Benefits of yoga in pregnancy: a randomised controlled clinical trial

Introduction

Practicing yoga during pregnancy provides many benefits and helps pregnant women develop their mental and physical health and build a connection with their unborn babies [1], [2], [3].

Childbirth is physically and mentally demanding. Yoga in pregnancy reduces maternal fear and anxiety during labour and allows women to labour without epidurals or drugs. Yoga may relieve discomfort and assist pregnant women to control their labour, improving satisfaction [4], 5].

Yoga is a body and mind practice. It is a system of various poses (asana) and stretching exercises combined with breathing (pranayama) and meditation (dharana) [6].

Yoga’s relaxation component helps women work and manage labour pain without medication. Anxiety and fear lower women’s self-confidence and empowerment, which is crucial during labour [7].

Caesarean section (CS) rates are rising globally, including 57.55 % in Turkey and 55.8 % in Brazil, posing a challenge to modern obstetrics [8]. CS rates in Europe rose from 11.2 to 25 %. Better neonatal and maternal outcomes do not support a significant rise in operative delivery [9]. CS increases global maternal morbidity due to abnormal placentation, peripartum hysterectomy, and obstetric haemorrhage [10], 11].

In 2015, the WHO recommended that CS rates not exceed 10–15 per 100 live births to improve foetal and mother outcomes [12]. Molina et al. revised WHO guidelines. They observed that WHO member states with a national CS rate of 19 % had lower maternal and newborn mortality. Hence, the limitations (15 %) were set too low [13].

Preventing needless CS remains a global priority. Various strategies have been implemented to reduce the proportion of CS to a reasonable level. Evidence shows that yoga during pregnancy is safe and may be better for physical and mental health than walking and typical prenatal workouts [14], [15], [16], [17], [18], [19], [20], [21], [22]. Pharmacological control of labour pain using invasive techniques like epidural analgesia is helpful but can cause difficulties, and adverse effects and prolong the second stage of labour [23], [24], [25]. Some pregnant women are hesitant to use epidural analgesia, therefore non-pharmacological labour pain treatment is preferable.

This study examined how yoga during pregnancy affects the CS rate. The secondary outcomes evaluated if prenatal yoga reduced labour pain intensity and the request for epidural analgesia.

Materials and methods

Results

Between May 2019 and September 2023, 236 pregnant women were recruited. Five women were eliminated before randomisation: three for not fulfilling recruitment criteria and two for not participating. Two hundred thirty-one women were randomly assigned; 214 (92 %) finished the trial. One hundred sixteen were allocated for yoga and 115 for the control group. Figure 1 shows the CONSORT study flowchart.

Figure 1:

CONSORT flowchart of the study.

Demographic data demonstrates that both study groups share identical characteristics. In the Yoga group, the average age was 29.6 ± 3.9 years, whereas in the Control group, it was 28.4 ± 4.5 years, and the remaining features of both groups were comparable (Table 1).

Our study included 196 NTSV (nulliparous term singleton vertex) women and two control group preterm vertex vaginal deliveries. All 16 women with breech-presented babies had CS. The overall CS rate was 22 %, and among NTSV women 17 % (Table 2).

Most CSs were In-labour CSs (66 %). The yoga group had a significantly reduced NTSV CS rate (p=0.008) and less frequent In-labour CS (p=0.004) across all participants. Prelabour-CS were primarily performed due to breech presentation in both groups, with no significant difference in Prelabour-CS rates between them.

The control group underwent more labour induction (p=0.032). Yoga significantly increased spontaneous vaginal birth (p=0.009). The yoga group experienced no preterm births. A few third- and fourth-degree perineal lacerations were noted in both groups, whereas the control group had more first- and second-degree lacerations (p=0.049). Both groups demonstrated the same episiotomy rate. The groups showed similar birth lengths. Epidural analgesia requests were similar at birth ward admission (Table 2).

The mean pain intensity indicated by VAS was significantly different at the end of the latent phase first stage of labour when the cervix was 3–6 cm dilated (p<0.001). Pathological CTG was more common in controls (p=0.038).

Table 3 shows indications for In-labour CS, cervical dilation at CS, and rates of induced vaginal birth that ended with CS. Given the limited number of patients with In-labour CS (n=31) in both the yoga (n=8) and control (n=23) groups, we applied Fisher’s Exact test to analyse the difference (Table 3).

Further investigation found that dystocia in 60 % of the control group necessitated In-labour CS, while yoga practitioners experienced in 37 %. We found no difference in induced labour ended with In-labour CS among the groups (Table 3).

Certain variables’ effects on CS termination were examined using binary logistic regression (Table 4). Linearity, marker association, and multicollinearity were examined. The analysis covered 212 participants. The model was significant (χ2=20.566; p=0.002), explaining 16.4 % (Nagelkerke R²) of the variation in In-labour CS. Only group membership and pathological CTG affected In-labour CS.

Analysis of neonatal data revealed no variations (Table 5).

Discussion

Our research indicates that yoga decreases the need for CS in healthy singleton primiparous women. We discovered a connection between pregnant women who engage in yoga and an increased probability of experiencing a spontaneous vaginal birth (p=0.009). Additionally, these women had a reduced possibility of undergoing a CS due to a lower occurrence of In-labour CS (p=0.004).

A Caesarean section is a surgical procedure that is performed when there is a medical need to protect the life and well-being of both the baby and the mother. Operative delivery is recommended when it is deemed to be a safer option than vaginal birth [27]. CS can be performed before or during labour. Several studies have examined the impact of yoga practice on delivery outcomes; however, they have not precisely specified whether prelabour or in labour CS were considered [17], [18], [19], [20]. Ostrovsky pointed out that existing evidence on prenatal yoga and birth outcomes lacks information regarding the timing and indications for CS [28].

One-third of CS was conducted before labour in our study, with similar rates in both groups.

The majority of CS was done during labour (66 %). CS were rare in the intervention group but common in the control group. Yoga during pregnancy reduces In-labour CS rates, as shown by our research.

No published studies have evaluated the association between yoga practice and In-labour CS, making it impossible to compare our results.

The analysis of indications for In-labour CS reveals that pregnant women from the control group saw a higher number of deliveries attributable to dystocia. However, the disparity was not statistically significant. Labour dystocia, characterised by slow cervical dilatation and foetal descent, is caused by a multitude of reasons. The pathophysiology of labour dystocia is not well-studied, creating opportunities for translational research focused on personalised labour management, specifically examining uterine metabolism and foetal position. Improved diagnostic methods and personalised therapy for labour dystocia could potentially result in enhanced results [29].

Yoga and midwifery care were combined in a randomised controlled trial by Jahdi et al. on pregnant women in their second trimester [17]. This study found a significant decrease in CS in yoga-practicing women. CS time: before or during labour is not mentioned in their report.

Thirty pregnant women practised yoga, and 30 received regular midwifery care. This calls into question these findings’ interpretation. Tripepi et al. emphasise the significance of sample size in the design of studies and the subsequent interpretation of findings in clinical medicine [30]. Our study included 214 pregnant women – 108 in the control group and 106 in the yoga group.

We found 27 % of control underwent CS, while Jahdi et al. reported 50 %. In their trial, there was a high rate of induction (57 % in the control group and 29 % in the interventional group). This may have influenced the CS result.

Apart from Jahdi et al., 37 % of the control and 24 % of women in the yoga group had induced labour in our experiment. Our study examined how labour induction influences CS using regression. While induction rates varied widely between groups, we found no correlation between induction and caesarean termination.

Induction of labour is one of the most frequently performed procedures during labour. The percentage of newborns after labour induction is 25 % in high-income nations but lower in low- and middle-income countries [31]. The WHO recommends 10 % birthing inductions, whereas Poland has above 43 % [32]. Our study’s labour induction rate for young, healthy primiparous women from both groups is too high.

Labour requires conscious maternal expulsive efforts, especially during the second stage. Inadequate mother participation can contribute to an increase in CS and interventional deliveries [33]. Mohyadin et al. found that the presence of fear and anxiety related to labour pain is associated with higher rates of CS in multiple countries [19]. Therefore, yoga, meditation, and breath-awareness assume greater significance throughout pregnancy and childbirth. A meta-analysis found that prenatal yoga had a substantial impact on reducing labour pain [34].

Pregnant women who engage in yoga have more abilities in managing labour pain, are skilled in relaxing and calming methods, have reduced stress and anxiety during childbirth, and show improved regulation of plasma cortisol release through the hypothalamus-pituitary-adrenal axis [15], 35].

Primiparous women have three times the risk of CS as multiparous women [36], 37]. In a meta-analysis of 10 trials on CS rate decrease, Chaillet and Dumont found a significant reduction [38]. The delivery hospital also affects the CS rate [39]. Slovenia has the second-lowest neonatal mortality rate in Europe (0.7 per 1,000 live birth deliveries) without CS at the mother’s request and a 21.4 % CS rate. Still, CS rates increased by 7.5 % between 2016 and 2021 [40].

Due to our nation’s rising number of CS, we intend to develop a new antenatal exercise that could minimise primary CS in healthy primiparas. We strictly selected pregnant women to ensure group homogeneity and avoid recognised risk factors for CS. One criterion for exclusion in our study was a BMI of 30 or higher. Among the research pregnant women, none, irrespective of the group, had a BMI of 30. This sample may not truly represent most pregnant women, especially in the America. The European Health Survey found 28.4 % of EU women overweight. Malta had 24 % obese women, Latvia 23.4 %, and Slovenia 21 % [41]. Our participants’ BMI may be related to women’s increased awareness of obesity’s negative impacts on health and life expectancy in our society.

While yoga can have many benefits during pregnancy, its specific impact on birth length might not be as significant as anticipated. In contrast to Corrigan et al. [2] we found similar birth lengths between the groups which is most likely due to group homogeneity. The benefits of yoga manifest in other areas, such as reduced stress or improved maternal health.

Physical activity is essential for pregnancy and is supported by research. According to the recommendations given by the American College of Obstetricians and Gynaecologists (ACOG), healthy pregnant women should exercise 150 min each week. Exercise during pregnancy reduces CS, premature birth, and increases vaginal delivery [42], 43]. Our study found that yoga during pregnancy has the same benefits as ACOG-recommended moderate-intensity physical exercise and should be promoted as a safe, effective antenatal activity. Yoga helped pregnant women gain self-confidence, competence, empowerment, and physical benefits. These skills keep pregnant women calm and in control during labour [15].

Conclusions

Engaging in yoga during pregnancy reduces the rate of In-labour CS, decreases discomfort and encourages spontaneous vaginal birth in primiparous singleton women.