Explaining the concept of self-care in Iranian pregnant women: A qualitative study

The present study was qualitative research of contractual content analysis. Purposeful sampling with maximum Variation was done among pregnant women under the care of health centers of Tehran University of Medical Sciences in 2020. In-depth and semi-structured individual interviews were used to collect data, which was saturated after 14 interviews with pregnant women and health care providers. Data analysis was done using the approach presented by Zhang and Wildmouth (2008).

the concept of self-care, considering the complexity of this concept and the increased needs during pregnancy (1).
While effective control and management of the negative consequences of the lack of self-care in pregnant women is required identi cation of this concept. So, this study aimed to clarify the dimensions of this concept and the factors affecting self-care in Low-risk pregnant women.

Methods
This study was qualitative research with a conventional content analysis approach conducted between January 2019 and May 2020 in Tehran, the capital of Iran. The study population included pregnant women referring to health centers a liated to Tehran University of Medical Sciences. University-a liated health centers are the best place that, pregnant women with different characteristics to go for prenatal care. Purposeful sampling was performed with maximum Variation in terms of maternal age, gestational age, parity, maternal occupation and education, economic, and social status, Husband's job, and education. The inclusion criteria Were literacy, the ability to speak Persian, no known cognitive impairments or mental and physical illness, the ability to take care of oneself. The exclusion criteria were unwillingness to participate in the study. Data were collected through individual interviews and note-taking. Interviews were conducted by telephone after receiving the code of ethics from the ethics committee of Tehran University of Medical Sciences. The rst author (MA) made contact before the interview to explain the objectives of the study, as well as to determine the appropriate day and time of the conversation. Written and informed consent was obtained from the mothers for participation in the study. At the beginning of the interview, mothers were asked to talk about the activities they do to keep themselves and their unborn babies healthy. Some of the questions were: What do you do to take care of your health and that of the fetus? What are the obstacles to doing this? What factors can improve your self-care behaviors? The interview continued with additional questions, including what do you mean? Or please explain more? Participants were asked to focus more on their experiences. At the end of each interview, participants were asked to permit for the next possible interview. The rst three interviews were pre-test and did not enter the principal analysis. The average duration of the discussion was 416± 6.51 minutes. Participants were reassured that they could leave the study at any time. Data were saturated after 14 interviews with pregnant mothers and health care providers. Interviews were recorded with the permission of the participants. Then, recorded interviews were converted to text. To the accuracy of the data, four criteria include credibility, dependability, conformability, and transferability used (Polite and Beck, 2008). To increase validity, Data were controlled by participants. In addition, we spent enough time collecting and analyzing data and also used various data collection sources, including pregnant mothers and Health Caregivers. To the reliability, we used the review by the research colleagues who they familiar with the analysis of qualitative research and had no role in this research. The researchers (FV) and (ZB) also coded several interviews simultaneously to ensure the accuracy of the research process. The accuracy of data was guaranteed by bracketing the researcher's opinions to avoid bias. In addition, the researcher tried to provide transferability by fully explaining the study context and research stages. Also, the sampling of this study was purposeful which helped to transferability. The content analysis was performed based on the method proposed by Zhang-Wildmouth (2009) (11) in seven-step included: Preparing data: in this step, the interviews were handwritten and then typed.
Decision-making on the unit of study: Each interview was considered a unit of analysis. Before coding, the text of each interview was read several times by the researcher. Then the semantic units were determined and coded.
Classi cation, at this stage, categories and sub-categories were designed. First, the codes were grouped into subgroups based on their similarity, and then sub-categories formed Categories based on their relevance.
Categories were extracted inductively from data.
Coding test in a piece of text: For this purpose, the researcher coded a sample of text, and the coding stability was checked by members of the research team. Discrepancies in the rules related to coding or classi cation of codes were resolved through discussion between the research team.
Extending the process of coding to the entire text: After the agreement of the research team members on coding stability, a reproducible process was achieved, and the coding process was extended to the whole text.
Conclusion From the classi ed data: at this step, the identi ed types of codes, and their characteristics were considered and the relationships between classes were identi ed.
In this study, Max QDA software (v.10) was used to manage qualitative data.

Results
The ndings of this study were the result of interviews with fourteen participants, including eleven pregnant mothers and three health care providers (midwives). Some demographic characteristics of the participants are summarized in Table 1. To explain the concept of self-care in pregnant women three main categories were extracted, including comprehensive care, barriers, and facilitators of care. Also, eleven subcategories were extracted. Categories and subcategories extracted from the qualitative data shown in Table 2. One of the physical cares that all participants mentioned was paying attention to nutrition and food diversity and having more meals, as well as paying attention to nutritional prohibitions.
"I intend to add habits to my diet, such as eating nutritious foods, increasing meals, food diversity, and eating more fruits and vegetables than before" (Participant 4).
Another example of self-care in pregnant women was an increase in sleep and rest.
One participant said: "I attempt to go to sleep early and get up at 11 a.m.; I rest for an hour at noon; I sleep a lot more than before" (Participant 4).
Planning to become pregnant was one of the self-care items that most pregnant women in the study performed through tests, thyroid checks, and dental visits. "Because I had infertility, I had already started basic health tests such as a thyroid test and a dental checkup" (Participant 7). Performing a medical visit immediately after diagnosis of pregnancy and prenatal care as recommended by a gynecologist and health center was another self-care behavior in pregnant women.
"I also had a health record at the health center; after I found out I was pregnant; I went to the doctor and did the necessary tests" (Participant 5).
Most participants avoided radiation and harmful chemicals during pregnancy, so many of them avoided dental procedures for fear of radiation. Said, one participant: "I got a problem in the second month; my teeth broke, and have been allowed me to go to the dentist in the fourth month but did not go because of the radiation in dental radiography" (Participant 1).
Most participants were aware of the dangers of smoking and exposure to secondhand smoke.
"I do not stay where there is cigarette smoke because it is very harmful during pregnancy" (Participant 9).
Most of the pregnant mothers participating in this study were aware of not using drugs, herbs, and avoided selfmedication.
One of our relatives said that he made tea for his daughter, who was pregnant and had a cold, and it was very effective, but I did not eat at all (participant 5).
One of the important aspects of care for pregnant mothers was oral hygiene. Some participants paid special attention to oral health.
"I brushed my teeth regularly and even more than before, so I think my tooth was less damaged"(Participant 1).
Other participants underwent oral hygiene and dental visits before becoming pregnant. One of the participants said: "Because of a minor problem with my teeth, I went to a complete dental checkup before pregnancy and made them" (Participant 6).
Interviews with pregnant women showed that they are often unaware of the importance of exercise and walking. They are lax in exercising and walking, and doing domestic activities is considered a sport.
"I didn't have a sport in pregnancy, but I had domestic activity" (Participant 5).
Participants in this study were often aware of the importance of vaccination. Some of them went to the clinic just to get vaccinated, even though they were being cared for in a private o ce. One of the participants said: "I went to the health center for the u vaccine" (Participant 5).
Many mothers do not care for underlying diseases associated with pregnancy, such as anemia, diabetes, thyroid problems, etc. It seems that there is a need for more attention and care. One health care provider said: "I think pregnant mothers are less focused on their underlying illnesses. For example, a mother with a history of low hemoglobin thinks it is simple anemia or refuses to take iron pills"(Participant 11).
Paying attention to pregnancy risk factors was also considered as a self-care activity.
"I think danger symptoms are the most important thing that should receive attention as a type of self-care "(Participant 14).

Sexual care
Many participants in this study reported a decrease in the frequency of sexual intercourse due to the couple's fear of harming the fetus.
" We took care of the sexual relationship. My husband was very terri ed because she heard that it was not good, so we reduced it to every other day or one day per week" (Participant 5).
Most of the participants changed their sexual position to take care of the fetus and used pregnancy positions during sexual intercourse.
"We were careful not to put pressure on the child, and We did more side by side" (participant 5).
Most participants in this study maintained genital hygiene to prevent sexually transmitted infections.
"I always clean the genital area with a cleansing gel, particularly to prevent infection during sexual relationship " (Participant 2).

Psychological care
Most of the participants in this study took care of their mental and emotional peace in times of stress and anxiety. The lack of controversy between the couples for a relaxed environment was one of the mothers' cares during pregnancy.
"I told my husband stop to argue with me; that is, there is no argument in our house at all" (Participant 1).
Thinking about pleasant memories and distracting the mind from anything; that is bothering the pregnant mother was expressed by some of the participants. One health care provider said: "I think a pregnant mother should reinforce positive thoughts and avoid annoying thoughts" (Participant 11).
In case of persistent, and severe anxiety problems, It is essential to consult a psychologist. One of the health care providers said in this regard: "Some of them are very temporary and go away, but those who are not temporary, such as anxiety problems, we refer them to a psychiatrist" (Participant 11).

Spiritual care
Paying attention to spirituality and connection with God was the care that some pregnant mothers observed to increase their spiritual peace.
"The spiritual connection with God creates a comforting sense to me; I no longer take some sensitivities seriously" (Participant 7).
One of the health care providers said: "In childbirth preparation training classes, we recommend to read the Qur'an (the holy book of Muslims) and communicate with God, because it gives them a sense of comfort that is necessary"(Participant 14).
Barriers to self-care The second major category was barriers to self-care in pregnant women, sub-categories of which included economic barriers, socio-cultural barriers, barriers related to the health system, and speci c conditions of the coronavirus epidemic.
Economic barriers "There are a lot of pregnant mothers who cannot even do a series of tests and self-care due to economic problems" (Participant 8).

Socio-cultural barriers
Another barrier to caring for many pregnant women was cultural barriers.
"There are some cultures where the mother has a severe toothache and should pulling instead of lling her tooth. I saw a similar case and even talked to her husband that he said this is our custom" (Participant 8).
"Some people do not take care of themselves in many elds and have nancial and cultural problems. For example, their husband says that my mother did not go to the doctor with multiple pregnancies. "(participant 11).
Barriers related to the health system One of the barriers to the health system was the lack of a speci c program for self-care and Insu cient training for pregnant women in health centers. Interviews with midwives showed no special self-care manual for pregnant women in health centers.
"Well, we do not have a self-care manual for pregnant women" (Participant 8).
"My friend said that you shouldn't sleep on your back from the 5th month of pregnancy. I did not know and the midwife did not say it; perhaps they considered it insigni cant" (participant 7).
Another barrier related to the health team was the poor communication between doctors, midwives, and pregnant mothers. One of the participants said: "In general, doctors are all the same. For example, my sister would go to the doctor and say I have these symptoms, but the doctor would not tell him about her problem"(participant 4).
Also, lack of facilities and incomplete services to expectant mothers in health centers was mentioned by some health care providers. One of them said that: "Pregnant mothers visit less to the center because we're on the limit to providing a series of services and they make pessimistic about the health center"(Participant 11).
Self-care facilitators The third major category was self-care facilitators. Its sub-categories included social support, effective use of social networks, maternal characteristics, and positive functioning of the health system.

Social support
Interviews with pregnant women showed that mothers need the full support of their husbands to carry out their caring activities.
"A spouse can be very emotionally effective. I'm like that and I feel so much better with my spouse" (Participant 6).
Most participants believe that accepting maternally responsible requires the support of families, especially in the rst trimester of pregnancy.
"During the rst trimester, I needed someone to cook for me because it was frustrating and confusing" (Participant 7).
Many expectant mothers stated that they were supported by friends, Colleagues, and relatives during pregnancy.
"Fortunately, my co-workers helped me to be very observant, they did not put too much pressure on me, they gave me the least work" (participant 7).
Health workers can help pregnant mothers to take care of themselves, especially by educating and raising mothers' awareness.
"We can also help with the training we give them to become more sensitive and take more care of themselves" (Participant 11).
One of the pregnant mothers also said: "Well, health care providers can also educate about what we do not know" (Participant 12).

Effective use of social networks
Obtaining valuable and comprehensive information from the Internet and social networks was one of the facilitators of self-care in pregnant women.
"My rst pregnancy was mostly experimental, but now, I use cyberspace more" (Participant 9).
Most of the participants stated that they have different applications and pages for obtaining information and receive helpful information in this way.
"I have two applications, one for fertilization; it gives mother and child information week by week. There are also pages about pregnancy where we ask questions and get the answer it" (participant 5).

Maternal characteristics
Some characteristics of mothers such as education, health literacy, and maternal information helped solve pregnancy problems and facilitate self-care. One of the participants said: "I am an educated person, and I knew a lot of things beforehand, I may know something that no one else knows " (Participant 7).
Mothers' experiences of previous pregnancies were another factor in uencing self-care in their current pregnancies.
"In my rst pregnancy, my belly did not even have striae because; I was fattening my belly, so I did this during this pregnancy, Or, if I had not given birth in my rst pregnancy, I might not have insisted so much now that my labor was normal" (Participant 4).
The Positive performance of the health system One of the effective factors was an effective relationship between health care providers and pregnant mothers.
"My midwife is constantly alert and reminds me of caring time. These are very helpful because it raises my spirits and makes me more responsible" (Participant 9).
Some mothers said that the information and calm of the doctor and the health care provider would make them calm and energized.
"Some doctors scare people and they are stressed, but well, fortunately, my doctor was a calm person" (Participant 7).

Discussion
According to the results of this study, the concept of self-care in pregnant women revolves around the three axes of comprehensive care, barriers, and facilitators of care. Pregnant women performed a wide range of physical, sexual, psychological, and spiritual health behaviors to maintain and improve their health and that of the fetus. The results of this study were consistent with the study of Mohamed (2018), the majority of pregnant women did Personal care such as dental care, breast, and skincare, proper diet as well as rest, activity, vaccinations, attention to danger signs and drug abuse in the second and third trimesters of pregnancy (12). Contrary to our results in the study of Gomora et al. (2015), some pregnant mothers did not follow the necessary measures such as HIV testing, taking prescribed drugs, avoiding alcohol, and treating sexually transmitted diseases (2). This shows the need to increase mothers' awareness to participate in pre-pregnancy care. In the present study, it was found that the rst aspect of self-care of pregnant women was attention to nutrition, which mentioned in various studies (13,14). Consistent with the results of the present study, the Higgins study found that pregnant women changed their diets to frequent, low-dose diets. They also noted the increase in the consumption of vegetables and fruits (15). The study of Mohamed (2018) showed that two-thirds of pregnant women had avoided substance abuse and drug use without a doctor's prescription (12). The results of this research were consistent with our ndings; pregnant women avoided taking any medication without a doctor's prescription and herbal medicines and tea. In our study, most pregnant women planned to become pregnant, and they underwent prenatal testing and regular prenatal care to maintain their health and that of the baby. Consistent with these ndings, Panamas et al. (2012) reported that most pregnant mothers planned for their current pregnancy and childbearing (16). The ndings of our study were consistent with the study of Kadham et al. (2015) that 68.7% of pregnant women attended routine antenatal care (17). Contrary to our ndings in the study of Lertsakor (2010) and Chaiathab (2006), the gestational age of Thai adolescent mothers at the beginning of prenatal care was between 10 and 24 weeks; due to a lack of planning, they started seeking prenatal care later than needed (18, 19). In our study, most pregnant women, although aware of the bene ts of exercise and physical activity in pregnancy, but their level of physical activity was low, many expectant mothers referred only to short walking and home and workplace activities as exercise. In line with our study, some researchers reported a decrease in the amount and intensity of exercise during pregnancy (20). Most pregnant women reported a dental checkup and increasing the frequency of brushing before pregnancy. In this regard, Christensen et al. (2003) write, "Pregnancy status seems to be 'stimulating' concerning oral self-care practices, so that many pregnant women, despite no signs of gum disease, improve their oral hygiene habits during pregnancy" (21). However, in the present study, some pregnant women avoided dental services during pregnancy due to fear of radiation. In a survey by Chaco et al. (2013), many women did not see a dentist because of the high cost of dental care unless they suffered from severe toothache. Chaco attributed this to their lack of information about the impact of unhealthy teeth on general health, as well as its adverse effects on pregnancy (22). In our study, pregnant women often described changes in sexual behavior as a decrease in the frequency of sexual intercourse due to fear of harm to the fetus and the use of pregnancy-speci c positions and genital hygiene. Gaizka et al. (2015) reported that 93% of couples reduced sex during pregnancy and cited concern about their baby's health as the main reason for abstaining from sexual intercourse. They also abandon the supine position and used the lateral position (23). In the present study, a wide range of measures to achieve peace of mind and stress management were expressed by the Cultural factors also were one of the barriers to self-care during pregnancy. In the Mohamed (2018) study, less than one-third of Egyptian pregnant mothers reported a pregnancy risk signal because they considered pregnancy a natural event due to cultural issues (12). The incomplete provision of services in government centers, and mothers' dissatisfaction with the quality of services provided in the health system, were obstacles to self-care for pregnant women. Similar to our study, Nemat-Shahrbabaki et al. (2020) also showed that in comprehensive health care centers in Iran, the examination by a physician is short, communication is often weak and training is insu cient (26). Based on the ndings of the present study, receiving support from the spouse, family, and health team was one of the facilitators of self-care in pregnancy. The study by Schwartz et al. (2011) showed that perceived social support of the family was statistically positively related to the health behaviors of pregnant adolescents (27). In addition, the study by Nicoloro-SantaBarbara et al. (2017) showed that strong relationships between pregnancy care providers and pregnant mothers lead to a reduction in maternal anxiety and more self-care behaviors during pregnancy (28).
The strength of our study was the comprehensive assessment of self-care activities in pregnant mothers to maintain and promote the health of themselves and the unborn baby, while other studies examined only some of these behaviors, such as dietary changes and physical activity. In addition, identifying barriers and facilitators of health behaviors based on the experiences of expectant mothers and the views of health care providers was one of the strengths of this research.
One of the limitations of our study was the use of their self-reporting to collect data, which may lead to bias because it may cause participants to hear what the researcher felt. In addition, this is a qualitative study that somewhat limits the generalization of results.

Conclusion
Understanding the different dimensions and aspects of self-care behaviors in pregnant women helps us to improve self-care behaviors and lifestyles of pregnant women by formulating policies and planning for necessary interventions. Also, midwives can enhance pregnant mothers' self-care behaviors through health education programs and effective communication with them. It is suggested that the results of this study be used as a guide for appropriate policymaking and planning to address barriers of self-care in pregnant mothers.

Declarations
Ethical approval and consent to participate The code of ethics was (TUMS.FNM.REC.1399.062).

Consent for publication
Not applicable.

Availability of data and materials
All data generated or analyzed during this study are included in this published article.

Competing interests
The authors declare that they have no competing interests.

Funding
There are no bene ts in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.