, respectively, whilst mostly the

mothers graduated from senior high school in the control group. The experimental group’s

husband had a lower education level than the control group. The experimental group’s wife

had a higher percentage of the working mothers than the control group.

In summary, there was a significant difference between two groups on the couple’s

age, gestational week, husband’s education level, and mother’s occupation (see Table 4.2).

56

Table 4.3 The comparison of the demographic characteristics between the experimental and control groups

Wife Husband Characteristics Experiment

(n=52) Control (n=35)

t/χ2 p Experiment (n=52)

Control (n=35) t/χ2 p

n(%) n(%) n(%) n(%) Age (M±SD) (23.92±1.89) (29.14±2.10) -

12.08a <.001 (26.75±2.40) (30.86±2.20) -8.11a <.001

Gestational week(M±SD) (29.83±1.45) (31.04±1.80) -.3.45a .001 NA NA NA NA Education level Elementary 18(34.6) 6(17.1) 3.85b .146 1(1.9) 5(1.9) 11.33b <.001 High school 24(46.2) 23(65.7) 42(80.8) 17(48.3) College 10(19.2) 6(17.1) 9(17.3) 13(37.1) Occupation Employed 36(69.2) 22(62.9) 14.94b <.001 52(100) 35(100) NA NA Unemployed 16(30.8) 13(37.1) 0(0) 0(0)

a= t test; b= chi square

57

4-2. The comparison of the baseline of the maternal anxiety, maternal-fetal attachment,

childbirth self-efficacy and marital satisfaction

The comparison of the pretest score of the maternal anxiety, maternal-fetal attachment,

childbirth self-efficacy and marital satisfaction between two groups were presented in Table

4.4. Using independent t test, as the baseline of information presented, the mean score of the

maternal anxiety in the experimental group (28.23) was lower compared to the score in the

control group (35.97). While the wife’s mean score of the marital satisfaction in the

experiment group was higher compared to the wife’s score in the control group

(Experimental= 75.18 vs. Control= 63.09). Thus, there was a significant difference (p < .05)

in term of the maternal anxiety and the wife’s marital satisfaction throughout the groups.

However, as the maternal-fetal attachment, the childbirth self-efficacy, and the husband’s

marital satisfaction pretest score in the experiment group (49.40, 181.44, and 39.93,

respectively) had no significant difference mean with the score in the control group (50.56,

171.51, and 38.27, respectively, p>.05).

Table 4.4. The comparison of the baseline pretest scores between two groups

Variable Experiment (n=52) M±SD

Control (n=35) M±SD

p

Maternal anxiety 28.23±7.70 35.97±6.92 <.001 Maternal fetal-attachment 49.40±7.20 50.56±7.74 .482 Childbirth Self-efficacy 181.44±49.41 171.57±42.24 .336 Marital Satisfaction - Wife 75.18±10.45 63.09±10.89 <.001 - Husband 39.93±6.19 38.27±6.71 .240

M= mean; SD= standard deviation

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4-3. The relationship among the maternal anxiety, maternal-fetal attachment, childbirth

self-efficacy, and marital satisfaction

The outcome measured were the maternal anxiety using the Pregnancy-Related

Anxiety Questionnaire Revised-2 (PRAQ-R2), the maternal-fetal attachment using the

Prenatal Attachment Inventory (PAI), the childbirth self-efficacy using the Childbirth Self-

Efficacy Inventory (CBSEI), and the marital satisfaction using the Enrich Marital Satisfaction

Scale (EMS scale). In the study, the Pearson’s correlation was used to analyze the

correlation for the outcome variables (Table 4.4). In the pretest measurement, Maternal

Anxiety (MA) had a significant negative correlation to the childbirth self-efficacy (CBSE)

(p<.01), the maternal-fetal attachment (MFA) (p<0.01), the wife’s idealistic distortion marital

(WIDM) (p<.05) and the wife marital satisfaction (WMS) (p<0.01). MA score had a negative

correlation with the score of CBSE, MFA, and WIDM (r =-.572, r = -.287, and r = -.226,

respectively, Table 4.4).

CBSE, had a significant negative correlation to the MA, whilst, it had a significant

positive correlation to the MFA (p<.01 for each). MFA had a significant negative correlation

to the MA, whereas, it had a significant positive correlation to the CBSE (p<.01 for each).

Wife ENRICH marital satisfaction (WEMS) had a positive correlation to its two subscales:

the wife’s idealistic distortion marital (WIDM) and the wife’s marital satisfaction (WMS)

(p<.01, Table 4.4), while WIDM had a significant negative correlation to the MA (r = -.226,

p<.01) (.432, p<.01) and had a positive correlation to the WEMS. Husband ENRICH marital

satisfaction (HEMS) corelated reciprocally to the Husband’s idealistic distortion marital

(HIDM) (r = .536 for each, p<0.01). However, for the husband’s marital satisfaction (HMS)

had no correlation to the others outcome variables including the maternal anxiety, the

maternal-fetal attachment, and the childbirth self-efficacy inventory. The detail information

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could be seen in the Table 4.4. In the posttest measurement, the result was quite similar. For

detail information it could be seen in Table 4.5.

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Table 4.5. Pearson correlation for pretest scores within outcome variables in the experimental (n= 52) and control groups (n =35)

MA CBSE MFA WEMS HEMS WIDM WMS HIDM HMS

Maternal Anxiety (MA) 1 Childbirth self-efficacy (CBSE)

-.572*** 1

Maternal-Fetal Attachment (MFA)

-.287** .607** 1

Wife ENRICH Marital Satisfaction (WEMS)

.182 -.060 .042 1

Husband ENRICH Marital Satisfaction (HEMS)

-.203 .098 .024 .050 1

Wife’s Idealistic Distortion Marital (WIDM)

-.226* .020 -.170 .432*** .038 1

Wife’s Marital Satisfaction (WMS)

.337** -.078 .146 .845** .032 -.117 1

Husband’s Idealistic Distortion Marital (HIDM)

-.106 -.015 -.031 -.111 .536** .012 -.129 1

Husband’s Marital Satisfaction (HMS)

-.204 -.018 .092 .060 .109 .029 .049 .185 1

*p < .05 ;** p< .01 ; *** p< .001

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Table 4.6. Pearson correlation for posttest scores within outcome variables in the experimental (n= 52) and control groups (n =35)

MA CBSE MFA WEMS HEMS WIDM WMS HIDM HMS

Maternal Anxiety (MA)

1

Childbirth self-efficacy (CBSE)

-.857*** 1

Maternal-Fetal Attachment (MFA)

-.564*** .590*** 1

Wife ENRICH Marital Satisfaction (WEMS)

.107 -.086 -.113 1

Husband ENRICH Marital Satisfaction (HEMS)

.413*** -.405** -.241* -0.173 1

Wife’s Idealistic Distortion Marital (WIDM)

-.676*** .699*** .430*** 0.139 -.402*** 1

Wife’s Marital Satisfaction (WMS)

.532*** -.529*** -.376*** .763*** 0.114 -.534*** 1

Husband’s Idealistic Distortion Marital (HIDM)

-0.021 -0.026 0.155 -0.107 .232* 0.077 -0.141 1

Husband’s Marital Satisfaction (HMS)

.548*** -.505*** -.313** -0.163 .881*** -.481*** 0.175 .250* 1

*p < .05 ;** p< .01 ; *** p< .001

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4.4 The effect of the childbirth education program on the maternal anxiety, maternal-

fetal attachment, childbirth self-efficacy and marital satisfaction

Due to the differences on some demographics data and baseline outcomes data, GLM

(General Linear Model) was used to adjust these demographics and baseline outcomes

variables to analyze the effect of the childbirth education program on the maternal anxiety,

maternal-fetal attachment, childbirth self-efficacy, and couple’s marital satisfaction.

a. The effect of the childbirth education program on the maternal anxiety

Table 4.7 described the effect of childbirth education program on the maternal anxiety.

The intervention group had a lower maternal anxiety score (-16.67) than the control group.

The increase of one point pretest anxiety score would increase 0.19 point of the posttest

maternal anxiety. The couple’s age, couple’s education level, couple’s marital satisfaction,

gestational weeks, maternal-fetal attachment, and childbirth self-efficacy were not related to

the maternal anxiety level.

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Table 4.7 The effect of childbirth education program on the maternal anxiety (n=87)

Variable B SE t P 95% CI Intercept 43.47 15.22 2.86 .006 13.11~73.82 Group (E vs C) -16.67 1.94 -8.58 <.001 -20.53~-12.80 Maternal age -0.49 0.33 -1.47 .145 -1.15~0.17 Gestational week 0.17 0.28 0.60 .555 -0.38~0.71 Husband’s age 0.13 0.28 0.46 .648 -0.42~0.67 Wife’s education (ref: College)

Elementary-junior -0.42 1.51 -0.28 .784 2.60~-3.43 High school 0.68 1.36 0.50 .616 -2.01~3.38

Husband’s education (ref: College) Elementary-junior 1.87 2.09 0.89 .375 6.03~-2.30 High junior -0.62 1.22 -0.51 .614 1.81~-3.04

Wife’s occupation: (ref: Unemployed)

Employed -2.10 1.19 -1.77 .081 0.26~-4.47 Baseline :

Maternal anxiety 0.19 0.0 2.290 .025 0.36~0.03 Maternal-fetal attachment 0.02 0.09 0.17 .868 0.20~-0.17 Childbirth self-efficacy -0.02 0.02 -1.40 .165 0.01~-0.05 Wife’s marital satisfaction -0.06 0.17 -0.38 .708 0.27~-0.40 Husband’s marital satisfaction -0.07 0.17 -0.42 .678 0.26~-0.40

Note: E= experimental; C = Control; CI= Confidence Interval; SE= Standard Error; ref =reference

According to Table 4.8 the intervention group had a higher maternal fetal attachment

(MFA) score (12.27) than the control group. The increase of one point of the pretest MFA

score would increase 0.24 point of the posttest MFA. The high school mother had a higher

MFA score (5.11 points) than college level. However, couple’s age, maternal occupation,

gestational weeks, spouse’s education level, couple’s marital satisfaction, maternal anxiety,

and childbirth self-efficacy were not related to maternal-fetal attachment level.

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Table 4.8 The effect of childbirth education program on the maternal-fetal attachment (n=87)

Variable B SE t P 95% CI Intercept 13.10 22.97 0.57 .570 58.91~-32.71 Group (E vs C) 12.27 2.93 4.19 <.001 6.43~18.11 Maternal age 0.16 0.50 0.31 .757 -0.85~1.16 Gestational week 0.31 0.42 0.75 .458 -0.52~1.14 Husband’s age 0.04 0.42 0.09 .928 -0.79~0.87 Wife’s education: (ref: College)

Elementary-junior 2.75 2.28 1.21 .232 -1.79~7.30 High school 5.11 2.04 2.51 .014 1.04~9.18

Husband’s education : (ref: College) ● Elementary-junior -3.96 3.15 -1.26 .213 -10.25~2.33 ● High junior -1.95 1.84 -1.06 .293 -5.61~1.71

Wife’s occupation: (ref: Unemployed) Employed -0.28 1.79 -0.16 .874 -3.85~3.29

Baseline: Maternal anxiety -0.15 0.13 -1.22 .226 -0.40~0.01 Maternal-fetal attachment 0.24 0.14 1.74 .086 -0.04~0.52 Childbirth self-efficacy -0.02 0.02 -0.66 .514 -0.06~0.03 Wife’s marital satisfaction 0.07 0.25 0.28 .781 -0.44~0.58 Husband’s marital satisfaction 0.30 0.25 1.20 .236 -0.20~0.79

Note: E= experimental; C = Control; CI= Confidence Interval; SE= Standard Error; ref =reference

According to Table 4.9 the intervention group had a higher childbirth self-efficacy

(CSE) score (88.20) than the control group. The increase of one point of the pretest CSE

score would increase 0.39 point of the posttest CSE. The high school mother had a higher

CSE score (20.01 points) than college level. However, the couple’s age, couple’s marital

satisfaction, gestational weeks, maternal occupation, maternal anxiety were not related to the

CSE level.

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Table 4.9 The effect of childbirth education program on the childbirth self-efficacy (n=87)

Variable B SE t p 95% CI Intercept 242.60 96.52 2.51 .014 50.16~435.05 Group (E vs C) 88.20 12.31 7.16 <.001 63.65~112.75 Maternal age 1.48 2.11 0.70 .485 -2.72~5.69 Gestational week -0.43 1.74 -0.25 .805 -3.91~3.04 Husband’s age -1.75 1.74 -1.00 .319 -5.23~1.73 Wife’s education: (ref: College)

Elementary-junior 13.09 9.58 1.37 .176 -6.01~32.18 High school 20.01 8.57 2.33 .022 2.92~37.09

Husband’s education : (ref: College) Elementary-junior 2.10 13.25 0.16 .875 24.33~-28.52 High junior 1.96 7.71 0.25 .800 13.42~-17.34

Wife’s occupation: (ref: Unemployed) Work 1.99 7.52 0.27 .792 -13.00~16.99

Baseline: Maternal anxiety -0.58 0.53 -1.09 .279 -1.63~0.48 Maternal-fetal attachment -1.09 0.59 -1.85 .069 -2.27~0.09 Childbirth self-efficacy 0.39 0.10 3.94 <.001 0.19~0.59 Wife’s marital satisfaction -0.05 1.07 -0.05 .960 -2.18~2.07 Husband’s marital satisfaction -0.83 1.05 -0.80 .428 -2.92~1.25

Note: E= experimental; C = Control; CI= Confidence Interval; SE= Standard Error; ref =reference

According to Table 4.10 the intervention group had a higher Wife’s Marital

Satisfaction (WMS) score (0.16) than the control group. The increase of one point of the

WMS pretest score would increase 0.24 point of the WMS posttest. The high score mother on

maternal-fetal attachment had a higher WMS score. The couple’s age, couple’s education

level, maternal occupation, maternal anxiety, childbirth self-efficacy, and husband’s marital

satisfaction, were not related to WMS level.

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Table 4.10 The effect of childbirth education program on the Wife’s marital satisfaction (n=87)

Variable B SE t p 95% CI Intercept 38.29 8.20 4.67 <.001 21.94~54.65 Group (E vs C) 0.16 1.05 0.15 .878 -1.93~2.25 Maternal age 0.22 0.18 1.21 .229 -0.14~0.60 Gestational week 0.09 0.15 0.57 .569 -0.21~0.38 Husband’s age 0.00 0.15 0.02 .988 -0.29~0.30 Wife’s education: (ref: College)

Elementary-junior -0.85 0.81 -1.05 .299 -2.47~0.77 High junior -0.14 0.73 -0.19 .847 -1.59~1.31

Husband’s education : (ref: College) Elementary-junior -0.26 1.13 -0.23 .821 -2.50~1.99 High junior 0.17 0.66 0.26 .797 -1.14~1.48

Wife’s occupation: (ref: Unemployed) Employed 0.18 0.64 0.28 .779 -1.09~1.45

Baseline: Maternal anxiety -0.01 0.05 -0.16 .872 -0.01~0.08 Maternal-fetal attachment -0.11 0.05 -2.23 .029 -0.21~-0.01 Childbirth self-efficacy 0.01 0.01 1.51 .136 -0.00~0.03 Wife’s marital satisfaction 0.24 0.09 2.63 .010 0.06~0.42 Husband’s marital satisfaction -0.10 0.09 -1.10 .273 -0.28~0.08

Note: E= experimental; C = Control; CI= Confidence Interval; SE= Standard Error; ref =reference

According to Table 4.11 the increase of one point of the HMS pretest score would

increase 0.23 point of the posttest HMS. However, there was no significance difference

means score on the Husband’s marital satisfaction between intervention and control group.

The maternal anxiety and childbirth self-efficacy were significant contribution to the score of

HMS. The couple’s age, husband’s education level, maternal occupation, and maternal-fetal

attachment, were not related to HMS level.

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Table 4.11 The effect of childbirth education program on the Husband’s Marital Satisfaction (n=87)

Variable B SE t P 95% CI Intercept 40.56 8.81 4.61 <.001 22.10~58.11 Group (E vs C) -1.48 1.12 -1.32 .191 -3.72~0.76 Maternal age 0.12 0.19 0.60 .549 -0.27~0.50 Gestational week 0.01 0.16 0.07 .948 -0.31~0.33 Husband’s age 0.16 0.160 0.98 .331 -0.16~0.47 Wife’s education: (ref: College)

Elementary-junior -0.26 0.87 -0.30 .765 -2.00~1.48 High junior -0.33 0.78 -0.42 .677 -1.89~1.23

Husband’s education : (ref: College) Elementary-junior -0.06 1.21 -0.05 .960 -2.47~2.35 High junior -1.44 0.70 -2.04 .045 -2.84~-0.03

Wife’s occupation: (ref: Unemployed)

Employed 0.23 0.69 0.41 .687 -1.09~1.65 Baseline:

Maternal anxiety -0.01 0.05 -2.01 .048 -0.19~-0.00 Maternal-fetal attachment 0.02 0.05 0.39 .696 -0.09~0.13 Childbirth self-efficacy -0.02 0.01 -2.25 .027 -0.04~-0.00 Wife’s marital satisfaction -0.03 0.01 -0.28 .780 -0.22~0.17 Husband’s marital satisfaction 0.23 0.01 2.42 .018 0.04~0.42

Note: E= experimental; C = Control; CI= Confidence Interval; SE= Standard Error; ref =reference

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CHAPTER V

DISCUSSION

This study answered three research questions. First, the result study on the

demographic characteristics described the mean of the couple’s age were 23.92 and 26.75

(Female and Male, respectively) in the experimental group, and 29.14 and 30.86 (Female and

Male, respectively) in the control group. As for the gestational age, the mean of the week was

29.83 in the experimental group and 31.04 in the control group. In both groups, the couple

mostly graduated from high school and more than 50% of the mothers go to work.

Second, in the study, the researcher found the significance difference between two

groups on the demographic data including the couple’s age, gestational week, husband’s

education level, and wife’s occupation. The researcher lost more than twenty percent

participants in the study. This may due to the Covid-19 pandemic which just began in

Indonesia. Another reason maybe because the missing participants did not gain the

knowledge as their expectation. Moreover, the class in the experimental group was set-up to

be more flexible than in the control group due to some participants who had to adjust with

their working hours. Therefore, maybe there was another cause why the observed group lost

many participants compared to the intervention group.

In this study, the researcher used five instruments to measure the variable outcomes;

Pregnancy-Related Anxiety-2 Revised (PRAQ2-R), Prenatal Attachment Inventory (PAI),

Childbirth Self-Efficacy Inventory (CBSEI), and ENRICH Marital Satisfaction Scale (EMS).

Excluding EMS scale, the researcher used the existing Indonesian version instruments that

had been translated and validated by the author and other researchers. To produce Indonesian

version of EMS scale, translation and back-translation process following WHO guideline

were conducted. The steps included forward translation and backward translation by

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independent translators to produce the preliminary draft of the Indonesian version of EMS.

Furthermore, committee review by the researcher and those two translators aimed to counter

some discrepancies and cultural context from the draft. Then, three experts in the field had

been invited to provide their judgement using content validity index to determine the validity

content for each item which resulted the final draft of the Indonesian version of EMS. As the

last step, testing the translated version to the targeted subject had been conducted. For the

reliability concern, all the Indonesian version of the instruments are distributed to the mothers

during pre and posttest as well as to the husband for the marital satisfaction measure tool.

5-1. Descriptive statistic of the demographic characteristic of the participants

This study conducted in five health public health centers (Puskesmas), namely

Puskesmas Mlati II, Puskesmas Jetis Kota, Puskesmas Mantrijeron, Puskesmas Godean I, and

Puskesmas Kraton Yogyakarta Province. The participants were recruited based on the block

random allocation for each public health center. In the experiment group, the researcher set

the optional schedule based on the participants’ availability and let them to choose one or

more of their availability time. As for the final confirmation to the participants, the researcher

sent the reminder including the place, date and time through an online group. Husband or

family companion were encouraged to join in the class. The session lasted for 180 minutes

once a week and had been set-up in the well-equipped mini laboratory of ‘Aisyiyah

University lab skill for four weeks. Using the guideline, the topic of the content was flexible

and developed progressively according to the participant’s need and suggestion during the

discussion session. The researcher also created an online group through WhatsApp©

messenger application for communication and to handle issue, while in the control group

there was no such online group. In the control group, the date and time for regular childbirth

education class had been set-up and then confirmed by the midwives during participants’

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antenatal care examination schedule. The duration and number of weeks were the same as in

the intervention group. The couple was also encouraged to join the class.

In general, following the protocol, the study was conducted while the outbreak of Covid-

19 began to hit Indonesia in the early February 2020. This might be the cause of the attrition

rate is quite high in this current study. Compared to the experiment group, the reduced

number of the participants in the control group were higher. In detail, according to the

comparison between the missing and non-missing subjects, there was a significant difference

mean in some demographic data, such as couple’s age, gestational weeks and mothers’

occupation. The couple’s mean age in the control group was higher compared to the couples’

mean age in the experimental group. The majority of the younger couples discontinued the

program in the control group. Some young expectant mothers decided to stop joining the

class in the control group might be because they move to another area or their hometown to

seek psychological support from their family when delivering the baby.

According to the result, a significant difference mean of the demographic characteristic

also had been found in the term of the mother’s occupation. In the control group, the

presentation of the employed mother was lower than in the experimental group. Time factor

may be the cause of this loss of follow ups since in the experimental group the participants

could reschedule the class according to their availability time. Thus, the sustainability of the

participant’s presence was gained in the experimental group. The result analysis on the

baseline data showed a significant difference on the maternal anxiety and the wife’s marital

satisfaction. In the experiment group, the anxiety level score was lower than in the control

group, while the wife’s marital satisfaction score in the experiment group was higher than in

the control group. Compared to the wife’s marital satisfaction, it was found that the

husband’s marital satisfaction had lower score in both groups.

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The correlation among outcome variable had been also confirmed in this study. In the

pretest measurement, the maternal anxiety had a negative correlation with the the maternal-

fetal attachment, the childbirth self-efficacy and the husband’s marital satisfaction. The

maternal anxiety correlated positively to the wife’s marital status. The posttest correlation

analysis was quite similar with the pretest result. The finding result had been confirmed by

the previous study conducted by Abazari et al. (Abazari, Pouraboli, Tavakoli, Aflatoonian, &

Kohan, 2019).

5-2. The effect of the childbirth education program on prenatal anxiety, childbirth self-

efficacy, maternal-fetal attachment, and marital satisfaction

In this study, the effectiveness of a four-week childbirth education program to

decrease maternal anxiety, improving maternal-fetal attachment, childbirth self-efficacy and

marital satisfaction were tested. According to the results, the maternal anxiety had decreased

significantly and the maternal-fetal attachment as well as the childbirth self-efficacy had

increased significantly among mothers after the intervention, compared to the mothers who

merely received standard childbirth education program. The marital satisfaction did not

significantly change among mothers and husbands in two groups. To elaborate each variable

outcome, the explanation is presented as follows.

5-2.1 The effect of the childbirth education program on the prenatal anxiety

The result of the covariate test showed that the mothers who participated in the

intervention group had lower score of anxiety in the past 4 weeks program, compared to the

mothers who participated in the control group (p<.001). The finding indicated that the set-up

childbirth education program was effective in decreasing maternal anxiety in the third

trimester of pregnancy. However, mother’s education level, gestational weeks, couple’s

marital satisfaction, maternal-fetal attachment, and childbirth self-efficacy were not related to

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the maternal anxiety level. Senior researcher, Bastani et al. (2006) reported the congruent

result. They conducted a 7-week class focused on the relaxation practice skill for a-52 first

time expectant mothers in Iran. Furthermore, the study described the importance of relaxation

technique during pregnancy in decreasing anxiety and its impact to the pregnancy outcome.

Mothers who participated in the intervention group performed more normal vaginal delivery

than those in the control group (p <.001). In the study, the mothers who participated in the

intervention group more less likely delivered baby with low birth weight than those in control

group (p<.05). The mothers who participated in the intervention group have higher baby’s

birth weight average than those in the control group (p<.05) (Bastani, Hidarnja, Montgomery,

Aguilar-Vafaei, & Kazemnejad, 2006). However, the conflicting result was found on some

demographic variables compared to the current study. Bastani and colleagues mentioned that

the mothers’ education level and the marital dissatisfaction did not correlate to the maternal

anxiety as well as the maternal-fetal attachment.

Yikar in 2019 conducted a randomize control trial for a-30 first time expectant mothers

who experienced some complains during their pregnancy that may lead to their anxiety.

Yikar created a booklet as a part of the prenatal education to educate 30 pregnant women in

the intervention group containing common complaint during pregnancy, the reason of their

complaint and how to cope with the complaint. While for 30 pregnant women in the control

group, they did not receive any intervention except from routine nursing care in the hospital.

After the program was conducted for the three meetings, mostly women in the intervention

group experienced less anxiety than those in the control group (Yikar, 2019). However, in

the current study, the researcher conducted the learning method to address mothers’ anxiety

during pregnancy. The learning method included the lecturing of anatomy and physiology of

pregnancy, demonstrating and practicing comfort measures to overcome some common

complaints during pregnancy. The program was delivered for four weeks and lasted for 120

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minutes for every session. To address the maternal anxiety, some relaxation techniques to

release such tension due to discomfort during pregnancy and for labor preparation were

provided.

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5-2.2 The effect of the childbirth education program on the maternal-fetal attachment

The maternal-fetal attachment can be established during the pregnancy, some particular

behaviors can be applied, for instance calling the baby with name, imagining the baby’s face,

observing and monitoring the baby’s movement, talking to the baby frequently, and buying

some stuffs for the baby. According to the result, the maternal-fetal attachment score in the

experimental group was higher than in the control group (p< .05). The mother’s level of

education correlated with the maternal-fetal attachment score. This result contradicted the

study conducted by Bastani and colleagues in 2006. Their study result showed that there was

no statistically correlation between the maternal fetal-attachment and the mother’s education

level. In the current study, the maternal-fetal attachment did no relate to the couple’s age,

maternal occupation, gestational weeks, spouse’s education level, childbirth-self-efficacy,

couple’s marital satisfaction, maternal anxiety, and childbirth self-efficacy. Gheibi,

Abbaspour, Hosein and Javdifar (2020) tested the effectiveness of childbirth program on the

maternal-fetal attachment. They invited 40 pregnant women to participate in their

randomized study for seven weeks. The childbirth program focused on the mindfulness-based

childbirth and parenting program. The class was set-up for 3 hours for each session once a

week. The participants in the intervention group performed significantly higher mean scores

of maternal-fetal attachment than those in the control group (Gheibi, Abbaspour, & Hossein,

2020). Other study recorded the identical finding (Serçekuş & Başkale, 2016).

Having a baby is a great and challenge phase for the male who are experiencing being a

father for the first time. The father’s emotion needs to be facilitated to gain knowledge and

experience to empower themselves as the wife’s partner during the childbearing process.

Therefore, 52 husbands or mother’s relatives were invited to be trained on the maternal-fetal

attachment in the experimental group, while 35 husbands were invited in the control group.

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In doing so, the husbands in the experimental group were trained regarding to the attachment

skill and practice the behavior of attachment at home. After the class, as the reminder session,

the husbands were followed up through massage contact and were asked to transfer their

information to their wives. The implication of husband’s involvement in the maternal-fetal

attachment behavior was supported by other study conducted by Akbarzade and colleagues in

2014. They investigated the effectivity of the father’s training regarding attachment skills on

the maternal-fetal attachment. In their randomized trial, 150 qualified pregnant women were

invited to complete the pretest of the maternal-fetal attachment questionnaire as well as the

anxiety measurement. After one month of intervention, the maternal-fetal attachment was

repeated and measured by the researcher and the result indicated that the posttest on the

variables was higher than those in the pretest. The maternal-fetal attachment score also

indicated to be higher in the experimental group than those in the control group (Akbarzade,

Setodeh, & Sharif, 2014). However, in that study, the intervention merely took part in four

90-minutes sessions, while in the current study, the fathers were trained for particular skill in

60-minutes sessions and additional practice at home.

5-2.3 The effect of the childbirth education program on the childbirth self-efficacy

The efficacy, according to Bandura, was from the performance accomplishment,

vicarious experience, social persuasion, and physiological and emotional states. The

childbirth self-efficacy was the mother’s ability to cope with the childbirth process. Using

Bandura’s guideline, this childbirth education material was set-up to address the maternal

efficacy to have childbirth process through four sources of efficacy. This resulted that the

women in the experimental group had higher score of self-efficacy to have childbirth process

than women in the control group. The test indicated that the childbirth education program

was effective to increase the mother’s efficacy on childbirth. The congruent study conducted

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by Sercekus and Baskale in 2016. They investigated the effectiveness of the antenatal

education on some variables including the maternal self-efficacy on childbirth. The class was

set-up for four to six couples every once a week (120 minutes). The total training was 16

hours and the content material included nutrition during pregnancy and the postpartum

period, physiological and psychological changes during pregnancy and how to cope with

these changes. They also included the content regarding the mechanism of labor and birth and

provided discussion on the feeling about childbirth coping with the labor pain and many

more. After eight weeks education classes, they found that the maternal self-efficacy had

increased significantly compared to the two groups (p value= .002) (Serçekuş & Başkale,

2016).

5-2.3 The effect of the childbirth education program on the marital satisfaction

According to the result, most of the instruments possessed a high internal consistency

at those time points. However, the pretest result of EMS scale for the wife participants solely

possessed low level of internal consistency, while the posttest reliability possessed high level

of internal consistency. In the pretest, some particular items would be resulted in a higher

Cronbach alpha if it was deleted. The items were “I am very pleased about how we express

affection and relate sexually’ and "I am dissatisfied about our relationship with my parents,

in-laws, and/or Friends”. Sexuality is a basic need of physical expression and affection

expression which is belonging and being related with someone (Marlow, Tolley, Kohli, &

Mehendale, 2012). In fact, in our culture, sexuality issue remains vague and taboo (Fujiati,

2016; Susilaningsih & Saluhiyah, 2013; Triani, 2020). Communication about sexuality

between couples rarely happened. In the study, the researcher did not explore whether they

live together with other relatives such as parents, in-laws and/or friends or not. However,

mostly people do not want to share their feeling about their parents, in-laws, and or friend in

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front of their couple. Culture is the most reason why they possess this attitude. Therefore, in

this item scale, the female participants provided inappropriate answer that may lead to the

low level of Cronbach’s Alpha. This instrument consisted of 15-likert scale composed by two

dimensions; idealistic distortion and marital satisfaction, which had negative and positive

statement. Different from other three tools, EMS scale was solely instruments which had

those negative and positive items. Prior to the questionnaire’s distribution, the researcher

explained to the participants the procedure to fill and asked them to pay attention to the

instruction of each scale. The researcher distributed all of the four scales in the same time just

before the class began. Therefore, it was assumed that the majority of the wife participants

did not fully pay attention to the negative mark on such scale, that may lead to the low level

of internal consistency during the pretest measurement.

The marital satisfaction scores were gained from the wife and the husband. The

finding confirmed that there was no significant difference of the mean score of WMS in the

experimental group and in the control group. This finding was in line with the previous study.

Daley-McCoy et al (2015) conducted a cluster randomized controlled trial to investigate the

couple relationship program during the pregnancy. Using analysis of variance (ANCOVA),

they reported that the women in the intervention group significantly less deterioration in

couple communication compare with women in the control group (Daley-McCoy, Rogers, &

Slade, 2015). However, maternal-fetal attachment, maternal anxiety and husband marital

satisfaction had no contribution to the score of WMS.

In contrast, there was no significant mean difference of HMS in the experimental

group and in the control group. Maternal anxiety and childbirth self-efficacy score had

contributed to the score of HMS, while maternal-fetal attachment had no contribution to the

score of HMS. Interestingly, it was found that the pretest score of HMS was lower than WMS

in both groups. This may due to the culture issue in our country. The researcher considered

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this issue as the part of the project to enhance the quality of marital relationship. As the

prenatal course was developed in line with the participant’s need, the basic material to

maintain couple communication was modified. For example, the researcher provided “letter

session” for couples to express their feeling, thought and expectation of their partner during

pregnancy following after birth (including sexuality topic and family problem). They were

asked to write down the letter and give it to their partner. Furthermore, the husbands were

allowed to stroke the wife’s head as common love expression in our culture. The glimmer of

light in the room and slow romantic back sound music were adjusted during this session. This

intervention may lead the reliability in the posttest of the wife’s marital satisfaction to be

higher than in the pretest. Another interesting finding in the study was the mean score of the

husband’s marital satisfaction was lower than the mean score of the wife’s marital

satisfaction in both groups.

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CHAPTER VI

CONCLUSION AND RECOMMENDATIONS

6-1. Conclusion

This study was addressed the research questions. In both groups, mostly the couples

graduated from high school and majority of the mothers go to work. In the current study, the

researcher found the significance difference between two groups in the demographic data

including couple’s age, gestational week, husband education level, and wife’s occupation.

The average mean of the couple’s age in our study who completed the program was younger

than those who missed the program. However, the couple’s occupation, education, and

maternal age were quite similar between two groups. It could be concluded that the childbirth

education program based on Roy Adaptation Model, which included three hours session with

topic and learning method modification, held once a week for four weeks, may be quite

effective in decreasing the maternal anxiety, improving maternal-fetal attachment, childbirth

self-efficacy and marital satisfaction.

6.2 Study Implications

The researcher prepared the prenatal education class following the health authority

guidelines. As an effort to promote the outcome variable according to Roy’s Adaptation

Model and to achieve learning needs of couple’s, the researcher considered to arrange the

material outline according to the participant’s suggestion. As adopted from the guidelines, the

learning method also has been modified according to the outline. The researcher conducted

lecture method for some basic knowledge about pregnancy, labor and delivery. The practice

was conducted for some skills and the discussion was conducted for solving some problems.

The researcher explored the couples’ thought and feeling as well as their expectation to their

80

partner during discussion sessions. The modified class was implied to change the couple’s

perspective on the discussion about sexuality with their partner and discussed the

uncomfortable feeling to their partner.

The husbands or other relative were encouraged to engage in practicing the skills,

such as how to apply the comfort measure, how to bath the baby, how to change baby’s

diaper, and how to establish attachment to the baby. The practice session has implied to the

husband’s motivation to actively take a part during the class. The discussion session had

stimulated the husbands to learn about their role during pregnancy, labor and delivery and

raised many questions from them during the session. Importantly, this program had implied

the mothers to perceive ability to manage their anxiety, increase their efficacy for the birth

process, engage in the maternal-fetal attachment skill, and change the intimate

communication pattern to the couple.

Based on that, the researcher may suggest for the health policy maker to consider that

the standard prenatal education program need to be modified. The prenatal education

program needs to include the material that is sensitive to be discussed between couple. The

prenatal education program also needs to consider the importance of the husband’s

engagement during the class and give them the chance to learn. The variation of the class

learning method also needs to take into account. As valid and reliable instruments are

confirmed in this current study, the researcher also may suggest the policy maker to include

the screening test for all pregnant women in the last trimester using those tools.

The midwives as the facilitator in the prenatal education program are expected to be

more innovative to modify the class to be attractive. Since couple may have different basic

knowledge and expectation and what they want to learn during the class, the Midwives may

conduct a learning contract prior to the class started. The current prenatal education programs

offers the innovation to bridge the gap between the couple and the healthcare provider. In the

81

study, the researcher used free online group discussion for couples to monitor their

attachment skill outside the class and to facilitate them to raise question on such matter and

even for free consultation. Considering that, the Midwives are suggested to provide such

innovation to increase the interaction between couples and certain health care providers

during their participation in the program. The midwives are also suggested to encourage the

husbands or other relative to attend the prenatal class.

As a theory-based intervention, this finding is expected to provide evidence to

enhance the effectivity of the modified childbirth education program. Compared to the

standard childbirth education program, the modified classes were emphasized on the variance

of the learning methods based on the topic and learning outcomes. The researcher also

conducted more discussion sessions with the mothers and their partner to explore their

thought and feeling, including their pregnancy and birth-related concern that may arise during

pregnancy. The community support for the couple during pregnancy was provided through

the participants’ group online. The researcher may underline that this new approach on the

childbirth education program could be effective in broaden the couple’s knowledge and skills

to promote their preparation to get ready for labor and delivery process. All in all,

considering the impact of this finding result, the leadership and the midwives’ perspective to

incorporate this modified classes to the existing program in Indonesia seems to be key to the

application of the research result in the clinical practice.

However, some limitations should be noted in this study. First, each class lasts for

three hours per session. For practicing and discussing session, this duration seems too short

and results in overtime session. In contrast, for lecturing session, the duration seems too long.

Therefore, the researcher would suggest to adjust the duration based on the topic and the

learning method but still has the same total hours as the guidelines (12 hours). Second, as the

pretest of the marital satisfaction indicated low level of the internal consistency, and the

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possibility that the instrument may not be really appropriate to our population or culture, the

researcher suggests to consider to delete or add some items that are appropriate with the

culture. Third, since the primary investigator functions as the facilitator during the program,

yet as a data collector, the researcher acknowledges this as the limitation in this current study.

Considering that, the bias may arise due to the participants are recruited as an intervention

subject that may lead to the subjective measurement. Fourth, the study was started whilst

situation was normal, however, the ongoing data collection was interrupted by the Covid-19

pandemic in Indonesia. Unfortunately, the facilitators in the control group just began the class

as late as their time availability while the restriction regulation is just released by the

government. This resulted higher attrition rate in the control group compared to the

experimental group.

6-3. Suggestion for the future research

Since the researcher only invited expectant mothers with normal pregnancy and

measured their outcome variables, for the next study it could be considered to invite pregnant

women with complication to test the efficacy of the prenatal education program on the

pregnancy outcomes. The next future study also needs to take into account to measure the

correlation of the variable outcomes to the postnatal event, therefore, longitudinal study

needs to be conducted. As a quantitative approach, the researcher only measured the variable

outcomes based on the questionnaire. Therefore, it is the researcher’s limitation to explore

what participant perceived in the prenatal education program. The future study must consider

to apply a qualitative approach through in-depth interview to gain couples’ understanding and

experience during their participation in the prenatal education program. This study result

functions as a crucial information resource to provide an evidence based to improve a better

prenatal education program in the next future. Importantly, the next study needs to consider

83

the identical study using double or triple blinded method to prevent bias that may affect to the

result. In addition, objective scale to measure the research outcome may consider as the

important recommendation for future research.

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APPENDIX A

Place 1

0001: Case 0003: Placebo 0005: Placebo 0007: Case 0002: Placebo 0004: Case 0006: Case 0008: Placebo ============================================================================================================== 0009: Case 0010: Placebo 0011: Case 0012: Placebo ============================================================================================================== 0013: Case 0014: Case 0015: Placebo 0016: Placebo ============================================================================================================== 0017: Case 0018: Placebo 0019: Placebo 0020: Case ==============================================================================================================

Place 2

0001: Case 0003: Placebo 0005: Case 0007: Placebo 0002: Case 0004: Placebo 0006: Placebo 0008: Case ============================================================================================================== 0009: Case 0011: Placebo 0013: Case 0015: Placebo 0010: Case 0012: Placebo 0014: Placebo 0016: Case ============================================================================================================== 0017: Placebo 0018: Case 0019: Placebo 0020: Case ==============================================================================================================

Place 3 0001: Case 0002: Case 0003: Placebo 0004: Placebo 0005: Placebo 0006: Case

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============================================================================================================== 0007: Placebo 0009: Case 0011: Placebo 0013: Case 0008: Case 0010: Case 0012: Placebo 0014: Placebo ============================================================================================================== 0015: Case 0016: Placebo 0017: Case 0018: Placebo ==============================================================================================================

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Place 4

0001: Case 0002: Placebo 0003: Placebo 0004: Case 0005: Placebo 0006: Case ============================================================================================================== 0007: Placebo 0008: Case 0009: Case 0010: Placebo 0011: Placebo 0012: Case ============================================================================================================== 0013: Case 0015: Placebo 0017: Case 0019: Placebo 0014: Case 0016: Placebo 0018: Case 0020: Placebo ==========================================================================================================

Place 5

0001: Case 0002: Placebo 0003: Case 0004: Placebo ============================================================================================================== 0005: Placebo 0006: Placebo 0007: Placebo 0008: Case 0009: Case 0010: Case ============================================================================================================== 0011: Case 0012: Placebo 0013: Case 0014: Placebo 0015: Case 0016: Placebo ============================================================================================================== 0017: Case 0019: Placebo 0021: Placebo 0023: Placebo 0018: Case 0020: Case 0022: Case 0024: Placebo ==========================================================================================================

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APPENDIX B

DRAFT OF FLYER AND STANDING BANNER

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APPENDIX C

THE PROGRAM OUTLINE OF CHILDBIRTH EDUCATION CLASSES

BASED ON ROY’S MODEL

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Plan curriculum for childbirth education classes

Week/Topic

Content of Topic

Material Duration (min)

Method Media Outcome

I/1 Introduction

● Facilitator will introduce herself as well as the research assistants

● The participants will do so

20 Brainstorming

None To establish the trust relationship

Mother’s blood pressure

Measuring mother’s blood pressure before class

10 Practiced by research assistants

- Stethoscope

- Sphygmomanometer

To measure mother’s blood pressure

I/2 Pretest Questionnaires 15 Self-administered

- Paper - Ballpoi

nt pen

Baseline monitor

Preliminary discussion

● Share mother’s though and feeling as well as her expectation to her partner during pregnancy

● Share father’s thought and feeling during his wife’s pregnancy as well as her expectation to his partner during pregnancy

30 Discussion None Brainstorming

I/3 Fetal heartbeat, Leopold’s palpation and belly mapping

● Father monitors fetal heartbeat

● Father palpates using Leopold’s maneuver

● Father draws a picture to represent baby’s position inside womb

40 Demonstration and practice, led by researcher and assisted by research assistances

- Doppler - Gel - Tissue

To decrease maternal anxiety To enhance parental attachment to the baby

Break 5 Free - Snack Refresh

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I/4 Introduction of anatomy and physiology during pregnancy and birth

● The comparison of anatomy and physiology before and after pregnancy

● Mother asked to share their discomfort during pregnancy

● Father asked for ideas about dealing with wife’s complaints during pregnancy

25 Discussion and brainstorming led by researcher

- Anatomy poster of pregnancy and birth

To decrease maternal anxiety To enhance marital relationship

I/5 Relaxation technique

Prenatal yoga 35 Practice led by prenatal yoga facilitator

Laptop, audio, aromatherapy, dark light

To increase childbirth self-efficacy

Homework

Mother have to practice the relaxation technique at home Father have to communicate with unborn baby every day before sleep

No limit Checklist To enhance maternal-fetal attachment To decrease anxiety during pregnancy

II/1 Physical

examination

Monitoring mother’s blood pressure before class

10 Done by research assistance

- Stethoscope

- Sphygmomanometer

To measure mother’s blood pressure

Fetal heartbeat

● Monitoring fetal heartbeat

● Father count baby’s movements

20 Demonstration and practice, led by researcher assistants

- Doppler - Gel - Tissue

To enhance parental attachment To decrease maternal anxiety

II/2 Ice breaking and study case

Researcher will ask mother and father to recall previous material in the last class Researcher describes a case and ask the couple how to deal with that situation

35 Led by researcher

None To enhance couple understanding of the material To increase marital relationship

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II/3 Type of comfort measure and movement to coping labor pain

Researcher will demonstrate movement during labor using phantom and a bottle* - Back massage - Rebozo technique - Slow dance

movement Father practices applying comfort measures to the mother

30 Demonstration and discussion

Phantom pelvic and baby - Two

bottles has been modified to demonstrate the goal Rebozo

- Shock and tennis ball*

- Mats

Increase childbirth self-efficacy Increase marital satisfaction

Movement during labor

Researcher shows a video on how to give birth naturally Couple share feelings and thoughts after watching the video

35 Instruction by the researcher

- LCD,

- Laptop

- Audio

To increase childbirth self-efficacy To decrease pregnancy-related anxiety

Break 5 Free - Snacks Refresh II/4 Commun

ication with unborn baby

Mother and father write a letter to baby and express their feelings about the baby and what they expect for the baby The couple reads each other’s letter

45 Led by researcher

- Paper - Ballpoi

nt pen

To promote parental-fetal attachment

Homework

Mother share to her unborn about her activity for a whole day in a book Father communicate and state his expectation to the baby before sleep

No limit To enhance maternal-fetal attachment To decrease anxiety during pregnancy

III/1 Blood

pressure - Measure the

mother’s blood pressure

10 Done by research assistants

- Stethoscope

- Sphygm

To monitor mother’s blood

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omanometer

pressure

Fetal heartbeat rate, Leopold’s palpation and belly mapping

Father monitors fetal heartbeat Father palpates using Leopold’s maneuver Father draws a picture to represent baby’s position

30 Demonstration and practice, led by researcher

- Doppler - Gel - Tissue

To decrease maternal anxiety To enhance parental attachment

III/2 Mechanism of labor

Engagement and dilatation process

20 Led by researcher

- Map of labor

- Balloon and ping pong ball*

- Anatomy pictures

To decrease maternal anxiety

Comfort measures during pregnancy and birth

- Birth ball - Acupressure

Father practice applying comfort measures for the mothers

30 Instruction by the researcher

- Birth ball

- Massage tool

Increase childbirth self-efficacy Increase marital satisfaction

Break 5 Free - III/4 Relaxati

on technique

Prenatal yoga

30 Practice led by prenatal yoga facilitator

Laptop, audio, aromatherapy, low lighting

Decrease anxiety during pregnancy

Preparing for breastfeeding

Preparation for breastfeeding Oxytocin massage by husband

30 Demonstration and practice led by researcher

Tools for demonstration

To increase childbirth self-efficacy To increase marital satisfaction

III/5 Reflection

Couple writes a letter to their partners about their expectation as partner and as parent

25 Couple’s Practice

- Audio

- Laptop

- Mats

Increase marital satisfaction

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Homework

Mother describes her activity for a while day in a book for her unborn child Father communicates and states his expectations for the baby before sleep For next class, couple needs to bring their own towels

Towel

IV/1 Blood

pressure Mother’s blood pressure measurement

10 Done by research assistants

- Stethoscope

- Sphygmomanometer

To measure mother’s blood pressure

IV/2 Ice breaking

Researcher asks mothers and fathers to recall previous material from the last class Couples shares their thoughts and feelings about upcoming delivery date

25 - Decrease maternal anxiety

Relaxation technique

Prenatal yoga

35 practice led by prenatal yoga facilitator

Laptop, audio, aromatherapy, low lighting

Decrease maternal anxiety

IV/3 Movement during birth

Practice movements and positions to open pelvis

20 Practice led by researcher

- Pelvic phantom

To increase childbirth self-efficacy

Parenting preparation

Father practices how to bathe the baby and change diapers Father assists mother to position baby for breastfeeding

40 Practice led by researcher

- Baby’s bathtub

- Soap - Baby’s

cloth - Phanto

m baby

To increase marital relationship

IV/4 Video of labor process and arrange birth plan

Couple watches a video of labor process and discuss as their birth plan

30 Discussion led by researcher

- To increase childbirth self-efficacy

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IV/5 Posttest 15 Second monitoring

- Questionnaire

- Ballpoint pen

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*the tools modified

a) Bottles with sand

b) Sock and tennis ball

Tennis ball put inside the socks

c) Balloon and ping pong ball

Ping pong ball put inside the blown balloon

Filled half sand and using tape, tied two bottles

+

+

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APPENDIX D

INSTRUMENTS

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The Prenatal Attachment Inventory

The following sentences describe thoughts, feelings, and

situations women may experience during pregnancy. We are

interested in your experiences during the past month. Please

circle the letter under the word that applies to you.

almost

almost

always often sometimes

never

1. I wonder what the baby looks like now..............a. b.

c. d.

2. I imagine calling the baby by name................. a. b.

c. d.

3. I enjoy feeling the baby move...................... a. b.

c. d.

4. I think that my baby already has a personality..... a. b.

c. d.

5. I let other people put their hands on my

tummy to feel the baby move......................... a. b.

c. d.

6. I know things I do make a difference to the baby... a. b.

c. d.

7. I plan the things I will do with my baby........... a. b.

c. d.

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8. I tell others what the baby does inside me......... a. b.

c. d.

9. I imagine what part of the baby I'm touching.......a. b.

c. d.

10. I know when the baby is asleep..................... a.

b. c. d.

11. I can make my baby move............................ a.

b. c. d.

12. I buy/make things for the baby..................... a.

b. c. d.

13. I feel love for the baby........................... a.

b. c. d.

14. I try to imagine what the baby is doing in there...a. b.

c. d.

15. I like to sit with my arms around my tummy......... a.

b. c. d.

16. I dream about the baby.............................a. b.

c. d.

17. I know why the baby is moving......................a. b.

c. d.

18. I stroke the baby through my tummy.................a. b.

c. d.

19. I share secrets with the baby......................a. b.

c. d.

20. I know the baby hears me...........................a. b.

c. d.

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21. I get very excited when I think about the baby..... a.

b. c. d.

Copyright Mary E. Muller, PhD 1989

Scoring: A=4, B=3, C=2, D=1. All items are summed for a single score.

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115

116

EMS

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118

119

Socio-demographic information questionnaire

1. Personal Information a. Number participation :

b. LMP :…/…/…G…P…A…..Ah…(feel by officer )

c. Gestational week :

d. Mother’s age :

e. Name (initial) :

f. Spouse age :

g. Date of married :

h. Spouse contact number:

i. Education Level : Elementary school ( )

Secondary school ( )

Tertiary school ( )

University ( )

j. Occupation : Housewife ( )

Employee ( )

Entrepreneur ( )

k. Pregnancy complication : Heart ( )

Asthma ( )

Migraine ( )

Bleeding ( )

Hyperemesis ( )%

Anemia/HB <9gr% ( )

Other, specify……………………

None ( )

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APPENDIX E

GRANT PERMISSION

121

122

123

124

APPENDIX F

INSTITUTIONAL REVIEW BOARD (IRB)

125

IRB application for one semester empirical thesis:

Effect of Prenatal Childbirth Program on Maternal Anxiety, Maternal-Fetal Attachment, Childbirth Self-Efficacy and Marital Relationship: A Randomized

Controlled Trial Using Roy’s Adaptation Model

Endang Koni Suryaningsih konnywae@yah

oo.co.id

Advisor: Professor Meei-Ling Gau

imeeiling@gmail.com

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Summary and Nature of Intent of Project

Past research has consistently pointed towards the childbirth education classes

as an effective method for alleviating discomfort during pregnancy, enhance self-

concept, role function and interdependence. Using the Roy’s adaptation model, nurse

and midwives can provide intervention through that four modes. This study looks to

determine whether childbirth education program based on the RAM can significantly

impact an individual’s levels of maternal anxiety during pregnancy, improving

maternal-fetal attachment, as well as childbirths elf-efficacy and marital relationship.

The study will consist of nullipara in the third trimester and absence from

pregnancy complication. Half of the participants will receive a session focused on

relaxation, prenatal yoga, maternal-fetal attachment skill, communication skill, and

comfort measure during pregnancy and birth while the other half will receive a

regular prenatal class control intervention. It is predicted that participants receiving

the childbirth education class based on the RAM intervention will have significantly

lower levels of pregnancy-related anxiety, higher level of maternal-fetal attachment,

childbirth self-efficacy, and marital relationship as compared to the participants

receiving the control intervention. The results of this study could aid in providing

evidence towards a framework to develop the childbirth classes based on theory and

provide knowledge that can help mother and husband to optimize the adaptation

during pregnancy and childbirth

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Procedure Section of Research Proposal

Participants

The sample will be comprised of as many individuals as possible, pulled from

the five puskesmas in Yogyakarta, Java Island. All participants will likely be between

the ages of 20 to 35 years old. Participants will also be recruited using randomized

sampling methods, and will be allocated using computer generating sequence and

opaque and sealed envelopes. Then they will be contacting via WhatsApp application

or phone to date and times for the program.

Materials and Procedure

Participants will sign up for 4-weeks childbirth education classes in the

mornings and/or weekends to come in and take part in the study. Prior to the start of

the study, consent will be taken from all participants (see attached). Participants will

be told that they are taking part in a study focused on measuring the effect of

childbirth education classes on four variables: pregnancy-related anxiety, maternal-

fetal attachment, short form of childbirth self-efficacy, and marital relationship. Each

participant, regardless of the experimental and control intervention condition they are

placed in, will have their initial levels of four variables measured as well as

demographic characteristics. Demographic data set consist of mother’s age,

gestational week, race, religion, education level, monthly income, and marital

duration. Anxiety during pregnancy will be completed using the Pregnancy-Related

Anxiety Questionnaire Revised (PRAQ-R2). This 10-item scale consists of

statements such as “I am afraid the baby will be mentally handicapped or will suffer

from brain damage” , “I am worried about the pain of contractions and the pain

during delivery” and “ I am anxious about the delivery because I have never

experienced one before.” All responses are measured on a five-point Likert scale,

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where 1 = definitely not true and 5 = definitely true. To measure the maternal-fetal

attachment, the participant will complete the Indonesian version of Prenatal

Attachment Inventory (PAI). The instrument developed by Muller (1993) consist of

21 consisting of Likert-type items ranging from 1 (‘almost never’) to 4 (‘almost

always’). All items are summed for a single score, and the possible range of scores is

21-84 (Muller, 1993).

Short form of Childbirth Self-Efficacy Inventory developed by Ip (2005) will

be used to measure the level of mother’s self-efficacy regarding the childbirth

process. Ip and colleagues created the short form consiste of 32 items divided to two

subscales; Outcome Expectancy and Second Stage Expectancy. To measure the

marital relationship, ENRICH Marital Satisfaction Scale (EMS) will be applied. The

instrument developed by Fower and Olson (1993) consist of 15-item comprising the

Idealistic Distortion (5 items) and Marital Satisfaction Scales (10 items). The

example item on Idealistic Distortion scale such as: “ My partner and I understand

each other perfectly”, “ My partner completely understands and sympathizes with my

every mood”. The example item on Marital Satisfaction scale such as : “ I am not

pleased with the personality characteristics and personal habits of my partner” and “ I

am very happy with how we handle role responsibilities in our marriage”. This scale

is a Likert-type ranging from 1 (strongly disagree) to 5 (strongly agree) which is

consist of positive and negative statement that indicate items scored direction

(Fowers & Olson, 1993). Items scored in negative direction would be reverse-scored

(i.e if it is mark 5, it would be scored 1; it is marked 4, it would be scored 2; a 3

remain unchanged) (Fowers & Olson, 1993).

After completing the questionnaire, the participant will start the program, 4-

week class and 3 hours for each session. Beforehand, the participant will be randomly

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assigned to one of two conditions and have confirmation when and where they will

have childbirth education classes. In this study, the monitoring of variables will be

measured two times: prior and after the program. All the participants will be

measured their blood pressure and fetal heart beat rate prior the class and they will

also complete the questionnaire. In the experimental condition, participants take part

in a focused program to decrease pregnancy-related anxiety, and increase maternal-

fetal attachment, childbirths elf-efficacy, and marital relationship. Participants will

be facilitated by prenatal yoga instructor, and midwives. During the class, learning

method include lecturer, break session, discussion, practice and demonstration. In the

control condition, participant also will join the program for 4-weeks and 3 hours for

lecturing and some discussion with the midwives regarding the content material such

as anatomy and physiology during pregnancy and birth, postpartum and newborn

care, family planning method, immunization, and birth certificate. In the end of

program, participants in this group will receive prenatal yoga as well as maternal-

fetal attachment skill after they completing the questionnaire as the final monitoring.

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Debriefing Form Ethical Committee ‘Aisyiyah University of Yogyakarta

Title of the Study: Effect of Prenatal Childbirth Program on Maternal Anxiety, Maternal-Fetal Attachment, Childbirth Self-Efficacy and Marital Relationship: A Randomized Controlled Trial Using Roy’s Adaptation Model

Researcher Name: Endang Koni Suryaningsih, email address: konnywae@yahoo.co.id Thank you for participating in this research study. We are conducting this study to test the effect of childbirth education on the pregnancy-related anxiety, maternal-fetal attachment, childbirth self-efficacy, and marital relationship. Our main research questions is how the effect of childbirth education program to the pregnancy-related anxiety, childbirth self-efficacy, maternal-fetal attachment and marital relationship? While participating in this study, you will participate in the childbirth education class during 4-weeks and 3 hours per each session. There is no potential harm intervention during this program. Prior the class, your blood pressure and fetal heart rate beat will be measured, and in the first as well as the end of program, you will be asked to complete the questionnaire include demographic data set, maternal anxiety, maternal and fetal attachment, self-efficacy for birth and marital relationship. The program will be conducted indoor, equipment and environment friendly for pregnant women will be provided, such as sufficient ventilation and light, no chemical contact, yoga mat and pillow, and access to restroom. Mineral water and snack for break session as well as T-shirt for couple uniform also will be provided. Additionally, compensate such as parenting book package will be presence for participant who complete the program. We expect to find that the childbirth education program will be effective to reduce pregnancy-related anxiety and increase maternal-fetal attachment, childbirth self-efficacy inventory, as well as marital relationship. If you are interested in learning more about this study, please feel free to ask us questions in person, or contact us using the email address above. If you have any concerns about your rights as a participant in this study, please contact the Ethic Committee ‘of ‘Aisyiyah University of Yogyakarta Institutional Review Board (komisietik@unisayogya.ac.id).

Thank you again for participating!

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Consent Form Title of the Study: Effect of Prenatal Childbirth Program on Maternal Anxiety, Maternal-Fetal Attachment, Childbirth Self-Efficacy and Marital Relationship: A Randomized Controlled Trial Using Roy’s Adaptation Model Research name : Endang Koni Suryaningsih

Contact information : +6285132439488 Advisor : Professor Meei-Ling Gau

The general purpose of this research is to test the effect of childbirth education on the pregnancy-related anxiety, maternal-fetal attachment, childbirth self-efficacy, and marital relationship. Participants in this study will be asked to follow the prenatal class during four weeks, 3 hours per each session. Findings from this study will be used in the thesis for the researcher’s PhD degree. I hereby give my consent to participate in this research study. I acknowledge that the researcher has provided me with: A. An explanation of the study’s general purpose and procedure. B. Answers to any questions I have asked about the study procedure.

I understand that: A. My participation in this study will take approximately four weeks, and 3 hours session. B. The probability and magnitude of harm/discomfort anticipated as a result of participating

in this study are not greater than those ordinarily encountered in daily life or during the performance of the childbirth education classes.

C. The potential benefits of this study include the knowledge beneficial, and the participation husband during the program may increase.

D. I will be compensated for participating in this study with T-shirt as the uniform for the classes, and if I complete the program, the parenting book will be provided.

E. My participation is voluntary, and I may withdraw my consent and discontinue participation in the study at any time. My refusal to participate will not result in any penalty or disadvantage.

F. Some aspects of the study purpose/procedure may be withheld from me until its end. What the investigators hope to learn from this study, the specific nature of and reasons for the procedure employed, and those aspects of my behavior that have been recorded for measurement purposes will all be fully explained to me at the end of the study. After the study’s purpose and procedure have been fully explained to me, I may, for any reason, choose to withhold use of any data provided by my participation, without penalty.

G. My responses in this study will be kept confidential, to the extent permitted by law. The data will be stored in a secure location in hard disk, will be available to the researcher only and research reports will only present findings on a group basis, without any personally identifying information.

Name (printed): __________________________________________________

Signature: _____________________________ Date: ____________________

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