The effect of acceptance and commitment counseling on the coping self-efficacy of mothers with unplanned pregnancy: A controlled clinical trial

doi:10.21203/rs.3.rs-5031746/v1

Background

Unplanned pregnancies present a significant challenge in reproductive health due to their unexpected nature, leading to adverse consequences for women, children, families, and society. Recognizing the importance of maternal self-efficacy in managing unplanned pregnancies, this study aimed to determine the impact of acceptance and commitment-based counseling on coping self-efficacy among mothers facing unplanned pregnancies.

Methods

This clinical trial involved 108 mothers with unplanned pregnancies in Ardabil city, located in northwest Iran. Participants were selected using convenience sampling, and block random allocation placed individuals into intervention and control groups. Data were collected through demographic and midwifery information forms, the London Measure of Unplanned Pregnancy (LMUP), Chesney’s Coping Self-Efficacy Scale (CES) and the Ghodratnama Social-Economic Questionnaire. The statistical analysis utilized SPSS version 16 and included T-Test, ANOVA, and repeated measures tests.

Results

The mean age of the intervention and control groups was 30.87 ± 6.32 and 29.11 ± 5.57, respectively. Most women in both groups (32.3%) were pregnant for the second time. The mean pregnancy age in the intervention and control groups was 13.22 ± 3.21 and 11.10 ± 4.16, respectively. Coping self-efficacy mean scores in the intervention group changed from 107.55 ± 35.84 before the intervention to 125.36 ± 34.78 two months after. In the control group, it changed from 98.6 ± 31.86 to 108.12 ± 22.38. There was no statistically significant difference in coping self-efficacy between the two study groups before the intervention. However, immediately after the intervention (p < 0.001) and two months later (p = 0.003), a significant difference was observed, demonstrating the effectiveness of acceptance and commitment-based counseling on coping self-efficacy among mothers with unplanned pregnancies.

Conclusion

Given the impact of acceptance and commitment-based counseling on coping self-efficacy among mothers with unplanned pregnancies, it is recommended to incorporate this counseling intervention into maternal care programs for unplanned pregnancies.

Trial registration

This study, identified as code A-11-38-10 at Zanjan University of Medical Sciences, was registered with the Iranian Clinical Trial Center under the code IRCT20151211025477N7 on August 28, 2023.

Unplanned pregnancy

Coping self-efficacy

Acceptance

Commitment therapy

Every year, approximately 121 million unplanned pregnancies occur worldwide, with 61% of them resulting in abortion [1]. Unplanned pregnancy encompasses both unintended and mistimed pregnancies[2]. Mistimed pregnancies refer to pregnancies that occur unexpectedly [3]. Unwanted pregnancies are those that happen by chance, without the couple intending to conceive, and where the woman and her partner are not in favor of the pregnancy [3]. In the United States, 49% of all pregnancies and 31% of live births are unintended [4]. The prevalence of unplanned pregnancies in partnered women in Iran is approximately 52% (ranging from 41–67%) [5]. Most unplanned pregnancies occur in women who did not use effective contraceptive methods [6]. In the city of Ardabil, studies conducted in 1381 and 1389 reported unplanned pregnancy rates of 30.8% and 60.7%, respectively [7, 8]. The increasing trend of abortion in Iran is evident, as selective abortion is currently unavailable in the country. Consequently, more women face illegal abortion and its associated risks. Therefore, special attention to women experiencing unplanned pregnancies is crucial in Iranian society [9].

Unplanned pregnancy is often accompanied by fear, anxiety, stress, and emotional challenges for the mother and fetus [10, 11]. Studies indicate that mothers with unintended pregnancies experience lower quality of life compared to planned pregnancies [12]. Inadequate care during pregnancy leads to neglect of both the mother and the newborn. Insufficient care, low birth weight, and increased neonatal mortality are negative consequences of unplanned pregnancies [13]. Additionally, unplanned pregnancies make women more vulnerable to psychological pressures, resulting in higher rates of anxiety and depression compared to mothers with planned pregnancies [14]. The likelihood of choosing abortion due to psychological distress is higher in cases of unplanned pregnancies [15]. Social support, self-efficacy, and commitment play essential roles in maternal acceptance of unplanned pregnancies. Self-efficacy involves organizing events and behaviors to achieve desired outcomes through appropriate actions [16] and significantly influences maternal self-perception and parenting roles [17].

Coping self-efficacy, perceived confidence in coping behaviors during challenging life events and threats, is a key concept in Bandura’s self-efficacy theory [18]. Perceived self-efficacy and social support are lower in unplanned pregnancies compared to planned pregnancies [19]. Studies have explored the impact of couple-based counseling on perceived stress and breastfeeding self-efficacy in women with unplanned pregnancies, demonstrating the effectiveness of counseling in improving breastfeeding self-efficacy and reducing perceived stress [20]. Another study by Bakhtiari Eqdam et al. found that counseling for women facing unplanned pregnancies reduced avoidance coping strategies and increased continuation of pregnancy compared to the control group[21]. Additionally, Samavati et al. (2021) demonstrated the positive impact of yoga on childbirth self-efficacy in primiparous women [22]. A study evaluating the effectiveness of a mobile app-based nursing program in increasing self-efficacy and reducing childbirth fear among pregnant adolescents also reported improved self-efficacy and reduced fear in the intervention group [23]. Finally, Falah et al. (2021) found that need-based counseling significantly improved self-efficacy in women regarding prenatal care [24]. In a study by Peyman et al., the relationship between perceived self-efficacy and fertility behaviors was explored among Iranian women to reduce unintended pregnancies [25]. Additionally, Poutreisi et al. reported a positive association between high self-efficacy and reduced postpartum depression [26]. Furthermore, a preconception care and education system based on the Robson classification system contributed to decreased pregnancy-related stress and improved overall self-efficacy in a study by Jing Sai et al [27]

Given the importance of accepting pregnancy in reducing the distress and anxiety associated with unwanted pregnancies in mothers, Acceptance and Commitment Therapy (ACT) as a unique psychological approach can be helpful in accepting unwanted pregnancies in mothers. According to ACT, human thoughts are the product of a natural mind, and what turns an individual’s thoughts into beliefs is the fusion of the individual with the content of those thoughts [28]. For example, when an individual state that due to the fear of potential problems arising from continuing an unwanted pregnancy, they intend to terminate the pregnancy, it means they have fused with the content of that thought, resulting in dysfunctional beliefs. This approach can help mothers with unplanned pregnancies by providing necessary interventions to reduce fusion with the content of thoughts and decrease dysfunctional beliefs. It aims to prevent mothers with unwanted pregnancies from rigidly surrendering to their thoughts and mental rules. By helping them accept challenges and recognize life values, it can bring significant benefits for leading a complete and meaningful life. Therefore, this study aims to determine the impact of ACT-based counseling on increasing coping self-efficacy in mothers with unplanned pregnancies.

Design and Participants

This study was a clinical trial conducted according to Consort guidelines. The research setting included healthcare centers in the city of Ardabil, and the study population comprised all unplanned pregnant mothers. A total of 108 participants were invited based on entry criteria. The study was conducted from September 2023 to December 2023, with follow-up assessments continuing until February 2024.

Sample Size Considering previous research and using α = 0.05 and β = 0.2, a sample size of 50 participants per group was estimated [29]. However, due to potential attrition, the sample size was increased to 54 participants in each group.

The intervention protocol was designed with the opinion of experts. Eligible pregnant women had pregnancies of less than 18 weeks, possessed a minimum level of literacy, reported no substance addiction, had no known mental disorders, and did not suffer from chronic disabling illnesses. They also scored between zero and three on the unplanned pregnancy questionnaire (Landon questionnaire). After obtaining written informed consent, they were enrolled in the study. Criteria for study withdrawal included missing more than two counseling sessions, simultaneous participation in similar educational classes, receiving unwanted pregnancy-related counseling, experiencing stress during the study, unwillingness to continue collaboration, and incomplete questionnaire responses.

Sampling and Random Assignment

The present study was conducted on 108 women with unplanned pregnancies, based on the London Measure of Unplanned Pregnancy (LMUP). To access research samples, the city of Ardabil was divided into four areas according to social and economic status. From each area, two centers were randomly selected, and then pregnant women meeting the criteria were enrolled using the convenience sampling method. Random allocation of participants into intervention and control groups was performed using a block design. The blocking was carried out by an individual not involved in the study. For this purpose, 27 blocks of four were selected using a random number table, resulting in a total sample size of 108 participants. Each generated random sequence was recorded on a card, and the cards were placed inside opaque envelopes in order. Finally, the envelopes were sealed and placed in a box. At the start of the intervention, one of the envelopes was opened in sequence to reveal the assigned group for that participant. Due to the counseling nature of the research, blinding was not feasible. The statistical analyst was unaware of group assignments.

Intervention

The intervention group was divided into 11-member subgroups, with each subgroup participating in eight 90-minute counseling sessions. These sessions, titled “Acceptance and Commitment-Based Counseling,” included elements of psychological and educational counseling, question-and-answer sessions, and group discussions. Clinical psychologists supervised the sessions, which were held twice a week. For the control group, standard prenatal care was provided. After the study concluded, participants received materials related to coping self-efficacy to ensure ethical considerations. Immediately and 2 months after the intervention, questionnaires were completed by the research units.

Session 1 Introduction and group interaction, definition of research components, familiarity with the core concept of psychological flexibility, introduction to acceptance and commitment-based treatment concepts, articulation of the project’s goals, and its importance in assisting unplanned pregnant mothers.

Session 2 Problem formulation of ineffective control, discussion of its consequences and relevance to client issues. Introduction to unwanted mental experiences and evoking psychological acceptance. Increased focused awareness of internal experiences and explanation of cognitive fusion. Reduction of personal storytelling and self-identification, along with home assignments.

Session 3 Review of previous session tasks, discussion on evaluating psychological experiences, introduction of self-efficacy as a measurement criterion, fostering creative hopelessness, and using relevant metaphors like the “toolbox” and “farm.” Challenges with client change plans. Teaching value clarification and creating motivation for committed action and home tasks.

Session 4 Training in mindful detachment and distancing from internal experiences, weakening self-alliance with emotions, and using metaphorical walking with the mind. Determining home exercises.

Session 5 Emotion regulation training, changing emotions through opposite action to recent emotions, addressing experiential avoidance, applying cognitive defusion techniques, and weakening self-alliance with thoughts. Focus on self as context and home assignments.

Session 6 Self-efficacy training through crisis coping skills, attentional defusion, mindfulness, and compassion skills. Determining home exercises.

Session 7 Behavioral and self-context exploration, self-observation as a context for self-connection through metaphor, redefined self-concept weakening, self-as-observer practice, and home exercises.

Session 8 Teaching values, establishing and maintaining commitment to values using the mental pivot exercise, practicing clean discomfort versus dirty discomfort, applying real-life experiences, summarizing, and relapse prevention exercises.

Data Collection Data collection was conducted through self-reporting. Demographic and midwifery profile forms (including age, education, occupation of the woman and her spouse, gestational age at study entry, family economic status, preferred fetal gender, duration of marriage, age at marriage, previous pregnancies, previous childbirths, history of miscarriage, background illnesses, medication use, method of obtaining pregnancy information, substance use, smoking, and history of psychiatric problems) were completed by the research units.

The Ghodratnama Socioeconomic Scale (2013) consisted of five main questions related to income level, economic class, housing status, and education. The questionnaire utilized a five-point Likert scale (ranging from “very low” to “very high”). Higher scores indicated a higher socioeconomic level. The validity (KMO coefficient of 0.752) and reliability (Cronbach’s alpha of 0.72) of the questionnaire were confirmed [30].

The London Measure of Unplanned Pregnancy (LMUP) questionnaire consists of six items measured on a three-point Likert scale from 0 to 2. The total score ranges from 0 to 12. Scores of 0 to 3 indicate unplanned pregnancy, 4 to 9 are considered uncertain, and above 10 represents planned pregnancy [31]. The validation of the Persian version of this questionnaire was conducted in Iran in 2014, and its reliability was confirmed with a Cronbach’s alpha coefficient of 0.87 [32].

The Coping Self-Efficacy Scale, developed by Chesney et al. in 2006, measures positive and constructive coping. It comprises 26 items According to the Likert scale, the option "I can't do it at all" gets a score of zero, the option "I can do it on average" gets a score between 1 and 5, and the option "I can always do it" The score is given between 5 and 10. The scale includes three subscales: Emotional and cognitive distress reduction, Problem-focused coping and Receiving support from family and friends [33]. The validity of the Persian version was confirmed using confirmatory factor analysis. The reliability coefficients for the entire scale were 0.88, and for the subscales, they ranged from 0.63 to 0.91. This self-report tool was completed by the participants [34].

Data Analysis

The collected data were analyzed using SPSS version 16. Independent-Sample T Test, ANOVA, repeated measures, Pearson Correlation and Post Hoc were used to examine the effect of acceptance and commitment-based counseling on coping self-efficacy. Prior to statistical tests, the normality of data distribution was assessed using the Kolmogorov-Smirnov test for single samples. A significance level of p < .05 was considered for statistical analysis.

A total of 108 women with unplanned pregnancies participated in this study. Four participants (7.40%) from the control group were excluded due to spontaneous abortion (2 participants) and induced abortion (2 participants). In the intervention group, five participants (9.25%) were excluded due to non-cooperation (4 participants) and referral to a psychiatrist (1 participant). Figure 1 illustrates the study flow.

The data on demographic characteristics and coping self-efficacy scores in both the intervention and control groups were normally distributed. There were no statistically significant differences between the two groups in terms of age and number of pregnancies. According to Pearson’s test results, the duration of marriage (p = 0.048, r = -0.200) and the number of pregnancies (p = 0.019, r = -0.236) had a significant relationship with the self-efficacy score before the intervention. There was a significant difference in gestational age at the time of sampling between the intervention and control groups (p = 0.006), but it was not significantly related to the study outcome. There was a statistically significant difference between the two groups regarding abortion history (p = 0.03) and fetal gender preference (p = 0.02). but these factors were not significantly related to the study outcome. There were no significant differences between the two groups regarding residence, education, occupation, smoking, type of previous delivery, and the occupation and education of the spouse. There was a significant correlation between the self-efficacy scores of spouses with salaried jobs and those with self-employed jobs before the intervention (p = 0.02). The majority of women in both the intervention and control groups had personal residences, high school diplomas, were housewives, and had a history of cesarean delivery. The majority of women in the intervention group had high school diplomas or associate degrees (40.8%), while the majority of women in the control group had bachelor’s degrees or higher (40%). Residence, spouse’s education, women’s occupation, smoking, maternal gender preference, abortion history, and type of previous delivery were not significantly related to self-efficacy scores before the intervention, immediately after, and two months’ post-intervention. According to ANOVA results, maternal education levels had a significant relationship with self-efficacy scores before the intervention (p = 0.003). Post Hoc tests revealed a significant association between self-efficacy scores of individuals with middle school education and those with a bachelor’s degree prior to the intervention (p = 0.002(. Additionally, the average family income had a significant relationship with self-efficacy scores before the intervention (p = 0.015). There was a significant relationship between low and average income (p = 0.026) and low and good income (p = .034) in self-efficacy scores before the intervention. The two groups did not show a statistically significant difference in socio-economic status; no significant relationship was found between this variable and the self-efficacy score. The demographic characteristics of the participants are summarized in Table 1.

Table 1

Demographic characteristics of the participants(n = 108)
Variable		Counseling (n = 49) Mean(SD)		Control (n = 50) Mean(SD)	p-value
Age (mean)		30.87(6.32)		29.96(5.57)	0.44
marriage age		19.20(4.68)		20.74(3.88)	0.07
Gravida		2.57(1.15)		2.64(1.32)	0.78
number delivery		1.28(0.84)		1.12(0.82)	0.32
Gestational age		13.22(3.21)		11.10(4.16)	0.006
Length of marriage		11.20(6.39)		9.20(6.27)	0.1
		Number (percent)		Number (percent)
Education	<high school diploma diploma/associate degree ≥Bachelor’s degree	17(34.7) 20(40.8) 12(24.5)		13(26) 17(34) 20(40)	0.251
Wife's Educational	<high school diploma diploma/ associate degree ≥Bachelor’s degree		19(38.8) 18(36.7) 12(24.5)	12(24) 19(38) 19(38)	0.204
Wife is a smoker			11(22.04)	14(28)	0.52
Underlying disease					0.83
	Yes		9(18.4)	10(20)
	no		40(81.6)	40(80)
Employment status					1/00
	housekeeper		41(83.7)	42(84)
	employed		8(16.3)	8(16)
wife's job					0.78
	Employee		7(14.3)	9(18)
	freelance job		42(85.7)	41(82)
average income					0.86
	weak		9(18.4)	11(22)
	medium		34(69.4)	34(68)
	good		6(12.2)	5(10)
Residence status					0.48
	private house		30(61.2)	34(68)
	rental		19(38.8)	16(32)

Table 1

(Continued)
Variable		Counseling (n = 49) Number (percent)	Control (n = 50) Number (percent)	p-value
The sex of the fetus preferred by the mother
	Girl	28(57.1)	39(78)	0.02
	Boy	21(42.9)	11(22)
Type of delivery	Type of delivery			1
	normal	15(30.61)	15(30.61)
	Cesarean section	24(48.97)	24(48.97)
	No childbirth experience	10(20.40)	10(20.40)
History of abortion				0.03
	Yes	7(14.3)	17(34)
	no	42(85.7)	33(661)
taking medication				0.96
	yes	7(14.3)	7(14)
	no	42(85.7)	43(86)

In the pre-intervention phase, the mean overall coping self-efficacy score was 107.55 in the intervention group and 98.60 in the control group, with no statistically significant difference. This score increased to 126.96 immediately after the intervention and to 125.36 two months later in the intervention group. In the control group, there was no significant change. The coping self-efficacy score immediately after the intervention (p < 0.001) and two months later (p = 0.004) showed a statistically significant difference between the two groups (Table 2).

Table 2

Comparison of mean score of coping self- efficacy in tree time periods among two groups
Variable	Counseling (n = 49) Mean (SD)	Control (n = 50) Mean (SD)	p-value
Coping self-efficacy
Before intervention	107.55(35.84)	98.6.03(31.86)	0.19
Immediately after the intervention	126.96(28.85)	105.36(24.44)	0.000
two month after the intervention	125.36(34.78)	108.12(22.38)	0.004

To compare the groups before and after the intervention, t-test were used

According to the results of the repeated measures ANOVA, the effect of time on coping self-efficacy in the periods immediately and two months after the intervention compared to before the intervention was significant between the two groups (p = 0.003) (Table 3).

The mean score of the first domain of coping self-efficacy, “stopping unpleasant emotions and thoughts,” was 54.44 in the intervention group and 51.32 in the control group before the intervention, with no statistically significant difference. Immediately after the intervention, the score in the intervention group increased to 63.65 and to 62.24 two months later, while in the control group, these changes were not significant. There was a statistically significant difference between the two groups in this variable immediately after the intervention (p < 0.001) and two months later (p = 0.01). According to the results of the repeated measures ANOVA, the effect of time on coping self-efficacy in the domain of stopping unpleasant emotions and thoughts in the periods immediately and two months after the intervention compared to before the intervention was significant between the two groups (p = 0.01) (Table 3). According to the results of the repeated measures ANOVA, the effect of time on coping self-efficacy in the domain of problem-focused coping in the periods immediately and two months after the intervention compared to before the intervention was significant between the two groups (p < 0.001) (Table 3).

The mean score of the third domain of coping self-efficacy, “seeking support from family and friends,” did not differ between the two groups immediately after the intervention and two months later. According to the results of the repeated measures ANOVA, the effect of time on coping self-efficacy in the domain of seeking support from family and friends in the periods immediately and two months after the intervention compared to before the intervention was not significant between the two groups (Table 3).

Table 3

Results of analysis of variance with repeated measurement of time effect
Variable	df	Mean Square	F	p-value	eta
Total coping self-efficacy	1	18846.075	9.089	0.003	0.086
The area of cessation of excitement and unpleasant thoughts	1	3759.074	6.962	0.010	0.067
The area of problem-oriented coping	1	5996.739	16.336	0.000	0.144
The scope of receiving support from family and friends	1	2.158	0.013	0.909	0.000

To compare the groups before and after the intervention repeated measures were used

In the present study, group counseling with an acceptance and commitment-based approach was effective in increasing coping self-efficacy among mothers with unplanned pregnancies. Consistent with this finding, Bakhtari’s study showed that counseling was effective in helping women cope with unwanted pregnancies and in their decision to continue the pregnancy, leading to a reduction in the use of avoidance strategies when deciding whether to continue or terminate the pregnancy [21]. Shojaeifar et al. also found that acceptance and commitment-based counseling was effective in reducing postpartum depression among mothers with unwanted pregnancies during the postpartum period [35]. It seems that to reduce adverse maternal and fetal outcomes in unwanted pregnancies and achieve better results, interventions for this group of mothers should be conducted during pregnancy. Hosseini’s study also reported the effectiveness of cognitive-behavioral counseling on mother-fetus attachment in women with unwanted pregnancies [36]. Given the prohibition of elective abortion in Iran, mothers with unplanned pregnancies need help to accept their unexpected pregnancies, which is significantly influenced by social support, self-efficacy, and commitment to the pregnancy. Acceptance in ACT represents the ability to experience personal thoughts, feelings, and physical sensations without engaging in control strategies [37]. In this study, to achieve better results, acceptance and commitment-based therapy was used to help mothers accept mental events, be present in the moment, discover a transcendent self, and identify life values instead of controlling unpleasant thoughts or feelings. This approach aimed to help individuals experience a meaningful life, increase psychological flexibility, and act committedly towards achieving their values [38].

The most significant changes in the self-efficacy scores of the intervention group were in the first and second domains of coping self-efficacy: “stopping unpleasant emotions and thoughts” and “problem-focused coping,” which aligns with the results of some studies. Malakouti et al. found a direct relationship between the level of concerns of pregnant mothers and the use of emotion-focused coping strategies [39]. Similarly, Jahangiri et al. found that acceptance and commitment-based therapy increased the scores of the problem-focused coping subscale of coping self-efficacy in individuals with substance use disorders undergoing methadone treatment [40].

The effectiveness of “acceptance and commitment-based therapy” on self-efficacy, relationship quality, and life meaning in infertile women [41], as well as on sexual self-efficacy and sexual quality of life in women of reproductive age, has been reported [42]. Additionally, this therapy’s impact on psychological flexibility and self-efficacy in various target groups, including divorced women [43], women with type 2 diabetes [44], girls with complicated grief [45], and individuals with substance use disorders undergoing methadone treatment, has been demonstrated [40]. The effect of ACT on self-efficacy, perceived stress, and resilience in patients with type 2 diabetes has also been shown [46]. In Norian et al.'s study, acceptance and commitment-based therapy increased the self-efficacy of women with obesity in changing their lifestyle and controlling their weight [47].

According to Bandura’s self-efficacy theory, awareness of an individual’s coping self-efficacy level is a prerequisite for intervening and treating maladaptive coping behaviors. Positive and constructive coping in coping self-efficacy is measured through three important and influential scales: stopping unpleasant emotions and thoughts, problem-focused coping, and seeking support from family and friends. Individuals with high coping self-efficacy are less likely to engage in maladaptive and non-adaptive behaviors (failure to manage stress and behavior during crises) and cognitive avoidance and escape behaviors (alcohol and drug use and avoidance of addressing the issue). The impact of a self-efficacy theory-based intervention on enhancing childbirth self-efficacy among pregnant women in Hong Kong showed that the intervention based on Bandura’s self-efficacy theory had beneficial effects but was unable to prove support [48].

It appears that the effectiveness of the intervention in the present study was due to techniques that helped mothers challenge their ineffective coping strategies through individual and group exercises and the use of various metaphors to evoke psychological acceptance and create constructive hopelessness. The follow-up of mothers’ homework assignments involved recording all unwanted mental and internal experiences and their struggles to escape or avoid pain, revealing the inefficacy of controlling and avoiding thoughts related to unplanned pregnancy.

Regardless of the mindfulness exercises guided by the therapist, numerous opportunities were created during the sessions to help mothers connect with their present experiences, especially when discussing painful memories or experiences. To enhance self-efficacy, crisis commitment skills and compassion skills were provided. Training on context and self as context, weakening the conceptualized self, practicing the observer self, and examining fusions with self-assessments using various metaphors were explained. Through this process, individuals were liberated from ruminative thoughts through acceptance and reduced fusion, recognized their life values, and organized their actions in line with these defined values.

One of the most important aspects of this therapy was increasing psychological acceptance and reducing avoidant behaviors while being present in the moment, preventing excessive focus on the individual’s self-constructed personal narrative. In this therapy, efforts were made not to impose a specific lifestyle on the mothers but to allow them to make decisions about change based on their value system. In this type of therapy, emphasizing committed action increases self-efficacy, and providing support and encouragement by the counselor strengthens self-confidence [49]. According to Ross Harris, everyone needs to learn and use this therapy to solve their problems [50].

One of the limitations of this study was the absence of the husbands of pregnant mothers. It is suggested that future studies consider the impact of counseling for the husbands of pregnant mothers to improve social and familial support. Due to the unplanned nature of the pregnancies and the significant anxiety and distress experienced, some pregnant mothers were reluctant to participate in the study. It seems that for this group of mothers, telephone counseling might be more appropriate.

Overall, the findings of the present study indicated that acceptance and commitment-based counseling was effective in enhancing coping self-efficacy among mothers with unplanned pregnancies. One of the most effective methods for unplanned pregnancies, due to their unexpected nature and the significant anxiety and distress they cause in mothers, is counseling. This helps reduce fear and anxiety and increases their self-confidence. ACT aimed at creating psychological flexibility, can be utilized in this context. The techniques used in the study included mindfulness training, identifying mothers’ avoidance strategies, focusing thoughts on feelings, teaching ineffective control, creating creative hopelessness, and replacing behavior based on the client’s values instead of controlling, separating personal evaluations and judgments from reality. These techniques impacted the individual’s self-efficacy and increased their perceived ability to cope with unplanned pregnancy. In this study, mothers scored the lowest in the subscale of family and friends’ support, which is understandable given that the husbands and families of the pregnant women were not involved in the study. This aspect of the study’s results needs more attention to prepare families and society to play their supportive roles when dealing with mothers with unplanned pregnancies.

LMUP

London Measure of Unplanned Pregnancy

CES

Chesney’s Coping Self-Efficacy Scale

SPSS

Statistical Package for the Social Sciences

ACT

Acceptance and Commitment Therapy

KMO

Kaiser–Meyer–Olkin

Ethics approval and consent to participate

This study, was approved by the ethics committee with code IR.ZUMS.REC.1402.121. The study posed no risk to participants. Ethical considerations such as obtaining informed consent from participants, maintaining confidentiality, allowing participants to withdraw from the study at any time during the intervention, and ensuring the confidentiality of information were all observed.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors have no conflicts of interest, financial or otherwise, that would influence their objectivity relating to this study.

Funding

This article is based on a student's thesis with SAMAT code A-11-38-10 and the code of ethics IR.ZUMS.REC.1402.121, which has been approved and funded by Zanjan University of Medical Sciences.

Authors' contributions

Study concept and design: M.R, O.S and E.A; acquisition of data: M. R; analysis and interpretation of data: M.R, R.N; drafting of the manuscript: E. A AND M.R; critical revision of the manuscript for important intellectual content: O. S; and Study supervision: E.A and O. S. All authors read and approved the final manuscript.

Acknowledgements

We extend our heartfelt gratitude to the Vice-Chancellor for Research and the Social Determinants of Health Research Center at Zanjan University of Medical Sciences, and the Vice-Chancellor for Health at Ardabil University of Medical Sciences. We also thank all the pregnant mothers who participated in the study, as well as those who assisted and collaborated in this research. Additionally, artificial intelligence (COPILOT) was employed to enhance the translation and correct grammatical errors in this manuscript.

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No competing interests reported.

The effect of acceptance and commitment counseling on the coping self-efficacy of mothers with unplanned pregnancy: A controlled clinical trial

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Version 1

Abstract

Background

Methods

Results

Conclusion

Trial registration

Figures

Introduction

Methods

Design and Participants

Sampling and Random Assignment

Intervention

Data Analysis

Results

Discussion

Limitations

Conclusion

Abbreviations

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References

Additional Declarations

Status:

Version 1