THE EFFECT OF SPIRITUAL EMOTIONAL FREEDOM TECHNIQUE (SEFT) ON ANXIETY DURING THE ACTIVE PHASE I LABOR

Anxiety often occurs in maternity mothers and not being treated will have an impact on the mother's physical and psychological. As many as 9% of mothers who experience anxiety will increase pain and result in a long labor process. Therefore, it is necessary to take action by the midwife to control anxiety so that the delivery process runs smoothly. SEFT is a psycho-religious therapy that can reduce maternal anxiety without causing side effects. To determine the effect of SEFT on anxiety in maternity mothers during the active phase I. This is pre-experimental research with one group pre-post-test design. This study used purposive sampling. The statistical test used the dependent t-test. The average anxiety score before SEFT therapy was 24.44, with a minimum score was 20 and a maximum score was 29. The average anxiety score after SEFT therapy was 19.06, with a minimum score was 14 and a maximum score was 25. The results of the dependent t-test showed a p-value 0.000 (<0.05) which means that there is a difference in the average anxiety score before and after the application of SEFT. There is an effect of the Spiritual Emotional Freedom Technique (SEFT) on reducing maternal anxiety scores during the Active Phase I in the Dempet Health Center Work Area. The application of SEFT can increase the relaxation that can be obtained from conditions of solemnity, sincerity, resignation, confidence, and gratitude so that mothers can produce responses that can reduce anxiety during the delivery


Introduction
The normal physiological process experienced by every woman is the birth process. Childbirth is an expulsion process of the products of conception, in the form of a fetus, amniotic fluid, amniotic membranes, and placenta from the uterus to the outside world. The labor process includes four stages, namely the first stage from the time the actual delivery process begins to the complete opening process. Complete dilatation until the birth of the baby is called the second stage, the birth of the baby until the birth of the placenta is called the third stage, and the fourth stage is 1 hour after the delivery of the placenta or until the mother's condition is stable. This process lasts approximately 6-18 hours in primigravida and 2-10 hours in multigravida (Oxorn, n.d.) Based on data from WHO related to national health status at the achievement of the Sustainable Development Goals (SDGs) target, it is stated that globally around 830 women die every day or as many as 216 per 100,000 live births due to complications during pregnancy and childbirth (WHO, 2018).
According to the Ministry of Health of the Republic of Indonesia in 2018, the maternal mortality rate in Indonesia generally decreased from 390 to 305 per 100,000 live births, although it has tended to decline but has not succeeded in achieving the MDGs target. In Central Java, the Maternal Mortality Rate (MMR) in 2018 was 78.6% per 100,000 live births, while in 2019 it fell to 76.9 per 100,000 live births. The cause of maternal death in Central Java was caused by severe pre-eclampsia 29.6%, bleeding 24.5%, circulatory system disorders 11.8%, infection 6%, and metabolic disorders 0.5 (Central Java Province Health Service, 2018).
The maternal mortality rate in Demak Regency in 2020 was 12 cases or 57.59 per 100,000 live births 2020 (Pemerintah Kabupaten Demak, 2020). The prevalence of mothers giving birth at the Dempet Health Center in 2020 is 896 people. The number of referred maternity mothers was 309 people. Long parturition is one of the reasons why mothers who give birth are referred to, as many as 190 mothers give birth. Of the total women who were referred due to prolonged labor, 160 (87.3%) were primigravida.
Based on the results of a land survey through interviews with midwives regarding 10 primigravida maternity mothers who experienced prolonged labor at the Dempet Health Center due to anxiety. This anxiety results in sub optimal uterine contractions, as a result, the mother experiences fatigue, and the results of monitoring the progress of labor using a partograph cross the alert line. This causes the mother to be referred (Pemerintah Kabupaten Demak, 2020).
Anxiety often appears in primigravida pregnant women. Anxiety will increase when approaching labor, especially when it enters stage 1. This anxiety is caused by several things including fear of giving birth, thinking fear of increased pain, fear of damage or body deformities such as an episiotomy, rupture, stitches, cesarean section, or mother's fear of hurting her the baby (Varney et al, 2007). In anxious mothers, signals that pass through the HPA axis (Hypothalamus-Pituitary-Adrenal) can cause the release of stress hormones including Adrenocorticotropic Hormone (ACTH), cortisol, catecholamines, endorphins, Growth Hormone (GH), prolactin and Luteinizing Hormone (LH)/ Follicle Stimulating Hormone (FSH).
The release of stress hormones can cause systemic vasoconstriction which can disrupt blood flow into the womb and will give a bad effect on the fetus. In addition, the increase of plasma cortisol will make the immune response of the mother and fetus decrease (Sari & Sulisno, 2012). Anxiety can also cause disturbances in the fetomaternal circulation and is a risk factor for postpartum depression (Soet et al., 2003).
Excessive anxiety can trigger the release of stress hormones, namely catecholamines and adrenaline. This released hormone can inhibit the release of the hormone oxytocin (a hormone produced naturally by the body that aims to stimulate uterine contractions). If the hormone oxytocin is inhibited, the strength of uterine contractions will weaken. This can result in the occurrence of a prolonged active phase of parturition. Anxiety can also cause fetomaternal circulation disorders and be a risk factor for postpartum depression. Both of these problems are important to overcome to prevent various negative events during and after childbirth (Difarissa et al., 2016).
Midwives as health workers in charge of assisting childbirth have a very important role in managing anxiety in primigravida mothers so as not to experience worsening conditions such as prolonged labor. Interventions that have been carried out by midwives in the working area of the Dempet Health Center to reduce maternal anxiety during the first active phase of labor are deep breathing relaxation techniques. However, this intervention is still not optimal in preventing or reducing anxiety in primigravida mothers. If this condition continues, the incidence of prolonged labor will increase and may contribute to an increase in MMR.
Anxiety in the labor process can be intervened by using stress and anxiety management strategies. Methods of controlling stress and anxiety can be done with psychotherapy.
The application of psychotherapy methods is highly recommended because it has several advantages including not harming the mother or fetus and does not have allergic effects or drug effects. Psychotherapy methods can be carried out according to the patient's needs (Sari & Sulisno, 2012) Several kinds of relaxation techniques psychotherapy include progressive muscle relaxation, diaphragmatic breathing exercises, visualization, meditation, massage, music therapy, yoga, hypnotize, therapy, and SEFT (Spiritual Emotional Freedom Technique) (Zainuddin, n.d.).
SEFT is a technique of combining the body's energy system (energy medicine) that uses spiritual elements to reduce psychological problems such as anxiety. The SEFT intervention emphasizes that the spiritual element can influence a person to accept with resignation and sincerity whatever conditions they are currently facing, including anxiety during the delivery process. The results of research showed that out of 10 maternity mothers (100%) who experienced moderate levels of anxiety, their anxiety decreased to mild after the SEFT intervention (Yuniarti et al., 2016). The results of research conducted by Anggraini, at Samarinda Hospital on the effect of SEFT therapy on anxiety in pregnant women facing childbirth, it is known that SEFT can stress and anxiety. The results of the Mann Whitney u test show a pvalue=0.000 (<0.05) so it can be concluded that there is an effect of providing SEFT intervention (spiritual emotional freedom technique) on reducing anxiety in third-trimester pregnant women in the experimental group (Anggraini, 2016).
Another advantage of SEFT is that there is an element of spirituality, where the basic philosophy is God-oriented. This SEFT incorporates the elements of surrender, solemnity, sincerity, and gratitude and leaves all healing only to God. When a person is in a state of humility, sincerity, and resignation, his brain waves are in the alpha and theta types, in these types of brain waves, the human body naturally releases endorphins. The secretion of endorphins can provide a relaxing effect so that it can reduce the sensation of pain and anxiety (A.D Nagara, E. Widianti,N.Hidyatai,2020).

Methods
This research uses pre-experimental research and one group pre-post-test design. The study was conducted in January-February 2022. This research was conducted on mothers with an estimated day of birth in January and February 2022 in the Dempet Health Center Work Area as many as 27 mothers. The number of research samples was 16 people. The sampling technique used purposive sampling.
The inclusion criteria in this study were: mothers in normal delivery who were willing to be respondents, mothers in primigravida, the membranes had not ruptured, and patients in the first stage of active labor (opening of labor 4-7 cm). While the exclusion criteria were: inpartum mothers who had a history of labor with complications prolonged labor, pregnant women who relocate, mothers with delivery complications such as placenta previa, and a history of bleeding.
The research instruments used in this study are the Hamilton Anxiety Rating Scale (HARS) Questionnaire and the Standard Operating Procedure (SOP) of SEFT. In this study, data analysis was carried out univariate and bivariate. This univariate analysis is presented in tabular form including the mean, standard deviation, minimum and maximum values of anxiety scores before and after the application of SEFT. Bivariate analysis was carried out to determine the effect of the application of SEFT on maternal anxiety in the first stage of the active phase. Before the bivariate analysis test was conducted to determine the difference in anxiety before and after the implementation of the intervention, the data normality test was first performed using Shapiro Wilk because the number of samples in this study was 16 respondents (≤50 respondents). Study as many as 16 respondents (≤50 respondents). normality test shows that pre-test p-value 0.86 (> 0.05) and post-test p-value 0.31 (> 0.05). It can be concluded that the data is normally distributed. The statistical test used is the Dependent t-test.

Maternal Anxiety Scores during Active Phase I Before SEFT in the Dempet Health Center Work Area
The average anxiety score of 16 mothers giving birth during the Active Phase I before SEFT was carried out in the Dempet Health Center was 24.44 and the SD value was 2.58. From the table above, it is also known that the lowest anxiety score was 20 and the highest score was 29.

Maternal Anxiety Score during Active Phase I After SEFT in the Dempet Health Center Work Area
The average anxiety score of 16 mothers giving birth during the Active Phase I, after SEFT was carried out in the Dempet Health Center, was 19.06 and the SD value was 3.25. From the table above, it is also known that the lowest anxiety score was 14 and the highest score was 25.
The effect of the application of SEFT on anxiety during the active phase I were as follows: Table 1.
Effect of Spiritual Emotional Freedom Technique (SEFT) on mother Anxiety *Test Dependent t-test Based on table 3 above, it shows that there is a significant difference in anxiety scores before and after the application of SEFT. This is evidenced by the p-value of the Dependent t-test of 0.000. Table 3 above also shows a decrease in the average score of respondents' anxiety after the application of SEFT compared to before the application of SEFT with a difference in score of 5.375. Based on these results, the results of the hypothesis test in this study are Ha is accepted, which means that there is an influence of the Based on discussing the effectiveness of SEFT in data analysis, the average score of respondents' anxiety before SEFT was carried out was 24.44 with a minimum score of 20 while the maximum score was 29. Anxiety is often felt by pregnant women, especially in primigravida. Symptoms of anxiety are usually caused by the mother's inaccurate perception of the birth process. Anxiety can cause involuntary activity in mechanisms in the body that are used for self-defense.
Physiologically, an anxiety situation can activate the hypothalamus in the body after that, 2 main pathways will be active, namely the autonomic nervous system (sympathetic and parasympathetic) and the endocrine system (adrenal cortex). The hypothalamus can receive stress or anxiety stimuli, and the anterior part of the hypothalamus will release Corticotropinreleasing hormone (CRH), which will instruct the anterior pituitary gland to secrete Adrenocorticotropin Hormone (ACTH). Furthermore, the secretion of the hormone ACTH into the blood can activate the zona fasciculata of the adrenal cortex to secrete the glucocorticoid hormone, namely cortisol. This hormone cortisol also plays a major role in the negative feedback process that is conveyed to the hypothalamus and then the signal will be transmitted to the amygdala to maximize the effects of stress on someone emotionally.
According to the researcher's analysis, the anxiety felt by the respondents was caused by a fear of increasing pain, fear of damage or deformities after giving birth, and fear that the baby would not survive or be unwell. Anxiety that occurs during childbirth often causes the mother to feel tense, and confused, often ask the officers about the progress of labor progress, and feel uncertain, restless, and easy to cry. This condition is certainly very influential on the smooth delivery process and the health condition of the mother and baby. The results of this study are by previous research conducted by Murdayah, that there are factors that can increase anxiety in maternity mothers (Murdayah et al., 2021). This is also in line with research conducted by Desi, that anxiety often arises in maternity mothers due to the large risks that are likely to be faced by both the mother and the baby being born (Desi trisiani, 2016).
Based on the results of data analysis, the respondent's anxiety score after SEFT was 19.06 with a minimum anxiety score of 14 while the maximum anxiety score was 25. The results showed that there was a change or a decrease in the respondent's anxiety level after being given SEFT therapy. Therapy SEFT, including this relaxation, is the development of a form of mind-body therapy that includes complementary and alternative therapies in providing midwifery care. This relaxation technique combines the body's energy system (energy medicine lightly tapping on nerve points (body meridians) (Musfiroh et al., 2021).
Spirituality in SEFT is manifested in prayers performed by patients from start to finish, namely on set-up, tune-in, and tapping. In the set-up phase, the patient will pray to God with humility and sincerity of heart, and surrender, whatever will happen during the process of surrender to God Almighty. In the tune-in phase, it is done by enjoying the pain experienced by the patient, then directing our mind to the place of pain, accompanied by our heart and mouth saying: "O Allah, I accept, I surrender whatever happens to the labor process, Ya Allah. I sincerely accept my illness; I leave it to You for the smooth running of my delivery process". For emotional problems, we tune in by thinking about certain specific things or events that can evoke negative emotions that we want to get rid of. When there is a negative reaction (anger, sadness, fear, etc.) our hearts and mouths say: O Allah, I am sincere, I surrender. Along with Tune-In, we perform step 3 (Tapping) in this process (Tune-In coupled with Tapping) we neutralize negative emotions or physical pain. Clients are asked to say a prayer with certain sentences when each meridian point is lightly tapped during tapping (Zainuddin, n.d.) The application of SEFT in this study aims to increase relaxation so that maternity mothers can produce responses that can reduce anxiety during the labor process. The application of SEFT during labor can inhibit the activity of the hypothalamus so that there is a decrease in the activity of the sympathetic and parasympathetic nerves. This can cause anxiety due to the thought that bad risks that will occur during the delivery process can be minimized. In addition, the application of SEFT in this study can also maintain blood pressure stability, slow breathing, slow pulse, and reduce heart muscle oxygen consumption and muscle tension (Brahmantia & Huriah, 2018). The results of this study are supported by previous research conducted by Candra that there was a decrease in anxiety scores after SEFT therapy was carried out on pre with a p-value of 0.000. This is because after being given SEFT therapy, respondents are more able to accept the conditions they are experiencing (Candra K, Eka cahyaningtyas, 2020).
Based on the results of the study, the average anxiety score of respondents before SEFT was 24.44, while the average anxiety score after SEFT therapy decreased to 19.06. The results of the statistical test dependent t-test obtained a p-value of 0.000 (<0.05). Based on this, it can be concluded that there is an effect of SEFT on maternal anxiety in the first stage of the active phase. Anxiety is a reaction that indicates there is a danger that warns someone 'from within' (instinctively) then the person can lose control in such situations and conditions. Anxiety triggers are feelings of guilt due to an action a person takes with unexpected results, in addition to being afraid of something about oneself, which will cause anxiety. From a psychological point of view, childbirth is a stressful situation in which most women in labor feel pain, fear, and increased anxiety (Ririn Widyastuti, n.d.).
First stage anxiety is a condition of fear of health, gestational age, anxiety about the condition of a baby born with physical or spiritual disabilities, anxiety about increased pain, and anxiety about damage or body deformities such as episiotomy or rupture. Anxiety experienced by mothers in the active phase of childbirth is characterized by being tense, confused, often asking officers about the progress of labor, feeling uncertain, restless, and crying easily, so the impact is very influential on the smooth delivery process, maternal and infant health (Siallagan & Lestari, 2018).
Feelings of fear and anxiety are the main factors that cause pain in labor and affect uterine contractions and cervical dilatation so that labor can last a long time. The phenomenon of the relationship between anxiety and pain and vice versa is a positively correlated relationship. With the progress of the labor process, the feelings of pregnant women will be more anxious and this anxiety causes the pain to be more intense, and vice versa (Hindu & Novita, 2021). Positive responses in laboring mothers are very necessary for childbirth because they can foster the confidence and mentality necessary to create the possibility of uncomplicated delivery opportunities, while negative responses such as fear and anxiety can produce muscle tension and increase a person's perception of pain. Maternity mothers who experience high anxiety or stress may experience prolonged labor and inadequate contractions. Psychological stress has a strong physical effect at the time of the process. Hormones and adrenaline will interact with beta receptors in the uterine muscle and will inhibit contractions and labor will slow down (Candra K, Eka cahyaningtyas, 2020) Therefore, health workers need to overcome the anxiety faced by mothers during the first stage of labor. This aims to prevent complications that can occur.
The effect of the spiritual Emotional Freedom Technique (SEFT) on decreasing maternal anxiety scores during the active phase I in the Dempet Health Center Work Area. When compared to previous studies, there are similarities, namely that there is an effect of SEFT on anxiety in the 1 st stage of labor (Solihah et al., 2018). The difference between this research and Solihah's research, this research is better, it is proven by the smaller value, this can happen by being influenced by many factors.
One of the interventions that can be done is SEFT. The simple principle used in the SEFT method is a combination of physical therapy and psychological therapy. Symptoms of anxiety that arise due to labor are body manifestations due to the emergence of contraction pain that occurs during labor. The feeling of pain is caused by the natural process and opening of the cervix to expel the products of conception. In addition, concerns that arise during childbirth such as fear if the child is born dies or is disabled fears that after delivery the mother will bleed and eventually die and various other things also have an impact on the occurrence of anxiety in every delivery (Anggraini Dwi Putrantri, 2021) The application of SEFT in this study was proven to significantly reduce maternal anxiety in the first stage of the active phase. SEFT works on more or less the same principles as acupuncture and acupressure. The SEFT mechanism in reducing maternal anxiety during the first active phase is possible to increase the relaxation effect obtained from being solemn, sincere, resigned, confident, and grateful (Zainuddin Ahmad Faiz, 2012). Tapping done at certain points influences the release of endorphins. Hormones Endorphin has an important role in the labor process. hormones Endorphin at Nerve cell synapses can decrease the sensation of labor pain and decrease psychological symptoms such as anxiety.
Endorphin hormone is also a neurotransmitter like morphine that the body produces naturally and has receptors that bind to the brain specifically. When the mother in labor is stimulated to reach a state where the body relaxes, endorphins will bind to opioid receptors on neurons which inhibit the release of neurotransmitters and ultimately block pain signals to the brain. This can reduce patient anxiety (Zainuddin, n.d.) (Farmawati, Cintami & Q, 2018). This study is supported by the results of research conducted by Rosidah, that SEFT has an influence on reducing anxiety and labor duration (Solihah et al., 2018)Another study conducted by Puspita also showed that anxiety is one of the factors that influence labor pain in the first stage (p-value 0.001) (Sunarsih & Sari, 2020).
This research has limitations that can be taken into consideration for future researchers to obtain better research results. These limitations include: The scope used in the study only covers one health center whose scope is not too big and wide so that the results of the study cannot be generalized to the population wider. This study only uses one independent variable which affects labor pain, namely; the administration of the SEFT intervention. There are still several other independent variables that can explain and possibly have an influence on the variables of labor pain.

Conclusions and Suggestions
Spiritual Emotional Freedom Technique (SEFT) affects the decrease in anxiety scores of active phase I pregnant women in the Dempet Health Center Work Area with the Dependent t-test results showing a p-value=0.000. One of the simple and minimal risk non-pharmacological interventions that can be done by midwives to reduce labor anxiety, especially in the first stage of the active phase, one of which is SEFT.