The Effect of Cognitive-Behavioral Counseling on the Empowerment of Pregnant Women Under 18 Years Old

Introduction

Pregnancy in adolescents is one of the most important public health issues worldwide, which is associated with significant social and medical consequences for maternal and neonatal health (1). The World Health Organization defines adolescent pregnancy in the age range of 10-19 years (2). However, in public conversation, adolescent pregnancy includes the women who have not reached the legal age of adulthood in the society (3).

Adolescent pregnancy is considered a negative phenomenon due to its consequences for mother and fetus and is considered as one of the major challenges of the health care system in achieving the goals of the third millennium (4). Because, pregnant adolescent mothers are more exposed to pregnancy complications such as maternal and neonatal mortality compared to adults due to exposure to important social issues such as poverty, low level of education and poor health behaviors (5-7). On the other hand, adolescence is a stage of transition from childhood to adulthood that demands its own developmental and health needs (8) and adolescent pregnant mothers in passing through this stage simultaneously face with several developmental challenges such as adolescence, marriage, pregnancy and motherhood responsibilities (6). So that, most adolescent mothers compared to adults experience more psychological problems such as higher levels of stress, depression, low self-esteem and suicidal thoughts (7).

One of the factors that can play a decisive role in maternal and neonatal health outcomes and care behaviors during pregnancy is the empowerment of adolescent women in pregnancy (9). So that, most of the problems related to maternal and neonatal health in adolescent pregnant mothers are related to the low level of pregnancy empowerment and their inability to support themselves (10). Therefore, the World Health Organization has greatly emphasized on the empowerment of the pregnant mother and the family to improve the health of mother and child (19).

Pregnancy empowerment includes a sense of self-sufficiency, independence, enhanced interaction with others and the environment, which can lead to successful pregnancy and childbirth by spontaneously increasing psychological energy (11). According to this definition, pregnancy empowerment is a psychological condition that can lead to increased self-management and participation in self-care behaviors in pregnant women (12).

One of the ways to strengthen the pregnancy empowerment in adolescents is formal education or through family planning clinics in the health care system (10). However, the main purpose of education in developed societies is to prevent pregnancy in adolescents (13). However, in developing or less developed societies, since adolescent pregnancy being norm, the main purpose of education is adolescent participation in prenatal care and the development of self-care behaviors (14). However, based on the results of the studies, it seems that the knowledge gained through education alone is not able to change health-related behaviors and enhance empowerment. So that, in order to increase its effectiveness, it is recommended that education-based interventions be combined with complementary components such as psychological counseling (15).

Cognitive-behavioral counseling is one of the approaches that is suggested as a routine care in the health system due to its education-oriented nature in order to overcome educational barriers to provide prenatal health care (16). Cognitive-behavioral counseling helps people to identify their distorted cognitive patterns and insufficient behaviors in life situations (17) and by correcting them through homework, to have effective coping responses in the face of negative emotions and adopt the desired behavior (18). Therefore, considering that pregnancy empowerment is a psychological concept and psychological issues related to pregnancy should be addressed in order to strengthen it (11), cognitive-behavioral counseling seems that can help accepting behavioral changes related to physical problems by changing catastrophic interpretations of it (17). Thus, the results of the studies have shown that cognitive-behavioral programs can be effective in reducing the symptoms of anxiety and depression during pregnancy (19) and before childbirth and the use of prenatal care (20). In Iran, the results of the studies also showed that cognitive-behavioral counseling can increase self-esteem in nulliparous pregnant women (21) and increase self-efficacy in women with gestational diabetes (22).

In all studies conducted in the field of cognitive-behavioral counseling inside and outside the country, other psychological issues of pregnant women over 18 years have been addressed, which cannot be generalized to adolescent pregnancy empowerment due to various developmental challenges of adolescents during pregnancy. On the other hand, in the studies on adolescent pregnancy outside the country, education in the field of contraception has often been considered (10), that since adolescent pregnancy being norm in some parts of Iran, long-term programs and policies of health care system are needed. Therefore, considering the importance of adolescent pregnancy empowerment in maternal and neonatal health outcomes, for the first time, this study was conducted with aim to determine the effect of cognitive-behavioral approach counseling on the empowerment of pregnant women under 18 years old.

Materials and Methods

This two-group randomized controlled trial was performed with pretest-posttest design in 2020-2021 on 64 pregnant women under 18 years of age referred to health care centers in Khaf city.

 Sample size was calculated based on the study of Jahdi et al. (2014) who studied the

effect of group care during pregnancy on the empowerment of pregnant women (23) using the formula of comparing the mean of the two communities "n = ((S_1 ^ 2 + S_2 ^ 2) 〖〖(Z_ (1-α / 2) + Z_ (1-β))〗 ^ 2) / 〖(X ̅_1-X ̅_2) ^ ^ 2 ". In the study of Jahdi et al. (2014), the mean score of empowerment after the intervention in the intervention group was (87.23±6.87) and in the control group was (82.39±7.78), which Considering the confidence level α = 0.05 and test power β = 0.15, the minimum sample size for each group was calculated to be 24.73. Taking into account the 20% probability of sample attrition, the final sample size for each group was estimated to be 35 people (A total of 70). At the end of the study, 3 women from the intervention group (one due to unwillingness to continue cooperation in the study, one due to non-participation in the post-test and one due to pregnancy complications) and 3 women from the control group (due to non-participation in the post-test) were excluded from the study and the final sample size was 64 (32 in the intervention group and 32 in the control group) (Figure 1).

Inclusion criteria were women with Iranian nationality and resident of Khaf, having at least a third secondary education, having a mobile phone to connect to the Internet and install Adob Connect software, with primiparous pregnancy, gestational age of 13-32 weeks based on LMP or first trimester sonography, no physical or psychiatric illness, no experiences of obstetric complaints and complications known during pregnancy. Exclusion criteria included absence in two sessions or more and the development of any obstetric complaints and complications during the study.

Data collection tools included demographic and pregnancy profile form and pregnant women empowerment scale. The demographic information form contained 14 questions including the information about age, age of spouse, age of marriage, duration of marriage, etc.

The Empowerment Scale for Pregnant Women (ESPW) was designed by Kameda and Shimada (2008). This scale contains 27 items that include 5 dimensions of self-efficacy (6 items), future image (6 items), self-esteem (7 items), support and assurance from others (4 items) and joy of an addition to the family (4 items). The empowerment score was calculated based on a four-point Likert scale, which is answered from strongly disagree= 1 to strongly agree= 4. In this questionnaire, the minimum score is 27 and the maximum score is 108. A higher score indicates greater pregnancy empowerment (11). The validity of the translation content of this tool in Iran was examined and confirmed in the study of Hajiabadi et al. (2016) in the form of backward-forward and passing the translation verification process. Reliability of this scale was confirmed in the study of Hajiabadi et al. (2016) by internal consistency method with Cronbach's alpha coefficient 0.89 for all tool items and for other subscales of self-efficacy, future image, self-esteem, support and assurance from others and joy of an addition to the family with Cronbach's alpha of 0.87, 0.82, 0.80, 0.82 and 0.94, respectively (24).

After the approval of the ethics committee of Mashhad University of Medical Sciences with the code IR.MUMS.NURSE.REC.1399.04, sampling was done by cluster-quota method based on the highest number of pregnant women aged 18 years referring to urban and rural health centers of Khaf city. Thus, among the health centers of Khaf city, two urban centers No. 1 and 2 of Khaf city and two rural health centers of Nashtifan and Sangan, which had the most referred pregnant women under 18 years in the city, were selected by quota. Then, by establishment in the maternal and child health care unit of these centers, pregnant mothers under 18 years who were eligible to participate in the study were selected and if they wished to participate in the study and after obtaining written consent, a list of them was prepared and then, they were assigned to two groups of intervention and control by random blocking method. For this purpose, before sampling and patients' participation in the study, based on the sample size, 7 blocks of ten cases from the groups of A and B (AAAAABBBBB, ABABABABAB, BABABABABA, ....) were determined. Then, each of the blocks was assigned a number between 1 and 7 and was determined by the table of random numbers of the sequence of entry of the blocks to the study and assigning patients to the intervention and control groups before the intervention.

Researcher performed the intervention after passing a cognitive-behavioral therapy workshop and obtaining a license to hold counseling courses by studying various books in the field of cognitive-behavioral therapy under the supervision of a master of psychology and a PhD student in psychiatric-behavioral therapy. So that, before performing the intervention, the general content of the sessions and how to present the materials was designed based on the cognitive-behavioral protocol techniques of Robert Leahy (2003) model (25).

In the intervention group, cognitive-behavioral counseling was performed in a group manner in the groups of 7 people (in 5 groups) based on the content prepared before the intervention in 6 sessions (3 in person sessions and 3 online sessions). The first three sessions (first to third session) in person and after coordination with the intervention group and according to the previously specified date in the training room located in the mother and child unit of health centers as two sessions per week (Saturdays and Wednesdays), each session was performed at 11-9 am for 120 minutes. During the sessions, corona prevention protocols such as the use of disinfectants for surfaces and hands, social distance, the use of masks, etc. were observed as much as possible. The second three sessions (fourth to sixth sessions) due to the implementation of restrictions on the prevalence of corona were performed in the form of webinars through Adobt Canect, after coordination with the participating pregnant mothers and according to the previously specified date two sessions per week on Saturdays and Wednesdays, each session at 5-7 pm for 120 minutes. For online sessions, one hour before the start of each session, all participants were coordinated to ensure Internet access.

The control group received routine prenatal care. After completing the research, in order to observe the ethical principles, the content of cognitive-behavioral counseling was presented as an educational pamphlet for the control group.

The pregnant women empowerment scale was completed in two stages before the intervention and two weeks after the intervention by both the intervention and control groups.

In all stages of the research, all ethical points in the research approved by the research vice chancellor of the University of Medical Sciences related to the present study were observed, including assuring the research units about the confidentiality of the collected information and presenting the research results as general, obtaining written consent informed from the research units to participate in the study after explaining the purpose of the research and the method of the research, answering the questions of the research unit in the field of research during the study and explaining to the research units about the optionality of participating in the study and the possibility of leaving the study in each time they want.

Data were analyzed by SPSS software version 25. First, the normality of the data was determined by Kolmogorov-Smirnov test. Also, Chi-square, Fisher's exact, Mann-Whitney and independent t-tests were used to evaluate the homogeneity of qualitative and quantitative variables before the intervention. Independent t-test was used for intragroup comparison between dependent variables in the case of normal variables and paired t-test was used for intergroup comparison. In all tests, the confidence level was 95% and P< 0.05 was considered statistically significant.

Results

The mean age of the study participants in the intervention group was (17.31±1.28) and in the control group was (16.56±1.85) years. The results showed that pregnant women under 18 years participating in the intervention and control groups were homogeneous in terms of demographic and pregnancy characteristics before the intervention (Table 2).

In the pre-intervention stage, the results of independent t-test showed no significant difference between the intervention and control groups in terms of mean total score of empowerment and other subscales of self-efficacy (p = 0.97), future image (p = 0.95), self-esteem (p = 0.87), support and assurance from others (p = 0.49) and joy of an addition to the family (p = 0.06) (Table 3).

In the post-intervention stage, the results of independent t-test showed that the mean total score of pregnancy empowerment (p = 0.001) and self-efficacy subscales (p = 0.002), support and assurance from others (p = 0.005) and joy of an addition to the family significantly increased in the intervention group compared to the control group (p <0.001). However, in the post-intervention stage, there was no significant difference between the intervention and control groups in terms of future image subscale (p = 0.16) and self-esteem (p = 0.35) (Table 3).

In the intra-group comparison, in the intervention group, the results of paired t-test showed that the total score of pregnancy empowerment (p = 0.001) and self-efficacy subscales (p = 0.01), future image (p = 0.03), self-esteem (P = 0.004), support and assurance from others (p<0.001) and joy of an addition to the family significantly increased in the post-intervention stage compared to pre-intervention stage (p<0.001).

However, in the control group, the results of paired t-test showed no significant difference between pre-intervention and post-intervention stage in terms of the total score of pregnancy empowerment (p = 0.37) and self-efficacy subscales (p = 0.89), future image (p = 0.64) and self-esteem (p=0.28) and joy of an addition to the family (p = 0.24). However, in the control group, the score of support and assurance from others significantly increased in the post-intervention stage compared to pre-intervention stage (p = 0.02) (Table 3).