The effect of integrating midwifery counseling with a spiritual content on improving the antenatal quality of life: A randomized controlled trials

This parallel randomized controlled trial was performed to examine the effect of integrating midwifery counseling with spiritual content on improving the antenatal quality of life among first-time pregnant women.

The study was performed on 60 first-time pregnant women who were referred to two childbirth preparation centers in Zanjan a city in northwest Iran, in 2019. There are three childbirth preparation centers in Zanajn. One of the childbirth preparations centers is located in a hospital and covers most high-risk pregnancies, so sampling was done from only two centers that provide services in the urban health community center.

The study population included first-time pregnant women who were referred to two childbirth preparation centers in Zanjan. Inclusion criteria consisted of living in Zanjan city, gestational age of 20-24 weeks, willingness to participate in the study, obtaining scores ≤10 according to the Edinburgh Postnatal Depression Scale (EPDS) [16], scores of 19 to 37 based on the Cohen Perceived Stress Scale (PSS-14) [17] and having a normal pregnancy with a singleton fetus.

Exclusion criteria before randomization were the presence of medical or obstetric complications, psychiatric disorders or use of psychiatric drugs, and no access to telephone for follow-up. There was no attrition in the study and after the interventions.

Pregnant women who met the inclusion criteria and signed the informed consent form were allocated into two intervention and control groups using randomized a block size of four. To ensure the concealment of the sequence of enrolment, an opaque sealed envelope system was used [18]. Envelope preparation and random allocation sequencing were performed by a person not involved in the research process. In the present study, participants & researcher were not blinded only outcome assessors were blinded. The research process is shown in Figure 1.

Figure 1

The counselling was conducted by a midwife (the first author) familiar with counselling approaches. The content of the sessions was developed under the supervision of a spiritual advisor by following the study of khodaKarmari et al.[19] and the method suggested by Richard and Bergin [20]. The intervention group received eight sessions of counseling in addition to routine care. The counseling was held in 8 sessions, as a group counseling (8-10 people) for 4 weeks (2 times per week for 45 minutes) in preparation classrooms. The counseling was conducted by a midwife (the first author) who that familiar with counseling approaches under the supervision of a clinical psychologist. Educational content was prepared using the Holy Quran and religious books (Hadis) and integrated with routine midwifery counseling. The main topic of counseling was reported in Table 1.

Each session was started with a focus on breathing exercises or the sacred name like “Allah”. Next, the counselor described the subject of the meeting and encouraged the mothers to express emotions, needs, concerns, and thoughts on pregnancy. At the same time, the counselor guided the participants to increase their knowledge to choose the appropriate remedy for emotional reactions during pregnancy and pay attention to spiritual aspects of life. Further advice was given as homework. At the end of each session, explanations and summaries were provided and the women discussed the topic.

According to the guidelines of the Iranian Ministry of Health, routine childbirth preparation classes were held from the 20th week of gestation every two weeks until the 32nd week of gestation. The sessions focused on making the mothers familiar with the different stages of pregnancy from fertilization to delivery, personal hygiene, nutrition, mental and physical changes during pregnancy, pregnancy risks, childbirth planning, postpartum health, breastfeeding, and child care. However, no spiritual content was included. The control group only received routine care.

The main outcome of this study was to determine antenatal QoL of first-time pregnant women which were collected using the SF-36 as a standard questionnaire of QoL, which was completed by the participants before and two months after the last session.

SF-36 a multidimensional measure evaluating health-related quality of life. It is widely used in clinical research and is a reliable and valid measure of health-related QoL in different populations [21, 22]. It measures the perceptions of health-related QoL in eight domains of health status: physical functioning (10 items); physical role limitations (four items); bodily pain (two items); general health perceptions (five items); energy/vitality (four items); social functioning (two items); emotional role limitations (three items) and mental health (five items). Responses are scored on a 5-point scale, that is transformed into a score of 0–100 with higher scores indicating better functioning or well-being. The validity and reliability of The Persian version of the questionnaire have been assessed by Montazeri et al. [21].

The statistical analysis was performed using the SPSS software version 16. Considering the 95% confidence level (Z1-α = 1.96), the test power of 80% (Z1-β = 0.85) and based on the QOL variable in Zamani’s study with the mean and standard deviation in the intervention group (M1=32.10 and S1=2.63), control group (M2=25.90 and S2=2.33), an attrition rate of 15% the sample size of was calculated for 30 pregnant women in each group [15].

Descriptive statistics were employed to describe demographic data. The chi-square test was used to compare the demographic characteristics of the groups. The Kolmogorov-Smirnov test revealed that the scores of the QoL and its components had normal distributions. Therefore, to compare total scores and all domains between and within the groups in pre-and post-intervention, the independent t-test, and paired samples t-test were applied, respectively. The level of significance was p<0.05.

The demographic data are shown in Table 2. Most of the participants were housewives and have academic-level education. There were no statistically significant differences between the two groups before the intervention in terms of demographic characteristics. The mean (SD) of gestational age in the counseling group and control group were 21.80 ± 1.27 and 21.60 ± 1.40 weeks, respectively. Also, term of the mean age of the participants and gestational age was not statistically significant between the two groups (p<0.05) (Table 2)

The mean (SD) of PSS-14 in the intervention group was 23.57 ± 3.81 and in the control group was 23.09 ± 4.29. In pre-intervention based on an independent t-test, the total score of PSS-14 was not statistically significant between the two groups (p=0.399).

The mean (SD) of the Edinburgh Postnatal Depression Score (EPDS) in intervention and control groups was 8.43 ± 1.56 and 8.40 ± 1.68, respectively. In pre-intervention based on an independent t-test, the total score of EPDS was not statistically significant between the two groups (p=0.092). All participants met the eligibility criteria for the study due to the scores of EPDS being lower than 10 and the scores of PSS-14 being between 19 to 37.

Intervention group before counseling the mean score of overall QoL was 85.66 ± 5.44 which increased to 96.46 ± 4.44 and in the control group, it was 86.86 ± 3.36 before intervention that decreased to 85.76 ± 4.04 two months after the intervention. The observed differences between the two groups were statistically significant after intervention (p=0.001).

After intervention based on an independent t-test, the mean score of four domains of QoL (Physical Role Limitations, General Health, Vitality, Role-Emotional, and Mental Health) in the counseling group was significantly higher than the control group (p=0.001). While in terms of Physical Functioning, Bodily Pain and Social Functioning domains were not statistically significant (p>0.05).

Comparing within-the group (before and after) scores of QoL and its domains in the control group showed no statistically significant differences (p>0.05).

Comparing within-the group (before and after) scores of QoL and the domains of “Physical Functioning, Physical Role Limitations, General Health, Vitality, Role-Emotional, and Mental Health” in the intervention group showed statistically significant improvements (p<0.05). Only the scores of two domains of “Bodily Pain, Social Functioning” were not statistically significant (p>0.05) (Table 3).

All the principles of control trial studies were observed in this study and we don’t have a loss of following in participants. Data collection tools were standard and psychometric properties of the Persian form of the questionnaires have been evaluated based on Iranian culture.

The sample size was small and the follow-up period was short. Also, samples were limited to the participants of childbirth preparation classes with moderate levels of perceived stress, which can affect the generalizability of findings. Also, the long duration of each session could be led to the exhaustion of mothers. However, the women were allowed to have rest and walk for a few minutes during the sessions.

In the present study, the spiritual intelligence of the participants was not examined before the intervention and is considered a limitation. It is suggested that additional studies should be performed by measuring spiritual intelligence and perceived stress with the long follow-up period, and participation of their spouses in future studies. Furthermore, for better conclusions about the long-term effects of the spiritual-based intervention on antenatal QoL, studies with a mixed-method design are needed to be conducted in the future.

Poor antenatal Quality of Life (QoL) is associated with adverse outcomes.

The integration of spiritual counseling with antenatal care can improve the QoL of pregnant women.