Complementary Therapies in Medicine 30 (2017) 1–9

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Complementary Therapies in Medicine

journal homepage: www.elsevierhealth.com/journals/ctim

Effect of Turkish classical music on prenatal anxiety and satisfaction:

A randomized controlled trial in pregnant women with pre-eclampsia
Eylem Toker (Assistant Professor Doctor (PhD)) a,∗ , Nuran Kömürcü (Professor Doctor) b
a
Department of Midwifery, Kahramanmaras High School of Health, Kahramanmaras Sutcu İmam University, Kahramanmaras, Turkey
b
Department of Nursing, School of Health Sciences, İstanbul Aydın University, İstanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The present study aimed to evaluate the effect of music therapy on anxiety and satisfaction
Received 25 February 2016 in pregnant women with preeclampsia.
Received in revised form 20 October 2016 Design, setting and subjects: A randomized controlled trial was performed on 70 pregnant women with pre-
Accepted 17 November 2016
eclampsia hospitalized in the research and application hospital of Kahramanmaras Sütcü İmam University
Available online 18 November 2016
between December 2012 and February 2014. The subjects were allocated to experimental or control
groups in a random manner (n = 35 each).
Keywords:
Interventions: Pregnant women in the experimental group were subject to a 30 min Turkish classical
Pre-eclampsia
Anxiety
music therapy trial each day for a period of 7 days (5 days before and 2 days after labor) whereas those in
Satisfaction the control group received routine care and also were assigned to 30 min of bed rest a day. The Personal
Music therapy Information Form, State-Trait Anxiety Inventory, and Newcastle Satisfaction with Nursing Scale were
administered to participants. Data were analyzed using descriptive statistics, student t-test, and Mann-
Whitney U test where appropriate.
Main outcome measures: Outcome measures were anxiety scale scores, satisfaction scale scores, vital
signs, fetal movement and fetal heart rate.
Results: The differences between anxiety scores were not statistically significant (p > 0.05). On the other
hand, Newcastle Satisfaction with Nursing Scale scores of the experiment group were higher than the
control group (p < 0.01). Finally, when considering fetal movement counts, a significant increase was
determined in the experiment group, whereas Music Therapy had a minimalizing effect on fetal heart
rate and a lowering effect on blood pressure (p < 0.05).
Conclusion: It may be suggested that nurses and midwives can utilize music therapy in the care and
follow-up of pregnant women with preeclampsia in obstetrics units.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Music therapy is a type of treatment performed with a struc-
tured method by arranging the physiological and psychological
effect of musical sounds and melodies.1 Scientific studies proved
years ago that music affects spiritual and mental well-being, and
the body, positively.2,3 Music therapy is thus one of the methods
that is as old as the history of medicine itself. There are many studies
showing that music therapy is beneficial to the anxiety experienced
by the ill and pregnant.4–8 Specifically, a type of music called Med-
ical Resonance Therapy (MRT) is known to have various beneficial
∗ Correspondence to: Kahramanmaraş Sütçü İmam Üniversitesi Sağlık
Yüksekokulu, Bahçelievler Kampüsü, İsmetpaşa mah., 46100 Dulka-
diroğlu/Kahramanmaraş Turkey.
E-mail addresses: eylem7@yahoo.com, tokereylem@gmail.com (E. Toker).
effects in high risk pregnancies and to reduce stress.9 In this con-
text, music therapy, which is a cognitive behavioral therapy type
with high effect on anxiety, can be used as a complementary and
alternative treatment method.10
Pre-eclampsia, which is categorized as hypertension
(≥140/90 mmHg) caused by pregnancy and can be seen alongside
proteinuria after the 20th week of pregnancy classically,11 causes
fear and anxiety in pregnant individuals regarding themselves
or their babies, and presents as anxiety during pregnancy.12,13 In
addition to a subjective feeling of expectation and anxiety charac-
terized by horror, worrying, or the feeling that a disaster is closing
in,14 pre-eclampsia, if not treated throughout pregnancy, may
cause negative outcomes such as babies with low birth weights
(SGA), variational APGAR scores, fetal hemodynamics, movement
disorders, increase in the risk of pre-eclampsia, early membrane
rupturing, or caesarean sections.15

http://dx.doi.org/10.1016/j.ctim.2016.11.005
0965-2299/© 2016 Elsevier Ltd. All rights reserved.
2 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
Pre-eclampsia and eclampsia, also known as toxemia, present
as a pregnancy complication in 2.8% of pregnancies in developing
countries and 0.4% of pregnancies in developed countries. Accord-
ing to the World Health Organization 2005 report (WHO), 12% of all
direct mother deaths are caused by eclampsia and this cause comes
third among the reasons for such deaths.16 In addition to this report,
in a report published in 2010, 18% of direct mother deaths were
stated to be caused by hypertension and the cause was stated to be
ranked second among causes for such deaths.17 In Turkey, 18.4% of
mother deaths are caused by oedema, proteinuria, and hyperten-
sive disorders, and 13.7% are caused by eclampsia, with eclampsia
coming second among reasons for such deaths.18
Music therapy is used today in many fields of medicine, espe-
cially in reducing anxiety caused by dental treatments, cardiac
procedures, medical and surgical procedures, obstetrics, and oncol-
ogy treatments, reducing stress, pain management, and reducing
hypertension.5–7,19–24
On the other hand, the use of music therapy on pregnant indi-
viduals is limited and studies on high risk pregnant women are
especially insufficient. In literature, music therapy was found to be
used on normal physiological pregnancies, in pregnancies where
transvaginal ultrasonography was performed, in pregnant woman
at delivery, and in pregnant women to whom the Non Stress Test
(NST) was applied in the reduction of anxiety.4,8,25,26 Although
among high risk pregnancies, studies on using the method on high
risk pregnant women who were suggested bed rest and pregnant
women with hypertension were present 7,9 no studies on pregnant
women with pre-eclampsia were found.
In literature, there are no studies investigating the effect of Clas-
sical Turkish Music presented before and after birth to pregnant
women with pre-eclampsia on anxiety, physiological parameters,
well-being of the fetus, and satisfaction. There are a limited num-
ber of research studies in our country regarding music therapy in
the field of obstetrics,4,8 and no clinical or experimental studies on
the effect of music therapy on satisfaction and anxiety of pregnant
women with pre-eclampsia were found in the literature. From this
aspect, the current study is original.
It was thought that Classical Turkish Music would have a posi-
tive effect on pregnant women with pre-eclampsia.2–9,24–26 For this
reason, the aim of this study is to investigate whether music ther-
apy performed with classical Turkish music would have positive
effects on the anxiety and physical symptoms of the mothers and
the fetuses, as well as investigating the general satisfaction of the
pregnant women with music therapy.
2. Methods
2.1. Study design
This was a parallel group, randomized controlled trial (RCT).
The study was conducted with pregnant women who were present
at the maternity unit of Kahramanmaras Sutcu Imam University
Research and Application Hospital and were diagnosed with pre-
eclampsia.
The hospital where the study was conducted was the only pub-
lic hospital which offers third step medical services in the city,
and all of the complicated cases such as pre-eclampsia were being
forwarded to this hospital. In the 12 bed Obstetrics Service, three
separate rooms for women with pre-eclampsia were present, and
these rooms were designed for three people or a single person.
2.2. Permissions for the study
Official permissions from Kahramanmaras Sutcu Imam Uni-
versity Medical School Research and Application Hospital Chief
Physician’s Office and Obstetrics Department through Kahra-
manmaras Sutcu Imam University Rector’s Office and written
permission from the Marmara University Ethical Board were taken
(Institution permission: 26.11.2012-9660; Ethic Board Permission:
14.09.212-1). Additionally, before the study, all of the participants
were informed about the study and an informed consent form was
given to each participant (Informed Consent Form). All participants
completed a consent form before the study.
2.3. Participants
The criteria of The American Congress of Obstetricians and
Gynecologists and the National High Blood Pressure Education Pro-
gram (NHBPEP) 11,27 were used in the study, and according to the
criteria, 126 hospitalized pregnant women who stayed at the hospi-
tal between the dates of December 1st 2012 and February 1st 2014
with a diagnosis of pre-eclampsia formed the population of the
study. Before sample selection, the whole population was planned
to be included in the study, however, only 84 women met the inclu-
sion criteria.
Inclusion criteria were:
(1) Being an inpatient for at least five days with a diagnosis of pre-
eclampsia,
(2) Being in the 30th week of pregnancy or above (Because Non
Stress Test would be taken during observation and the music
would continue until birth and after birth);
In this study, in order to measure the Fetal Health and reaction
of the fetus on music, we used the Electronic Fetal Monitoring and
measured the fetal heart rate and fetal movements before and after
music by non-stress test (NST). NSTs are generally performed after
28 weeks of gestation. Before 28 weeks, the fetus is not developed
enough to respond to the test protocol. Additionally, pre-eclampsia
usually depends on at third trimester in the pregnancy. In addition,
at third trimester of the pregnancy fetus can hear the extrauterine
voices and music and reflect the music more than second trimester.
Due to these reasons, the pre-tests were given in the 30th week of
pregnancy or above.
(3) Being at or above 18 years of age (for detailed Informed Consent
Form),
(4) Having a live, single, healthy fetus.
Exclusion criteria were:
(1) Having hearing deficiencies, (2) Not agreeing to participate,
(3) Being illiterate, (4) Having communication problems, (5) Being
admitted with severe pre-eclampsia, (6) The newborn not being
alive.
2.4. Study protocol
Out of 126 pregnant women who were hospitalized were eval-
uated with regard to how appropriate they were for the study and
84 of those women were included in the study. After second evalu-
ation, for reasons such as infant deaths and staying at the clinic for
less than five days, 14 women were excluded and 70 women were
included in the study (Fig. 1).
Using a computer program module designed for randomized
controlled studies (http://www.randomizer.org/form.htm), a ran-
domization list was formed and participants were accordingly
assigned to the study and control groups. Participants were num-
bered according to their order of admittance to the hospital, and
they were assigned randomly to the study and control groups in
two equal groups (experimental group n = 35, control group n = 35).
According to the results of the randomization, there could be two
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9 3

Assessed for eligibility (n=126)

Excluded (n=42)
§ Not meeting inclusion criteria (n=32)
§ Declined to participate (n=0)
§ Other reasons (n=10)

Randomization (n=84)

Measurements prior to study

§ Personal Information Form
§ State Trait Anxiety Inventory (STAI TX-I)

Music group (7 days) (n=42) Control group (7 days) (n=42)

§ Music exposure, 30 min § Music exposure, 30 min
§ Pre-test and post-test § Pre-test and post-test
o SBP/DBP o SBP/DBP
o Pulse and respiratory rate o Pulse and respiratory rate
o Non-stress test, fetal movements, o Non-stress test, fetal movements,
fetal heart rate (the first 5 days) fetal heart rate (the first 5 days)

§ Lost to follow-up (Hospitalized fewer than § Lost to follow-up (Hospitalized fewer than
five days at the clinic) (n=6) five days at the clinic) (n=6)
§ Discounted intervention (newborn ex) § Discounted intervention (newborn ex)
(n=1) (n=1)

Measurements following the study

§ State Trait Anxiety Inventory (STAI TX-I)
(retest on the 5th day before labor)
§ New Castle Satisfaction with Nursing Scale
(NNCS) (on the 2nd day following labor)

Analyzed (n=35) Analyzed (n=35)

Fig 1. Flow-chart of the study (SBP, systolic blood pressure; DBP, diastolic blood pressure).

experimental group participants, two control group participants, The power analysis of the study, for ␣ = 0,05 significance level
or one of each in each day. Data was collected together until the ␤ = 0,20, 0,80 test power in the experimental and control group
sample size was reached. based on equal exemplify ∼
= 0,70 for each group n = 35, respectively.
4 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
3. Measurements
The following scales were used in the study.
3.1. Personal information form
The personal information form prepared by the researcher con-
sisted of 29 questions including socio demographic characteristics
(age, education, health insurance in area lived), obstetrics infor-
mation (obstetric history, history of present pregnancy and birth,
information on the infant) and the relationship of the participants
with music (if they enjoy listening to music, what kind of music
they like, and usually when they listened to music). The form was
applied to both groups before the study.
3.2. State trait anxiety inventory (STAI TX-I)
The scale was developed by Spielberger et al. 1970 in order to
measure State and Continuous Anxiety levels, consisting of two
scales,28 and was tested for validity and reliability in Turkish by
Öner and Le Compte.28 The State Trait Anxiety Scale used in this
study determines how an individual feels in a certain environ-
ment under certain conditions, consisting of 20 straight and inverse
scored terms, and is scored between 20 and 80 in a likert type scor-
ing between 1 and 4. High scores show high anxiety levels while
low scores indicate low anxiety levels.28
For STAI, the Cronbach’s alpha for the total scores was ␣ = 0,81,28
in the study for STAI, the Cronbach’s alpha for the total scores was
0.86.
The scale was applied to both groups before (the intervention)
and after (in the fifth day of the intervention) the study.
The post-tests timing on STAI on the fifth day of the inter-
vention before birth, because we would like to measure and find
the effect of music therapy on anxiety levels of pregnancy period
of pre-eclamptic women which is at last five days before the
delivery during hospitalization on the clinic, when anxiety levels
were expected very high. Normally after birth, anxiety levels were
expected to decrease.
3.3. The newcastle satisfaction with nursing scale (NNCS)
The scale was tested for validity and reliability in Turkish in 2007
by Akın and Erdogan. The total score is converted into 100 before
evaluation, and the maximum and minimum scores that can be
taken from the scale are 95 and 19 respectively. An increase in the
total score taken from the scale shows high satisfaction with the
nursing care received.29
For NNCS, the Cronbach’s alpha for the total scores was
␣ = 0,81,29 also in the study for NNCS the Cronbach’s alpha for the
total scores was 0.95.
The NNCS is a scale about nursing satisfaction and since the
nursing care continued while the participants were staying at the
hospital. As a result, the NNCS was applied on the last day of hos-
pitalization, and it was recommended in such way. With this scale,
in the study we would like to measure of satisfaction scores at pre
and postpartum period holistically, which is not effected by deliv-
ery, so it was applied after the birth. The scale was applied to the
participants in both groups after birth (in the 7th day of the inter-
vention). Because in our country the women at postpartum period
were usually hospitalized optimal two days in the hospital.
3.4. Vital findings
The systolic and diastolic blood pressures of each participant
were measured with a newly calibrated classical manual blood
pressure monitor (the same monitor was used in all participants),
and their pulse and respiratory rates were assessed and recorded
by the researcher.
3.5. Non stress test (NST)
The Fetal Non-Stress test is a non-invasive, simple test per-
formed in pregnancies over 28 weeks gestation. Fetal heart rate
(FHR) and Fetal Movements (FM) were recorded by applying 15 min
of NST through Electronic Fetal Monitoring preferred in the clinic
where the study was conducted.
4. Interventions
4.1. Classical Turkish music presentation
The “Nihavend” and “Buselik” modes of Turkish music suggested
by the Turkish Music Research and Promotion Group (TUMATA)
that have relaxing properties were used by taking expert views.
Participants in the study group listened to the mode of music they
selected from between the Nihavend and Buselik modes regularly
30 min a day for seven days through an MP3 player and headphones
whilst lying down.
The participants in the study group arranged the sound level of
the music according to their desires, and the steps taken care of
during application included the bladder of the participants being
empty, starting the music presentation by taking three deep breaths
for concentration, repeating the breathing exercise in case of lost
concentration, closing cell phones, and not having any medical
interventions during the presentation.
4.2. Bed rest
Both the experimental and control groups received routine care
of assessment of vital signs, drug administration, etc., but while
the experimental group received music therapy, the control group
had 30 min of bed rest a day. Before bed rest, special care was
given to the bladder of the participants being empty, the partici-
pants not being hungry, cell phones being closed, and no medical
interventions being performed during bed rest.
4.3. Data collection
In the literature, music therapy was used consecutively, at least
three days and at most 15 days. Researcher advices music therapy
should be used consecutively, so in this study we would like to
search effects of music therapy on participants before birth and
after birth.
The participants listened to music five days before birth and two
days after birth during they were in the hospital. They did not listen
to music during labor.
The participants were monitored for seven days, five before and
two after birth. During this time, the participants in the study group
had 30 min presentations of Classical Turkish Music (the music
therapy group), and the participants in the control group received
30 min of daily bed rest. The systolic blood pressures and diastolic
blood pressures of each participant were measured with a newly
calibrated separate manual blood pressure device, and their pulse
and respiratory rate were directly assessed and recorded by the
researcher (7 days total).
Additionally, FHR and FM were recorded by applying 15 min
of NST through Electronic Fetal Monitoring preferred in the clinic
where the study was conducted (only the 5 days before birth). The
participants in the control group were asked to perform bed rest
30 min daily, and their vital and fetal findings were also recorded
before and after rest, but they did not listen to music. In this study
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
the music therapy was given by the researcher only at the hospital
during they were hospitalized.
4.4. Statistics
Data was defined as averages ± standard deviations and per-
centages. For statistical analysis, the NCSS (Number Cruncher
Statistical System) 2007&PASS (Power Analysis and Sample Size)
2008 Statistical Software (Utah, USA) program, and the G*Power
(v3.1.7) program were used. In data analysis, tests such as the Paired
and unpaired Student t-tests, the Wilcoxon signed-rank and Mann-
Whitney U tests, the Pearson Chi squared test, Pearson-correlation
test, Spearman-correlation test, and Post-hoc power analysis were
used. All evaluations were performed for a 95% confidence interval;
significance threshold was set at a p-value of 0.05 and a p < 0.01 was
considered highly significant.
5. Results
The participants in the study were found to have an average
age of 30.64 ± 5.81, with most being elementary school graduates
and unemployed (Table 1). The average number of pregnancies was
found to be 3.16 ± 1.77, with 24.2% having their first pregnancy,
the women giving an average of 2.26 ± 1.19 births, 9.4% having a
history of stillbirth, and 49.1% having a history of miscarriage. The
participants included in the study were found to give their births in
an average of 36.20 ± 2.40 weeks (Table 2). With regard to the socio
demographic characteristics and other obstetric characteristics, no
statistically significant difference between the groups was found
(p > 0.05) (Tables 1 and 2).
According to the STAI TX-I applied before the interventions, anx-
iety in the participants included in the context of the study was
found to be on an average level, and no statistically significant dif-
ference between the anxiety starting levels were found between
the groups (Table 3). According to the STAI TX-I scale applied on
the 5th day after 5 days of interventions before birth, anxiety lev-
els were again found to be average. In the comparison performed
between the groups before and after five days, no statistically sig-
nificant differences in anxiety levels were found (Table 3).
When the NNCS scores obtained on the 2nd day after birth were
evaluated, the scores of the study group were found to be higher
on a significant level compared to the control group (Table 4).
When the first measurements performed in the beginning of
the study were taken into consideration, no significant difference
between the groups regarding average systolic blood pressure was
found (Table 5). Similarly, no difference was found in the mea-
surements obtained after the application (Table 5). On the other
hand, when the groups were compared according to the difference
between these two values, the music group was seen to have a
larger reduction, and this significant difference was seen between
the groups (Table 5). In the study, the effects of music therapy in
both the prenatal and postnatal period were shown not to cause
significant differences with regard to pulse and respiratory rate in
or between groups (Not given in Tables).
The diastolic blood pressure average values were found to be
similar between the groups in the beginning. The blood pressure
measurements performed after the applications, diastolic blood
pressure values were found to decrease significantly in both the
prenatal and postnatal periods, and this significant difference was
seen within the groups, with no sustainable significant decrease in
the control group. This significant difference was also seen between
the groups in the prenatal period. Especially in the postnatal period,
music therapy was found to cause significant differences between
the groups (Table 6).
5
The fetal health related data (FM, FKH) were found to be simi-
lar in the beginning, with no differences between the groups. The
music therapy applied to the study group was found to increase FM
and FKH values, and this seemed to bring a significant difference
within the group.
Between the groups, these values were found to cause signifi-
cant differences in FM (Table 7) and no statistical differences were
found in FKH (Table 8).
6. Discussion
With regard to the socio demographic characteristics and
other obstetric characteristics, no statistically significant difference
between the groups that could affect the results of the study was
found.
As a result of our study, music therapy was not found to have
a significant decreasing effect on anxiety in pregnant women with
pre-eclampsia. This result is considered to have arisen from the
facts that the participants in our sample were high risk, each of the
situations such as pre-eclampsia bringing risks regarding fetal and
maternal health and hospitalization causing pregnancy anxiety to
increase. Minimal changes occurring in the anxiety scores of the
participants and the anxiety levels not being higher than average
at the end of five days are also seen as positive results. Some stud-
ies report no significant effect or minimal effect for music therapy
on anxiety.24,26,30–33 but in some studies performed with pregnant
women, music was found to be effective on the anxiety of preg-
nant women, differing from our results 4,7,8,25,34 Additionally, music
therapy was used as a complementary and alternative treatment in
the removal of anxiety, and that in most of the studies, music ther-
apy was used to remove status anxiety seen in individuals before
medical and operative interventions.3,5,6,19–21,23 Although it seems
not to have an effect on anxiety levels in our study, participants
tended to close their eyes and mostly sleep while listening to music.
Music may create a feeling of peace. When it is considered that
pre-eclampsia is a medical condition that creates anxiety on its
own, participants relaxing while listening to music is an expected
situation.
Music therapy applied to pregnant women with pre-eclampsia
as a complementary care method in our study has increased satis-
faction with nursing care in pregnant women.
This situation is realized through a certain selected type of music
reducing neuroendocrine and sympathetic nervous system stimuli,
causing an increase in endorphin release and peace and satisfaction
feelings to form in the individual.33,35
Many studies have shown that music therapy increases patient
satisfaction and these results support our study.34,36,37 Addi-
tionally, compared to some other studies evaluating patient
satisfaction, the appeasement scores in our study were especially
higher.38–41
On the other hand, the fact that we found the effect of music to
decrease blood pressure is thought to have arisen from the fact that
music therapy affects the autonomous and central nervous system,
having a positive effect on physiological parameters. Chlan 22 stated
that musical stimuli, especially rhythm and tempo, could be used to
change the physiological responses of the body (heart rate, respira-
tion, blood pressure) through synchronization, and that music has
a positive effect on vital findings and the psychological and phys-
iological well-being of an individual. Parallel to our study, studies
showing that music has a decreasing effect on blood pressure are
present 3,7,9,24,42
Even though there are studies in literature showing that music
has a decreasing effect on blood pressure,3,7,24,42 only a single study
performed with pregnant women with hypertension was found.9
In this study performed by Sideronko9 Medical Resonance Therapy
6 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9

Table 1
Comparison of Socio Demographic Characteristics according to groups.

Study Group (n = 35) Control Group (n = 35) Total (n = 70) ta p

X̄ ± SD X̄ ± SD X̄ ± SD

Age (years) 30.69 ± 5.60 30.60 ± 6.10 30.64 ± 5.81 0.061 0.951

n (%) n (%) n (%) 2 p

Education level
Literate 3 (8.6) 6 (17.1) 9 (12.8) 1.403b 0.548
Elementary 26 (74.3) 25 (71.4) 51 (72.9)
High-College. 6 (17.1) 4 (11.5) 10 (14.3)

Employment status
Employed 3 (8.6) 3 (8.6) 6 (8.6) 0.000c 1.000
Unemployed 32 (91.4) 32 (91.4) 64 (91.4)
a
Student’s t test.
b
Fisher-Freeman-Halton test.
c
Fisher’s exact test.

Table 2
Comparison of Findings regarding Obstetrics Characteristics according to groups.

Study Group (n = 35) Control Group (n = 35) Total (n = 70) td /ze p

X̄ ± SD X̄ ± SD X̄ ± SD

Birth Week 35.76 ± 2.00 36.64 ± 2.69 36.20 ± 2.40 −1.560d 0.123
Number of Births (n = 53)1 2.10 ± 1.06 2.45 ± 1.34 2.26 ± 1.19 −1.110e 0.267

n (%) n (%) n (%) 2a.b.f p

Number of pregnancies
f
1 5 (14.3) 12 (34.3) 17 (24.3) 5.208 0.074
2–3 12 (34.3) 13 (37.1) 25 (35.7)
≥4 18 (51.4) 10 (28.6) 28 (40.0)

Number of stillbirths (n = 53)1

No 26 (86.7) 22 (95.7) 48 (90.6) 1.230b 0.374
Yes 4 (13.3) 1 (4.3) 5 (9.4)

Number of miscarriages (n = 53)1

No 13 (43.3) 14 (60.9) 27 (50.9) 1.676a 0.464
1 12 (40.0) 7 (30.4) 19 (35.8)
≥2 5 (16.7) 2 (8.7) 7 (13.3)
1
was calculated by removing first births from n.
d
Student’s t test.
e
Mann Whitney U test.
a
Fisher-Freeman-Halton test.
b
Fisher’s exact test.
f
Pearson Ki-kare test.

Table 3
Comparison of State Trait Anxiety Inventory (STAI TX-I) scores.

Study Group Control Group Total (n = 70) td p

(n = 35) (n = 35)

PREN Pre Application Min-Mak 32–57 32–64 32–64 −0.522d 0.603

1. day STAI TX-1 X̄ ± SD 42.03 ± 5.92 42.83 ± 6.86 42.43 ± 6.37
PREN Post application Min-Mak 36–54 30–64 30–64 1.008d 0.317
5. day STAI TX-I X̄ ± SD 43.86 ± 4.69 42.34 ± 7.55 43.10 ± 6.29
tg ; p −1.776; 0.085 0.504; 0.617

Change evaluation ze p
Difference1 X̄ ± SD 1.83 ± 6.09 −0.49 ± 5.70 −1.910e 0.056
(median) −1.00 0.00

PREN.: Prenatal.
1
STAI TX-I score difference between the 5th and 1st day before birth.
d
Student’s t test.
g
Paired samples t test.
e
Mann Whitney U test.

Table 4
Comparison of Newcastle Satisfaction with Nursing Scale (NHNS) scores.

Study Group (n = 35) Control Group (n = 35) Total (n = 70) t p

NHNS Min-Mak 69.74–100.00 35.53–100.00 35.53–100.00 2.920t 0.005**

X̄ ± SD 86.54 ± 10.42 74.62 ± 21.78 80.58 ± 17.98
t
Student’s t test.
**
p < 0.01.
 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9 7

Table 5
Comparison of Systolic blood pressure measurements and differences according to groups.

Average Systolic Blood pressure Study Group (n = 35) Control Group (n = 35) td /ze p
X̄ ± SD X̄ ± SD

PREN Pre app1 133.49 ± 12.17 131.17 ± 11.09 0.831d 0.409

Post app2 128.74 ± 11.24 129.46 ± 11.79 −0.261d 0.795
Difference (2-1) tg ; p 4.703g ; 0.001** 1.462g ; 0.153 −2.171e 0.030*
POSN Pre app3 127.71 ± 11.67 126.64 ± 9.29 0.425d 0.672
Post app4 125.14 ± 11.16 126.14 ± 10.49 −0.386d 0.701
Difference (4-3) tg ; p 1.823g ; 0.077 0.407g ; 0.687 −1.264e 0.206

PREN.: Prenatal POSN.:Postnatal App.: Application.

d
Student’s t test.
e
Mann Whitney U test.
g
Paired samples t test.
*
p < 0.05.
**
p < 0.01.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.
3
Postnatal period Pre application 2 day averages.
4
Postnatal period Post application 2 day averages.

Table 6
Comparison of Diastolic blood pressure measurements and differences according to groups.

Average Diastolic Blood pressure Study Group (n = 35) Control Group (n = 35) td /ze p
X̄ ± SD X̄ ± SD

PREN Pre app1 83.81 ± 9.16 83.07 ± 8.59 0.347d 0.730

Post app2 80.00 ± 6.68 83.09 ± 7.75 −1.784d 0.079
Difference (2-1) tg ; p 3.711g ; 0.001*, * −0.021g ; 0.984 −3.211e 0.001**
POSN Pre app3 79.00 ± 11.62 82.36 ± 8.72 −1.367d 0.176
Post app4 76.00 ± 8.73 81.07 ± 8.75 −2.428d 0.018*
Difference (4-3) tg ; p 2.569g ; 0.015* 1.704g ; 0.290 −0.909e 0.364

PREN.: Prenatal POSN.:Postnatal App.: Application.

d
Student’s t-test.
e
Mann Whitney U test.
g
Paired samples t test.
*
p < 0.05.
**
p < 0.01.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.
3
Postnatal period Pre application 2 day averages.
4
Postnatal period Post application 2 day averages.

Table 7
Comparison of Fetal Movement Number (FM) measurements and differences according to groups.

Average FM Number Study Group (n = 35) Control Group (n = 35) ze p

X̄ ± SD (median) X̄ ± SD (median)

Pre app1 4.36 ± 3.45 (3.40) 3.57 ± 1.60 (3.40) −0.600e 0.549
Post app2 5.43 ± 3.93 (4.20) 3.72 ± 1.62 (4.00) −1.996e 0.046*
Difference (2-1) th ; p −3.089h ; 0.002** −0.422h ; 0.673 −2.348e 0.019*

FM: Fetal Movement Number.

e
Mann Whitney U test.
h
Wilcoxon signed ranks test.
*
p < 0.05.
**
p < 0.01.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.

Table 8
Comparison of Fetal Heart Rate (FKH) measurements and differences according to groups.

Average FKH Number Study Group (n = 35) Control Group (n = 35) td /ze p
X̄ ± SD X̄ ± SD

Pre app1 140.15 ± 7.04 141.42 ± 6.89 −0.762d 0.449

Post app2 141.26 ± 7.27 141.34 ± 6.60 −0.048d 0.962
Difference (2-1) tg ; p −2.437g ; 0.020* 0.076g ; 0.940 −1.111e 0.266

FKH: Fetal Heart Rate.

d
Student’s t test.
e
Mann Whitney U test.
g
Paired samples t test.
*
p < 0.05.
1
Prenatal period Pre application 5 day averages.
2
Prenatal period Post application 5 day averages.
8 E. Toker, N. Kömürcü / Complementary Therapies in Medicine 30 (2017) 1–9
(MRT) was used as the music type and there is no study evaluating
the effect of Classical Turkish Music on anxiety and blood pressure
in pregnant women with pre-eclampsia. This study is thus unique.
On the other hand, studies similar to ours showing that music ther-
apy causes no differences in pulse and respiratory rates are also
present.34,43
Alongside these changes seen in pregnant women with
pre-eclampsia, the positive and significant differences in fetal
parameters obtained during fetal evaluation are also similar to
studies in literature on the subject.7–9 This result is thought to have
arisen from the response given by the fetus to the music listened
to. The fact that it was already reported that fetuses close to term
would show increased movement as a response to music 44 also
supports our finding.
6.1. Study limitations
When the limitations of the study are considered, the type of
music selected seems to be the first limitation of our study. Differ-
ent results may be obtained with different types of music. However,
it should be taken into consideration that the efficiency of Classi-
cal Turkish Music was found in other studies and that the type of
music was selected by the participants. The researcher knowing
the groups and taking care of the participants during the inter-
ventions and measurements may have affected the results. This
may have prevented more and more significant results obtained
between the groups. The facts that satisfaction was found to be
high in the control group as well and the control group also having
changes in blood pressure show there is no bias. However, a third
group in addition to those listening to music and receiving bed rest
could be added for comparison. However since the study was per-
formed with pregnant women with pre-eclampsia, which is a high
risk pregnancy group, this fact brought along the additional bar-
rier of not having sufficient cases in the clinic. Also the number of
cases is another limitation of the study. Additionally, more compre-
hensive studies with larger samples on the effectiveness of music
therapy on pregnant women with pre-eclampsia would verify the
effectiveness of Classical Turkish Music.
6.2. Recommendations for clinical practice
The study found significant differences between the groups and
the music therapy is suggested for use in the clinical environment
by obstetrics nurses/midwives after they received some training in
regard to education about music therapy. Steps of using the music
therapy may be:
– Maternity units and hospitals facilities could be designed
for music therapy in the clinical environment by obstetrics
nurses/midwives (such as specific areas for music therapy, and
allowance of listening music through loudspeaker or an MP3
player and headphones).
– The pregnant women with pre-eclampsia may be taken in a sep-
arate room.
– The steps before music therapy mentioned in the study should be
taken into considerations such as −the bladder of the participants
being empty, etc.
– The pregnant women should listen to the music selected among
different types of therapeutic musics according to their taste
regularly 30 min daily through an MP3 player and headphones
whilst lying down.
6.3. Suggestions for further studies
– Further studies may be performed with pregnant women with
pre-eclampsia, during prenatal, intrapartum and postpartum
period in order to test its and do research of the effectiveness
of music therapy on women.
– Another study may be performed on women with high risk of
pre-eclampsia and search of effectiveness of music therapy on
prevention of developing pre-eclampsia.
– More comprehensive studies with larger samples (qualitative or
quantitative studies), different measurements on the effective-
ness of music therapy on pregnant women with pre-eclampsia,
fetus and newborn would verify the effectiveness of Classical
Turkish Music.
7. Conclusion
In conclusion, through the findings obtained by applying music
therapy to pregnant women with pre-eclampsia, music therapy
was found to increase satisfaction with nursing care in pregnant
women, decrease blood pressure, the positive effect on fetal move-
ment counts, and minimalizing effect on fetal heart rate. Although
it seems not to have an effect on anxiety levels in our study, par-
ticipants relaxed while listening to music. The participants’ pulse
and respiratory rates were normal before the study so there were
no differences in pulse and respiratory rates before and after the
study.
Briefly, music therapy was found to have positive effects and
help provide a supportive and humane environment as well as
improve the experience and environment of the pregnant women,
and it may be suggested that nurses and midwives can utilize music
therapy in the care and follow-up of pregnant women with pre-
eclampsia in maternity units.
Conflict of interest statement
We, the authors of the present study, declare that there is no
conflict of interest regarding the paper entitled “Effect of Turk-
ish Classical Music on Prenatal Anxiety and Satisfaction: A RCT in
Pregnant Women with Pre-eclampsia”.
Acknowledgment
The TUMATA Association was consulted in every step of this
study from planning to application, and complete cooperation was
received from the team working at the obstetrics clinic where the
application was performed.
The present study is a dissertation completed in the Department
of Obstetrics and Gynecology Nursing, Faculty of Health Sciences,
Marmara University, İstanbul, Turkey.
This manuscript has been presented orally at the Complemen-
tary and Supportive Care Applications Congress, held in Kayseri,
Turkey, 27–29 May 2015.
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