Psychoeducation Dhikr Increases Spiritual Responses of Primiparous

Women

Sri Wahyuni

, Anies

, Ariawan Soejoenoes

2,3

and Suhartono Taat Putra

Midwifery Department, Health Polytechnic of Surakarta, Klaten, Central Java, Indonesia

Faculty of Medicine, Diponegoro University, Semarang, Indonesia.

Department of Obstetrics/ Gynaecology, Dr. Kariadi Hospital, Central Java, Indonesia.

Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.

Keywords: Dhikr, Postpartum, Pregnancy, Primiparous, Spiritual.

Abstract: The transition period in the primiparous women requires not only the physical, psychological and social

readiness but also an attitude of willingness in adaptation during perinatal period. The adding a spiritual aspect

is required to facilitate the mother to accept changes after giving birth. This study aims to explore effect of

psychoeducation dhikr for spiritual responses on primiparous women. This study used the randomized pre-

test post-test control group design. A number of 47 participants completed up to the analysis. Variables that

included patience, gratitude, willingness and wisdom examined 4 times. Statistical analysis saw the difference

within and between groups. There was difference of mean score of patience, gratitude, willingness and

wisdom before and after (p <0.001) in intervention group. There was a difference of mean score of patience,

gratitude and willingness (p <0.05) but there was no difference in wisdom (p = 0.35) in the control group.

There was a mean difference (Δ) before and after intervention between groups (p <0.05). Routine midwifery

care plus psychoeducation dhikr further increases spiritual responses based on patience, gratitude, willingness

and wisdom compared with a routine midwifery care on primiparous women.

1 BACKGROUND

The transition period in the primiparous women

requires not only the physical, psychological and

social readiness but also an attitude of willingness to

accept changes after giving birth. The available

maternal health programs generally do not facilitate

the emotional preparedness of mothers (Hung et al.

2011; Care Quality Commission 2010; Care Quality

Commission & NHS 2015), the provision of services

is still related to physical health, treatment, infant care

and family planning (Khalaf et al. 2007).

The literatures on the spirituality around childbirth

are concern to human well-being, although they do not

seem to recognize the experience of labor as

spiritually meaningful (Crowther & Hall 2015).

However, several strategies have been undertaken to

improve interventions such as adding the spiritual

aspects and integrating religious elements into

interventions (Hefti 2011), which the approaches

using belief and spirituality are identified as relevant

sources during the pregnancy and childbirth in dealing

with stress, difficult situations and insecurities

(Büssing et al. 2017). Research suggested that the

period of pregnancy, childbirth and motherhood were

condition to be closer to the God and made life more

meaningful with the use of religious beliefs as a

powerful coping mechanism (Callister & Khalaf

2010), the mother in the period of childbirth has

development of transcendental, spiritual,

psychological experience and positive inner feelings

as self-actualization in the natural life cycle as a

woman (Taghizdeh et al. 2017). Some studies have

concluded that the religious instruction increased

religious knowledge and attitudes and reduced the

postpartum blues (Akbarzadeh et al. 2015), and

helped to deal with the early stress during motherhood

(Mann et al. 2008) and up to the next year (Cheadle et

al. 2015).

In term, dhikr means to remember. In the context

of spirituality, dhikr (remembering) means

remembering God (Allah SWT). By definition, dhikr

is the consciousness of beings in a unified relationship

of their whole life with the God. Dhikr as the ritual

and meditation of Muslims is closely related to the

affective and cognitive conditions of the individual

Wahyuni, S., Anies, ., Soejoenoes, A. and Putra, S.

Psychoeducation Dhikr Increases Spiritual Responses of Primiparous Women.

DOI: 10.5220/0008319800220028

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 22-28

ISBN: 978-989-758-336-0

(Hamsyah & Subandi 2017). The dhikr is practice;

where short phrases or prayers are repeated through

oral or inner speech, body movement or the heart with

resignation and meaningfulness, prayer, praise,

thanksgiving, not limited to time and certain readings.

Some of the main purposes of the dhikr are to get

closer to the God through surrender or sincerity, guard

against self-destruction of demons, as tranquilizer,

make peace of the heart and causing salvation from

adversity, find humility, tranquility, peace, and divine

love in this noble exercise (Husain 1998). Dhikr is

also used as a treatment for spiritual illness, which is

not always a separate disease category but can be

incorporated into current diagnostic and classification

systems (Laher 2014).

Several studies of the dhikr have been done, with

the results of relaxation training with the dhikr could

reduce anxiety and improve controlled feelings in

patients with Acute Myocardial Infarction treated by

Intensive Cardiac Care Unit (Mardiyono 2012), as an

important strategy for coping against cancer and

contributes to spiritual care (Mesquita et al. 2013), the

spiritual activities such as repentance and the dhikr

increased the psycho-physiology changes to the

positive ways (Nubli et al. 2013).

There are no research on the psychoeducation

dhikr on the effects for the perceived spiritual on the

primiparous women. The psychoeducation dhikr in

this study was the use of dhikr to deal with the

emotional condition, which begins with the relaxation

and continued with spoken utterance, the body

movements or vibration of the heart in order to get

closer to Allah Subhanahu wa Ta’ala, by reading

some verses, praying and mentioning some names of

Allah Subhanahu wa Ta’ala, done with a soft voice,

with the present heart and mind. The number of

interventions was 5 times @ 45-60 minutes, two times

in T III of pregnancy and on the 3rd, 7th and 10th day

of postpartum. The sequence of activities undertaken

in accordance with the protocol.

The psychoeducation dhikr was chosen by

considering to utilize the provision of beliefs and

knowledge possessed by the respondents. Another

reason was that the dhikr was an easy practice to do

and not limited to reading and time, so the mother

abled to perform during the perinatal period. In

addition, the dhikr could increase the faith and

devotion of the pregnant women to postpartum along

with the increasing need of the additional spiritual

aspect in health services especially the midwifery

care.

Therefore, the psychoeducation dhikr became an

option in order to develop and optimize the mother's

spiritual and the sustainability of that as an effort to

achieve and improve the spiritual health of the

perinatal mother is possible.

The results of this study were expected to be the

scientific basis for the application of the spiritual

intervention dhikr from the TM III of pregnancy up to

postpartum period and suggested the intervention into

the perinatal service program for improvement of the

perceived stress and prevention of the PDS.

This study aims to explore effect of the

psychoeducation dhikr for the spiritual responses on

the primiparous women. The hypothesis of the study

were the routine midwifery care plus psychoeducation

dhikr are more increased the spiritual responses

compared with the routine midwifery care.

2 METHODS

2.1 Study Design

This study used experimental with the randomized

pre-test post-test control group design to explore two

independent groups mean of spiritual responses. The

study done in the six health centers in Klaten,

Indonesia 2017, by doing a pretest by measuring the

spiritual responses (patience, gratitude, willingness

and wisdom). The treatment group received routine

obstetric care plus psychoeducation of dhikr and the

control group only received routine obstetric care, and

then performed posttests.

2.2 Sampling

The permission was asked to the health centers, and

then, based on the recommendation of midwives, the

participant recruitment was conducted. The

researchers explained the research objectives, benefits

and consequences orally and written to the

participants and to provide participants the

opportunity to decide on participation in the study.

We applied the following inclusion criteria:

normal third-trimester (26 – 36 weeks of gestation)

pregnant women who wish to give birth vaginally and

can read and write in Bahasa. Eligible participants of

78 the pregnant women in the TM III of pregnancy

met the inclusion criteria, randomly allocated to either

an intervention or a control group. Random allocation;

used close envelope; had been done only to the level

of the health centers, to avoid the occurrence of gaps

and conflicts between respondents if in one health

center there were different treatments. The number of

respondents who completed until the end of the study

period and up to the analysis were 47, consisted of 24

for intervention group and 23 for control group.

Psychoeducation Dhikr Increases Spiritual Responses of Primiparous Women

2.3 Measurement

Spiritual perception has been examined relatively four

times, ie in the TM III of pregnancy, one week before

due date of birth, day 3 and 11 after childbirth. The

spiritual response questionnaire consists of indicators

of patience, gratitude and willingness of heart, as well

as the wisdom, to measure the spiritual response in

pregnancy to postpartum. Items are based on

theoretical sources and expert judgments. Each item

with four choices of answers: very unsuitable,

mismatch, accordant, very match, on a scale of 3

ranging from highly unsuitable (0) to very appropriate

(3). The spiritual response questionnaire shows the

value of Cronbach Alpha, on the impatient indicator

of 0.772, the gratitude of 0.730, the willingness of the

heart of 0.756, the intelligence of taking 0.768

wisdom.

2.4 Procedures

Pregnant women who have fulfilled inclusion and

exclusion were invited to participate in this study and

for accessibility reasons, pregnant women were

invited to the nearest health center. After signing

informed consent the respondents were asked to fill

out the questionnaire.

The tools and materials used in the study include

the Spiritual Psychoeducation Dhikr (SPD) module,

which has been compiled and reviewed by Islamic

religious expert. The SPD module was then tested and

refined before testing is used. The SPD module was

used 5 times in the same sequence of activities,

beginning with a relaxation activity with deep breath,

followed by reading some Al-Qu'ran letters, Sholawat

Prophet Muhammad, some Asmaul Husna, Toyyibah

sentences, Istighfar, Tauhid sentences and end with a

deep breath.

Interventions were administered five times twice

in the TM III of pregnancy, on the 3

, 7

and 10

postpartum days, each for 45-60 minutes.

Interventions were conducted by researchers who

were assisted by six midwife instructors, each of

which was owned by a selected community health

center that had been subjected to a perception

equation and was given special training three times.

2.5 Ethical Consideration

Ethical permission was obtained from Research

Ethics Committee at Faculty of Medicine Diponegoro

University, number 80 / EC / FK-RSDK / III / 2017,

March 3, 2017. All respondents signed Informed

Consent in Bahasa Indonesia.

2.6 Data Analysis

Data were primary data obtained directly from the

respondents, tested to test the difference of mean score

of the variable before and after intervention in the

intervention group and control group using Paired

sample t-Test.

Difference test of mean score difference between

intervention group and group using Independent

Sample t-Test. Difference test of mean difference

every time measurement of variable score using

ANOVA with post hoc Bonferroni.

3 RESULTS

Table 1 shows that the age categories of respondents

were mostly low risk (95.8%) in the intervention

group and (87%) in the control group. Based on Mann

Whitney U test that found characteristics of

respondents be based on age category, education

category, occupation, family income, breastfeeding

status and family support were obtained p> 0, 05, so

it can be concluded that the respondent characteristic

data in two groups was homogeneous.

Different test results based on Mann Whitney U

Test on the score of patience, gratitude, willingness

and wisdom on before the intervention obtained p

value > 0,05, so it can be concluded that there was no

initial difference of intervention in two groups. Table

2 shows there were significant difference of mean

score of patience, gratitude, willingness and wisdom

before and after the intervention, in groups who get

additional psychoeducation of dhikr (p <0.001).

Respondents in the group who only received

routine midwifery care there were differences before

and after on patience, gratitude and willingness (p

<0.005), while there was no difference of mean score

of the wisdom (p= 0.350).

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

Table 1: Characteristics of primiparous women.

Characteristics

Intervention Group (n=24)

Control Group (23)

n (%)

mean+SD

n (%)

mean+SD

Age (years)

23,96±3,30

22,83±3,92

0.294

Age category:

0,281

High risk

1 (4,2)

3 (13)

Low risk

23 (95,8)

20 (87)

Educational:

0,733

Primary

3 (12,5)

3 (13)

Secondary

19 (79,2)

19 (82,6)

Tertiary

2 (8,3)

1 (4,3)

Occupation:

0,591

Employed

8 (33,3)

6 (26,1)

Unemployed

16 (66,7)

17 (73,9)

Household Income:

0,691

< Regional Min. Wage

14 (58,3)

15 (65,2)

>Regional Min. Wage

10 (41,7)

8 (34,8)

Breastfeeding:

1,000

Yes

24 (100)

23 (100)

0 (0)

Family support:

0,435

Often

4 (16,7)

6 (26,1)

Always

20 (83,3)

17 (73,9)

*Mann Whitney U test

3.1 Patience

The first indicator was patience, in table 3 that the

analysis using repeated ANOVA test showed mean

score in TM III of pregnancy with one week before

due date (p=0,019), TM III pregnancy with three days

postpartum (p=0,079) and TM III pregnancy with

eleven postpartum days (p=0.905). The analysis with

post hoc Bonferroni showed no interaction between

measurement time and group (p = 0.173).

However, the independent t test analysis on the

mean difference (Δ) indicated p = 0.002 (table 4), so

it can be concluded that there was difference of

patience before and after intervention between groups

who got additional psychoeducation dhikr and who

only get routines midwifery care.

3.2 Gratitude

The test analysis of gratitude (table 3) obtained mean

score of measurement result at TM III of pregnancy

with one week before due date of childbirth (p =

0,183), TM III pregnancy with three postpartum days

(p = 0,794) and TM III pregnancy with eleven

postpartum days (0,137).

The next analysis showed no interaction between

measurement time and group (p = 0.158). However,

table 4 shown that the mean difference analysis (Δ)

before and after the between group indicated p value

0.012, so it is concluded that there was a difference in

gratitude score before and after the intervention

between groups.

3.3 Willingness

The third indicator was willingness, the analysis

obtained mean scores of willingness in TM III with

one week before due date (p = 0.169), with three

postpartum days (p = 0.952) and with eleven

postpartum days (0.646 ). There was no interaction

between measurement time and group (p = 0.351).

The result of independent t test analysis on the

mean difference (Δ) between groups showed p value

0.026 (table 4), so it can be concluded that there was

difference of willingness score before and after

intervention between group.

Psychoeducation Dhikr Increases Spiritual Responses of Primiparous Women

Table 2: Difference scores before and after the intervention based on group

Score

Intervention group (Mean± SD)

Control group (Mean± SD)

Before

After

Before

After

Patience

1.767±0.26

2.43±0.28

<0.001

2.12±0.13

2.43±0.27

<0.001

Gratitude

1.86±0.19

2.38±0.27

<0.001

2.00±0.36

2.23±0.39

0.030

Willingness

1.93±0.26

2.45±0.29

<0.001

2.12±0.21

2.41±0.32

0.004

Wisdom

1.92±0.28

2.41±0.25

<0.001

1.93±0.34

2.05±0.49

0.350

*Before vs after: paired t test.

Table 3: The spiritual responses score pre and post intervention within and between groups.

Variable

Time

Intervention

group

Control

group

Difference (∆ )

(CI 95%)

p**

(Mean± SD)

Patience

1st

1,77±0,26

2,12±0,13

0,173

2nd

2,05±0,31

2,28±0,33

-0,23 (-0,42–[-0,04])

0,019

3rd

2,06±0,35

2,25±0,39

-0,19 (-0,41 - 0,02)

0,079

4th

2,43±0,28

2,43±0,27

-0,01 (-0,17 - 0,15)

0,905

Gratitude

1st

1,86±0,19

2,01±0,36

0,158

2nd

1,97±0,30

2,10±0,39

-0,14 (-0,34 - 0,07)

0,183

3rd

2,07±0,36

2,10±0,39

-0,03 (-0,25 - 0,19

0,794

4th

2,38±0,27

2,23±0,39

0,15 (-0,05 - 0,35)

0,137

Willingness

1st

1,93±0,26

2,12±0,21

0,351

2nd

2,14±0,40

2,28±0,25

-0,14 (-0,33 - 0,06)

0,169

3rd

2,26±0,37

2,25±0,32

0,01 (-0,20 - 0,21)

0,952

4th

2,45±0,29

2,41±0,32

0,04 (-0,14 - 0,22)

0,646

Wisdom

1st

1,92±0,28

1,93±0,34

0,017

2nd

2,05±0,30

2,01±0,50

0,04 (-0,20 - 0,28)

0,730

3rd

1,91±0,38

2,02±0,46

-0,11 (-0,36 - 0,14)

0,382

4th

2,41±0,25

2,05±0,50

0,36 (0,13 - 0,59)

0,003

* Repeated ANOVA test, **post hoc Bonferroni. 1

: measurement on TM III of pregnancy,

2nd: measurement on one week before due date of childbirth, 3

: measurement on 3 days after birth,

4th: measurement on 11 days after birth.

3.4 Wisdom

The fourth indicator was that wisdom, by using

ANOVA repeated test showed the measurement

result at TM III of pregnancy with one week before

due date (p = 0,730), TM III pregnancy with three

postpartum days (p = 0,382) and TM III pregnancy

with eleven days postpartum (0.003). Based on the

analysis result (table 3) there was interaction between

measurement time and group (p = 0.017).

The results of the analysis using independent t

test showed the difference of the mean difference

(delta) of the wisdom before and after the intervention

between groups showed the value p = 0.013 (table 4),

so it can be concluded that there was a difference in

the score of wisdom before and after intervention

between groups who received additional

psychoeducation of dhikr and who only received

routine midwifery care.

4 DISCUSSION

The hypothesis of research that psychoeducation of

dhikr increases the spiritual response of primiparous

mother is acceptable, as illustrated by the increase of

mean score of patience, gratitude, willingness and

wisdom. Further described below.

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

Table 4. Difference (Δ) before and after intervention between groups

∆ Score

Difference ∆ ± SD

CI (95%)

Intervention

Control

Patience

-0.658 ± 0.402

-0.313 ± 0.323

-3.234

-0.560 – (-0.130)

0.002

Gratitude

-0.525 ± 0.282

-0.226 ± 0.468

-2.665

-0.524 – (-0.131)

0.012

Willingness

-0.525 ± 0.262

-0.287 ± 0.430

-2.302

-0.450 – (-0.030)

0.026

Wisdom

-0.492 ± 0.295

-0.122 ± 0.611

-2.661

-0.657 – (-0.083)

0.013

*Intervention group vs Control group: Independent t test.

First indicator was the patience. Based on this

study result obtained that psychoeducation dhikr

increases the respondents’ patience in accepting

pregnancy and childbirth along with consequences.

Intervention in this study involved an element of

beliefs held by respondents; shaped dhikr and written

in a module containing dhikr reading and meaning

and meaning. The previous the study revealed that

the guidance of religious belief was effective in

increasing the religious knowledge and attitudes

(Akbarzadeh et al. 2015), and the religious women

supported in coping with the stress of early

motherhood (Mann et al. 2008). When respondents

got guidance and do dhikr, it is interpreted as an

attempt to recall and get closer to add and strengthen

the knowledge of respondents that the conditions,

trials or pressures faced today are in accordance with

the limits of ability and can be faced with the help of

the God.

Second indicator was the gratitude. This study

showed that psychoeducation dhikr increases the

respondents’ gratitude during pregnancy and

childbirth. The previous studies stated that the

spiritual activities such as repentance and the dhikr

increased the psycho-physiology changes to the

positive ways (Nubli et al. 2013). Based on the

literature, it stated that Islam offers a comprehensive

methodology to solve mankind's spiritual,

intellectual and nothing happens without His

permission (Husain 1998). Peoples deed their lives

through the understanding of the faith of a particular

religious that it can direct how an individual will cope

with life stress (Gall et al. 2005).

Another study shown that dhikr creates positive

influences and eliminates negative influences and life

satisfaction can also be achieved immediately when

one performs dhikr, for in dhikr there is humility, fear

of His power, and helplessness before Him, therefore

developed gratitude, making it easy to achieve life

satisfaction (Hamsyah & Subandi 2017). In this

study, through stimulus of the psychoeducation dhikr

which is accompanied by understanding the meaning

of the reading so that happening strengthening and

increase of knowledge, thus giving gratitude to the

favors, fortune and grace in the form of pregnancy

and childbirth.

Third indicator was the willingness. The

psychoeducation dhikr facilitates the willingness of

the respondent's heart in accepting pregnancy,

childbirth and childbirth with all its consequences.

Recurrent pronunciation and hearing, such as those

characterized by dhikr have the ability to obtain a

state of consciousness, because there is

synchronization between the frontal cortex and the

limbic system, and then the parasympathetic nerves

coordinate relaxation, decrease stress hormones and

stimulate serotonergic function to enhance calmness

and increase response immune (Saniotis 2015).

However, another study found that dhikr has a

substantial immediate short-term effect in reducing

depression, anxiety and stress in mothers with

children suffering from Congenital Heart Disease

(Mirzaei et al. 2015). In this study, dhikr interpreted

as a means in increasing the understanding that

everything that happens is the will and has been

arranged by Allah SWT and it reinforces the

understanding and beliefs of pregnancy and

childbirth are the nature of women in continuous

descent.

Fourth indicator was the wisdom. The

psychoeducation of dhikr increases the wisdom on

the events of pregnancy, childbirth and childbirth.

Dhikr lowers perceived stress with improvement the

respondent's knowledge through comprehension and

comprehension of the meaning of reading so that

formed belief that behind condition of pregnancy,

childbirth and childbirth there is a useful wisdom to

be used as base in leading the life forward.

The previous study showed that cultural,

contextual and religious factors affect the experience

and positive attitude toward the pain during labor

(Taghizdeh et al. 2017). Psychoeducation of dhikr

awakens maturity thinking, confidence, and memory

to always be grateful for all the gifts of Allah SWT,

as well as new understanding and knowledge in the

face of pregnancy, childbirth and childbirth, so in the

end pregnant women have better mental health.

Although the respondents did dhikr

Psychoeducation Dhikr Increases Spiritual Responses of Primiparous Women

independently, beyond programmed time could not

be controlled, however, psychoeducation dhikr

increases the spiritual response of primiparous

mother, which was reflected from the increase of

mean score of patient indicator, gratitude,

willingness and wisdom.

5 CONCLUSIONS

Based on this study results, the psychoeducation

dhikr increased the patience, gratitude, willingness

and wisdom of the primiparous women, and it can be

concluded that the routine midwifery care plus

psychoeducation dhikr are more increased the

spiritual responses compared with the routine

midwifery care only.

Psychoeducation of dhikr becomes an option in

order to develop and optimize the mother's spiritual

aspect. By adding psychoeducation dhikr on the

routine midwifery care further increases spiritual

responses based on patience, gratitude, willingness

and wisdom on primiparous women.

ACKNOWLEDGEMENTS

The authors would like to thank to the primiparous

women as participants and the midwives as

facilitators in this research. There is no conflict of

interest.

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INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research