Effectiveness of psycho-educational counseling on anxiety in preeclampsia

Introdução: A pré-eclâmpsia é uma complicação séria durante a gravidez que não apenas influencia a saúde física da mãe e do feto, mas também tem consequências para a saúde mental materna, por exemplo ansiedade. A ansiedade pré-natal tem efeitos negativos e de longo prazo sobre a saúde mental da mãe antes e após o parto, sobre o parto, assim como sobre a saúde mental em gestações subsequentes. Objetivo: Investigar a eficácia do aconselhamento psicoeducacional individual com relação aos níveis de ansiedade em gestantes com pré-eclâmpsia. Métodos: Este foi um estudo randomizado, controlado, que envolveu dois hospitais governamentais na cidade de Sirjan, Kerman, de 30 de janeiro de 2017 a 31 de março de 2017. Um total de 42 gestantes com pré-eclâmpsia foram avaliadas. As mulheres foram randomicamente divididas em dois grupos: controle (n=22) e intervenção (n=22). A intervenção consistiu de duas sessões de aconselhamento psicoeducacional individual. O nível de ansiedade foi medido usando-se o Spielberger State-Trait Anxiety Inventory (STAI) antes da primeira sessão (pré-teste) e após a segunda seção (pós-teste), durante o período de hospitalização. Resultados: Houve uma redução significativa no nível de ansiedade após as sessões de aconselhamento no grupo intervenção (p<0,005). Além disso, houve um discreto aumento no nível de ansiedade no grupo controle após o estudo. Conclusão: De acordo com os resultados deste estudo, o aconselhamento psicoeducacional pode reduzir de forma significativa o nível de ansiedade em gestantes com préeclâmpsia. Assim, recomenda-se que os profissionais de saúde ofereçam esse tipo de intervenção terapêutica para gestantes após a hospitalização, a fim de reduzir o nível de ansiedade e seus desfechos negativos. Registro do ensaio clínico: IRCT2017082029817N3. Descritores: Aconselhamento psicoeducacional, ansiedade, pré-eclâmpsia, gestantes. Abstract


Introduction
Pregnancy is usually considered a happy phase of the woman's life. 1 This physiological and natural phenomenon is a pleasant and satisfying experience for many mothers. Although usually blissful, pregnancy is also a stressful period for many women, and some psychologists consider it as a period of emotional crisis. 2 Exposure to different life crises and stressful conditions can lead to anxiety; pregnancy is one of these stressful conditions. In pregnancy, there are many stressors for fetal health that make a person susceptible to mental disorders such as anxiety. 3 Preeclampsia is one of these stressors and is an independent risk factor for the development of anxiety. 4 A pregnancy-related disorder, preeclampsia may affect all organs in the body and is diagnosed in the presence of high blood pressure and excess protein in the urine (proteinuria) after 20 weeks of pregnancy. After diagnosis of this condition, immediate treatment and examination of the mothers, as well as prevention of its complications, such as maternal seizure, are of great importance. 5 Preeclampsia is associated with high maternal mortality and serious complications, as well as risk of perinatal death, premature birth, and intrauterine growth restriction. Even though many studies have investigated preeclampsia, its causative agents are still unknown. 6 Because of the long-term hospitalization required for diagnosis, treatment or follow-up of the patients, as well as the possible occurrence of unpredictable and uncontrollable events, such as preterm labor and fetal complications, this condition represents a major burden on pregnant women. In addition, unexpected medical interventions, and sometimes fear of death, also lead to anxiety and severe fear in mothers. 7 Pregnant women with preeclampsia often present more health complaints compared to those with uncomplicated pregnancies, and they may suffer from both psychological and physical problems. 8 Additionally, mean anxiety scores have been shown to be significantly increased in women with preeclampsia. 5 In the study by Rigó et al., anxiety levels in pregnant women with preeclampsia were significantly higher than those in healthy pregnant women. 9 Cetin et al. reported that the frequency of symptoms of mental disorders in pregnant women with preeclampsia was higher than those found in the healthy women. In addition, the highest anxiety score and insomnia severity index were observed in women with severe preeclampsia.
Also, they found out that preeclampsia had a negative effect on mental and emotional health and believed that obstetricians should recommend an appropriate mental health care to their patients with preeclampsia at the bedside and in the postpartum period. 10 Pregnancy-related anxiety is of great importance because it causes various complications. Some researchers believe that severe anxiety during pregnancy may affect the relationship between the mother and the infant and reduce the mother's ability to play her maternal roles, thus influencing the quality of the mother's life. 11,12 Anxiety is a psychopathological condition that even in the absence of clinical symptoms may have short-and long-term effects on pregnancy (mother and fetus). Common outcomes include preterm labor, low birth weight, lack of prenatal care, reduction in breastfeeding initiation, and postpartum depression and anxiety. [13][14][15][16][17][18] Maternal stress in pregnancy has negative postpartum side effects and influences children's physical and mental development. At age 2, children of more anxious mothers showed lower mental health scores. 19 Even though there is no direct relationship between the maternal and the fetal nervous systems, maternal emotional and mental states have significant effects on fetal responses and growth. In addition, distortion of the mother's nervous system may disable the fetus to adapt to the maternalfetal environment. 20,21 Providing mental health interventions for the pregnant woman is one of the social determinants of mental health and is of great importance: the mother is the first to give affection and love to the child, two essential components of security for the emotional development of children; in other words, maternal affection is the basis for the development of family emotional relationships. The emotional development of children depends on the quality of this affection, and its profound and permanent effects on the child's mental health will be quite evident in adulthood. Therefore, maternal mental health is of great importance, and mothers are expected to be able to deal with problems and to take care of the baby. By knowing the warning signs of mental disorders, midwives contribute to a timely diagnosis and to the mothers' referral to anxiety treatment programs. 22 Considering the effects of anxiety on mother and fetus, especially in pregnant women with preeclampsia, this study aimed to evaluate the effectiveness of psycho-educational counseling on anxiety in pregnant women with preeclampsia at two public hospitals in the municipality of Sirjan, Kerman. It is expected that the intervention will decrease anxiety levels in the sample and consequently improve pregnancy outcomes and the mothers' quality of life.

Materials and methods
In this clinical trial, the effectiveness of psychoeducational counseling on anxiety in pregnant women with preeclampsia admitted to two public hospitals of the municipality of Sirjan in 2016 was investigated. The objectives of the study were explained by the researcher to the participants, and those who signed the consent form were included. Before any procedure, including injection of magnesium sulfate, the mothers' anxiety level was measured using the STAI questionnaire. Pregnant women with scores ranging from 20 to 60 were selected and divided into the control and intervention groups as described above, i.e., using block randomization. All the women who entered the study filled and signed informed consent forms.
The control group received the service's routine care. Results Table 1 shows the frequency distribution and percentages of demographic characteristics in the intervention and control groups: the two groups were similar in terms of demographic characteristics that may influence maternal anxiety during pregnancy, with no significant differences between the groups.
Comparison of mean anxiety scores between the intervention and control groups before and after the intervention, as shown in Table 2, illustrates that after holding counseling sessions, this difference was significant. There was no data normality in the pretest step. Therefore, Mann-Whitney's test was applied to check the relationship between mean anxiety scores obtained in the two groups before the intervention.
For the same reason, ANCOVA was used after the intervention to control for inconsistency of data normality between pretest and posttest results.
Comparison of pre-and posttest mean anxiety scores in the intervention and control groups (Table 3) shows that the psycho-educational intervention led to a significant reduction of anxiety. Conversely, in the control group, not only did anxiety not reduce, it slightly increased after the intervention.

Discussion
Preeclampsia, as an emergency event that affects 1.2 to 27% of pregnancies, is an important stressor in nulliparous as well as multiparous women. [40][41][42] Contrariwise, anxiety can increase the risk of preeclampsia in pregnancy. 43 The

Conclusion
It seems that psycho-educational counseling can be generalized and is applicable to other similar settings.
This method has shown positive effects in reducing the level of anxiety as well as improving the mental health of pregnant women with preeclampsia.