The results of the present study showed that counselling with a spiritual approach was effective in improving the sleep quality in pregnant women. In the intervention group, the mean score of sleep quality decreased in the second and third trimesters compared to the control group. Although no available studies were showing the effect of spiritual content counselling on sleep quality during pregnancy, the positive effects of spiritual counselling on improving sleep quality have been reported in the non-pregnant research community. Taheri et al. (2013) showed that after spiritual care based on the "Ghalb Salim" nursing model, the mean score of sleep quality in patients with coronary artery disease had a statistically significant difference in comparison with the control group (13). Soheili et al. (2013) in a similar study found that the score of disabled veterans' sleep quality after spirituality training based on the teachings of Islam was significantly reduced (32). In the present study, spiritual content counselling had a significant effect on all areas of sleep quality, except for habitual sleep efficiency. However, in the above studies, an improvement was observed in all areas of sleep quality.
Some studies have emphasized various beliefs about the biological and psychological effects of spiritual-oriented counselling (33, 34). Spirituality, as a powerful factor, can influence one's attitude, cognition, and behaviour, and as a mediator can affect one's thinking and evaluation process (35). In the Qur'an, God describes sleep with the word "Noum" and says in the ninth verse of Surah Naba “We have made your sleep a source of peace, the mentally and physically rejuvenation, and to rebuild the worn-out limbs and relieve any fatigue or discomfort”. From the content of the tenth verse of Surah Anfal, it is clear that sleep causes the elimination of fear and the feeling of security. This shows that sleep and a sense of security complete each other(36).
The peace of mind caused by religious activities (e.g., listening to religious sounds) has been emphasized to reduce anxiety and pain during pregnancy (37, 38). Peace of mind and healthy sleep are essential in exuding positive hormones from the brain, improving protein metabolism, increasing the function of the immune system, and reducing the stress reactions in the body (34). According to our result, another positive effect of spirituality-based counselling is the improvement of sleep quality during pregnancy, from which the providers can benefit in the form of maternity care service packages.
In the present study, we used religious sounds during relaxation and meditation exercises, which had similar effects on the results of mindfulness and relaxation-based interventions (12). Mindfulness strategies play a role in reducing stress and regulating emotional response. For instance, yoga leads to communication with higher and superior powers. The results of the present study show that spiritual counselling as well as the two interventions listed are useful in reducing the cognitive and physical arousal associated with insomnia in pregnancy.
In the present study, part of the intervention focused on sleep health education and identifying sleep stimuli. It seems that increasing spiritual attention, along with health advice and behaviour modification, can have a positive effect on sleep quality. The present study was consistent with that of Lee et al. in 2017, and they showed that health behaviour education bases on the BETTER approach can be significantly reduced insomnia symptoms compared to the control group among 25 pregnant women who admitted to the hospital (39).
The results of the present study showed that after the intervention, the mean score of the areas of subjective sleep quality, sleep latency, sleep duration, sleep disturbances, use of sleeping medication, and daytime dysfunction in the intervention group decreased significantly. In contrast, the score of these areas in the control group had significant increase. Comparing the scores of habitual sleep efficiency in the two groups was not statistically significant. Also, none of the participants in either group used medication to control sleep disorders. In a clinical trial study, Felder et al. examined the efficacy of digital counselling using the cognitive-behavioural approach in treating the symptoms of insomnia among 208 pregnant women with a mean gestational age of 17 weeks. The intervention group received 6 sessions of online counselling per week in 5 areas (sleep restriction, stimulus control, cognitive therapy, relaxation techniques, and sleep hygiene training), and the control group received routine care. The follow-up period was 10 weeks after the end of the intervention. The results showed that the mean score of sleep quality and habitual sleep efficiency in the intervention group was significantly lower than the control group, while the mean score of sleep duration did not differ (40). The results of the above study were consistent with the results of the present study in terms of overall sleep quality score, but not in terms of habitual sleep efficiency and sleep duration, which can be due to easy access to an online consultant.
The results of a review of 24 articles show that the mean score of sleep quality during pregnancy was 6.07. About 45.7% of pregnant women experience some degree of diminished sleep quality during pregnancy. However, changes in sleep quality score increase in the third trimester were 1.68 times higher than in the second trimester (2). In the present study, the changes in the overall score of sleep quality in the control group were consistent with the results of the above study, so that the mean score of sleep quality of pregnant women increased from 9.26 in the first quarter to 11.47 in the third quarter. However, spiritual-oriented counselling reduced the overall score of sleep quality from 9.45 to 5.40. Therefore, using the present approach can be considered as a basis for improving sleep quality during pregnancy.
Religious activities can be a social determining factor in the state of sleep. So those who engage in the religious activity are more likely to have a healthy sleep than those who do not. Based on the conceptual model proposed in a study, religious conflict may increase with hope, better support for mental health, a healthy lifestyle, reduced stress, healthier physiological function, limited substance use, and exposure to stress leading to healthy sleep (41). However, conflicting results have also been reported. For example, Gillum et al. (2013) showed that there was no significant relationship between participation in religious ceremonies in people over 40 years of age and sleep disorders (42), the results of which are inconsistent with the results of the present study because of the difference in the research population.
The results of the present study showed that spiritual content counselling was effective in improving the severity of insomnia in pregnant women. In the intervention group, the mean score of insomnia severity before the intervention decreased from 7.05 to 1.55 in the third trimester, and in the control group, it increased from 7.05 to 12.63. Comparing the mean scores in the three time periods between the two groups was significant. So far, many interventions have been made to treat insomnia in pregnant women, but due to the adverse effects of drugs in pregnancy, researchers are trying to focus on non-pharmacological methods. The results of the present study are consistent with the results of some non-pharmacological interventions. As Jalal Marvi et al. showed (2019), distance education has positive effects on improving the intensity of insomnia in pregnant women (43). In another study, Felder et al. (2020) showed that the implementation of 6 sessions of digital counselling based on the cognitive-behavioural approach could alleviate the intensity of insomnia in pregnant women (40). Tomfohr-Madsen et al. reported similar results in 2017. In their study, holding 5 group counselling sessions based on the cognitive-behavioural approach had positive effects on alleviating the intensity of insomnia in pregnant women in the second trimester of pregnancy (44). The findings of our study showed that integration of sleep hygiene training with spiritual orders can be as effective as other interventions.
It can be argued that some cognitive patterns, psychological characteristics, and behavioural patterns created by spiritual-oriented methods lead to improved health and improved physiological function of the body, followed by high psychological resistance in inappropriate physical and social situations. Accordingly, religious and spiritual practices lead to increased tolerance, patience, self-control, positivism, satisfaction, emotional control, optimism, self-efficacy (based on trust in God's blessing), altruism, kindness, and love(34). The skill of "spiritual resilience" is another technique of spiritual counselling that encourages the audience to overcome physical and mental problems in a variety of ways .The present study had several limitations. Data collection was performed using a self-report questionnaire and all participants were Muslim which should be considered in the generalizability of our findings.
Implications for Practice and/or Policy
In the present study, the effects of spiritual content counselling were not significant on habitual sleep efficiency. Given the importance of sleep in the physical and mental health of pregnant mothers, it is recommended that educational programs be conducted using other psychological approaches in this field.