Document Type : Original Research Article
1 MSc Student of Counseling in Midwifery, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2 Associate Professor, Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
3 Assistant Professor, Department of Obstetrics and Gynecology, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
4 Professor, Department of Biostatistics and Epidemiology, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
Blood pressure disorders severely affect the quality of life of pregnant women with these disorders and they are known to be one of the main causes of maternal mortality in the perinatal period. The prevalence of this disorder in the world is reported to be approximately 5 to 10% (1). blood pressure disorders in pregnancy increased from 3.57 to 5.86 per thousand hospital births in the world from 1994 to 2016 (2). In a study in Tehran, this rate was reported at 6/5% in 1396 (1). Blood pressure disorders in pregnancy classified to preeclampsia and eclampsia, chronic hypertension of any etiology, chronic hypertension added to preeclampsia syndrome, gestational hypertension (for which there is no conclusive evidence of preeclampsia and hypertension resolves by 12 weeks postpartum.). High blood pressure in pregnancy means a systolic blood pressure greater than or equal to 140 mm Hg and diastolic blood pressure greater than or equal to 90 mm Hg. Hypertension in the second half of pregnancy without proteinuria is differentiated from preeclampsia syndrome. Proteinuria with the diagnosis of hypertension is an objective indicator of preeclampsia and indicates a general leakage of the endothelial system. Blood pressure disorders can lead to preterm labor, fetal growth retardation, placental abruption, thromboembolism, and maternal death and endanger the health of mother and fetus (3). Many changes occur in women’s body during pregnancy, that makes them both physically and mentally vulnerable and reduce their quality of life (4). In pregnant women with chronic diseases, these changes are more important and puts their quality of life more in focus in health care (5).
Quality of life is a multidimensional and complex concept and in fact includes objective and subjective factors and often defined as a personal understanding of life satisfaction, physical health, social and family health, social etiquette, and mental health (3). These dimensions can be measured during pregnancy (6). Changes in quality of life in high-risk pregnancies, such as pregnant women with gestational hypertension, in addition to the mother, also changes the performance of her family and reduces the quality of life in other members of her family (7). Falcão et al. (2016) in a study entitled “The relationship between blood pressure and quality of life in pregnancy" showed that the quality of life in pregnant women with gestational hypertension was lower and the incidence of more pathological complications in mother and fetus is higher than pregnant women with normal pregnancies (8). Low quality of life in pregnant women leads to increased anxiety, low birth weight and increased birth mortality (3). Another study showed that low quality of life in women with high-risk pregnancies such as gestational hypertension is associated with an increased incidence of depressive symptoms during pregnancy and postpartum (9). In the study of Black KD et al. (2007), a significant relationship was observed between low quality of life and the incidence of preeclampsia with gestational hypertension (10). Numerous factors such as age, education, duration of disease, complications of hypertension, side effects of medications and comorbidities affect the quality of life of patients with hypertension (11). Libbus MK et al. (1991) in their study showed that prenatal care education, especially in high-risk pregnant women such as women with hypertension or gestational diabetes, reduces the incidence of pregnancy complications, delivery risks and subsequent issues (12).
Self-care behaviors increase client awareness and satisfaction, increase participation in health care programs and reduce the Possibility of hospitalization and related costs of patients with chronic diseases (13). Self-care is a conscious, learned, and purposeful action that a person takes to maintain own life and the health of oneself and one's family (14). Conscious self-care by the mother during pregnancy can ensure the health of her and the fetus during pregnancy, delivery and postpartum. Pregnant women need information, skills, and social support to be able to take care of themselves during pregnancy so that they can adopt the right behaviors to take care of themselves (15). In previous research, individual and group training has been able to increase the knowledge, attitude and self-care skills of people with chronic diseases such as diabetes (16). However, there are several studies that indicate a lack of proper self-care in these mothers (17). This indicates the inadequacy of existing interventions and care to correct the self-care behaviors of mothers with gestational hypertension during pregnancy.
Counseling is one of the midwifery interventions to increase women's awareness. Conscious choice helps to improve the behavior of clients to be able to meet the needs and solve problems related to their health and to examine their health problems and make the right decisions (18). Counseling can also be done in groups, group counseling is a two-way process in which a counselor and a group of people in similar situations scrutiniz problems and attitudes and it is an effort to improve the knowledge and perceptions of the individuals so that they can take better action to solve their problems. Members' reactions to each other are much greater in group counseling, and this leads to more insight (19). Also, when counseling is done to provide information and prevent disease and problems, group counseling is more cost-effective in terms of time and cost than individual counseling (20).
In self-care counseling, the counselor helps the clients to be able to identify their needs by gaining the necessary knowledge and ability, and to reduce the problems and complications caused by their illness by modifying their self-care behaviors (21). Self-care counseling monitors the performance of pregnant women such as: rest and activity, nutrition and diet care, disease and injury care, health care follow-up and pregnancy and delivery awareness, it relies on the pregnant mother's ability to take care of herself. Self-care counseling can be done through the GATHER counseling steps (15). Mir Mohammadi et al. (2017) in a clinical trial study showed a significant relationship (p <0/05) between counseling based on GATHER counseling steps and adherence to clinical examination and breast mammography (22). Ganji et al. (2017) in a clinical trial on 45 patients with hypertension showed that the self-care education program in 4 sessions has improved the quality of life and health literacy of patients with chronic hypertension (23). In the study of Wang et al. (2019), a significant relationship (p <0/05) was observed between self-care education and quality of life in patients with breast cancer treated with chemotherapy (24).
Due to the fact that having gestational hypertension during pregnancy is in the category of high-risk pregnancies, so it requires more care to prevent complications. Also, despite the existence of routine pregnancy care in pregnancy care centers and the lack of special counseling and education for pregnant women with hypertension, many problems have remained in relation to quality of life and self-care behaviors of patients with hypertension. So, solving these issues require the use of more effective approaches (15, 17). Therefore, the present study was conducted to determine the effect of self-care counseling on the quality of life of pregnant women with gestational hypertension.
Materials and Methods
This two-group clinical trial study with pretest-posttest design was conducted in 2021-2022 on 90 pregnant women with gestational hypertension referred to Shahidan-Mobini Obstetrics and Gynecology Hospital in Sabzevar. This study was registered in the Clinical Trial Registration Center with the code (IRCT20201117049426N1) after obtaining permission from the ethics committee of Mashhad University of Medical Sciences (ethics code: IR.MUMS.NURSE.REC.1399.091). The reason for choosing this center was the high cooperation of the officials and the high number of patients in this hospital. The inclusion criteria for this study were : Satisfaction to participate in research, aged over 18 years old, gestational age betweeen 24 to 32 weeks, have the ability to communicate verbally, being Iranian and living in Sabzevar, medical diagnosis of gestational hypertension by measuring systolic blood pressure greater than or equal to 140 mm Hg or diastolic blood pressure greater than 90 mm Hg more than twice measured, diagnosis of mild preeclampsia without serious complications, no drug addiction (Psychedelics and stimulants, alcohol, cigarettes and hookah), Lack of underlying diseases that require constant medication (Heart, Respiratory, Kidney Diseases, Thyroid Disorders, Epilepsy, Hypertension, Anemia, Orthopedic Limitations, Immune Diseases), no serious problems and other medical and obstetric complications (Pregnancy poisoning, diabetes, fetal malformation and erythroblastosis, amniotic fluid disorders, abnormal bleeding, placenta previa, twin pregnancy), fetal malignancy, gestational toxicity), have a phone number to call, have a minimum literacy and a desire to participate in the study. Exclusion criteria also include: hospitalization and termination of pregnancy due to hypertension, severe preeclampsia and eclampsia, not attending counseling sessions for more than one session and unwillingness to continue the intervention. The sample size was determined by using the article of Aghajani et al. (25) with 95% confidence level and 80% statistical power. At least 41 samples were determined in each group that for more accuracy and the possibility of dropping the sample by 10%, eight people were added to it and finally the number of samples in each group was determined to be 45 people
Sampling was done by available method and 90 pregnant women with hypertension were selected. Then the participants were divided into control and intervention groups by simple randomization method and using a table of random numbers generated by the software, Thus, in the table of random numbers, the first random number selected belonged to the intervention group and the second random number belonged to the control group. In addition to receiving routine care, the participants in the intervention group participated in 4 group counseling sessions that were held by the researcher for 45 to 60 minutes each week in health centers. Group counseling sessions were held with 4 to 6 pregnant mothers and a total of 40 group counseling sessions were held for these mothers. The mothers who were in the same group in the first counseling session were together in other sessions. In the group counseling sessions, the researcher, while introducing herself to the clients and explaining the purpose of this research and its benefits, assured the clients that this data will remain completely confidential and the results will be presented in general. Then they were asked to sign an informed consent form to participate in the study if they would like to cooperate. It was considered for quiet and private environment for counseling and counseling was done in the form of GATHER counseling steps (Greet, Ask, Tell, Help, Explain, Return). In group counseling sessions, the counselor first explained the purpose of the forming the group and their duties. The goals of counseling included identifying mother’s problems with self-care, prioritizing the problems, advantages and disadvantages of the problems, reviewing available solutions to their problems and deciding on women’s free choice of self-care behaviors. The counselor's duty was to guide, encourage group participation, and facilitating. The group rules were proposed by the counselor, and the counselor sought to establish a therapeutic relationship that was accomplished through the skills of listening, empathy, companionship, understanding emotions, attention, and other techniques. The content of the counseling sessions was as follows:
Session 1: Greetings to pregnant mothers and open-ended questions, Group Q&A with mothers about their own problems and needs, identify misconceptions about physical, mental health and Self-care behaviors and encourage them to think about ways to reduce the risk to the mother and fetus. (G and A)
Session 2: Providing self-care counseling based on the needs and problems of mothers, provide information to pregnant mothers about the proper physical activity for them, proper diet of these mothers, manage stress and improve relationships of these mothers in interaction with family and Acquaintances, strengthen awareness about self-care and effective ways to reduce maternal and fetal risks (T).
Session 3: Helping to freely choose the best self-care behaviors. In this session, the counselor used group problem-solving techniques to explore possible solutions to the remaining problems of mothers, and after prioritization, the best solution for performing correct self-care behaviors was freely selected by mothers. (H)
Session 4: The counselor strengthened the awareness and reviewed the content, explained to the mother about how to use the correct self-care behaviors according to the individual needs of mothers. Also in the fourth session, follow-up times and weekly contacts with mothers were explained (E and R).
Data were collected by using demographic characteristics questionnaire and quality of life questionnaire (SF-36) in two stages, before the intervention and two weeks after the intervention in the control and intervention groups.
The standard quality of life questionnaire (SF 36: Quality of life) examines the quality of life in eight dimensions. In this questionnaire role disorder due to mental health with 3 two-choice questions, role disorder due to physical health with 4 two-choice questions, physical function with 10 three-choice questions, feeling cheerful with 4 six-choice questions, , social function with 2 five-choice questions mental function with 5 six-choice questions, feeling of pain and helplessness with 2 five-choice questions and a sense of general health with 5 five-choice questions was measured and there is a question related to the feeling of changing health that is not included in any of the dimensions of the questionnaire and is only added to the total score. The scale of the items in this Likert questionnaire is between 1 and 5. The range of scores of this questionnaire is between 0 and 100 and the higher score shows the better score of quality of life. The validity and reliability of the Persian version of the Quality of Life Questionnaire has been confirmed in the study of Montazeri et al. (26) Internal reliability of SF-36 quality of life questionnaire was calculated by internal consistency (Cronbach's alpha) and r = 0.92 was obtained, which indicates the internal reliability of the questionnaire. Reliability was also based on test-retest (p <0.001, r = 0.92), which indicates the external reliability of the questionnaire. At first, the normality of quantitative data distribution was determined by Kolmogorov-Smirnov test and depending on the normality or abnormality of the data, parametric or non-parametric tests suitable for both control and intervention groups were used. Descriptive statistical methods were used to describe the demographic characteristics of participants and independent t-test and Mann-Whitney test were used to compare the groups and paired t-test and Wilcoxon test were used to compare before and after data in each group. Independent t-test was used for confirmation of group homogeneity for a small variable, Mann-Whitney for ranking variable and Chi-square for nominal variable. For this purpose, SPSS statistical software version 25 was used and the significance level of P value was less than 0.05.
The two groups were examined for homogeneity of confounding variables by using relevant tests, which is presented in Table 1. Comparison of indices with t-test, chi-square and Fisher's exact test was performed. There is no statistically significant difference between the control and intervention groups in terms of the following variables, except for the history of hypertension in first degree relatives the two groups are homogeneous in terms of these variables. But the history of hypertension in first degree relatives was 37/8% in the control group and 64/4% in the intervention group which had a statistically significant difference between the two groups (p = 0.011) (Table 1).
Comparison of quality of life score indicators was performed using Mann-Whitney, t-test, paired t-test and Wilcoxon tests. The results of independent t-test showed that there was a significant difference in quality of life score between the control and intervention groups before counseling (p = 0/04). Also, after counseling, the quality of life score in the two groups was significantly different (p <0/001). The mean score of quality of life in the difference after counseling compared to before was -1/34 ± 4/3 in the control group and 28/74± 7/1 in the intervention group. The result of Mann-Whitney test showed that there was a significant difference between the two groups (p <0/001) (Table 2).
Due to the significant difference in quality of life score before the intervention and history of hypertension in first degree relatives and adjusting their effect on the intervention, analysis of covariance was used to assess the quality of life score after the intervention between the two groups. Also, the defaults of covariance analysis such as: continuity of quality of life variable, the confounding variable of the history of hypertension in first degree relatives was qualitative variable, independence of observations, absence of discarded data and normality of residues were examined. By controlling the history of hypertension in first degree relatives (p = 0/06) and quality of life before counseling (p <0/001), the average quality of life score in the intervention group was higher than the control 29/13 which was also statistically significant (p <0.001) (Table 3).
Also, in the Review of quality of life dimensions before counseling in the control group, the dimensions of emotional well-being, energy / fatigue and general health had the highest score, respectively and in the intervention group, the highest scores were reported for the dimensions of emotional well-being, general health, social function, physical function and energy / fatigue.
After counseling, all aspects of quality of life showed statistically significant changes compared to before the intervention (p <0/001). In the control group, emotional well-being, energy / fatigue and general health had the highest scores, and in the intervention group, the highest scores were reported for the dimensions of physical function, role disorder due to emotional health, social function, and pain.
The prevalence of hypertensive disorders in pregnancy is high and increasing, and women with these disorders face many problems. The present study was conducted to determine the effect of self-care counseling on quality of life in pregnant women with high blood pressure. The findings generally showed that self-care counseling improved the average score of quality of life in pregnant women with hypertension and this indicates the effect of counseling in the study.
Ganji et al. (2017) in an interventional study titled "The effect of self-care education on quality of life and health literacy of patients with hypertension " were examined 90 patients with hypertension referred to Mashhad health centers in the control and intervention groups. The intervention group received a self-care education program in four 45 minutes’ sessions as group discussion and lecture. Post-test was performed 4 weeks after the training sessions and the results showed a positive effect of self-care education program on quality of life as well as health literacy of patients with hypertension. After the intervention, a statistically significant difference was observed in the intervention group before and after the intervention (21). These findings are consistent with the results of the present study. Also, Aulia et al. (2018) in their clinical trial that was performed on 48 patients with hypertension, found that counseling sessions can have a positive effect on the quality of life of hypertensive patients and regulate their blood pressure. These results are also consistent with the findings of the present study (27).
In 2020, Zandi Nova et al. conducted a clinical trial titled” The effect of educational package on self-care behavior and quality of life in women with gestational diabetes”. In this study, 92 pregnant women with gestational diabetes were investigated. The intervention group participated in four training sessions (one hour) each week in the form of lectures and question-and-answer method. Data analysis did not show a statistically significant difference in the mean score of quality of life before and after the intervention between the control and intervention groups. These results are not consistent with the results of our study (28). In the study of Zandi Nova et al., the quality of life score was measured four weeks after self-care training and in our study the quality of life score was measured two weeks after the intervention. Considering that the quality of life score may change in the long time, so the possible reason for the inconsistency may be the lack of long-term follow-up of quality of life in our study. Also, the intervention program in our study was counseling that is different from the educational intervention program. Therefore, it seems that by conducting self-care counseling, it is possible to improve the quality of life of pregnant women with hypertension, and using this approach help to prevent the maternal and fetal complications of low quality of life in these women, Therefore, the inclusion of counseling programs to improve the quality of life of women with high-risk pregnancies such as gestational hypertension is recommended.
Explaining these findings based on the research of Rasouli et al. (17), it can be said that proper counseling about self-care helps patients to make appropriate changes in their self-care behaviors. It should be known that one of the main goals of self-care counseling is to increase patients' self-awareness and knowledge of the nature of their disease because the patient's knowledge of the disease and the factors affecting it, is very important in controlling and improving the disease. It can also be said that counseling about patients' self-care behaviors leads to increased knowledge and awareness, improved quality of life, reduced anxiety, increased client satisfaction, reduced morbidity, increased patient participation in health care programs and patient independence in daily activities.
One of the limitations of this study is the individual differences in the effectiveness of the training provided in counseling sessions. Also, ensuring the accuracy of the answers given by the participants was another limitation of this study. To control this limitation, it was tried to be ensured of the honesty of the participants in answering to the questions and reflecting the facts by providing explanations and gaining subjects' confidence.
It is suggested that future studies examine the educational and counseling needs of women with high-risk pregnancies in terms of quality of life and self-care measures, explaining the barriers and facilitators of self-care activities in women with high-risk pregnancies and patients with chronic diseases through qualitative research and also compare other counseling methods with the method used in this study on the quality of life of pregnant women with hypertension.
The results showed that the quality of life of pregnant women with hypertension will be improved by education and counseling programs. The results of this study can be used in planning to raise awareness and knowledge of pregnant women with hypertension in the field of self-care measures to control the disease. Also, it provides a new way of providing self-care counseling services to health care providers and midwives, and leads to more patient satisfaction in making the right decision about self-care behaviors in high-risk pregnancies such as hypertension. The results of this study showed that by improving the quality of life, pregnant mothers will feel better about their pregnancy and will be able to take better care of their health and that of their fetus. Having a high-risk pregnancy is often associated with unpleasant experiences and the decision to not to be pregnant in the future. But with proper control of pregnancy and providing healthy and satisfactory conditions for mothers and improving their quality of life, the possibility of making decision for more childbearing and spending it in healthy conditions will be increased.
This manuscript was extracted from a M.Sc. thesis in the field of Counseling in Midwifery under the identification code of 991424 in Mashhad University of Medical Sciences, Mashhad, Iran. The Vice president for Research of Mashhad University of Medical Sciences is appreciated for financial support of the dissertation expenses. We also thank all those involved in this study, including all participating women, officials of Mashhad School of Nursing and Midwifery, all staff of Sabzevar Shahidan Mobini Women's Hospital and all those who helped us in this study.
Conflicts of interest
Authors declared no conflicts of interest.