The effect of relaxation exercises on sleep quality in pregnant women in the third trimester: A randomized controlled trial

Complementary Therapies in Clinical Practice 32 (2018) 79–84

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The effect of relaxation exercises on sleep quality in pregnant women in the third trimester: A randomized controlled trial

T

Semiha Aydın Özkana,∗, Gülay Rathfischb a

Adıyaman University School of Health, Adıyaman, Turkey Istanbul University, Florence Nightingale Nursing Faculty, Department of Women's Health and Diseases Nursing, Abide-i Hurriyet Street Florence Nightingale Nursing Faculty, 34381, Sisli, Istanbul, Turkey b

A R T I C LE I N FO

A B S T R A C T

Keywords: Pregnancy Sleep quality Relaxation exercise

Objective: To assess the effects of relaxation exercises on subjective sleep quality of in third-trimester pregnant women. Materials and methods: The pretest posttest randomized controlled trial recruited 84 pregnant women in the third trimester. Following random assignment of subjects, the treatment group (n = 46) performed relaxation exercises for four weeks and the control group (n = 46) received standart cares. At baseline and after the intervention sleep quality was assessed. Data obtained were analyzed in SPSS. Results: The mean score of the global Pittsburgh Sleep Quality Index was 7.12 ± 3.66. It was determined that relaxation exercises improved some sleep quality subscales including subjective sleep quality, sleep latency, sleep duration and habitual sleep efficiency, sleep disturbances, daytime dysfunction and global sleep quality. The difference between the two groups was found to be statistically significant (p < 0.05). Conclusion: A four -week compact disc guide relaxation exercises program can be effective in improving sleep quality.

1. Introduction Hormonal and physical changes during pregnancy cause significant changes in regular sleep routine and sleep quality [1]. Sleep problems in pregnancy are common, and they vary depending on the trimesters [2]. By the third trimester, women experience more problems in sleeping [3,4]. Studies investigating sleep quality in pregnancy indicate that pregnant women in the third trimester have poor sleep quality at percentages ranging from 50% to 89.3% [2,5–7]. Studies on sleep quality show that poor sleep quality in pregnancy has negative effects on labor as well as on fetal health. It is indicated that pregnant women with poor sleep quality usually have cesarean section, or they experience prolonged labor if they have vaginal birth. The effect of poor sleep quality on neonatal health is revealed in low APGAR scores and low birth weight [8–10]. Besides, it is reported that prenatal sleep disorders trigger the development of postpartum depression [11,12]. Some non-pharmacological relaxation therapy approaches, including progressive muscle relaxation, imagery training, meditation, biofeedback, and hypnosis can be especially effective for initiating sleep [13,14]. Relaxation exercises are important as they reduce the tension in muscles. They involve conscious contraction and relaxation of the big

∗

muscle groups in all body. The purpose is to help individuals to check their entire body and notice the tensions, to be able to control their muscles, and to relax the tension in their body in the shortest time possible. By reducing the tension in muscles, relaxation exercises help pregnant women to have more comfortable sleep and better sleep quality [15]. Studies on improving sleep quality show that progressive relaxation exercises are used in cancer patients, in the treatment of insomnia, in hemodialysis patients, and in patients with multiple sclerosis [16–19]. Studies on relaxation exercises in pregnancy indicate that the exercises reduce backache, improve lung parameters of pregnant women with bronchial asthma, have various effects on biological and psychological stress systems, prolong pregnancy week in pregnant women with preterm action risk, and increase birth weight [20–22]. The present study was guided by the positive effects of relaxation exercises on sleep quality and their use for pregnant women [13,14]. There is scarcity of studies in literature about the effect of relaxation exercises on sleep quality. This is important because sleep quality during pregnancy and its possible effects on the quality of life of pregnant women may affect pregnancy outcomes. This study aims to investigate the effects of relaxation exercises on subjective sleep quality

Corresponding author. Adıyaman University School of Health, Adıyaman, Turkey. Tel.: +90 5348894218; fax: +90 4162233005. E-mail addresses: [email protected] (S.A. Özkan), [email protected] (G. Rathfisch).

https://doi.org/10.1016/j.ctcp.2018.05.008 Received 8 May 2018; Accepted 25 May 2018 1744-3881/ © 2018 Elsevier Ltd. All rights reserved.

Complementary Therapies in Clinical Practice 32 (2018) 79–84

S.A. Özkan, G. Rathfisch

d ≥ 0.5) [7] and the power as 80%. The sample size was determined 40 patients for comparison of means between the two groups. With an anticipated 15% dropout rate and to ensure adequacy of final sample size, 46 patients were selected per group. However, a total of 84 patients took part in the study, including 42 in the relaxation exercises group and 42 in the control. The reasons for participants' dropping out were women's withdrew consent in the course of the study (n = 1 from control group and n = 1 from relaxation exercises group) and women who develop gestational diabetes (n = 2 from control group and n = 3 from relaxation exercises group) and preterm birth (n = 1 from control group). Fig. 1 demonstrates the Consort Flow Diagram (Fig. 1). The study was conducted in the Republic of Turkey Ministry of Health (RTMH) Zeynep Kamil Training and Research Hospital, Pregnant Women Monitoring Clinic, Pregnancy training class. The pregnant women who consulted to the clinic for pregnancy monitoring were provided with training on pregnancy, labor, puerperality, and newborn care. The training lasted for four weeks and was composed of 5 courses, and each course lasted for 3 h. Courses in the pregnancy training class were actively conducted with a midwife. Voluntary pregnant women in the third trimester were included in the relaxation exercises group and control groups. . Relaxation exercises group and control groups were formed according to the number of the pregnant women who volunteered to participate in the study. The demographic variables that affected sleep quality demonstrated similar distribution in both groups after the randomization (p > 0.05). After the training, the pregnant women in the relaxation exercises group were asked to stay in the classroom. Data collection process was started, and the relaxation exercises were implemented then.

of the pregnant women in the third trimester. 2. Methods 2.1. Study design This study is a randomized controlled trial with a prospective pretest post-test experimental design. 2.2. Population, sample and randomization process This study was conducted between September 2012 and July 2013 at Pregnant Women Monitoring clinic, pregnancy training class at Republic of Turkey Ministry of Health (RTMH) Zeynep Kamil Training and Research Hospital in Istanbul, Turkey. The Pregnant Women included in the study were randomized as control and intervention (relaxation exercises) groups. Relaxation exercises were applied in the experimental group, standard care was applied to the control group. The following inclusion criteria were established for participants: volunteer pregnant women in the third trimester who were 20 and over, who had primipara, normal (one fetus and riskless) pregnancy, who were in gestational age between 28 and 34 weeks, who had pre-pregnancy Body Mass Index (BMI) of 25 kg/m2 or less, and whose neck circumference is less than 38 cm [23], and who did not experience Restless Legs Syndrome (RLS). A total of 165 pregnant women were visited the pregnancy training class, and 73 pregnant women were excluded for various reasons (Fig. 1). A total of 92 patients met the inclusion criteria and consented to take part in the present study. The patients were randomly assigned to relaxation exercises group (n = 40) and control (n = 40) groups using block randomization with randomly selected block sizes of 4 and an allocation ratio of 1:1 [24]. Sample size was calculated using the Free Statistics Calculators website [25]. Confidence interval was taken as 95%, effect size as 0.64 (Cohen

2.3. Data collection and procedure At the beginning of the first course, the pregnant women in the relaxation exercises group were asked to fill in the structured

Fig. 1. Consort flow diagram. 80

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S.A. Özkan, G. Rathfisch

2.5. Ethical considerations

information form, Pittsburgh Sleep Quality Index (PSQI). At the end of the first course, the instructor mentioned the importance of sleep quality in pregnancy and the effect of relaxation exercises on sleep quality. Then, the pregnant women listened to a 10-min relaxation exercises compact disc (CD) developed by Turkish Psychological Association. The pregnant women were given the relaxation CD to help them to do the relaxation exercises before they sleep. The exercises were repeated each week by the help of the CD when the women came for the course. When the 4-week program that consisted of 5 courses was completed, the pregnant women were reevaluated with PSQI. The pregnant women in the control group were also asked to fill in the structured information form, PSQI at the beginning of the first course. At the end of the first course, the instructor mentioned the importance of sleep quality in pregnancy. When the 4-week program that consisted of 5 courses was completed, the pregnant women were reevaluated with PSQI. All the forms were filled in by the pregnant women. The pregnant women were told that they could call the researcher any time they wanted and given the researcher's contact information card. The data were collected through the structured information form in identifying socio-demographic and general health characteristics of the pregnant women, “Pittsburgh Sleep Quality Index” in identifying the sleep quality.

Target population of the study was the pregnant women who consulted to Zeynep Kamil Training and Research Hospital. Ethics committee approval was obtained from the institution where the study was conducted (Ethics Committee protocol no: 12353, Decision date: 08.06.2012). 2.6. Statistical analysis The data were analyzed using Statistical Package for Social Sciences (SPSS) 15.0 program. In addition to the descriptive statistics, the comparison of quantitative data was performed using Student T-test for comparing data with normal distribution, and Mann Whitney U test for comparing data which did not show normal distribution. Comparison of the qualitative data was performed using Pearson chi-square test, Fisher's Exact test, Fisher-Freeman-Halton Exact Test and Yates' Continuity Correction Test. Statistical significance was taken p < 0.01 and p < 0.05. 3. Results Socio-demographic characteristics of pregnant women in the third trimester are presented in Table 1. No statistically significant differences were found between the experimental (relaxation exercises) group and control group in terms of education level, working or not, the week of pregnancy, and BMI before pregnancy. PSQI pre-test and post-test score percentages of the participants are demonstrated in Table 2. When compared to the control group, sleep quality of the participants in the relaxation exercises group was found to increase significantly in the post-test (χ2 = 43.077, p = 0.001). The participants' scores regarding PSQI components are demonstrated in Table 3. Post-test results indicate statistically significant differences between the relaxation exercises group and the control group in terms of the subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, and daytime dysfunction component in favor of the relaxation exercises group (p = 0.001). Since none of the participants used Sleeping Medication, they scored “0” in this component. Thus, no statistical analysis was conducted about it. According to pre-test PSQI mean scores, there were no statistically significant differences between the relaxation exercises group and control group (Z = −0.360, p = 0.719). Post-test PSQI scores were found 3.31 ± 1.96 in the relaxation exercises group and 8.74 ± 2.80 in the control group. Post-test PSQI mean scores were found to be lower in the relaxation exercises group than those in the control group. The difference between the groups was found to be statistically significant (Z = −7.004, p = 0.001). (Table 3, Fig. 2).

2.4. Structured information form The structured information form developed by the researcher in line with the related literature consists of 25 items. The form, which investigated the descriptive features of the pregnant women, contained questions in relation to the pregnant women’ socio-demographic and obstetrics features, their habits before or during pregnancy, their sleeping habits, and the medicines they used regularly. 2.4.1. Pittsburgh Sleep Quality Index (PSQI) Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), a self-report questionnaire that assesses sleep quality and disturbance during the previous month. The PSQI contains 19 items and measures seven components of sleep quality: subjective sleep quality, sleep latency (time to fall asleep and frequency of not falling asleep within 30 min), sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Each item is scored on a 0 to 3 scale, whereby 3 reflecting the negative extreme on the Likert scale. The summed scores for the seven components form a global PSQI score (range = 0–21), and higher scores indicate poorer sleep quality. A global score ≥5 indicates poor sleep, and yields a diagnostic sensitivity of 98.7% and specificity of 84.4% for diagnosing sleep disturbances. Cronbach's α for the present study was found 0.85 [26,27].

4. Discussion 2.4.2. Relaxation exercises CD Relaxation exercises were given by using a handbook including relaxation exercises (information about how to perform relaxation, respiration control, and progressive relaxation exercises) and a relaxation exercises CD. Relaxation exercises CD was composed of three parts apart from the introduction; it was prepared by the Turkish Psychologists Association based on E. Jacobson's relaxation techniques. The 4-min introduction part gives information about the content of the CD. The following 10-min part contains information about deep relaxation exercises as well as the points to take into consideration during the exercise. The 30-min second part introduces relaxation exercises with an instruction; and the 30-min third part includes only relaxation music without instructions. As instructed in the relaxation exercises CD, the pregnant women in the relaxation exercises group were asked to listen to the first and second parts of the CD together throughout the 4week program [28].

This study aims to evaluate and increase sleep quality of the pregnant women in the third trimester of pregnancy by the help of the relaxation exercises which enable to shorten sleep latency, prolong sleep duration, and decrease the number of sleep disturbances in one night. Review of the related literature indicates that some factors which affect sleep quality include age, level of education, working or not, socio-economic status, and BMI [3,5,6,29–31]. Factors such as age, level of education, working or not, socio-economic status, and BMI display similar distribution in the relaxation exercises and control group, which is important in terms of revealing the effect of relaxation exercises on sleep quality. Sleep disorders especially in the third trimester of pregnancy are common problems that could have negative effects on health [32]. Pittsburgh Sleep Quality Index developed by Buysse et al. (1989) provides a subjective evaluation of sleep quality, and global score > 5 81

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Table 1 Characteristics of the third trimester pregnant women. Characteristic

Maternal Age Maternal Age. years Education

Working status Montly family income TL

Week of pregnancy (pre-test) Planned pregnancy Pregravid BMI (kg/m2) Neck Circumference

Mean ± sd Min-Max 20–29 30–39 Elementary School High School University Works Does not work 500–1000 $ 1000–2000 $ ≥2000 $ 28–30 31–34 Yes No Mean ± sd Min-Max Mean ± sd Min-Max

Relaxation Exercises Group (n = 42)

Control group (n = 42)

Total (n = 84)

Statistics

n (%)

n (%)

n (%)

T*/ χ2

p

27.93 ± 4.56 20.00–39.00 26 (61.9) 16 (38.1) 4 (9.5) 14 (33.4) 24 (57.1) 21 (50.0) 21 (50.0) 6 (14.3) 17 (40.5) 19 (45.2) 26 (61.9) 16 (38.1) 30 (71.4) 12 (28.6) 22.10 ± 2.44 15.92–24.97 32.81 ± 2.30 29.00–36.00

27.79 ± 3.90 20.00–37.00 28 (66.7) 14 (33.3) 5 (11.9) 15 (35.7) 22 (52.4) 21 (50.0) 21 (50.0) 8 (19.0) 17 (40.5) 17 (40.5) 25 (59.5) 17 (40.5) 33 (78.6) 9 (21.4) 21.94 ± 2.12 16.14–24.91 32.52 ± 2.00 29.00–36.00

27.86 ± 4.22 20.00–39.00 54 (64.3) 30 (35.7) 9 (10.7) 29 (34.5) 46 (54.8) 42 (50.0) 42 (50.0) 14 (16.7) 34 (40.5) 36 (42.9) 51 (60.7) 33 (39.3) 63 (75.0) 21 (25.0) 22.02 ± 2.27 15.92–24.97 32.67 ± 2.15 29.00–36.00

0.154

0.878

a

0.820

0.052

b

0.296

0.890

c

0.000

1.000

c

0.397

0.820

0.000a

1.000

a

0.254

0.614

0.337

0.737

0.607

0.545

*Student t-test. a Yates' Continuity Correction Test. b Fisher-Freeman-Halton Exact Test. c Pearson Ki-Kare Test.

less than 15 min was higher in the relaxation exercises group. Studies on pregnant women in the third trimester demonstrate the difficulty the women had in falling asleep [6,7,35]. These results are in line with the pre-test results of the present study. Studies also show that relaxation exercises reduce psychological tension, stress, and pain [21,35,36]. The pregnant women in the relaxation exercises group of the present study reported to fall asleep more comfortably as a result of the decrease in the muscle tension, stress, and pain perception by the help of the relaxation exercises. Sleep duration needed by people is 20–22 h for babies, 10–12 h for children, 6–8 h for adults, and 5–6 h for people aged 60 and over [37]. Sleep duration of the pregnant women in the third trimester is 7,5 h on the average [38]. According to the results obtained from the sleep duration component of the PSQI, almost all of the women in the relaxation exercises group slept more than 7 h after the relaxation exercises. Sleep duration indicated in the related literature for the pregnant women in the third trimester was found to be similar to the pretest results of the present study [5,39]. Given the post-test results of the present study regarding the increase in the sleep duration, relaxation exercises seem to increase the sleep duration of pregnant women. Habitual sleep efficiency component of the PSQI shows the results obtained by dividing the sleep duration into the duration between going to bed in the evening and waking up in the morning and multiplying it by 100. This proportion is expected to be over 85% in pregnant women who sleep well [26]. The ratio of pregnant women whose habitual sleep activity after relaxation exercises was over 85%, which was higher in the relaxation exercises group. In their study conducted with pregnant

indicates poor sleep quality [26]. The present study found that with a 60,7% pre-test PSQI scores, the pregnant women participating in the study had poor sleep quality. Studies which aimed to evaluate sleep quality in the third trimester of pregnancy show that pregnant women had poor sleep quality at various proportions [2,5–7]. Studies show that more than half of the pregnant women in the third trimester have poor sleep quality, which is similar to the results of the present study. It was found that the number of pregnant women who evaluated the subjective sleep quality component of PSQI in the past 4 weeks as “very good” was higher in the relaxation exercises group. The difference between the two groups was found to be statistically significant (p < 0.05). Scores of the subjective sleep quality component in pregnant women in the third trimester conducted by Naud et al. (2010) are in line with the findings of the present study [5]. Subjective sleep quality mean scores of pregnant women in the third trimester are affected by the enlargement in their uterus, which causes such disturbances as difficulties in breathing, frequent urination, and backache. Pregnant women evaluated their subjective sleep quality as “very good” after the relaxation exercises, which indicates that they spent time for themselves after the relaxation exercises, recognized the muscle groups they contracted and relaxed with the relaxation exercises, focused on their breath, and increased their awareness of sleep. Physiological and psychological changes in the third trimester of pregnancy make falling asleep at night more difficult for pregnant women [15,33,34]. The present study found that according to the results obtained from the sleep latency component after relaxation exercises, the number of pregnant women who reported to fall asleep in

Table 2 PSQI pre-test and post-test score percentages of the third trimester pregnant women. PSQI Pre-test Post-test

Good sleep quality* Poor sleep quality** Good sleep quality* Poor sleep quality**

Relaxation Exercises Group (n = 42)

Control group (n = 42)

Total (n = 84)

χ2

Pa

17(40.5) 25(59.5) 35(83.3) 7(16.7)

16(38.1) 26(61.9) 4(9.5) 38(90.5)

33(39.3) 51(60.7) 39(46.4) 45(53.6)

0.000

1.000

43.077

0.001

*PSQI global scor < 5 ** PSQI global scor ≥5. a Yates' Continuity Correction Test. 82

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Table 3 Global score and components of PSQI in the third trimester pregnant women mean and standard deviation distribution. PSQI

Subjective sleep quality Sleep latency Sleep duration Habitual sleep efficiency Sleep disturbances Daytime dysfunction Use of sleep medication Global PSQI

PRE-TEST

POST-TEST a

Relaxation Exercises Group (n = 42)

Control group (n = 42)

Total (n = 84)

Za p*

0.635

0.78 ± 0.52

1.80 ± 0.55

1.30 ± 0.74

−6.548

0.001

−1.824 −0.448 −1.176

0.068 0.654 0.239

0.55 ± 0.63 0.02 ± 0.15 0.14 ± 0.35

1.79 ± 0.75 0.60 ± 0.80 1.33 ± 0.95

1.17 ± 0.93 0.31 ± 0.64 0.74 ± 0.93

−6.184 −4.249 −6.241

0.001 0.001 0.001

1.64 ± 0.57 0.94 ± 0.81

−0.408 −1.254

0.683 0.210

1.31 ± 0.52 0.50 ± 0.63

1.88 ± 0.39 1.33 ± 0.61

1.59 ± 0.54 0.92 ± 0.75

−4.905 −5.142

0.001 0.001

0.00 ± 0.00

0.00 ± 0.00

–

–

0.00 ± 0.00

0.00 ± 0.00

0.00 ± 0.00

–

–

6.83 ± 3.27

7.12 ± 3.66

−0.360

0.719

3.31 ± 1.96

8.74 ± 2.80

6.02 ± 3.64

−7.044

0.001*

Relaxation Exercises Group (n = 42)

Control group (n = 42)

Total (n = 84)

Z p*

1.43 ± 0.77

1.45 ± 0.67

1.44 ± 0.72

−0.475

1.57 ± 1.02 0.67 ± 1.00 1.00 ± 1.13

1.17 ± 0.96 0.52 ± 0.83 1.26 ± 1.13

1.36 ± 1.00 0.60 ± 0.92 1.31 ± 1.13

1.67 ± 0.57 1.07 ± 0.89

1.61 ± 0.58 0.80 ± 0.70

0.00 ± 0.00 7.40 ± 4.03

*p < 0.001. a MannWhitney U test.

conducted by Naud et al. (2010) shows similarity with the pre-test results of the present study [5]. Moreover, it was found that the pregnant women who did relaxation exercises had no difficulty in staying awake in daytime activities such as driving a car, eating, or conducting their social activities. Medicine used in pregnancy can be transmitted from mother to fetus through placenta. Therefore, pregnant women do not want to use medication because they think it might harm their baby. Using medication component of the PSQI investigates the use of sleeping medication to cope with the sleeping problems. None of the women participating in the present study were found to use sleeping medication. Studies show that only a few pregnant women who had poor sleep quality used sleeping medication [5,40]. Unlike the case revealed in this study, the related literature demonstrates the use of sleeping medication in pregnancy, which indicates the high sensitivity of the pregnant women in the present study regarding the use of medication with the fear that it may harm their baby. PSQI scores range between 0 and 21, and sleep quality decreases with the increase in the total index score [27]. PSQI mean global score is 7.2 ± 3.66 in the pre-test for all the participants. Findings of the pretest in the present study are parallel to the ones in the related literature [5,6,41,42]. Pre-test PSQI global score of the women in the relaxation exercises group in pre-test was 7.40 ± 4.03, and it was found 3.31 ± 1.96 in the post-test after the relaxation exercises (p < 0.001). Pre-test and post-test global scores of the pregnant women in the relaxation exercises and control group indicate that the relaxation exercises done by the women in the third trimester had effects in increasing the sleep quality. Studies found that the relaxation exercises conducted in pregnancy improved lung parameters in pregnant women with bronchial asthma [21], the exercises had various effects on biological and psychological stress systems [20], prolonged pregnancy week in pregnant women with preterm action risk, and increased birth rate [22]. This study was guided by the fact that relaxation exercises had positive effects on sleep quality and that they could be used in pregnant women. The study also found that relaxation exercises increased sleep quality of the pregnant women. It is by far the only study that utilized randomized controlled pre-test post-test experimental and control design, which indicates the importance of the results.

Fig. 2. Sleep quality changes pre-test (time1) and post-test (time2) relaxation exercises group and control group.

women in the third trimester, Tsai et al. (2011) found the habitual sleep activity as 80% [6]. Ko et al. (2010) report that pregnant women with poor sleep quality have lower habitual sleep activity [32]. Pre-test results of this study are in line with the findings in the related literature. Relaxation exercises seem to increase habitual sleep efficiency of the pregnant women in the relaxation exercises group. PSQI sleep disorder component encompasses sleep disturbances due to such factors as waking at midnight or early in the morning, going to the bathroom, having difficulty in breathing, snoring noisily, being cold, being hot, having bad dreams, and having pain. In their study conducted with pregnant women in the third trimester, Hutchison et al. (2012) found that the women had difficulty in falling asleep and maintaining sleep due to such reasons as uneasiness, pain, thinking bad things, being hot, being cold, having breathing problems, having bad dreams, and coughing [2]. The present study shows that the number of women who reported to have sleep disorders once or twice a week decreased in the relaxation exercises group after the relaxation exercises. Mean score for the sleep disorder component of the study conducted by Naud et al. (2010) is similar with the pre-test results of the present study [5]. The finding which revealed a decrease in the number of pregnant women who had sleeping disorders in the relaxation exercises group indicated the effect of relaxation exercises. Daytime dysfunction component of PSQI shows how the sleeping problems experienced during the night cause problems in daytime functions. The present study showed that the number of pregnant women in the relaxation exercises group who did not have daytime dysfunction throughout one week was more than that of the control group. Mean score for the daytime dysfunction component of the study

5. Strengths and limitations A major strength of this study was that it was designed as a randomized controlled trial one with a prospective pre-test post-test experimental design. It was conducted with relaxation exercises group and control group. It is also the first experimental study in Turkey 83

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within the scope of alternative practices that examined the effect of relaxation exercises on sleep quality. Several limitations of our study are noteworthy. First, there is no validated questionnaire for sleep disorders in pregnancy, and although we used questions from other validated tools such as PSQI questionnaire, the relative contributions of common symptoms of pregnancy and true sleep disorder are unclear. Second, majority of the participating women were highly educated, motivated to learn more about the obstetric benefits of relaxation techniques, and had stable partners and jobs, which makes them not a complete representative of the general population. Our sample consisted of healthy participants. Finally, another limitation is that the frequency of home practice of applied relaxation was based on unverified, subjective self-reports from each participant in the relaxation exercises group. However, the women in this study experienced a wanted pregnancy, which could have motivated them to use the relaxation techniques at home to ensure a healthy pregnancy outcome.

pregnancy? J Obstet Gynaecol Can. 32 (1) (2010) 28–34. [6] S.Y. Tsai, L.T. Kuo, Y.H. Lai, C.N. Lee, Factors associated with sleep quality in pregnant women: a prospective observational study, Nurs. Res. 60 (6) (2011) 405–412. [7] N. Taskıran, Pregnancy and sleep quality, Turk. J. Sociol. Obstet. Gynecol. 8 (3) (2011) 181–187. [8] K.A. Lee, C.L. Gay, Sleep in late pregnancy predicts length of labor and type of delivery, Am. J. Obstet. Gynecol. 191 (2004) 2041–2046. [9] I. Naghi, F. Keypour, S.B. Ahari, S.A. Tavalai, M. Khak, Sleep disturbance in late pregnancy and type and duration of labour, J. Obstet. Gynaecol. 31 (6) (2011) 489–491. [10] N. Zafarghandi, S. Hadavand, A. Davati, S.M. Mohseni, F. Kimiaiimoghadam, F. Torkestani, The effects of sleep quality and duration in late pregnancy on labor and fetal outcome, J. Matern. Fetal Neonatal Med. 8 (2011) 10–18. [11] K.A. Thomas, S. Spieker, Sleep, depression, and fatigue in late postpartum, MCN Am. J. Matern./Child Nurs. 41 (2) (2016) 104–109. [12] M.L. Okun, B.H. Hanusa, M. Hall, K.L. Wisner, Sleep complaints in late pregnancy and the recurrence of postpartum depression, Behav. Sleep Med. 7 (2) (2009) 106–117. [13] D. Cunnington, M.F. Junge, A.T. Fernando, Insomnia: prevalence, consequences and effective treatment, Med. J. Aust. 199 (8) (2013) 36–40. [14] A.T. Siebern, S. Suh, S. Nowakowski, Non-pharmacological treatment of insomnia, Neurotherapeutics 9 (4) (2012) 717–727. [15] K.A. Lee, Sleep promotion in the childbearing family, in: N. Redeker, G.P. McEnany (Eds.), Sleep Disorders and Sleep Promotion in Nursing Practice, Springer Publishing Company, New York, 2011. [16] R. Simeit, R. Deck, B. Conta Marx, Sleep management training for cancer patients with insomnia, Support. Care Canc. 12 (3) (2004) 176–183. [17] M.K. Means, K.L. Lichstein, M.T. Epperson, C.T. Johnson, Relaxation therapy for insomnia: nighttime and day time effects, Behav. Res. Ther. 38 (7) (2000) 665–678. [18] M. Saeedi, T. Ashktorab, K. Saatchi, F. Zayeri, S.A. Ali Akbari, The effect of progressive muscle relaxation on sleep quality of patients undergoing hemodialysis, Iran. J. Crit. Care Nurs. 5 (1) (2012) 23–28. [19] N. Dayapoğlu, M. Tan, Evaluation of the effect of progressive relaxation exercises on fatigue and sleep quality in patients with multiple sclerosis, J. Alternative Compl. Med. 18 (10) (2012) 983–987. [20] C. Urech, N.S. Fink, I. Hoesli, F.H. Wilhelm, J. Bitzer, J. Alder, Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial, Psychoneuroendocrinology 35 (9) (2010) 1348–1355. [21] C. Nickel, C. Lahmann, M. Muehlbacher, et al., Pregnant women with bronchial asthma benefit from progressive muscle relaxation: a randomized, prospective, controlled trial, Psychother. Psychosom. 75 (2006) 237–243. [22] L.L. Chuang, L.C. Lin, P.J. Cheng, C.H. Chen, S.C. Wue, C.L. Chang, The effectiveness of a relaxation training program for women with preterm labour on pregnancy outcomes: a controlled clinical trial, Int. J. Nurs. Stud. 49 (2012) 257–264. [23] M.S. Ip, K.S. Lam, C. Ho, K.W. Tsang, W. Lam, Serum leptin and vascular risk factors in obstructive sleep apnea, Chest 118 (3) (2000) 580–586. [24] Research randomizer https://www.randomizer.org/ [Accessed 11 August 2012]. [25] Free Statistics Calculators https://www.danielsoper.com/statcalc/calculator.aspx?id=47 [Accessed 11 August 2012]. [26] D.J. Buysse, C.F. Reynolds, T.H. Monk, S.R. Berman, D.J. Kupfer, The Pittsburgh Sleep Quality Index: a new ınstrument for psychiatric practice and research, Psychiatr. Res. 28 (2) (1989) 193–213. [27] M.Y. Ağargün, H. Kara, O. Anlar, The validity and reliability of the Pittsburgh sleep quality index, Turk. J. Psychiatr. 7 (2) (1996) 107–115. [28] Turkish Psychologists Associated. Effective Stress Management Method: Relaxation Exercises, Turkish Psychologists Associated Publication, 2010. [29] J. Worth, C.I. Onyeije, A. Ferber, J.S. Pondo, M.Y. Divon, The association between fetal and maternal sleep patterns in third-trimester pregnancies, Am. J. Obstet. Gynecol. 186 (5) (2002) 924–925. [30] M.M. Kennelly, A. Fallon, N. Farah, B. Stuart, J. Turner, Effects of body mass index on sleep patterns during pregnancy, J. Obstet. Gynaecol. 31 (2) (2011) 125–127. [31] G. Bourjeily, C. Raker, M. Chalhoub, M. Miller, Excessive daytime sleepiness in late pregnancy may not always be normal: results from a cross-sectional study, Sleep Breath. 17 (2013) 735–740. [32] S.H. Ko, S.C. Chang, C.H. Chen, A comparative study of sleep quality between pregnant and non-pregnant Taiwanese Women, J. Nurs. Scholarsh. 42 (2010) 23–30. [33] S. Sharma, R. Franco, Sleep and its disorders in pregnancy, Wis. Med. J. 103 (2004) 48–51. [34] G.G. Urizar, M. Milazzo, H.N. Lec, K. Delucchi, R. Sotelo, R.F. Muñozb, Impact of stress reduction ınstructions on stress and cortisol levels during pregnancy, Biol. Psychol. 67 (2004) 275–282. [35] J.A. DiPietro, K.A. Costigan, P. Nelson, E.D. Gurewitsch, M.L. Laudenslage, r Fetal responses to induced maternal relaxation during pregnancy, Biol. Psychol. 77 (2008) 11–19. [36] F. Bastani, A. Hidarnia, A. Kazemnejad, M. Vafaei, M.A. Kashanian, Randomized controlled trial of the effects of applied relaxation training on reducing anxiety and perceived stress in pregnant women, J. Midwifery Wom. Health 50 (4) (2005) 36–40. [37] M.H. Kryger, A Woman's Guide to Sleep Disorders, McGraw-Hill Companies, USA, 2004. [38] K.A. Lee, A.B. Caughey, Evaluating Insomnia during Pregnancy and Postpartum, in: H.P. Attarian (Ed.), Sleep Disorders in Women a Guide to Practical Management, Humana Press Inc, Totowa, New Jersey, 2006, p. 186. [39] F.L. Facco, J. Kramer, K.H. Ho, P.C. Zee, W.A. Grobman, Sleep disturbances in pregnancy, Obstet. Gynecol. 115 (2010) 77–83. [40] H. Ko, J. Shin, M.Y. Kim, et al., Sleep disturbances in Korean pregnant and postpartum women, J. Psychosom. Obstet. Gynaecol. 33 (2) (2012) 85–90. [41] S. Coo, J. Milgrom, J. Trinder, Mood and objective and subjective measures of sleep during late pregnancy and the postpartum period, Behav. Sleep Med. 11 (2013) 1–14. [42] F.E. Daryani, M. Mirghafourvand, S.M.A. Charandabi, F.S. Sarand, Sleep quality and its relationship with quality of life in Iranian pregnant women, Int. J. Nurs. Pract. 23 (2) (2017) e12518.

6. Conclusions The present study found that with a 60,7% pre-test PSQI scores, the pregnant women participating in the study had poor sleep quality. The four-week relaxation exercises improved subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, daytime dysfunction, and sleep quality of the pregnant women in the third trimester. Health care providers, especially nurses and midwives, should not overlook sleep problems as part of natural experience of pregnancy. Complementary treatments, such as relaxation exercises, should be used as a nursing intervention to improve sleep quality of the pregnant women in the third trimester. Future studies to investigate the effects of relaxation exercises increasing sleep quality on birth outcomes would shed more light on the issue. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest The authors declare there are no conflicts of interest. Authorship All authors made significant contributions to the study design, acquisition of data, drafting of the article, and final approval of the article. Acknowledgement The authors would sincerely like to thank the pregnant women who participated in this study. References [1] E.P. Sloan, Sleep disruption during pregnancy, Sleep Med. Clin. 3 (2008) 73–80. [2] B.L. Hutchison, P.R. Stone, L. McCowan, A.W. Stewart, J. Thompson, E. Mitchell, A postal survey of maternal sleep in late pregnancy, BMC Pregnancy Childbirth 12 (144) (2012) 2–7. [3] C. Hedman, T. Pohjasvaaara, U. Tolonen, A.S. Suhonen-Malm, V.V. Myllylä, Effects of pregnancy on mothers sleep, Sleep Med. 3 (1) (2002) 37–42. [4] G.W. Pien, R.J. Schwab, Sleep disorders during pregnancy, Sleep 27 (2004) 1405–1417. [5] K. Naud, A. Ouellet, C. Brown, J.C. Pasquier, JM. Moutquini Is sleep disturbed in

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