THOUGHT STOPING AND GUIDED IMAGERY THERAPY EFFECTS ON ANXIETY LEVEL OF THIRD TRIMESTER PRIMIGRAVIDA PREGNANT WOMEN

Background: The first pregnancy can cause psychological problems, namely anxiety, if left untreated it will have a negative impact on both the mother and the fetus. Actions to reduce anxiety include thought stopping and guided imagery. The purpose of this study was to analyze the effect of Tought Stopping and Guided Imagery therapy on the anxiety level of third trimester primgravida pregnant women in the New Basirih Health Center area. Method: This type of research is quantitative with a non equivalent control group design pretest-posttest. The study population was all third trimester primigravida pregnant women in the Puskesmas Basirih Baru area. The research samples were 20 trimester primigravida pregnant women, divided into thought stopping intervention and guided imagery groups with total sampling technique. Instruments for measuring anxiety, namely HRS-A, Wilcoxon and Mann Whitney test analysis. Results: Thought stopping statistic result p-value = 0.005 and guided imagery statistic result p-value = 0.007 so both has affected the anxiety level of pregnant women. Conclusion: Thought stopping and guided imagery can be used by pregnant women to reduce anxiety levels.


BACKGROUND
In general, pregnancy is a valuable experience for a woman, especially if the pregnancy is the first and most desirable pregnancy. The first pregnancy can give a very big emotional meaning such as feeling happy and hopeful, but can also cause anxiety caused by doubts about the ability to go through various difficulties in terms of adjusting to the conditions that will be faced during pregnancy. Pregnancy is a natural process, where there will be changes in various physiological organs (Zuhrotunida, 2016).
These physiological changes include changes in physical and psychological aspects. In general, changes in physical aspects include changes in anatomy and organ function, while psychological changes that are often felt are changes that occur in the natural feeling and mood swing that causes the mother's emotions to become unstable, irritability, fear, discomfort and excessive anxiety (Anggarani et. al., 2018).
Anxiety is an individual response that occurs due to unpleasant conditions, which can be experienced by all living things when experiencing deep pressure and feelings (Shodiqoh, 2018). Anxiety can also be felt during pregnancy, which can occur throughout the pregnancy process but with different levels, ranging from mild anxiety to panic. The inability of pregnant women to deal with anxiety constructively is the main cause of pathological behavior that will continue until the postpartum period. In the first trimester (1-3 months gestational age) anxiety is often associated with the incidence of morning sickness and the risk of abortion. Trimester II (4-6 months of gestation) anxiety will be felt a little reduced because physiologically the pregnant woman has begun to be able to adapt to the changes that occur and start enjoying her pregnancy. In the third trimester (7-9 months of gestation) anxiety will be felt to increase again, which is often caused by excessive thinking about the smooth delivery, physical condition of the prospective baby, pain that will be felt and so forth (Maimunah, 2016). This description is supported by the results of a study by Astria (2017) who obtained data that the increase in majority anxiety occurred in mothers who had pregnancy in the third trimester.
The World Health Organization (WHO, 2017) outlines the global prevalence of anxiety that occurred in 2015 as many as 3.6% of pregnant women, the Ministry of Health of Republic of Indonesia (MOH) also explained that in 2016 there were approximately 377,000,000 people experiencing anxiety and of the 377,000,000 pregnant women obtained as many as 107,000,000 people experienced an increase in anxiety in the third trimester. There are a lot of negative impacts that occur when during pregnancy, mothers experience anxiety including risk of weakening uterine muscle contractions, inhibiting cervical dilatation, slowing labor, increasing the risk of emotional imbalance after childbirth, baby blues and postpartum depression and weak bonding attachments between mothers with baby.
In addition to having a negative impact on pregnant women, babies conceived are also at risk of developing growth disorders, low birth weight (LBW) and increased hypothalamic activity Adrenal Pituitary (HHA) which causes changes in steroid hormone production, damage to social behavior and a high risk of infertility as adults (Shahhosseini, 2015). The description above is supported by research conducted by Maimunah, S. (2016) with the results of mothers who experience anxiety during pregnancy, most of whom experience premature birth and give birth to babies with LBW.
In order to avoid negative impacts on pregnant women and babies who are conceived, measures must be taken to overcome these anxieties. There are 2 types of therapy that can be used, namely pharmacological therapy and non-pharmacological therapy. Pharmacological therapy can be done by administering anti-anxiety drugs, but it has an adverse effect, especially for pregnant women because it can cause a high risk of drug dependence, giving birth to babies with low weight and preterm birth, so it is advisable to use non-pharmacological therapy for reasons of therapy it is simpler and easier to do. Some literature also states effective and minimal side effects. Many types of non-pharmacological therapies are currently being developed with the aim of relaxing pregnant women including thought stopping and guided imagery therapy.
Therapeutic thought stoppping is one of the behavioral therapies used to help pregnant women change the thinking process. Positive thinking habits can form positive behavior too. Thought stopping therapy can also cause changes in brain wave activity (the pre frontal cortex, limbic system, and hypothalamus) which are capable of increasing regulation of emotions and sympathetic nerve activity thereby increasing relaxation conditions, increasing neurotransmitters (melatonin, sirotonin, beta endorphin and acetycholine) that affect positive emotional conditions that depress neurotransmitters (norepinephrine and cortisol) which can increase anxiety (Agustarika, 2017).
In addition to thought stopping, another therapy that is recommended is guided imagery therapy, which is a relaxation technique using directed imagination to reduce anxiety. This therapy can stimulate the emergence of chemical substances similar to beta blockers in the peripheral nerves that can close the sympathetic nerve nodes which are useful for lowering blood pressure, reducing tension which has an impact on reducing anxiety levels (Mayasari, 2018).
The results of a preliminary study conducted at the New Basirih Community Health Center showed that of the 10 primigravida trimester III pregnant women, 50% of pregnant women experienced moderate anxiety and 10% experienced severe anxiety. In general, the impact of perceived anxiety include mothers feeling restless, easy to cry, disrupted rest and sleep patterns that have an impact on daily living activities. Based on the description above, the purpose of this study is to analyze the effect of Tought Stopping and Guided Imagery therapy on the anxiety level of third trimester primgravida pregnant women in the New Basirih Health Center area.

METHODS
This research is a quantitative research with a quasi experiment non equivalent control group (pretest-posttest) design. The entire population in the study was taken as a sample of the third trimester primigravida pregnant women in the work area of the New Basirih Health Center with 20 people divided into 2 groups, namely 10 thought stopping intervention groups and 10 guided imagery intervention groups. The thought stopping intervention was carried out after giving the pretest to the sample. If the sample is stated to have anxiety, the intervention is carried out. In the thought stopping intervention group, the intervention was carried out for 10 times with a frequency of 1 time in 1 day with the duration of implementation of the 30-minute work phase every 1 intervention, as well as the same actions carried out in the guided imagery intervention group. After the intervention was completed in the 2 groups, then on the 10th day posttest will be conducted to assess the level of anxiety by using the same measuring instrument as the pretest.\ The instrument used to measure anxiety levels are standard questionnaire Hamilton Rating for Anxiety (HRS-A) and non-verbal observation sheets to measure anxiety levels. The sampling technique used was consecutive sampling. The analysis test used in this study was the Wilcoxon signed rank test used to test the differences in the value of anxiety levels before and after intervention both in thought stopping intervention groups and in guided imagery intervention and Mann Whitney test to determine the differences in the effects of thought stopping and guided therapy imagery of the anxiety level of primigravidian pregnant women.

Frequency distribution of age of third trimester primigravida pregnant women based on anxiety
level.  Table 1 shows that most pregnant women aged less than 20 years experience moderate levels of anxiety as many as 3 people (15%) and experience anxiety levels of as many as 4 people (20%)  Table 2 shows that the majority of pregnant women with elementary education (SD-SMP) experience moderate levels of anxiety as many as 3 people (15%) and anxiety levels as heavy as 4 people (20%) Table 3.

The frequency distribution of work in third trimester primigravida pregnant women based on anxiety level
No Work Work 5 (25) 0 0 5 (25) 2 Unemployee 6 (30) 5 (25) 4 (20) 15 (75) Total 11 5 4 20(100) Table 3 shows that the majority of pregnant women who are not working experience moderate levels of anxiety as many as 5 people (25%) and anxiety levels as heavy as 4 people (20%)  Table 4 shows that most mothers who enter gestational age 33-36 weeks experience moderate levels of anxiety as many as 3 people (15%) and anxiety levels as heavy as 3 people (15%)  Table 5 shows that the Wilcoxon Signed Rank Test test results obtained p = 0.005 and α = 0.05, it can be concluded that there are differences in the anxiety level of primigravida pregnant women in the third trimester before and after thought stopping therapy.  Table 6 shows that the Wilcoxon Signed Rank Test test results obtained p = 0.007 and α = 0.05, it can be concluded that there are differences in anxiety levels of third trimester primigravida pregnant women before and after guided imagery therapy.  Table 7 describes the results of the Mann Witney test, p = 0.007 and α = 0.05, then p <α. so that it can be concluded that there is the effect of giving thought stopping and guided imagery therapy to the anxiety level of third trimester primigravida pregnant women

DISCUSSION
The frequency distribution of age in third trimester primigravida pregnant women based on anxiety level.
The results showed that most pregnant women aged less than 20 years experience moderate anxiety and experience severe anxiety. The age of the mother during pregnancy is very influential on the process of pregnancy itself. This is related to the readiness of the physical and psychological aspects of the mother, where if the pregnancy occurs at a young age (less than 20 years) then the reproductive organs are still immature and not ready to perform their functions properly related to pregnancy so they are at risk of complications, disability and even maternal death and fetus.
In addition, during pregnancy, the physiological levels of the hormone progesterone will experience an increase which results in the mother becoming more irritable, easily experiencing changes in feelings and experiencing a mood swing which results in increased susceptibility to higher levels of anxiety, which in this study proved to be the mother pregnant who are less than 20 years old mostly experience moderate and severe anxiety. An increase in the grade of anxiety that is felt also occurs due to undergoing the first pregnancy (primigravida) where the mother still does not have sufficient experience so that the ability to adapt to changes that occur is also lacking, which results in the emergence of excessive anxiety, If viewed from the psychological aspect where pregnancy itself causes physiological and emotional stress simultaneously, which is aggravated by emotional instability, maturity in the thinking process and problem solving perspective is not yet adaptive, this will result in the mother being more at risk of anxiety with a more severe level.
.The above description is supported by the results of the study of Astria et al. (2009) where the majority of pregnant women with young age experience anxiety when compared to reproductive age pregnant women. The above description is in line with the results of Zamriati's research (2019) where the age of the mother during pregnancy affects the emergence of feelings of fear and anxiety. If pregnancy occurs at less than 20 years of age, the tendency of the mother is not ready to adapt adaptively to the physical and psychological changes that occur due to pregnancy and has not yet experienced emotional maturity, making it very easy to experience anxiety.
Frequency distribution of education level for third trimester primigravida pregnant women based on anxiety level The results showed that the majority of pregnant women with only elementary education (SD-SMP) mostly experienced moderate level anxiety and severe anxiety. Notoatmodjo (2013), describes that education is one of the basic human needs that is very necessary for selfdevelopment and increased intellectual maturity. This intellectual maturity influences one's insight and way of thinking, both in actions that can be seen as well as in the way decisions are made. Intellectual maturity is very necessary for pregnant women to be able to undergo the pregnancy process normally.
During the pregnancy process, there are many changes that occur in the physical and psychological aspects. If pregnant women do not have intellectual maturity in this case, they are insights and good thinking skills, they will have difficulty not even being able to adapt to these changes so that they are susceptible to disorders such as anxiety. In order for pregnant women to adapt well, intellectual maturity is needed, one of which is obtained from education. The results of Hawari's study (2008) describe that the level of education is related to a person's ability to adapt to anxiety.
The description above is in line with the results of this study, where most pregnant women with elementary education (SD & SMP) experience moderate and severe anxiety. Low education for pregnant women is one of the things that causes intellectual maturity (insight, ways of thinking and the ability to adapt) become less so that anxiety occurs at moderate and severe levels.

The frequency distribution of work in third trimester primigravida pregnant women based on anxiety level
The results showed that most pregnant women who did not work experienced moderate anxiety and severe anxiety. Working generally is an activity that can take time and focus attention so that there is a shift in focus from things that can cause interference.
According to Said (2015) work can divert someone's attention from something that is felt like anxious feelings, because dense activity is very time consuming so that a person does not have the opportunity to focus more on perceived anxiety. Likewise the case with pregnant women who have jobs will be more active outside the home and will interact more with other people so they do not have the chance and a lot of time just thinking about something that is felt. Working outside the home can also be used as an activity to refresh thoughts and feelings because they can see and find new experiences so that they are not only fixated on routines, things are monotonous and there are no changes. This description confirms that pregnant women who have jobs rarely experience higher levels of anxiety when compared to pregnant women who do not have jobs.
The above description is in line with the results of this study, where the third trimester primigravida pregnant women who do not have work (housewives) mostly experience moderate and severe levels of anxiety. Pregnant women who do not have jobs have more free time so they will be more focused on thinking about things that make them feel anxious, lack the opportunity to interact with other people and not get the opportunity to see and have new experiences, so that one of the impacts is limited information -New information and help to overcome the anxiety that is felt, which if left to drag it will fall into a more severe state. namely moderate and severe anxiety.
Frequency of gestational age for primigravida third trimester mothers based on anxiety level The results showed that most mothers who entered gestational age 33-36 weeks experienced moderate level anxiety and severe anxiety. The gestational age approaching labor is one of the causes of anxiety that occurs in third trimester pregnant women. Anxiety will be felt to increase again because too much thinking about various things such as the smooth delivery, physical condition of the prospective baby and pain that is felt during labor. Anxiety is felt to increase in level (moderate and severe anxiety) when the mother does not have previous experience through labor. The results of this study are supported by Maya, et. al (2018) where mothers with gestational age> 33 weeks the majority experience anxiety which is higher in level when compared to mothers whose gestational age is less than 29 weeks. Value difference Significance of anxiety level of third trimester primigravida pregnant women before and after thought stopping intervention.
The results of the study showed that before being given thought stopping therapy, most pregnant women experienced moderate anxiety and severe anxiety. Anxiety is an unpleasant feeling characterized by concern, concern and fear that is sometimes experienced at different levels. The higher the level of anxiety that is felt, the greater the risk of harm that will be obtained by the individual. In this case, anxiety can be experienced by all individuals including women who are undergoing pregnancy. Anxiety that occurs in the mother during pregnancy can occur throughout the pregnancy period (from the first trimester to the third trimester), but when the pregnancy enters the third trimester, anxiety will be felt more because it will face the labor process.
Mothers who experience prolonged anxiety are more likely to experience difficulties during labor and are at risk of giving birth to abnormal babies compared to mothers who are relatively calm (Desmita, 2010).
In this study before being given thought stopping therapy, most primigravida pregnant women who entered pregnancy in the third trimester experienced moderate levels of anxiety and severe levels of anxiety, which if not treated immediately would provide a very detrimental risk to the mother and baby contained, including increasing the risk of baby blues, postpartum depression, weak bonding attachments, developmental disorders in infants, LBW, damage to social behavior and a high risk of infertility in adulthood. In order to avoid the adverse risks above, action must be taken to overcome these anxieties. One simple and safe action is thought stopping therapy.
The results of Malfasari's study (2017) showed a significant decrease in anxiety rates in patients who received thought stopping therapy. This is also in line with the theory of Nursalim (2013), where thought stopping therapy is one example of therapy that uses cognitive psychotherapy techniques. behavior that can be used to help and improve the ability of pregnant women to control their thoughts and images of themselves by suppressing or eliminating negative awareness.
In this study, after being given thought stopping therapy, pregnant women who experienced moderate levels of anxiety decreased because there was a decrease in anxiety levels and those who experienced severe anxiety decreased to moderate levels of anxiety, so it can be concluded there were differences in anxiety levels of third trimester primigravida pregnant women before and after thought stopping therapy.
This research result is in line with Naikare VR, Kale P, Kanade A. B., Mankar S., Pund S, and Khatake S (2015) research which adresses intervention thought stopping has significant influence of anxiety level decrease. Based on the data above, the thought stopping is one of the nonpharmacological therapies that have been shown that reduces anxiety levels in pregnant woman and help stop thoughts that cause anxiety, then replace those thoughts by choosing alternative positive thoughts.
The difference in the significance value of the anxiety level of third trimester primigravida pregnant women before and after being given guided imagery intervention The results showed that before being given guided imagery therapy most pregnant women experienced moderate anxiety and severe anxiety. Moderate level anxiety and severe anxiety is a very detrimental situation for pregnant women, because when the anxiety is felt by pregnant women unable to think positively about things that are real, the concentration level deteriorates and is unable to solve problems effectively. This situation must be addressed immediately in order to reduce the adverse risks that might occur.
According to Mayasari (2018) guided imagery is one of the non-pharmacological interventions that has been shown to be effective in reducing anxiety. This is also in accordance with the study of Bastani (2018) which describes that relaxation exercises in pregnant women can improve the psychological health of the mother by reducing perceived anxiety. Relaxation can stimulate the emergence of chemicals similar to beta blockers in the peripheral nerves that can close the sympathetic nerve nodes which are useful for lowering blood pressure and reducing tension The results of this study also showed that after being given guided imagery therapy, pregnant women who had moderate levels of anxiety decreased to mild levels of anxiety and those who experienced severe anxiety decreased to moderate levels, so it can be concluded that there Wilcoxon Signed Rank ere differences in anxiety levels of third trimester primigravida pregnant women before and after guided imagery therapy. Jallo N. (2014) proved that the guided imagry theraphy have influence in improving the anxiety level decrease. The above can occur because guided imagery therapy teaches someone who experiences anxiety to focus more on positive imagination that can lead to a relaxed state (Nguyen, 2012). When the body is relaxed and parasympathetic it will work to stimulate the appearance of chemicals similar to beta blockers in the peripheral nerves to suppress or close the sympathetic nerve nodes which are useful for lowering blood pressure and reducing tension so that the body and mind can be relaxed. Based on the data above, the guided imagery are able to decrease anxiety levels in pregnant woman twice as great than who were only treated by general nursing intervention.
Effect of thought stopping therapy and guided imagery therapy on anxiety levels in third trimester primigravida pregnant women The results of the study describe that the provision of thought stopping and guided imagery therapy affected the anxiety level of the third trimester primigravida pregnant women. Thought stopping therapy is a form of behavioral therapy that is used to help pregnant women change the thinking process. Changing the thinking process of pregnant women who experience anxiety is very important so that behavioral changes that are expected to be very bad are expected to become adaptive behavior.
Thought stopping therapy in addition to being able to change the thinking process that is all negative to positive, this therapy also causes changes in brain wave activity (cortex, pre-prontal, limbic and hypothalamus systems) which increase emotional regulation, increase parasympathetic activity and increase heart rate relaxation conditions, improve neurotransmitters that affect positive emotional conditions such as melatonin, serotonin, beta endorphin, and acetylcholine so as to reduce neurotransmitters (norepinephrine and cortisol) which have an increased anxiety (Parmadi, 2017).
In this study for the implementation of thought stopping therapy the pregnant women were directed to do attention so that it would be easier to do each thought stopping therapy session. In session 1, pregnant women are asked to identify and disconnect threatening thoughts or cause anxiety. This is done because when a pregnant woman realizes and can identify negative thoughts that appear to accompany an event that demands self-adjustment, pregnant women will more easily overcome the problem, which in this case is anxiety. During session 2 of thought stopping therapy, pregnant women practiced to decide their thoughts by using the recording of the word "STOP" and if it was successful the recording would be replaced with a whisper and imagine hearing the word "STOP", and finally changing the voice "STOP" using rubber bracelet, pinch yourself or press finger nails so that negative thoughts can be removed immediately and replaced with positive thoughts. In session 3 pregnant women practiced deciding negative thoughts automatically. This therapy is done 10 times with a frequency of 1 time in 1 day with a duration of approximately 65 minutes. This study found that thought stopping therapy can reduce the anxiety level of pregnant women.
The results of this study are supported by Laela (2010) where pregnant women who get thought stopping therapy experience decreased levels of anxiety. This is also in accordance with Rafati et al. (2017) 's research, where thought stopping therapy is an effective therapy to stop negative thoughts. And then this research result is in line with Bakker M., Ross D. M (2009) research which adresses thought stopping theraphy is effective to change and control negative thoughts in someone who has anxiety, depression and especially in someone who has obsessive compulsive disorder. Changing the thinking process is an action that must be done immediately so that the mechanism of destructive behavior change will change into constructive behavior.
This therapy is proven to be effective in reducing anxiety, issuing negative thoughts and suggesting oneself with positive thoughts. By thinking positively indirectly can make a person become calmer and relaxed.
In addition to thought stopping therapy, the results of this study also prove that guided imagery therapy is effective in reducing anxiety levels in pregnant women. Guided imagery is a relaxation technique that uses directed imagination from yourself by imagining pleasant things so that the body's condition will relax which results in a reduction in anxiety levels.
Someone who is in a state of anxiety often focuses only on negative thoughts and because of the above causes a feeling of fear and excessive worry about things that will happen in the future without being accompanied by rational reasons. Pomerantz (2014) supports a description of someone who is in a state of psychological disorders such as depression and anxiety psychologically due to a reaction to his own thoughts so that an action is needed to relax physical and psychological conditions.
Relaxing conditions in the body will inhibit the increase in sympathetic nerves, so that the hormones that cause body dysregulation can be reduced in number. The parasympathetic nervous system that has work functions that are opposite the sympathetic nerves will slow or weaken the workings of the body's internal organs. The result is a decrease in heart rate, rhythm of breath, blood pressure, muscle tension, metabolic rate and production of stress-causing hormones. With the regulation above, pregnant women will feel relaxed along with the decrease in anxiety symptoms.
In guided imagery therapy, pregnant women who are used as research participants are directed to focus on pleasant experiences, while also involving all the senses of the body to share the comfort and beauty of the experience, such as being able to see, smell, feel and experience fun that has been experienced before so that there is interaction between cognitive and affective centers in the brain which can lead to psychomotor changes that can lead to relaxed conditions in the body and mind. This therapy is done 10 times with a frequency of 1 time in 1 day with a duration of approximately 65 minutes. This study found that guided imagery therapy can reduce the anxiety level of pregnant women. This is supported by Naparstek (2007) by imagining time, place and events in all sensory comforts and beauty -sights, sounds, smells, feelings can produce a positive emotional response as a pleasant distraction to divert thoughts and attention from an inconvenience such as anxiety.
The above description is in line with Resmaniasih (2018) where guided imagery therapy is effective in reducing tension by stimulating the emergence of chemicals similar to beta blockers in the peripheral nerves that can close the sympathetic nerve nodes which are useful for lowering blood pressure and reducing tension. Based on the data above, the thought stopping and guided imagery is one of the choice non-pharmacological therapies that have been shown to reduce anxiety levels in pregnant woman.

CONCLUSION
There are differences in anxiety levels of third trimester primigravida pregnant women before and after thought stopping therapy There are differences in anxiety levels of third trimester primigravida pregnant women before and after guided imagery therapy There is an effect of giving thought stopping and guided imagery therapy to the anxiety level of third trimester primigravida pregnant women.