Solution Focused Anxiety Management" on Anxiety in Women with a History of Abortion

The effectiveness of midwifery consultation in " solution focused anxiety management" on anxiety in women with a history of abortion

Seyedeh Marziyeh Bayat Ghiasi 1, Nahid Bolbol Haghighi 2*, Ali Mohammad Nazari 3, Afsaneh Keramat 4, Shahrbanoo Goli 5

1 Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran. 2 Assistant Professor, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran. 3Associate Professor, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran. 4 Professor, Department of Reproductive Health, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran. 5 Assistant Professor, Department of Epidemiology, School of Health, Shahroud University of Medical Sciences, Shahroud, Iran.

Correspondence: Nahid Bolbol Haghighi, Assistant Professor, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran. Email: [email protected] ABSTRACT Introduction: Miscarriage can reduce the quality of life by affecting various aspects of one’s life and by creating psychological, physical and marital problems. Miscarriage is considered a major psychological stressor, resulting in high levels of anxiety and mood disorders. Although national and international studies using standard tools have shown that women after miscarriage suffer anxiety, the effect of purposeful interventions to reduce the anxiety has not been well investigated. Accordingly, a study was conducted to evaluate the effectiveness of midwifery counseling based on "solution-focused anxiety management" on anxiety of women with a history of miscarriage. Methodology: This randomized clinical trial study was conducted with the participation of 84 women who had a history of spontaneous miscarriage, less than one week of miscarriage, and high level of anxiety using Beck Anxiety Inventory. Based on random allocation sequence, subjects were assigned into two groups of control (routine health care) and intervention (4-session of solution- focused anxiety management counseling). Demographic Questionnaires and Beck Anxiety Inventory were completed by both groups before and immediately after the intervention and three months after the intervention. Data were compared in two groups using t-test, chi-square (x2), Fisher's exact test, independent t-test, and repeated measures. All relationships were considered significant at a significance level of P <0.05. Results: The intervention used in this study (solution-focused anxiety management counseling) significantly reduced the anxiety of women with a history of spontaneous miscarriage in the intervention group, compared to control group (p-value = 0.001). Mean and standard deviation of anxiety scores of women before and after the intervention were 36.67± 9.07 and 40.12± 20.71, respectively, in the intervention group, and 39.02±9.66 and 38.45± 13.60, respectively, in the control group. Conclusion: based on the results of this interventional study, it seems that using a solution-focused anxiety management approach can reduce the anxiety of women with a history of miscarriage. Thus, using this method for post-miscarriage interventions to control anxiety seems to be one of the purposeful interventions.

Keywords: Solution-focused anxiety management counseling, women, anxiety, miscarriage.

The World Health Organization defines miscarriage as Introduction termination of pregnancy before 20 weeks of gestation or embryonic weight of less than 500 g [1]. World Health Organization, Centers for Disease Control and Prevention, and the National Statistics Center also define it as termination of Access this article online pregnancy before 20 to 23 weeks of gestation or termination of [2] Website: www.japer.in E-ISSN: 2249-3379 pregnancy with embryonic weight of less than 500 g . In

general, miscarriage is divided into three classes of spontaneous, induced and recurrent [2]. Based on studies conducted, with the How to cite this article: Seyedeh Marziyeh Bayat Ghiasi, Nahid Bolbol Haghighi, Ali Mohammad Nazari, Afsaneh Keramat, Shahrbanoo Goli. The increase in population growth, the number of miscarriages has effectiveness of midwifery consultation in " solution focused anxiety increased from 50.4 to 56.3 per year from 1990 to 2014 [3]. Based management" on anxiety in women with a history of abortion. J Adv Pharm Edu on the statistics provided by the Ministry of Health, 80000 Res 2020;10(S4):95-102. Source of Support: Nil, Conflict of Interest: None declared. miscarriages occur in Iran every year [4]. An average of 35

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Seyedeh Marziyeh Bayat Ghiasi et al.: The effectiveness of midwifery consultation in " solution focused anxiety management" on anxiety in women with a history of abortion miscarriages per 1000 women aged 15-44 occur annually around information gap and the importance of designing interventional the world [3]. In Iran, miscarriage is prohibited due to cultural, studies on anxiety in people with a history of miscarriage and religious and legal restrictions. For this reason, many since anxiety disrupts women's mental health and even their miscarriages are performed under unfavorable health and hospital quality of life, and the necessity of providing counseling by conditions [5]. Another reason that miscarriage is not accurately midwives to promote the mental health of women who play a identified in statistical reports in Iran is that Iran’s population has major role in prenatal and post-pregnancy care, counselors can decreased in recent years, leading to fewer reports [6]. play a major role in preventing mental health problems. Hence, Miscarriage is one of the significant challenges for women of the present study was conducted to evaluate the effectiveness of childbearing age. Due to psychological and physical problems midwifery counseling based on solution-focused anxiety that occur after miscarriage, it affects various aspects of life and management on anxiety of women with a history of miscarriage. can change the quality of life [7]. A study performed in the United States reported that post-miscarriage psychological problems are Methodology similar to postpartum psychological problems [8], indicating the importance of paying attention to post-miscarriage care. Also, The present study was conducted by considering the Helsinki studies suggest that about 50% of women suffer mental diseases ethics criteria with the ethics code of IR.SHMU.REC.1398.027. after miscarriage and 40% experience symptoms of grief [9]. Also, this randomized intervention study was registered in the Using diagnostic and standard tools, previous international Clinical Trial Registry Center of Iran with the code of studies have shown that anxiety is one of the most common IRCT20190521043657N1. problems caused by miscarriage [10, 11], so that it is considered a Characteristics of the research population: To conduct this psychological destructive factor, leading to a high level of anxiety research, two educational and medical centers affiliated to Alborz [12]. Evidence also suggests that women are at risk for anxiety University of Medical Sciences (Kamali Hospital and Imam Ali symptoms up to four months after miscarriage [13]. To investigate Hospital) were selected for sampling and project the importance of post-miscarriage anxiety, studies have shown implementation. To find women with a history of miscarriage, that psychological counseling, in addition to medical care, is the researcher visited to the hospital (time recorded in the useful in reducing post-miscarriage anxiety [14]. Based on the hospital medical records) at the end of each day and prepared a previous studies, counseling is recommended as one of the most list of nulliparous women with definite symptoms of miscarriage practical and practical methods for treatment of depression and and having the inclusion criteria. According to previous studies anxiety [14]. For example, it has been reported that mood [14] and considering the probability of dropout of samples, the disorders and miscarriage-induced anxiety decrease during the sample size in each group was considered 28 people in each group first year after miscarriage with care-based counseling and over considering the first type error of 5% and test power of 90%. time [15]. In the study conducted by Haj Nasiri et al, results Considering the probability of dropout in samples, their final revealed that cognitive and emotion-based counseling reduced number was estimated at 90 people (45 people in the anxiety and depression in women with an experience of legal intervention group and 45 people in the control group) using the miscarriage [14]. formula of 2 2 2 The level of anxiety after a miscarriage decreases normally over (z(1−α⁄ 2 )+z(1−β)) (σ1+σ2) Based on time of their entry into2 the study and also the reviewing time, but this reduction occurs more quickly in the people n = d . receiving counseling and achieving mental health [16]. of inclusion criteria, they were placed in the central list by the Studies have also shown that counseling by a midwife can be researcher and were coded. Since 18 eligible people were found, effective in post-miscarriage stress. For this reason, preventive they entered the executive phase of the study (90 people in 18- cares provided by health care providers is recommended for all member groups were considered as, of which 9 people were in women after miscarriage [17]. Counseling sessions enable the the intervention group and 9 people were in the control group). patient to manage the miscarriage-induced anxiety. Solution- Based on the random allocation sequence, they were divided into focused anxiety management method is a counseling method for two groups of A and B (before the start of the study and managing anxiety and is a combination of solution-focused, performing random allocation, the letter A was assigned to the strategic, cognitive-behavioral therapy. Although several studies control group and the letter B to the intervention group). have been conducted around the world to develop women's Then, the patients of the intervention group were contacted to physical support after miscarriage, fewer studies have been participate in counseling sessions and they were invited to conducted on psychological support and psychological participate in the study. Sessions in each group of 9 people were management of women with a history of miscarriage and couples' held at the nearest health center of the subjects. In each center, awareness of it. In Iran, few studies have been conducted so far to protect the privacy of the participants, in addition to providing to reduce anxiety in women with an experience of miscarriage. consultations by a trained midwife, a quiet and comfortable For example, Moradi et al provided counseling for women who environment was provided for the participants. Counseling had a miscarriage to reduce their anxiety [17]. Thus, given the intervention sessions were held in 4 90-minute sessions by the

96 Journal of Advanced Pharmacy Education & Research | Oct-Dec 2020 | Vol 10 | Issue S4 Seyedeh Marziyeh Bayat Ghiasi et al.: The effectiveness of midwifery consultation in " solution focused anxiety management" on anxiety in women with a history of abortion intervener with a master's degree in counseling in midwifery, point Likert scale ranging from 0 to 3. Each of the test items who has acquired the skill of conducting counseling classes with describes one of the most common symptoms of anxiety. The a solution-focused anxiety management approach. Then, the total score range is between 0 and 63. A score of 0-7 indicates no questionnaires were completed after the intervention and three or minimum anxiety, a score of 8-15 indicates mild anxiety, a months after the intervention, and the data were entered into the score of 16-25 indicates moderate anxiety, and a score of 26-63 statistical software. indicates severe anxiety. If the sum of the items is higher than 8, Inclusion criteria of the study included informed consent of individuals were included in the study. The reliability and validity individuals to participate in the study, miscarriage confirmed by of Beck Anxiety Inventory were confirmed by Salari Moghadam the relevant specialist, first pregnancy, gestational age 20 weeks et al in 2017 on 250 students. Its Cronbach's alpha was reported and less, ability to speak and understand Persian language, no at 0.89 [18]. history of infertility, no history of mental diseases, no history of Implementation method: In addition to routine health care, physical diseases (including cancer and any incurable disease), not intervention group received solution-focused anxiety addicted to cigarettes, alcohol and other drugs, not experiencing management counseling sessions. Solution-focused anxiety a recent accident that causes sadness, anxiety and depression management sessions were performed for 4 weeks, 90 minutes (such as the death of loved ones) in the last 2 months, no acute per session. During the first week after the miscarriage, the first behavioral symptoms (such as constant talking, obvious session was held individually or in groups, and participants were illusions), and obtaining an anxiety score of eight or higher. welcomed at the beginning of the sessions. In the next sessions, a Exclusion criteria of the study also included unwillingness of text message was sent to the participants to remind them of the participant to continue participating in the study, experience of session. The control group received only the routine care of the life-threatening incidents during the study, people who have used health center. After 4 sessions and also three months after the last out-of-research counseling services during the study, people who session, the questionnaires were completed again and the results become pregnant during the study, absences in more than two were compared. In the next sessions, three subjects of the control sessions. group were excluded from the study due to participating in Data collection tools: In the present study, in addition to the sessions outside the study and three subjects in intervention general and demographic information questionnaire, a standard group were excluded from the study due to not participating in anxiety inventory was used. The Beck Anxiety Inventory consists the sessions. The structure of the sessions [19] was as follows. of 21 items, each of which contains 4 options. It is scored on a 4-

Table 1: The structure of solution-focused anxiety management sessions session Titles and headings Introducing the members of the group and introducing the program, stating its goals and structure, the main criteria of the group including: building trust and confidentiality, number of sessions, listening and respecting, avoiding two-person talking Class description: 4 weekly sessions, physical emotions and adjustment techniques, natural physical reactions to stressful stimuli: How do they 1 sometimes cause us to fear? (Panic cycle), discover how these emotions are reduced spontaneously? A set of adaptation tools including: abdominal breathing, wave (against the panic cycle), autogenic training (relaxation), mindfulness (turning unpleasant thoughts into pleasant thoughts), feedback form (determining anxiety score), next week's task (each person finds the best physical fitness technique for himself or herself and expresses the physical fitness technique he or she already knows) Reviewing the assignments of the previous session and discussing on it Behavioral techniques, including confrontation (exposing oneself to scary situation, place, emotion, and thoughts), habituation (remaining in those situations long enough so that those situations and thoughts to lose their power). Common sense and contrary to common sense (common sense: 2 correct and rational judgment, contrary to common sense: the opposite of what you might expect). Ladder of courage (by writing small steps to reach the position that will be safest for you.), the technique of write, read, tear apart. End of session feedback form, assignment (everyone finds the best behavioral adjustment technique for himself or herself) Discussing on last week generalities, exploring thinking techniques: acceptance (reality and your reaction to it), change (change your thoughts and your 3 connection to your thoughts) and replacing it, stubbornness (being stubborn against the abnormal thoughts), Feedback form, assignment

discussing on last week generalities, writing the advantages and disadvantages of managing anxiety in a table, discovering strategies for coping with 4 'disadvantages', feedback form, filling out questionnaires

Methods of analysis: a code was assigned to each patient and Results all information was entered into SPSS Version 23 software and saved. Data were analyzed using t-test, Chi-square (X2), Fisher's Based on the results of the data in Table 1 and using t-test, mean exact test, independent t-test and repeated measures. All and standard deviation of age of the subjects in the control group statistical relationships were considered significant at the (27.5 ± 57.17) do not show a significant difference compared to significant level of P <0.05. the intervention group (28.50 ± 5.64). Also, the results obtained from the qualitative data of the participants showed that most of

Journal of Advanced Pharmacy Education & Research | Oct-Dec 2020 | Vol 10 | Issue S4 97 Seyedeh Marziyeh Bayat Ghiasi et al.: The effectiveness of midwifery consultation in " solution focused anxiety management" on anxiety in women with a history of abortion the respondents in both control and experimental groups were age of most respondents is 9 and 10 weeks, respectively, and the aged between 20 and 35 years and the maximum age range of the results were homogeneous in the two groups (p-value=0.459 participants' spouses was between 26 and 30 years. Also, the and x2: 3.63). Respondents were asked about the type of results obtained from the qualitative data of the participants' pregnancy acceptance and most respondents (64% in each group) education showed that most of the participants in both the referred to wanted pregnancy. control and experimental groups had a diploma level of education The results of the two groups were analyzed by chi-square test (p-value = 0.84). Also, the results obtained from the qualitative (p-value = 0.765 and x2= 0.54) and the two groups were data of the education of the participants’ spouses showed that homogeneous in terms of pregnancy acceptance. Concerning the most of them had a diploma level of education in both control history of taking Anxiety, blood pressure, glands (thyroid and and experimental groups. diabetes), 45% of the subjects in the experimental group Investigating the job of participants by using Chi-square test answered negative and 55% answered positive, and in the control showed that most of the respondents in both groups (50% in the group, 43% answered negative and 57% answered positive experimental group and 47% in the control group) were p=0.958, x2:0.05). Both groups were homogeneous in this housewives. The lowest frequency in both groups was related to regard. hard work (p-value = 0.971, x2: 0.06). Investigating the job of Also, in terms of smoking and using alcohol and drugs, most participants’ spouses by using Chi-square test showed that most respondents answered negative (81% in the experimental group of them in both groups (50% in the experimental group and 50% and 79% in the control group). The Chi-square test results in the control group) are employees. The lowest frequency in showed that both groups were homogeneous in this regard both groups was related to Unemployed (p-value = 0.769 and (pvalue = 0.964 and x2=0.07). The basic information of the x2: 0.52). Based on the results of Chi-square test, the gestational participants is presented in Table 1.

Table 1: Mean and standard deviation of quantitative demographic variables based on t-test and frequency distribution of qualitative variables based on Chi-square test intervention (n=42) control (n=42) sub-group SD Mean SD Mean quantitative variable test p-value age 5.64 28.50 5.17 27.57 Ttest: -0.771 0.445 spouse age 6.23 31.23 7.17 31.57 T test: 0.218 0.828 education 2.90 13.52 3.26 13.73 Ttest: 0.202 0.787 spouse education 2.90 13.52 3.29 13.11 Ttest:-0.512 0.611 percentage of percentage of qualitative variable sub-group n n test p-value frequency frequency 20-25 years 11 26 14 33

26-30 years 15 36 15 36 X2: 31-35 years 10 24 10 24 0.715 age 1.36 35 years and older 6 14 3 7 20-25 years 9 21 11 26

26-30 years 15 36 15 36 X2: spouse age 31-35 years 12 29 10 24 0.944 0.38 35 years and older 6 14 6 14 secondary and lower 1 2 3 7 diploma 30 48 17 41 associate 4 10 1 2 education bachelor 11 26 13 31 Fisher 0.842 master and higher 6 14 8 19 secondary and lower 1 2 5 12 diploma 20 48 17 41

associate 4 10 5 12 spouse education Fisher 0.522 bachelor 11 26 9 21 master and higher 6 14 6 14 housewives 21 50 20 47

job job hard work 7 17 7 17 X2: 0.459 easy work 14 33 15 36 3.63 employee 21 50 21 50 spouse job 2 self-employed 17 40 15 36 X : 0.769

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unemployed 4 10 6 14 0.52 9 weeks 14 33 11 26

10 weeks 10 24 9 21 gestational age 11 weeks 8 19 5 12 X2: 12 weeks 7 16 9 22 3.63 0.459 13 weeks 3 7 8 19

wanted 27 64 27 64

pregnancy acceptance X2: unwanted 9 22 7 17 0.765 0.54 planned 6 14 8 19 history of taking any no 19 45 18 43 X2: 0.958 drug yes 23 55 24 57 0.05 no 34 81 33 79 X2: history of smoking 0.946 yes 8 19 9 21 0.07

Table 2 shows that the mean anxiety in the experimental group significantly different in the two groups of control and decreased from 36.67 in the pre-test to 20.71 in the post-test, intervention. which shows a significant decrease in the post-test in the Also, using independent t-test, post-test anxiety was assessed in experimental group. The mean anxiety in the follow-up stage in two groups of control and intervention (pvalue: 0.001). Given the experimental group was 23.21, which does not much the significance level of p <0.05, there is a significant difference difference. In the control group, the mean anxiety in the pre-test between the two groups of control and intervention and mean was 39.02, which reached 38.45 in the post-test stage, showing anxiety in the intervention group is less than that of the control a slight decrease, and in the follow-up stage, the mean anxiety group. Using an independent t-test, anxiety in the follow-up was 38.79, indicating that the anxiety scores in the control group stage was assessed in both control and intervention groups and were not different in three stages of pre-test, post-test and given the significance level of p <0.05 (pvalue: 0.001), it was follow-up. Also, using independent t-test, anxiety was assessed found that the mean score of anxiety in the follow-up stage in the in the pre-test and post-test stages (pvalue: 0.252) and results control group is significantly different from that of the showed that the anxiety scores in the pre-test stage were not intervention group.

Table 2: Description of the self-esteem variable separately for group types and test stages experimental control p-value variables stages mean SD mean SD pre-test 36.67 9.07 39.02 9.66 0.252

post-test 20.71 12.40 38.45 13.60 0.001 anxiety follow-up 23.21 10.02 38.79 10.48 0.001 pre-test and post-test difference 15.96 3.33 0.57 3.94 - pre-test and follow-up difference 13.46 0.95 0.23 0.82 -

Table 3 presents the results of variance analysis of repeated test and follow-up). Results show that the effect of time factor measures to compare the effects of time and group on anxiety. on anxiety is significant (p-value = 0.001). It means that the Table 3 shows the within-subject effects and the corrected results mean anxiety has changed significantly in different stages of pre- related to the Hyunh-Feldh test. This test examines to see if the test, post-test and follow-up. Time and group interaction was mean of anxiety has changed at different stages (pre-test, post- also significant (p-value <0.001).

Table 3: Analysis of variance with repeated measures to compare the effects of time and group on anxiety source of effect df mean squares F value p-value

group 1 8904.78 79.73 > 0.001 time 1.93 1698.64 13.09 > 0.001 time and group 1.93 1507.90 11.62 > 0.001

Between-subject results showed that the effect of group that the intervention was effective on anxiety and the (intervention) on anxiety was significant (p = 0.001), meaning intervention caused a significant change in mean anxiety in the

Journal of Advanced Pharmacy Education & Research | Oct-Dec 2020 | Vol 10 | Issue S4 99 Seyedeh Marziyeh Bayat Ghiasi et al.: The effectiveness of midwifery consultation in " solution focused anxiety management" on anxiety in women with a history of abortion post-test and follow-up stages. According to the results of Table The advantage of solution-focused therapy over traditional 3, it can be concluded that the level of anxiety at different stages counseling methods is that it focuses on discovering a solution has changed significantly in experimental group, which was due instead of analyzing the problem [25]. In this regard, Spilsbury and to the effect of intervention in this group. Dahl concluded that a solution-focused anxiety therapy (short- term) has a significant role in reducing anxiety and depression [26, 27] Discussion . Also, the results of this study, in line with the results of the research conducted by Dashtizadeh et al, showed the

effectiveness of short-term solution-focused anxiety therapy in The results of the present randomized trial study showed that reducing depression and anxiety in women [22]. In a study solution-focused anxiety management counseling can reduce the conducted in China, results revealed that depression and anxiety mean anxiety score in women with spontaneous miscarriage. decreased three months and one year after spontaneous After the intervention, the results of statistical tests revealed that miscarriage [28]. Comparison of the mentioned study with the the mean score of anxiety decreased significantly. Spontaneous present study indicates that anxiety decreases normally over miscarriage is the most common complication of pregnancy, time, but in people receiving counseling, this decrease occurred resulting in psychological complications in women [20]. Several more quickly and it was more sustainable. The results of a studies conducted in the world in this regard suggest that research carried out by Catherine et al revealed that people who miscarriage leads to mental disorders [7]. These studies show that did not receive psychological counseling after a miscarriage the majority of women can accept the reality of miscarriage experienced anxiety and depression problems [29]. In another without any problems, but many studies have shown that family study, the effect of short-term solution-focused therapy on the problems may occur after miscarriage [17]. Mental and physical quality of women with recurrent miscarriage was considered problems caused by miscarriage can reduce the quality of life by positive, which is consistent with present study [4]. Gold (2012) affecting various aspects of people life and by creating physical also argues that training and counseling are very effective in and marital problems [7]. Thus, since midwives are in direct reducing psychological complications after miscarriage [30], which contact with women and also counseling and improving the is consistent with the present study. In another study, Parsaei et quality of life is one of their tasks, it seems that they can play a al reported that discussing about the health and feelings of women supportive and advisory role in reducing the complications of with miscarriage with counseling is crucial [31]. Also, in a study miscarriage. carried out by Haj Nasiri, results revealed the need for post- The results of the present study are in line with the results of miscarriage counseling services to reduce post-miscarriage other studies conducted with the aim of reducing the anxiety or anxiety and depression [14]. Another study conducted in China increasing self-esteem of women with spontaneous miscarriage confirmed the use of solution-focused therapy in the management [14, 15, 21]. In a study similar to the present study, cognitive- of anxiety before miscarriage [32]. In a study conducted by Azizi behavioral counseling reduced anxiety in women with recurrent et al on women with a history of traumatic labor, 2-session miscarriages [22]. Since cognitive-behavioral therapy is one of the counseling was performed by a midwife and the results showed components of solution-focused anxiety management, the that counseling sessions were effective in reducing anxiety in present study is consistent with the above research. Anxiety these women [33]. It seems that solution-focused anxiety management helps people to manage their anxiety and identify management approach to play a major role in post-miscarriage situations that cause anxiety and gain a better understanding of and even postpartum psychological interventions. it [23]. Anxiety and stress are involved in development of dysfunctional thoughts and anxiety, and as anxiety causes Conclusion physical and muscular stresses, training techniques to relax the [23] body can decrease anxiety and stress of body and one of the As an intervention in midwifery services, using a solution- anxiety management counseling sessions was dedicated to this focused anxiety management approach can reduce the anxiety of technique. In the solution-focused therapy, which is one of the women with a history of miscarriage. Given the important role components of solution-focused anxiety management, rating of spouses in the family as a supporter, it is recommended to techniques are used to measure the progression of anxiety or conduct a study on the effect of solution-focused anxiety depression in clients, and they are asked to rate their anxiety or management counseling with the presence of spouses on anxiety depression on a scale of 1 to 10. At the end of each session, the and self-esteem of women with a history of miscarriage and clients are asked about their anxiety and accordingly their status compare the results with those of the present study. Also, since is determined on a rating scale and they can observe rate of this approach is useful in supportive interventions for women reduction in their problem each time and thus be aware of the with a history of miscarriage, it might be useful even after labor [24] process of improving their status . The results of the and it is recommended to pay more attention to midwifery mentioned study were consistent with those of the present counseling programs. study.

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