Yoga and Pregnancy

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Yoga is a holistic practice that incorporates physical postures (asanas), breathing techniques (pranayama) and meditation to promote mental and physical well-being. Studies have shown that yoga is beneficial in cases such as anxiety, depression, low back pain and sleep disorders during pregnancy, and that it positively affects mother-baby bonding, birth and postpartum period. Nevertheless, there are a limited number of studies that have demonstrated an improvement in outcomes for high-risk pregnancies. The positive outcomes, applicability and cost-effectiveness of yoga during pregnancy, birth and postpartum period are stated in the studies. When the studies conducted are examined, the positive results and economic dimension of yoga practices draw attention. Being aware of the positive effects of yoga on pregnancy, childbirth and postpartum processes can greatly improve the health and well-being of both mother and baby.  It is believed that healthcare professionals, particularly obstetricians and midwives, should enhance their training and education in this area and further research will provide substantial benefits.

Origins of Yoga

Yoga is a Sanskrit word derived from the term “yuj”, which means to unite or union, wholeness, to become one. Expressed in inscriptions dating back to 400 BC as a set of systematic methods for the individual to recognize himself, to remember his direct connection with the source and to open the mind to higher consciousness, yoga is accepted as a science and art as a way of living in full consciousness. Yoga is not a religion or belief, but a system of philosophy. It is a practice that includes deep breathing (pranayama) and meditation based on the unity of mind and body, as well as stretching exercises and postures (asanas). In the early 1920s, Jagannath Gune, a scientific researcher, established the Kaivalyadhama Health and Yoga Research Center in India, making yoga a form of exercise for health and wellness. In the late 1930s, women began practicing yoga and it became a widely recognized form of exercise that became a worldwide phenomenon.

Yoga is a holistic system that encompasses all ethical, emotional, mental and spiritual teachings and is based on 8 principles: yama, niyama, asana, pranayama, prathayara, dhrana, dhyana, samadhi. Yama is the rules for living by a moral code, avoiding negative behaviors such as violence, lying, stealing, obsessions and etc. Niyama is to teach self-regulation, self-discipline, and to incorporate positive behaviors such as purity, cleanliness, contentment, simplicity, work and surrender. Asana, the postures of the body, and pranayama, the breathing exercises, refer to training the body and mind with basic practices for physical, functional, spiritual and mental health.

Pranayama controls the mind by taming basic instincts, while pratyahara, the principle of detachment from the outside world, controls the outward flow of the senses. Dhrana, or concentration, directs consciousness so that attention can be focused on a single point. Dhyana, or meditation, is a state of constant concentration in which conscious energy dissolves. Samadhi is the final goal of meditation, where the mind and spirit remain awake while the body and senses rest. Yoga philosophy considers the person as a physical, mental, spiritual, intellectual, emotional concept and consists of three main components. The first is asana or physical posture, the second is pranayama or breathing exercises and the third is meditation or relaxation. There are many types of yoga, the best known ones being bhakti yoga, ashtanga yoga, karma yoga, raja yoga, kundalini yoga, yin yoga and hatha yoga, which is the most common yoga taught in the West, especially in the United States, consisting of postures and exercises designed to make the body smooth and flexible, combined with relaxation in the later stages of training.

Yoga has a physiological and neurophysiological effect on Beta-Endorphin release and changes in brain neurotransmitter levels. With the relaxation response in yoga, the physiological de-activation response activates the parasympathetic activity, releasing dopamine and serotonin, which especially affect emotional changes, and provides relaxation and thus has a positive effect on stress. Successful results have been obtained when yoga is practiced on healthy individuals as well as in various diseases such as chronic heart diseases, hypertension, diabetes, asthma, multiple sclerosis, complaints such as fatigue, pain, muscle spasm, sleep, depression and during pregnancy.

Yoga in Pregnancy

Yoga, which is practiced in many areas, has been practiced in pregnancy since the 20th century. It has been found that women who practice yoga regularly during pregnancy experience fewer pregnancy disorders, stress, anxiety, depression and sleep disturbances. As it is known, pregnancy is a natural process, but changes in physiological and psychosocial balance, differentiation of roles in life, and adaptation to the new changing role require bio-psychosocial adaptation for the pregnant woman and her environment. Changes and behavioral patterns during pregnancy affect pregnancy outcomes, the fetus and the mother both physiologically and psychologically. In addition, since the lifestyle of the expectant mother and father affects the developing baby, couples who decide to have a child need to review and adjust their lifestyle. In this respect, the holistic approach of yoga before pregnancy is an important method to increase the chances of getting pregnant by optimizing reproductive health and to meet the needs that arise during pregnancy, birth and postpartum. In addition to strengthening the uterine and perineal muscles and supporting the spine, yoga is effective in dealing with common problems of pregnancy such as poor circulation, blood pressure fluctuations, excessive weight gain, fatigue, edema and urinary problems. The discipline inherent in asanas and the ability to create mental ease allows the body to meet contractions in labor with less anxiety, making it easier to relax and let go between each contraction. In terms of applicability, yoga asanas during pregnancy are organized in three sections according to the week of pregnancy.

Yoga in early pregnancy (first 16 weeks): During this period, the emphasis is mostly on relaxation and breath awareness practices. The aim during this period is not to teach yoga to new pregnant women, but to help them gain a certain attitude towards pregnancy and childbirth and to guide them towards appropriate practices. In the early weeks of pregnancy, yoga practice can last up to 45 minutes on average. During this time, five minutes can be devoted to breathwork, 25 minutes to yoga asanas, 15 minutes to mother-baby communication and meditation. Yoga in mid-pregnancy (16-34 weeks); lying on your back can be very uncomfortable during this period due to the growing baby and uterus. Excessive weight gain can negatively impact posture and increase pressure on the spine and legs. As a result, more emphasis is placed on postures performed on the floor. In the middle pregnancy week, yoga practice can take about an hour on average. Within this hour, five minutes can be devoted to breathwork, 40 minutes to yoga asanas, 15 minutes to mother-baby communication and meditation.

Yoga in late pregnancy (34th week and later): In the last weeks of pregnancy, it is aimed to ensure the comfort of the pregnant woman, to prepare her spiritually, physically and mentally for birth and to support the baby to settle in the birth canal in the correct position. During this period, the pregnant woman can be taught breathing exercises and yoga asanas that she can use during labor. During this time, transitions between postures should be slower and rest breaks should be incorporated. In the final weeks of pregnancy, yoga practice can take around 40 minutes on average. During this time, 5 minutes can be devoted to breathwork, 20 minutes to yoga asanas, 15 minutes to mother-baby communication and meditation. It is stated that the meditation practice in yoga helps to relieve pressure and tension, to develop the self, to increase feelings of love and compassion, and to become more enthusiastic, peaceful and happy. It is also stated that yoga during pregnancy has many benefits such as activating muscles, providing relaxation, enabling healthy progression of labor, relaxing blood flow to the uterus and baby, providing immunity to labor pain, activating instincts and intuition, strengthening mother-baby communication, increasing confidence in the woman’s own body, and reducing fear and stress of childbirth. The number of studies revealing evidence suggesting the beneficial effects of yoga has been increasing recently.

The Psychological Effects of Yoga During Pregnancy

Pregnancy is a period of happiness in a woman’s life where positive emotions are experienced and spiritual fulfillment is achieved, but it is also a period where negative psychological emotions such as stress, anxiety, anxious waiting, and overload can be experienced. Therefore, pregnancy is a relatively stressful process at certain times. The two main factors affecting this process are the physiological and psychological differences that occur in hormones as a result of changes in endocrine physiology and the situations arising from the ongoing innovations in the woman’s life flow. In a study conducted by Satyapriya et al. in 2009 on perceived stress during pregnancy, yoga and deep relaxation technique were compared with standard prenatal exercises; at the end of the study, a significant decrease was observed in the yoga group, while stress increased by 6.60% in the control group. In another study by Chen et al., prenatal yoga and routine prenatal care were compared and their effects on stress were examined; it was found that the stress levels of pregnant women in the yoga group decreased significantly compared to the control group. In a randomized controlled trial, yoga was found to positively affect psychosocial well-being In other studies, pregnancy yoga was found to improve the quality of life of pregnant women and reduce stress. Depression is common in pregnancy, affecting 10-49% of women.

In the study conducted by Khalajzadeh et al, it was found that anxiety was lower in the experimental group after yoga applied to 2nd and 3rd trimester pregnant women for 8 weeks, 2 days a week and 60 minutes, and it was reported that yoga is an effective method to reduce anxiety during pregnancy. In another study, the effects of yoga and social support control group on prenatal depression and anxiety were examined, and at the end of the study, improvement was observed in both groups; however, it was found that the yoga group had less depression, anxiety, anger, leg and back pain compared to the support group. A systematic review reported that yoga reduced pain and stress and was more effective than standard prenatal exercises and walking. Battle et al. found that yoga significantly reduced the severity of depression and was a feasible method. Davis et al. compared yoga therapy with standard treatment and looked at their effects on depression and anxiety; both groups were found to significantly reduce symptoms of depression and anxiety, but there was no significant difference between the groups. In a study comparing prenatal hatha yoga with standard care, symptoms of depression were assessed during pregnancy and postpartum, and yoga was found to improve mood at that time. In studies, it is stated that prenatal attachment level is higher in pregnant women who exercise and do relaxation exercises.

Physiological Effects of Yoga During Pregnancy

There are natural physiological adaptations that occur during pregnancy, such as an increase in cardiac output, heart rate and plasma volume. Pranayamic breathing, commonly referred to as deep breathing, is a deliberate manipulation of the breathing process and is a fundamental aspect of yoga practice. Slow, controlled, deep breathing often activates the parasympathetic nervous system by stretching the lung tissue and vagal nerves. This results in a physiological response characterized by a decrease in heart rate, blood pressure, metabolic rate and oxygen consumption. Sun et al. compared yoga exercises with a control group in primiparous pregnant women and reported significantly less pregnancy discomfort in the yoga group compared to the control group. In the study by Yi-Chin and Ya-Chi, it was reported that yoga program significantly reduced maternal discomfort and in the study by Vogler et al. it was reported that yoga increased physical well-being, and in another study by Jiang et al. it was reported to alleviate prenatal discomfort during pregnancy.

It is not uncommon for pregnant women to experience sleep disturbances, however, these issues are often overlooked. Poor sleep during pregnancy can be linked to negative pregnancy outcomes such as premature delivery and pre-eclampsia. Not only do physiological changes that occur during pregnancy play a role in sleep changes, but emotional factors such as anxiety surrounding the impending childbirth and transition to parenthood can also contribute to sleep disturbances. This was demonstrated in a pilot study conducted by Beddoe et al, which found that when yoga was initiated in the second trimester, there was a significant improvement in sleep parameters. Pregnancy-related low back pain and pelvic pain is a prevalent problem, affecting around half of all pregnant women. Approximately 25% of these pregnant women suffer from severe pain, while 8% have severe disability during pregnancy. There is at least one randomized controlled trial that was conducted to study the impact of yoga on pregnancy-induced lumbar and pelvic pain which was found to be effective. The study compared hatha yoga exercises with posture exercises and found that yoga was more effective in reducing the severity of lumbopelvic pain than posture exercises. In the study comparing prenatal hatha yoga with standard care, when the effects of exercises on cortisol levels were examined, it was found that yoga significantly reduced cortisol levels.

Risky Effects of Yoga on Pregnancy

There are no clear criteria to distinguish between a “high” or “low” risk pregnancy; however, pregnancies with maternal and/or fetal conditions that may pose a threat to the life of the mother or fetus are considered “high” risk pregnancies. Each year, over half a million women die from pregnancy complications. It is known that untreated psychopathologies during pregnancy can lead to health problems such as inadequate weight gain, pre-eclampsia and premature birth. Javanbakht et al. reported that anxiety and depression decreased in the yoga group and can be used as an alternative to medical treatment. In a randomized controlled trial in high-risk pregnant women, the control group received standard care and traditional antenatal exercise, while the experimental group received standard care plus a one-hour daily yoga session three days a week. The yoga group had significantly fewer cases of pregnancy-induced hypertension, preeclampsia, gestational diabetes, intrauterine growth retardation, small-for-gestational-week infants, and infants with low APGAR scores.

In another study conducted by Rakhshani et al. in high-risk pregnant women, the effects of yoga on fetal circulation were examined. At the end of the study, significantly higher results were obtained in biparietal diameter, head circumference, femur length and estimated fetal weight. In a meta-analysis of 6 randomized controlled trials, it was reported that prenatal yoga practice was significantly effective in reducing depressive symptoms in pregnant women diagnosed with depression. In a study conducted by Youngwanichsetha et al. in high-risk pregnant women, the effects of yoga and mindful eating on blood glucose levels in pregnant women with gestational diabetes were examined; fasting blood glucose, postprandial glucose and HbA1c levels were significantly reduced in the yoga group. In another study, yoga for simple meditation and walking exercises in addition to standard care were compared in high-risk pregnant women. At the end of the study, uric acid levels and platelet counts were within normal limits in both groups, while the number of pregnant women with preeclampsia was significantly lower in the yoga group.

Effects of Yoga on Childbirth

Labor pain is known to be unique to each mother and is a complex and multifaceted event. The methods recommended for labor pain are divided into pharmacologic and non-pharmacologic, and when they are preferred, the features of being reliable, simple, accessible and not harming the physiology of mother and baby are taken into consideration. In this context, there have been studies examining the effects of yoga practice, which includes respiratory relaxation, exercise and deep relaxation, on labor. In the study investigating the effect of yoga on labor pain, it was found that pregnant women who underwent a yoga program felt higher maternal comfort and less pain throughout labor and up to 2 hours after delivery, and there was a significant decrease in the total duration of labor compared to the control group. It was also reported that women with labor pain were significantly less in the yoga group. In another randomized controlled trial, antenatal yoga program was compared with a control group. When cervical dilatation reached 3-4 cm and 2 hours after delivery, the pain felt in the experimental group was significantly less. In addition, the duration of labor was shorter in the experimental group. In the study by Narendran et al, a group receiving yoga exercises, breathing techniques and meditation and a control group walking for 30 minutes twice a day were evaluated. The number of women with a birth weight of 2500 g or more was significantly higher in the yoga group than in the control group, and the rates of preterm birth, intrauterine growth retardation and pregnancy-induced hypertension were significantly lower.

Effects of Yoga on the Postpartum Period

While estrogen, progesterone and cortisone levels increase in the endocrine system during pregnancy, some conditions return to their previous levels and some conditions improve, prolactin levels increase, and the mother’s transition to new roles and responsibilities creates a difficult period of life. While many women can easily adapt to the physiological, psychological and social changes that occur during this period, women who have difficulty in adapting or cannot adapt may experience different emotional problems. When we look at the literature on the postpartum effects of yoga, it is seen that there are fewer studies related to birth compared to pregnancy. In the study by Ko et al. there was a significant decrease in depression, body weight, body fat percentage and fat mass, while no significant difference was observed in fatigue symptoms. In the study by Buttner et al. the impact of yoga on postpartum depression was investigated and it was found that depression symptoms were significantly lower, anxiety measurements decreased and overall well-being and quality of life were significantly improved in women who practiced yoga.

To sum it up, pregnancy is a stressful and complex process even in the absence of any health problems. When we look at the studies in the literature, as a result, it is seen that yoga reduces perceived stress and is therefore effective in protecting against stress-related complications; it increases health, affects positively, increases mother-baby attachment, and has a positive effect on insomnia, low back and leg pain due to changes in physical, physical and mental health during pregnancy.

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