Health Behaviors in Pregnant Women with Psychological Problems and Disorders: Scoping Review

Background : The negative impact of anxiety on the mother is changes in the behavior of pregnant women such as diet, lifestyle or physical activity, resulting in labor complications, anxiety problems in the puerperium period. While the impact on the baby such as stunted fetal growth, preterm birth, asphyxia, Low Birth Weight (LBW) and can even cause death in the baby. Objective : To review scientific evidence based on published articles related to the health behavior of pregnant women with psychological problems and disorders. Methods : This research method was a scoping review, using PEO framework. Literature search used PubMed, ScienceDirect, Wiley Online Library, and grey literature using Google Scholar and Research Rabbit. Articles were critically appraised by using JBI and MMAT critical appraisal tools. Results: There were 7 articles out of 7,796 that were relevant to the research objectives. The articles come from 4 developed countries and 3 developing countries. Three themes were found namely health behavior, the impact of anxiety, and stress reduction strategy. Conclusion: Based on the 7 articles obtained, the health behavior of pregnant women is in accordance with the objective are knowing compliance with ANC visits in pregnant women, knowing health behavior related to consumption of nutritious food in pregnant women, knowing the physical activity of pregnant women with psychological problems and disorders.


INTRODUCTION
Pregnancy is a time when a woman's life undergoes significant changes that go beyond the physiological and affect the physical, hormonal, and emotional aspects. These changes can have a significant impact on daily life and lead to worsening mental health conditions. Sometimes pregnant women may experience sadness, fear, or doubt about the future, and they may feel more fragile and sensitive (Hanifah & Utami, 2019).
Stress in pregnant women is related to unhealthy behaviors, which can have a longterm negative impact on the child's health and development. Social relationships with others are believed to have a positive effect on maternal and child health. Stress in pregnant women can be caused by a variety of psychological, physiological, social, and sociodemographic factors (Hanifah & Utami, 2019).
Anxiety is the most important factor that can influence pregnant women's health behaviors concerning ANC visits. Because, during the Covid-19 pandemic, pregnant women are concerned not only about the condition of the fetus, but also about whether the mother and fetus will be healthy from COVID-19 infection, and whether or not they will recover during the pandemic (Nurhasanah, 2020).
According to research (Hanifah et al., 2013), three important aspects of health behavior are not using drugs, not smoking, and engaging in minimal physical activity every week. This demonstrates that pregnant women engage in health-promoting behaviors such as not smoking or using drugs and engaging in physical activity with minimal exercise every week.
Preterm birth is associated with smoking and narcotic use, and inadequate nutrition is a risk factor for Low Birth Weight Infants (LBW). Meanwhile, physical activity has been linked to positive benefits during labor. A mother who exercises regularly is not at risk of having labor difficulties, whereas pregnant women who partake in excessive physical activity are at risk of preeclampsia, stunted fetal growth, and preterm labor (Utami, 2019).
The prevalence of anxiety in pregnant women varies greatly across countries. In high-income countries, pregnancy anxiety is estimated to range between 7% and 20%. Pregnancy anxiety is 20% or higher in low and middle-income countries. Behavior was measured using the Prenatal Health Behaviors Scale (PHBS), which assesses the frequency of women's involvement in nutrition-related behaviors, physical activity, sleep, vitamins, smoking, and alcohol in the past two weeks. According to research, three important aspects of health behavior are not using drugs, not smoking, and engaging in minimal physical activity every week. Based on this category, it is grouped into good behavior if all the indicators are met, while if there is one that deviates, it is categorized into bad behavior (Harmel & Höfelmann, 2022b).
This scoping review is being conducted due to the seriousness of the problems caused by the health behavior of pregnant women who have psychological problems and disorders. Antenatal anxiety has a negative impact on both mother and baby. The negative impact of anxiety on the mother is changes in pregnant women's behavior such as diet, lifestyle, or physical activity, resulting in labor difficulties, and anxiety problems in the postpartum period. While the impacts for the baby include stunted fetal growth, premature birth, and asphyxia, LBW can even result in infant death. Furthermore, knowing pregnant women's anxiety allows midwives to plan holistic midwifery care.
The primary objective of this scoping review is to map scientific evidence systematically based on published articles on the topic and to investigate the quality of the articles. The question to be addressed in this review is how pregnant women with psychological problems and disorders behave in terms of their health.

METHOD
The method used in this literature is an exploratory review or scoping review using the PEO Framework for Population (Pregnant Women/Pregnancy/Antenatal), Exposure (Psychological distress depression/Anxiety disorders/mental disorders/stress) and Outcome (Health Behavior/Antenatal visit/Eating behavior/Exercise). The articles were selected with a prism flowchart, and critical appraisal used Joanna Briggs Institute (JBI) and Mixed Method Appraisal Tool (MMAT) were used for critical appraisal. This review consists of five steps: identifying articles from search results, selecting articles based on title and abstract, assessing article feasibility based on full text, critical appraisal, and data synthesis or data combination, summarizing and presenting results.

Article selection/selection
The database search yielded 7,796 articles from Pubmed, ScienceDirect, and Wiley Online Library, as well as grey literature from Google Scholar and Research Rabbit, with keywords such as pregnant women OR antenatal OR pregnancy AND psychological distress OR anxiety disorder OR mental disorder OR stress AND health behavior OR antenatal visit OR eating behavior OR exercise. The initial search used 3 databases, but during the search process only a few articles were found, so additional searches were carried out on grey literature. Following that, 29 articles were duplicated using the Zotero application, and the article was excluded. The articles were then selected using Rayyan based on their titles and abstracts. The author assigned eligibility and ineligibility marks to each article, so data was obtained after screening 25 articles. The article was then chosen according to the results of the article, population, and research studies. Then, seven articles were obtained. Co-authors (CSPs) have a role to play in improving the quality of scoping review during the screening and data charting processes. Themes and subthemes were developed based on the discussion of the two authors. The flowchart prism, can be seen in figure 1.

Data charting
Based on the 7 relevant articles, data diagrams or charting data were then made to include some of the article's main points or key points, such as the author, location, purpose, method, sample or participant, and study findings. Charting data is created in Microsoft Excel. Table 4 shows the charting data which was adapted from The Joanna Briggs Institute (JBI) 2015.

Critical Appraisal
Critical appraisal is used to carefully, methodically, and relevantly evaluate the article. The author evaluated the article using the tools of The Joanna Briggs Institute (JBI) Critical Appraisal Checklist and Mixed Method Appraisal Tool (MMAT). Articles 4,5,6,7 have the advantage of being more dominant from developed countries than developing countries, with articles in developed countries having more samples than articles in developing countries. Articles 4 & 6 have the advantage of including ethical procedures which are useful as a reference for researchers to uphold the values of integrity, honesty, and fairness in conducting research. While the limitations of Articles 1, 2, 3, 4, 5, and 7 are more dominant in quantitative research, so little is known about the health behavior of pregnant women with psychological disorders and problems. Articles 1, 2, 3, 4, 5, 6, and 7 have limitations in that anxiety measurement instruments differ between developed and developing countries, and no one tests validity and reliability.

Article Characteristics
The database search yielded 7,796 articles from Pubmed, ScienceDirect, and Wiley Online Library, as well as Grey Literature from Research Rabbit dan Google Scholar, with keywords such as pregnant women OR antenatal OR pregnancy AND psychological distress OR anxiety disorder OR mental disorder OR stress AND health behavior OR antenatal visit OR eating behavior OR exercise. Following that, 29 articles were duplicated using the Zotero application, and the article was excluded. The articles were then selected using Rayyan based on their titles and abstracts. The author assigned eligibility and ineligibility marks to each article, so data was obtained after screening 25 articles. The article was then selected according to the results of the article, population, and research studies. Then, seven articles were obtained. The research article consists of 6 Quantitative articles (6 cross-sectional) and 1 mixed-method study. Articles 4,5,6,7 are from developed countries (Ireland, Brazil, England, Sri Lanka) and articles 1,2,3 are from developing countries (Indonesia).

Thematic Analysis
The results of the scoping review revealed three main themes based on a review of seven articles: health behavior, the impact of anxiety, and stress reduction strategies. The three major themes are segmented into several sub-themes. The themes are processed with thematic analysis by reading the article several times. The two authors then discuss themes and sub-themes. The results of these findings can be seen in table 5 below:

Theme 1: Health behavior in pregnant women with psychological problems and disorders
Behavior was measured using the Prenatal Health Behaviors Scale (PHBS), which assesses the frequency of women's involvement in nutrition-related behaviors, physical activity, sleep, vitamins, smoking, and alcohol in the past two weeks. According to research, three important aspects of health behavior are not using drugs, not smoking, and engaging in minimal physical activity every week. Based on this category, it is grouped into good behavior if all the indicators are met, while if there is one that deviates, it is categorized into bad behavior (Harmel & Höfelmann, 2022a).

ANC Visit
Non-compliance with the ANC examination results in the unknown various pregnancy risks, which can affect the continuation of pregnancy and, if not quickly resolved, can result in an increase in maternal mortality. Anxiety affects the behavior of pregnant women in making ANC visits to health facilities. In the United States, 25.8%, or approximately 706 pregnant women, have discontinued ANC visits due to increased anxiety during Covid-19. This is because pregnant women are concerned about the effects of Covid-19, which causes anxiety during delivery (Rokhanah et al., 2022).

Consuming nutritious food
During the pandemic, Irish women reported good health behaviors, with the majority of women regularly eating healthy, exercising, and taking vitamins. Furthermore, very few women reported consuming alcohol or smoking. Because certain health behaviors, such as diet, exercise, smoking, and alcohol consumption, are linked to obstetric and child health outcomes (Nutley et al., 2021).
Maintaining healthy eating habits, such as eating fruits, vegetables, and nuts, may be linked to a lower prevalence of common mental disorders during pregnancy. If not identified and treated, this disorder can cause psychiatric problems in the postpartum period, interfering with the mother's quality of life and breastfeeding. Pregnancy is an important time to identify high-risk groups and ideal periods for nutritional counseling, as dietary changes, eating habits, and lifestyle changes are becoming more acceptable. The promotion of healthier living habits among pregnant women can be passed down to the child, with positive consequences that have the potential to last into adulthood (Paskulin et al., 2017).

Taking Multivitamins
Behavior of pregnant women with psychological problems and disorders in taking multivitamins is non-compliance with taking blood supplement tablets is a risk factor for anemia in pregnant women. Increase in iron needs during pregnancy that cannot be met solely through the consumption of nutritious foods, necessitating the use of blood-added tablets as recommended (Anggraeni, 2019).

Physical activity/exercise
Pregnant women with psychological problems and disorders as contributing factors to decreased exercise behavior. Inactivity during pregnancy have a negative impact on both the woman and the fetus, in prenatal phase. Women who don't do sports ignore many health benefits. health behavior pregnant women in the form of exercise. Sports activities are one of the forms of behavior carried out by pregnant women in maintain and improve the health of her pregnancy as well prevention of disease or childbirth complications (Ayuningtyas, 2019).

Theme 2: The impact of anxiety on pregnant women with psychological problems and disorders
Untreated pregnancy anxiety can have negative effects on the mother and fetus, such as disrupted labor, stunted fetal growth, weakening of uterine muscles, and premature delivery until miscarriage (Nurhasanah, 2020). Anxiety adversely affects pregnancy, but not every pregnant woman experiences negative effects because everyone's immunity is different (Sulistyowati & Trisnawati, 2021).

Impact on Mother
Because antenatal care focuses on the mother's physical health rather than her mental health, it is more likely that the mother's psychological problems will go unnoticed and untreated. According to the findings of interviews with midwives at health centers, many cases during childbirth experience psychosocial problems, such as patients being moody, shouting, and uncooperative during labor, as well as postpartum blues symptoms. However, the data is unreliable, making it difficult to determine the number of complications caused by pregnant women's anxiety. As a result, prenatal detection with a thorough assessment during pregnancy using the appropriate instruments is required.

Impact on Infants
Anxiety during pregnancy is detrimental to childbirth, fetal health, postpartum maternal mental health, and child health. Complications of an untreated pregnancy increase the risk of depression developing after pregnancy, which can harm the health and well-being of the mother and child as well as the child's development. Other authors assert that antenatal complications such as preterm birth, Low Birth Weight (LBW), asphyxia, and or even infant mortality result from antenatal anxiety (Sari & Rokhanawati, 2018).

Theme 3: Stress reduction strategies for pregnant women with psychological problems and disorders
There are many stress-reduction strategies, such as connecting with others, exercise, entertainment, relaxation, relating to nature, hobbies, and food or drink, but the article only mentions social support or connecting with others and exercise (Matvienko-Sikar et al., 2021;Meaney et al., 2022).

Exercise
The most common activities respondents did to reduce women's stress were connecting with others (45.5%; n = 242) and exercising (41.0%; n = 218). This was also reflected in the responses of women when asked what support they used and/or thought would help them reduce stress.

Social Support
The support of family, friends, and closest people is a supporting factor in overcoming anxiety. Pregnant women report that interacting and relating with others is a stress reduction strategy during covid-19. So, if pregnant women do not receive social support during covid-19, it may be harmful to both the mother and child's health.

DISCUSSION
The main findings of this scoping review are that the articles obtained are consistent with the scoping review's specific objectives, which are ANC visits, multivitamin consumption, nutritious food consumption, and physical activity in pregnant women with psychological problems and disorders. In addition to the various factors mentioned above, additional factors such as stress management and eating a healthy diet should be considered when determining how important it is to maintain health. Other factors to consider include exercise, a healthy lifestyle, avoiding smoking, drugs, and alcohol, and being able to control stress. The connection between balanced nutrition and food preparation is one particular aspect of this issue that needs to be addressed. When viewed from a nutritional perspective, a healthy diet must include a variety of foods, such as carbohydrates, proteins, fats, and vitamins, as well as additional milk to meet calcium requirements (Rofi'ah et al., 2017).
Poon et al. in 2020 stated that physical activity was also associated with pregnant women's anxiety levels. To help reduce strain on the back and joints, pregnant women should perform daily activities, and improve sleep quality while reducing the risk of hypertension and diabetes. When pregnant women engage in free and open activity during Covid-19, they may feel happy and optimistic, which will help them lessen any anxiety they may already be feeling.
Psychological evaluation of pregnant women is necessary and can be done effectively in order to address problems connected to anxiety and ensure that antenatal visits to evaluate the health of mother and baby are not hampered by worry among pregnant women during the Covid 19 epidemic. Pregnant women's anxiety can affect the mother's and fetus's health. Due to the Covid-19 epidemic, anxiety in pregnant women may increase, necessitating extra therapy to prevent detrimental effects on the mother's and fetus' health (Silvian & Ekasari, 2021).
Antenatal care, which tries to identify the mother's health status early on, is one of several factors that affect pregnancy health. In order to provide appropriate and prompt treatment, Kumar et al. claim that midwives can assess fetal development, maternal health, and potential dangers during prenatal care. Understanding a pregnant woman's health status from antenatal care services is intended to improve the mother's physiological preparedness for childbirth (Gusmadewi et al., 2022).
The role of midwives, according to academics, is to support, encourage, and help pregnant women comply with their nutritional needs. By offering support, you can substantially alter how pregnant women react, thereby lowering stress. So, pregnant women's decision-making may be positively impacted by nutritional contentment (Amelia & Darmadja, 2017).
Due to the potential impact on baby growth, pregnant women are among the population groups most susceptible to nutritional issues. According to certain study, Indonesia understands the critical function a mother plays in developing good human resources. Good maternal health and nutritional status throughout pregnancy is a fantastic opportunity for the fetus conceived to be healthy and the mother's safety during childbirth to be ensured (Dewi et al., 2021).
Because motivation is a human condition similar to the desire that propels people to act in a certain way to achieve their goals, it makes sense that someone who is more motivated is less likely to refuse to take Fe tablets. This is not in line with Budiarni's findings, which indicate a connection between motivation and pregnant women's use of Fe tablets (Anggraeni, 2019).
Predisposing factors, risk factors, and causal factors are all factors that influence how pregnant women behave in terms of their health. Predisposing factors include age, level of education, occupation, parity, knowledge, and individual attitudes (Lilliecreutz et al., 2021).
Possible factors such as distance of residence, family income, and available news sources. Strengthening factors such as family, social, and personal attitudes as well as access to health care providers are also considered supporting factors. Antenatal care, also referred to as antenatal services, is provided by educated and experienced health professionals who can identify complications in mothers and children early on to prevent unfavorable outcomes from developing later in life (Rahmawati et al., 2019).
Leaving these conditions untreated will have long-term effects that will worsen both the patient's and the fetus's health. Therefore, it is necessary to implement preventive strategies by conducting health promotion as a potential measure of security and prevention.
Exercise has greatly contributed to addressing depression-related problems and can reduce the negative effects of pharmacology, reduce excess weight and reduce pain. Exercise can increase the BDNF-Serotonin system, provide positive responses and adaptations, affect circulating levels of two neurotransmitters (serotonin and dopamine), and reduce anxiety and depression. Intense physical activity such as brisk walking is recommended by doctors to be done for 30 minutes every day.
The additional benefit of this scoping review is that it uses articles from developed countries rather than developing countries, and articles from developed countries have more samples than articles from developing countries. Then, articles focusing on developed countries include useful ethical procedures as a reference for researchers to uphold the values of integrity, honesty, and fairness when conducting research.
The limitation of this scoping review is that most research articles are crosssectional, so the health behavior of pregnant women with psychological disorders and problems is not well understood. Thus, it is expected that in the future, qualitative research designs will be used to investigate in-depth health behaviors in pregnant women with psychological problems and disorders.
Another limitation is that anxiety measurement instruments differ between developed and developing countries, and testing validity and reliability are still uncommon. To emphasize the importance of providing antenatal care that reflects best practices in serving pregnant women with anxiety problems and concerns, standard national and international guidelines are required. It is also critical to conduct validity and reliability tests on each instrument.

CONCLUSION
Based on the 7 articles obtained, the health behavior of pregnant women is in accordance with the objective are knowing compliance with ANC visits in pregnant women, knowing health behavior related to consumption of nutritious food in pregnant women, knowing the physical activity of pregnant women with psychological problems and disorders. Based on the results of the review of the articles, the researchers found limitations in this study, namely: 1) Quantitative research is more dominant, so it is not known in depth about the health behavior of pregnant women with psychological disorders and problems. 2) The anxiety measurement instruments in developed and developing countries are different, dominantly no one has tested the validity and reliability.

SUGGESTIONS
According to the author's review, it is expected that qualitative research designs will allow researchers to further investigate in-depth health behaviors in pregnant women with psychological problems and disorders. In addition, there needs to be national and international guidelines or instruments that can be used and have gone through instrument validity and reliability tests.

FUNDING
This scoping review was created without receiving funding from any party.