Running head: YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 1

Using Yoga Among Pregnant Women to Reduce Anxiety and Depression

Morgan Dooley

University of South Florida
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 2

Abstract

Clinical Problem: It is common for women during pregnancy to experience depression, anxiety,

and stress. There are interventions that can reduce these experiences and help increase maternal-

fetal wellbeing.

Objective: The objective of this paper is to discuss the practice of yoga compared to physical

inactivity in decreasing the incidence of depression and anxiety among pregnant women.

CINAHL was the database used to research this topic. Key words used in the investigation

include: anxiety, pregnancy, depression, and yoga. Results were filtered to ensure only

randomized control trials (RCT) were populated. Results were also filtered to narrow the

publishing date of 2012-2017. Clinical guidelines for pregnancy, prenatal physical activity, and

prenatal medications were found through the Centers for Disease Control and Prevention (CDC).

Search terms used were pregnancy, depression, treatment, and yoga.

Results: There was a decrease in stress, anxiety, and depression among pregnant women who

participated in yoga. Chen, Yang, Chou, Li, Chang, and Liaw et al. (2017) demonstrated that

there was a decrease in salivary cortisol levels (p< .001) and higher IgA levels (p < .001)

immediately after yoga. A study conducted by Field, Diego, Delgado, & Medina, (2013) found

lower levels of depression and anxiety among pregnant women after performing yoga (p < .001).

Satyapriy, Nagarathna, Padmalatha, & Nagendra (2013) demonstrated a decrease in anxiety (p <

.001) and depression (p < .001) among pregnant women after performing yoga.

Conclusion: Women who participated in yoga classes during pregnancy had reduced experiences

of depression, anxiety, and stress within nine months of pregnancy.
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 3

Using Yoga Among Pregnant Women to Reduce Anxiety and Depression

There are several interventions that are used in order to help reduce the incidence of

prenatal depression and anxiety. According to the Centers for Disease Control and Prevention

(CDC, 2017b) it is most common for women to use antidepressants or anxiolytics for treatment

These treatments have an increased risk for fetal and newborn health defects (CDC, 2017b).

Alternative treatments are needed in order to reduce this risk while decreasing the incidence of

prenatal depression and anxiety. Yoga is a physical activity that uses the coordination of breath

and movement to promote relaxation, flexibility, and overall health (Field, Diego, Delgado, &

Medina, 2013). The practice of yoga during pregnancy can be studied to further understand its

benefits to maternal wellbeing. An evidence-based practice (EBP) question is: Among pregnant

women (P), how does the practice of yoga (I), compared to inactivity (C), affect the incidence of

prenatal depression and anxiety (O), over nine months (T)? The expected outcome measure for

clinical improvement is a decreased incidence of depression and anxiety in pregnant women by

integrating the practice of yoga.

Literature Search

CINAHL was accessed to obtain randomized controlled trials (RCT) related to pregnancy

and yoga, and its effect on depression, anxiety, and stress. Key search terms used included the

following: pregnancy, yoga, depression, anxiety, stress, and alternative therapies. Results were

filtered to ensure only RCTs published within 2012-2017 were populated. Clinical guidelines for

pregnancy, prenatal physical activity, and prenatal medications were found through the CDC

website. Search terms used were pregnancy, depression, treatment, and yoga.

Literature Review
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 4

Chen et al., (2017) tested the hypothesis that prenatal yoga can reduce the stress hormone

cortisol, and enhance the biomarker immunoglobulin A (IgA) during pregnancy. Evaluating

levels of cortisol can determine the amount of stress a pregnant woman is experiencing.

Evaluating levels of IgA can indicate how effective a pregnant woman’s immune system is

working. The measures of this study were stress and immunity salivary biomarkers from 16-36

weeks’ gestation. Higher cortisol levels are indicative of higher levels of stress and anxiety.

Lower IgA levels indicate higher levels of immunity. Salivary cortisol and IgA levels were

collected before and after yoga sessions, every four weeks from 16-36 weeks’ gestation. A

certified yoga instructor led 70-minute yoga sessions.

The sample size of this study was healthy pregnant women (N=94) at 16 weeks’

gestation. The control group (n=46) received routine prenatal care. The intervention group

(n=48) participated in group yoga sessions. The study was conducted in a clinic in Taipei. The

demographics of this sample were Chinese women between 20-24 years old. The intervention

group (women who participated in yoga) had a lower salivary cortisol level (p< .001) and higher

IgA (p < .001) immediately after yoga than the control group (no yoga). This RCT demonstrated

that women who participated in yoga during 16-36 weeks’ gestation experienced decreased

levels of stress, and higher levels of immunity, in comparison to the control group, who only

received routine prenatal care.

There are weaknesses of this study that were determined upon RCT appraisal. It was

undetermined if random assignment was concealed from the individuals enrolling in the study.

The study did not mention if the participants or providers are blinded, only the statisticians who

randomly assigned participants were blinded. Follow up assessments were only done
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 5

immediately after yoga sessions. There was no significant long-term effect on salivary cortisol

levels, but the study tested up to gestational week 36.

There were several strengths of this study. Women were randomly assigned to the control

or intervention group. The study provided reasons why the subjects did not complete the study.

The subjects were analyzed in the group they were randomly assigned. The control group was

appropriate (routine prenatal care). Instruments used to measure the outcome were valid and

reliable (using an enzyme-linked immunoassay kit and double-antibody method). The subjects in

each clinical group had similar demographics and health characteristics.

Field, Diego, Delgado, and Medina, (2013) tested the hypothesis of whether yoga

(physical activity) versus social support (verbal activity) had an effect on prenatal and

postpartum depression. Measures of this trial included the following: levels of depression using

The Center for Epidemiologic Studies Depression Scale (CES-D), which is a questionnaire for

participants that is used to calculate depression scores; and the State-Trait Anxiety Inventory

scores (STAI), which is a questionnaire for participants that is used to determine levels of

anxiety the participants are experiencing.

The study sample included pregnant women with a diagnosis of depression (N=92). The

control group (n=46) used social support. The intervention group (n=46) used yoga. All

participants were of low-income status, mostly African-American or Hispanic, and of a high

school level of education. Ages of the participants were 20-38 years of age.

Both the control and intervention group had decreased levels of depression according to

the CES-D scores (p< .001). Both the control and intervention group had decreased levels of

anxiety on the STAI scores (p< .001). Both groups also showed reduced levels of cortisol from

pre- to post- session on the first and last days. This study demonstrates that both yoga and social
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 6

support are effective in decreasing levels of anxiety and depression, and decreasing levels of

cortisol throughout pregnancy. The use of social support groups and group yoga can be shown to

increase maternal well-being in pregnancy.

There were several strengths of this study. The subjects were randomly assigned to the

intervention and control groups. The researchers were blinded to the group assignment and to the

study hypothesis. The study provided reasons why the subjects did not continue the study.

Follow up assessments were conducted long enough to fully study the effects of the intervention.

The subjects were analyzed in the group to which they were randomly assigned. The control

group of social support was appropriate for this study. The instruments used to measure

outcomes were valid and reliable. Measures were tested using analysis of variance. The subjects

in each group were similar based on demographics and health. A weakness was that the study did

not state if the participants were concealed from the control or intervention.

Satyapriy, Nagarathna, Padmalatha, and Nagendra (2013) tested the hypothesis that

integrated yoga during pregnancy can affect anxiety and depression levels among women during

a normal pregnancy. The sample of this study included healthy pregnant women (N=96) at their

20th week of normal pregnancy. The control group (n=45) used standard antenatal exercises,

which consisted of stretching exercises without the use of breathing. The intervention group

(n=51) practiced integrated yoga, which included stretching with coordination of breath and

movements. All women were recruited in south Bengaluru, India.

The measures of this trial included the following: Pregnancy related experience (PEQ)

questionnaire, which includes questions regarding concerns during pregnancy including somatic

symptoms, pregnancy, parenting concerns, baby-image, and attitudes to sex; the State Anxiety

Inventory scores (STAI I), which is a questionnaire that assesses self-reported levels of anxiety
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 7

at that precise moment; the Trait Anxiety Inventory scores (STAI II), which assesses the

participants’ level of anxiety in general; and a Hospital Anxiety Depression Scale (HADS),

which is a questionnaire that is used to assess the levels of anxiety and depression in a non-

psychiatric population.

In the intervention group, the yoga participants had reduced STAI I scores by 15.56% (p<

.001), and increased 13.76% in the control group (p< .001). In the intervention group, the yoga

participants had reduced PEQ by 26.85% (p< .001). For the STAI II trait anxiety, the

intervention group had decreased scores by 8.97% (p <.001), and increased scores in the control

group by 5.02% (p< .001). For the HADS scores, the intervention group had a decrease by

30.67% (p< .001) and the control group had a 3.57% increase in score (p < .001). This RCT

demonstrated integrated yoga can decrease STAI I, STAI II, PEQ, and HADS scores in

comparison to standard antenatal exercises, from 20 weeks’ gestation through 36 weeks’

gestation.

There were several strengths of this RCT. The subjects were randomly assigned to the

intervention and control group. The study provided reasons why subjects discontinued the study.

The RCT stated follow up assessments were conducted long enough to fully understand the

intervention. The subjects were analyzed within the group to which they were randomly

assigned. The control group for the study was appropriate (no prenatal yoga). The instruments

used were valid and reliable (questionnaires). The subjects in each group were similar in

demographic and health characteristics. Upon RCT appraisal, weaknesses were found. Random

assignment was not concealed from individuals first enrolling subjects into the study. The

subjects and providers were not blind to the intervention groups, but the statisticians were blind

in conducting statistics.
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 8

There are several clinical guidelines and findings to treat prenatal depression and anxiety.

According to the CDC (2017b), the typical treatment for pregnant women experiencing prenatal

depression and anxiety is the use of antidepressants. However, the CDC identified risks to the

fetus and newborn with the use of selective serotonin-reuptake inhibitors (SSRI), which is a

typical antidepressant medication prescribed (CDC, 2017b). The CDC (2017b) has also found

that taking buproprion (Wellbutrin), a medication used to treat depression, anxiety, and smoking

cessation, can increase the risk for newborn heart defects.

The CDC has recommended pregnant women seek treatment for experiencing emotional

changes, and speak with a health care provider to discuss possible treatment options (CDC,

2017a). The CDC states it is necessary to inform the health care provider that the patient is

pregnant or may become pregnant (CDC, 2017a). The CDC has established guidelines for

pregnant women that physical activity is good for overall health (CDC, 2015). The CDC (2015)

states that physical activity will help to improve moods during and after pregnancy. The CDC

(2015) recommends pregnant women begin a workout regimen cautiously, and participation in a

moderate-level aerobic activity with low-impact.

Synthesis

Chen et al. (2017) demonstrated that the levels of cortisol (stress hormone) and IgA

(immunity levels) decrease immediately after participating in yoga from 16-36 weeks’ gestation.

These pregnant women had a decreased level of stress (p < .001), and higher levels of immunity

(p < .001), in comparison to the control group (p = .018). According to Field et al. (2013), it was

determined that both prenatal yoga and prenatal support groups experience less incidence of

prenatal depression and anxiety. The group of prenatal yoga for both anxiety and depression (p <

.05) had decreased levels for short-term effects. According to Satyapriya et al. (2013), there were
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 9

decreased levels of prenatal anxiety by 15.56% (p< .001), and decreased levels of depression by

30.67% (p< .001). It can be concluded that the practice of yoga during the prenatal period can

decrease levels of anxiety and depression in pregnant women.

These RCTs have similarities and differences. The studies each had a different way of

evaluating the outcomes of stress reduction: biomarkers, and different types of questionnaires.

Field, Diego, Delgado, and Medina, (2013) compared yoga practice to a social support group.

Overall, the studies found yoga will decrease the stress, anxiety, and depression among pregnant

women.

Clinical guidelines recommended by the CDC have several gaps. There are no clinical

findings in relation to prenatal yoga and its effect on depression and anxiety. Only prenatal

physical activity and consultation with a health care professional were recommended to pregnant

women. The CDC (2017b) also states possible treatment for prenatal depression may include

medication such as an SSRI or an anxiolytic. There is a need for further evaluation for the use of

alternative therapies due to the increased risk of fetal and newborn health risks associated with

these medications.

Clinical Recommendations

The CDC (2015) recommends pregnant women achieve 150 minutes of physical activity

per week. The physical activity can be low-impact and have moderate aerobic activity. The CDC

(2015) states that physical activity can help improve the mood of pregnant women. Further

investigation is needed to determine other ways to improve the mood of women during

pregnancy. The CDC (2017b) also recommends pregnant women with levels of depression and

anxiety seek help from health professionals to determine if anxiolytics or antidepressants are

right for them.
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 10

Physical activity can be difficult to achieve during pregnancy due to time, financial, and

health constraints. Finding a low-impact activity such as yoga can be an alternative therapy to

treat depression and anxiety. RCTs have shown the decreased incidence of anxiety and

depression for pregnant women during the prenatal period of nine months. Supplemental

research is needed to determine if the social aspect of yoga classes affect the incidence of

prenatal depression and anxiety.
YOGA TO DECREASE PRENATAL ANXIETY AND DEPRESSION 11

References

Centers for Disease Control and Prevention. (2015). Physical activity: Healthy pregnant or

postpartum women. Retrieved from

https://www.cdc.gov/physicalactivity/basics/pregnancy/index.htm

Centers for Disease Control and Prevention. (2017a). Maternal depression. Retrieved from

https://www.cdc.gov/features/maternal-depression/index.html

Centers for Disease Control and Prevention. (2017b). Treating for two: Research. Retrieved from

https://www.cdc.gov/pregnancy/meds/treatingfortwo/research.html

Chen, P., Yang, L., Chou, C., Li, C., Chang, Y., & Liaw, J. (2017). Effects of prenatal yoga on

women’s stress and immune function across pregnancy: A randomized controlled

trial. Complementary Therapies in Medicine, 31,109-117. doi:

10.1016/j.ctim.2017.03.003

Field, T., Diego, M., Delgado, J., & Medina, L. (2013). Yoga and social support reduce prenatal

depression, anxiety and cortisol. Journal of Bodywork & Movement Therapies, 17(4),

397-403. doi:10.1016/j.jbmt.2013.03.010

Satyapriya, M., Nagarathna, R., Padmalatha, V., & Nagendra, H. (2013). Effect of integrated

yoga on anxiety, depression & well being in normal pregnancy. Complementary

Therapies in Clinical Practice, 19(4), 230-236. doi:10.1016/j.ctcp.2013.06.003