Psychoeducation Through Bakera Cultural Approach (Maternity Spa) to Cure the Anxiety of Postpartum Mothers During the COVID-19 Pandemic

Document Type : Original Research

Authors
I.W. Desiyanti
S.D.M. Riu
D. Anggraeny
L. Ardiningtyas
Faculty of Health Sciences, University of Muhammadiyah Manado, Manado, Indonesia
10.58209/hehp.11.4.687
Abstract
Aims: The COVID-19 pandemic has had an indirect effect on the psychology of postpartum mothers, such as stress, anxiety, and even depression. Postpartum women who have mental health histories can be more at risk of facing depression, anxiety, and fear during the COVID-19 pandemic.

We investigated the effect of psychoeducation through the Bakera Culture Approach (maternity spa) to cure the anxiety of postpartum mothers during the COVID-19 pandemic

Materials & Methods: This research was quantitative, with a quasi-experimental approach with pre-test and post-test and a control group. The Zung Self-Rating Anxiety Scale (SAS/SRAS)was used to measure anxiety.

Findings: The anxiety level between the Bakera+psychoeducation and Bakera group after treatment (post-test) is obtained Z value of 2.948 and a significance value of 0.003, so it was stated that there is a significant difference in the anxiety level between Bakera+psychoeducation and Bakera groups after treatment (post-test).

Conclusion: There is an effect of psychoeducation through the cultural approach bakery (maternity spa) to cure the anxiety of postpartum mothers during the COVID-19 pandemic. There is a significant reduction in anxiety levels in the Bakera group + psychoeducation. There is a significant difference in anxiety levels between the Bakera + Psychoeducation group and the Bakera group after treatment (posttest).

Keywords

Subjects

Introduction
The postpartum mother undergoes changes in her physiology and psyche. Her reproductive system and hormones undergo alterations as part of her physiological adaptation. The emergence of worries and anxieties in the new mother is one of the psychological adjustments during this period [1]. Currently, the COVID-19 pandemic is contributing to increased stress among expectant mothers [2]. Pregnant and postpartum mothers are experiencing psychological repercussions, including stress, anxiety, and possibly depression, due to the COVID-19 epidemic [3]. Pregnant and postpartum moms with a prior mental health history are at a heightened risk of experiencing despair, anxiety, and panic during the COVID-19 epidemic [4]. The anxiety experienced by postpartum moms during the COVID-19 pandemic stems from concerns regarding the potential danger of infection both during pregnancy and after giving birth, as well as the possibility of transmitting the virus to their infants and other family members [5]. In addition, there are also physical limitations and quarantines that alter the standard prenatal treatment, causing concern among moms about receiving optimal care [4]. The presence of psychological symptoms, like anxiety, should not be prolonged, since they have the potential to escalate into more severe psychological illnesses, such as postpartum blues [6].
According to a study conducted in poor nations, the occurrence of postpartum blues is said to be quite high, ranging from 26% to 85%. However, Anggraeni et al. discovered that the frequency of postpartum blues among women in Indonesia is between 50% and 70% [7]. Various studies have demonstrated that a combination of face therapy using full-blooded techniques and lavender aromatherapy can effectively reduce anxiety in postpartum mothers [8]. By using hypnosis and relaxation techniques including suggestion, visualization and wish fulfillment, endorphin-related messages [9] can be delivered. Muscle relaxation therapy can be employed to alleviate the anxiety experienced by postpartum mothers. Additionally, muscle relaxation can improve focus, combat sleeplessness, and foster the development of pleasant emotions from negative emotions. These muscular relaxations have been empirically demonstrated as an effective technique for mitigating patient anxiety [10].
Maternity spa therapy, including steam baths, is a form of muscular relaxation treatment for moms after giving birth. Witari et al. found that the utilization of herbal steam baths aids in the postpartum recovery of mothers belonging to various ethnic groups residing within the elevated regions and flat areas of Thailand [11]. Steam baths in Indonesia are known by different names in different places. The Minahasa language refers to them as "Bakera," while in the Batak region of Sumatra, they are known as "Lookup." In Java, they are called "Lulur," whilst in Bali, they are referred to as "Both." In Madura, they are known as "So'oso," and in Bugis, South Sulawesi, they are called "Beta Lotting" [12]. Bakera is a customary practice observed by individuals in North Sulawesi, specifically by women following childbirth or during the postpartum period. Bakera has been demonstrated to effectively serve as a medium for delivering information and giving education, particularly in the context of psychoeducation for postpartum women [13]. Psychoeducation has a tangible effect on decreasing the levels of postpartum blues [15].
The presented picture highlights the necessity for a more comprehensive examination of the effects of COVID-19 on the maintenance and enhancement of postnatal mental well-being among women. Therefore, this research was conducted with meticulous attention to the ramifications of anxiety and tension, as they will significantly influence the welfare of the mother, baby, and the entire family, both directly and indirectly. The problem formulation proposed in this research aimed to analyze the impact of psychoeducation utilizing the Bakera approach (maternity spa) on alleviating anxiety among postpartum mothers during the COVID-19 pandemic.

Materials and Methods
This quasi-experimental study utilized a quantitative research approach, employing a pre- and post-test methodology to compare the control and experimental groups, and was conducted from December 2020 to May 2021. The samples (mothers) were assigned to the control and experimental groups using a totally random randomization technique. Both groups underwent a pre-test, followed by the administration of Bakera treatment. Both groups were subjected to a post-test. Prior to the post-test, the experimental group received concurrent Bakera therapy and psychoeducation intervention. This study examined psychoeducation as the independent variable, exploring its role in both avoiding and understanding the causes of postpartum stress. The study focused on the dependent variable of postpartum anxiety in moms.
We used a purposive sampling technique, by selecting participants based on specific inclusion and exclusion criteria. Inclusion criteria were postpartum mothers who have undergone the postpartum period for at least 21 days, willingness to be respondents and no perineal sutures or perineal sutures that have completely healed. The exclusion criteria were mothers with physical health problems and mothers whose babies had health problems. The sample consisted of 70 postpartum mothers, with 35 people in the psychoeducation+Bakera group and 35 in the Bakera group.
The data collection was done by a questionnaire to assess anxiety levels. The researcher asked for a list of respondents' names. Participants must be postpartum mothers with at least 21 days postpartum. Researchers counted the number of postpartum mothers and then distributed the research questionnaires and then collected them after they were filled in completely.
The arrangement was conducted using the Self-Rating Anxiety Scale (SAS) to assess the level of anxiety in adult patients designed by William W. K. Zung and developed based on the symptoms of stress in the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) [19].
Data were analyzed by SPSS 24.0 using univariate and bivariate analyses, such as the Wilcoxon, Mann-Whitney, and Chi-square tests at a confidence level of p<0.05.

Findings
Characteristics of the Research Subject
The participants' age, age at marriage, age at first pregnancy, birth weight, birth length, ethnicity, religion, education level, occupation, income, the husband's involvement, domestic violence, and trust in the baker were assessed and are presented in Table 1.

Table 1. Characteristics of the subjects in both groups



Table 1 shows that in the Bakera+psychoeducation group, most cases were in the age range of 20-35 years (29 cases (41.4%).  In the Bakera group, the highest number of persons fell within the age bracket of 20-35 years (30 cases (42.9%). The Mann-Whitney U test revealed a lack of statistical significance in age differences between the groups, as evidenced by a p-value greater than 0.05. Among individuals in the Bakera+psychoeducation group, there was a notably high occurrence of marriage at a young age (<20 years) (22 cases (31.4%). The age bracket with the largest number of participants in the Bakers group was under 20 years old (20 cases (28.6%). The Mann-Whitney U test was used to compare the age of marriage between the groups. The findings revealed a lack of statistical significance, as evidenced by a p-value beyond 0.05.
The Bakera+Psychoeducation group consisted of a maximum of 35 newborns, representing 50% of new mothers, who fell into the category of moderate birth anxiety. In the Bakera group, the highest number of mothers who had just given birth, namely 34 mothers or 48.6%, also belonged to the anxiety category for those who had just given birth. The Mann-Whitney U test findings, which assessed groups based on New Maternal Anxiety, did not reveal any statistically significant differences (p-value>0.05). In the Bakera+Psychoeducation group, most mothers experienced varying levels of anxiety during the birthing process. This number includes 22 mothers, equivalent to 31.4% of the total, out of a group of 25 new mothers, constituting 35.7% of the group. The Mann-Whitney U test, on the other hand, demonstrated a statistically significant difference in the anxiety levels of new mothers between the two groups, indicated by a p-value below 0.05.
Out of all the participants, 29 individuals, which accounts for 41.4%, belonged to the Minahasa ethnic group and got Bakera along with psychoeducation. In the Bakera group, the Minahasa tribe comprised the majority, consisting of 21 individuals or 30.0%. The Mann-Whitney U test was utilized to evaluate groupings and tribes, and the findings revealed that there was no statistically significant differentiation between them (p-value>0.05). The religious composition of the Bakera+Psychoeducation group revealed that the majority, including 34 individuals or 48.6% were Christians. In the Bakera group, the Christian population comprised the largest portion, consisting of 27 individuals or 38.6%. The Mann-Whitney U test revealed that there was no statistically significant difference between the groups in terms of religion (p-value>0.05).
The educational attainment of the Bakera+Psychoeducation group indicated that the majority, including 31 people or 44.3%, had achieved a maximum of secondary education. Among the Bakera group, the secondary education category comprises the largest number of individuals, accounting for 29 people or 41.4%. The Mann-Whitney U test indicated that there was no statistically significant difference in education among the groups (p-value>0.05). Bakera was designated to undertake the duty inside the group, and the maximum capacity for workers on this assignment is 15, which accounts for 21.4% of the overall workforce. Among the members of the Bakera group, the majority were private employees, totaling 16 individuals or 22.9% of the entire group. The Mann-Whitney U test indicated that there was no statistically significant difference between the groups in occupation (p-value>0.05).
The combined income generated by Bakera and psychoeducation for the group did not exceed 45.7% of the minimum wage, indicating minimal achievable earnings. Within the specified category, a significant proportion of individuals in the Bakera group earned less than the minimum wage (28 individuals (40.0%)). The Mann-Whitney U test yielded a non-significant result regarding the difference in income between the groups (p-value>0.05). Among the role categories, the husband's involvement in the Bakera+Psychoeducation group was the most prevalent, comprising 30 individuals or 42.9%. Also, 27 individuals, representing 38.6%, served as Bakera. The Mann-Whitney U test was utilized to evaluate the comparison between groups regarding the husband's role and the results indicated that there was no statistically significant difference (p-value>0.05).
The group who received Bakera+psychoeducation intervention reported no physical or psychological domestic violence. The group given Bakera did not experience any physical or psychological domestic violence. The findings of the Mann-Whitney U test, which compared groups in terms of domestic violence, indicated no statistically significant distinction (p-value>0.05). The group's confidence in Bakera stems from the amalgamation of Bakera and psychoeducation, leading to a prevailing conviction in Bakera. It is widely recognized inside the given group that Bakera was highly trusted and had the complete confidence of all members. The results of the Mann-Whitney U test, which compared groups in terms of confidence in Bakera, revealed no statistically significant distinction (p-value>0.05).
Anxiety levels in the Bakera+psychoeducation and Bakera groups
The study measured the levels of anxiety as a quantifiable variable before and during the intervention (Table 2).

Table 2. Anxiety levels in the Bakera+psychoeducation and Bakera groups


Table 2 displays the pre-treatment anxiety levels in the Bakera+psychoeducation group. Out of the total number of cases, none were exempt from experiencing anxiety. One individual experienced a mild level of concern, while 31 individuals experienced a moderate level of anxiety. Lastly, three individuals confronted a significant level of fear that posed challenges for them. Subsequently, following the administration of treatment (post-test), three individuals did not exhibit any distress, 22 experienced mild anxiety, ten experienced moderate pressure, and none experienced severe panic.  
Furthermore, the Baker group's anxiety level was assessed before therapy (pre-test). The results showed that of the total sample, no one reported any stress, two people experienced mild anxiety, 26 people experienced moderate pressure, and four people experienced severe anxiety. After giving the treatment (post-test), none of the individuals experienced stress, while 14 people experienced mild tension. Of the total 20 participants, most experienced moderate pressure, while one person experienced severe stress.
Impact of treatment on anxiety levels in the Bakera+psychoeducation and Bakera groups
We evaluated the impact of treatment on anxiety levels in each group by the Wilcoxon test and the Z value was -5.135 and the significance value was 0.0001. Findings showed a statistically significant reduction in anxiety levels in the Bakera+psychoeducation group after treatment (p-value<0.05).
A Wilcoxon test was conducted to evaluate the anxiety levels of the Bakera group before and after therapy; the Z value was -3.742, and the significance value was 0.0001. The research revealed a statistically significant reduction in anxiety levels in the Bakera group (p-value<0.05).   
Differences in anxiety levels in the groups before and after the intervention
The Mann-Whitney U test was used to assess whether there exists a discrepancy in anxiety levels between the groups before treatment (pre-test). The test resulted in a Z score of 0.019 and a p-value of 0.985, indicating no statistically significant difference in anxiety levels between the Bakera+psychoeducation and Bakera groups before treatment (pre-test). Next, the Mann-Whitney U test was used to evaluate differences in anxiety levels between the Bakera group who received psychoeducation and the Bakera group who underwent therapy (post-test). The analysis yielded a Z score of 2.948 and a p-value of 0.003, indicating statistically significant results, which suggests that there is a substantial difference in the level of anxiety between the Bakera+Psychoeducation and Bakera groups after treatment (post-test) (p-value<0.05).

Effect of subjects’ characteristics on anxiety levels
The relationship between the characteristics of research subjects and anxiety levels in Bakera+psychoeducation was carried out using the Chi-square test. There was a significant relationship between education (p-value=0.012) and income (p-value=0.035) and a decrease in anxiety levels. However, there was no significant relationship between age (p-value=0.441), marriage period (p-value=0.726), age at first pregnancy (p-value=0.726), body length at birth (p-value=0.235), ethnicity (p-value=0.441), religion (p-value=0.612), occupation (p-value=0.115), and husband's role (p-value=1.000) and anxiety levels.

Discussion
Postpartum anxiety negatively impacts various aspects of infant development, including breastfeeding, bonding, interaction and temperament, sleep patterns, mental development, health, and the internalization of behavior. Additionally, it can contribute to the development of behavior disorders in teenagers [14]. According to the findings, the anxiety levels described by the participants in the Bakera+psychoeducation group increased before receiving therapy (pre-test). Out of the total population, no individuals are exempt from experiencing worry. One person experiences mild anxiety, 31 individuals experience moderate anxiety, and three individuals endure severe anxiety. Following the implementation of the treatment (post-test), three individuals exhibited no anxiety, 22 experienced mild anxiety, ten experienced moderate anxiety, and none experienced severe anxiety.
In the pre-test stage, all cases experienced anxiety to some degree, whereas two individuals only experienced minor anxiety, 26 individuals experienced moderate anxiety, and four individuals experienced severe anxiety. Following the treatment (post-test), the results indicated that no individuals experienced pressure, 14 individuals experienced mild concern, 20 individuals experienced moderate stress, and one individual had severe anxiety. Psychoeducation is a methodical intervention aimed at altering patients' understanding of their illness and its treatment, encompassing emotional and motivational factors. Its purpose is to assist patients in managing their condition and enhancing the efficacy of their treatment. Psychoeducation plays a crucial role in the treatment of physical and mental diseases, particularly those that are linked to cognitive impairment. The psychoeducation program covers several aspects, such as the causes of the condition, the treatment plan, the potential side effects of medicine, techniques for managing stress, educating the family, and training in essential life skills [15].
Psychoeducation has a beneficial impact on mothers experiencing postpartum depression, particularly in cases that are mild to moderate. Mothers who have received treatment have improved abilities to manage emotional problems, parenting stress, and child care, as well as increased communication skills and problem-solving abilities. This study utilized the Bakara as a tool for psychoeducation. Bakera is a traditional herbal steam bath commonly employed in the Minahasa district of North Sulawesi, Indonesia. This old tradition works as a treatment, especially for women in the postpartum period. Bakera is widely regarded as an exceptional approach to postpartum therapy. Bacra also relieves symptoms of muscle tension, leg heaviness, edema, loss of appetite, and constipation, expels stomach contents, promotes lactation, relieves migraines, rejuvenates pallor, accelerates, increases blood flow, and heals the posterior and lower parts of the vertebral column [20]. The terms Bakera or modern language spa, sauna, or herbal steam may vary from place to place. However, it offers benefits, such as eliminating stagnant blood from the uterus and reducing body odor [17].
The Mann-Whitney U test was utilized to assess the disparity in anxiety levels between the Bakera+psychoeducation and Bakera groups prior to treatment (pre-test) and no statistically significant difference was obtained. The results indicated that there was no statistically significant change in anxiety levels between the groups before treatment (pre-test). There was a significant difference in anxiety levels following treatment between the Bakera+psychoeducation and Bakera groups (post-test).
Rihi et al. stated that psychoeducation is one of the education or training forms for a person with psychiatric disorders aiming for treatment and rehabilitation. Psychoeducation seeks to develop and enhance the patient's acceptance of the diseases or conditions, strengthening the patient to be a therapy participant and developing coping mechanisms when the patient faces a problem related to the illness. Based on their research, a decrease in the level of anxiety after psychological training was observed on the postpartum mother suffering from depression [18]. This aligns with the research carried out by Berthelot et al. who used an education package and relaxation technique, which consisted of providing health education about postpartum blues and prevention by using a booklet, listening to the baby blues relief music, and oxytocin massage. The results showed that the health education package and relaxation technique reduced postpartum blues incidents [21].
The relaxing approach employed in this study was a Bakera. Bakera is a conventional therapeutic approach originating from Minahasa, a region in North Sulawesi, aimed at facilitating the recovery of postpartum traumas in mothers. Bakera is useful for postpartum treatment as it gives reliable results to mothers after delivery, which helps in the healing process. The objective of implementing the Bakera is to improve one's well-being and minimize the likelihood of disease transmission through the provision of familial support and role. Ahmadi et al. compared the Bakera custom with the term "Spa" in current urban life [22]. Bakera is a prominent figure in the healthcare sector in North Sulawesi, representing the native culture. This is increasingly becoming an attractive opportunity for businesses, particularly those in the Spa industry. From a medical perspective, the presence of plant-based ingredients in bread products has been scientifically demonstrated to have a beneficial impact on health. Plants possess immunomodulatory properties, and analgesic effects, and can induce a state of tranquility, in addition to exhibiting potent antibacterial properties [20]. The Bakera technique involves the use of both steam baths and traditional herbs and spices that possess a fragrant aroma and contain bioactive chemicals, particularly volatile alkaloids. Essential oils are biologically active substances present in many sections of plants, such as leaves, stems, fruits, seeds, and rhizomes. They are used in aromatherapy to provide a relaxing and revitalizing effect on health. Consequently, they can aid in the recovery of maternal health after childbirth, specifically in cases of postpartum blues [21].
The Wilcoxon test was utilized to assess anxiety levels before and after therapy utilizing Bakera+psychoeducation. The analysis revealed a statistically significant reduction in anxiety levels in mothers following the implementation of Bakera+psychoeducation. This is supported by the research conducted by Rustikayanti et al. [10]. Psychoeducation has a statistically significant impact on reducing postpartum blues. Psychoeducation is a therapeutic intervention that is offered to individuals and families who are impacted by mental health disorders. Its purpose is to improve coping mechanisms. Bakera has proven to be a successful medium for providing information and education to women after childbirth.  
As stated by Rangkuti et al., the postpartum phase is characterized by bodily changes, psychological shifts, and women's adaption. The intricate physiological and psychological transition necessitates a shift toward a lifestyle that accommodates the many stages of pregnancy. A woman undergoes a process of adjustment, both physically and psychologically, as she takes on the new responsibilities and role of motherhood in the initial weeks and months following childbirth [9].
The researcher conducted a correlation analysis between demographic variables and the reduction in postpartum maternal anxiety levels resulting from the combination of Bakera therapy and psychoeducation, in order to identify the factors that influence anxiety. During a correlation analysis, two demographic characteristics were found to have a strong association with a decrease in anxiety levels, including education and income. This is consistent with the results of Septianingrum et al., who stated that education is a contributing factor to heightened anxiety levels in postpartum mothers [23]. Higher levels of education facilitate greater ease in accepting new experiences, adapting to changes, and acquiring extensive knowledge. Education enhances an individual's capacity for deliberate and logical thinking. Pursuing further education enables individuals to acquire profound information. Knowledge is a crucial factor in influencing behavior. Greater levels of education correlate with increased competence and a broader range of talents. A person's mentality and actions become more expansive as their level of education increases [10]. Additional studies have also demonstrated a correlation between a lower level of education and a higher occurrence of postpartum depression and related symptoms [12].
The Chi-square test yielded a correlation coefficient of 4.466 for the relationship between income and variations in anxiety levels, with a significance level of 0.035. The results indicated a statistically significant link between income and changes in anxiety levels. The results of Ahmadi et al. corroborate these findings, confirming that households that get revenue from employment can improve the mental well-being of their members [22]. On the other hand, when there is no income from the job, it causes stress in every person. The inclusion of unemployed respondents, their unemployed spouses, and families with no income may have an impact on the anxiety levels of postpartum mothers. Mothers who have just given birth and have greater family earnings are more capable of fulfilling their requirements. Conversely, postpartum moms who have poor household earnings face challenges in fulfilling their daily necessities, which has an impact on the occurrence of postpartum depression.
Mothers are expected to meet certain expectations after giving birth. Postpartum mothers can employ Bakera and psychoeducation as an approach to expedite the recovery process during the postpartum period and to augment the comprehension and knowledge of mothers regarding postpartum matters, including psychological aspects, thereby enabling a better understanding of the condition during this period. Healthcare professionals are anticipated to utilize this research finding to offer support for postpartum mothers experiencing anxiety, in order to prevent the persistence of maternal stress during the postpartum period. 

Conclusion
Utilizing psychoeducation with a Bakera cultural approach (maternity spa) has a positive impact on lowering anxiety in postpartum women amidst the COVID-19 pandemic.

Acknowledgments: The authors would like to thank the University of Muhammadiyah Manado for providing the time and support to carry out this research.
Ethical Permissions: Informed consent was obtained.
Conflicts of Interest: The authors declared no conflicts of interests.
Authors’ Contribution: Wida Desiyanti I (First Author), Introduction Writer/Methodologist/Main Researcher (30%); Mayasari Riu SD (Second Author), Assistant Researcher (25%); Anggraeny D (Third Author), Discussion Writer (25%); Ardiningtyas L (Fourth Author), Statistical Analyst (20%)
Funding/Support: This research was fully funded through a grant from the Academic Scientific Research Program of the Ministry of Education, Culture, Research and Technology, Education Fund Management Institute.
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Health Education and Health Promotion
Volume 11, Issue 4
Autumn 2023
Pages 687-694