Associated Factors with Hypnobirthing Implementation in Trimester III Pregnant Women at Diana Panitra Clinic Medan in 2020

Almost all maternal experienced anxiety and fear during pregnancy, labor, and after childbirth. One of the methods is used to reduce childbirth anxiety namely hypnobirthing. The purpose of this study was to determine the factors associated with the implementation of hypnobirthing in third trimester pregnant women at the Diana Panitra Clinic Medan in 2020. The design of this study used an analytic survey with a cross-sectional approach. The population of the study were all 30 third trimester pregnant women, and sample using accidental sampling techniques. The independent variables in this study are knowledge, husband’s support, distance from facilities, and mother’s interest. The instrument used a questionnaire. The data analysis technique used univariate and bivariate analyses. The results showed that there is a relationship implementation of hypnobirthing between knowledge with p-value (sig) = 0.044, husband’s support with p-value (sig) = 0.004, facility distance and p-value (sig) = 0.019, and maternal interest with p-value (sig) = 0.015. The conclusion of this study is that there is a relationship between knowledge, husband’s support, the distance of facilities, and mother’s interest with the implementation of hypnobirthing in trimester III pregnant women at the Diana Panitra Clinic Medan in 2020. And it is hoped that health workers will participate in providing information about the benefits of hypnobirthing during pregnancy.


INTRODUCTION
Labor that cannot be handled properly can cause the delivery process to not take place smoothly, so that labor takes a long time. One of the factors affecting long labor is inadequate uterine contractions (his) during the first stage of labor. The first stage of a long labor will cause the mother to experience fatigue and exhaustion. As a result, uterine contractions are increasingly inadequate and in turn, this condition can lead to labor failure. Another condition that causes prolonged labor is a psychological condition including the mother's perception of pain and anxiety during childbirth. (1) The pain that occurs can affect the mother's condition in the form of fatigue, fear, worry, causing stress. Stress can cause the uterine contractions to weaken and result in a prolonged labor. Currently, many new methods are being used to reduce anxiety or worry in dealing with childbirth. One of them is hypnobirthing. (2) Hypnobirthing is a new method specifically for pregnant women by doing deep relaxation which aims to prepare for a smooth, comfortable, painless birth process.(2) Hypnobirthing was developed based on the belief that with thorough preparation for labor, mothers and their companions can go through a safe, comfortable, and satisfying delivery experience, away from fear and anxiety that cause tension, and pain. Hypnobirthing works based on the power of suggestion and visualization to calm the body, guide the mind, and control the breath. (3) Through four basic hypnobirthing techniques starting from muscle relaxation, breathing relaxation, mind relaxation, visualization exercises and communicating with the fetus that are carried out regularly and concentration can help the body relax so that the body releases endorphins which function as controlling pain and persistent pain and controlling feelings of stress. (4) Many third trimester pregnant women who still do not know the term hypnobirthing and not many know hypnobirthing relaxation techniques. Knowledge about hypnobirthing in society is also very lacking, especially in the middle to lower class society. There are still many people who still cannot accept the concept of this method, especially people who think hypnosis is a condition that makes people unaware of what they are doing, because hypnosis is often used in crime. The little interest of pregnant women in this hypnobirthing relaxation method is caused by a lack of knowledge and benefits of hypnobirthing both during pregnancy, childbirth and after childbirth. (5) In addition, socialization about hypnobirthing and sources of information obtained by pregnant women either from brochures or articles about hypnobirthing and there are still a few certified health workers who apply this hypnobirthing method. The low knowledge of mothers about the hypnosis method in pregnant and childbirth women has an impact on the mother's interest which will then affect the mother's behavior in using the hypnosis method in pregnancy. (6) The support of the husband in pregnancy is needed by the mother. Husbands who are always active in finding information, and are always alert in pregnancy can help mothers deal with complaints experienced during pregnancy, so that mothers are interested in participating in positive activities such as the implementation of hypnobirthing classes. So that mothers are active in participating in every positive activity with support from their husbands and support from their families. And also with easy access to health facilities, so it is easier for pregnant women to get information about pregnancy, as well as information about delivery assistance methods, and with easy-to-reach facilities, it's easier to get immediate treatment in an emergency. If the distance to health facilities is difficult to reach, it can reduce the interest of the mother to have her pregnancy checked. (7) The hypnobirthing method was developed by Marie F. Mongan, a certified hypnotherapist. Since 1959 based on Dr. theory Grantley Dick-Read (a British obstetrician who lived in , also known as the father of natural birth in 2002, hypnobirthing was developed in Indonesia by Lanny Kuswandy. Hypnobirthing is a relaxation method that is based on the belief that pregnant women experience labor through instinct and give suggestions that giving birth is delicious.(8) Some countries even have various professional institutions that are active in the education and application of hypnotherapy, for example the American Society of Clinical Hypnosis and the Indonesian Medical Hypnotherapy Association. The therapeutic effect of hypnosis has also received recognition from British Medical Association (BMA), American Medical Association (AMA), as well as various Australian and Indian institutions.
Hypnobirthing success rate is 85%.(9) Hypnosis has been recognized by WHO as an alternative therapy outside the legal sciences of western medicine. (10) In Indonesia, hypnobirthing is not widely known by people because of the lack of socialization, especially to hospitals and maternity hospitals. Lanny Kuswandi, a midwife and Dr. Tb Erwin Kusuma, SpKj, is the person who developed the hypnobirthing method, training was held for midwives and nurses to learn the hypnobirthing method, but the cost of attending hypnobirthing training which was quite expensive resulted in not all of them being able to attend the training. Hypnobirthing has been implemented in several regions, namely Malang, Makassar, Denpasar, North Sumatra, Surakarta. Several studies have shown that hypnosis methods can minimize and even eliminate fear, tension, pain syndrome, and panic during childbirth and the period thereafter so that they do not become postpartum trauma compared to other methods such as aromatherapy, acupuncture, audio-analgesia, and massage. (11) In the area of North Sumatra Province, the implementation of hypnobirthing has also been carried out by pregnant women and women who give birth such as in Medan, Tebing Tinggi, Binjai. As in the research conducted by Yulida Effendi Naustion, and Asrul in 2018 with the title of the relationship between maternal perceptions of hypnobirthing with pain reduction in normal delivery mothers at the Clinic Diana Medan with the result there is a relationship between the hypnobirthing method and pain reduction. (12) Based on the description, the researcher is interested in conducting a research entitled "Factors related to the implementation of Hynobirthing in third trimester pregnant women at the Diana Panitra Clinic, Medan in 2020".

MATERIALS AND METHODS
The research design used was an analytical survey, using a cross sectional approach, which is to determine the factors associated with the implementation of hypnobirthing at Diana Panitra Clinic, Medan in 2020. This research will be conducted from May to July 2020. The sample in this study used accidental sampling technique, which is sampling accidentally without being planned, with 30 respondents. The variables in this study were knowledge, husband's support, distance from facilities, and mother's interest.

Knowledge Relationship between Trimester III Pregnant Women and Hypnobirthing Implementation
Respondents who have good knowledge but are not willing to implement hypnobirthing, due to a lack of interest from respondents, which is caused by the distance of health facilities far from their place of residence. On the other hand, experience greatly influences a person's behavior, mothers who have sufficient knowledge about hypnobirthing, but have experience during pregnancy that make them unnecessary to do hypnobirthing during pregnancy, this will influence the mother not to do hypnobirthing during pregnancy, whereas mothers who have less knowledge about hypnobirthing, but are not willing to do hypnobirthing, because mothers still think, hypnosis is a condition that makes humans unaware of what they are doing, because hypnosis is often used in crime.
Based on the results of the bivariate analysis carried out, the chi-square test results obtained with the value of p (sig) = 0.044 less than 0.05, indicating that there is a relationship between knowledge and the implementation of hypnobirthing at the Diana Panitra Clinic, Medan in 2020.
Knowledge is the result of knowing, and occurs after a person senses a certain object. Without knowledge, a person does not have a basis for making decisions and determining action on the problem at hand. (5) In accordance with Notoatmodjo's theory, if someone has a high level of education, that person tends to be more receptive to new information. And conversely, if someone has a basic level of education, that person tends to find it difficult to accept new information. Knowledge of someone who is obtained from the learning process, apart from being obtained from the use of the senses which has its own value. A person's knowledge is usually obtained from experience, which comes from various mass media, electronic media, health manuals, media posters, close relatives and so on. (5) So that the researchers assume, the better the knowledge and experience of the mother, about pregnancy and about preparation for the delivery process, the more information will be obtained about pregnancy, and preparation for the delivery process, especially about hypnobirthing in pregnancy, and can also facilitate communication of health workers, if recommend to carry out hypnobirthing. Conversely, if the mother has less knowledge about pregnancy, and about preparation for the delivery process, the less information the mother will get about pregnancy, especially about hypnobirthing in pregnancy.

Relationship between Husband's Support and Implementation of Hypnobirthing in Trimester III Pregnant Women
The results showed that respondents who did not receive support from their husbands but were willing to implement hypnobirthing because, the form of husband's support was divided into several, namely: emotional support, instrumental support, information support, and assessment support. Some respondents who do not get support from their husbands do not mean they do not get support at all, often respondents only get instrumental support and appraisal support, not accompanied by emotional support and information support.
Based on the results of the bivariate analysis carried out, the results of the fisher exact test were obtained with a value of p (sig) = 0.004 smaller than 0.005. From the analysis above, it can be concluded that there is a relationship between husband's support and the implementation of hypnobirthing at Diana Panitra Clinic, Medan in 2020.
The most important person for a pregnant woman is her husband. A lot of evidence shows that women who are cared for and loved by their partners during pregnancy, will be easier to adjust during pregnancy and fewer complications will occur. (13) A supportive husband is a husband who has great concern for the condition of his pregnant wife, a husband who is always active in any way for the health of the mother and the fetus. Husband's support during pregnancy and childbirth includes calming the wife's discomfort, paying attention, accompanying the wife to go for examinations, building bonds with the prospective baby, providing advice or decisions, knowledge about pregnancy and about preparation for the delivery process. (14) So that the researchers assume, husband's support is very important during pregnancy and preparation for the delivery process. Because the husband who is closest to the mother, the higher the support from the husband, it will make the mother more enthusiastic about pregnancy and with the support of the husband, the husband helps the mother find information about pregnancy and especially about hypnobirthing in pregnancy.

Relationship between Facility Distance and Implementation of Hypnobirthing in Pregnant Women Trimeseter III
The results of this study indicate, that respondents who have a far distance from health facilities from their residence, are not willing to carry out hypnobirthing because the distance is so far from their place of residence, making mothers not interested in implementing hypnobirthing, and also because of the distance from health facilities place of residence, making mothers also rarely do classes for pregnant women, this is due to inadequate transportation, and husbands who do not spend much time at home accompanying mothers to visit pregnant women, thus making mothers less informed about pregnancy, especially information about hypnobirthing. This can make it difficult for mothers to accept hypnobirthing as a new method, which is used to reduce anxiety and worry during pregnancy and in preparation for childbirth.
Based on the results of the bivariate analysis, the results of the fisher's exact test were obtained, the value of p (sig) = 0.019, smaller than 0.05, from the analysis above, it can be concluded that there is a relationship between facility distance and the implementation of hypnonirthing at Diana Panitra Clinic, Medan in 2020.
In accordance with the theory, the availability of adequate health facilities at an easily accessible distance will make it easier for pregnant women to frequently check their pregnancies, and to get treatment in an emergency. Midwives can provide information or instructions to mothers and their families about the use of health facilities such as maternity homes, polindes, PKM, and other health facilities that are important and safe for pregnancy and childbirth. (15) So the researchers assume, the farther the health facilities are from the place where pregnant women live, and the more difficult it is to access health facilities, the more pregnant women are interested in conducting antenatal care, the less information will be obtained about pregnancy and preparation for the delivery process, in particular. about the benefits of hypnobirthing in pregnancy. The distance from health facilities will make mothers think twice about carrying out antenatal care, because it will take a lot of energy and time for each pregnancy check-up.

Relationship between maternal interest and the implementation of Hypnobirthing in Trimester III pregnant women
The results showed that respondents who were not interested in the implementation of hypnobirthing with the category of not willing to carry out hypnobirhing, because of the mother 's lack of knowledge, and also the information obtained about hypnobirthing relaxation methods in pregnant women was still small, and also because of the distance from the place of residence to far health facilities make mothers less interested in doing hypnobirthing. While respondents who are not interested in implementing hypnobirthing but are willing to implement hypnobirthing, because there is support from their husbands that make mothers willing to implement hypnobirthing From the results of the bivariate analysis, the results of the fisher's exact test were obtained, the value of p (sig) = 0.015, smaller than 0.05, from the analysis above, it can be concluded that there is a relationship between maternal interest and the implementation of hypnobirthing at Diana Panitra Clinic, Medan in 2020.
In accordance with the theory, interest in essence is the acceptance of a relationship between oneself and something from outside oneself, the stronger or closer the relationship is, the greater the interest. Someone who is interested in something, tends to pay more attention to something that is interested in it, and completely ignores anything else.21 Interest is the main motivational tool that can generate excitement in activity, and an important interest in making decisions. (16) According to the researcher's assumption, the minimum interest of pregnant women in implementing hypnobirthing is caused by the lack of knowledge of pregnant women and the benefits of hypnobirthing both during pregnancy, childbirth, and after childbirth. In addition, socialization about hypnobirthing and sources of information obtained by pregnant women either from brochures or articles about hypnobirting, and there are still few certified health workers who apply this hypnobirthing method.