Literature Review: The Effect of Audio Hypnobirthing on Anxiety Levels in First Childbirth Mothers

. Anxiety in childbirth is a response to certain threatening situations, often anxiety can be characterized by feelings of irritability, anxiety, nervousness, excessive vigilance, and feelings of tension when facing the labor process. Maternal mothers who cannot control their anxiety and fear before giving birth will release high amounts of catecholamine hormones. Stress hormones that are produced in excess in pregnant women can interfere with the blood supply to the fetus and can make the fetus hyperactive. This literature study aims to determine the effect of audio hypnobirthing on maternal anxiety levels. This study uses a descriptive narrative method in the form of a literature study, literature searches are carried out through Google Scholar, Indonesia One Search (IOS), Digital Reference Garba (GARUDA) and text books. The literature used is published in 2011-2020 both nationally and internationally and is relevant to the topic taken. The results of the study of literature in 6 journals and 3 books found that there was an effect of audio hypnobirthing on the anxiety level of maternity mothers. Based on the results of the study, it can be concluded that hypnobirthing can prevent anxiety in maternity . The results of the study showed a decrease in anxiety levels after the intervention with an average decrease of points. The results of the static test showed a p value of 0.000. this means that there is a significant difference between the level of anxiety in the case group and the control group. It can be concluded that the hypnobirthing method can reduce maternal anxiety levels.


INTRODUCTION
Anxiety before childbirth is a physiological thing, but in dealing with childbirth there will be a series of physical and psychological changes starting from uterine contractions, cervical dilatation, and expulsion of the placenta ending with maternal and infant care. Anxiety is an emotional reaction to subjective individual judgments, influenced by the subconscious and the cause is not known specifically. Anxiety can arise due to various factors that suppress life, including in the face of the pregnancy process.
Maternal mothers who cannot control their anxiety and fear before giving birth will release catecholamine hormones in high amounts. Stress hormones that are produced in excess in pregnant women can interfere with the blood supply to the fetus and can make the fetus hyperactive. Antenatal depression and anxiety also have a direct impact on | 34 postnatal parental stress and physiologically will cause uterine contractions to feel more painful and painful. On the other hand, if the mother faces childbirth with a calm, sincere and resigned feeling, the body will naturally release endorphins that will make the mother feel comfortable, and can reduce or even eliminate pain. The effect of these endorphins is said to be 200 times stronger than that of morphine. The mother will be in a relaxed state so that the uterus will naturally be able to make rhythmic movements that are in rhythm with the movement of the fetus that is looking for a way out. The fetus will find a way out in peace and the pain during childbirth is reduced.
Efforts to reduce anxiety in mothers in the face of childbirth is to inform a comfortable delivery, one of which is by introducing the hypnobirthing method. The hypnobirthing method is a combination of the natural birth process with hypnosis to build positive perceptions and self-confidence and reduce fear, anxiety and tension, and panic before, during and after childbirth. According to the American Pregency Association, this hypnobirthing relaxation technique can be used to prepare a mother for childbirth and to try to overcome a number of issues ranging from fears and health conditions related to pregnancy and to reduce anxiety.
Hypnobirthing is one of the techniques of autohypnosis (self hypnosis), which is a natural effort to instill positive intentions/suggestions into the soul or subconscious mind during pregnancy and preparation for childbirth. Thus, pregnant women can enjoy the beauty of pregnancy and the smooth delivery process. This method is based on the belief that every woman can go through the process of giving birth in a calm, natural, and comfortable way. Hypnobirthing is the right step to neutralize and reprogram the negative thoughts of the mother's subconscious with positive thoughts. As a result, the thoughts that are embedded in the subconscious that the frightening and painful process can be erased and replaced with new beliefs that childbirth take place are very spiritual, easy, smooth, and comfortable (Kuswandi, 2014).
The techniques used in hypnobirthing can help mothers to feel less painful contractions. If the mother feels sick, worried or afraid during the delivery process, her body tends to tense up and stress hormones, especially adrenaline, will flood the body. Blood that flows quickly to the muscles will make the uterine muscles not work properly due to lack of blood and oxygen so that childbirth will be more difficult and longer. In addition, the baby may be deprived of oxygen (Ayuningtyas, 2019).
The results of research from Sariati, et al (2016), the presentation of maternal anxiety during hypnobirthing relaxation was 73.3%. This shows a decrease in the level of anxiety in mothers after hypnobirthing relaxation. This decrease in anxiety levels is due to the hypnobirthing relaxation that brings the brain to work on alpha waves, namely waves that have a frequency of 14-30 HZ. In this condition the brain is in a relaxed state, relaxed, between conscious, unconscious and almost asleep when the body begins to secrete serotonin and endorphins (Sariati et al., 2016) The World Health Organization (WHO) noted that around 830 women worldwide die every day due to complications related to pregnancy and childbirth and 99% of them are in developing countries. In developing countries, in 2015 the maternal mortality rate reached 239 per 100,000 live births, compared to developed countries which only reached 12 per 100,000 live births (World Health Organization, 2018) The maternal mortality rate (MMR) according to the Indonesian Ministry of Health, 2015 was 126 per 100,000 live births. Based on the Data and Information Center of the Ministry of Health (Infodatin), in 2013 the high maternal mortality rate was caused by | 35 bleeding 30.3%, preeclampsia 27.1, infection 7.3%, and other causes, namely 40.8% ( Ministry of Health RI, 2014). In Gorontalo district itself, the number of mothers giving birth in Gorontalo district from January to December 2019 was 7,711 mothers

METHODS
This research is a research using literature study method or literature review. A literature review is a comprehensive overview of the research that has been done on a specific topic to show the reader what is already known about the topic and what is not known, to seek rationale from research that has been done or for further research ideas. Literature studies can be obtained from various sources, both journals, books, documentation, internet and libraries. The literature study method is a series of activities related to the method of collecting library data, reading and taking notes, and managing writing materials (Nursalam, 2016). The type of writing used is a literature review study that focuses on the results of writing related to the topic or variable of writing.

RESULTS AND DISCUSSION
Based on the journal search results from the IOS search engine, Google Scholar and Digital Reference Garba (GARUDA) with the keywords: 1st stage labor, anxiety, hypnobirthing, resulting in 272 journals. The journals are then screened, taking into account the suitability of the source, the suitability of the content, through a quick reading of the abstract, headings, sub headings, as well as document statements or important sentences contained in the abstract and introduction of the journal, plus taking into account the condition of the journal such as: journals cannot be opened, cannot be downloaded, are incomplete, only have abstracts, journals originating from research conducted outside the health sector, journals conducted outside the ranks of universities, and journals containing only one keyword are not included in the journal review. So that through the screening, 6 journals were obtained.
The results after the inclusion of the inclusion criteria obtained 6 journals, the journal was then carried out a feasibility test by reading it in its entirety and thoroughly. Journals that are articles or literature reviews, journals with the same title, and journals that are not in accordance with the author's objectives will be eliminated. To speed up the process of eliminating journals, an objective evaluation of the contents of journals that are supportive or debilitating is carried out, using skimming (gliding) with the intention of focusing on reading the journal's core, by reading quickly, and capturing the essence of the journal. If the use of skimming is still not able to capture the intent of the journal author, then read it repeatedly, in depth, and focus on research methods and results, and get 6 journals that match the number of journals. The appropriate journals are then analyzed and extracted.
Based on the six journals taken and reviewed, it was found that PICO (Problem, Intervention, Comparison, Outcome): The problem discussed was the level of anxiety of pregnant women and mothers giving birth, then the intervention given to reduce the level of anxiety was hypnobirthing. The result of giving hypnobirthing is hypnobirthing can reduce anxiety levels in pregnant women or mothers in labor.
Mothers giving birth in the 1st stage will feel anxiety which can cause excessive pain, tension, and feelings of discomfort at the time of delivery. Anxiety is a feeling disorder characterized by excessive worry or fear, is not disturbed, and remains intact to assess personality, disturbed behavior but is still in a normal state.

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Maternal mothers who cannot control anxiety will release catecholamine hormones in high amounts into the blood and suppress the hormone epinephrine and oxytocin hormones which will result in decreased uterine contractions, reduced blood flow and oxygen so that physiologically it can cause increased pain. On the other hand, if the mother faces childbirth calmly and comfortably, the body will automatically release endorphins which will make the feeling feel comfortable, reduce, and even eliminate pain.
Anxiety can be overcome by pharmacological and non-pharmacological therapy. For non-pharmacological therapy can use the hypnobirthing method. This method teaches that fear and tension (or special medical conditions), intense pain do not always have to be present in labour. According to the American Pregency Association, this hypnobirthing relaxation technique can be used to prepare a mother for childbirth and to try to overcome a number of issues ranging from fears and health conditions related to pregnancy and reducing anxiety.
In the study (Jamir and Aguswatiawati 2020) maternity mothers who were given hypnobirthing experienced a decrease in anxiety to become less anxious compared to mothers who were not given hypnobirthing. This is because mothers who are given hypnobirthing feel more relaxed, comfortable and calm, so they are able to face the birth process comfortably and by applying the suggestions given during hypnobirthing. Mothers who are given hypnobirthing will feel calm, comfortable and will reduce anxiety until the delivery process ends (Jamir & Agustiawati, 2020). This is in line with the theory of Lany Kuswandi (2011), by doing hypnobirthing mothers can be directed naturally to increase self-confidence and instill programs or positive suggestions until the delivery process. Thus the mother can neutralize all negative recordings in her subconscious mind about the birth process, and then it will be replaced with a positive program. Therefore, if the pregnant woman is in a calm condition (alpha), theta, the fetus will feel a comfortable and calm condition because the frequency of the mother is easily connected to her fetus. In addition, all positive programs or intentions can be well received by both mother and fetus. Every fetal movement can be understood by the mother. The mother can cooperate with the fetus, especially during the labor process so that the delivery process can be passed calmly, comfortably, and without pain (Lany, 2011).
Hypnobirthing technique aims to teach mothers to stay in control during labor. Hypnobirthing is also useful in shortening the first stage of labor, reducing pain, and anxiety after the delivery process is complete. Actually, hypnobirthing cannot relieve pain, but the technique used in giving hypnobirthing can help mothers to feel less painful contractions. Hypnobirthing can also control emotions in order to prevent feelings of stress from developing. The methods chosen in this method vary, either through video or listening to audio.
Similar to the research conducted by Sugeng Triyani, et al, (2016) with a sample of 40 people, of which 20 people were in the case group and 20 people were in the control group. It is known that from 20 samples observed, it can be seen that the average level of anxiety before hypnobirthing is 24.10 and the average level of anxiety after hypnobirthing is 2.55. From the -t test, it is known that the average difference between the level of anxiety before and after being given hypnobirthing is 21,550. from the results it can be concluded that the level of anxiety before giving hypnobirthing is moderate and severe anxiety. While the level of anxiety in mothers who have been given hypnobirthing is mild anxiety and no anxiety (Triyani et al., 2016)

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The results of the study showed a decrease in anxiety levels after the intervention with an average decrease of 21,550 points. The results of the static test showed a p value of 0.000. this means that there is a significant difference between the level of anxiety in the case group and the control group. It can be concluded that the hypnobirthing method can reduce maternal anxiety levels.
The decrease in anxiety levels with the provision of hypnobirthing is also supported by the results of the study. 8 The results of this study showed that the percentage of anxiety of pregnant women who were given the hypnobirthing method was 73.3% with no symptoms of anxiety. Meanwhile, 40% of those who were not given the hypnobirthing method showed symptoms of anxiety and 33.3% showed symptoms of severe anxiety. 53.3% of the group given the hypnobirthing method had normal delivery, while 60% of the group that was not given the hypnobirthing method had fast labor and 40% had normal delivery. This shows that childbirth using the hypnobirthing method can reduce labor anxiety levels. (2018) can also strengthen the above theories. From this research, 62.5% of mothers who used hypnobirthing did not experience anxiety and 37.5% experienced anxiety. Meanwhile, mothers who did not use the hypnobirthing method all experienced anxiety. For this reason, it can be concluded that there is a relationship between the hypnobirthing method and the level of anxiety, which means that using the hypnobirthing method will be able to reduce the risk of maternal anxiety levels at 1.15

Research conducted by Erni Hernawati and Belva Metta Ardelia
In the research of Fatimah Jamir and Agustiawati, (2020) the sample used was 42 people, of which 21 were the treatment group and 21 other respondents were the control group. Prior to treatment, all groups were first measured (pre-test) to determine the respondent's level of anxiety. Furthermore, the treatment group was given an intervention while the control group was not given an intervention. The results of this study were from 21 mothers without hypnobirthing, there were 12 mothers who experienced moderate levels of anxiety, namely 12 mothers (57.1%), severe anxiety as many as 6 mothers (28.65), and mild anxiety levels as many as 3 mothers ( 14.3%) while the other anxiety levels were 0. Then after no treatment (post) from 21 mothers, the highest level of anxiety was moderate anxiety as many as 15 mothers (71.4%), both severe anxiety as many as 6 mothers (28.6 %) and three mothers with mild anxiety (14.3%). This shows that changes in the level of maternal anxiety in the first stage without hypnobirthing are very small. This means that without giving hypnobirthing all mothers experience anxiety both before giving birth and after giving birth. The group of maternity mothers who were given hypnobirthing as many as 21 people showed the highest level of anxiety in childbirth before (pre) treatment was moderate anxiety as many as 13 mothers (61.9%) and severe anxiety as many as 8 mothers (38.1%). Then after being given treatment (post), all mothers with a total of 21 mothers did not experience anxiety, which means that all mothers who were given 100% treatment did not experience anxiety. This study can be concluded that the provision of hypnobirthing can affect the level of anxiety in maternity mothers (Jamir & Agustiawati, 2020). Furthermore, research conducted by Imannuara & Susanti (2018) shows that the decrease in anxiety scores before and after hypnobirthing is the average anxiety score before the hypnobirthing class given is 55.80 to 41.33 as has been given the hypnobirthing class. This shows that there is an effect of releasing hypnobirthing classes in reducing anxiety levels of primigravida and multigravida pregnant women in facing childbirth. It can be concluded that giving hypnobirthing can effectively reduce anxiety in pregnant women during childbirth (Imannuara & Susanti, 2018).
Although they have the same goal, namely to reduce maternal anxiety levels, these studies have differences in methods, population and number of samples. As in Sitit Haniyah's research (2013), using quantitative research methods with a pre-experimental one-group pre-post test design, with a population of all pregnant women with a sample of 16 primigravida pregnant women (Haniyah, 2013).
The research of Fatimah Jamir and Agustiawati (2020) used the Quasi Experiment method with a nonequivalent control group pre-test and post-test design, the number of population used were all mothers who gave birth with a sample of 30 mothers who gave birth. Finally, the research conducted by Imannuara and Susanti (2018), using an analytical experimental method with a Randomized Controlled Trial (RCT) design, the total population is pregnant women with a gestational age of 30-34 weeks and a minimum sample size of 30 pregnant women. It has been reviewed that the hypnobiting method can reduce maternal anxiety levels without the use of medical drugs. This hypnobirthing method uses a combination of natural birth and hypnosis to build positive perceptions and self-confidence and reduce fear, anxiety and tension, and panic before, during and after childbirth. Anxiety can decrease because hypnobirthing works based on the power of suggestion, uses positive affirmations, makes the body and mind relax so that the body can respond to secrete endorphins that can suppress the release of catecholamine hormones so that the mother relaxes and will put the brain in an alpha state so will reduce pain in childbirth. This is evidenced from several studies that were reviewed that there was a decrease in the level of anxiety for maternity mothers who were given hypnobirthing compared to those who were not given hypnobirthing

CONCLUSION
Based on the results of the literature study, it can be concluded that there is an effect of hypnobirthing on the anxiety level of mothers in first stage of labor. This hypnobirthing method can build positive perceptions and self-confidence and reduce fear, anxiety, and tension before and after childbirth. Hypnobirthing reduces maternal anxiety because when doing hypnobirthing it will bring the brain to work in alpha waves, which are alpha waves with a frequency of 14 to 30 Hz. In this condition the brain will naturally instill positive thoughts or suggestions and be able to neutralize all negative thoughts that exist in the mother's subconscious so that it will make the mother feel more comfortable, relaxed, calm and can reduce or even eliminate pain during childbirth.