Journal Pre-proof

Effects of Self-Acupressure on Pregnancy-Related Constipation: a

Single-blind Randomized Controlled Study

Ayça SOLT KIRCA , Derya KANZA GUL

PII: S1550-8307(20)30222-6
DOI: https://doi.org/10.1016/j.explore.2020.07.004
Reference: JSCH 2526

To appear in: EXPLORE

Received date: 2 June 2020

Revised date: 14 July 2020
Accepted date: 23 July 2020

Please cite this article as: Ayça SOLT KIRCA , Derya KANZA GUL , Effects of Self-Acupressure on
Pregnancy-Related Constipation: a Single-blind Randomized Controlled Study, EXPLORE (2020), doi:
https://doi.org/10.1016/j.explore.2020.07.004

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Highlights

 In the present study, the application of self-acupressure to the pregnant women

 to the TH-6 point 2 times a day, caused to reduce constipation which can
 occur in every trimester of pregnancy
 The study sample consisted of 150 pregnant women. Of these women, 75 were
 the acupressure (intervention) group and 75 were the control group.
 It was determined that constipation during pregnancy could be reduced by the
 effective use of self-acupressure without using a pharmacological method.
 Effects of Self-Acupressure on Pregnancy-Related Constipation: a Single-blind
Randomized Controlled Study

Running Title: Effects of Self-Acupressure Pregnancy-Related Constipation

Author’s Informations

Ayça SOLT KIRCA1, Derya KANZA GUL2

1
Ayça Solt Kırca. Assistant Professor, PhD.
Postal address: Kirklareli University School of Health, Midwifery Depertmant Kirklareli,
Turkey.
Phone: +90 (539) 268 41 85
E-mail: aycasolt@hotmail.com

2
Derya Kanza Gül. Assistant Professor, MPH, PhD.
Postal address: Medipol University School of Medicine Health, Istanbul, Turkey.
Phone: +90 (532) 700 70 39
E-mail:deryakanza@yahoo.com

Corresponding Author
1
Ayça Solt Kırca. Assistant Professor, PhD. Orcıd 0000-0001-6733-5348
Postal address: Kirklareli University School of Health, Midwifery Depertmant Kirklareli,
Turkey.
Phone: +90 (539) 268 41 85
E-mail: aycasolt@hotmail.com
Abstract
Objectives: This study aimed to demonstrate that acupressure could be used to relieve the
symptoms of constipation during pregnancy.
Design: Single-blind randomized controlled trial
Setting: Private Medipol Nisa Hospital, Istanbul, Turkey
Intervention: This trial including 120 women aged ≥20 years was conducted from November
2019 to February 2020. The participating women who were in the 1st, 2nd or 3rd trimester of
their pregnancy, had singleton pregnancy and had a complaint of constipation were
randomized into the acupressure (n=75) and control groups (n=75). The women in the
acupressure group applied 15 minutes of self-acupressure to the TH-6 acupuncture point twice
a day for one week. The women in the control group received no intervention treatment.
Main outcome measures: Constipation levels of the participants in the two groups were
assessed before and after the procedure using the Constipation Severity Instrument
Results: In the present study, after the application of self-acupressure, the severity of
constipation decreased significantly in the acupressure group compared to the control group
(before treatment: 41.36 ± 6.5 vs. 37.56 ± 6.17 respectively, after treatment: 26.08 ± 7.93 vs.
36.88 ± 5.93, respectively, p < 0.01)
Conclusion: Although it is safe to use medical drugs in constipation associated with
pregnancy, can‘t reduce it to the extent desired. This study's evidence indicates that self-
administered acupressure can effectively alleviate the symptoms of constipation in clinical
practice.
Keywords: Self-acupressure, constipation, pregnancy, education
Introduction
In pregnancy, among gastrointestinal system (GIS) complaints, constipation is second
only to nausea.3,4 In their systematic review, Rungsiprakan et al. (2015) determined that the
prevalence of constipation during pregnancy ranges from 11% to 44%.1 The results of a study
conducted in Turkey found the prevalence of constipation among pregnant women to be
38.8%–47%.5,6 Several factors are responsible for the development of constipation during
pregnancy. In pregnancy, the internal abdominal pressure is increased, and the muscles (anal
sphincters and levator ani muscle) that are primarily responsible for the defecation process
and supporting the pelvic organs and the urethra are subjected to structural changes.4 Another
factor in decreasing bowel movements is the increase in the hormone progesterone during
pregnancy. Other factors influencing constipation during pregnancy are the enlargement of
the uterus, decreased physical activity, stress, consumption of iron and calcium supplements,
inadequate fluid intake, and changes in diet.3,7-9 In their prospective study, Van Brummen et
al. (2006) found that pregnant women in the first trimester (8.9%) suffered more constipation
problems than women in their third trimester (4.5%).10 In Derbyshire et al.‘s (2006) study, the
feeling of both difficulties in defecating and incomplete emptying of the bowel was found to
be high in all trimesters of pregnancy.11 In a study conducted by Shamim and Begum (2019)
with 332 pregnant women, 62.3% of participants suffered from pregnancy-related
constipation.12
Although exercise, increased dietary fibre, and consuming more water are
recommended to alleviate constipation during pregnancy, pharmacological drugs (laxatives)
are often used for therapeutic purposes,3,13 but the administration of these drugs may have
negative effects on the health of both mother and baby.3,14,15 Therefore, complementary and
alternative medicine has drawn more attention, especially in recent years. Many women prefer
to use non-pharmacological methods, such as acupuncture, acupressure, aromatherapy,
homoeopathy, and herbal laxatives instead of pharmaceuticals.16-19 Acupressure is one of
these methods. Acupressure is a manipulative treatment method that ensures the essential
balance of life energy (Qi) through applied pressure on more than 365 and 2000 acupuncture
points via 14 main energy pathways (meridians) on the skin.20,22,42 Qi is the vital energy found
everywhere in the universe and also all individuals are born with qi. The meridians like the
branches of a tree. The meridians provide that direct the flowing of Qi all around the body.22
If qi is disrupted, the body fails to maintain balance then diseases may occur. Acupressure
helps to establish balance by helping the regulation of blood circulation and providing the
necessary qi energy for the body. Also, acupressure promotes the balanced by releasing of
many chemicals, such as beta-endorphin, serotonin, dopamine, and adrenaline, into the
blood.20-22,40,41 After that when the body restores balance, pain, constipation, nausea, vomiting
and the other symptoms will reduce.20-23,25
Acupressure is an easy-to-apply, non-invasive, cost-effective, and safe method that
can be applied by a specialist or by a patient after being taught the technique.23,24 A review of
previous studies in the literature revealed that acupressure application increased the intestinal
motility of tested individuals and improved the symptoms of constipation.2,19,25-27 There are
several acupressure points (LIV3, ST36, SP15, CV12, CV4, ST25, SP14, ST37, and TH-6)
related to reducing constipation symptoms.19,25,29,30 In the current study, the Triple Heather
Meridian (TH-6) acupressure point (which in four finger-widths above the wrist on the back
of the forearm) was chosen because it is easy to find, and the pregnant women can apply self-
acupressure on this point. In the literature review, although a considerable amount of research
can be found devoted to the investigation of how acupressure reduces constipation in women
with chronic constipation, patients undergoing hemodialysis, and patients with cancer,19,25,27,28
no attention has been paid to the application of acupressure to reduce pregnancy-related
constipation or to teaching this practice so the person can perform it on herself. With regard to
these few evidence, we hypothesized that the woman's ability to perform this application by
herself may have reduce the need for laxatives used to eliminate constipation, and this will
enable the woman to perceive her health improve and develop a perception of self-
healing.21,24
This single-blind randomized controlled experimental study was intended to evaluate
the effects of self-acupressure on pregnant women's self-reported constipation symptoms in
Turkey.
Methods
Research design and participants
The study was conducted as a single-blind randomized controlled trial. The study population
included pregnant women who presented to the maternity outpatient clinics of the private
Medipol Nisa Hospital in Istanbul, between November 9, 2019, and February 29, 2020, for
pregnancy follow-up. The average number of pregnant women who presented to the hospital
was 600 per month. The appropriate sample size for the study was calculated using G*Power
software (version 3.1.9.3). Because there were no studies in previous literature of the
application of acupressure to reduce constipation during pregnancy, the Cohen standard effect
size (between medium and large effect) determined the sample size for the study to be 0.55.
Thus, according to the two-sided hypothesis, standard effect size: 0.55, Type I margin of error
0.05, power analysis 0.80 (α = 0.05, 1–β = 0.80) and a one-to-one distribution of the groups,
the minimal sample size was calculated as 106 (n = 53 for each group). To allow for losses
during the study, it was decided to include 75 people in each group. After excluding 23
participants who had used laxatives and seven who withdrew, the results for the remaining
120 pregnant women were analyzed (Fig. 1).
Pregnant women who met the inclusion criteria were included in the study.
Participants were randomly assigned to the acupressure (Group 1) and the control (Group 2)
groups with a simple random number generator program
(https://stattrek.com/statistics/random-number-generator.aspx). In the program, given the
number of participants to be included in the sample and the number of groups, the box with
the minimum value was numbered ―1,‖ and the box with the maximum value was numbered
―2.‖ Then, the "allow duplicate entries" box was selected as "True." Finally, ―set the seed‖
value was set to 1. According to the random numbers table at the end of the procedure, the
first entry was ―2.‖ Therefore, the first volunteer was assigned number 2 (control group). The
second entry was "2." Hence, the second volunteer was also assigned number 2 (control
group), and so on. Volunteer No. 150 was assigned the 150th number in the list, which was
"1," so the 150th volunteer was assigned to the acupressure group (Group 1).
The midwives and gynaecologists working in outpatient clinics were different every
day. To prevent bias, a midwife working in the outpatient clinic that day but not involved in
the study oversaw the participants in filling out the Maternal Information Form and the
Constipation Severity Instrument (CSI) one week before and one week after the week of
treatment. The obstetrician and the midwife working in the outpatient clinic that day were
informed about the purpose of the study and the procedure of acupressure application. But the
obstetrician and the midwife who administered the questionnaires did not receive details
about the TH-6 point and its effects. The obstetrician did not know which group (acupressure
or control) the participating pregnant women were assigned, thus, avoiding psychological
influences on either group of participants minimized the placebo effect. Mobile phone
interviews were conducted by the researcher, the pregnant women who met the study criteria
and assigned to the experimental group were told on which day they will receive training.
Thus, experiment and control groups never met each other. Also, the participants were
informed about the purpose of the study and the procedure of acupressure application. But the
participants did not receive details about the TH-6 point and its effects. The acupressure
specialist and the pregnant women in the acupressure group first met during the training.
 In the retrospective power analysis using the G*Power software after data collection,
the power was calculated as 100% for the acupressure and control groups based on the mean
scores for the CSI and 5% alpha margin of error. The sample size of the study was considered
sufficient.
Inclusion criteria: Pregnant women between ages 20 and 40 years, in any trimester of
gestation, with a singleton pregnancy, being primipara or multipara, and scoring ≥ 37 on the
CSI scale were included (To ensure that the degree of constipation problems in the test group
and the control group would be similar, the scale‘s mean score was calculated, and only
women scoring higher than the mean were included in the study).
Exclusion criteria: Women with a chronic disease, such as diabetes, hypertension,
thyroid disorders, chronic constipation, sigmoid colon (enlarged or colon resection), and the
like, those taking the medication regularly, those with verbal communication difficulties, with
current use of pharmacological or non-pharmacological methods to reduce constipation, and
those undergoing psychiatric treatment (pharmacotherapy or psychotherapy) were excluded.
Data collection tools
Maternal Information Form: The form, prepared by the researchers based on relevant
literature, consisted of 10 items regarding the participants‘ socio-demographic characteristics,
diet, daily water consumption, and participation in sports activities.
Constipation Severity Instrument (CSI): The CSI, developed by Varma et al. (2008), is used
to assess defecation frequency, intensity, problems/difficulty in defecating, and symptoms of
constipation.31 The scale is divided into three sections: obstructive defecation, colonic inertia,
and pain. The minimum and maximum scores possible in each of the three sections are 0 to
28, 0 to 29, and 0 to 16, respectively; therefore, the lowest and highest possible total scores
are 0 and 73, respectively. There is no cutoff point for the scale—an increasing score reflects
increasing severity of constipation. Kaya and Turan confirmed the validity and reliability of
the Turkish version of the CSI in 2010.32 The Cronbach‘s alpha value of the scale was 0.92
both in the original study and in the present study.
Data collection procedure
Maternal Information Form and CSI: To prevent bias, a midwife who was working in
the outpatient clinic but not involved in the study administered the completion of the forms,
which took approximately 20 minutes. All pregnant women who met the inclusion criteria
were informed about the procedures to be performed before the application of treatment. They
were further advised that they could withdraw from the study at any time, and they signed the
informed consent forms. Researcher registered a list of the groups.
 Acupressure application steps for Group 1: The participants who had been assigned to
the study group were taken to a private training room in the outpatient clinics and divided into
groups of two or three women. Illustrated brochures containing information about acupressure
were handed out to the participants, and they watched a short video recorded by the researcher
on how to perform acupressure. Then, the researcher who had been trained in acupressure
demonstrated to the participants on which point, how often, and how to apply pressure on her
body. Due to the location of the TH-6 point (four finger-widths above the wrist on the back of
the forearm, Figure 3), the use of an acupressure wristband, magnets, or other devices is not
practical; therefore, the participants were trained to apply pressure using only their fingers and
with sufficient force to see a colour change in their nail bed colour. Finally, the women were
allowed to find the point and practice the technique on their own. Training the acupressure
group and practising the technique took approximately 40–45 minutes. It should be mentioned
that, due to the location of the TH-6 point, acupuncture was not performed to minimize
invasive applications during pregnancy and to allow the women to continue taking part in
routine prenatal care.
Number, time, duration, type, and technique of the application: The researcher
demonstrated how to find the TH-6 point. The participants were told to apply acupressure on
both points for 15 minutes twice a day, in the morning and evening, for a week (40–45
seconds of heating and massaging, then 2.5 minutes of pressure, and 30 seconds of rest). The
participants were asked to be alone in a quiet room for the application and to use a stopwatch
during the application. If ıt is necessary, the participants were provided phone numbers
enabling them to contact the researchers 24/7.
Application steps for the control group: Because participants in the control group
could not use pharmacological or non-pharmacological methods, they did not undergo any
intervention. They were given the phone numbers of the two researchers whom they could
contact at any time, day or night, or advised to come to the hospital, if necessary, in case their
condition became serious.
The pre- and post-application CSI scores of the participants in both groups were
evaluated statistically (one week before initiating was identified as CSI-1, one-week post-
procedure was identified as CSI-2).
Data analysis
The IBM SPSS v.23 (SPSS, Inc., Chicago, IL, USA) software package was used to analyze
descriptive statistics, numbers, percentages, arithmetic mean, and standard deviation. The
results of the Shapiro–Wilk test demonstrated that the scores derived from the scale were
normally distributed. The Chi-square test was used to compare the categorical data. In the
comparison of the groups the first, missing value analysis was performed. Loss data were
estimated with both EM and Regression analysis and similar results were obtained. Finally,
the analysis was completed. While the independent samples t-test was used for inter-group
comparisons, the dependent samples t-test was used for the intra-group comparisons. The
Mann–Whitney U test was used for comparison of data with non-normal distribution. To
present the results of the analysis, median values (minimum-maximum) were used for the
data with non-normal distribution, mean ± standard deviation was used for data with normal
distribution, and frequency (percentage) was used for the categorical data. A p-value of < 0.05
was established as statistically significant. Our analyses were based on the ‗Intention to Treat
(ITT)‘ principle.
Ethical considerations
Approval for the study was obtained from İstanbul Medipol University Clinical
Researches Ethics Committee (Reference number: 10840098-604.01.01-E.60992, Decision
number: 928, Date:8/11/2019). All the procedures were performed by rules about studies
involving human participants by considering the ethical standards of the institutional and/or
national research committee.
Results
The findings of the study are charted below in Tables 1 and 2, and Figure 2:
Comparison of the women‘s socio-demographic and descriptive characteristics reveal
that the two groups were similar in terms of age, educational status, employment status,
number of pregnancies, gestational age, type of diet (principal and snacks), a diet including
high-fibre foods, amount of fluid intake, duration and intensity of participation in physical
activity (sports) (p > 0.05, Table 1).
[Table 1 here]
In the present study, the results of intra-group and inter-group comparisons of
constipation levels of the participants in the acupressure group, who underwent acupressure
intervention, and of participants in the control group, who did not assess twice using the CSI
tool, are given in Table 2. The intra-group comparisons of the CSI scores of the participants
in the acupressure group demonstrated that their post-application mean score (26.08 ± 7.93)
was lower than their pre-application mean score (41.36 ± 6.5) and that the difference was
highly significant (p < 0.001, Table 2). As for the control group, there was no statistical
difference between their pre- and post-study CSI scores (37.56 ± 6.17 and 36.88 ± 5.93,
respectively) (p > 0.05, Table 2).
The inter-group comparisons of the CSI scores demonstrated that the pre-application
mean CSI score of the participants in the acupressure group (41.36 ± 6.5) was significantly
higher than that of the participants in the control group (37.56 ± 6.17) (p < 0.001, Table 2).
However, the post-application means CSI score of the participants in the acupressure group
(26.08 ± 7.93) was significantly lower than that of the participants in the control group (36.88
± 5.93) (p < 0.001, Table 2, Fig. 2).
[Table 2 here]
[Figure 2 here]
Discussion
This study, to the best of the authors‘ knowledge, is the first trial ever, carried out to evaluate
the efficacy of acupressure in participants with constipation during pregnancy. As a result of
this randomized controlled study, acupressure applied to TH-6 acupuncture point reduced the
symptoms of constipation during pregnancy. The results were discussed within the framework
of the results of other studies in which acupressure and acupuncture were applied to pregnant
women experiencing constipation.
The similarity of the groups in terms of their socio-demographic and descriptive
characteristics (age, number of pregnancies, trimester, educational status, working status, a
diet including high-fiber foods, amount of fluid consumed, and active participation in sports)
supports the reliability of the study. The results are similar to those of other national and
international studies.6,11,12,33-36
In the present study, the CSI scores of the participants who applied self-acupressure
dropped significantly compared to those of the control group. In a study conducted with 30
women, Chen et al. (2013) reported that constipation symptoms decreased significantly in
women who received electro-acupuncture treatment compared to women who did not.26
According to the results of Shin and Park‘s (2016) randomized controlled study conducted
with 52 women with constipation effects from chemotherapy for breast cancer, constipation
symptoms decreased significantly in the participants who were administered auricular
acupressure, compared to participants in a control group.27 In Chen et al.'s (2017)
experimental study conducted with 56 female patients with functional constipation, difficulty
in defecating, and diminished quality of life who underwent acupuncture were significantly
improved, compared to a control group.37 According to the results of a randomized controlled
experimental study in which Zhou et al. (2019) administered 28 sessions of electro-
acupuncture to 415 of 822 women suffering from chronic constipation, the application
regulated bowel movements of the women with serious functional constipation, enabling
them to defecate more comfortably and not experience further constipation problems for 12
weeks after the treatment.19 In their randomized controlled study, Yang et al. (2019) applied
auricular acupuncture to 120 primiparous puerpera who underwent cesarean section and
found that the incidence of constipation in these women was lower than in women who did
not undergo auricular acupuncture.38 The results of the present study are consistent with those
of similar studies.
Results of various studies conducted to date have supported the use of acupressure,
which is among the traditional and alternative therapy methods for the treatment of diseases.
In the literature, it has been reported that no complications detract from the effectiveness and
reliability of this method. In the present study, application of self-acupressure to the TH-6
point by the participant‘s controlled intestinal peristalsis and gastrointestinal system functions
increased production and re-secretion of body fluid, and increased blood,39 which contributed
to a significant drop in their CSI scores. Therefore, acupressure can be recommended as an
effective method to reduce the symptoms of pregnancy-related constipation.
Limitations
The results of this randomized controlled study apply only to the women surveyed, and
they cannot be generalized to other women. The first limitation of the study was that the
training took longer than planned. The researcher demonstrated how to apply self-acupressure
to the TH-6 point to each participant individually. Due to the location of the TH-6 point, it
took a long time for the participants to find exactly where to apply the pressure during
training. The second limitation is that the study was performed voluntary; all the women
recruited volunteered to participate in the study, which increased the duration of the study.
The third limitation was the relatively small sample size. The fourth limitation of the study
was to not apply any method to the participants in the control group. Therefore, the interview
time with this group was shorter than the experimental group. The fifth limitation was that the
time allocated to the application was limited to one week because in Turkey, the use of non-
pharmacological treatments is uncommon, and it was believed that and if longer time had
been allocated to the application, the participants might have wanted to abandon the study to
use pharmacological methods. Therefore, it is recommended that future studies be planned for
long term treatment and should include larger study groups. Besides, the provision of training
on non-pharmacological methods to women by midwives/nurses/gynaecologists in prenatal
classes may increase interest and acceptance of non-pharmacological treatment methods. The
strength of this study was the participants were not informed what the TH-6 point serves to
avoid creating a placebo effect.
Conclusions
The study data indicate that CSI scores decreased in pregnant women who were taught
how to apply self-acupressure, and this practice was an effective intervention to relieve the
symptoms of constipation during pregnancy. Training of pregnant women by healthcare
professionals (midwives, nurses, and gynaecologists) in the clinic on how to apply self-
acupressure can help them relieve symptoms of constipation without resorting to
pharmacological methods. Because the location of the area where the application of
acupressure for constipation is performed is easy to find, it is recommended that acupressure
should be applied to these points.
Conflict of interest
The authors have no conflicts of interest to disclose.
Informed consent
In the data collection phase, written permission was obtained from Private X Hospital. After
explaining the purpose and objective of the study, written consents of the participants were
obtained.
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Figure 1. Diagram showing the recruitment of pregnant women and progression throughout the trial.
 Table 1. Comparison of the socio-demographic and descriptive characteristics (the number of meals,
amount of water consumed, duration of sports) of the groups

Acupressure Group Control Group Total Group Test Statistics p*

(n=75) (n=75) (n=150)
(min-max) (min-max) (min-max)
Age 30 (22 - 41) 29 (21 - 40) 30 (21 - 41) U= 2453 0.175
p**
n % n % n %
Number of Pregnancy
Primiparous 38 50.7 46 61.3 84 56
Multiparous 37 49.3 29 38.7 66 44 1.732 0.188

Trimester
1.trimestır 21 28 19 25.3 40 26.7
2.trımestır 19 25.3 27 36 46 30.7 2.054 0.358
3.trımestır 35 46.7 29 38.7 64 42.7

Education status
Primary education 9 12 7 9.3 16 10.7
High school 45 60 55 73.3 100 66.7 3.132 0.209
University 21 28 13 17.3 34 22.7
Work status

48 64 52 69.3 100 66.7

Housewife 0.481 0.786
14 18.7 12 16 26 17.3
Self-employment
13 17.3 11 14.7 24 16
Officer
Fibre food
Yes 48 64 42 56 90 60
No 27 36 33 44 60 40 1.000 0.317

Active sports
Yes 37 49.3 31 41.3 68 45.3
No 38 50.7 44 58.7 82 54.7 0.986 0.325
Number of main meals 3 (2 - 4) 3 (2 - 5) 3 (2 - 5) U_2703 0.570*
Number of snacks 2 (0 - 4) 2 (1 - 3) 2 (0 - 4) U=2737 0.743*
Water (glass) 3 (1 - 6) 3 (2 - 5) 3 (1 - 6) U=2570 0.339*
Sport (hour) 7 (2 - 0) 7 (2 - 0) 7 (2 - 0) U=2539 0.258*
*Mann Whitney U test, ** Chi-square test statistics,
Table 2. Intra- and inter-group comparisons of the mean CSI scores obtained by the participants in the
acupressure and control groups

Acupressure Group Control Group

t* P2
(n=75) (n=75)
CSI-1 41.36 ± 6.5 <.001
37.56 ± 6.17 t= 3.673
CSI-2 26.08 ± 7.93 36.88 ± 5.93 t= -9.449 <.001
t** t= 15.013 t= 1.256

P1 <.001 .213
t* = Independent samples t-test, t** = Dependent samples t-test
p1: Comparison of CSI-2 results completed with Expectation-Maximization (EM) method with CSI-1 results,
p2: Comparisons between groups
CSI: Constipation Severity Scale
CSI-1: Before intervention, CSI-2: After intervention

Figure 2. Average and number deviation graph of the total scores before and after the procedure according to the
groups
 TH-6 point

Figure 3. TH-6 acupuncture point

 J Acupunct Meridian Stud 2016;9(1):11e15

Available online at www.sciencedirect.com

Journal of Acupuncture and Meridian Studies

journal homepage: www.jams-kpi.com

RESEARCH ARTICLE

Acupressure on Self-Reported Sleep Quality

During Pregnancy
Isabella Neri*, Raffaele Bruno, Giulia Dante, Fabio Facchinetti

Obstetrics and Gynecology Department, University of Modena and Reggio Emilia, Modena,
Italy

Available online 27 November 2015

Received: Apr 13, 2015 Abstract

Revised: Nov 4, 2015 The aim of this study was to investigate the short-term effect of acupression at the H7 point
Accepted: Nov 5, 2015 on sleep quality during pregnancy. After oral consent had been obtained, the midwife invited
the women claiming to have poor sleep quality and anxiety symptoms to complete the Pitts-
KEYWORDS burgh Sleep Quality Index questionnaire and the State-Trait Anxiety Inventory-1. Then, the
acupression; same midwife, previously trained by an expert acupuncturist (I.N.), advised the women to
Point 7 of the heart put on the wrist overnight compression H7 Insomnia Control half an hour before going to
meridian; bed and to take it off upon awakening, for 10 consecutive days and thereafter every odd
pregnancy; day (active group). Women refusing to wear the device for low compliance toward acupres-
sleep quality sion were considered as the control group. After 2 weeks, a second questionnaire evaluation
was completed. In the active, but not in the control, group, a significant improvement of
sleep quality was observed after H7 device application. The study suggests that H7 acupres-
sion applied for 2 weeks improves sleep quality in pregnant women. This preliminary result
should serve to stimulate further studies on the long-term effects of acupression.

1. Introduction frequently reported by women [1]. Many factors could be

suggested to explain such phenomena, in particular, the
Poor sleep quality is commonly reported during the 3rd physiological changes occurring during pregnancy such as
trimester of pregnancy; sleep walking, difficulty in falling increases in progesterone and prolactin levels, size of the
asleep, and early awakening are the disorders most maternal abdomen, and fetal movements [2]. Low back

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
* Corresponding author. Obstetrics and Gynecology Department, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124 Modena,
Italy.
E-mail: isabella.neri@unimore.it (I. Neri).
pISSN 2005-2901 eISSN 2093-8152
http://dx.doi.org/10.1016/j.jams.2015.11.036
Copyright ª 2016, Medical Association of Pharmacopuncture Institute.
12
pain and girdle pain, which frequently occur during preg-
nancy (30%e90%), and some not well-defined worries about
pregnancy and the newborn often worsen sleep quality [3].
Moreover, poor sleep quality could be amplified by the
anxiety disorders that most frequently occur during late
pregnancy [4].
However, during pregnancy, the Food and Drug Admin-
istration of Italy has recommended avoiding sleep medica-
tions such as mefloquine, flurazepam, and temazepam
(labeled as X-drugs), which are thought to be strongly
related to teratogenic effects [5], and zolpidem (labeled as
a C-drug), which is unrelated to teratogenic effects, but is
related to adverse fetaleneonatal outcomes such as
smallness with respect to gestational age and preterm de-
livery [6]. In addition, pregnant women are cautious about
using medications; indeed, in the past 10 years, a growing
interest in nonpharmacological approaches to treating
several pregnancy disorders, including poor sleep quality,
has been observed [7].
A recent systematic review analyzed the results of
existing studies by taking into account the effects of
acupuncture, yoga, aerobic exercise, and massage on sleep
quality during pregnancy without reaching any strong con-
clusions [8]. However, two studies included in the above-
mentioned review demonstrated that acupuncture applied
twice a week for 8 weeks reduced sleep disorders during
pregnancy in half of the treated patients [9,10]. No
maternal or fetal side effects were found during the
treatment period, and a very high compliance toward
acupuncture was reported. On this subject, a recent
Cochrane Review analyzed the uses of needle acupuncture,
electroacupuncture, acupression, and magnetic acu-
pression for sleep improvement in the general population.
An analysis of 33 studies (2,293 participants) comparing
acupression with no treatment or with placebo/sham acu-
pression showed acupression to be more effective than
placebo/sham acupression for improving sleep quality. Due
to poor methodological quality and high levels of hetero-
geneity of the studies, no definitive conclusions were
reached, supporting the need for high-quality clinical
studies [11]. The aim of the present study was to investi-
gate, in a sample of healthy pregnant women, the short-
term effects of acupression on the H7 point by comparing
baseline and post-treatment values obtained from the
Pittsburgh Sleep Quality Index (PSQI) questionnaire for
sleep quality [12] and the State-Trait Anxiety Inventory-1
(STAI-1) for anxiety feelings often related to worsening
sleep quality [13].
2. Materials and methods
Pregnant women referred to the Ante-partum Outpatient
Clinic from January 2012 to September 2013 were enrolled
in the study. The study was approved by the Local Ethics
Committee (Institution of Azienda Ospedaliero-Uni-
versitaria Policlinico di Modena), and oral consent was ob-
tained from all women included in the study. Inclusion
criteria were the ability to understand the Italian language,
a singleton pregnancy, and feelings of anxiety and poor
sleep quality. Exclusion criteria were maternal or fetal
disease, planned elective cesarean section, and a previous
I. Neri et al.
history of severe anxiety or depressive disorders requiring
drugs or psychological support. During the first visit at the
Outpatient Clinic, the women routinely underwent a file
compilation, a vaginal swab, and a fetal heart-rate evalu-
ation, which were administered by a midwife. Thereafter,
oral consent to take part in the study was obtained from
each included woman, and each included woman
completed the PSQI questionnaire and the STAI-1.
The PSQI questionnaire investigates seven aspects of
sleep quality: “sleep latency” indicating difficulty in going
to sleep, “habitual sleep efficacy” indicating the real time
spent in sleep and not the total time spent in bed, “sleep
duration” indicating the presence of nocturnal awakening,
“sleep disturbances” indicating frequent arm or leg move-
ments, “subjective sleep quality” indicating the personal
perception of one’s own sleep, “use of sleeping medica-
tion,” and “daytime dysfunction” indicating difficulties
encountered during the day time caused by poor sleep
quality. Each of these seven aspects is given a score of 0e3
points, with a higher score meaning worse sleep quality;
the sum of the scores on all seven items ranged from 0 to
21. Usually, a PSQI score of  5 is associated with good
sleep quality, while a PSQI score of > 5 is associated with
poor sleep quality. In our study, we associated good sleep
quality with a PSQI score of  7 and moderateesevere poor
sleep quality with a PSQI score of > 7e21 points.
Next, the same midwife, who had previously been
trained by an expert acupuncturist (I.N.), advised the
women to wear a soft rubber pin kept in place by an ad-
hesive plaque able to exert acupressure on Point 7 of the
heart meridian (HT 7; H7 Insomnia Control; Consulteam
S.R.L., Como, Italy). The HT 7 point, called Shenmen or
“gate of the spirit,” is located on the outer side of the wrist
on the radial side of the flexor carpi ulnar tendon between
the ulna and the pisiform bone. Following the traditional
Chinese medicine indications, its stimulation by needle
insertion or acupressure is indicated to improve insomnia
and reduce anxiety [14]. The device was applied half an
hour before going to bed and removed upon awakening, for
10 consecutive days and on every odd day thereafter. Two
weeks later, a second visit was scheduled to complete the
post-treatment PSQI questionnaire and the STAI-1.
A Chi-square analysis was used for noncontinuous vari-
ables such as the PSQI and STAI-1 items. Student t-tests
were used for demographic continuous variables. A p value
of < 0.05 was considered significant.
3. Results
A total of 263 women met the inclusion criteria, and 235
agreed to participate in the study, of whom 134 received
acupression (active group); the remaining 101 refused the
treatment because of low compliance toward acupression
and were considered as the control group. The low
compliance was due to their believing that the device
would not be able to affect the symptoms or that it might
cause skin irritations. No differences were observed be-
tween the control and the active groups in terms of
maternal age (33  3.1 years vs. 32.4  4.3 years), rate of
nulliparous women (65% vs. 70%), and gestational age at
entry into the study (36  4.1 days vs. 36  3.8 days). After
HT 7 Acupressure for Sleep Quality During Pregnancy 13

2 weeks, 209 women completed the second questionnaire

evaluation; 21 in the active group had been removed from
the study because they had removed the device during the
night, and five in control group refused to complete the
second questionnaire.
The STAI-1 evaluation showed that the percentage of
women reporting mildesevere anxiety did not differed
significantly between the control and the active groups,
both at baseline (94.6% vs. 100%) and after 2 weeks of
treatment (100% vs. 90%). However, the Chi-square analysis
showed a significant reduction in the number of women
suffering from mildesevere anxiety in the active (100% vs.
90%; p < 0.02), but not in the control (94.6% vs. 100%, no
significance) group.
The PSQI evaluation showed that moderateesevere
symptoms occurred more frequently in the active group
than in the control group, based on the total score and the Figure 1 Percentage of women reaching a PSQI total score
score for each PSQI item, as shown in Table 1. In the active ranging from 7 to 21, suggestive of moderateesevere insomnia,
group, the percentages of women complaining of moder- in the control and active groups at the baseline interview and
ateesevere symptoms based on the PSQI total score and the after 2 weeks. * For the H7 (active) group, p < 0.02. PSQI Z
scores for five of the seven aspects of sleep quality, sleep Pittsburgh Sleep Quality Index.
latency, habitual sleep efficacy, sleep duration, sleep dis-
turbances, and subjective sleep quality, were lower after
the 2 weeks of treatment, as shown in Figs. 1e6. Two as-
pects, use of sleeping medications and daytime dysfunc-
tion, were not considered in the analysis because no
women interviewed reported the use of medications during
pregnancy or difficulties in taking part in routine activities
during the day. In the control group, no significant differ-
ences were observed between the baseline and the post-
treatment PSQI values (p < 0.894).

4. Discussion

In this preliminary study, acupression on the HT 7 point

improves sleep quality and reduces feelings of anxiety in
pregnant women in the 3rd trimester of pregnancy. High
compliance toward acupression was observed: just 10% of
Figure 2 Percentage of women reaching a PSQI sleep latency
the women reported incorrect application, and none re-
score ranging from 7 to 21, suggestive of moderateesevere
ported side effects or negative feelings during treatment.
insomnia, in the control and active groups at the baseline
Acupuncture has been shown to be able to significantly
interview and after 2 weeks. * For the H7 (active) group,
reduce sleep disorders when compared with a placebo
p < 0.02. PSQI Z Pittsburgh Sleep Quality Index.
group or the general population [15]. Moreover, human
biochemical studies on HT 7 acupoint stimulation have
suggested the involvement of melatonin or opioid system reduced feelings of anxiety during pregnancy even though
regulation [16e18]. methodological bias may have affected the results. The
Our study suggested that overnight acupression on the baseline symptoms of anxiety and insomnia differed be-
HT 7 point applied for 2 weeks improved sleep quality and tween the two groups in this study, being higher in women

Table 1 Percentage of women reaching a PSQI score ranging from 7 to 21, suggestive of moderateesevere insomnia at the
baseline interview.*
PSQI Total Sleep Sleep Sleep Sleep Sleep Sleep Daytime
score latency efficacy duration quality disturbances drugs dysfunction
Control group (N Z 96) 41 (42.7) 24 (25) 32 (33.3) 32 (33.3) 21 (22) 62 (64.6) 2 (2) 5 (5)
Active group (N Z 113) 86 (76%) 65 (57.5) 55 (48.7) 69 (61) 63 (56.8) 98 (87.5) 1 (0.9) 26 (23)
p-value < 0.01 0.01 0.01 0.01 0.01 0.05 e 0.05
Data are presented as n (%).
PSQI Z Pittsburgh Sleep Quality Index.
* The total PSQI score and the scores for the seven aspects of the PSQI are shown. Values < 0.05 are considered as significant.
14
Figure 3 Percentage of women reaching a PSQI habitual
sleep efficacy score ranging from 7 to 21, suggestive of mod-
erateesevere insomnia, in the control and active groups at the
baseline interview and after 2 weeks. * For the H7 (active)
group, p < 0.02. PSQI Z Pittsburgh Sleep Quality Index.
Figure 4 Percentage of women reaching a PSQI sleep dura-
tion score ranging from 7 to 21, suggestive of moderateesevere
insomnia, in the control and active groups at the baseline
interview and after 2 weeks. * For the H7 (active) group,
p < 0.02. PSQI Z Pittsburgh Sleep Quality Index.
in the active group, whereas the women refusing to wear
the device, and considered as the control group, probably
experienced a lower degree of symptoms. The post-
treatment PSQI evaluation was performed too early (at
2 weeks) considering that such a questionnaire evaluates
the symptoms of the past month. Moreover, no data were
available after the 2 weeks of observation, so no conclu-
sions could be drawn about the long-term effects of acu-
pression on the H7 point.
In conclusion, HT 7 overnight acupression for 2 weeks
seems to affect sleep quality and anxiety feelings. Even
though the poor sample pool and the methodological bias
did not allow us to draw any strong conclusions, this report
should serve to stimulate further studies on the long-
term effects of acupression on the H7 point during
pregnancy.
I. Neri et al.
Figure 5 Percentage of women reaching a PSQI subjective
sleep quality score ranging from 7 to 21, suggestive of mod-
erateesevere insomnia, in the control and active groups at the
baseline interview and after 2 weeks. * For the H7 (active)
group, p < 0.02. PSQI Z Pittsburgh Sleep Quality Index.
Figure 6 Percentage of women reaching a PSQI sleep disor-
der score ranging from 7 to 21, suggestive of moderateesevere
insomnia, in the control and active groups at the baseline
interview and after 2 weeks. * For the H7 (active) group,
p < 0.02. PSQI Z Pittsburgh Sleep Quality Index.
Disclosure statement
The authors declare that they have no conflicts of interest
and no financial interests related to the material of this
manuscript.
Acknowledgments
This research was conducted without any financial support.
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Iranian Red Crescent Medical Journal. 2013 September; 15(9): 854-61. DOI: 10.5812/ircmj.12984
Published Online 2013 September 05. Research Article

Acupressure and Ginger to Relieve Nausea and Vomiting in Pregnancy: a

Randomized Study
1 2 3, * 4
Farzaneh Saberi , Zohreh Sadat , Masoumeh Abedzadeh-Kalahroudi , Mahboobeh Taebi
1 Department of Midwifery, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran
2 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
3 Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
4 Department of Midwifery, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, IR Iran

*Corresponding author: Masoumeh Abedzadeh-Kalahroudi, Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran. Tel: +98-3615620634Fax: +98-3615620634,
E-mail: abedzadeh@kaums.ac.ir.

Received: June 17, 2013; Revised: July 21, 2013; Accepted: August 10, 2013

Background: Nausea and vomiting of pregnancy (NVP) is the most common medical condition of pregnancy, affecting up to 85% of
expecting mothers. NVP can have serious adverse effects on the quality of a woman's life, social, and domestic functioning, and her general
well-being. Therefore, it is very important to treat this condition.
Objectives: The effectiveness of ginger and acupressure in the treatment of NVP was compared in the present study.
Patients and Methods: 159 eligible pregnant women with symptoms of mild to moderate nausea and/or vomiting before 16 weeks
gestational age participated in a 7-day clinical trial. They were divided randomly into three groups: the acupressure, ginger, and control.
Participants did not receive any intervention for three days and interventions were performed for the women in acupressure and ginger
groups for four days. No intervention was performed for the control group. Data was collected by self-recorded symptoms according to
the Rhodes index. Data was analyzed by ANOVA, Kruskal-Wallis, Chi-square, and Fisher exact tests for quantitative and qualitative variables.
Results: There were no statistical differences in the baseline demographics between the three groups. ANOVA test showed that there were
significantly differences in mean difference Rhodes index scores (vomiting, nausea, retching and total score) in the three groups (P <
0.001).
Conclusions: Ginger is more effective than acupressure to relieve mild to moderate nausea and vomiting in symptomatic pregnant
women in less than 16 weeks of gestational age.

Keywords: Ginger; Acupressure; Nausea; Vomiting; Pregnancy

1. Background
Nausea and vomiting of pregnancy (NVP) is the most
common complication of pregnancy which occurs up to
85% of mothers (1). This problem starts about the 4th week
of pregnancy, and usually continues to the 16th week in a
few mothers (2). The etiology of NVP is unknown. It oc-
curs due to hormonal, immunological, and anatomical
changes, although in many studies were not accepted (3).
NVP develops to hyperemesis gravidarum in less than 2%
of women. This complication characterized by repeated
vomiting leading to fluid and electrolyte imbalance, nu-
trition deficiency, and a weight loss of more than 5% of the
prepregnancy weight, often leading to hospitalization
(4). Women with hyperemesis in first pregnancy have a
high risk for recurrence in next pregnancy (5). Studies
in Iran showed that the frequency of severe nausea and
vomiting was 16% to 21.7% (6, 7). Severe NVP may lead to de-
pression, feelings of inadequacy, loss of working hours,
hospitalization and termination of pregnancy (8, 9). NVP
has adverse effects on the quality of a woman's life, social,
relationship with family, and her general health; then,
properly and effectively treatment is very important in
this condition (3, 10). It is typically treated with pharma-
cologic and nonpharmacologic (acupressure, acustimu-
lation, acupuncture, ginger and vitamin B6) antiemetic
(11, 12). Several researches have been performed about the
effect of ginger or acupressure on nausea and vomiting in
pregnancy in Iran (13-16). In addition, surveys have shown
that some herbal products were recommended to treat
NVP by midwives (17). Ginger is an herb which its rhizome
is used as spice and medicine. It can be used fresh, dried
and powdered, or as a juice or oil. It is commonly used to
treat various types of stomach problems (18). Since years
ago, ginger has been used for treating nausea and vomit-
ing in early pregnancy (13, 19). Studies have used powder

Implication for health policy/practice/research/medical education:

Midwives and obstetricians can recommend use of acupressure or ginger for relieving nausea and vomiting in pregnancy.
Copyright © 2013, Iranian Red Crescent Medical Journal; Licensee KowsarKowsar Ltd. This is an Open Access article distributed under the terms of the Creative Com-
mons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
 Saberi F et al.
or capsule forms to relieve NVP in Iran (13, 14, 20).
Heitmann et al. in a review study reported that the risk
of congenital malformations, stillbirth / perinatal death,
preterm birth, low birth weight, or low Apgar score did
not increase when ginger was used during pregnancy
(21). Therefore, a safe and effective treatment choice for
NVP is ginger (22). The use of ginger products may be
helpful to relieve nausea and vomiting, but the evidence
of effectiveness was limited (23).
The effectiveness of acupressure at P6 point compared
to the placebo group in reducing NVP has been reported
in various trials (24). Acupressure works on the precardi-
um 6 (P6 or Neiguan) as acupressure point on the wrist.
This point is found by measuring, with the mother´s
own finger, three fingers width up from the inner wrist
crease where the hand joins the arm, approximately
where the buckle of watchstrap might rest (25). A group
of evidence-based medicine reviewers, reviewed the use
of P6 for nausea and vomiting, and resulted that it is an
effective method for reliving postoperative nausea. They
concluded that acupressure may be a useful method for
the management of nausea and vomiting in a variety of
patients, but accurate trials are needed (26).
2. Objectives
To our knowledge, the use of ginger and acupressure
(two nonpharmacological therapies) has not been com-
pared in a randomized clinical trial. Therefore, compari-
son of the effectiveness of ginger and acupressure in the
treatment of nausea and vomiting in pregnancy was the
aim of our study.
3. Materials and Methods
The research ethics committee of the Kashan Universi-
ty of Medical Sciences approved the study with the num-
ber code of 29/5/1/4406 in 06/11/2007. It was registered
in the Iranian registry of clinical trial with this number:
201103192699N4. This randomized control clinical trial
was performed from 10 November 2008 to 20 Septem-
ber 2009 in antenatal clinic at Naghvi hospital, Kashan,
Iran. Inclusion criteria were: (1) willingness to partici-
pate in the study, (2) having mild to moderate nausea
and/or vomiting, (3) less than 16 weeks’ gestation, (4)
singleton pregnancy, (5) literate, (6) no history of other
diseases such as gastrointestinal disorder, (7) not using
other methods for treatment of NVP in the past 3 weeks,
(8) able to eat the ginger capsules or place the wrist-
bands as prescribed in the correct placement, and (9)
lived in Kashan.
Women were excluded if they were unable to return
for a follow-up visit one week later, had complications
when using ginger or wristbands, the advised method
for treatment failed to relieve nausea and vomiting, and
Iran Red Crescent Med J. 2013;15(9)
NVP was progressing to severe (> 5 episodes per day).
After obtaining verbal informed consent, women un-
derwent general physical examinations and routine
obstetric evaluations. They were subsequently random-
ized into three groups (ginger, acupressure and control)
using a table of random numbers.
At first, the demographic form including age, age of
marriage, gestational age, occupation, parity, wanted
or unwanted pregnancy and education was completed.
Women were instructed not to take any other medica-
tions except the treatment advised by the researchers.
Women were followed for 7 days. They did not receive
any intervention for the first three days but interven-
tions were performed for the acupressure and ginger
groups for the next four days. All women in the three
groups were instructed to go on diet during the study
[split their meals into frequent small ones, rich in car-
bohydrates and low fat. Also avoiding or not to eat food
that may actually make nausea worse, try eating before
or as soon as you feel hungry, stop smoking, eat dry
bread or cookie on awaking, avoiding fried, odorous,
spicy, greasy, or gas forming foods, maintaining good
posture, drinking cold, clear, and carbonated or sour
fluids (27)].
The benefits, risks and effectiveness of new interven-
tion were described. We explained that the privacy of
women and their personal information would be pro-
tected. In addition, at the end of the study, the women
would be informed about the results. They were asked
to start a medication if the advised treatment failed or
vomiting was more than 5 times per day and excluded
the study.
All eligible women received a package containing 14
copies of Rhodes index of nausea and vomiting. In addi-
tion, we instructed to evaluate their symptoms every 12
hours (twice daily for seven consecutive days). At a 7-day
follow-up, women reported the severity of their symp-
toms by the Rhodes index form. The Rhodes index was
expanded to eight items. Eight 5-point self-report items
measure the patient's perception of duration of nausea,
frequency of nausea, distress from nausea, frequency
of vomiting, amount of vomiting, distress from vomit-
ing, frequency of retching, and distress from retching.
This form arranges the eight items, which describes the
level of symptoms. The likert- type scale for each item
was scored from zero (indicating minimal or no symp-
tom) to four (representing the worst symptom). The
item scores were summed for a total score with a range
of 0 to 32. Patients were asked to evaluate the syndrome
every 12 hours on a 5-point scale (28). The Rhodes index
has been used for assessment of NVP in some studies in
Iran (7, 29-33), and other countries (24, 34, 35). In Iranian
research, its validity was confirmed by content valid-
ity, and its reliability was calculated and confirmed by
855
 Saberi F et al.
Cronbach's alpha (α = 0.898) (29). Also its coefficient cor-
relation was high in other researches (with Cronbach
alphas of 0.77 in the United Kingdom, 0.897 in the USA,
and 0.929 in China) (36-38).
Each women in acupressure group was given a pair of
sea band (acupressure wristband) (Sea- Band, the U.K.,
Ltd., Leicester, England) and trained to use it continu-
ously (remove only when bathing) for four days (From
the fourth to seventh day) in the appropriate place in
both hands. Sea band is a buttoned elastic wristband
which is used to pressure on the Neiguan point.
Figure 1. Location of Acupressure Wristband
Each woman in ginger group received 12 ginger cap-
sules 250 mg (with the brand named Zintoma made in
Goldaroo manufacturing Pharmaceutical Company) for
4 days (during the four to seven days) and daily 3 cap-
sules. No intervention was performed for the control
group during 7 days.
The women were called twice: once in the fourth and an-
other in the eighth day. On the fourth day, we answered
the women's questions in three groups; also, we remind-
ed the use of ginger capsules and wristbands in the in-
tervention groups. On the eighth day, we thanked the
women for their participation in this study and request-
ed to hand over the Rhodes forms for evaluation of their
responses to the advised methods of treatment. NVP was
evaluated by the Rhodes index score.
Data was analyzed by SPSS software version 14. In the
descriptive analysis were represented as means and stan-
dard deviation, while the categorical variables were rep-
resented as frequency and percentages. ANOVA, Kruskal-
Wallis, Chi-square and Fisher exact tests were used for
quantitative and qualitative variables.
The hypothesis tested whether ginger and acupressure
were different in reduce nausea, vomiting and retching
856
symptoms. These were indicated by mean difference
Rhodes index scores between the three groups by ANOVA
test. It was calculated by mean Rhodes index scores in
four days after the intervention (post intervention) mi-
nus in three days before the intervention (pre interven-
tion).
A pilot study was performed and sample size was calcu-
lated (n = 10). The mean differences Rhodes index scores
were 4.2 and 7.5 in acupressure and ginger groups, re-
spectively. To reject the null hypothesis of improvement
in symptoms with a power of 80% and a significance level
of 5%, sample size of 48 women per group was calculated.
Considering 10% loss in follow up, 53 women in any group
were needed. A significance level of P < 0.05 was used for
all tests.
4. Results
All women were included in the intention to treat (ITT)
analysis. From 10 November 2008 to 20 September 2009,
461 pregnant women were screened, and among them,
159 women were recruited and 302 were excluded. In gin-
ger group, one woman had heartburn when taking the
ginger capsules, one woman used medication, and one
woman did not return to clinic. In acupressure group,
one woman used other medication, two removed their
bands prior to the end of study period, and two women
did not return to clinic. In control group, five women
used medication treatment, and three women did not
return to the clinic. They were excluded from the study.
Finally, there were 50 women in ginger groups, 48 in
acupressure and 45 in control. Analyses were performed
on 143 women (Figure 2).
We checked normal distribution in variables. All vari-
ables had normal distribution apart from age and age
of marriage. ANOVA test was used to compare variables
with normal distribution and Kruskal-Wallis test was
used to compare non-normal variables in three groups.
There were no statistically significant differences in
the baseline characteristics between the three groups
(Table 1).
We compared the mean difference Rhodes index
scores between the three groups. The mean difference
Rhodes index scores calculated by mean Rhodes index
scores in pre intervention (three days before interven-
tion) minus mean Rhodes index scores in post interven-
tion (four days after intervention). It was significantly
greater in ginger group than acupressure and control
groups. ANOVA test showed that there were significant
differences in the mean differences in vomiting, nau-
sea, retching and total scores between the three groups
(P<0.001). These results were presented by error bar
plot in Figure 3.
Iran Red Crescent Med J. 2013;15(9)
 Saberi F et al.

Figure 2. Trial Profile of Recruitment and Randomization to Acupressure, Ginger or Control Groups

Table 1. Baseline Characteristics of the Patientsa

Characteristics Acupressure (n = 53) ginger (n = 53) control (n = 53) P-value
Age (years) 25.68 ± 4.64 26.64 ± 6.18 25.79 ± 3.64 NSb(0.531)
Age of marriage 19.75 ± 1.96 18.66 ± 4.41 19.39 ± 1.93 NSb(0.063)
Gestational age (weeks) 9.32 ± 2.38 8.78 ± 2.32 9.11 ± 0.18 NSc(0.441)
Occupation NSd(0.479)
Housewife 51 (96.2) 50 (94.3) 48 (90.6)
Employee 2 (3.8) 3 (5.7) 5 (9.4)
Parity NSe(0.187)
Nulliparous 33 (62.3) 26 (49.1) 24 (45.3)
Multiparous 20 (37.7) 27 (50.9) 29 (54.7)
Pregnancy NSe(0.288)
wanted 50 (94.3) 45 (84.9) 47 (88.7)
Unwanted 3 (5.7) 8 (15.1) 6 (11.3)
Education NSe(0.557)
Less than high school 20 (37.7) 15 (28.3) 19 (35.8)
High school or more 33 (62.3) 38 (71.7) 34 (64.2)
a Data are presented as mean ± SD or No., (%)
b Kruskal-Wallis test was used
c ANOVA test was used
d Fisher exact test was used
e Chi-squared test was used

Iran Red Crescent Med J. 2013;15(9) 857

 Saberi F et al.

Figure 3. Comparing the Mean Difference Rhodes Index Scores of Vomiting (A), Nausea (B), Retching (C), and Total (D) between the Three Groups

Paired t-test was also used to compare the mean pre intervention in ginger and acupressure groups. No sig-
and post intervention scores. Results indicated that there nificant differences were found apart from vomiting in
were significant differences in the mean pre and post control group (Table 2).

Table 2. The Mean Pre and Post Intervention and Difference Rhodes Index Scores in the Three Groupsa
Groups Ginger (n = 50) Acupressure (n = 48) Control (n = 45) ANOVA
Variables
Pre intervention

Post intervention

Paired t test

difference

Pre intervention

Post intervention

Paired t test

difference

The first 3 days

The second 4 days

Paired t test

difference

P value

Vomiting 5.14 ± 3.10 2.49 ± 2.24 0.00 2.66 ± 2.64 5.14 ± 3.00 4.49 ± 2.76 0.043 0.64 ± 2.14 5.14 ± 2.13 4.50 ± 2.76 0.029 -0.71 ± 2.12 < 0.001
Nausea 8.42 ± 2.25 4.48 ± 2.06 0.00 3.94 ± 2.58 9.22 ± 2.31 7.21 ± 2.91 0.00 2.00 ± 2.37 8.41 ± 2.21 8.24 ± 2.53 0.50 0.18 ± 1.74 < 0.001
Retching 4.34 ± 2.13 2.33 ± 1.63 0.00 2.01 ± 1.56 4.35 ± 2.29 2.82 ± 2.03 0.00 1.52 ± 1.86 4.34 ± 2.19 4.65 ± 2.01 0.137 0.31 ± 1.36 < 0.001
Total score 17.91 ± 6.11 9.30 ± 4.68 0.00 8.61 ± 5.24 17.91 ± 5.90 13.74 ± 6.66 0.00 4.17 ± 5.53 17.90 ± 5.30 18.75 ± 5.60 0.137 -0.84 ± 3.72 < 0.001
a ANOVA were used to compare the mean difference scores

858 Iran Red Crescent Med J. 2013;15(9)

 Saberi F et al.

Tukey post hoc test was performed and the results
showed that the mean differences in vomiting, nausea,
retching, and total scores between the groups were sig-
nificantly different except for vomiting score between
acupressure and control groups (P = 0.98), and retching
score between acupressure and ginger groups (P = 0.29).
One-way repeated measure ANOVA was used to compare
three group means of vomiting, nausea, retching and to-
tal score in the first to seventh days. These means were
statically significant between the three groups (Table 3).

Table 3. Mean and Standard Deviation of Vomiting, Nausea, Retching and Total Rhodes Index Score in Days 1 to 7 in the Three Groups
Variables and The First The Second The Third The Fourth The Fifth The Sixth The Seventh P
Groups Day Day Day Day Day Day Day
Vomiting < 0.001
Ginger 4.62 ± 4.05 5.24 ± 3.47 5.58 ± 3.61 3.06 ± 3.07 2.42 ± 2.73 1.90 ± 2.32 2.58 ± 3.19
Acupressure 5.42 ± 3.92 5.54 ± 3.40 4.46 ± 3.15 4.90 ± 3.42 4.69 ± 3.55 4.15 ± 3.29 4.25 ± 3.38
Control 5.23 ± 2.53 5.08 ± 2.94 5.10 ± 2.82 5.37 ± 2.91 6.26 ± 3.42 6.12 ± 3.40 5.66 ± 3.10
Nausea < 0.001
Ginger 8.92 ± 2.44 7.90 ± 2.88 8.46 ± 2.55 5.88 ± 2.17 4.44 ± 2.26 4.00 ± 3.02 3.62 ± 3.15
Acupressure 10.18 ± 2.19 8.93 ± 3.17 8.55 ± 2.61 7.32 ± 3.60 6.83 ± 3.70 6.68 ± 2.71 8.03 ± 4.11
Control 9.17 ± 2.39 7.90 ± 3.28 8.17 ± 2.80 7.82 ± 3.68 8.71 ± 3.35 9.35 ± 3.03 7.08 ± 3.0
Retching < 0.001
Ginger 4.24 ± 2.56 4.32 ± 2.08 4.42 ± 2.22 3.10 ± 1.51 2.34 ± 1.33 2.02 ± 1.98 2.12 ± 2.27
Acupressure 5.06 ± 2.81 5.12 ± 2.42 4.56 ± 1.89 3.56 ± 2.48 3.37 ± 2.04 3.12 ± 2.42 3.66 ± 2.47
Control 4.85 ± 2.51 3.79 ± 2.51 4.39 ± 2.70 4.61 ± 2.26 4.70 ± 2.01 4.92 ± 2.70 4.48 ± 2.25
Total < 0.001
Ginger 17.78 ± 7.43 17.46 ± 7.67 18.46 ± 5.98 12.04 ± 5.38 9.20 ± 5.24 7.92 ± 5.40 8.32 ± 7.48
Acupressure 19.27 ± 7.17 18.20 ± 6.72 16.19 ± 5.51 14.39 ± 8.53 13.50 ± 8.12 12.56 ± 7.26 14.56 ± 8.66
Control 19.25 ± 5.16 16.78 ± 6.95 17.67 ± 7.21 17.81 ± 7.50 19.67 ± 6.70 20.41 ± 7.58 17.23 ± 6.91

Analysis showed that total Rhodes index scores reduced in treating nausea, vomiting and retching. In Ozgoli et
49% in ginger group and 29% in acupressure group. It was al. study, the experimental group received 250 mg cap-
raised up to 0.06% in control group (Table 4). sules of ginger, 4 times a day for 4 days, and the control
group took placebo with the similar prescription form.
Table 4. The Reduction Percentage of Rhodes Index Scores in They found that ginger was an effective herbal therapy
the Studied Groups for relieving nausea and vomiting, and an improvement
Variable Ginger Acupressure Control
in nausea symptoms during pregnancy was reported by
(n = 50) (n = 48) (n = 45) the most of pregnant women in the ginger group (13). In
a randomized controlled study, intervention group took
Vomiting 52% 19% -0.24%
1 g/day for 4 days. In that trial, an improvement in nausea
Nausea 48% 29% 0.03% symptoms was reported by 82.8% of women in the gin-
Retching 46% 37% -0.09% ger group (20). However, the results in the present study
Total Score 49% 29% -0.06% showed that vomiting and nausea in the ginger group de-
creased 52% and 48% respectively. This may take place due
In general, the women in ginger group found that using to the lower ginger dose in our study (750 mg/day versus
this method was useful for relieving nausea, vomiting, 1 g/day).
and retching in pregnancy. In addition, randomized studies results have shown
statistically significant effects of acupressure in the treat-
5. Discussion ment of nausea, vomiting, and retching symptoms (P <
As our knowledge, this is the first randomized, prospec- 0.001) (24, 39). In our study, acupressure was effective in
tive trial to compare the effectiveness of ginger and acu- relieving nausea, vomiting and retching. This finding is
pressure in the treatment of NVP in referring women to consistent with the results of jamingorn study; however,
antenatal clinic. Many studies had been performed and is inconsistent with the findings of Sinha et al. study. In
provided the information of the treatment of NVP, both their trial, the frequency of nausea and vomiting during
pharmacological and nonpharmacological methods. labor and delivery did not reduce when the acupressure
Results in this trial showed that ginger was effective wristbands were applied bilaterally on women hands

Iran Red Crescent Med J. 2013;15(9) 859

 Saberi F et al.
(40). It is possible because there was no control group
in their study and two groups revived intervention, one
group in the P6 point and the other one in the sham
point. Then, there was a placebo effect in both the inter-
vention and placebo groups.
In previous studies the efficacy of ginger and vitamin B6
was compared with placebo for the treatment of nausea
and vomiting in pregnancy. These studies reported that
ginger and vitamin B6 were useful for the management
of nausea and vomiting in pregnancy, and ginger was
more effective than vitamin B6 (20, 41). Also in a random-
ized study, the effectiveness of acupressure and vitamin
B6 in relieving symptoms of nausea and vomiting in
early pregnancy has been compared. Finding showed
statistically significant decrease in nausea, retching, and
vomiting symptoms in both acupressure (P < 0.001) and
vitamin B6 groups (P < 0.001) (24).
To our knowledge, this is the first randomized con-
trolled trial study which compared the effectiveness of
ginger and acupressure in alleviating mild to moderate
nausea, vomiting and retching in pregnancy. According
to Table 2 the mean difference Rhodes index scores in
ginger group was more than acupressure and control
groups. There were statistically significant differences
in the mean difference Rhodes index scores (vomiting,
nausea, retching and total) between the three groups (P
= 0.00).
Total reduction percentage of Rhodes Index scores in
the present study were 49%, 29% and -0.06% in ginger, acu-
pressure and control groups respectively. These findings
indicated that ginger is more effective than acupressure
in treating nausea and vomiting.
In conclusion, ginger is more effective than acupres-
sure in alleviating mild to moderate NVP in symptomatic
women before 16 weeks’ gestation of pregnancy. Since
this study was performed on mild to moderate nausea
and vomiting, the results could not be generalized to
severe nausea and vomiting, And it can be considered as
a limitation. We suggest comparing the effectiveness of
ginger and acupressure to relieve severe nausea and vom-
iting in pregnancy in future clinical trials.
Acknowledgements
This study was funded and supported by the Deputy of
research, Kashan University of Medical Sciences (KaUMS),
the Grant No: 8614. We would like to thank for their co-
operation as well as all women who made this study pos-
sible.
Authors’ Contribution
Farzaneh Saberi was responsible for planning of the
project and analysis of the data, Zohreh Sadat and
Mahboobeh Taebi performed the experimental work.
Masoumeh Abedzadeh- Kalahroudi prepared the first
draft of the paper and made data collection, and super-
860
vised the study.
Financial Disclosure
The authors declare that they have no competing inter-
ests.
Funding/Support
This study was funded and supported by the Deputy of
research, Kashan University of Medical Sciences (KaUMS),
Grant No: 8614.
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How to cite this article:
Silva FCB, Brito RS, Carvalho JBL, Lopesd
TRG. Using acupressure to minimize
discomforts during pregnancy. Rev
Gaúcha Enferm. 2016 Jun;37(2):e54699.
doi: http://dx.doi.org/10.1590/1983-
1447.2016.02.54699.
DOI: http://dx.doi.org/10.1590/1983-
1447.2016.02.54699
a
Universidade Federal do Rio Grande do Norte
(UFRN), Escola de Saúde. Natal, Rio Grande do Norte,
Brasil.
b
Universidade Federal do Rio Grande do Norte
(UFRN), Centro de Ciências da Saúde, Programa de
Pós-Graduação em Enfermagem. Natal, Rio Grande
do Norte, Brasil.
Online Version Portuguese/English: www.scielo.br/rgenf
www.seer.ufrgs.br/revistagauchadeenfermagem
Original Article
Using acupressure to minimize
discomforts during pregnancy
Uso da acupressão para minimizar desconfortos na gestação
Utilización de acupresión para minimizar las incomodidades en el embarazo
Flávio César Bezerra da Silvaa
Rosineide Santana de Britob
Jovanka Bittencourt Leite de Carvalhoa
Thaís Rosental Gabriel Lopesb
ABSTRACT
Objective: To describe responses issued by pregnant women, and the improvement of the gravidic discomforts after the use of the
acupressure technique.
Method: Qualitative and descriptive study conducted with 15 pregnant women between November 2013 and February 2014 in a
Basic Health Unit in Natal, RN, Brazil. The data were collected through unstructured interviews and depositions that were then trans-
cribed and treated according to Minayo’s operative proposal, carefully read, compared and organized into two groups.
Results: The categories that resulted were: Positive effects of acupressure, and the recommended use of acupressure. According to
pregnant women, the discomforts of pregnancy cramps, fatigue in the legs, lower back pain and headaches decreased with the use
of acupressure.
Conclusions: Based on the results, acupressure should be introduced by the nurse in pre-natal care as a therapeutic resource for the
pregnant woman’s well-being.
Keywords: Midwifery. Pre-natal care. Acupressure. Assistance humanization.
RESUMO
Objetivo: Descrever respostas emitidas por gestantes, quanto à melhora dos desconfortos gravídicos após aplicação da técnica da
acupressão.
Método: Estudo qualitativo e descritivo desenvolvido com 15 gestantes entre novembro de 2013 e fevereiro de 2014 em uma Unida-
de Básica de Saúde de Natal-RN, Brasil. A coleta de dados ocorreu por meio de entrevista não estruturada, e os depoimentos, depois de
transcritos e tratados de acordo com a proposta operativa de Minayo, foram lidos criteriosamente, comparados entre si e organizados
em dois grupos.
Resultados: As categorias suscitadas foram: Repercussões positivas da acupressão e Recomendações do uso da acupressão. Segundo
as gestantes, os desconfortos da gravidez como câimbras, cansaço nos membros inferiores, lombalgia e cefaleia diminuíram com o
uso da acupressão.
Conclusões: Baseado nos resultados obtidos, a acupressão deve ser introduzida pela(o) enfermeira(o) em consultas pré-natais como
recurso terapêutico em prol da obtenção do bem-estar da gestante.
Palavras-chave: Enfermagem obstétrica. Cuidado pré-natal. Acupressão. Humanização da assistência.
RESUMEN
Objetivo: Describir las respuestas de las mujeres embarazadas correspondiente a la mejora de las molestias gravídicas después de
la aplicación de la acupresión.
Método: Estudio cualitativo, descriptivo desarrollado con 15 mujeres embarazadas entre noviembre de 2013 y febrero 2014 en una
Unidad Básica de Salud de Natal-RN, Brasil. Los datos fueron recolectados a través de entrevistas no estructuradas y las declaraciones,
después de transcriptas y tratadas según propuesta operative de Minayo, fueron leídas con atención, comparadas y organizadas en
dos grupos.
Resultados: Se plantearon las siguientes categorías: Repercuciones positivas de la acupresión y Recomendaciones de uso de la
acupresión. Mediante el uso de acupresión en las mujeres embarazadas se obtuvo disminución de calambres, fatiga en las piernas,
dolor de espalda y dolor de cabeza.
Conclusiones: Basándose en los resultados, la acupresión debe ser introducida por la enfermera en las reuniones prenatales como
recurso terapéutico para obtener bienestar de la mujer embarazada.
Palabras clave: Enfermería obstétrica. Atención prenatal. Acupresión. Humanización de la atención.
Rev Gaúcha Enferm. 2016 Jun;37(2):e54699 1
 Silva FCB, Brito RS, Carvalho JBL, Lopes TRG
INTRODUCTION
During the pregnancy period, women experience
many physical and emotional changes. Regarding the
physical and physiological aspects, such changes occur in
order to maintain the stability of the mother-child dyad,
and fetal vitality. In this phase, discomforts that are charac-
teristic of pregnancy arise, permeating the common com-
plaints related to structural and/or functional changes of
the maternal organism.
From the perspective of promoting a consistent ap-
proach to the needs presented by the woman, prenatal
care constitutes an effective remedy in order to main-
tain the stability of the pregnancy, prevent injuries, and
monitor maternal and fetal health. In this process, atten-
tion is brought to the discomforts experienced by most
pregnant women, like cramps, headache, backache and
fatigue(1). When such symptoms are present, the use of
non-interventionist practices, such as light technology,
are recommended in order to minimize the sensations
reported by women. In accordance with this design, al-
ternative and non-pharmacological therapies are placed
in the Unified Health System (SUS) as a way to provide
assistance that is focused on behaviors that encourage
the pursuit of physiological and emotional balance of the
human being.
Thus, the National Policy on Integrative and Com-
plementary Practices in Health (PNPIC), implemented in
2006, appears as a resource to regulate the practices used
throughout society’s experiences. It is noteworthy that
the therapeutics contained in PNPIC are based on the
National Policy of Health Promotion, established in Bra-
zil since 2004, and based on the premisses of the World
Health Organization (WHO)(2).
In the context of PNPIC, experiences with the use of
Integrative and Complementary Practices (PICs) such as
aromatherapy and foot baths for women with medical
complications of pregnancy, the result was relief of their
physical and psychological symptoms(3). Thus, the use of
PICs is seen as a form of support in midwifery assistance
that focuses on humanization.
The aforementioned PICs are included in the PNPIC,
however, it emphasizes the existence of acupressure as
a therapy contained in that policy, whose principles are
based on the balance of energy channels called meridians,
according to Traditional Chinese Medicine (TCM). In these
ways, the Qi flow of energy (chi) is conducted under the
influence of equal and opposite forces Yin and Yang. From
the imbalance of these energies arise the physical and/or
emotional discomforts in the body of individuals(4-5).
2 Rev Gaúcha Enferm. 2016 Jun;37(2):e54699
This therapy applies precise stimuli in anatomical lo-
cations, through pressure with one or two fingers, mild or
medium intensity, associated with circular massage to the
skin, keeping firm and constant contact on specific meridi-
an points that are, in their majority, bilateral(6). It is notewor-
thy that the application of acupressure does not demand
technology resources and/or adverse inputs from those in
the Basic Health Units (BHU).
In the context of non-pharmacological therapy use,
studies on acupressure as a strategy to reduce discomforts
of pregnancy have been developed essentially for nausea
and vomiting(7-8). However, there is evidence that acupres-
sure can be performed on individuals affected by more
than one clinical symptom(5). This leads to the need to
consider investigating the applicability of the acupressure
technique in improving other discomforts inherent to the
pregnancy period.
In the case of pregnant women, it is assumed that the
discomforts occur due to the very energetic inharmonies
of the pregnancy status. Therefore, it is assumed that the
use of acupressure in pregnant women contributes to
maintaining the balance between forces and, consequent-
ly, relieves feelings that are unfavorable to the woman’s
well-being during the course of pregnancy. Upon this as-
sumption, the study had the following question: how do
women feel with respect to the discomfort of pregnancy
after undergoing acupressure? The objective was to de-
scribe the responses given by women about the discom-
forts after undergoing the acupressure technique.
METHOD
A qualitative descriptive study, originated from the
Research Group Nursing Care in Different Stages of Life,
which used the operative proposal advocated by Minayo
as its benchmark. The field of study was a BHU, located
in western health district of Natal, Rio Grande do Norte,
Brazil. This institution adopts the Family Health Strate-
gy (FHS), and among its actions is the development of
guidelines for activities related to the assistance offered
to pregnant women groups.
Fifteen pregnant women enrolled in the prenatal pro-
gram at the BHU above and participated in the investi-
gation. The following were used as inclusion criteria: be-
ing over 18 years of age, being a woman with usual risk
pregnancy (classified as such according to the Ministry of
Health - MH) and that presents discomforts related to preg-
nancy. The following were set as exclusion criteria: preg-
nant women who were using a drug to minimize the dis-
comforts presented. Data collection took place between

the months of November 2013 and February 2014, and
proceeded as follows: pregnant women were contacted
at the beginning of prenatal care and questioned about
the presence of any gravidic discomfort. Upon positive re-
sponse, they were asked about the possibility of participat-
ing in the investigation.
Thus, five women were invited to to undergo the tech-
nique. To this end, five properly trained undergraduate Nurs-
ing students participated, each attending the same preg-
nant woman during the four scheduled meetings. These
meetings occurred weekly, at the same time as the preg-
nant group meetings. Once the four-meeting series was
over, another group of five pregnant women was formed,
following the process described above. Thus, three groups
of pregnant women constituted the study participants.
Women who agreed to participate in the research were
asked to withdraw from the technique application group.
Participants were accommodated in chairs in a circle in a
heated room scented with lavender and where music was
played, in order to promote an environment that was con-
ducive to relaxation. In the first meeting, there were ques-
tions made about the discomforts present, which were fol-
lowed by the application of accupressure in specific points
related to these complaints.
The most cited discomforts during the consultations re-
ferred to cramps, fatigue in the lower limbs, headache and
lower back pain, which were present at the time the tech-
nique was applied. Considering the answers, the points
following the caudal-cranial anatomy were used, namely:
Yongquan (R1), which is part of the kidney meridian, and is
located in the middle of the sole, the height corresponding
to the metatarsophalangeal articulation of fingers 2 and
3; Taichong (F3), part of the liver meridian, located in the
instep, specifically in the interosseous space between the
1st and 2nd metatarsals; Chengshan (B57), bladder merid-
ian constituent, is in the middle third of the calf and Ciliao
(B32), also a bladder meridian element located on the sec-
ond sacral foramen.
In subsequent meetings, the women were asked about
the result of the technique applied previously and if they
had any new discomfort(s). Thus, subsequent meetings
occurred. The sessions were developed with five women
simultaneously, according to the number of nursing stu-
dents, with each student becoming responsible for the
care of one pregnant woman, and weekly meetings that
took place over the period of one month. The fact that the
pregnant woman was seen by a single person is justified by
the possibility of creating a link between the therapist and
the person receiving the care, considered a basic principle
in the care process.
Using acupressure to minimize discomforts during pregnancy
The application of the technique followed a treatment
protocol established in the study. In it, it was determined
that the feet be sanitized with a damp handkerchief, then
massaged with a lavender base cream, alternating with the
application of the acupressure technique. On average, five
deep acupressure cycles were applied, with a three-time
repetition on each specific point. After finishing the ap-
plication of the lower limbs, attention was directed to the
lumbosacral region, the upper limbs, trapezius and face.
These regions are energy points related to the discomforts
usually mentioned by pregnant women. The average ser-
vice time for each woman was one hour per meeting.
Once the fourth week after the first session had elapsed,
unstructured interviews were held with the participants,
using the following guiding question: “How do you feel
after the application of acupressure for pregnancy discom-
forts cited by you in your first session?”
The interviews were transcribed and processed in ac-
cordance with the operative proposal, which is the study
of the mapping in the exploratory phase of research and
interpretation, representing the encounter with empirical
facts. The interpretative phase is divided into sorting and
classification of data, whose operational dynamics include
horizontal and exhaustive reading of texts. Followed by
cross-reading, final analysis and construction of the report
presenting the results(9).
According to these principles, after the acupressure
technique was applied, the women were questioned on
the improvement or not of the discomforts. The answers
were read carefully, setting a comparison between them,
and then organized into two groups according to similar-
ities presented: positive effects of acupressure, and its rec-
ommended use.
It is noted that the research followed the ethical princi-
ples of Resolution 466/2012 and the signature of the Free
and Informed Consent Form (FICF) by the interviewees.
The project obtained a favorable opinion No. 461388/2013
and CAAE 01224913.1.0000.5537 from the Research Ethics
Committee (CEP) of the Federal University of Rio Grande
do Norte (UFRN), on 12/08/2014. The Municipal Health
Department of Natal (SMS) and the heads of the BHU also
issued approval to use the unit as a researcch field.
RESULTS AND DISCUSSION
Socio-demographic data of the participants
The socio-demographic data revealed that the ages of
the respondents ranged from 18 to 38 years of age, where
eight (53.3%) were in the age group of 28-38 years of age.
Rev Gaúcha Enferm. 2016 Jun;37(2):e54699 3
 Silva FCB, Brito RS, Carvalho JBL, Lopes TRG
As for family income, 10 (66.7%) reported having income
between 1 and 2 times the minimum wage (BRL 724.00)
and 14 (93.3%) declared having completed high school.
With regard to the pregnancy period, nine (60.0%) of the
women were in the 2nd trimester of pregnancy. With re-
gard to marital status, eight (53.3%) reported living with
their partner in a common law marriage. In addition, 11
(73.3%) of the pregnant women were experiencing their
first pregnancy.
Positive impact of acupressure
The women reported cramps, fatigue in the lower
limbs, back pain and headaches. Furthermore, they report-
ed the result of acupressure on those claims. Participants
reported the use of acupressure as co-responsible for ob-
taining feelings of comfort, stress relief and relaxation.
[...] So it was very nice and acupressure helped the
backaches, headaches and cramps a lot [...]. (Pregnant
woman 02)
[...] Before the massage I felt cramps, back pain and leg
pain and when I got the massage I improved and relaxed
[...]. (Pregnant woman 03)
Discomforts cited by these pregnant women are con-
sistent with the pregnancy trimester in which they were.
The pregnancy period develops within 40 weeks, which
comprises 280 days, divided into three trimesters. The
2nd quarter is highlighted as period that is most perme-
ated with structural changes in the woman’s body. For
this reason, the main gravidic discomforts are shown in
this phase(10).
In order to minimize the complaints arising from the
pregnancy process and monitor the pregnancy, prena-
tal care service has ensured the monitoring of physical,
physiological and emotional changes. In this scenario, it
is understood to be necessary for the professional to use
non-invasive strategies to promote and recover the preg-
nant woman’s well-being. In this sense, acupressure has
been used by nurses on pregnant women, providing phys-
ical and emotional well-being during the birth process(11).
The positive effects of the use of acupressure in the
active phase of labor intensify the need to enter this tech-
nique as a clinical strategy to discomforts that arise in
women during the pregnancy period. As the statements
described above, cramps and lumbago played down con-
siderably after the application of the therapy used. This is
supported with innovative and successful experiences of
4 Rev Gaúcha Enferm. 2016 Jun;37(2):e54699
obstetrical nurses with usual risk pregnant women related
to the relief of discomfort mentioned by the use of com-
plementary health techniques according to the individual
needs of women(12-13).
It is understood that during the assistance to women in
the pregnancy period, burses need to consider their phys-
iological discomforts, using light technology and alterna-
tive coping strategies. Therefore, to encourage pregnant
women to the use of non-pharmacological techniques
during pregnancy, the pregnant woman can experience
the benefits from the holistic approach in this period.
By using holism, one stimulates the acceptability of the
pregnant woman, and this changes the perspective of
overcoming the difficulties arising from the discomforts. To
the extent that this culture of care is developed in the pre-
natal care, it is believed it promotes effects on other phases
of pregnancy and childbirth, because women have been
prepared to smoothly deal with the feelings implied.
In fact, in this study, the non-pharmacological meth-
od of acupressure decreased unwanted sensations arising
from gravidic discomforts as can be read in the following
report:
Look, I felt very well indeed. [...] no one had taken care of
me like that, with a massage, worrying about my pain [...].
(Pregnant woman 05)
In addition to the cramps and the headaches having de-
creased after this massage, I can calm down [...]. (Pregnant
woman 11)
These women make positive reference to the tech-
nique and refer feel to the well-being resulting from the
use of acupressure by graduate nursing students. Thus,
manual contact is considered an important feature in the
humanization of assistance and the bond established.
In this regard, the National Humanization Programme of
Care and SUS Management, established in 2003, advocates
the need to evaluate all aspects of the individual and his or
her family. For this to happen, it is essential to raise aware-
ness among health professionals in order to welcome and
accompany women during pregnancy(14). In this context,
the way in which the nurse conducts prenatal care, with
dialogue about and active listening of the pregnant wom-
an’sparticularities, they develop the patient’s confidence in
the process of care(15).
The fact that the study participants were welcomed
with the use of a technique in which you use hand con-
tact that supplies touch, attention and comfort refer to
the concept of humanization recommended by the MH.

Thus, the strengthening of the bond between the mother
and the professional applying the acupressure technique
allows women to experience the pregnancy period within
the standards of a low-risk pregnancy.
Given the reduction or disappearance of discomforts,
some interviewees said they would recommend the use of
the technique to other pregnant women.
Recommendations of the use of acupressure
With the results of the use of acupressure to relieve
gravidic discomforts came the desire of participants to
receive the massage more often. This was motivated by
feeling of well-being during and after the application of
the technique.
[...] When I’m here I trust what you do. [...] I’ve never experi-
enced this before [...]. (Pregnant woman 08)
[...] Too bad no one at the health care unit does massages
on other days [...]. It makes me feel good and confident. [...].
(Pregnant woman 10)
These mothers make their satisfaction in having been
submitted to acupressure evident, but also recognize that
this is not part of the list of activities in the prenatal care
process. In this context, to the extent that the individual
is received and conducted in a way that is specific to their
needs, a relationship of trust is established, and with it,
the sense of security, physical and emotional well-being is
built. So when care is recognized as beneficial, it results in
the desire to have routine access to it(16).
It is worth highlighting that Nursing as a Science uses
care as a tool to provide health promotion and disease pre-
vention of the assisted population. Thus, in order to pro-
vide decent care for pregnant women the nurse needs to
develop sensitivity and technical and scientific capacity to
conduct prenatal care, assist the particularities and diag-
nose problems in each pregnant woman. Through these
steps it is possible to prescribe behaviors towards the
maintenance and recovery of well-being, and evaluate the
results from the implemented actions.
With regard to care, the speeches refer to considering
acupressure as a health care technique:
[...] I did not believe much in these massage things, I
thought it was not for me because I have never had this
kind of care in my life, but how it helps surprised me [...].
I would love for you to continue this service [...]. (Pregnant
woman 12)
Using acupressure to minimize discomforts during pregnancy
I think the care you provide me [...] is wonderful. One of the
most important things in being cared for is the importance
you give us. So it was very nice and would like to receive this
type of care more often. (Pregnant woman 15)
It is possible to observe the recognition of these
women regarding the care offered to them through acu-
pressure. Care is found in the core of the human being,
it comes before birth. So it is recognized as essential and
always present in the reality of individuals(17). From the per-
spective of care, as a profession, nursing has knowledge,
skills and practices based on theoretical frameworks. These
represent the extensive ideas of the care process and guide
the systematization of actions employed in its praxis. In this
understanding, the nursing care is anchored in theories or
theoretical models consistent with the transformations in
contemporary health care models.
It is conceived that health care models that underlie
the approaches used in prenatal care, from the influence of
Flexner to social determination, compete today for the use
of systemic thinking. This refers to the thinking process in
which the form is associated with the process, the interre-
lationship and interaction. So, when considering a systemic
view of life, it is necessary to have intuitive knowledge aris-
ing from the direct, holistic and non-linear experience of
reality between people(18).
During the prenatal visit, considering systemic thinking,
the nurse is able to acquire information about the discom-
forts of pregnancy and use the therapeutic care consistent
with the needs of women during pregnancy. At this stage,
dialogue between the nurse and the mother becomes es-
sential, where the sensitive and affective attitude demon-
strated by this professional favors the explanation of the
pregnant woman’s complaints.
In the context of this discussion, it is recognized that
the practice of care is inherent to the Nursing profession.
However, once the theme of complementary therapies
is approached, specifically acupressure, its use as a ther-
apeutic resource has not often been explored. It should
be noted that the Federal Nursing Council, in Resolution
COFEN-197 of 19 March 1997, establishes and recognizes
alternative therapies as a specialty and/or qualification of
nursing professionals(19).
In addition to the speeches of the women, it was pos-
sible to observe the involvement of each participant as to
whether they allowed themselves to be cared for by acu-
pressure. For every touch and application of the technique,
their facial and body expressions stated their well-being,
relief of discomfort and tensions in bundles of muscles, es-
pecially in the lower back, shoulders and neck. However,
Rev Gaúcha Enferm. 2016 Jun;37(2):e54699 5
 Silva FCB, Brito RS, Carvalho JBL, Lopes TRG
the practice of touch as a therapeutic resource used in face
of the experiences of pregnant women is almost nonexis-
tent. On this subject, studies carried outwith this technique
confirmed improvement in the severity of pain and anxiety,
with increased relaxation and subsequent improvement in
the quality of sleep(20).
According to the result obtained from the relief of
discomforts and relaxation of the study participants after
application of acupressure, there was unanimity among
the pregnant women on the desire to add acupressure to
routine services from the prenatal BHU where the research
program was held. In addition, the individual experience of
the interviewees made some of them indicate massage to
other pregnant women:
[...] I have had other pregnancies and the massage wasn’t
offered here at the time. After the massage, I improved a
lot, so I recommend acupressure to all pregnant women.
(Pregnant woman 04)
[...] I felt very good right from the first day of massage. [...] in
other pregnancies I didn’t have this experience. It’s so good
that I recommend it to other pregnant women [...]. (Preg-
nant woman 06)
These statements portray the sense of well-being and
relief of discomforts experienced by participants due to the
use of acupressure, awakening the desire for this type of
care to be extended to other pregnant women. Thus, one
can say that the acupressure technique in the study pop-
ulation was recognized as a means to minimize or abolish
the discomforts of pregnancy. The feeling of well-being
and relaxation associated with the relief of discomforts is
also considered, as well as the care provided during the
therapy sessions.
CONCLUSIONS
The answers given by pregnant women concerning
discomforts presented by them after using the acupres-
sure technique indicate improvement of cramps, fatigue in
the legs, lower back pain and headaches. Given the posi-
tive results obtained in this study, it is understood that the
inclusion of the acupressure technique is necessary as an
adjunct strategy in health promotion and disease preven-
tion for pregnant women.
On the understanding that Nursing is based on the pro-
cess of care and seeks the human being holistically, acu-
pressure is presented as a procedure within the reach of
nurses. In the context of prenatal care, this care has histori-
6 Rev Gaúcha Enferm. 2016 Jun;37(2):e54699
cally been driven by this professional, whose tender care is
guided on the needs of each woman. Thus, as a non-phar-
macological technique, acupressure, to minimize different
gravidic discomforts should be introduced by the nurse in
pre-natal consults as a therapeutic resource for the sake of
obtaining the pregnant woman’s well-being.
The limitations of the study are recognized, since it
was only developed in one BHU. This recognition leads to
suggesting that such research is designed to cover a larger
contingent of pregnant women.
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Resmi, D. C., Hadisaputro, S., Runjati. Belitung Nursing Journal. 2017 December;3(6):722-728
Received: 16 March 2017 | Accepted: 27 December 2017
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© 2017 The Author(s)

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ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF YOGA AND ACUPRESSURE ON PAIN AND FUNCTIONAL

CAPABILITY OF LOWER BACK IN PREGNANT MOTHERS DURING THE
THIRD TRIMESTER OF PREGNANCY

Dewi Candra Resmi*, Suharyo Hadisaputro, Runjati

Postgraduate Midwifery Program, Semarang Health Polytechnic, Semarang, Indonesia

*Corresponding author:
Dewi Candra Resmi
Postgraduate Midwifery Program, Semarang Health Polytechnic
Jl. Tirto Agung, Pedalangan, Banyumanik Kota Semarang, Jawa Tengah, Indonesia (50268)
E-mail: decha_qyut@yahoo.co.id

Abstract
Objective: To examine the effect of yoga and acupressure in lower back pain and functional capability in pregnant women
during the third semester of pregnancy.
Methods: A quasi-experimental design with pretest posttest with non-equivalent control group. The research was
conducted at the Community Health Center of Kalikajar I, Selomerto I and Garung I in Wonosobo regency Indonesia in
January 2017. The samples of this research were 42 pregnant women in trimester III selected using purposive sampling,
which 14 samples assigned in the yoga group, acupressure group, and control group. A Visual Analog Scale (VAS) was
used to measure pain level, and Oswestry Disability Index to measure functional capability of lower back. Data were
analyzed using paired t-test and one-way ANOVA.
Results: Findings showed that there was a statistically significant effect of yoga, acupressure, and pregnancy exercise
(control group) in reducing lower back pain and lower back functional capability with p <0.05. Pregnancy exercise (mean=
-1.43) was more effective in reducing lower back pain compared with yoga (mean=-2.29) and acupressure (mean=-2.71);
and acupressure (mean=-14.29) was more effective in improving lower back functional capability than yoga (mean=-6.57)
and pregnancy exercise (mean= -13.29).
Conclusion: There were significant effects of yoga, acupressure, and pregnancy exercise in reducing pain and in
improving the functional ability of the lower back. It is recommended for midwife to use these interventions as an
alternative to deal with back pain and functional capability in pregnant women, especially in the Community Health Center
in Wonosobo regency, Indonesia.

Keywords: yoga; acupressure; pregnancy exercise; pain; functional ability

INTRODUCTION
Back pain in pregnancy is a pain that occurs and Israel have spinal pain. While in the
in the lumbosacral area. Back pain intensity Northern America, Africa, the Middle East,
usually increases as the gestational age Norway, Hong Kong and Nigeria have higher
increases. It is because this pain is the result prevalence ranging from 21% to 89.9%
of a shift in the center of gravity and its (Ansari, Hasson, Naghdi, Keyhani, & Jalaie,
posture (Varney, Kriebs, & Gegor, 2007). 2010). Survey conducted by the University of
Improper posture will force additional Ulster in 2014 showed that 70% of a total of
stretching and fatigue in the body, especially 157 pregnant women experienced lower back
in the spinal cord, causing pain or back pain pain (Dase, RphD, BmedsSc, & PgChep,
(Brayshaw, 2007). Previous study revealed 2014). In Indonesia, 60-80% pregnant women
that more than 50% of pregnant women in the experienced lower back pain; and in the
United States, Canada, Iceland, Turkey, Korea Community Health Center of Ungaran

722 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

Editor’s Note: This article has been updated on 6 July 2020 in terms of minor changes in the reference format. The update is according to BNJ Policy on article correction.

showed that there were 45 pregnant women in
the trimester III had lower back pain
(Pravikasari, 2014).
Based on preliminary study conducted at the
Community Health Center of Kalikajar I,
Selomerto I and Garung I in Wonosobo
regency, there were 187 pregnant women in
the third trimester from January to May 2016.
An effort to reduce low back pain in pregnant
women in these health centers is by only
providing health education about mobilization
and following the class of pregnant women to
do pregnancy exercise. While based on the
results of interviews on 16 pregnant women in
trimester III revealed that 12 mothers
experienced lower back pain, and to reduce
the pain they did more rest and warm
compresses on the lower back area.
The lower back will sometimes spread up to
the pelvis, thighs and down to the legs,
sometimes will increase tenderness above
pubic sympathetic (Cunningham, Leveno,
Bloom, Spong, & Dashe, 2014). This will
cause pregnant women to have difficulty in
performing activities such as standing up after
sitting, moving from bed, sitting too long,
standing too long, undressing and removing
clothes, or lifting and moving objects around
(Kozier, 2008).
There are two kinds of treatments to deal with
pain and functional ability, namely
pharmacology and non-pharmacology.
Considering the impacts of pharmacological
therapy, non-pharmacologic therapy should be
implemented to reduce back pain experienced
by the third trimester pregnant women, those
include cutaneous stimulation (massage, hot
and cold application, acupressure, and
contralateral stimulation), TENS,
acupuncture, relaxation, imagination,
meditation, hypnosis, aromatherapy, yoga and
reflexology (Thompson, 2004). This study
aimed to apply yoga and acupressure to deal
with pain and functional capability in
pregnant women.
Yoga is one of non-pharmacological therapies
that can reduce pain. Yoga is a practical effort
in harmonizing body, mind, and spirit, which
its benefits are to build a strong posture, and
foster flexible and strong muscles, and purify
BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017
Resmi, D. C., Hadisaputro, S., Runjati. (2017)
the central nervous system in the backbone
(Lebang, 2014; Mander, 2003). While
acupressure emphasis on the trigger point,
where in the case of activating point pain is
the same as the acupuncture point. This is in
accordance with the theory by previous study
stated that one of the benefits of acupressure
is to reduce back pain (Khomsah, Suwandono,
& Ariyanti, 2017).
METHODS
Research Design
This was a quasi-experimental design with
pretest posttest with non-equivalent control
group.
Setting
The research was conducted at the
Community Health Center of Kalikajar I,
Selomerto I and Garung I in Wonosobo
regency in January 2017. The research was
conducted for 3 weeks.
Sample
The target population in this study was all
pregnant women in trimester III the
Community Health Center of Kalikajar I,
Selomerto I and Garung I in Wonosobo
regency. The samples of this research were 42
pregnant women in trimester III selected
using purposive sampling, which 14 samples
assigned in the yoga group, acupressure
group, and control group. The inclusion
criteria were: pregnant women in trimester III
who experienced back pain and lower back
functional ability, did not have a bad history
of pregnancy, could communicate well,
cooperative and willing to be a respondent;
while the exclusion criteria included: pregnant
women with gestational age less than 29
weeks.
Intervention
For the yoga group, yoga was given two times
per week for 3 weeks. Yoga was done for 60
minutes per session in the morning in the
Community Health Center of Kalikajar I.
Yoga consisted of warm-up exercises,
breathing (pranayama), and the core
movement as a series of yoga asana
movement including Tadasana, Baddakosana,
Upavistha konasana, Dandasana, Suptha
723
 Resmi, D. C., Hadisaputro, S., Runjati. (2017)

baddakosana, and savanna. Yoga was done by Suwandono, Ariyanti, Mashoedi, &
an expert for yoga for pregnancy. Fatmasari, 2017), and functional capability of
lower back was measured using Oswestry
For the acupressure group, acupressure was Disability Index (ODI) questionnaire
done for 15 minutes per session, which was (Fairbank & Pynsent, 2000). Back pain and
implemented two times per week for 3 weeks. functional capability were measured during
Acupressure is an emphasis on certain points pretest and posttest.
in the body part of the lower back and legs of
the third trimester pregnant women who Ethical Consideration
experienced lower back pain. The points of The ethical consideration of this research was
acupressure included: BL23 (shenshu), GV 3 obtained from the Ethics Commission of
(yaoyangguan), GV 4 (Mingmen), Ki 3 Poltekkes Kemenkes Semarang
(taixi). The acupressure was performed by an No.141/KEPK/Poltekkes-Smg/EC/017. Prior
acupressure therapist at the Community to data collection, each respondent was signed
Health Center of Selomerto I. a written informed consent.

The control group was given the standard Data Analysis

action of pregnancy exercise performed in 60
minutes per session and done two times per
week for 3 weeks. Pregnancy exercise is an
exercise performed to maintain blood
circulation, reduce cramps and stiff
complaints. Exercise was done in the form of
basic exercises, breathing, and stretching
which is different from breathing techniques
in Yoga. Poses performed differently, which
more with sitting position upright and
crawling to stretch the lower back muscles.
This exercise was done by a midwife in the
Community Health Center of Garung.
Instrument
Back pain was measured using a Visual
Analog Scale (VAS) adopted from (Rosyida,
Paired t-test was used to determine the mean
effect before and after intervention. To
determine the difference in the three groups,
ANOVA test was used and followed by post-
hoc test. The homogeneity test used a Levene
test, and normality test used Shapiro-wilk test
because the number of respondents was less
than 50.
RESULTS
Normality test
The results of Shapiro Wilk test as shown in
the Table 1 indicated that lower back pain and
functional capabilities in the three groups
were in normal distribution with p-value
>0.05.

Table 1 Normality test on lower back pain and functional capability before and after given intervention using
Shapiro Wilk
Group
Yoga Acupressure Control
Variable
(p-value) (p-value) (p-value)
Pretest Posttest Pretest Posttest Pretest Posttest
Back Pain 0.251 0.057 0.683 0.504 0.271 0.251
Lower back functional
0.809 0.297 0.120 0.539 0.064 0.223
capability

Homogeneity test F 0.629 and p= 0.893 (>0.05), which

Levene’s test as shown in the Table 2 showed indicated that the group of yoga, acupressure
back pain variable with F = 3.192 and p= and control group were homogenous.
0.052 (>0.052), and functional capability with

Table 2 Homogeneity test on lower back pain and functional capability using Levene’s test
Variable F P-value
Back Pain 3.192 0.052
Lower back functional
0.629 0.893
capability

724 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017

 Resmi, D. C., Hadisaputro, S., Runjati. (2017)

Characteristics of respondents
Table 3 Characteristics of respondents based on age, employment status, parity, and body weight
Group
Intervention Control
Variable P-value
Yoga Acupressure Pregnancy exercise
n (%) Mean±SD n (%) Mean±SD n (%) Mean±SD
Age (year)
- <19 0 (0) 1(7.1) 2 (14.3) 0.590
- 20-35 13(92.9) 11(78.6) 10 (71.4)
- >36 1 (7.1) 2 (14.3) 2 (14.3)
Employment status
- Employed 5 (35.7) 6 (42.9) 11 (78.6) 0.253
- Unemployed 9 (64.3) 8 (57.1) 3 (21.4)
Parity
- Primipara 6 (42.9) 6 (42.9) 5 (35.7) 0.906
- Multipara 8 (57.1) 8 (57.1) 9 (64.3)
Body weight 60.164±8.72 61.86±8.67 58.71±4.87 0.102

Table 3 shows that there were no significant (p=0.590), employment status (p=0.253),
differences of the characteristics of parity (p=0.906), and body weight (p=0.102).
respondents in the three groups based on age

Difference of lower back pain before and after given intervention

Table 4 Difference of lower back pain before and after given intervention
Experiment group Control group
Pregnancy
Variable Yoga Acupressure p-value
exercise
Mean±SD Mean±SD
Mean±SD
Lower Pretest 4.14±1.127 4.93±2.056 4.86±1.562 0.3682
back pain Posttest 2.71±1.204 2.64±1.646 2.14±1.027 0.4652
p-value 0.0001 0.0001 0.0001
Mean
-1.43±0.852 -2.29±0.914 -2.71±1.069 0.0002
difference
1
Paired T test, 2One Way ANOVA

Table 4 shows that the mean of lower back

pain in the yoga group before given
intervention was 4.14 ± 1.127, and decreased
to 2.71 ± 1.207 after the intervention, and the
mean difference of pain levels before and
after intervention was -1.43. The results of
Paired t-test obtained p-value 0.000, which
indicated that there was a significant effect of
yoga in decreasing back pain level. The mean
of lower back pain in the acupressure group
before given intervention was 4.93 ± 2.056,
and decreased to 2.64 ± 1.646 after the
intervention, and the mean difference between
pain levels before and after intervention was -
2.29. Paired t-test showed p-value 0.000,
which indicated that there was a significant
effect of acupressure in lowering back pain.
The mean of lower back pain in the control
group before given intervention was 4.86 ±
1.56, and decreased to 2.14 ± 1.02 after
intervention. The mean difference of pain
level before and after intervention was -2.71.
Paired t-test showed p-value 0.000, which
indicated that there was a significant decrease
of lower back pain after given pregnancy
exercise. One-way ANOVA test obtained p-
value 0.000, which indicated that yoga,
acupressure, and pregnancy exercise have a
significant effect in reducing lower back pain
in pregnant women. However, the mean
difference in pregnancy exercise group
showed a higher decrease of pain level
compared with yoga and acupressure group.

BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017 725

 Resmi, D. C., Hadisaputro, S., Runjati. (2017)

Difference of lower back functional capability before and after given intervention
Table 5 Difference of lower back functional capability before and after given intervention
Experiment group Control group
Pregnancy
Variable Yoga Acupressure P-value
exercise
Mean±SD Mean±SD
Mean±SD
Lower back functional Pretest 32.14±13.091 36.29±12.048 31.14±13.421 0.5392
capability Posttest 25.57±10.383 22.00±7.104 17.86±5.736 0.0482
1 1 1
p-value 0.009 0.000 0.000
Mean -6.57±7.978 -14.29±6.510 -13.29±9.15 0.0292
difference
1
Paired T test, 2One Way ANOVA

Table 4 shows that the mean of lower back
functional capability in the yoga group before
given intervention was 32.14 ± 13.091, and
after intervention was 25.57 ± 10.383, and the
mean difference of lower back functional
capability before and after intervention was -
6.57 ±7.978. The results of Paired t-test
obtained p-value 0.009, which indicated that
there was a significant effect of yoga on lower
back functional capability. While the mean of
lower back functional capability in the
acupressure group before given intervention
was 36.29 ± 12.048, and after intervention
was 22.00 ± 7.104, and the mean difference
between lower back functional capability
before and after intervention was -14.29
±6.510. Paired t-test showed p-value 0.000,
which indicated that there was a significant
effect of acupressure on lower back functional
capability.
The mean of lower back functional capability
in the control group before given intervention
was 31.14 ± 13.421, and after intervention
was 17.86 ± 5.736. The mean difference of
lower back functional capability before and
after intervention was -13.29 ±9.15. Paired t-
test showed p-value 0.000, which indicated
that there was a significant effect of
pregnancy exercise on lower back functional
capability. One-way ANOVA test obtained p-
value 0.029, which indicated that yoga,
acupressure, and pregnancy exercise have a
significant effect in increasing lower back
functional capability in pregnant women.
However, the mean difference in acupressure
group showed a higher increase of back
functional capability compared with yoga and
control group.
Table 6 shows that there was a significant
difference of pain level between yoga and
pregnancy exercise group with mean value
1.500 and p-value 0.000 (<0.05); and between
yoga and acupressure group with mean value -
1.071 and p-value 0.013 (<0.05). There was
no significant difference between acupressure
and pregnancy exercise with p-value 0.697
(>0.05).
For lower back functional capability, post hoc
test showed a significant difference between
yoga and acupressure with mean 7.714 and p-
value 0.042 (<0.05). There was no significant
difference between yoga and pregnancy
exercise with mean 6.714 and p-value 0.094
(> 0.05), and between acupressure and
pregnancy exercise with p-value 1.000
(>0.05).

Table 6 Mean difference of lower back pain and functional capability using post hoc test
Mean
Variable Group p-value
Difference
Lower back pain Yoga vs pregnancy exercise 1.500 0.000
Acupressure vs pregnancy exercise 0.429 0.697
Yoga vs acupressure -1.071 0.013
Lower back functional Yoga vs acupressure 7.714 0.042
capability Yoga vs pregnancy exercise 6.714 0.094
Acupressure vs pregnancy exercise -1.000 1.000

726 BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017


DISCUSSION
Effect of yoga on lower back pain and
functional capabilities compared with
pregnancy exercise
The results showed that there was a
significant effect of yoga on the decrease of
lower back pain. Back pain in pregnancy is
the pain that occurs in the lumbosacral area.
This is in line with previous study stated that
alternative treatments to reduce low back pain
in pregnancy were massage (61.4%),
acupuncture (44.6%), yoga (40.6%) and
chiropractic (36.6%) (Wang et al., 2005).
Yoga is one form of exercises that can be
done by pregnant women. Yoga can make the
body more flexible and comfortable in
addition to supporting blood circulation,
overcoming back pain, waist, aches and
swelling (Kozier, 2008). Doing yoga routinely
can increase ability to stand better, walk
longer, run faster and all done without leaving
the pain after doing so. The function and
efficacy of yoga can overcome problems
related to the anatomical functions of the body
(Brayshaw, 2007). This study also revealed
that there was a significant effect of Yoga in
the improvement of lower back functional
capability.
However, in this study, pregnancy exercise
was more effective in reducing lower back
pain and improving functional capability in
pregnant women compared with yoga.
However, it does not mean that yoga has no
effect to decrease the lower back pain level
and increase functional capability, but there
are several factors that can affect the decrease
of pain level in the yoga group, one of which
is the environment. The physical environment
has an influence on human thoughts, feelings,
and behavior. Environment is stimuli from the
outside that can be responded by the system
of the five senses of human (sight, hearing,
tasting, smell and touch), where
psychologically potentially form a perception
that indirectly affects the emotional and
human behavior.
Physical environment referred to in this study
is that during the implementation of yoga
where 14 respondents with a narrow room
will cause uncomfortable feelings, and there
was a sense of stuffy and hot and lack of
ventilation for air circulation that will cause
BELITUNG NURSING JOURNAL, VOLUME 3, ISSUE 6, NOVEMBER – DECEMBER 2017
Resmi, D. C., Hadisaputro, S., Runjati. (2017)
poor yoga movements. In addition, different
instructors in yoga group and pregnancy
exercise group might be one of factors. In
pregnancy exercise, the instructor was the
midwife of the health center itself so that the
respondents were easily to communicate and
more comfortable, while a yoga instructor was
not a midwife who was not yet known by the
respondents. Pregnancy exercise is one of the
activities in the prenatal care service during
pregnancy to provide better pregnancy or
delivery compared with pregnant women who
do not do pregnancy exercises (Thompson,
2004). This is in accordance with previous
research revealed the effectiveness of
pregnancy exercise on decrease of back pain
in pregnant mother at the Community Health
Center of Inpati Karya Wanita Pekanbaru
with p-value 0.001 (<0.05) (Lebang, 2014).
Effect of acupressure on lower back pain
and functional capabilities compared with
pregnancy exercise
Findings showed that there was a significant
effect of acupressure on lower back pain and
functional capabilities. It proves that
acupressure is a healing technique by
pressing, massaging, massage the body to
activate the circulation of energy.
Acupressure is one of the traditional
treatments by doing massage on acupuncture
points. Acupressure enhances body relaxation
and creates positive thoughts (Mander, 2003).
Acupressure is powerful to alleviate
discomfort and working greatly in improving
mother’s mental and emotional well-being
because of the key to learning disorders and
emotional trauma. Emphasizing in the
acupressure points could improve blood
circulation and stimulate the release of
endorphin hormones (Khomsah et al., 2017).
This is line with previous study revealed that
acupressure could reduce lower back pain by
86%, and more effectively when combined
with psychotherapy (Wang et al., 2005).
Supported by another study stated that
acupressure can effectively build a weak body
and increase muscle strength and range of
upper extremity motion in stroke patients. The
results of this study revealed that acupressure
was more effective in improving lower back
functional capability compared with yoga and
pregnancy exercise (Pravikasari, 2014).
727

CONCLUSION
It is concluded that there was a significant
effect of yoga and acupressure in reducing
lower back pain and improving functional
capability of lower back. Therefore, it is
recommended for midwife to use these
interventions as an alternative to deal with
back pain and functional capability.
Declaration of Conflicting Interest
None declared.
Funding
This study was supported by Postgraduate Midwifery
Program, Semarang Health Polytechnic, Semarang,
Indonesia.
Author Contribution
All authors contributed equally in this study.
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