Health, Spirituality and Medical Ethics

Introduction
According to the World Health Organization, in 2008,1.4 million pregnant women experienced anxiety at the time of delivery. In a study conducted in Deli Serdang, Indonesia, around 30% of pregnant women were reported to experience anxiety when facing childbirth. In the mentioned study, the pregnant women had higher levels of anxiety in the third trimester than in the first and second trimesters. Moreover, there was a significant difference between primigravida and multigravida mothers in terms of anxiety(1)
Various reasons account for maternal anxiety about pregnancy. Primigravida mothers are more worried about the multiple changes occurring in their lives. The most commonly reported types of anxiety are anxiety about perineal tearing (64%), pain during labor (60%), loss of the neonate (50%), and fetal abnormalities (50%). In a study, the most frequently reported concerns were related to the health status of the neonate (94%), neonatal condition (93%), maternal physical (91%), and incidence of unexpected events during childbirth (89%) (2)
Prenatal anxiety can develop into depression and stress if not managed properly and have a negative impact on labor outcomes by leading to prolonged labor, preterm labor, low birth weight, and unplanned cesarean section. Based on the evidence, prenatal anxiety is a core predictor of many adverse labor outcomes therefore, the routine screening of this anxiety should be integrated into prenatal care. In Indonesia, prenatal anxiety screening is not carried out,as a part of midwifery service standards pregnant women.
One of the distraction techniques used to overcome anxiety is murottal therapy (listening to the verses of the Quran). Listening to the Holy Quran can stimulate delta waves that cause listeners to be calm, and comfortable. Murotal is a way to read the Quran with a moderate rhythm, (i.e., neither too slowly nor too fast) (3)
The Quran reading therapy with a slow and harmonious tempo can reduce stress hormones, and activate natural endorphins (serotonin). This mechanism can increase the sense of composure, reduce the feelings of fear, anxiety, and tension, and improve the body's chemical system through reducing blood pressure, and slowing down breathing, heart rate, pulse, and brain wave activity.
The Quran therapy has never been introduced or recommended in health centers specifically for the third-trimester pregnant women to help reduce labor.Regarding this, the present study was conducted to examine the effect of listening to the Quran recitation on anxiety in primipara, pregnant women. It is expected that  listening to, the Quran recitation can facilitate the reduction of third-trimester anxiety in primipara women, thereby maintaining their physical and psychological health and protecting them from labor complications.
 
Materials and Methods
This non-blind randomized controlled trial was conducted on 30 primipara women referring to the Meningting Health Care, in West Nusa Tenggara Barat., Indonesia, during May-November 2018. The study population was selected using convenience sampling technique, and then randomly allocated into two groups of intervention and control. The sample size estimated at 15 subjects in each group using the results of a local study and considering a type I error probability of 0.05 and a power of 0.80.
The inclusion criteria entailed: 1) primiparity, 2) gestational weeks of 28-34, 3) mild anxiety, 4) Islamic religion, 5) lack of hearing impairment, and 6) literacy. On the other hand, the exclusion criteria included: 1) pregnancy with complications, 2) mother with the presence of a husband who is outside the area, and 3) emergence of complications during the research process. The data collection instrument consisted of two parts. The first part included the clinical and demographic information (e.g., age, educational status, and  income level), and the second part entailed the Hamilton Anxiety Rating Scale (HARS).
The HARS consists of 14 items., each of which is scored on  point Likert scale ranging from almost never=0 to almost always.=4). The minimum and maximum scores of each subscale are 0 and 56, respectively. In this regard, higher scores represent higher levels of anxiety. In this study, Indonesian version of HARS was utilized., which has yielded satisfactory validation results. The validity of this instrument was reported at > 0,.05 and > 0,06 by Fuad Kautsar et al. (13)
,After the attendance of the researcher to this unit and identification of the eligible pregnant women  
who were in the third trimester and signed the consent form, they were randomly allocated into two groups of intervention and control. Subsequently, the researcher extracted the patients’ demographic and clinical information and entered them in the first
 part of the instrument.
In the intervention group Quran recitation (Ar -Rahman with the voice of Syekh Al Ghomidi) was played back with a headphone for each patient
for 15 min. This intervention was implemented three times a week for 4 four consecutive weeks. The patients in the control group only rested during this period. The level of anxiety was measured in two stages, namely immediately before, the intervention and after the study, and then entered into the second part of the instrument.

Statistical analysis
The data were analyzed in the Statistical Package for Social Sciences (version 11.5).
 The difference between the two groups regarding demographic and clinical data was assessed by independent- samples t-test. The independent- samples t-test was also used to assess the effect of Quran recitation on the level of anxiety. P-value less than 0.05 was
 considered statistically significant.
Ethical consideration
This study was approved by the Ethics Committee of  the Faculty of Medical Sciences of University of Mataram, Indonesia. In addition, permissions were obtained from the authorities, of the healthcare under study. The researchers explained the aims and process of the study, to the participants. Furthermore, they were informed about the voluntariness of study, participation and probability of study withdrawal at any time,. They were also ensured of the confidentiality of their personal information. In addition, written informed consent was obtained from each participant.
 
Results
The results of the study regarding the effect of listening to the Quran recitation on reducing primigravida anxiety are shown in:
Table 1. Characteristics of research subjects

Variable	Group		P-value
	Intervention (%)	Control (%)
Age
< 20	3 (18,.8%)	1 (6,.25%)	0,.53*
20-24	12 (75%)	14 (87,.5%)
25-29	1 (6,.25%)	1 (6,.25%)
Education level Primary School Junior High School Senior High School University	0 (0%) 1 (6,.25%) 15 (93,.8%) 0 (0%)	0 (0%) 1 (6,.25%) 14 (87,.5%) 1 (6,.25%)	0,.60*
Income level Below standard Above standard	13 (81,.2%) 3 (18,.8%)	11 (68,.7%) 5 (31,.3%)	0,.10*

 
 
From table As indicated in Table 1 above shows , the two groups were comparable in terms of age, education, and income in the two study groups did not differ significantly (p> (P>0.05), thus both groups were equal. With the ). The homogeneity of these characteristics, facilitates the implementation of further analysis can be carried out. Next is an analysis that compares. Table 2 presents the comparison of anxiety inbetween the two research groups presented in table 2.
 
Table 2. Comparison of Anxiety Level in Both Research Groups

Anxiety level	Group		P-value
	Intervention	Control
Pre-intervention Mean (SD) Range	15,.12 (0,.86) 14-16	15,.06 (0,.77) 14-16	0,.83
Post-intervention Mean (SD)       Range	12,.88 (1,.31)      10-15	15,.06 (0,.77)     14-16	<0,.01

 
Discussion
The subjects of this study consisted of primipara pregnant women in the third trimester with 28-36 weeks of gestation referring to Meninting Community Health Center. The majority of the subjects in this study were within 20-24 years of age. There was no significant difference between the two groups.
In terms of age. The age range of 20-24 years is a period of healthy reproductive age during which women pregnant easily.
However, 3 subjects in the intervention group and 4 subjects in the control group were younger than 20 years. People at a young age have unstable psychological conditions; therefore, this group is more vulnerable to prenatal anxiety. Accordingly, age is regarded as a factor in determining anxiety during pregnancy. Tolerance will increase with aging and understanding of anxiety.
 
One's ability to respond to anxiety is influenced by his/her age. In adults who are more mature allows them to use good coping mechanisms, compared to younger age groups. Coping mechanisms include task orientation behaviors and ego defense mechanisms, which can provide psychological protection. However, sometimes under certain conditions, this coping mechanism deviates and no longer is able to help someone adapt to stressors, thereby causing anxiety and stress.(3).
Another characteristic investigated in this study is the education level of the research subject. As indicated in Table 1, the majority of the subjects in the two groups had high school education. The results revealed that the two groups were comparable in this regard. A high education level will expand the views and scope of individuals and make it easier for respondents to receive information about health, resulting in the reduction of the level of anxiety.
On the other hand, Hawari (2004) states that the individuals with a high level of education are more probable to find  or receive information regarding their condition and severity of the disease therefore, they are more prone to anxiety. Knowledge is obtained formally; in this regard, individuals have a mindset and behavior in accordance with the education they obtain.
A person's knowledge of the disease or pregnant women’s information about labor that might have been obtained from the education bench still needs to be improved in order to increase the mother's sense of security and make them prepared for labor. Mother's knowledge can be improved by providing health education about the care of pregnant women during pregnancy and preparation for delivery. (3)
The results of the present study revealed no significant difference between the two groups in terms of economic status. In this regard, 13 and 11 subjects in the intervention and control groups had an income level of 2.3 million rupiahs, respectively. The availability of facilities and a good environment can help overcome the anxiety experienced by pregnant women.
Poor economic conditions, low education, minimal information, and lack of adequate health facilities make mothers less aware of the ways of overcoming anxiety Maryam and Kurniawan (2008) demonstrated that income as an indicator of economic status had an influence on the level of anxiety. In this regard, they reported that individuals with an income level below the 
experienced more anxiety than those with an income level above the regional minimum wage.(4).
As indicated in Table 2, the comparison of anxiety scores between the two study groups showed  no significant difference before receiving the intervention. However, following the intervention, the two groups were significantly different in terms of the anxiety score.
In this study, murottal Quran therapy was implemented by means of audio Quran in mp3, using the voice of Sheikh Al Ghomidi from the Middle East, reciting the verses of Ar-Rahman Surah. Murottal therapy was carried out three times a week for four consecutive weeks. Our results revealed that this intervention led to the reduction of anxiety in primipara  pregnant women in the third trimester. This is in line with the findings obtained by Handayani (2014) stating that the recitation of the Quran which is an amazing healing instrument that is also accessible.  can reduce stress hormones, activate natural endorphins, increase feelings of composure, divert attention from fear, anxiety, and tension, and improve the body's chemical system. It also lowers the blood pressure and slows down breathing, heart rate, pulse, and brain wave activity. Deeper or slower breathing rates can efficiently cause calmness, emotional control, deeper thinking, and better metabolism. (5-10).
In a study, Cooke, et al. (2005) investigated the Quran therapy using a tape recorder, Quran recitation tape, and  consisting of short notes of the juz 30 of the Quran which is easier to memorize and more familiar to people, played for 15 min giving an impact psychological towards the positive, this is because when  the Quran is heard and reaches the brain, this Quran will be translated by the  brain. Our perceptions are determined by all, desires, needs, and prejudices.
The Quran stimulant as a relaxation therapy can be used as a new alternative treatment, which is even better than other audio therapies because the Quran can generate a delta wave of 63.11%. Low sound intensity is a sound intensity of fewer than 60 dB, which gives comfort and causes no pain. Murottal has an intensity of 50 dB that exerts a positive influence on the listener. This audio therapy is also a cheap treatment that is accompanied by no side effects.(11)
            Babaai Atye et al., . (2015) also conducted a study on 60 patients subjected to cardiac catheterization measurement in two groups of control (n=30) and intervention (n=30). The intervention group was exposed to 18 min of the Quran recitation. They observed a significant decrease in the mean score of anxiety in the intervention group.. Music stimulation increases the release of endorphins, thereby reducing the need for medication. This release also provides a distraction from pain and can reduce anxiety.
According to the Candace Pert's theory, neuropeptides and biochemical receptors released by the hypothalamus are closely related to emotional events. cheerful/relaxed state can reduce cortisol levels, epinephrine-norepinephrine, dopa, and growth hormone in the serum (8-10).
Nayef et al., . (2017 examined the effects of the Quran on human emotions. Accordingly, the evidence is indicative of the positive effects of the Quran on mental health. Spiritual approaches in a positive form, such as listening to the Quran, help solve problems and reduce anxiety as much as possible. The daily spiritual activities related to the health and emotional aspects are a source of support, and emotional strength, facilitating the reduction of anxiety.
The human spiritual dimension is one of the four dimensions of a holistic approach, and like the biological, psychological, and social aspects. Based on the evidence, attention to the spiritual dimension of care will produce significantly different results from attending to its physical, psychological, and social dimensions. In addition, participation in religious and spiritual rituals is associated with better health outcomes, such as increased life expectancy, reduced cardiovascular diseases, and decreased risk of depression, anxiety, substance abuse, and suicide. (12).
Based on the study performed by Nayef et al.., the Quran facilitates the stabilization of the heart rate, breathing, and emotion. Nayef revealed that listening to the Quran recitation can control the brain to reduce anxiety, fatigue, and boredom. and result in spiritual relaxation. Listening to the Quran recitation is a therapeutic approach that can control the heart rate, breathing, blood pressure, brain waves, temperature, and muscle pressure.(12)
 
Conclusion
The results of the present study revealed a significant difference between the intervention and control. groups in terms of anxiety level after listening to the Quran recitation. Integration of the Holy Quran recitation into the care process of primipara pregnant women would be accompanied by a positive effect reducing their anxiety.
 
Acknowledgments
We would like to extend our special thanks to Poltekkes Kemenkes Mataram and all medical staff at Puskesmas Meningting.

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