The relationship between self-esteem and husband support with body image perception in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar

The relationship between self-esteem and husband support with body image perception in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar Ignasius Yulianus Jagkson Bomba1, Cok Bagus Jaya Lesmana2, Ni Ketut Sri Diniari2, Luh Nyoman Alit Aryani2*, Anak Ayu Sri Wahyuni2, Lely Setyawati2, Ni Ketut Putri Ariani2, Ida Ayu Kusuma Wardani2, I Gusti Ayu Indah Ardani2 Background: Childbirth is a big, happy event for a mother. In post-partum mothers, physical changes and psychological changes can occur. It is reported that 50% to 70% of post-partum mothers experience psychological disorders, such as a mother can feel uncomfortable with body image perception changes, which result in feelings of lack of husband support. Body image perception itself can cause an effect on self-esteem. This study aimed to analyze the relationship between selfesteem and husband’s support with body image perception among primiparous mothers after vaginal delivery. Methods: An observational analytic study was conducted among 30 post-vaginal delivery primiparous mothers in independent Delima midwife practice in Denpasar. Data regarding respondents’ characteristics, self-esteem, husband’s support and body image perception were obtained using the Rosenberg self-esteem questionnaire, the Revised Dyadic Adjustment Scale (R-DAS) questionnaire Multidimensional Body-Self Relations Questionnaire Appearance Scales (MBSRQAS). The relationship between self-esteem and husband’s support with body image perception was analyzed using SPSS version 23 for Windows. Results: The average age of the respondents were 24.73 years old, and most of them were graduated from high school (50%), employed (53.3%) and have no conflict in their marriage (80%), have normal self-esteem (96.6%), didn’t get enough husband’s support (56.7%) and have positive perception regarding the evaluation of physical appearance (96.6%). We found a significant relationship between self-esteem and body image perception (p = 0.001), husband’s support and body image perception (p = 0.001) and husband’s support and self-esteem (p = 0.010) in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar. Conclusion: Self-esteem, husband’s support and body image perception were essentials factors that contributed to postpartum woman mental health stability that should be understood by family and health workers to avoid psychological disorder in post-partum woman.


INTRODUCTION
Pregnancy is a process every married woman desires because pregnancy is an expression of self-realization and identity as a woman. During pregnancy, a mother will experience various changes in both physiological and psychological changes. Psychological changes can continue in the post-partum period. Reportedly about 50-70% of post-partum mothers will experience psychological disorders. This happens if the mother does not get enough support from her husband, family, and the environment. Not enough support for a new mother can lead to various psychological disorders. 1 This research will discuss maternal psychological disorders, such as selfesteem and body image perception disorders during post-partum. After childbirth, a mother's self-esteem plays a vital role in determining the mother's behavior during the post-partum period and her acceptance of herself. A mother's self-esteem will be related to whether she is worthy, valuable, useful, and capable of performing duties as a mother and wife. Life experiences are very influential on psychological changes and changes in

RESEARCH LETTER
Low self-esteem in post-partum mothers can affect physical satisfaction and lead to changes in body image perception. This resulted in a feeling of dissatisfaction with her body. A study found post-partum mothers are very susceptible to body image perception problems. When viewed from a social approach, multiparous mothers have a better body image perception than primiparous mothers due to unrealistic expectations of primiparous mothers. Satisfaction with body image perception can have various effects. 3,4 If a mother feels that she has a negative body image perception, it is unlikely to breastfeed her baby and do negative attitudes. The mother's negative attitude can be in the form of a lack of sensitivity in child care, disturbed feelings in parenting, and can cause feelings of fear and stress in the baby. 4,5 Because of self-esteem, the husband's support and body image perception is closely related to the mental health of post-partum mothers. This study aims to know the relationship between those three factors in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar.

METHOD
This research is an observational analytic study with a cross-sectional approach to determine the relationship between selfesteem and husband's support with body image perception in primiparous postdelivery vaginal mothers at the Delima midwife practice in Denpasar. This study was conducted in May 2020.
The affordable population is all primiparous post-partum vaginal delivery woman in Delima midwife practice in Denpasar. Subjects were determined through consecutive sampling. The inclusion criteria are post-partum women by vaginal delivery with age 21-40 years old, a delivery process without complication, post-partum less than six months, minimal education in junior high school, understanding Indonesia, and filling the informed consent. While the exclusion criteria are a woman with psychotic and body dysmorphic disorder and unable to answer the questionnaire. Data regarding body image perception, husband's support and self-esteem were obtained through Multidimensional Body self-esteem in a mother after childbirth. The formation of good self-esteem cannot stand alone; it requires the support of the husband, family, and the environment. 2, 3 The role of partners, especially in postpartum mothers, is becoming increasingly important to reduce and prevent psychological disorders in mothers. Hence, a stable marital relationship helps new parents adjust to marriage, babies, and family demands. Some studies showed that poor marital relationships are a psychosocial predictor for postpartum mental disorders such as postnatal depression. This showed that postpartum mental disorders such as lack of self-acceptance are related to self-esteem, which leads to post-natal depression. 4,5 Self Relations Questionnaire-Appearance Scale (MBSRQ -AS), Rosenberg Selfesteem Rating Scale, The Revised Dyadic Adjustment Scale (RDAS) instrument. Data were collected and processed in distribution tables and then further presented in diagrams according to the respective distribution. Descriptive analysis was used to describe the respondents' characteristics. The relationship between husband's support and self-esteem with body image perception was analyzed using Pearson if the data distribution is normal; if not, the Spearman test was carried out using SPSS version 23 for Windows. The relationships were considered statistically significant if the p-value is less than 0.05. Data were analyzed using SPSS version 23 for Mac.

RESULT
Thirty respondents who had met the inclusion and exclusion criteria and no drop out criteria were obtained. The respondents' average age was 24.73 years old, with most of the respondents graduated from high school (50%), employed (53.3%) and have no conflict in their marriage (80%) as seen in Table 1.
From the Rosenberg questionnaire analysis, we found 3.3% of respondents have low self-esteem and 96.7% with normal self-esteem. From the husband's support of the assessment using the RDAS questionnaire, we found 17 people (56.7%) experienced distress in marital relationships, which resulted in the feeling they did not receive support from their husbands. While 43.3% of respondents get enough support from their husbands, as seen in Table 1.
From the analysis result of body image perception using the MBSRQ-AS questionnaire with five dimensions, we found most of the respondents have positive perception regarding the evaluation of physical appearance (96.6%), positive perception regarding physical appearance orientation (96.6%), positive body area satisfaction (90%), have anxiety against obesity (73.3%), categorize as ideal in body size category 1 (43.3%) and categorize as fat in body size category 2 (36.6%) as we can see in Table 2.
From the analysis of the relationship between self-esteem and body image perception using five dimensions, we only found a significant relationship between self-esteem with the evaluation of physical appearance (p=0.001), while the other four dimensions found no significant relationship with p>0.05, as seen in Table   3.
Based on the above result, the relationship between self-esteem and body image perception in the dimensions of evaluating physical appearance has a strong relationship. If the self-esteem value of primiparous mothers is high, body image perception has a positive value. From the analysis of the relationship between husband's support with body image perception, we found there is a significant relationship between husband's support with body image perception in the physical appearance orientation dimension with a p-value 0.001, which means that husband's support is inversely proportional to the positive value of physical appearance orientation. The results were not significant for other dimensions with a p value > 0.05, as we can see in Table 4. We also found a significant relationship between husbands' support with self-esteem in primiparous postpartum mothers based on the satisfaction dimension with p-value=0.010.

DISCUSSION
This research found an appropriate hypothesis between lower self-esteem in primiparous mothers and multiparous mothers. The primiparous mother tends to have lower self-esteem due to her excessive expectations. In comparison, the multiparous mother tends to have higher self-esteem because they learned from their previous experience as a mother. 2,6 This research also found that about 50% of the below six months post-delivery mother, has a problem in their husbands' support. This can be explained by their dissatisfaction with her husband's support that only felt by herself. This result showed that husband education regarding postpartum mothers is essential. 7 We found that primiparous mother has a higher positive value to body image perception than the negative value from the body image perception. This can be explained by their lot of tasks as a new mother so that they don't have enough time to think in detail about their body shape changes so that the perception of body image is on the priority list. We found no relationship between self-esteem with body image perception in primiparous post-delivery vaginal mothers. A baby's presence will

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add the demands for new adjustments on a mother, especially for mothers with 1 to 6 months-old babies. A mother with many tasks and demands often puts aside her appreciation for herself, both in body image and in others, so that a mother will focus more on the needs of the baby and the family rather than her own. 6,7 From the relationship between a husband's support with body image perception in primiparous post-delivery vaginal mothers, our finding showed that a good husband's support would increase the positive value of a woman's body image perception, but this does not necessarily apply to the condition of postpartum mothers. In primiparous mothers, body image perception in the dimension of physical appearance orientation has a relationship that the husband's support plays a significant role in a new mother's attention and efforts to improve and enhance her appearance. 8 The last is the relationship between the husband's support with self-esteem. We found a significant relationship between them. This is following Hegde's theory that self-esteem has a relationship with life experiences, such as the experience of previous childbirth, where a postpartum mother who has more than one child, based on previous experiences so that the husband's support does not influence increasing the mother's selfesteem. 9 Qualitative study research by Stapleton et al. also supports that selfesteem does not provide a relationship to the husband's support because psychosocial characteristics may influence the meaningless relationship between selfesteem and husband's support, cultural differences, social norms, and previous experiences and support from other families. 4 The level of education is a factor that underlies decision-making in marriage, the risk of having children, and health knowledge. Mothers who have higher education status generally tend to plan for the number of children. High education often encourages parents' awareness not to have many children, and the number of children is not significantly related to marital conflict. The difference between myths and reality (expectations and experiences) can make mothers feel unable to understand their experiences, which leads to feelings of hopelessness, feelings of trapped and low self-esteem. 10, 11 At post-delivery, apart from the mother, the spouse or husband also experiences a period of adjustment. A stable marriage relationship will help new parents adjust to the demands of marriage, children's presence, and creating a new family. Poor marital relationships are the most consistent psychosocial predictor of postdelivery maternal mood swings. 11 So that the husband's support can be reflected in the scale of marriage satisfaction. A mother who has many demands often puts aside her appreciation for herself, both in her body image and in others, so that a mother will focus more on her baby and family's needs than her own needs. In theory, it is stated that a good husband's support will increase the positive value of a woman's body image perception, but this does not necessarily apply to post-delivery mothers' condition. 6, 11 This study's limitation is the small sample size; there is a possibility of bias in results when associated with the general population. The other is the sampling technique requires caregiver assistance, so post-partum mothers who do not have a caregiver seem to rush to answer the questionnaire.

CONCLUSION
There is a positive relationship between self-esteem and body image perception, husband's support and body image perception, and husband's support and self-esteem in post-vaginal delivery primiparous mother in independent Delima midwife practice in Denpasar. Thus, self-esteem, body image perception and husband's support are essentials parts for post-partum women's mental health stability that should be understood by family and health workers.