Husband's Support, Anxiety and Maternal-Fetal Attachment in Pregnant Women: A Scoping Review

MFA is an emotional bond that develops between mother and fetus. Maternal-fetal attachment is based on cognitive representations such as thoughts, feelings, and behaviors representing a pregnant mother's affection for her fetus. Husband's support and anxiety are factors that influence the quality of MFA and birth outcomes. Objective: to analyze husband's support, anxiety level and MFA level. Method: Scoping review using the PRISMA Scr framework. Using the PICO Framework, the search strategy was searched using keywords in the Scopus, Ebsco, Pubmed, ScienceDirect and Proquest databases. Critical Assessment is done with JBI. Results: 14 articles were obtained that were screened using the PRISMA ScR framework, 50% came from developing countries and 50% from developed countries. Articles with cross-sectional research methods, cohort and longitudinal studies each 28.6% and case control studies 14.2%. JBI results from 14 articles resulted in a score of > 50% so it was accepted. Conclusion: MFA is influenced by husband's support and anxiety which impacts birth outcomes and infant development. Efforts are needed to increase MFA through MFA training for pregnant women and constructive anxiety management


INTRODUCTION
Pregnancy is an event that happensin women as a result of fertilization that grows and develops into a fetus in the mother's womb. As the gestational age increases, the physical and emotional condition of the mother changes. The main developmental task in pregnancy is to prepare the mother psychologically for physical changes and to increase the emotional connection with the fetus (Čėsnaitė et al., 2019). The emotional involvement of mother and fetus is called Maternal-Fetal Attachment/MFA. MFA is an emotional bond that develops between mother and fetus. The mother-fetus attachment is based on cognitive representations such as thoughts, feelings, and behaviors that represent the pregnant mother's affection for her fetus. Caring behaviors shown include parenting (eating well, not consuming harmful substances, such as alcohol, cigarettes), calming (stroking the stomach), and physical preparation (preparing the baby's birth kit) as well as learning more about fetal development and care (Suryaningsih et al., 2020;Hassan & Hassan, 2017). The results of the study stated that 69% of pregnant women with good MFA showed better fetal wellbeing and healthy babies as indicated by an increase in body mass index at birth (Baltacı & Başer, 2018).
Adaptation to the mother's role is a potentially anxietyinducing process, which can have a detrimental effect on MFA. Anxiety is a common problem that occurs in the context of pregnancy, around 16% of pregnant women experience anxiety in the first trimester of pregnancy (Wallace & Araji, 2020). Other research states that the prevalence of anxiety during pregnancy in the world shows between 11%-21% (Fawcett, et.al., 2019). Pregnancy anxiety is associated with parenting stress, unsafe MFA and poor birth outcomes. Anxiety during pregnancy can have serious consequences for the physical health of the baby and the mother including underutilization of prenatal care, increased use of substances (alcohol, smoking), premature birth, low birth weight and small for gestational age babies. The anxiety of pregnant women can have a detrimental effect on the development of MFA. Anxiety experienced by pregnant women can affect the mother's reaction to her pregnancy so that the mother becomes ambivalent about pregnancy, feels less involved with the fetus and expresses dislike about body image due to body changes that occur during pregnancy (Mohamadirizi & Kordi, 2016 ;Alhusen, J. L, et.al., 2014 ;Katrine Røhder et al., 2020).
Previous research on the quality of MFA between pregnant women who experienced anxiety and who did not experience anxiety showed that psychosocial problems during pregnancy were negatively related to the development of the relationship between mother and fetus. Mothers who experience anxiety during pregnancy are associated with lower quality of MFA (Abazari, Pouraboli, 2017). In a study of 73 third trimester primigravida pregnant women, there were 40% of mothers experiencing anxiety, 44.8% of them with low MFA scores, p-value = 0.019 and correlation coefficient -0.250. These results prove that pregnant women who experience anxiety produce lower MFA scores, measured by the prenatal attachment inventory (PAI), an instrument that describes feelings, thoughts and situations experienced in relation to their fetus (Baroah et al., 2020).
MFA quality is the basis for the mother-infant relationship after birth. Mothers who exhibit more intense MFA behavior show more involvement in mother-infant interactions around 12 weeks postpartum. Mothers with MFA disorders show a decreased ability to understand and interpret baby's signals and respond inappropriately to the baby's needs. Babies born with a good history of MFA, good mother-infant bond after birth, produce healthy babies, more optimal cognitive, mental and social development of babies (Bazari, P, 2017, Røhder et al., 2020. Prenatal anxiety and MFA are associated with the social support role of the family and specifically that of the husband. The support provided by the husband is a vital resource for dealing with anxiety. Husbands play an important role in maintaining positive emotions in pregnant women. Husband's emotional support affects the inner peace and pleasure of pregnant women, making it easier to adjust to changes during pregnancy, reducing tension or anxiety and increasing MFA. Effective spousal support can improve health and relationships during the transitional period of pregnancy, resulting in a comfortable psychological relationship that affects the quality of the mother-fetus relationship (Ramsdell et al., 2020) (Doss & Rhoades, 2017) (Calkins & Brock, 2022). Study of 285 pregnant women, 252 (88.4%) who received good family support had a strong maternal-fetal attachment relationship than mothers with poor family support 33 (11.5%) with P=0.001 (Hassan & Hassan, 2017).
Husband's support and anxiety are important factors in MFA which research findings have found. However, an analysis of husband's support, anxiety and MFA level has not yet been found. The purpose of this study was to analyze husband's support, anxiety level and MFA level in the prenatal period, carried out by scoping review method.

METHODS
This study is a scoping review to identify available evidence according to the topic of discussion, looking for an overview of the research implementation to identify key characteristics or factors related to the concept (Munn. Z., et.al, 2018). The stages of conducting a scoping review include focusing the review on research questions, using the PICO (Population, Intervention, Comparation and Outcome) framework, identifying relevant studies, describing the process of identifying literature with PRISMA flowcharts, data extraction and mapping or scoping (Arksey & O'Malley, 2005). Preparation of scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018;Devi et al., 2022). Scoping review protocol registration on OSF home on doi: 10.17605/OSF.IO/UJRZP.
Step 1. Identify the research question This scoping review aims to analyze husband's support, anxiety and the level of MFA during the prenatal period. The review question is "What are the results of the analysis of husband's support in prenatal anxiety and MFA?" Step 2. Identify relevant studies The use of PICO is used in identifying key concepts in the focus of the review, developing appropriate search terms to describe the problem, and determining inclusion and exclusion criteria. The article used for scoping this review is a quantitative research (Torous et al., 2021). The PICO framework is shown in table 1. The article search strategy uses the Scopus, Ebsco, Pubmed, ScienceDirect and Proquest databases. In searching for articles, use the boolean operators "AND" and "OR".
Boolean Operator is a logical system that can be used as a word connector to combine, select, or exclude keywords when searching for information data using Search Engines.
The AND operator is used to narrow search results, because this operator will show search results with all of the keywords used. The OR operator expands search results, as it will show any or all of the keywords used (Design et al., 2019). The keywords used in the search for articles are "Pregnant Women AND Social Support OR Family Support OR Husband Support AND Anxiety OR Social Anxiety AND Maternal Fetal Attachment OR Prenatal Attachment" Step 3. Study selection and data processing management The selection of articles is determined based on the criteria (table 2): The findings of the articles were selected according to duplication, suitability criteria using the Mendeley format were then described in PRISMA-ScR (Tricco et al., 2018) shown in figure 1: Step 4. Charting Data Articles that meet the requirements for synthesis are mapped in a table which includes: (a) author and year of publication, (b) country and journal name (c) research objective, (d) subjects/respondents (e). research design and methods, (f). research result. Charting data is shown in table 3: Bergh PRA Questionnaire Data analysis with Independent sample t-test and chi quare -MFA was higher at week 36 than at week 12 (p < 0.001). The increase in MFA scores was higher in the ART group compared to natural (p < 0.001). Anxiety scores decreased in both groups (p = 0.84).
-Pregnant women on ART and experiencing anxiety levels decreased as gestational age increased and MFA increased, but it was higher in pregnant women on ART. A11 Zhang et al., -Anxiety correlates with milk production, MFA is not proven to correlate with milk production. -Milk production is affected by anxiety during pregnancy and family support Step 5. Assessment of Article Quality with Critical Appraisal The tool for carrying out a careful and systematic assessment of the results of scientific research is Critical Appraisal to assess the quality of articles (Pollock et al., 2021). Critical Appraisal in the scoping of this review uses The Joanna Briggs Institute Critical Appraisal tools (JBI) for cross-sectional, cohort and case control studies . Assessment criteria are given a value of "yes", "no", "unclear" and "none". Every criteria with a "yes" score are given one point while the others are given a zero point. Each study score is then calculated and summed. The literature used has at least a minimum score of 50%. If it is less than 50% then it means that it is rejected and if it is more than 50% then the literature is accepted (Moola et al., 2016;Moola, Munn, et al., 2017;. The results of critical appraisal on 14 articles, obtained a score of > 50%, so that all articles were synthesized in this scoping review.

RESULTS
Through the steps of filtering data using the Mendeley format, charting data has been obtained and JBI has been carried out. The articles found are described as follows:

Characteristics of Articles by Country
Based on the 14 articles found, 7 (50%) articles were obtained from research in developing countries, namely 2 Iran, 2 Turkey, and 1 article each from China, Brazil and India. It was found that another 7 (50%) articles came from developed countries, namely 1 article each from the following countries: Australia, Germany, USA, Korea, Denmark, France and Italy. Husband's support is needed by all pregnant women in developing and developed countries and will affect anxiety and MFA levels. The distribution of country characteristics is described in a pie chart in Figure 1.

Characteristics of Articles Based on Research Methods
The research method found in 14 articles, that is, on average using the case-control method in 4 (28.6%) articles, namely articles A1, A7, A11, A14. Cross sectional 4 (28.6%) articles, namely A2, A5, A9, A13. Longitudinal 4 (28.6%) articles, namely A6, A8, A10, A12 and cohort 2 (14.2%) articles, namely A3, A4. Experimental study results were not found in this study. The distribution of the characteristics of the research method is described in the pie chart in Figure 2.

Theme Mapping
In the 14 articles found, the themes obtained are as follows (table 4): a. Social support Pregnant women need other people to talk to and help with the pregnancy situation they are experiencing. Social support is physical and psychological comfort provided by friends, neighbours, health workers and family. Social support can be in the form of emotional support, awards, instrumental, information, and group support (Pasricha, K., et al., 2021). The support obtained by pregnant women will affect safety, calm so as to reduce the risk of psychological adverse effects, namely anxiety, stress and depression. The positive impact of social support given to pregnant women is adjustment to the pregnancy situation with various physical and psychological changes (Maccotta, 2022). The support that pregnant women get will make them calm and comfortable during pregnancy, which has the effect of increasing the mother's concern for her fetus. Pregnant women pay attention to the growth and development of the fetus, care for the fetus and carry out antenatal care regularly and actively participate in prenatal classes that are beneficial in maintaining pregnancy, fetal health and giving birth to healthy babies (Pasricha, K., et al., 2021). The results of the 5 research articles show evidence that is in line with the importance of family support for pregnant women, from the first trimester to the third trimester, both in normal, highrisk pregnancies and pregnancies due to Assisted Reproductive Technology (ART) (Ranjbar et al., 2021;Hopkins et al., 2018). The social support that pregnant women get affects lower anxiety and stress levels and has an impact on high maternal fetal attachment and healthy baby birth outcomes. Even though social support can be obtained from friends, relatives, health workers, family, the support that most dominantly affects the safety and comfort of pregnant women is more important than the partner/husband (Ertmann et al., 2021 Family support is social support, but comes from relatives who have blood ties such as parents, in-laws, siblings or the nuclear family which includes husband and children. The support given is proof of love, concern, and willingness to listen to complaints. Family support acts as a mediator to reduce the decline in MFA due to anxiety and depression. The bond that pregnant women feel with their parents as a source of support is an emotional experience from their parents from infancy, children to adolescents so that they feel close and comfortable being close to parents/family (Yoon & Sung, 2021).
Family support has a big contribution in determining the health status of pregnant women. Families expecting a pregnancy show great support and concern for pregnant women. Pregnant women are more confident, happy, ready to go through pregnancy, childbirth and postpartum. Family support affects the level of maternal anxiety during pregnancy and has an impact on MFA (Bäckström et al., 2017;Yoon & Sung, 2021). Family support increases feelings of security, reduces anxiety and increases mother's concern for the fetus. In parallel research  mentioned, family support is needed by pregnant women in dealing with pregnancy until the birth of the baby, reducing stressors for pregnant women and having an impact on the response of pregnant women in assessing the situation they are experiencing. Pregnant women feel safe and comfortable because there are families who are ready to help so that they change their response to the source of anxiety by confiding in the family about the situation they are experiencing.

c. Husband's Support
Husband's support is verbal and non-verbal communication, advice, help tangible or behavior given by the husband to pregnant women. Husband's support is a form of attention and affection given physically and psychic as the closest individual physically and psychologically to pregnant women.
Husband has a big share in status mother's health (Fielding-Miller et al., 2022). Good husband support can motivate mothers to have their pregnancies checked. Husband can help with choreswife, meet the wife's needs during pregnancy, deliver check-ups, accompany the wife to do exercise activities during pregnancy so that the growth and development of the fetus is better (Doss, 2010;Bäckström et al., 2017). The results of the study are in line with the fact that pregnant women with good husband support show higher MFA, shorter delivery times and normal birth babies (Ross et al., 2018).

Theme 2: Psychological Change
Based on the analysis of 14 articles, the theme of prenatal psychological change was found, with 2 sub-themes covering: anxiety symptoms in 5 articles and coping mechanisms in 3 articles.

a. Anxiety symptoms
Anxiety is a psychological condition of a person who is fullwith fear and worry about something that is not certain to happen. Symptoms of anxiety include restlessness, nervousness, unexplained worry and avoidance behavior. Relevant research results state that pregnant women with high anxiety produce low MFA (Beauquier-Maccotta et al., 2022). According to Branjerdporn et al., (2021) and Smorti, et al., (2020) who conducted research on pregnant women that physical changes cause body image disturbance and fear of giving birth causes an increase in anxiety which affects the decrease in the ability of pregnant women to adapt to pregnancy. Anxiety in pregnant women can interfere with positive affective experiences and cognition in the fetus so that the MFA is low.

b. Coping mechanism
Coping mechanisms are ways to adapt to the anxiety and stress experienced by individuals (Ozcan,et.al., 2019). Pregnant women who experience mild anxiety are easier to overcome by crying, telling stories with their husbands, meeting with the community of pregnant women in prenatal classes. In conditions of severe anxiety, it requires greater coping and involves health workers. If anxiety cannot be resolved, there is a risk of pathological problems due to the inability to deal with threats (Hyer et al., 2022). Pregnant women with high anxiety and worry about giving birth have negative expectations of childbirth, so they choose analgesics as an effort to relieve pain. The results of the study prove that the choice of coping mechanism with the choice of anesthesia has a lower MFA than pregnant women who choose not to use anesthesia during childbirth (Smorti et al., 2020). In pregnant women with Assisted Reproductive Technology (ART) coping who are chosen to be more careful in treating pregnancies, every change in the fetus is considered so that it increases MFA better than natural pregnant women (Ranjbar et al., 2021). For anxiety that occurs during pregnancy, coping mechanisms can generally be obtained from other people, namely family members, especially husbands and health workers. Health workers can screen anxiety, attachment behavior and socialize attachment behavior so that pregnant women can better adapt to pregnancy so that MFA increases Ranjbar et al., 2021).

Theme 3. Maternal-Fetal Attachment
The results of the analysis of 14 articles found the theme of maternal fetal attachment (MFA) which consisted of 3 sub-themes namely: factors influencing MFA, found in 6 articles, interaction quality in 8 articles and intensity of interaction in 6 articles.

a. Factor affecting
The results of the analysis found 6 articles discussing the factors that influence MFA. In this study, the factors that affect MFA are relatively the same, but the level of MFA is influenced by the diagnosis of normal or high-risk pregnancy (Ranjbar et al., 2021). It was found in other studies, factors that influence MFA include anxiety levels, perceived support during pregnancy, age level, educational level, socioeconomic status, attitude towards pregnancy and personality characteristics of pregnant women (Yoon & Sung, 2021;da Rosa et al., 2021;Silahli et al., 2021). The results of other studies state that anxiety and attachment to partners affect MFA. These findings confirm that the husband's support factor is an important factor affecting the safety and comfort of pregnant women. Husband is the closest source of support emotionally capable of providing peace, security and comfort to pregnant women which affects the fetus, stimulates optimal growth and development Smorti et al., 2020). The experience of attachment that was obtained during the pre-pregnancy period stimulated the activation of the internal working model and was manifested in emotional and behavioral responses to the pregnancy encountered, so that the support of the closest people was very important to support positive behavior MFA .
b. Interaction quality Based on charting data, the majority of articles discussed the quality of interaction between mother and fetus, there were 8 of 14 articles. MFA is a behavior that represents the affiliation and interaction of mother and fetus. A good quality MFA is important with regard to preparation for motherhood, care of the fetus and interest in the baby. The quality of interaction determines the quality of care and the physical, cognitive, affective, social, mental development of the baby (Ozcan, U., et.al., 2019). Pregnant women with poor MFA quality will interfere with the health of the fetus (Beauquier-Maccotta et al., 2022). Pregnant women with high anxiety reduce the quality of interactions and mediate interactions after birth are still of less quality. Evidence suggests prenatal anxiety is related to low quality MFA. The quality of MFA can lay the foundation for a more quality attachment relationship after the baby is born (Schmidt et al., 2016).

c. Interaction Intensity
The intensity of mother-fetus interaction is the number or frequency of pregnant women showing concern for the fetus through the act of communicating/telling stories with the fetus, stroking the fetus when the fetus moves or listening to music/murrotal together. The results of the study are in line, stating that pregnant women who interact more positively with their fetuses show higher MFA and lower risk of delivery. Mothers also give birth with tolerable pain or less pain so less use of epidural anesthesia (da Rosa et al., 2021;Smorti et al., 2020). Pregnant women who are active in sensory interaction with their fetus, spend more time in thoughts and behaviors related to the fetus, activities that are expressed as pleasant for the mother and her fetus (Branjerdporn et al., 2021). Reinforced in research that the intensity and frequency of MFA will increase with increasing gestational age in line with the development of the fetus. The expectant mother imagines and describes the appearance and personality of the fetus in her mind. Besides that, routine pregnancy checks so that you can listen to the fetal heart rate via Doppler, see and feel fetal movements via ultrasound stimulate more increased MFA intensity (Ranjbar et al., 2021).

Theme 4. Impact
The theme of impact resulted in 3 sub-themes including: birth outcomes, in 4 articles, baby growth and development in 4 articles and birth experience in 1 article.

a. Birth Results
Anxiety during pregnancy can affect MFA and have an impact on poor pregnancy care, lack of nutrition needed for fetal growth and development, lack of concern for health guidelines during pregnancy, unhealthy behavior. This can affect the health of the mother and poor fetal growth and development as well as unhealthy neonatal outcomes (Shamasbi et al., 2020). Low MFA, associated with high anxiety and poor support can lead to negative health consequences for mother and baby, can be at risk of producing unhealthy babies, preterm labor, low birth weight, low birth APGAR scores, prolonged labor and developmental delays child. The results of other studies also state that the level of MFA can predict the development of children's emotional behavior abilities from an early age Yoon & Sung, 2021;da Rosa et al., 2021).
b. Baby's growth There are 4 articles that reveal the quality of MFA with the growth and development of the baby after birth. The quality of MFA is a major factor in the cognitive, emotional and mental development of infants, children and adolescents (Ranjbar et al., 2021). The results of the study found that consistently low MFA scores were preceded by perinatal anxiety and depression that persisted after delivery. This is a risk factor for the growth and development of children that is detrimental to long-term child mental and behavioral disorders (Ertmann et al., 2021). Study of Punamäki et al., (2017), a negative MFA is associated with poorer infant language and sensorimotor development and poorer continuation of mother-infant interactions in the postpartum period. A low MFA indicates a decrease in the ability to understand and interpret the baby's signals after birth accurately so that the response given by the mother becomes less precise. Lack of concern is a trigger for cognitive, emotional, mental and social problems in infants (Schmidt et al., 2016;Silahli et al., 2021). This explains that maternal anxiety and depression during pregnancy affect MFA and have an impact on attachment after birth and poor infant growth and development.

c. Childbirth experience
Maternal fetal attachment is a mother-fetus bond of affection that influences the mother's focus on the delivery aspect. Strong affection and attention to the fetus, has an impact on the complex interaction between physical and hormonal signals from mother to fetus that affect aspects of labor. The attachment of maternal-fetal affection affects ambivalent expectations of labour, but will lead to the focus of labour, pain being perceived as a non-threatening transformative event and supported by a strong desire to hold the baby immediately. In other words, strong prenatal attachment has an impact on a positive birth experience. Pregnant women give birth normally, naturally and healthy babies, reduce the risk of childbirth with actions, both induction, caesarean section and the use of anesthesia in the delivery process (Smorti et al., 2020;Whitburn et al., 2017;Rookesh et al., 2021).

LIMITATION OF THE STUDY
The findings of the articles in this scoping review were carried out by a critical appraisal using The Joanna Briggs Institute Critical Appraisal tools (JBI). There were 4 articles with longitudinal studies for which JBI instruments were not available for critical appraisal, so that articles with longitudinal studies were carried out critical appraisal using JBI Tools cross sectional studies.

CONCLUSIONS AND SUGGESTIONS
Maternal fetal attachment (MFA) is a bond of motherfetus affection. The high or low quality of attachment is influenced by husband's support and anxiety. Husband's support is the main part of social support for pregnant women, because the husband is the individual who is emotionally closest to pregnant women. Anxiety for pregnant women can occur due to social status, readiness in pregnancy, husband's acceptance, worries about childbirth and health during pregnancy. Husbands who provide good support are beneficial for the comfort of pregnant women so that MFA increases. A high MFA has an impact on fetal development, readiness for childbirth, birth outcomes and growth and development of infants up to adolescents. It is necessary to optimize husband's support for pregnant women and increase the comfort of pregnant women to increase MFA,