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Effects of yoga on anxiety and depression for high risk mothers on hospital bedrest
Complementary Therapies in Clinical Practice 38 (2020) 101079
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Complementary Therapies in Clinical Practice journal homepage: http://www.elsevier.com/locate/ctcp
Effects of yoga on anxiety and depression for high risk mothers on hospital bedrest Angela Gallagher *, Daria Kring, Tracey Whitley Forsyth Medical Center, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: Antepartum Anxiety Bedrest Depression High-risk pregnancy Yoga
Background: and purpose: In recent years, yoga practitioners have joined forces with medical programs to approach patients’ well-being holistically. This study is a randomized controlled trial to assess the effects of a specialized adapted yoga program on anxiety and depression for high-risk expectant mothers on bedrest in a hospital setting. Materials and methods: Seventy-nine pregnant subjects on physician ordered hospitalized bedrest were ran domized into two groups: receiving biweekly yoga sessions (intervention group) or receiving no yoga (control group). Data collection tool was the Hospital Anxiety and Depression Scale (HADS) to assess outcomes after delivery. Results: Yoga, even as little as three sessions, showed significant impact in reducing anxiety and depression highrisk pregnant women on hospitalized bedrest. Perceived anxiety and depression overall scores were lower in the intervention group than in the control group (p < 0.001). Conclusion: Results demonstrated that yoga is an effective intervention to decrease anxiety and depression in high-risk antepartum women on hospitalized bedrest.
1. Introduction Each year, an estimated one million women in the United States are placed on bedrest due to a high-risk pregnancy or complications, with 700,000 of those women confined to hospital antepartum units [1–3]. With approximately 71–87% of USA obstetricians currently using bed rest to prevent preterm births, although not scientifically proven, the transfer of high-risk mothers to perinatal centers before delivery has shown to produce outcomes that are more favorable for extremely low birth weight infants [1,4]. However, studies report expectant women on bedrest face a host of problems caused by lack of activity and psycho social distress of being removed from their usual social networks and support systems, which include depression, boredom, isolation, anxiety and somatic complaints [5,6]. “A host of psychosocial side effects are associated with bedrest intervention; the most common being ante partum depressive symptoms” [1, p.388]. (see Fig. 1) Multiple studies have shown a correlation between maternal stress, often seen in pregnant women faced with a high-risk diagnosis, which can be exacerbated when confined to the hospital, and adverse preg nancy outcomes [7–12]. These unfavorable outcomes can include
preterm labor and low birth weight infants. Resulting research indicates an increase in mortality and morbidity in the neonatal period for infants of low birth weight, which furthers the need to consider implementation of stress reduction programs for this population of high-risk mothers. A growing body of evidence also suggests that babies born to mothers with high maternal anxiety can be impacted by impaired fetal bonding and attachment with an inimical long-term health trajectory resulting in behavioral, emotional and cognitive issues as toddlers and even into adolescent years [13–16]. Previous studies have explored the segue of anxiety into depressive states for expectant mothers while numerous others have documented negative maternal and fetal outcomes associ ated with antenatal depression including higher fetal heart rate, reduced vagal tone, shorter length of gestation and longer hospital stays with reduced rates for breastfeeding initiation and premature delivery [17–23]. In comparison, pregnant women who experience depression as opposed to nondepressed females, encounter higher incidences of maternal complications such as preeclampsia, spontaneous abortion and preterm delivery that can in turn require doctor prescribed bedrest [24, 25]. There is paucity of evidence about yoga’s effects on anxiety and
* Corresponding author. E-mail address: [email protected] (A. Gallagher). https://doi.org/10.1016/j.ctcp.2019.101079 Received 24 April 2019; Received in revised form 10 December 2019; Accepted 10 December 2019 Available online 14 December 2019 1744-3881/© 2019 Elsevier Ltd. All rights reserved.
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for a multitude of health issues, it could be concluded that expectant mothers on bedrest may greatly benefit from a specifically designed yoga program as opposed to a medical regimen of anti-depressants or even worse, no intervention. Perinatal depression and anxiety disorders can affect 10%–20% of women respectively. Yet, previous research indicates a mere 5.5% of pregnant women identified as having one or more psychiatric disorders received some form of treatment [20,44,45]. Pharmacological therapies can effectively treat some mental disorders; however, medical pro fessionals need greater consideration before prescribing psychoactive drugs during pregnancy. Some mood stabilizers and antidepressants are proven teratogens, and may lead to adverse events including miscar riage, malformations and birth defects [45,46]. In this context, yoga can offer pregnant women an effective adjunct therapy to traditional med ical protocol [27,47–52]. As a non-pharmaceutical alternative approach to alleviate the stress of hospitalized bedrest pregnant women, the medical center established a high-risk antepartum bedrest yoga program in 2009, as part of a pa tient wellness initiative. The goal was to provide the confined women with professionally guided in-bed exercise and relaxation techniques that have been effective in low-risk pregnant women attending classes provided by the medical center in the past decade. Upon review of the highly positive patient satisfaction scores related to the yoga program, reviewing prior work showing high incidence of anxiety and depression among pregnant women during doctor prescribed hospital admissions and anecdotal observations, the researchers hypothesized that yoga could decrease the anxiety and depression of high-risk antepartum pa tients on bedrest. The aim of this study was to assess the effects of a
depression in the high-risk antepartum bedrest population. In the few studies available, it was noted that high-risk expectant mothers, on bedrest in a hospital setting, experience psychosocial implications, physical pain and discomforts including muscle atrophy and decondi tioning, loss of strength and endurance, bodily aches, and stiffness as well as the aforementioned emotional and depressive complications, suggesting an area of needed clinical research into protocols, such as yoga, to administer relief for this population [1,26]. Yoga has been shown to have positive health benefits for individuals suffering from a variety of complaints requiring comprehensive medical care and often hospitalization such as asthma and cancer related dis comforts including fatigue [27–30]. Patients in treatment for heart disease have also benefitted, with a regular yoga practice demonstrating clinically important improvements in blood pressure and pre hypertension as well as improving heart rate variability in women with perceived elevated depressive symptoms [31–35]. Likewise, insomniacs have gained relief through yoga practice with significantly positive gains in sleep quality, duration and fatigue [36]. Antepartum research has shown participation in a prenatal yoga program may enhance a woman’s ability to positively manage her labor and help reduce labor pain [37,38]. Other research identifies yoga-based interventions as a feasible non-pharmacological option for pregnant women with depres sion and anxiety [39–41]. Previous findings also show positive effects for women with a high-risk pregnancy diagnosis who practice yoga, which include reduced frequency of maternal hypertension and gesta tional diabetes [ [42,43]]. With an ever-growing evidence-based repu tation citing the positive outcomes and non-invasion holistic approach of a yogic lifestyle toward increasing emotional and physical wellbeing
Fig. 1. Study design flow diagram. 2
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structured yoga program in reducing anxiety and depression in high-risk pregnant women on hospitalized bedrest.
one session format. As the researchers also wanted to determine the correlation between anxiety and depression scores in those who participated more in the yoga intervention than those who did not, there was no single prescribed amount of yoga for any participant. The instructor offered the one-on-one, specialized adapted yoga program to the intervention group twice per week, in their rooms, for the duration of their hospitalization. The program began with 5 min of relaxed breathing including specific pranayama breath work followed by instructor lead visualization in which the PI guided the expectant mother to imagine each feature of her unborn child, including the shape of the baby’s face, color of the eyes and hair, and picturing a perfectly formed body with arms, legs, fingers and toes. The instructor then asked the mother to silently speak to her baby, sharing any thoughts, dreams or wishes she had about the pregnancy. Guided visualization can rein force maternal wellbeing and help promote a positive thinking mindset in the mother as well as a positive connection between mother and baby. Breathing and baby visualization was followed by 15 min of modified, bed-adapted yoga moves (such as neck rolls, arm raises, gentle seated rotations, pelvic tilts, thoracic/lumber stretches and foot pumps, all approved by the director of the neonatal unit as safe and appropriate for mothers with restricted movement) to maintain muscle tone, loosen stiff joints, relieve aching muscles and increase circulation. The session ended with Yoga Nidra, a 10-min traditional yogic final relaxation to relieve emotional and mental tension and increase the patient’s ability to rest comfortably. The intervention group patients were encouraged to access the video at their own discretion between instructor guided ses sions, allowing the study to determine if more yoga sessions, with or without the instructor, would improve patient outcomes. The inter vention group also maintained a yoga log that included the total number of sessions with the yoga researcher/instructor and minutes spent practicing yoga utilizing the video during their hospitalization. The control group received standard care with no yoga instruction and did not have access to the yoga video.
2. Materials and methods 2.1. Design A randomized controlled trial design was used to measure the effect of yoga on anxiety and depression levels. 2.2. Setting The study took place at a 932-bed tertiary medical center in the southeastern United States from May 2012 through May 2014. This medical center delivers approximately 6200 babies per year. Pregnant women requiring bed rest were hospitalized on a 20-bed high-risk antepartum care unit. 2.3. Participants A power analysis was conducted using G*Power. It was determined that 44 participants in each arm of the study were needed in order to detect an R2 of 0.40, with a 5% chance of a type I error and a 20% chance of a type II error. Women admitted to the High-Risk Maternity Care Unit were recruited during the data collection period by the Primary Inves tigator (PI). Potential study subjects were screened from the antepartum admission roster. Women who met the enrollment criteria were approached by the PI within one to four days of hospital admission. Once patients agreed to participate in the study, they were added to the demographic roster and assigned a participant number and intervention or control group patient code. Each patient was required to sign Health Insurance Portability and Accountability Act (HIPAA) and Research Project Informed Consent forms. Assignment to intervention or control group was made in an alternating sequence based upon a roster assembled by the charge nurse. Women assigned to the intervention and control groups were allowed to opt out of the study if they did not agree to participate. The study participants included 48 women in the inter vention group, and 31 in the control group. Inclusion criteria were: confirmed pregnancy, physician activity orders requiring bedrest, abil ity to speak and understand English, physical ability to move indepen dently in bed, and an anticipated minimum stay of two weeks. Exclusions to the study were women who delivered before the two week length of stay, those under psychiatric supervision or incarcerated. The study was approved by the Institutional Review Board (IRB) prior to implementation.
2.5. Outcome assessment Participants in the intervention and control groups completed a short researcher-designed demographic survey and the Hospital Anxiety and Depression Scale (HADS) prior to the day of discharge from the medical center. This was a self-administered questionnaire provided to each participant in a sealed unmarked envelope that was returned after completion to the head of research and filed in a locked cabinet until data entry. The demographic survey included: participant’s age, gesta tional age at enrollment, gestational age at end of program, education level, length of stay on antepartum unit, and entire length of stay for that admission. The HADS was developed as a short tool to identify patients at risk for two common psychological disorders, anxiety and depression, and has been successfully used as a clinical screening tool for anxiety and depression in pregnant women in previously published research [ [20,53–57]]. The HADS has 14 items—seven related to anxiety and seven related to depression. Each item is a statement in which re spondents choose the degree of anxiety, and depression that is true for them on a four-point Likert-type scale. The scale ranges from 0 to 3, with 0 representing no symptoms and 3 representing the clear presence of symptoms related to anxiety or depression. The two subscales (HADS-A and HADS-D) are summed separately and may also be added together for a total score. The cut-off score for determining the presence of anxiety or depression is eight for each subscale [57]. Concurrent validity has been reported in several studies. When the HADS was administered to 50 people who had been previously diag nosed with anxiety or depression, the cut-off points were the same for each subscale, with only one false positive for each subscale [53]. In a systematic review of HADS, Bjelland found that six studies reported positive correlations between the HADS-D and Beck’s Depression In ventory, which ranged from 0.62 to 0.73 [50]. In two other studies, correlations between the HADS-A and the Clinical Anxiety Scale were
2.4. Study intervention The PI is a certified registered yoga instructor with 33 years of yoga training and 22 years of pre and postnatal international yoga teaching experience acquiring extensive accreditation. The PI has been affiliated with the medical center for 19 years, providing hospital-based com munity perinatal yoga including pregnancy, postnatal, mommy/baby courses, expanding that role to include the hospitalized antepartum patient population as well as one on one individualized yoga protocols for cancer patients through the hospital’s Integrative Medicine Department. The charge nurse provided the yoga instructor/primary investigator with a list of patients meeting the inclusion/exclusion criteria. Each participant was consented for participation by the investigator once they had completed a HIPAA authorization and research project consent form. Once consented, the participants were randomly assigned to either control or intervention group. The intervention group had 30 min of individually led yoga sessions with the certified yoga instructor/researcher as well as an on-demand yoga video created by the same instructor using an identical one-on3
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than in the control group (9.03 � 3.97; p < 0.001). Likewise, patients in the intervention group had significantly lower levels of depression (3.33 � 2.26) than those in the control group (6.06 � 3.58; p < 0.001). Among patients with less than a college degree, both anxiety and depression levels were lower (p ¼ 0.013; p ¼ 0.004, respectively) in the interven tion group than those in the control group. Patients in the intervention group had an average of 7.46 (3–16) instructor-led sessions, and 2 (0–24) video sessions; and the number of instructor-led sessions or video sessions did not correlate with either anxiety or depression scores (see Table 3).
0.69 and 0.75 [57]. In addition, correlations between the HADS-A and Spielberger’s State-Trait Anxiety Inventory ranged from 0.64 to 0.81 [57]. 2.6. Statistical methods Statistics were reported for all groups as n (%) for categorical vari ables and as means � SD for continuous variables. Comparisons between groups (intervention vs controls) were performed using Student t-test for parametric outcomes and Chi-square analysis for all categorical out comes; association between outcomes were measured using Pearson’s correlation. All statistical tests were two-sided, and p � 0.05 was considered significant.
4. Discussion This study supported the hypothesis that yoga is an effective inter vention to decrease anxiety and depression in high-risk hospitalized antepartum women on bedrest. Previous research has found that peri natal depression and anxiety disorders can affect 10%–20% of women respectively, which can be exacerbated by confinement of doctor pre scribed bed rest [1,44]. The results from this study are in-line with previous findings that show yoga is a safe and acceptable intervention for pregnant women with anxiety and depressive symptoms [58]. Yet, to our knowledge, this is the first randomized controlled trial to assess the effects of a specially designed and adapted yoga program on anxiety and depression for high-risk expectant mothers on bedrest in a hospital setting. Often removed from their families for up to 12 weeks, this special ized group of patients are confronted with a host of emotionally debil itating situations that are unobserved by their low risk peers. The hospital where the study took place services a geographical area of over 200 km. Due to socioeconomic reasons, many families cannot afford the added burden of traveling up to 2 h to visit the confined mother as they are financially incapable of missing work or paying the extra fuel costs to fund traveling to the medical center. Therefore, the patient is unable to see her other children, spouse, family and friends on a regular basis. Not having access to everyday social networks and support systems leaves the mother with enhanced feelings of isolation which in turn, increases her chances of developing anxiety and depression [5,6]. In addition, having to miss important holidays and milestone events, such as birth days and graduations, is an extra emotional burden on the mother restricted to bedrest. Traditional yoga has shown to be effective in relieving symptoms of mental disorders including depression and anxiety [35,59]. It is important to note that a traditional yogic lifestyle approach in cludes positive thinking, meditation, specific breathing and relaxation techniques, as well yoga poses [60]. By modifying the full spectrum of traditional yoga techniques to accommodate the specific medical needs of the patient while addressing heightened sensitivity to depressive states, the researcher developed a program that showed significant improvement in their overall mental health and well-being. An important aspect of the yoga program’s design is to teach the mother relaxed breathing, positive thinking techniques and safe bed adapted movement that she can easily replicate outside of the scheduled visits from the yoga instructor. This provides the patient with specific tools to enhance her physical and mental well-being anytime during her antepartum stay. As gentle bed adapted yoga had no occurrence of adverse events, there is a possibility that any medical center can use a bedrest yoga
2.7. Ethical considerations Before the initiation of the study, the medical center’s Nursing Research Council and the Institutional Review Board approved the research protocol and all investigators completed Collaborative Insti tutional Training Initiative (CITI) for the Protection of Human Subjects Research Curriculum. All participants were fully informed of the study’s purpose, required to sign consent and HIPAA forms and at any time, were free to remove themselves from the study without any negative repercussions. Participant names were kept on a master list, along with a unique participant code. The master list was held in a locked cabinet in the secured office of the Director of Nursing Research. Data collection forms only contained participant codes, with no patient names or other identifiers and were held in a separate locked drawer. All study related computer files had password protection. Yoga sessions were free of charge. Otherwise, no incentives for participation were given. 3. Results During the study period, 79 patients met the inclusion criteria. Table 1 summarizes the overall patient characteristics. Patient mean age (30.44 � 6.17 vs. 27.65 � 7.46; p ¼0.074) and gestational age at enrollment (28.33 � 3.18 vs. 27 � 3.63; p ¼ 0.186) were comparable between the intervention group (yoga) and control group, respectively. Of the patients, 77 (98%) had a live birth and 2 (2%) experienced fetal demise. There were no differences in the number of fetal demises (p ¼ 0.634) or length of stay in the hospital (p ¼ 0.237) between groups. Patients in the intervention group had a higher education level than those in the control group (p < 0.001). To study the effects of the proposed yoga program, we compared perceived anxiety and depression scores between groups at the end of their stay in the antepartum unit as shown on Table 2. Perceived anxiety levels (5.88 � 2.91) were significantly lower in the intervention group Table 1 Demographic variables of high-risk hospitalized pregnant women in the study groups. Demographic variable
Intervention group (n ¼ 48)
Control group (n ¼ 31)
pvalue*
Age (years) Fetal demise (instances) Gestational age at enrollment (weeks) Gestational age at discharge (weeks) Length of stay in antepartum unit (days) Length of stay in hospital (days) Education level Less than college degree College degree or greater
30.44 � 6.17 1 28.33 � 3.18
27.65 � 7.46 1 27.30 � 3.63
0.074 0.634 0.186
32.45 � 2.86
31.28 � 3.40
0.104
33.40 � 13.45
30.00 � 14.45
0.290
36.21 � 14.34
32.19 � 15.04
0.237
24 (50%) 24 (50%)
29 (93.5%) 2 (6.5%)
0.617 <0.001
Table 2 Difference in anxiety and depression scores between high-risk hospitalized pregnant women in the intervention and control groups.
* Chi-square test; significance level p � 0.05.
Outcome
Intervention Group
Control Group
p-value *
Perceived anxiety Depression
5.88 � 2.91 3.33 � 2.26
9.03 � 3.97 6.06 � 3.58
<0.001 <0.001
*Independent sample t-tests; significance level p � 0.05. 4
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Health Forsyth Medical Center.
Table 3 Correlations between number of instructor-led and video yoga sessions with anxiety and depression scores in the intervention group. Variables Instructor-led sessions r value (p-value)a Video sessions r value (p-value)a a
Anxiety score
Depression Score
- 0.164 (0.266)
- 0.162 (0.271)
- 0.036 (0.811)
0.075 (0.611)
Declaration of competing interest
Total HADS score
The authors declare that they do not have a conflict of interest.
0.202 (0.168)
Acknowledgements
0.016 (0.914)
Pearson’s correlations.
Many thanks to Renata S. Magalhaes, MD, PhD for editorial assis tance. Gloria Walters PhD, RN, RN-BC, CCRN-K for proof reading, writing and data assistance of the article.
program as an alternative or augmentative approach to standard med ical treatment for hospitalized mothers. In addition, yoga has become increasingly more popular and commonplace in Western society allowing easy acceptance of such a program into conventional medical institutions. Potential limitations for this study were the relatively small sample size within one hospital, which limits generalizability. Self-reported data collection tools (yoga log and HADS) may not have been completed accurately. Due to the volatile nature of being a high-risk antepartum patient, sudden changes in condition could have occurred that required the participant to complete the survey after an unexpected and possibly traumatic event such as premature rupture of membranes, onset of early uterine contractions or vaginal bleeding that may have altered the responses due to stress. In addition, baseline measurement for anxiety and depression were not performed due to elevated stress levels experienced at the time of admission. Furthermore, quantification of stress was not controlled for length of stay or long-term effects of yoga sessions after discharge.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi. org/10.1016/j.ctcp.2019.101079. References [1] J.A. Maloni, Lack of evidence for prescription of antepartum bedrest, Expert Rev. Obstet. Gynecol. 6 (4) (2011) 385–393, https://doi.org/10.1586/eog.11.28. [2] J. Maloni, S. Park, Postpartum symptoms after antepartum bed rest, J. Obstet. Gynecol. Neonatal Nurs. 34 (2) (2005) 163–171, https://doi.org/10.1177/ 0884217504274416. [3] J. Maloni, J.H. Kane, L.J. Suen, K.K. Wang, Dysphoria among high risk pregnant hosptitalized women on bed rest: a longitudinal study, Nurs. Res. 51 (2) (2002) 92–99. [4] L.W. Doyle, for the Victorian Infant Collaborative Study Group, Changing availability of neonatal intensive care for extremely low birth weight infants in Victoria over two decades, Med. J. Aust. 181 (2004) 136–139. [5] C.L. Bauer, D. Victorson, S. Rosenbloom, J. Barocas, R.K. Siver, Alleviating distress during antepartum hospitalization: a randomized controlled trial of music and recreation therapy, J. Women’s Health 19 (3) (2010) 523–531, https://doi.org/ 10.1089/jwh.2008.1344. [6] M. Richter, C. Parkes, J. Chaw-Kant, Listening to the voices of hospitalized highrisk antepartum patient, J. Obstet. Gynecol. Neonatal Nurs. 36 (4) (2007) 313–318, https://doi.org/10.1111/j.1552-6909.2007.00159. [7] N.K. Grote, J.A. Bridge, A.R. Gavin, J.L. Melville, S. Iyengar, W.J. Katon, A metaanalysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction, Arch. Gen. Psychiatr. 67 (10) (2010) 1012–1024. [8] M.C. Hoffman, S.E. Mazzoni, B.D. Wagner, M.L. Laudenslager, R.G. Ross, Measures of maternal stress and mood in relation to preterm birth, Obstet. Gynecol. 127 (3) (2016) 545–552. [9] C. Liu, S. Cnattingius, M. Bergstrom, V. Ostberg, A. Hjern, Prenatal parental depression and preterm birth: a national cohort study, BJOG 123 (2016) 1973–1982, 2016. [10] E.T. O’Brien, T. Lavendar, Women’s views of high-risk pregnancy under threat of preterm birth, Sex. Reprod. Healthc. 1 (3) (2010) 79–84, https://doi.org/10.1016/ j.srhc.2010.05.001. [11] S. Saigal, L.W. Doyle, An overview of mortality and sequelae of preterm birth from infancy to adulthood, Lancet 371 (2008) 261–269. [12] P.D. Wadhwa, C.A. Sandman, M. Porto, C. Dunkel-Schetter, T.J. Garite, The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigation, Am. J. Obstet. Gynecol. 169 (1993) 858–865. [13] B. Figueiredo, R. Costa, Mother’s stress, mood and emotional involvement with the infant: 3 months before and 3 months after childbirth, Arch Womens Mental Health 12 (2009) 143–153. [14] R. Hart, C.A. McMahon, Mood state and psychological adjustment to pregnancy, Arch Womens Ment Health 9 (2006) 329–337. [15] S. Misri, K. Kendrick, T.F. Oberlander, S. Norris, L. Tomfohr, H. Zhang, et al., Antenatal depression and anxiety affect postpartum parenting stress: a longitudinal, prospective study, Can. J. Psychiatr. 55 (2010) 222–228. [16] T.G. O’Connor, J. Heron, V. Glover, ALSPAC Study Team, Antenatal anxiety predicts child behavioral/emotional problems independently of postnatal depression, J. Am. Acad. Child Adolesc. Psychiatry 41 (2002) 1470–1477. [17] D. Da Costa, M. Dritsa, J. Larouche, W. Brender, Psychosocial predictors of labor/ delivery complications and infant birth weight: a prospective multivariate study, J. Psychosom. Obstet. Gynaecol. 21 (2000) 137–148, 2000. [18] D. Davalos, C.A. Yadon, H.C. Tregellas, Untreated prenatal maternal depression and the potential risks to offspring; A review, Arch. Wom. Ment. Health 15 (2012) 1–14. [19] S. Grigoriadis, E.H. VonderPorten, L. Mamisashvili, G. Tomlinson, C.L. Dennis, G. Koren, et al., The impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis, J. Clin. Psychiatry 74 (4) (2013) e321–e341. [20] A.M. Lee, S.K. Lam, S.M. Sze Mun Lau, C.S. Chong, H.W. Chui, D.Y. Fong, Prevalence, course, and risk factors for antenatal anxiety and depression, Obstet. Gynecol. 110 (5) (2007) 1102–1112, https://doi.org/10.1097/01. AOG.0000287065.59491.70.
5. Clinical implications Hospitals with antepartum patients requiring long periods of bedrest should consider implementing bedrest yoga programs to alleviate anx iety and depression. The intervention used in this study was developed at a teaching hospital and has been found to positively impact the wellbeing of the mother. This program may be readily adapted for use in other hospitals; the lead instructor is enthusiastic to help implement trainings for local yoga instructors in areas that have established highrisk maternity units for patients on physician ordered bedrest. In addi tion, hospitals may find that bedrest yoga is a patient satisfier, improving patient engagement scores and likelihood to recommend the hospital to other expectant mothers. The cost of implementing such a program can be minimized using videos after an initial session. In structors need not be highly experienced practitioners of yoga to teach the techniques to expectant mothers. 6. Conclusion Our results indicated that yoga, even just a few sessions, is an effective strategy to mitigate anxiety and depression in hospitalized bedrest high-risk mothers. We adapted a traditional yoga approach that could be easily implemented in stress-reduction programs within any medical center. Future studies using multiple validated screening tools such as Edinburgh Postnatal Depression Scale (EPDS) and Postpartum Depression Screening Scale in a large number of patients within multicentric institutions could be conducted to assess the beneficial effects of the proposed program as well as to identify the ideal number of ses sions needed. Such programs could be adapted and optimized for structured implementation in medical centers nationwide. Additionally, long-term follow-up may provide insight into the implications of the yoga stress management protocol on mother and infant well-being. Funding Funding was provided by the Nursing Research Grant at Novant 5
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Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: http://www.elsevier.com/locate/ctcp
Effects of yoga on anxiety and depression for high risk mothers on hospital bedrest Angela Gallagher *, Daria Kring, Tracey Whitley Forsyth Medical Center, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: Antepartum Anxiety Bedrest Depression High-risk pregnancy Yoga
Background: and purpose: In recent years, yoga practitioners have joined forces with medical programs to approach patients’ well-being holistically. This study is a randomized controlled trial to assess the effects of a specialized adapted yoga program on anxiety and depression for high-risk expectant mothers on bedrest in a hospital setting. Materials and methods: Seventy-nine pregnant subjects on physician ordered hospitalized bedrest were ran domized into two groups: receiving biweekly yoga sessions (intervention group) or receiving no yoga (control group). Data collection tool was the Hospital Anxiety and Depression Scale (HADS) to assess outcomes after delivery. Results: Yoga, even as little as three sessions, showed significant impact in reducing anxiety and depression highrisk pregnant women on hospitalized bedrest. Perceived anxiety and depression overall scores were lower in the intervention group than in the control group (p < 0.001). Conclusion: Results demonstrated that yoga is an effective intervention to decrease anxiety and depression in high-risk antepartum women on hospitalized bedrest.
1. Introduction Each year, an estimated one million women in the United States are placed on bedrest due to a high-risk pregnancy or complications, with 700,000 of those women confined to hospital antepartum units [1–3]. With approximately 71–87% of USA obstetricians currently using bed rest to prevent preterm births, although not scientifically proven, the transfer of high-risk mothers to perinatal centers before delivery has shown to produce outcomes that are more favorable for extremely low birth weight infants [1,4]. However, studies report expectant women on bedrest face a host of problems caused by lack of activity and psycho social distress of being removed from their usual social networks and support systems, which include depression, boredom, isolation, anxiety and somatic complaints [5,6]. “A host of psychosocial side effects are associated with bedrest intervention; the most common being ante partum depressive symptoms” [1, p.388]. (see Fig. 1) Multiple studies have shown a correlation between maternal stress, often seen in pregnant women faced with a high-risk diagnosis, which can be exacerbated when confined to the hospital, and adverse preg nancy outcomes [7–12]. These unfavorable outcomes can include
preterm labor and low birth weight infants. Resulting research indicates an increase in mortality and morbidity in the neonatal period for infants of low birth weight, which furthers the need to consider implementation of stress reduction programs for this population of high-risk mothers. A growing body of evidence also suggests that babies born to mothers with high maternal anxiety can be impacted by impaired fetal bonding and attachment with an inimical long-term health trajectory resulting in behavioral, emotional and cognitive issues as toddlers and even into adolescent years [13–16]. Previous studies have explored the segue of anxiety into depressive states for expectant mothers while numerous others have documented negative maternal and fetal outcomes associ ated with antenatal depression including higher fetal heart rate, reduced vagal tone, shorter length of gestation and longer hospital stays with reduced rates for breastfeeding initiation and premature delivery [17–23]. In comparison, pregnant women who experience depression as opposed to nondepressed females, encounter higher incidences of maternal complications such as preeclampsia, spontaneous abortion and preterm delivery that can in turn require doctor prescribed bedrest [24, 25]. There is paucity of evidence about yoga’s effects on anxiety and
* Corresponding author. E-mail address: [email protected] (A. Gallagher). https://doi.org/10.1016/j.ctcp.2019.101079 Received 24 April 2019; Received in revised form 10 December 2019; Accepted 10 December 2019 Available online 14 December 2019 1744-3881/© 2019 Elsevier Ltd. All rights reserved.
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for a multitude of health issues, it could be concluded that expectant mothers on bedrest may greatly benefit from a specifically designed yoga program as opposed to a medical regimen of anti-depressants or even worse, no intervention. Perinatal depression and anxiety disorders can affect 10%–20% of women respectively. Yet, previous research indicates a mere 5.5% of pregnant women identified as having one or more psychiatric disorders received some form of treatment [20,44,45]. Pharmacological therapies can effectively treat some mental disorders; however, medical pro fessionals need greater consideration before prescribing psychoactive drugs during pregnancy. Some mood stabilizers and antidepressants are proven teratogens, and may lead to adverse events including miscar riage, malformations and birth defects [45,46]. In this context, yoga can offer pregnant women an effective adjunct therapy to traditional med ical protocol [27,47–52]. As a non-pharmaceutical alternative approach to alleviate the stress of hospitalized bedrest pregnant women, the medical center established a high-risk antepartum bedrest yoga program in 2009, as part of a pa tient wellness initiative. The goal was to provide the confined women with professionally guided in-bed exercise and relaxation techniques that have been effective in low-risk pregnant women attending classes provided by the medical center in the past decade. Upon review of the highly positive patient satisfaction scores related to the yoga program, reviewing prior work showing high incidence of anxiety and depression among pregnant women during doctor prescribed hospital admissions and anecdotal observations, the researchers hypothesized that yoga could decrease the anxiety and depression of high-risk antepartum pa tients on bedrest. The aim of this study was to assess the effects of a
depression in the high-risk antepartum bedrest population. In the few studies available, it was noted that high-risk expectant mothers, on bedrest in a hospital setting, experience psychosocial implications, physical pain and discomforts including muscle atrophy and decondi tioning, loss of strength and endurance, bodily aches, and stiffness as well as the aforementioned emotional and depressive complications, suggesting an area of needed clinical research into protocols, such as yoga, to administer relief for this population [1,26]. Yoga has been shown to have positive health benefits for individuals suffering from a variety of complaints requiring comprehensive medical care and often hospitalization such as asthma and cancer related dis comforts including fatigue [27–30]. Patients in treatment for heart disease have also benefitted, with a regular yoga practice demonstrating clinically important improvements in blood pressure and pre hypertension as well as improving heart rate variability in women with perceived elevated depressive symptoms [31–35]. Likewise, insomniacs have gained relief through yoga practice with significantly positive gains in sleep quality, duration and fatigue [36]. Antepartum research has shown participation in a prenatal yoga program may enhance a woman’s ability to positively manage her labor and help reduce labor pain [37,38]. Other research identifies yoga-based interventions as a feasible non-pharmacological option for pregnant women with depres sion and anxiety [39–41]. Previous findings also show positive effects for women with a high-risk pregnancy diagnosis who practice yoga, which include reduced frequency of maternal hypertension and gesta tional diabetes [ [42,43]]. With an ever-growing evidence-based repu tation citing the positive outcomes and non-invasion holistic approach of a yogic lifestyle toward increasing emotional and physical wellbeing
Fig. 1. Study design flow diagram. 2
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structured yoga program in reducing anxiety and depression in high-risk pregnant women on hospitalized bedrest.
one session format. As the researchers also wanted to determine the correlation between anxiety and depression scores in those who participated more in the yoga intervention than those who did not, there was no single prescribed amount of yoga for any participant. The instructor offered the one-on-one, specialized adapted yoga program to the intervention group twice per week, in their rooms, for the duration of their hospitalization. The program began with 5 min of relaxed breathing including specific pranayama breath work followed by instructor lead visualization in which the PI guided the expectant mother to imagine each feature of her unborn child, including the shape of the baby’s face, color of the eyes and hair, and picturing a perfectly formed body with arms, legs, fingers and toes. The instructor then asked the mother to silently speak to her baby, sharing any thoughts, dreams or wishes she had about the pregnancy. Guided visualization can rein force maternal wellbeing and help promote a positive thinking mindset in the mother as well as a positive connection between mother and baby. Breathing and baby visualization was followed by 15 min of modified, bed-adapted yoga moves (such as neck rolls, arm raises, gentle seated rotations, pelvic tilts, thoracic/lumber stretches and foot pumps, all approved by the director of the neonatal unit as safe and appropriate for mothers with restricted movement) to maintain muscle tone, loosen stiff joints, relieve aching muscles and increase circulation. The session ended with Yoga Nidra, a 10-min traditional yogic final relaxation to relieve emotional and mental tension and increase the patient’s ability to rest comfortably. The intervention group patients were encouraged to access the video at their own discretion between instructor guided ses sions, allowing the study to determine if more yoga sessions, with or without the instructor, would improve patient outcomes. The inter vention group also maintained a yoga log that included the total number of sessions with the yoga researcher/instructor and minutes spent practicing yoga utilizing the video during their hospitalization. The control group received standard care with no yoga instruction and did not have access to the yoga video.
2. Materials and methods 2.1. Design A randomized controlled trial design was used to measure the effect of yoga on anxiety and depression levels. 2.2. Setting The study took place at a 932-bed tertiary medical center in the southeastern United States from May 2012 through May 2014. This medical center delivers approximately 6200 babies per year. Pregnant women requiring bed rest were hospitalized on a 20-bed high-risk antepartum care unit. 2.3. Participants A power analysis was conducted using G*Power. It was determined that 44 participants in each arm of the study were needed in order to detect an R2 of 0.40, with a 5% chance of a type I error and a 20% chance of a type II error. Women admitted to the High-Risk Maternity Care Unit were recruited during the data collection period by the Primary Inves tigator (PI). Potential study subjects were screened from the antepartum admission roster. Women who met the enrollment criteria were approached by the PI within one to four days of hospital admission. Once patients agreed to participate in the study, they were added to the demographic roster and assigned a participant number and intervention or control group patient code. Each patient was required to sign Health Insurance Portability and Accountability Act (HIPAA) and Research Project Informed Consent forms. Assignment to intervention or control group was made in an alternating sequence based upon a roster assembled by the charge nurse. Women assigned to the intervention and control groups were allowed to opt out of the study if they did not agree to participate. The study participants included 48 women in the inter vention group, and 31 in the control group. Inclusion criteria were: confirmed pregnancy, physician activity orders requiring bedrest, abil ity to speak and understand English, physical ability to move indepen dently in bed, and an anticipated minimum stay of two weeks. Exclusions to the study were women who delivered before the two week length of stay, those under psychiatric supervision or incarcerated. The study was approved by the Institutional Review Board (IRB) prior to implementation.
2.5. Outcome assessment Participants in the intervention and control groups completed a short researcher-designed demographic survey and the Hospital Anxiety and Depression Scale (HADS) prior to the day of discharge from the medical center. This was a self-administered questionnaire provided to each participant in a sealed unmarked envelope that was returned after completion to the head of research and filed in a locked cabinet until data entry. The demographic survey included: participant’s age, gesta tional age at enrollment, gestational age at end of program, education level, length of stay on antepartum unit, and entire length of stay for that admission. The HADS was developed as a short tool to identify patients at risk for two common psychological disorders, anxiety and depression, and has been successfully used as a clinical screening tool for anxiety and depression in pregnant women in previously published research [ [20,53–57]]. The HADS has 14 items—seven related to anxiety and seven related to depression. Each item is a statement in which re spondents choose the degree of anxiety, and depression that is true for them on a four-point Likert-type scale. The scale ranges from 0 to 3, with 0 representing no symptoms and 3 representing the clear presence of symptoms related to anxiety or depression. The two subscales (HADS-A and HADS-D) are summed separately and may also be added together for a total score. The cut-off score for determining the presence of anxiety or depression is eight for each subscale [57]. Concurrent validity has been reported in several studies. When the HADS was administered to 50 people who had been previously diag nosed with anxiety or depression, the cut-off points were the same for each subscale, with only one false positive for each subscale [53]. In a systematic review of HADS, Bjelland found that six studies reported positive correlations between the HADS-D and Beck’s Depression In ventory, which ranged from 0.62 to 0.73 [50]. In two other studies, correlations between the HADS-A and the Clinical Anxiety Scale were
2.4. Study intervention The PI is a certified registered yoga instructor with 33 years of yoga training and 22 years of pre and postnatal international yoga teaching experience acquiring extensive accreditation. The PI has been affiliated with the medical center for 19 years, providing hospital-based com munity perinatal yoga including pregnancy, postnatal, mommy/baby courses, expanding that role to include the hospitalized antepartum patient population as well as one on one individualized yoga protocols for cancer patients through the hospital’s Integrative Medicine Department. The charge nurse provided the yoga instructor/primary investigator with a list of patients meeting the inclusion/exclusion criteria. Each participant was consented for participation by the investigator once they had completed a HIPAA authorization and research project consent form. Once consented, the participants were randomly assigned to either control or intervention group. The intervention group had 30 min of individually led yoga sessions with the certified yoga instructor/researcher as well as an on-demand yoga video created by the same instructor using an identical one-on3
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than in the control group (9.03 � 3.97; p < 0.001). Likewise, patients in the intervention group had significantly lower levels of depression (3.33 � 2.26) than those in the control group (6.06 � 3.58; p < 0.001). Among patients with less than a college degree, both anxiety and depression levels were lower (p ¼ 0.013; p ¼ 0.004, respectively) in the interven tion group than those in the control group. Patients in the intervention group had an average of 7.46 (3–16) instructor-led sessions, and 2 (0–24) video sessions; and the number of instructor-led sessions or video sessions did not correlate with either anxiety or depression scores (see Table 3).
0.69 and 0.75 [57]. In addition, correlations between the HADS-A and Spielberger’s State-Trait Anxiety Inventory ranged from 0.64 to 0.81 [57]. 2.6. Statistical methods Statistics were reported for all groups as n (%) for categorical vari ables and as means � SD for continuous variables. Comparisons between groups (intervention vs controls) were performed using Student t-test for parametric outcomes and Chi-square analysis for all categorical out comes; association between outcomes were measured using Pearson’s correlation. All statistical tests were two-sided, and p � 0.05 was considered significant.
4. Discussion This study supported the hypothesis that yoga is an effective inter vention to decrease anxiety and depression in high-risk hospitalized antepartum women on bedrest. Previous research has found that peri natal depression and anxiety disorders can affect 10%–20% of women respectively, which can be exacerbated by confinement of doctor pre scribed bed rest [1,44]. The results from this study are in-line with previous findings that show yoga is a safe and acceptable intervention for pregnant women with anxiety and depressive symptoms [58]. Yet, to our knowledge, this is the first randomized controlled trial to assess the effects of a specially designed and adapted yoga program on anxiety and depression for high-risk expectant mothers on bedrest in a hospital setting. Often removed from their families for up to 12 weeks, this special ized group of patients are confronted with a host of emotionally debil itating situations that are unobserved by their low risk peers. The hospital where the study took place services a geographical area of over 200 km. Due to socioeconomic reasons, many families cannot afford the added burden of traveling up to 2 h to visit the confined mother as they are financially incapable of missing work or paying the extra fuel costs to fund traveling to the medical center. Therefore, the patient is unable to see her other children, spouse, family and friends on a regular basis. Not having access to everyday social networks and support systems leaves the mother with enhanced feelings of isolation which in turn, increases her chances of developing anxiety and depression [5,6]. In addition, having to miss important holidays and milestone events, such as birth days and graduations, is an extra emotional burden on the mother restricted to bedrest. Traditional yoga has shown to be effective in relieving symptoms of mental disorders including depression and anxiety [35,59]. It is important to note that a traditional yogic lifestyle approach in cludes positive thinking, meditation, specific breathing and relaxation techniques, as well yoga poses [60]. By modifying the full spectrum of traditional yoga techniques to accommodate the specific medical needs of the patient while addressing heightened sensitivity to depressive states, the researcher developed a program that showed significant improvement in their overall mental health and well-being. An important aspect of the yoga program’s design is to teach the mother relaxed breathing, positive thinking techniques and safe bed adapted movement that she can easily replicate outside of the scheduled visits from the yoga instructor. This provides the patient with specific tools to enhance her physical and mental well-being anytime during her antepartum stay. As gentle bed adapted yoga had no occurrence of adverse events, there is a possibility that any medical center can use a bedrest yoga
2.7. Ethical considerations Before the initiation of the study, the medical center’s Nursing Research Council and the Institutional Review Board approved the research protocol and all investigators completed Collaborative Insti tutional Training Initiative (CITI) for the Protection of Human Subjects Research Curriculum. All participants were fully informed of the study’s purpose, required to sign consent and HIPAA forms and at any time, were free to remove themselves from the study without any negative repercussions. Participant names were kept on a master list, along with a unique participant code. The master list was held in a locked cabinet in the secured office of the Director of Nursing Research. Data collection forms only contained participant codes, with no patient names or other identifiers and were held in a separate locked drawer. All study related computer files had password protection. Yoga sessions were free of charge. Otherwise, no incentives for participation were given. 3. Results During the study period, 79 patients met the inclusion criteria. Table 1 summarizes the overall patient characteristics. Patient mean age (30.44 � 6.17 vs. 27.65 � 7.46; p ¼0.074) and gestational age at enrollment (28.33 � 3.18 vs. 27 � 3.63; p ¼ 0.186) were comparable between the intervention group (yoga) and control group, respectively. Of the patients, 77 (98%) had a live birth and 2 (2%) experienced fetal demise. There were no differences in the number of fetal demises (p ¼ 0.634) or length of stay in the hospital (p ¼ 0.237) between groups. Patients in the intervention group had a higher education level than those in the control group (p < 0.001). To study the effects of the proposed yoga program, we compared perceived anxiety and depression scores between groups at the end of their stay in the antepartum unit as shown on Table 2. Perceived anxiety levels (5.88 � 2.91) were significantly lower in the intervention group Table 1 Demographic variables of high-risk hospitalized pregnant women in the study groups. Demographic variable
Intervention group (n ¼ 48)
Control group (n ¼ 31)
pvalue*
Age (years) Fetal demise (instances) Gestational age at enrollment (weeks) Gestational age at discharge (weeks) Length of stay in antepartum unit (days) Length of stay in hospital (days) Education level Less than college degree College degree or greater
30.44 � 6.17 1 28.33 � 3.18
27.65 � 7.46 1 27.30 � 3.63
0.074 0.634 0.186
32.45 � 2.86
31.28 � 3.40
0.104
33.40 � 13.45
30.00 � 14.45
0.290
36.21 � 14.34
32.19 � 15.04
0.237
24 (50%) 24 (50%)
29 (93.5%) 2 (6.5%)
0.617 <0.001
Table 2 Difference in anxiety and depression scores between high-risk hospitalized pregnant women in the intervention and control groups.
* Chi-square test; significance level p � 0.05.
Outcome
Intervention Group
Control Group
p-value *
Perceived anxiety Depression
5.88 � 2.91 3.33 � 2.26
9.03 � 3.97 6.06 � 3.58
<0.001 <0.001
*Independent sample t-tests; significance level p � 0.05. 4
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Health Forsyth Medical Center.
Table 3 Correlations between number of instructor-led and video yoga sessions with anxiety and depression scores in the intervention group. Variables Instructor-led sessions r value (p-value)a Video sessions r value (p-value)a a
Anxiety score
Depression Score
- 0.164 (0.266)
- 0.162 (0.271)
- 0.036 (0.811)
0.075 (0.611)
Declaration of competing interest
Total HADS score
The authors declare that they do not have a conflict of interest.
0.202 (0.168)
Acknowledgements
0.016 (0.914)
Pearson’s correlations.
Many thanks to Renata S. Magalhaes, MD, PhD for editorial assis tance. Gloria Walters PhD, RN, RN-BC, CCRN-K for proof reading, writing and data assistance of the article.
program as an alternative or augmentative approach to standard med ical treatment for hospitalized mothers. In addition, yoga has become increasingly more popular and commonplace in Western society allowing easy acceptance of such a program into conventional medical institutions. Potential limitations for this study were the relatively small sample size within one hospital, which limits generalizability. Self-reported data collection tools (yoga log and HADS) may not have been completed accurately. Due to the volatile nature of being a high-risk antepartum patient, sudden changes in condition could have occurred that required the participant to complete the survey after an unexpected and possibly traumatic event such as premature rupture of membranes, onset of early uterine contractions or vaginal bleeding that may have altered the responses due to stress. In addition, baseline measurement for anxiety and depression were not performed due to elevated stress levels experienced at the time of admission. Furthermore, quantification of stress was not controlled for length of stay or long-term effects of yoga sessions after discharge.
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5. Clinical implications Hospitals with antepartum patients requiring long periods of bedrest should consider implementing bedrest yoga programs to alleviate anx iety and depression. The intervention used in this study was developed at a teaching hospital and has been found to positively impact the wellbeing of the mother. This program may be readily adapted for use in other hospitals; the lead instructor is enthusiastic to help implement trainings for local yoga instructors in areas that have established highrisk maternity units for patients on physician ordered bedrest. In addi tion, hospitals may find that bedrest yoga is a patient satisfier, improving patient engagement scores and likelihood to recommend the hospital to other expectant mothers. The cost of implementing such a program can be minimized using videos after an initial session. In structors need not be highly experienced practitioners of yoga to teach the techniques to expectant mothers. 6. Conclusion Our results indicated that yoga, even just a few sessions, is an effective strategy to mitigate anxiety and depression in hospitalized bedrest high-risk mothers. We adapted a traditional yoga approach that could be easily implemented in stress-reduction programs within any medical center. Future studies using multiple validated screening tools such as Edinburgh Postnatal Depression Scale (EPDS) and Postpartum Depression Screening Scale in a large number of patients within multicentric institutions could be conducted to assess the beneficial effects of the proposed program as well as to identify the ideal number of ses sions needed. Such programs could be adapted and optimized for structured implementation in medical centers nationwide. Additionally, long-term follow-up may provide insight into the implications of the yoga stress management protocol on mother and infant well-being. Funding Funding was provided by the Nursing Research Grant at Novant 5
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