Preventive Medicine 55 (2012) 333–340

Contents lists available at SciVerse ScienceDirect

Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

The effects of yoga in prevention of pregnancy complications in high-risk

pregnancies: A randomized controlled trial
A. Rakhshani a,⁎, 1, R. Nagarathna a, R. Mhaskar b, A. Mhaskar b, A. Thomas b, S. Gunasheela c
a
SVYASA University, Department of Life Sciences, Bengaluru, India
b
St. John's Medical College and Hospital, Department of OBG, Bengaluru, India
c
Gunasheela Surgical & Maternity Hospital, Bengaluru, India

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

Available online 2 August 2012 Objective. While previous studies have shown the potential effects of yoga in normal pregnancies, this
randomized controlled trial investigated the effects of yoga in prevention of pregnancy complications in
Keywords: high-risk pregnancies for the first time.
Yoga Methods. 68 high-risk pregnant women were recruited from two maternity hospitals in Bengaluru, India
Preventive medicine
and were randomized into yoga and control groups. The yoga group (n = 30) received standard care plus
Pregnancy complications
High-risk pregnancies
one-hour yoga sessions, three times a week, from the 12th to the 28th week of gestation. The control
Pregnancy outcomes group (n = 38) received standard care plus conventional antenatal exercises (walking) during the same pe-
riod.
Results. Significantly fewer pregnancy induced hypertension (PIH), preeclampsia, gestational diabetes
(GDM) and intrauterine growth restriction (IUGR) cases were observed in the yoga group (p = 0.018,
0.042, 0.049, 0.05 respectively). Significantly fewer Small for Gestational Age (SGA) babies and newborns
with low APGAR scores (p = 0.006) were born in the yoga group (p = 0.033).
Conclusion. This first randomized study of yoga in high-risk pregnancy has shown that yoga can potential-
ly be an effective therapy in reducing hypertensive related complications of pregnancy and improving fetal
outcomes. Additional data is needed to confirm these results and better explain the mechanism of action
of yoga in this important area.
© 2012 Elsevier Inc. All rights reserved.

Introduction
Background
Annually, more than half a million women die worldwide due to
pregnancy complications (Hogberg, 2005). These disorders affect
over 15% of pregnancies in developing countries, resulting in negative
maternal and perinatal outcomes (Hogberg, 2005). A pregnancy com-
plication is defined as a problem that arises during pregnancy and can
potentially put the health of the mother, fetus or both at risk (Beers et
al., 2003). Pregnancies that have a higher chance of developing com-
plications are often referred to as high-risk pregnancies (Beers et al.,
2003). While there are many complications that can occur during preg-
nancy, hypertensive disorders of pregnancy (pregnancy induced hyper-
tension (PIH), preeclampsia (PE), and eclampsia) (Gifford et al., 2000),
intrauterine growth restriction (IUGR) (Alberry and Soothill, 2007),
gestational diabetes (GDM) (American Diabetes Association, 2004),
⁎ Corresponding author at: SVYASA University, 19, Eknath Bhavan, Gavipuram Cir-
cle, K.G. Nagar, Bengaluru-560 019, India. Fax: +91 26612669.
E-mail address: abbas616@gmail.com (A. Rakhshani).
1
11408 E. Queensway Drive, Tampa, FL 33617, USA.
and preterm deliveries (Lawn et al., 2005) are some of the more common
disorders. Ironically, preterm delivery, which endangers the health of the
baby, is one of the more widely used conventional treatments for most
pregnancy complications (Autret-Leca et al., 2011). The etiology of these
complications is not clearly understood; however, there is increasing ev-
idence that maternal oxidative stress (Agarwal et al., 2005; Hsieh et al.,
2012; Lappas et al., 2011) and psychological stress (Austin and Leader,
2000; Mancuso et al., 2004; Nakamura et al., 2008; Orr et al., 2002;
Roy-Matton et al., 2011) play a strong role. Recent studies have shown
yoga to be effective in reducing oxidative (Hegde et al., 2011) and psycho-
logical stress (Chong et al., 2011; Stoller et al., 2012; Streeter et al., 2012;
Vancampfort et al., 2011). In this preliminary study in high-risk preg-
nancies, we investigated whether simple stress-reducing yoga tech-
niques can prevent the incidence of pregnancy complications in
high-risk women, and improve their delivery outcomes.
Over 5000 years old, yoga is a holistic approach to physical, men-
tal, and spiritual wellbeing that originated in India (Bijlani, 2008). It
involves a combination of stretching, breathing, posture, and medita-
tion that promote health and spiritual growth in the practitioners
(Chandler, 2001). These techniques are low-impact, non-invasive,
and have few side-effects (Benson and McCallie, 1979). A growing
body of research data now supports the use of yoga for prevention

0091-7435/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ypmed.2012.07.020
334 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340
and management of chronic lifestyle-related ailments (Bijlani, 2008;
Hanser, 2009; McCall, 2007; Taylor, 2003). Narendran et al. investi-
gated the effectiveness of yoga during pregnancy and reported higher
birth weights and fewer complications in the yoga group (Narendran
et al., 2005b). However, Narendran's study was not a randomized
controlled trial (RCT), and low-risk pregnancies were not excluded
from the study. Hence, we planned to study the effects of yoga on pre-
vention of complications in women with high-risk pregnancies. The
primary objectives of this study were to assess the feasibility of
using yoga interventions in high-risk pregnancies, and the effects of
yoga in preventing major pregnancy complications. The secondary
objective was to investigate the effects of yoga interventions in im-
proving pregnancy outcomes in high-risk population.
Materials and methods
Sample-size calculations
Based on our literature search, the nearest RCT with non-pharmacological
interventions that aimed at prevention of pregnancy complications was that
of Kanako (1999) which used simple water exercises to prevent preeclamp-
sia. Using the event ratios (106/573 = 0.185 in the experimental group and
83/164 = 0.506 in the control group) reported in that study, with α set at
0.05, probability of type I error at 0.01, and powered at 0.8, a minimum sam-
ple size of 27 per group was obtained. The final analysis was made on 30 sub-
jects in the yoga group and 38 in the control group.
Design and settings
This randomized controlled prospective stratified single-blind study was
conducted at the obstetric unit of St. John's Medical College & Hospital
(SJMCH) and Gunasheela Maternity Hospital (GMH) in Bengaluru, India
from February 2010 to May 2011.
Selection criteria
Inclusion: Pregnant women within 12 weeks of gestation and with any of
the following risk factors were considered qualified for the study: 1) history
of poor obstetrical outcomes—women who had experienced any of the compli-
cations listed in Table 2 in previous pregnancies; 2) twin pregnancies—
pregnancy with two fetuses; 3) extremes of age—maternal age below 20 or
above 35 years; 4) obesity—maternal body mass index of above 30 at the
time of recruitment, and/or 5) family history—women with a history of poor
obstetrical outcomes among blood relatives, i.e. sister, mother or grandmoth-
er (pregnancies with family history of these disorders carry an increased risk
of these disorders; Andelova et al., 1998; Ramos-Levi et al., 2012). Exclusion
criteria: 1) severe renal, hepatic or gallbladder, or heart disease; 2) structural
abnormalities in the reproductive system; 3) hereditary anemia; 4) seizure
disorders; 5) sexually transmitted diseases, or 6) any medical conditions
that prevented the subject from safely and effectively practicing the inter-
ventions. While we did not exclude women with diabetes or essential hyper-
tension, none of the participants enrolled in the study were ever diagnosed
with these conditions prior to this pregnancy.
Recruitment process
Subjects within the 12th week of gestation were approached by a re-
search staff at the reception of the OBGyn department of SJMCH or GMH
and introduced to the project. Those who were interested were escorted by
a staff to a private room, where the study was explained in detail, and then
were screened using a written protocol. Qualified subjects were given the op-
portunity to sign the informed consent form in order to complete the recruit-
ment process.
Randomization
An online random number generator by GraphPad Software (http://
graphpad.com/quickcalcs/randomize1.cfm, last accessed on July 3, 2012)
was used to randomize subjects into two groups: yoga and control. The selec-
tions (yoga or control) were then written on papers and placed in sealed,
opaque envelopes, which were kept in a locked cabinet. Recruited subjects
were assigned an ID and were permitted to pick one of the available enve-
lopes to determine group selection.
Blinding and masking
This was a single blind study: The physicians, laboratory technicians, and
hospital staff were blinded on the group selection.
Ethical clearance and informed consent
Clearance from the ethical committee of SJMCH was obtained before
commencement of the study. All qualified subjects were required to sign
the informed-consent form approved by the ethical committee of SJMCH be-
fore enrollment in the study.
Interventions
The yoga group received standard care plus a one-hour yoga session three
times a week from the beginning of the 13th week to the end of the 28th
week of gestation (a total of 28 sessions), while the control group received
standard care plus walking for half an hour mornings and evenings (the rou-
tine antenatal exercise offered by the hospital) during the same period. The
rationale for selecting these gestational periods for the interventions was
that most women detect pregnancy by the 12th week of gestation and
those that are at high risk are likely to deliver preterm. Also, organ develop-
ments are usually complete by the 28th week of gestation. The yoga classes
were conducted by well-trained certified yoga therapists, who used an in-
struction manual at a reserved room within the premises of SJMCH/GMH.
Standard care offered to both groups included: 1) pamphlets about diet and
nutrition during pregnancy; 2) regular check-ups by the obstetrician, and
3) bi-weekly follow-ups by the research staff. The purpose of these
bi-weekly telephone follow-ups was to check if the subjects were adhering
to their intervention practices and routine hospital check-ups.
Three categories of yoga interventions were offered to the study group:
1) breathing exercises, 2) yogic postures, and 3) meditative exercises. The
latter included visualization, guided imagery, and sound resonance tech-
niques. The subjects were asked to visualize the fetus in the uterus, the um-
bilical cord, and the placenta. Then the subjects were guided to imagine the
blood flowing from their bodies, into the placenta, through the umbilical
cord, and bringing nourishment to their fetuses. Table 1 outlines the exer-
cises practiced by the yoga group.
Table 1
Yoga interventions.
Practicesa Duration
hasta āyama śvasanam (Hands In and Out Breathing) 1 min
hastavistāra śvasanam (Hands Stretch Breathing) 2 min
gulphavistāra śvasanam (Ankles Stretch Breathing with wall support) 1 min
ka iparivartana śvsanam (Side Twist Breathing) 1 min
Deep Relaxationb 5 min
uttānapādāsana śvasanam (Leg Raise Breathing) 1 min
setubandhāsana śvasanam (Hip Raise Breathing) 1 min
pādasañcālanam (Cycling in supine pose) 1 min
supta udarākar a asana śvasanam (Supine Abdominal Stretch Breathing) 1 min
vyāghrāsana śvasanam (Tiger Stretch Breathing) 1 min
Deep Relaxationb 5 min
gulphagūra am (Ankle Rotation) 2 min
jānuphalakākar a am (Kneecap Contraction) 1 min
ardhātitaliāsana (Half Butterfly Exercise) 3 min
Poornātitaliāsana (Full Butterfly Exercise) 1 min
Deep Relaxationb 5 min
jyotitrā aka (Eye Exercises) 2 min
nā īśuddhi pranayam (Alternate Nostrils Breathing) 2 min
Deep Relaxation in matsyakrī āsana (Lateral Shavasana)a 10 min
Note: This study was conducted in high-risk pregnancies at St John's Medical College &
Hospital in Bengaluru, India from February 2010 to April 2011.
a
Except the deep relaxation, all the practices are part of Integrated Approach of
Yoga Therapy outlined in detail in the book ‘Integrated Approach of Yoga Therapy for
Positive Health’ by Dr R Nagarathna and Dr HR Nagendra.
b
Meditation techniques used during deep relaxation: Visualization, guided imagery
and sound resonance techniques.
 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340 335

Assessments
Definitions
While there are many complications of pregnancy, this trial studied only PIH
(Gifford et al., 2000), PE (Gifford et al., 2000), eclampsia (E) (Gifford et al.,
2000), GDM (American Diabetes Association, 2004), premature rupture of am-
niotic membrane (PROM) (Beers et al., 2003), low birth weight (LBW)
(Mahajan and Gupta, 1995), small for gestational age (SGA) (McCowan et al.,
2010), large for gestational age (LGA) (McCowan et al., 2010), IUGR
(Mandruzzato et al., 2008), APGAR score (Finster and Wood, 2005), and pre-
term deliveries (Mandruzzato et al., 2008) as defined in Table 2. Due to the di-
versity in demographics of the Indian population and the non-availability of
normative birth weight graphs for Indian babies in Bengaluru, substantial
amount of time was spent searching for suitable normograms to determine
SGA or LGA. It was finally decided to use the data from a US study (Oken et
al., 2003) for the singleton babies since it included African-American and Latino
babies, who have birth weights lower than those of white Caucasians and the
one from an English study (Buckler and Green, 1994) for twin pregnancies.
Maternal information
The maternal weight, height and sitting blood pressure were assessed at
baseline and at the 20th and the 28th week of gestation. The demographic
data, which included the subjects' age, socio-economics, education, and religion
were obtained through a self-reported questionnaire. The financial status of
the subjects was measured in two ways: 1) subjectively—by recording the
monthly household income (in Indian rupees) reported by the subjects, and
2) objectively—by having the subjects complete a socio-economic status (SES)
form, used by other Indian research groups at SJMCH. The score for SES, ranging
from 0 to 60, was the sum of the listed number of possessions and household
features.
Samples T-test for variables that had normal distribution and Mann–Whitney U
test for those that were not normally distributed. Chi-Square test was used to
test significance between groups when frequencies were used.
Results
Recruitment and retention
Fig. 1 presents the consort diagram. The main reason for the larger
dropouts in the yoga group was that, when the subjects in the yoga
group went to their hometowns, they were dropped because they
couldn't attend the yoga sessions, while the subjects in the control
group could still continue with their walking interventions. At the end
of the recruitment period, the numbers in the five risk categories
were: 1) history of poor obstetrical outcomes: 8 in the yoga and 10 in
the control group; 2) twin pregnancies: 4 in each group; 3) extremes
of age: 6 in the yoga and 8 in the control group; 4) obesity: 6 in the
yoga and 7 in the control group, and 5) family history: 6 in the yoga
and 9 in the control group. There was no subject with essential diabetes,
essential hypertension, or multiple risk factors among the recruited
subjects. During the final analysis, the sample sizes for different out-
come measures differed because the delivery forms returned by the
subjects who chose to deliver at other hospitals were incomplete and
had missing data; mostly on complications. This was generally a prob-
lem with the subjects in the control group since the study group sub-
jects attended the yoga classes and usually delivered at SJMCH or
GMH (see the Limitation section).

Pregnancy complications
Maternal blood pressure, and details of all incidents of pregnancy compli-
cations were noted from the hospital records.
Delivery data
Fetal measurements, birth weight, gestational age at delivery, and mode of
delivery were noted from the hospital record. Birth weight normograms for sin-
gleton (Oken et al., 2003) and twin pregnancies (Buckler and Green, 1994) were
used to document the number of babies with LBW, SGA, LGA, or normal for ges-
tational age (NGA). Some subjects chose to deliver at other hospitals. The obste-
trician in charge of the delivery completed our study's delivery form after
obtaining subject's written consent.
Data analysis
For data analysis, PASW Statistics (formerly known as SPSS) version 18.0.3
for Mac was used. Shapiro–Wilk's test was utilized to test the normality of
data. Baseline comparison of the two groups was performed using Independent
Demographic data and baseline comparison
The average age of the subjects in both groups was about twenty
seven years. More than 65% of the subjects in the yoga group and 45%
in the control group had college and higher education, which is substan-
tially higher than the average for the Indian population, which is 13.2%
according to 2004 National Sample Survey. The average household in-
come was 38,230 rupees for the yoga group and 40,270 rupees for the
control group, which is substantially higher than the national average
of 2879 rupees (http://cee45q.stanford.edu/2003/briefing_book/india.
html, last accessed on July 3, 2012). More than 55% of the subjects in
the yoga group, and 50% of the control group lived independently
with their immediate family (husband and any children), which is
also not surprising from the affluent population of Bengaluru. It is inter-
esting to note that although we recruited 6 obese subjects in the yoga
group and 7 in the control group, the average body mass index (BMI)

Table 2
Definitions of the complications of pregnancy used for this study.

Complication Definition

Pregnancy induced hypertension (PIH)
Preeclampsia (PE)
Eclampsia (E)
Gestational diabetes mellitus (GDM)
Premature rupture of membranes (PROM)
Low birth weight (LBW)
Small for gestational age (SGA)
Large for gestational age (LGA)
Normal for gestational age (NGA)
Intrauterine growth restriction (IUGR)
APGAR score
Preterm deliveries
Development of new arterial hypertension (BP systolic ≥140 mm Hg diastolic ≥90 mm Hg) after 20 weeks of gestation
without proteinuria.
Pill with new onset of proteinuria (24-hour urine protein ≥300 mg).
Severe preeclampsia associated with grand mal seizures.
New onset of glucose intolerance during pregnancy (serum glucose ≥l00 mg/100 ml).
Spontaneous rupture of the amniotic sac before the onset of labor.
≤2500 g irrespective of the duration of the gestational period.
≤l0th percentile for their gestational age.
≥90th percentile for their gestational age.
Between 10th and 90th percentiles for their gestational age.
Fetus unable to reach its required growth potential for its gestational age due to some pathological inhibition
Calculated using estimated fetal weight and gestational age from the ultrasound and Doppler data.
A total score of 0 to 10 obtained by summing individual score (0–2) given to each of the five categories (skin color,
heart rate, flexibility, muscle tone, and breathing pattern) of a newborn. The test was performed at 1 min after delivery
(APGAR-1) and then again at 5 min after the delivery (APGAR-5).
Deliveries prior to the 37 weeks of gestation.

Note: This study was conducted in high-risk pregnancies at St John's Medical College & Hospital in Bengaluru, India from February 2010 to April 2011.
336 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340
Fig. 1. Consort diagram for trial profile.
of the subjects remained relatively normal in both groups, 25.1 and
25.34 in yoga and control, respectively (Table 3).
Primary outcome measures
Feasibility
One of the objectives of this preliminary study in high-risk preg-
nancies was to assess the feasibility of administering yoga interven-
tions as a preventive medicine to women at high risk of pregnancy
complications. The hospital administration proved to be very open
to the practices of yoga as a mind–body medicine and was quite ac-
commodating to the project. The research staff was able to teach
yoga classes without interruptions. There were no reported com-
plaints of the exercises taught and all subjects were able to practice
them. The visualization and guided imagery exercises were particu-
larly well received. While in the West, yoga is uniformly practiced
by all faiths, we found some hesitation in the Moslem and Christian
families, as they associated it with the Hindu faith. However, those
that joined the study, continued with the sessions.
Hypertensive disorders of pregnancy
There were 11 (36.7%) cases of PIH in the control group and
3 (10.3%) cases in the study group (p = 0.02, chi 2). The inci-
dents of preeclampsia were also significantly less in the yoga
group (0% in the yoga group versus 13.3% in the control, p =
0.04, chi 2). There were two cases of eclampsia in the control
group and none in the yoga group; however, the results were
not statistically significant (p = 0.16, chi 2).
Other complications
The yoga group had significantly fewer cases of IUGR (p = 0.05,
chi 2) and preterm deliveries (p = 0.04, chi 2), which are prevalent is-
sues in India (Park, 2000). There were also fewer occurrences of
GDM in the yoga group (p = 0.05, chi 2). There was one dropout due
to abortion in the control group. There were no cases of miscarriages,
fetal deaths, or congenital anomalies.
Secondary outcome measures
Fetal outcomes
Significantly fewer babies born from the women in the yoga group
had low APGAR-1 and APGAR-5 scores (p = 0.01 and p = 0.04 chi 2,
respectively). There were significantly lower SGA newborns in the
yoga group than in the control group (p = 0.03, chi 2). However, the
number of LGA and LBW babies was not significantly different be-
tween the groups (p = 0.12 and 0.76 chi 2, respectively).
The results of the outcome measures are listed in Table 4.
Discussion
The results of this preliminary study in high-risk pregnancies,
in-line with some of the previous findings, showed fewer occurrences
of PIH, GDM, preeclampsia, IUGR, and preterm deliveries in the yoga
 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340 337

Table 3
Demographic and maternal data at baseline.

Groups p-Values

Yoga Control group

Subjects' educational profilea

Finished 8th grade 2 5 0.11b
Finished 10th grade 8 7
Finished 12th grade 0 4
Finished Junior College 0 4
Bachelors degree 13 13
Masters degree 7 5
Living arrangementc
Living independently 17 20 0.86b
Living with parents 10 15
Living with relatives or friends 3 3
Religion
Hindu 25 29 0.18b
Moslem 0 4
Christian 5 5
Age Mean(SD) 27.77 (5.15) 27.21 (5.2) 0.66d
(95% CI) (25.50–28.92) (25.50–28.92)
Household monthly incomee Mean (SD) 38.23 (30.4) 40.27 (45.12) 0.74d
(95% CI) (26.67–49.79) (25.01–55.54)
Socio-economicf Mean (SD) 36.2 (8.07) 36.05 (8.86) 0.6d
(95% CI) (33.19–39.21) (33.10–39.01)
Maternal weight (kg) Mean (SD) 61.88 (12.62) 62.51 (1432) 0.85d
(95% CI) (57.17–66.59) (57.81–67.22)
Maternal height (a) Mean (SD) 1.56 (0.05) 1.57(0.05) 0.96d
(95% CI) (1.55–1.59) (1.55–1.59)
Maternal BMI Mean (SD) 25.1 (4.68) 25.34(4.94) 0.84d
(95% CI) (23.35–26.85) (23.71–26.96)
Maternal systolic BP Mean (SD) 109(13.54) 104 (8.281) 0.083d
(95% CI) (103.95–114.25) (101.27–106.79)
Maternal diastolic BP Mean (SD) 67.62 (9.08) 65.59 (7.94) 0.34d
(95% CI) (64.19–71.05) (62.95–68.24)

Note: This study was conducted in high-risk pregnancies at St. John's Medical College & Hospital in Bengaluru, India from February 2010 to April 2011.
a
No subject had education below the 8th standard.
b
Calculated using Chi-Square Test.
c
Subject could live with her husband and any children independently, live with parents, or live with relatives or friends.
d
Calculated using Independent-Samples T-Square Test.
e
Family monthly income was reported by the subjects and is in thousands of Indian Rupees.
f
Socio-economic was measured objectively by a questionnaire (see the Demographic section).

group. To our knowledge, this is the first RCT that has investigated the
effects of yoga in high-risk pregnancies.
Previous studies have investigated the effects of acupuncture
(Betts et al., 2012; Borup et al., 2009), homeopathy (Hochstrasser and
Mattmann, 1994), Ayurveda (Jayashree, 2008), yoga (Narendran et al.,
2005b; Rakhshani et al., 2010), and Qigong (Zhou and Lian, 1989) dur-
ing pregnancy (Bishop et al., 2011; Kalder et al., 2011; Steel and Adams,
2011). Such interventions have been shown to be effective in reducing
occurrences of hypertensive disorders of pregnancy (Hofmeyr et
al., 2010; Zhou and Lian, 1989), preventing preterm deliveries
(Hochstrasser and Mattmann, 1994; Imdad et al., 2011; Sibai, 2011),
improving fetal outcomes (Hochstrasser and Mattmann, 1994; Sabour
et al., 2006), and enhance quality of life (Rakhshani, 2013; Rakhshani
et al., 2010).
In the Narendran study also, yoga interventions resulted in signifi-
cantly less incidents of IUGR (pb 0.003, 22.06% vs. 32%), PIH (pb 0.025,
17.65% vs. 28%), and preterm labor (pb 0.0006, 13.24% vs. 20.75%) in
the yoga group. A study of Qi-gong practices, which are similar to
yoga exercises, has shown that they can significantly reduce the clinical
manifestations of PIH (pb 0.01, 90% vs. 55%) (Zhou and Lian, 1989).
The APGAR-1 and APGAR-5 scores, as well as the number of preterm
deliveries and SGA babies, were significantly less in the yoga group of
this study. That is important because SGA is a prevalent issue in India
(Hofvander, 1982), and it has been argued that it is a key indicator of
the health trajectory of a child (Schaffer et al., 2009; Woelfle, 2008).
These results also conform with Narendran's, which reported that
there were significantly less LBW infants in the yoga group (pb 0.01,
19.12% vs. 30.19%) (Narendran et al., 2005a). In a study of acupuncture
therapies, the investigators found that the mean APGAR-5 improved
significantly in the acupuncture group (Borup et al., 2009).
Mechanism
An important issue is that yoga encompasses a broad set of practices
with different benefits. Due to the characteristic of the high-risk popu-
lation for this study, the yoga interventions (yogic breathing and med-
itation) chosen were mostly focused on relaxation and rest with
awareness, which have been shown to be effective in management of
hypertension and diabetes (Cohen et al., 2009; Gokal et al., 2007;
Hegde et al., 2011; Kyizom et al., 2010; Murthy et al., 2011; Yang et
al., 2009) in non-pregnant subjects, potentially due to their reducing
maternal stress and anxiety (Brown and Gerbarg, 2005a, 2005b). There-
fore, the meditative and relaxing nature of the interventions in this
study could be a possible explanation for the significant improvement
in hypertensive disorders of pregnancy and gestational diabetes that
were observed in the yoga group. The reduction in the maternal stress
could also have: 1) fostered multiple positive downstream effects on
neuroendocrine pathway, metabolic function, and associated inflam-
matory responses (Innes et al., 2007); 2) activated the vagal nerve
and thereby improved parasympathetic output leading to enhanced
cardiac-vagal function, mood, energy state, and related neuroendo-
crine, metabolic, and inflammatory responses (Bowman et al.,
1997; Taylor et al., 2010); and/or 3) promoted a feeling of
well-being (Rakhshani, 2013), perhaps by reducing the activation
and reactivity of the sympathoadrenal system and the hypothalamic
pituitary adrenal (HPA) axis (Ross and Thomas, 2010).
338 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340

Table 4
Pregnancy complications and fetal outcomes.

Statistics p-Valuesa

nb Observed (%)

Pregnancy induced hypertension (PIH) Yoga 29 3 (10.3) 0.02

Control 30 11 (36.7)
Preeclampsia (PE) Yoga 29 0 (0.0) 0.04
Control 30 4 (13.3)
Eclampsia (E) Yoga 29 0 (0.0) 0.16
Control 30 2 (6.7)
Gestational diabetes (GDM) Yoga 29 1 (3.4) 0.05
Control 30 6 (20)
Intra-uterine growth restriction (IUGR) Yoga 29 2 (6.9) 0.05
Control 31 8 (25.8)
Premature rupture of amniotic membrane (PROM) Yoga 29 4 (13.8) 0.92
Control 31 4 (12.9)
Preterm deliveriesc Yoga 29 6 (20.7) 0.04
Control 35 16 (45.7)
Emergency C-section Yoga 29 15 (51.7) 0.62
Control 38 22 (57.9)
d
Low birth weight (LBW) Yoga 29 7 (24.1) 0.76
Control 38 8 (21.1)
e
Small for gestational age (SGA) Yoga 29 6 (20.7) 0.03
Control 37 17 (45.9)
Large for gestational age (LGA)e Yoga 29 0 (0) 0.12
Control 37 3 (8.1)
Normal for gestational age (NGA)e Yoga 29 23 (79.3) 0.01
Control 37 17 (45.9)
f
Low 1-minute APGAR score Yoga 20 1 (5) 0.01
Control 33 13 (39.4)
f
Low 5-minute APGAR score Yoga 20 1 (5) 0.04
Control 32 9 (28.1)

Note: This study was conducted in high-risk pregnancies at St. John's Medical College & Hospital in Bengaluru, India from February 2010 to April 2011.
a
Chi square calculations.
b
The sample size variation from one condition to another is due to missing data on complications observed in the delivery forms received from subjects who delivered outside of
SJMCH and GMH.
c
Deliveries below 37 weeks of gestation.
d
LBW infants were those below 2500 g regardless of gestational age.
e
SGA infants had birth weight less than the 10th percentile, LGA infants had birth weight larger than the 90th, and NGA infants had birth weight between 10th and 90th per-
centiles for their gestational age.
f
Scores below 8 were considered low for 1-minute APGAR score and scores below 9 were considered low for 5-minute APGAR score.

Study limitations
There are a few limitations for this study: 1) the affluent popula-
tion of the city of Bengaluru is not a representative of the Indian pop-
ulation as a whole; 2) some subjects chose to deliver in a hospital in
their home towns according to the Indian tradition, and the protocol
used for determining C-section or for inducing labor at those hospi-
tals could have been different from SJMCH or GMH; 3) the subjects
were recruited based on five risk factors, and it would have been in-
teresting to see the effects of yoga on each of these categories, but
the number of subjects with some of these risk factors was too
small for meaningful data analysis; 4) although our research staff
made regular follow-up calls to the subjects in the control group to
ensure compliance to the walking regime, the documentation was ul-
timately self-reported, and 5) medication and undocumented home
remedies could have been confounding factors in the study. Other
confounding variables could have been the practices of Lamaz and
aerobics by the participants without informing our research team.
We do not expect these as these practices are not popular in India.
Recommendations for future studies
yoga on each of the risk factors could offer better insight on the mecha-
nism of action of yoga. Also, a study that starts the yoga interventions
much earlier in the first trimester, or even before conception, could
shed some light on the role of yoga in placentation and oxidative stress.
Finally, a review of the pregnancy and childbirth related Indian tradi-
tions and rituals in the Vedic literature can be very helpful in designing
future studies that will reduce potential dropouts.
Conclusion
The results of this preliminary randomized single blind control study
suggest that yoga, a non-invasive and cost-effective mind–body medi-
cine, could be a feasible therapy in high-risk pregnancies and could po-
tentially reduce the frequency of hypertensive disorders of pregnancy,
gestational diabetes, intrauterine growth restriction, and possibly im-
prove fetal outcomes. Substantially more data is required to establish
the role of yoga in different categories of high-risk pregnancies.
Conflict of interest statement
The authors claim no conflicts of interest.

The result of this preliminary study in high-risk pregnancies can be Source(s) of support in the form of grants
used to power a larger cohort follow up study, which may, not only con-
firm these results, but also allow meaningful statistical analysis be- This study was funded by a grant from the Central Council for Re-
tween the subgroups. Independent RCTs investigating the impact of search in Yoga & Naturopathy (CCRYN) of the Department of AYUSH
 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340
within the Ministry of Health of the Government of India (grant num-
ber 13-1/2010-11/CCRYN/AR-90).
Acknowledgment
This study was funded by a grant from the Central Council for Re-
search in Yoga & Naturopathy (CCRYN) of the Department of AYUSH
within the Ministry of Health of the Government of India (grant number
13-1/2010-11/CCRYN/AR-90). The time that was invested by Dr.
Chindananda Murthy, the director of CCRYN and other board mem-
bers of CCRYN in reviewing this project is acknowledged with deep
gratitude. Also, the support of SVYASA University, St. John's Medical
College and Hospital, and Gunasheela Maternity Hospital is greatly
appreciated. Finally, we are grateful for Dr. Sat Bir Khalsa's guidance
during the initial stage of this project.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://
dx.doi.org/10.1016/j.ypmed.2012.07.020.
References
Agarwal, A., Gupta, S., Sharma, R., 2005. Role of oxidative stress in female reproduction.
Reprod. Biol. Endocrinol. 3, 28.
Alberry, M., Soothill, P., 2007. Management of fetal growth restriction. Arch. Dis. Child.
Fetal Neonatal Ed. 92, F62–F67.
American Diabetes Association, 2004. Diagnosis and classification of diabetes mellitus.
Diabetes Care 27 (Suppl. 1), S5–S10.
Andelova, K., Velebil, P., Stroufova, A., Sula, K., 1998. Prediction of pregnancy-induced
hypertension in women with risk factors. Ceska Gynekol. 63, 443–446.
Austin, M., Leader, L., 2000. Maternal stress and obstetric and infant outcomes: epidemio-
logical findings and neuroendocrine mechanisms. Aust. N. Z. J. Obstet. Gynaecol. 40,
331–337.
Autret-Leca, E., Cissoko, H., Jonville-Bera, A.P., 2011. Neonatal risks of drugs exposure at
the end of pregnancy. Therapie 66, 431–436.
Beers, M.H., Fletcher, A.J., Jones, T.V., Porter, R., 2003. The Merck Manual of Medical In-
formation. Simon & Schuster, Inc., New York, NY.
Benson, H., Mccallie, D.P., 1979. Angina pectoris and the placebo effect. N. Eng. J. Med.
300, 1424–1429.
Betts, D., Smith, C., Hannah, D., 2012. Acupuncture as a therapeutic treatment option
for threatened miscarriage. BMC Complement. Altern. Med. 12, 20.
Bijlani, R., 2008. Yoga: An Ancient Tool in Modern Medicine.
Bishop, J., Northstone, K., Green, J., Thompson, E., 2011. The use of complementary and al-
ternative medicine in pregnancy: data from the Avon Longitudinal Study of Parents
and Children (ALSPAC). Complement. Ther. Med. 19, 303–310.
Borup, L., Wurlitzer, W., Hedegaard, M., Kesmodel, U., Hvidman, L., 2009. Acupuncture
as pain relief during delivery: a randomized controlled trial. Birth 36, 5–12.
Bowman, A.J., Clayton, R.H., Murray, A., Reed, J.W., Subhan, M.M., Ford, G.A., 1997. Ef-
fects of aerobic exercise training and yoga on the baroreflex in healthy elderly per-
sons. Eur. J. Clin. Invest. 27, 443–449.
Brown, R.P., Gerbarg, P.L., 2005a. Sudarshan kriya yogic breathing in the treatment of
stress, anxiety, and depression: Part I—neurophysiologic model. J. Altern. Comple-
ment. Med. 11, 189–201.
Brown, R.P., Gerbarg, P.L., 2005b. Sudarshan kriya yogic breathing in the treatment of
stress, anxiety, and depression: Part ii—clinical applications and guidelines. J.
Altern. Complement. Med. 11, 711–717.
Buckler, J., Green, M., 1994. Birth weight and head circumference standards for English
twins. Arch. Dis. Child. 71, 516–521.
Chandler, K., 2001. The emerging field of yoga therapy. Hawaii Med. J. 60, 286–287.
Chong, C., Tsunaka, M., Tsang, H., Chan, E., Cheung, W., 2011. Effects of yoga on stress
management in healthy adults: a systematic review. Altern. Ther. Health Med.
17, 32–38.
Cohen, D., Bloedon, L., Rothman, R., et al., 2009. Iyengar yoga versus enhanced usual
care on blood pressure in patients with prehypertension to stage I hypertension:
a randomized controlled trial. Evid. Based Complement. Altern. Med.
Finster, M., Wood, M., 2005. The APGAR score has survived the test of time. Anesthesi-
ology 102 (4), 855–857.
Gifford, R.W., August, P.A., Cunningham, F.G., et al., 2000. Report of the national high
blood pressure education program working group on high blood pressure in preg-
nancy, 183, pp. S1–S22.
Gokal, R., Shillito, L., Maharaj, S., 2007. Positive impact of yoga and pranayam on obe-
sity, hypertension, blood sugar, and cholesterol: a pilot assessment. J. Altern. Com-
plement. Med. 13 (10), 1056–1057.
Hanser, S.B., 2009. From ancient to integrative medicine. Music Med. 1, 87.
Hegde, S., Adhikari, P., Kotian, S., Pinto, V., D'Souza, S., D'Souza, V., 2011. Effect of 3-
month yoga on oxidative stress in type 2 diabetes with or without complications:
a controlled clinical trial. Diabetes Care 34, 2208–2210.
339
Hochstrasser, B., Mattmann, P., 1994. Homeopathy and conventional medicine in the
management of pregnancy and childbirth. Schweiz. Med. Wochenschr. Suppl. 62,
28–35.
Hofmeyr, G., Lawrie, T., Atallah, A., Duley, L., 2010. Calcium supplementation during
pregnancy for preventing hypertensive disorders and related problems. Cochrane
Database Syst. Rev. CD001059.
Hofvander, Y., 1982. International comparisons of postnatal growth of low birthweight
infants with special reference to differences between developing and affluent
countries. Acta Paediatr. Scand. Suppl. 296, 14–18.
Hogberg, U., 2005. The world health report 2005: make every mother and child count—
including Africans. Scand. J. Public Health 33, 409–411.
Hsieh, T., Chen, S., Lo, L., Li, M., Yeh, Y., Hung, T., 2012. The association between mater-
nal oxidative stress at mid-gestation and subsequent pregnancy complications.
Reprod. Sci. 19, 505–512.
Imdad, A., Jabeen, A., Bhutta, Z., 2011. Role of calcium supplementation during preg-
nancy in reducing risk of developing gestational hypertensive disorders: a meta-
analysis of studies from developing countries. BMC Publ. Health 11 (Suppl. 3), S18.
Innes, K.E., Vincent, H.K., Taylor, A.G., 2007. Chronic stress and insulin resistance-
related indices of cardiovascular disease risk, part I: neurophysiological responses
and pathological sequelae. Altern. Ther. Health Med. 13, 46–52.
Jayashree, K., 2008. Maternal care through mainstreaming Ayurvedic approach. Anc.
Sci. Life 28, 49–54.
Kalder, M., Knoblauch, K., Hrgovic, I., Munstedt, K., 2011. Use of complementary and al-
ternative medicine during pregnancy and delivery. Arch. Gynecol. Obstet. 283,
475–482.
Kanako, K., 1999. Studies on prophylaxis of preeclampsia by water exercise during
pregnancy. J. Aichi Med. Univ. Assoc. 27, 103–114.
Kyizom, T., Singh, S., Singh, K., Tandon, O., Kumar, R., 2010. Effect of pranayama & yoga-
asana on cognitive brain functions in type 2 diabetes-p3 event related evoked po-
tential (erp). Indian J. Med. Res. 131, 636–640.
Lappas, M., Hiden, U., Desoye, G., Froehlich, J., Hauguel-De Mouzon, S., Jawerbaum, A.,
2011. The role of oxidative stress in the pathophysiology of gestational diabetes
mellitus. Antioxid. Redox Signal. 15, 3061–3100.
Lawn, J., Cousens, S., Zupan, J., 2005. 4 million neonatal deaths: When? Where? Why?
Lancet 365, 891–900.
Mahajan, B.K., Gupta, M.C., 1995. Textbook of Preventive and Social Medicine. Jaypee
Brothers Medical Publishers Pvt. Ltd., New Delhi.
Mancuso, R., Schetter, C., Rini, C., Roesch, S., Hobel, C., 2004. Maternal prenatal anxiety and
corticotropin-releasing hormone associated with timing of delivery. Psychosom. Med.
66, 762–769.
Mandruzzato, G., Antsaklis, A., Botet, F., et al., 2008. Intrauterine restriction (IUGR). J.
Perinat. Med. 36, 277–281.
McCall, T., 2007. Yoga as Medicine: The Yogic Prescription for Health & Healing: A Yoga
Journal Book. Bantam.
Mccowan, L.M., Roberts, C.T., Dekker, G.A., et al., 2010. Risk factors for small-for-
gestational-age infants by customised birthweight centiles: data from an interna-
tional prospective cohort study. BJOG 117, 1599–1607.
Murthy, S., Rao, N., Nandkumar, B., Kadam, A., 2011. Role of naturopathy and yoga
treatment in the management of hypertension. Complement. Ther. Clin. Pract.
17, 9–12.
Nakamura, K., Sheps, S., Arck, P., 2008. Stress and reproductive failure: past no-
tions, present insights and future directions. J. Assist. Reprod. Genet. 25,
47–62.
Narendran, S., Nagarathna, R., Gunasheela, S., Nagendra, H.R., 2005a. Efficacy of yoga in
pregnant women with abnormal Doppler study of umbilical and uterine arteries. J.
Indian Med. Assoc. 103, 12–17.
Narendran, S., Nagarathna, R., Narendran, V., Gunasheela, S., Nagendra, H.R.,
2005b. Efficacy of yoga on pregnancy outcome. J. Altern. Complement. Med.
11, 237–244.
Oken, E., Kleinman, K., Rich-Edwards, J., Gillman, M., 2003. A nearly continuous mea-
sure of birth weight for gestational age using a united states national reference.
BMC Pediatr. 3, 6.
Orr, S., James, S., Blackmore Prince, C., 2002. Maternal prenatal depressive symptoms
and spontaneous preterm births among African-American women in Baltimore,
Maryland. Am. J. Epidemiol. 156, 797–802.
Park, K., 2000. Park's Text Book of Preventive and Social Medicine. Banarsidas Bhanot,
Jabalpur.
Rakhshani, A., 2013. Yoga and quality of life. In: Encyclopedia of Quality of Life
Research, Michalos, A.C. (Eds.), Springer, Dordrecht (In print).
Rakhshani, A., Maharana, S., Raghuram, N., Nagendra, H., Venkatram, P., 2010. Effects of
integrated yoga on quality of life and interpersonal relationship of pregnant
women. Qual. Life Res. 19, 1447–1455.
Ramos-Levi, A.M., Perez-Ferre, N., Fernandez, M., et al., 2012. Risk factors for gestation-
al diabetes mellitus in a large population of women living in Spain: implications for
preventative strategies. Int. J. Endocrinol. 2012, 312529.
Ross, A., Thomas, S., 2010. The health benefits of yoga and exercise: a review of com-
parison studies. J. Altern. Complement. Med. 16, 3–12.
Roy-Matton, N., Moutquin, J., Brown, C., Carrier, N., Bell, L., 2011. The impact of per-
ceived maternal stress and other psychosocial risk factors on pregnancy complica-
tions. J. Obstet. Gynaecol. Can. 33, 344–352.
Sabour, H., Hossein-Nezhad, A., Maghbooli, Z., Madani, F., Mir, E., Larijani, B., 2006. Re-
lationship between pregnancy outcomes and maternal vitamin d and calcium in-
take: a cross-sectional study. Gynecol. Endocrinol. 22, 585–589.
Schaffer, L., Muller-Vizentini, D., Burkhardt, T., Rauh, M., Ehlert, U., Beinder, E., 2009.
Blunted stress response in small for gestational age neonates. Pediatr. Res. 65,
231–235.
340 A. Rakhshani et al. / Preventive Medicine 55 (2012) 333–340
Sibai, B., 2011. Calcium supplementation during pregnancy reduces risk of high blood
pressure, pre-eclampsia and premature birth compared with placebo? Evid.
Based Med. 16, 40–41.
Steel, A., Adams, J., 2011. The role of naturopathy in pregnancy, labour and post-natal care:
broadening the evidence-base. Complement. Ther. Clin. Pract. 17, 189–192.
Stoller, C., Greuel, J., Cimini, L., Fowler, M., Koomar, J., 2012. Effects of sensory-enhanced
yoga on symptoms of combat stress in deployed military personnel. Am. J. Occup.
Ther. 17, 32–38.
Streeter, C., Gerbarg, P., Saper, R., Ciraulo, D., Brown, R., 2012. Effects of yoga on the au-
tonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, de-
pression, and post-traumatic stress disorder. Med. Hypotheses 78 (5), 571–579.
Taylor, M.J., 2003. Yoga therapy in rehabilitation. In: Davis, C. (Ed.), Complementary
Therapies in Rehabilitation: Evidenced Based Practices. Slack, New York, NY.
Taylor, A., Goehler, L., Galper, D., Innes, K., Bourguignon, C., 2010. Top–down and bot-
tom–up mechanisms in mind–body medicine: development of an integrative
framework for psychophysiological research. Explore (NY) 6, 29–41.
Vancampfort, D., De Hert, M., Knapen, J., et al., 2011. State anxiety, psychological stress
and positive well-being responses to yoga and aerobic exercise in people with
schizophrenia: a pilot study. Disabil. Rehabil. 33, 684–689.
Woelfle, J., 2008. Postnatal consequences of intrauterine development: pubertal devel-
opment in children born small for gestational age. Klin. Padiatr. 220, 10–15.
Yang, K., Bernardo, L., Sereika, S., Conroy, M., Balk, J., Burke, L., 2009. Utilization of 3-
month yoga program for adults at high risk for type 2 diabetes: a pilot study.
Evid. Based Complement. Altern. Med.
Zhou, M., Lian, M., 1989. Observation of qi-gong treatment in 60 cases of pregnancy-
induced hypertension. Zhong Xi Yi Jie He Za Zhi 9 (16–8), 4–5.