Prenatal Yoga on Anxiety, Cortisol and Sleep Quality

Journal of Critical Reviews

ISSN- 2394-5125 Vol 7, Issue 13, 2020

EFFECT OF PRENATAL YOGA ON ANXIETY, CORTISOL AND SLEEP QUALITY

Finta Isti Kundarti1,4*, Ira Titisari2, Tri Cahyo Sepdianto3

1Departement of midwifery, Health Polytechnic, Ministry of Health, Malang, Indonesia 2Departement of midwifery, Health Polytechnic, Ministry of Health, Malang, Indonesia 3Departement of nursing, Health Polytechnic, Ministry of Health, Malang, Indonesia 4Post Graduate Program, Faculty of Medicine, Diponegoro University, Semarang, Indonesia *Corresponding Email: [email protected]

Received: 15.04.2020 Revised: 16.05.2020 Accepted: 11.06.2020

Abstract Background Anxiety is a psychological problem that is often faced by women during pregnancy, especially women who are first pregnant. Psychological disorders that are too long will affect the condition of the mother, fetus, and outcomes. Prenatal yoga is a technique that has been adapted to the condition of pregnant women. Examination of psychological conditions such as anxiety through plasma cortisol biomarkers is needed and measuring sleep quality in pregnant women has not been much studied. Our study compared anxiety, plasma cortisol, and sleep quality in primigravida among pregnant women who received prenatal yoga interventions and received routine prenatal care. Methods randomized control trial test. We recruited all 59 healthy primigravida women with 20 to 32 weeks' gestation. Participants were divided into 2 groups randomly, the yoga intervention group (n = 30) and the control group (n-29). Yoga interventions are given every week for 8 weeks, the duration of the exercise is 90 minutes per session. Anxiety assessment uses state-trait anxiety inventory (STAI), plasma cortisol using ELISA, and sleep quality using PSQI conducted at the beginning of week 1 and end of week 8. Results the yoga intervention group had lower anxiety and blood cortisol levels than the control group (p <0.001), the quality of sleep in the yoga intervention group was better than the control group (p <0.001). Conclusion Prenatal yoga significantly decreases anxiety and cortisol plasma, improves the sleep quality of pregnant women. Our findings can be recommendations for health workers, especially midwives, to improve prenatal care in overcoming psychological problems during pregnancy.

Keywords: prenatal yoga, anxiety, cortisol, sleep quality

INTRODUCTION children (Andrea et al., 2013). Pregnant women who experience Pregnancy is a very important event in a woman's life. Pregnancy depression show adverse effects on the mother, fetus, or causes changes in physical, psychological, and social aspects that newborn (Fishell, 2010). Prolonged stress during pregnancy can can cause stress (Ngai., 2011 and Curtis., 2012). Most pregnant cause preterm labor and low birth weight (Yuksel et al., 2013), women feel anxiety about neonatal developmental disorders, the uterine contractions, fetal brain growth disorders, pregnancy possibility of birth trauma, newborn breathing abilities, and the hypertension, preeclampsia, gestational diabetes, premature ability to give birth (Liana D et al., 2015). Anxiety is more rupture of membranes, and low Apgar scores in newborns common in young pregnant women, lacks support from (Dunkel., 2012 and Rakhshani A et al, 2012). husbands (Gouronti., 2013), low socioeconomic status, problematic work situations, low levels of education, lack of Stress affects the hypothalamic-pituitary-adrenal (HPA) axis access to prenatal care facilities, and conflicts with partners system so that the hypothalamus produces corticotropin- (Cardwell. , 2013). releasing factor and stimulates the anterior pituitary to excrete the hormone adrenocorticotropin and ultimately the adrenal During pregnancy, women experience sleep disorders and this secretes cortisol (Chida, 2018 and Waffarn., 2012). The placenta can cause insomnia (Palagini., 2014), changes in sleep duration produces corticotropin during pregnancy which stimulates (Hutcinson, 2012), sleep quality (Mindell., 2015). Insomnia is cortisol release (O'donnell., 2009). Increased cortisol increases approximately 1.41 times more common in women than in men after 15 weeks' gestation and decreases after delivery (Glynn., (Zhang., 2006). The female population is more susceptible to 2012). insomnia in conditions such as hormonal changes follicles stimulating hormones (FSH), luteinizing hormones (LH), and Anxiety and stress during pregnancy can be prevented by progesterone, which plays an important role in influencing interventions that can reduce the increase in cortisol levels women's sleep construction (Kische et al., 2016) during which can ultimately prevent complications in pregnancy, adolescence (Calboun., 2014), pregnancy and postpartum childbirth, and the puerperium. Pharmacological stress (Kizilimak., 2012) or menopause (Kravits., 2003). Poor sleep management cannot be used in pregnant women because it can quality during pregnancy is a risk factor for depression have teratogenic effects. Some non-pharmacological (Thomfohr., 2015 and Mellor., 2014). A study shows that sleep interventions that can be used are yoga (Gong., 2015), music disorders can cause intrauterine growth restriction, preterm therapy (Liu., 2016), cognitive-behavioral intervention (Richter birth, higher risk of cesarean birth, and longer labor (Okun., 2012)), massage (Field 2012), breathing relaxation techniques 2011, August., 2012 and Naghi., 2011). Stress and anxiety during (Urech., 2010). pregnancy are related to changes in the immune system in

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Some evidence shows that pregnant women use complementary Research related to women's sleep quality during pregnancy is and alternative medicine (CAM) therapies to overcome also still very rarely studied. The gap we found led us to design psychological problems (Cramer et al., 2015) and these this study to evaluate the effect of prenatal yoga on anxiety interventions are quite popular (Steel et al., 2014, Cramer et al., through blood cortisol biomarkers and to evaluate the quality of 2015, Babbar et al., 2015). Pregnant women look for CAM for sleep of pregnant women during pregnancy. Our hypothesis is various reasons (Cramer et al., 2015), such as for managing yoga intervention in pregnancy will reduce anxiety levels and stress and depression (Kinser and Masho., 2015), back pain blood cortisol levels and improve sleep quality compared to (Holden et al., 2015), to control birth (Cramer et al., 2015). This pregnant women who only receive routine standard pregnancy alternative therapy can also improve general health and prevent care. disease (Holden et al., 2015) and is beneficial for psychological and physical aspects (Kinser and Masho., 2015). Yoga is the most METHODS widely used intervention by pregnant women with the aim of Participants reducing health problems related to pregnancy (Cramer et al., Participants in this study were primigravida women aged 18-35 2015 and Holden et al., 2015). Yoga is a mind-body practice that years, 20 to 32 weeks gestation (trimesters 2 and 3). We originated in India (Kawanishi et al., 2016). excluded primigravida women who had obstetric complications: placenta previa, placental solution, pre eclampsia, hypertension, Evidence shows that following yoga during pregnancy can reduce infection. the risk of birth complications (Peters and Schlaff., 2016), decrease discomfort during pregnancy, increase self-confidence Study design in labor (Sun YC., 2010), decrease plasma epinephrine and Randomized controlled trial design. Pastisipan who meet the increase serotonin, decrease proinflammatory cytokines IL-1 and inclusion and exclusion criteria were randomly assigned to the an increase in anti-inflammatory cytokines IL-10 shows a better yoga intervention group and the control group. Participants were immune function (Rajbhoj., 2015), lower labor pain rates at 3-4 taken from primigravida women who examined their cm opening, decreased amount of labor induction, less sectio pregnancies at the health center in the city of Kediri, Indonesia. caesarea frequency, longer on stage II and III shorter labor Of the 72 participants, having obstetric complications 8 and 4 (Jahdi., 2016), reduce pain (Posadzki P et al., 2011 and Jiang., eligible but declined to participate in the study. At the next 2015), reduce lumbopelvic pain (Martin., 2014), reduce meeting all participants signed an informed consent and premature labor (Jiang., 2015), decrease the stress level with participants were asked to fill in a questionnaire containing high-risk pregnancy complications (CS Deshpande et al., 2013, demographic information, medical history, assessment of anxiety Jiang., 2015 and Kusaka., 2016), effective in reducing anxiety and with the Perinatal Anxiety Screening Scale (PASS) and depression in pregnant women (Karen., 20 16, Bhershadsky assessment of sleep quality with PSQI. Participants were also 2014, Newham., 2014 and Davisk., 2015, Gong., 2015), reduce the examined plasma cortisol levels. After the initial measurement negative effects of anxiety and depression in pregnancy (Kyle the participants were randomly assigned to the yoga group (n = Davis, 2015) reduction of psychological stress, increased 30) and the control group (n = 30). The researcher explains to relaxation, bonding with the fetus and social relations with yoga participants about what needs to be done during the study. The group friends, improve skills that help with labor and birth laboratory section is blinded to the allocation group. The study (Styles., 2019), are more relaxed during pregnancy, have a was conducted from January to May 2016. The yoga intervention positive attitude (Polis., 2015, Jiang., 2015, Babbar., 2017 and group followed the yoga program for 8 weeks and the control Hall., 2015 ), helps women stay in shape during pregnancy group did not get the intervention and only received routine (Oakley and Evans., 2014). prenatal care. All participants completed the initial assessment Six studies have been identified, three were randomized before the intervention and after the yoga group completed the controlled trials (RCTs) and three were controlled trials (CTs). intervention for 8 weeks. The findings show that yoga can be indicated for pregnant women and gives good results for pregnancy, childbirth, and birth. However, RCTs are needed to provide more information regarding the use of yoga interventions for pregnancy (Curtis., 2012). Sixteen studies were selected by evaluating the effectiveness of interventions against insomnia. Only 6 randomized controlled trials, and four studies evaluating longitudinal results. This shows lack of evidence and the need to conduct high-quality randomized controlled trials as interventions during pregnancy for insomnia (Bacaro., 2019). One study said that yoga interventions were reported to have an increased incidence of intrapartum / postpartum hemorrhage (Steel., 2014). These inconsistent findings require further study of the effects of prenatal yoga on pregnancy, childbirth and outcomes.

Yoga is an intervention of the mind body and soul and is a good intervention. Prenatal yoga is yoga that has been modified using gentle movements and is easily followed by pregnant women. Several studies with prenatal yoga interventions that have been carried out are assessing anxiety or stress using salivary cortisol biomarkers and maternal immunity, namely immunoglobulin A.

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Assesment for eligibility Enrollment (N=72)

Complication obstetric (N=8) Eligible but declined (N=4)

Randomized (N=60)

Yoga exercise group Allocation Control group (N=30) (N=30)

8 minggu exercise Intervention Treatment as usual and follow up Dropout (n=1)

• Migration Analysed Analysed(n=1) Analysis (N=30) (N=29)

Figure 1 Flow Chart

Interventions score of this instrument ranging from 0 to 21. The higher the The yoga group attends the 90 minute workout once a week for 8 obtained score, the worse the sleep quality. A score higher than 6 weeks. Yoga classes are taught by midwives who are certified as denotes undesirable sleep quality. The PSQI validity is 0.80 and yoga instructors. The yoga practice sequence class consists of reliability examined through re-testing has been reported breathing exercises (pranayama), physical posture (asanas), between 0.93 and 0.9818. The validity and reliability of this relaxation through meditation or shavasana. The control group questionnaire has also been confirmed in Iran (the Cronbach- received routine prenatal care only. Routine care is provided by alpha coefficient of this questionnaire was obtained between midwives at the place of health care. 0.78 and 0.82) (Hasanzadeh., 2008).

Data collection procedure / measures Statistics analysis Anxiety is measured by The PASS scale, consisting of 31 items Data were analyzed using SPSS Version 20.0. Independent t-test originally developed by Somerville et al. A study assessing the to compare continu variables (age, gestational age, anxiety, base scale's validity and reliability was published in 2014. The plasma cortisol, and sleep quality) yoga group and control group. four sub-dimension of the scale are: (1) acute anxiety and X2 test is used to compare dichotomous variables (education, adjustment disorder, (2) general anxiety and specific fears, (3) employment and pregnancy planning). Changes in groups on perfectionism, control and trauma, and (4) social anxiety. In the anxiety, cortisol and sleep quality variables were measured using validity reliability study, the Cronbach Alpha coefficients for the paired t-tests. Independent t-tests were used for between-group sub-dimensions are 0.90, 0.89, 0.86, and 0.87 respectively. The comparisons of scores before and after the intervention. answers for the questions/items in the scale are “never” “sometimes,” “often,” and “almost always”; the scores are 0,1,2,3. RESULTS In the research that first gave rise to the scale, the cut-off value Participants' characteristics was indicated to be 26 (Somerville, S., et al., 2014). Plasma Our sample was from 59 pregnant women (30 in the intervention cortisol is measured using Diagnostic Biochem Canada Inc (DBC). group, 29 in the control group). The average age of participants Put 4-5 mL of blood in a tube then label it. Centrifuge carefully to in the intervention group (M = 23.4) and the control group (M = get serum. Store at 4 ° C to 24 hours or -10 ° C or lower if the 25.1). The mean gestational age of participants in the analysis has to be done at a later date. Normal plasma cortisol intervention group (M = 23.5) and the control group (M = 26.4). values in women (AM), Mean (15.59 μg / dL) and Range (3.95 μg Pregnancy planning in the majority of the intervention group / dL - 27.23 μg / dL). For measuring sleep quality in the subjects, was planned (6.9%) and the control group (93.1%). There was a the Pittsburgh Sleep Quality Index (PSQI) was employed. This significant difference between the two groups in the education questionnaire is an instrument with seven components (sleep variable (p = 0.03). There were no significant differences quality, delay in falling asleep, the sleep duration, the sleep between the two groups on occupational variables (p = 0.605), efficiency, sleep disorders, consumption of sleep-inducing pregnancy planning (p = 3.89). Average anxiety in the medications, and the daily performance) and 18 questions. The intervention group (M = 39.23) and control (M = 39.36) before score of every item in this questionnaire is between 0 and 3 treatment. Average cortisol in the intervention group (M = 35.08) where the score of every component is at most 3. The sum of the and control (M = 38.06) before treatment. Average sleep quality scores means of these seven components accounts for the total in the intervention group (M = 8.86) and control (M = 8.93)

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before treatment. There were no significant differences between administration of intervention (M = 13.16) vs (M = 35.30), the two groups on anxiety, cortisol and sleep quality variables average cortisol levels of intervention and control (M = 16.50) vs (table 1). (M = 9.91 ), the average quality of intervention and control sleep (M = 4.76) vs. (M = 8.33). There were no significant differences Effects of prenatal yoga on anxiety, plasma cortisol levels between the two groups at the time of the posttest (p <0.00). and sleep quality This showed that the practice of yoga given to pregnant women Measurements of anxiety, plasma cortisol and sleep quality were at 20-32 weeks' gestation for 8 weeks could reduce anxiety, performed twice before and after the intervention (week 8). plasma cortisol levels and improve quality living pregnant Average anxiety in the intervention and control group after the women (table 2).

Table 1 characteristic of participants by groups Karakteristik responden Kelompok p Intervension Control (n=29) (n=30) n(%) / M(SD) n(%) / M(SD) Umur 23,4 (3,27) 25,1 (3,27) 0,049a Usia kehamilan 23,5 (2,83) 24,6 (4,41) 0,255a Pendidikan • Sekolah dasar 8 (26,7%) 1 (3,4%) 0,03b • Sekolah menengah 18 (60%) 21 (72,5%) • Sekolah tinggi 4 (13,3)% 7 (24,1%) Pekerjaan 0,605 b • Tidak bekerja 17 (56,7%) 15 (51,7%) • Bekerja 13 (43,3%) 14 (48,3%) Perencanaa kehamilan 0,389 b • Tidak Direncanakan 4 (13,3%) 2 (6,9%) • Direncanakan 26 (86,7%) 27 (93,1%) Cemas 39,23 (21,79) 39,36 (21,04) 0,89a Cortisol 35,08 (10,66) 38,06 (9,77) 0,722a Kualitas tidur 8,86 (1,59) 8,93 (1,11) 0,196a

Uji : independent t testa. chi squareb

Tabel 2. Pengaruh yoga terhadap cemas, cortisol dan kualitas tidur pada kelompok intervensi dan kelompok kontrol Variables Pretest p Posttest p Intervention group control group Intervention group control group (n=30 ) (n= 30) (n=30 ) (n= 29) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

Cemas 39,23 (21,79) 39.36 (21,04) 0,981 13,16 (7,31) 35,30 (20,76) 0,00 Kortisol 35,08 (10,66) 38,06 (9,77) 0,264 16,50 (6,80) 33,01 (9,91) 0,00 Kualitas tidur 8,86 (1,59) 8,93 (1,11) 0,851 4,76 (0,77) 8,33 (2,05) 0,00

Independent samples test

DISCUSSION increase relaxation of pregnant women so that anxiety decreases Our results provide input to the literature that yoga provides a (Styles., 2019). Yoga therapy helps restore the HPA balance of positive effect during pregnancy by providing yoga intervention pregnant women and reduces stress responses resulting in for 8 weeks can reduce anxiety, plasma cortisol levels and decreased cortisol levels (Bershadsky., 2014, Field., 2013, improve sleep quality in pregnant women trimester 2 and 3 Newham., 2014, Kusaka., 2016). Yoga can be an effective compared to the control group. Our results support our alternative treatment or augmentation for pharmacotherapy in hypothesis that yoga interventions can reduce anxiety, plasma pregnant women (Muzik., 2012) and yoga is also a promising cortisol levels and improve sleep quality. Our findings are in line non-pharmacological intervention choice (Ng., 2019). Yoga with previous reports that yoga can reduce anxiety and cortisol interventions that are feasible and acceptable to be applied (Gong et al., 2015, Van der R., 2019, Davis., 2015, Chen., 2017, during pregnancy (Davis., 2015). Among studies with varying Kawanishi., 2012, Desphande., 2013, Shonani. , 2018, Field., types, duration, and frequency of yoga practice, yoga is evidence 2014, Hayase., 2018,). Pregnancy induces the mother's adrenal as an effective alternative intervention because it provides many glands to secrete adrenocorticotropin, which stimulates the benefits in improving physical health and psychological adrenal cortex to produce cortisol, this is the regulation of problems of the mother during pregnancy, during labor, and normal mechanisms and feedback during pregnancy (O'Donnell., after childbirth (Mooventhan., 2019 ). 2009). Complementary therapies such as yoga help restore the HPA balance of pregnant women and reduce stress responses Our findings also prove that yoga practice can improve the sleep (Bershadsky., 2014, Field., 2013, Newham., 2014, Kusaka., 2016). quality of pregnant women. This finding is in line with previous Yoga is a physical activity of moderate intensity in pregnant research that yoga practice can improve sleep quality (Wei-Li women (Peters., 2016). Yoga interventions that we provide for 8 Wang., 2020, Raghavendra., 2017, Karen., 2013, VR Hariprasad., weeks have a positive effect in overcoming the psychological 2013 , Mohsen., 2014). There is little research related to the problems of pregnant women during pregnancy by reducing effect of yoga on sleep quality in pregnant women. Yoga has an anxiety related to pregnancy or outside pregnancy as evidenced effect on sleep disturbance in the elderly who suffer insomnia by a decrease in plasma cortisol levels. This is because yoga can and poor sleep quality (Halpern., 2014). Other research studies

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also prove that 6 weeks of yoga practice resulting in increased Acknowledgments physical and mental health, social relations, and improve sleep The authors would like to thanks to Health Polytechnic, health quality in parents (Hariprasad., 2013). Other studies support that ministry, Malang, Indonesia and Faculty of Medicine, Diponegoro the practice of yoga causes sleep to be restful during at night, University, Semarang, Indonesia lower stress levels during the day, more energetic and increased happiness thereby reducing disruption in daily activities (Tsai., REFERENCES 2016). Other studies also report that there are variations in 1. Ngai FW, Chan SW. Psychosocial factors and maternal hormone levels caused by physical activity including Growth wellbeing: an exploratory path analysis. Int J Nurs Stud. hormone Receptor (GHR), melatonin, interleukin-1, prolactin, 2011;48(6):725–731. and prostaglandin D2 so it has the desired modulation effect on 2. Curtis K, Weinrib A, Katz J. 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