Hypnobirthing as an Effort to Reduce Anxiety in Pregnant Women: A Literature Review

Background : Pregnancy is a physiological state, they may cause anxiety because of the various discomforts that the mother feels during pregnancy. Hypnobirthing is a birthing method that uses hypnotherapy techniques to reduce anxiety and increase comfort during the birthing process. This technique is believed to be able to increase the mother's control over the birth process, as well as improve the quality of childbirth. Purpose : The purpose of this study was to find out how the application of hypnobirthing techniques can reduce anxiety in pregnant women Methods : This research method was a literature review study. Journal searches were carried out by applying online database such as Pubmed database, Garuda Portal, ScienceDirect and Google scholar. Articles were selected based on inclusion and exclusion criteria. Results : The analysis was carried out on 21 research articles. It was found that hypnobirthing give comfort and confidence in the body's abilities. The application of Hypnobirthing techniques can and effectively reduce the anxiety level of pregnant women and even eliminate the anxiety during pregnancy. Conclusion : The influence of hypnobirthing is useful in overcoming anxiety during pregnancy.


BACKGROUND
According to the International Federation of Obstetricians and Gynecologists (FIGO), pregnancy is defined as the fertilization or union of a sperm and egg followed by implantation. If calculated from the time of conception until the birth of the baby, a normal pregnancy will occur within 40 weeks or 9 months according to the international calendar. Pregnancy is divided into 3 trimesters, the first trimester lasts 12 weeks, the second trimester 15 weeks (13 th to 27 th week) and the third 13 weeks (28 th to 40 th week) (Horton & Astudillo, 2014).
During pregnancy, pregnant women usually experience many disturbances, such as emotional disturbances or anxiety.Various emotional changes that occur during pregnancy are caused by the addition of the hormones estrogen and progesterone. Every pregnant woman feels different anxiety, especially during her first pregnancy because this is a new experience for a pregnant woman, or for a mother who has had a previous pregnancy experience that caused trauma (Humphrey et al., 2019). This can be a factor causing stress, fear and anxiety in women. Some problems can occur due to environmental influences, anxiety to myths of parental beliefs in the form of prohibitions for pregnant women, stress about prenatal risks such as childbirth complications, worry about the baby in the womb, fear of premature birth and fear of having a disabled child and the like. Pregnant women are increasingly worried because the gestational age until the delivery date is getting closer (Einion, 2021;Kuswandi, 2013).
Anxiety is a frightening thought and in threatening situations caused by hypermotor functions such as tremors, fatigue and sensations of autonomic hyperactivity such as shortness of breath, palpitations, cold feet and hands, dizziness, nausea and insomnia. Panic, anxiety and excessive fear, or increased stress cause the brain to release substances that interfere with the release of endorphins (Esther et al., 2021).
Feelings of anxiety will cause various physiological responses in the body of pregnant women. In the cardiovascular system there is an increase in blood pressure, palpitations, increased pulse rate, decreased pulse pressure and shock. In the respiratory system, breath feels fast and shallow, a feeling of pressure in the chest and a feeling of suffocation. On the skin there will be a feeling of heat or cold on the skin, pale face, sweating all over the body, burning sensation on the face, sweaty palms and itching. In the neuromuscular system there will be reactions of surprise, eye blinking, insomnia, tremors, seizures and facial tension (Berthelot et al., 2020).
One effort that can be done to reduce anxiety in pregnant women is to do hypnobirthing techniques. Hypnobirthing is an autohypnotic technique (self hypnosis), which is a non-pharmacological method or natural effort that instills positive intentions/suggestions into the subconscious mind in undergoing pregnancy and childbirth preparation. Pregnancy relaxation helps pregnant women achieve a more relaxed and calm state. The effects of this condition affect pregnant women and their surroundings, up to the delivery process (Bauer et al., 2016).
Hypnobirthing can help remove negative notes from the subconscious with a positive program and reprogram. Then, the subconscious notes about the terrible and painful birth will be replaced with a new belief that childbirth is very spiritual, easy, smooth and comfortable. 6 This can provide psychological support which can have a positive impact on the mother. Mother's mental health will affect a smoother delivery process. This hypnosis method is based on the belief that every woman can naturally, calmly and comfortably (without pain) go into labour. This program teaches pregnant women to believe that the body can function normally to move the mind and body and relieve pain and anxiety with body movements and rhythms during childbirth (Nath et al., 2019).
In a study conducted by Luluk et al 8 Before hypnobirthing was carried out, 33% of pregnant women experienced mild anxiety, 44% experienced moderate anxiety and 22% experienced severe anxiety. After hypnobirthing, the anxiety of pregnant women decreased, namely 44% of pregnant women did not experience anxiety, 22% experienced moderate anxiety and 22% experienced mothers still experiencing mild anxiety (Nainggolan et al., 2022).
After considering the brief explanation above, the authors are interested in conducting a literature study on the relationship between the application of hypnobirthing techniques and the level of anxiety in pregnant women in facing childbirth (Onah et al., 2017). Every mother has a level of anxiety in childbirth, of course it varies depending on her physical, psychological and environmental conditions. Especially a mother who is pregnant and giving birth for the first time, feelings of anxiety will increase as the gestational age increases and labor approaches. Therefore, preventive efforts are made to overcome the anxiety problems encountered. Prevention (preventive) includes main services in addition to promotive services that can be carried out in the field of midwifery practice (Schetter & Anner, 2021).

OBJECTIVE
The purpose of this study was to find out how the application of hypnobirthing techniques can reduce anxiety in pregnant women

METHODS
The method used in writing this article is narrative literature review. This literature study was conducted from November 2021 to February 2023. Data collection was carried out through four database; PubMed, Google Scholar, Science Direct, and Garuda web portal. The keywords used in the journal search are "hypnotherapy" OR "hypnobirthing" OR "hypnosis" AND "anxiety" OR "fears" AND "Pregnant" AND "labor" OR "childbirth" in English and Indonesian.
The inclusion criteria for journal searches are full-text journals that discuss the topic of pregnant women, hypnobirthing, the effectiveness of hypnobirthing and the effect of implementing hypnobirthing on anxiety in pregnant women, research primary journals, English-language international journals indexed by Scopus, Indonesian-language national journals indexed by SINTA 1, 2, 3, & 4 and the year of issue 2017-2022. Meanwhile, the inclusion criteria for journal searches are secondary journals or research tertiary journals.

RESULTS
Journal searches are carried out through a database by selecting journals based on the criteria for inclusion and exclusion of established literature studies.

Figure 1. Journal selection steps
Relevant articles based on the inclusion criteria found in the three databases is 21 articles in 14 journals. In the analyzed articles, 11 articles discussed the benefits of hypnobirthing techniques for pregnant women. 10 articles that discuss the relationship between the application of hypnobirthing techniques to pregnant women in reducing anxiety. A total of 2 articles discussed the sub-theme of the relationship between the application of hypnobirthing techniques in pregnant women in reducing anxiety during the COVID-19 pandemic and 2 articles discussing the relationship between the application of hypnobirthing techniques in pregnant women in reducing anxiety in women with a history of pre-eclampsia.

DISCUSSION Benefits of Hypnobirthing Techniques for Pregnant Women
Hypnobrithingis an effort to instill positive suggestions into the subconscious during pregnancy and preparation for childbirth (Einion, 2021). The hypnobirthing step begins with instilling the belief that every pregnant woman can go through the birth process naturally, without worry and anxiety (Tabatabaeichehr & Mortazavi, 2020).
According to Nainggolan (Khuzaiyah et al., 2020) hypnobirthing method can help pregnant women to strengthen their belief that they will go through labor smoothly, calmly, comfortably and as expected. This opinion is in line with research by Tiawaningrum et al (Atis & Gülay, 2018) a natural alternative that pregnant women can do to make their souls happy. calmer with positive energy and help smooth labor as well as relieve pain and anxiety during contractions and speed up the delivery process is the technique of relaxation and hypnobirthing.
Based on research by Munafiah et al (Nainggolan et al., 2022) hypnobirthing is effective for overcoming psychological disorders experienced by pregnant women, in this case to reduce symptoms of anxiety, worry, stress and fear experienced by pregnant women. Hypnobirthing with mindfulness training is useful for overcoming fear and pain during childbirth can lead to important maternal mental health benefits, including improved assessment related to childbirth and prevention of postpartum depressive symptoms (Uludağ & Mete, 2021).
Hypnobirthing exercises will help pregnant women to feel relaxed naturally to reduce tension and help overcome anxiety starting with relaxing the muscles and body, visualization techniques presenting a comfortable place, communicating with the limbs and communicating with the baby regularly will make the body and psychological condition better. comfortable and helps reduce pain when the brain has reached alpha waves. At this time the body will release serotonin and endorphins so that pregnant women will be in a relaxed state without anxiety and tension (Chen & Chen, 2015;Malahayati Inke, 2021;Zahra, 2013). Based on research by Legina et al 18 hypnobirthing is able to reduce the anxiety level of pregnant women and even eliminate the anxiety faced by pregnant women during their pregnancy. pregnancy. Reducing anxiety levels from relaxation techniques makes the brain work on alpha waves, namely waves that have a frequency of 14-30 HZ. In this condition the brain is in a relaxed state, between conscious and unconscious and almost asleep, the body begins to secrete the hormone serotonin which is useful for managing mood and preventing depression and endorphins which are useful for relieving stress.
The use of breathing techniques is beneficial for increasing blood circulation and oxygen flow and reducing stress, both for the mother and the fetus. If pregnant women learn about mindful breathing, they have a calmer and more comfortable birth experience. The use of slow and deep breathing techniques can help pregnant women to control themselves when contractions occur, hypnobirthing for pregnant women will have a calming effect since pregnancy so that they can give birth comfortably, relieve pain and avoid drugs and drug dependence (Atis & Gülay, 2018). The advantages of hypnosis during pregnancy is to increase self-esteem which is beneficial for the health of the mother's body and fetus and reduces feelings of anxiety, worry, emotion, fear and dizziness. Hypnobirthing can train pregnant women to always relax (Idayanti et al., 2019). Based on the results of this study it can be concluded that hypnobirthing has a significant effect on the frequency and duration of contractions, cervical dilatation and descent of the fetal head. Therefore, primiparous mothers are advised to develop hypnobirthing techniques independently from the beginning of pregnancy until the delivery process to accelerate the progress of normal labour. Midwives are also encouraged to apply hypnobirthing techniques in antenatal care services. This technique is expected to assist midwives in reducing the risk of obstacles and complications in normal delivery (Vural & Aslan, 2019).
Based on the results of a study by Juinar et al (Fitrianingtyas, 2022) hypnobirthing has been shown to reduce caesarean delivery rates thereby reducing the risk of infection and bleeding requiring transfusion or hysterectomy, preventing preeclampsia and being able to control uterine contractions, heart rate and systolic blood pressure so as to prevent delivery complications. Opinions this is in line with the study of Olendzki et al (Olendzki et al., 2020) which stated that it has a positive effect on reducing blood pressure in pregnant women with pre-eclampsia. Hypnobirthing lowers blood pressure through relaxation steps, activation of parasympathetic nerves, reduces cardiovascular activity, increases vasodilation in plasma and lowers blood pressure.

The Relationship between the Application of Hypnobirthing Techniques in Pregnant Women in Reducing Anxiety
Takegata et al (Takegata et al., 2018) explained that pregnant women, especially primiparas, experience fear in facing childbirth. Some of the causes are risks to the mother and child such as bleeding, preterm birth and having to undergo caesarean delivery, the pain that will be experienced leads to pain in the delivery process and perineal injuries due to perineal tears and episiotomy, loss of control related to panic the mother cannot maintain her composure , the fear of uncertainty refers to the mother's worry about unpredictable events, such as when labor starts, the duration of labor, whether their delivery was vaginal and the labor took a long time, the mother is also worried that her husband might behave uncomfortably and be busy at work so that he cannot accompany the birth process. That way, the mother will be lonely before being admitted to the hospital. The various fears of pregnant women about childbirth are associated with negative effects, such as postnatal traumatic symptoms. Mothers who undergo hypnobirthing relaxation will always achieve a relaxed and calm state that will affect themselves and their environment until the birth process. This is in line with research by Maulida et al (Raju, 2014) hypnobirthing can reduce anxiety in pregnant women. The anxiety of pregnant women before and after hypnobirthing was carried out was measured by the HARS questionnaire. Prior to hypnobirthing, 33% of pregnant women experienced mild anxiety, 44% experienced moderate anxiety and 22% experienced severe anxiety. After hypnobirthing, the anxiety of pregnant women decreased, namely 44% of pregnant women did not experience anxiety, 22% experienced moderate anxiety and 22% experienced mothers still experiencing mild anxiety. Anxiety occurs in both primigravida and multigravida mothers.
In the research conducted by Sulistiyanti & Farida (Khuzaiyah et al., 2020) it showed that the anxiety level of primigravida pregnant women before hypnobirthing was carried out found that 19 respondents (63.3%) experienced mild anxiety and 11 respondents (36.7%) experienced moderate anxiety. Then after hypnobirthing, it was found that 14 respondents (46.7%) experienced mild anxiety, 3 respondents (10%) experienced moderate anxiety and 13 respondents (43.3%) did not experience anxiety. This shows that there were changes before and after the hypnobirthing technique was applied to pregnant women, there was a decrease in anxiety levels in pregnant women after doing hypnobirthing relaxation exercises (Khuzaiyah et al., 2020).
In 2019 the whole world was hit by the COVID -19 pandemic which disrupted the health system and limited space for movement as well as fears of contracting the Covid-19 virus, especially happening to pregnant women who are often afraid not only for themselves but also for their unborn babies . Pregnant women are worried about the isolation imposed on patients diagnosed with COVID-19 and the possibility of transmitting COVID-19 to the fetus (Seyed Ahmadi Nejad et al., 2015). In a study by Güney E, et al (Berthelot et al., 2020;López-Morales et al., 2020) it was shown that Mindfulness-Based Stress focuses on awareness given to pregnant women diagnosed with COVID-19 can reduce the level of pressure, anxiety and fear of pregnant women before giving birth. The results of this study indicate that, after the implementation of the MBSR program, the level of prenatal pressure, matter this is in line with the results of Irwan's 2021 study. Based on the results of statistical tests to see the average level of anxiety between the control group and the intervention group with the hypnobirthing technique, it was shown that the 30 samples observed showed that the average pre-test anxiety level was 16.86 and the average -the average post test anxiety level is 14.46. The results of this study can prove that the hypnobirthing method can help reduce anxiety in third trimester pregnant women during the Covid-19 pandemic.
Based on research by Juinar et al (Güney et al., 2022) it shows that out of 51 (100.0%) respondents who did not attend ANC hypnobirthing services, 33 (64.7%) respondents were in the case group of childbirth complications and 18 (35.3%) respondents were control group of labor complications. Meanwhile, of the 27 (100.0%) respondents who attended ANC hypnotherapy services, 6 (22.2%) respondents were in the case group of labor complications and 21 (77.8%) respondents were in the control group of labor complications. This study shows that ANC hypnobirthing services have an effect on preventing the risk of complications of childbirth, where respondents who do not attend ANC hypnobirthing services are at risk of 6 times experiencing delivery complications compared to respondents who attend ANC hypnobirthing services.
Hypnobirthing relaxation affects changes in fetal heart rate and vital signs of pregnant women with pre-eclampsia, including blood pressure, heart rate and respiratory rate. Hypnotic relaxation also affects the stabilization of the fetal heart rate in pregnant women with pre-eclampsia (Amanak et al., 2019). The physiological response of fear is to activate the central nervous system to activate the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system which is characterized by an increase in heart rate frequency and blood pressure (Agorastos et al., 2019). There is a strong relationship between psychology of mother and fetus. Mother and baby have a strong bond since they were in the womb, what the mother feels is also felt by the fetus. Therefore, if the mother feels calm, the fetus can feel it, and one of the responses is a regular and stable heartbeat (Abdollahi et al., 2019;Ferrari et al., 2018).
Hypnobirthinghas a positive effect on reducing blood pressure in pregnant women with pre-eclampsia. This study shows that hypnosis has an effect on reducing blood pressure both systolic and diastolic in pregnant women with preeclampsia, which will further reduce the risk of death in women affected by preeclampsia. The mean decrease in systolic and diastolic respectively was 20 mmHg and 7.5 mmHg. Hypnobirthing makes mothers more relaxed, stabilizes pulse frequency, respiratory rate and heart rate. Hypnotic relaxation creates deep rest, both physical rest and spiritual and emotional rest (Gueguen et al., 2021).
According to Abdollah et al (Uludağ & Mete, 2021) research, hypnobirthing can reduce general anxiety levels in pregnant women with large effect sizes. It can be seen from the results of research conducted from 35 respondents before hypnobirthing, as many as 10 (28.6%) respondents experienced mild fear of childbirth and 25 (72.4%) of respondents admitted that they were very afraid of childbirth. Then, hypnobirthing therapy was carried out for 5 weeks with a meeting duration once a week for 2 hours, 22 (62.9%) respondents were no longer experiencing fear in facing labor and 13 (37.1) experienced mild fear and were in labor. This suggests that psychological interventions can reduce general anxiety in pregnant women.
Uluda et al (Uludağ & Mete, 2021) research, in 60 pregnant women as many as 39 (65.6%) respondents did not experience fear and anxiety in facing childbirth after being given hypnobirthing training and as many as 21 (34.4%) still experienced mild fear and anxiety in facing labor. Stating that hypnobirthing helps relaxation, increases peace and confidence, reduces pain and helps adjust to emotions. Hypnobirthing is effective in reducing the average fear score (Runjati & Nurcahyani, 2021).
In line with the research by Runjati et al (Runjati & Nurcahyani, 2021), respondents to the positive affirmation pregnancy class experienced a sharper decrease in average stress scores (-4.36) in the second measurement after 4 weeks. This shows that there is a significant difference in the average stress score before (21.30) and after the second measurement (16.40) and the third measurement (14.64) during labor after affirmative intervention. Positive affirmations with abdominal breathing can increase the work of the parasympathetic system, provide a calming effect and stimulate the release of oxytocin (WHO, 2010). So that reducing cortisol will ultimately improve the welfare of the mother and fetus so that they are ready physically and mentally, breathing improves memory, overcomes eye disorders, eliminates insomnia, relieves pent-up thoughts and emotions, and reduces stress, anxiety and depression levels.

CONCLUSION
Based on the purpose of the literature study on application of hypnobirthing techniques as an effort to reduce anxiety in pregnant women it is concluded as follows.
1. Hypnobirthing can help mothers reduce their anxiety levels since pregnancy, hypnobirthing provides a sense of security and confidence in herself. Hypnobirthing is effective for overcoming psychological disorders experienced by pregnant women, in this case to reduce symptoms of anxiety, worry, stress and fear experienced by pregnant women. 2. The application of hypnobirthing techniques can and effectively reduce the anxiety level of pregnant women and even eliminate the anxiety faced by pregnant women during pregnancy.