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WOMBI-523; No. of Pages 7

Women and Birth xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Women and Birth


journal homepage: www.elsevier.com/locate/wombi

Original Research – Quantitative

Immediate stress reduction effects of yoga during pregnancy:


One group pre–post test
Momoko Kusaka, Masayo Matsuzaki *, Mie Shiraishi, Megumi Haruna
Department of Midwifery and Women’s Health, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo,
7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Background: Excessive stress during pregnancy may cause mental disorders in pregnant women and
Received 15 October 2015 inhibit fetal growth. Yoga may alleviate stress during pregnancy.
Received in revised form 26 January 2016 Aim: To verify the immediate effects of yoga on stress response during pregnancy.
Accepted 4 April 2016
Methods: One group pre–post test was conducted at a hospital in Japan. We recruited 60 healthy
primiparas without complications and asked them to attend yoga classes twice a month and to practice
Keywords: yoga at their homes using DVD 3 times a week from 20 gestational weeks until childbirth. Salivary
Exercise
cortisol and alpha-amylase concentration were measured before and after yoga classes at time 1 (27–32
Pregnant women
Saliva
gestational weeks) and time 2 (34–37 gestational weeks). Subjective mood was assessed using the
Stress, Physiological profile of mood states. Saliva values and mood scores before and after each yoga class were compared
Stress, Psychological using paired t-test and Wilcoxon rank-sum test, respectively.
Findings: We analyzed 44 and 35 women at time 1 and time 2, respectively. The mean salivary cortisol
concentration declined significantly after each yoga class [time 1: 0.36–0.26 mg/dL (p < 0.001), time 2:
0.32–0.26 mg/dL (p = 0.001)]. The mean salivary alpha-amylase concentration also decreased
significantly following each class [time 1: 72.2–50.8 kU/L (p = 0.001), time 2: 70.6–52.7 kU/L
(p = 0.006)]. The scores for negative dimensions of mood (Trait-Anxiety, Depression, Anger-Hostility,
Fatigue, and Confusion) decreased significantly. The scores of Vigor for a positive dimension of mood
significantly increased.
Conclusion: This study indicated the immediate stress reduction effects of yoga during pregnancy.
ß 2016 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf
of Australian College of Midwives.

Summary of Relevance: What this Paper Adds


Problem Participants’ subjective mood improved after participation in
Excessive stress during pregnancy may cause mental disorders one yoga session. Moreover, physiological stress response mea-
in pregnant women and inhibit fetal growth. Yoga may alleviate sured using salivary cortisol and a-amylase was alleviated.
physiological and psychological stress during pregnancy; how- Thus, yoga may be useful for immediate stress reduction during
ever, the effects have yet to be clearly shown. pregnancy.

What is Already Known


Previous studies showed that performing yoga during pregnan-
cy decreases perceived stress. In contrast, its effects on physio- 1. Introduction
logical stress response have not been clarified.
Pregnant women often experience challenges adapting to the
physical, mental, and social changes associated with progressing
pregnancy, which may trigger psychological and physiological
stress responses.1 Psychological stress responses include depres-
sive symptoms and anxiety, which potentially lead to maternal
* Corresponding author. Tel.: +81 3 5841 3396; fax: +81 3 5841 3396. psychological illness. In addition, excessive maternal physiological
E-mail address: msumi-tky@umin.ac.jp (M. Matsuzaki). stress responses can increase the risk of obstetric complications,

http://dx.doi.org/10.1016/j.wombi.2016.04.003
1871-5192/ß 2016 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.

Please cite this article in press as: Kusaka M, et al. Immediate stress reduction effects of yoga during pregnancy: One group pre–post
test. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.003
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2 M. Kusaka et al. / Women and Birth xxx (2016) xxx–xxx

including preterm birth and low birth weight.2,3 High physiological 2.2. Participants
stress may induce preterm birth because high cortisol secretion
can disturb hormonal regulation of placenta and fetus.2,3 It is Women at 18–22 gestational weeks were identified from the
suggested that fetal growth is hindered by the reduction of list of patients who were scheduled to attend the prenatal check-
placental perfusion due to the elevation of cortisol and catechol- up on the day. One researcher evaluated the study eligibility of
amine levels (norepinephrine, epinephrine, and dopamine).4 328 pregnant women who visited the outpatient section for their
Cortisol is secreted during activation of the hypothalamic- check-up, between March and August 2013. Participants’
pituitary-adrenal axis (HPA axis) as an endocrine-related physio- eligibility criteria were as follows: women who were primiparas;
logical stress response. The level of catecholamine is also elevated with singleton pregnancies; and were permitted to participate in
during activation of the sympathetic-adrenal-medullary axis (SAM yoga classes by their doctors. The exclusion criteria were as
axis). Following HPA- and SAM-axis endocrine activity, several follows: women who were less than 20 years old; had inadequate
changes occur in the circulatory system, such as the elevation of Japanese literacy skills; were planning to transfer to another
blood pressure and heart rate.5 Stress reduction methods could hospital; had previously experienced still birth or repeated
provide a useful way to alleviate HPA- and SAM-axis activation. abortion; had a psychiatric disorder before or during pregnancy;
It is known that stress responses among pregnant women are were at risk for premature delivery or abortion; had cervical
relieved by guided imagery, progressive muscle relaxation6,7 and incompetency; were diagnosed with low-lying placenta or
massage8. In contrast, the stress reduction effect of yoga has not placenta previa; or were restricted from performing exercises
been clearly demonstrated in pregnant women. Yoga is suitable for for cardiovascular disease or other complications. One researcher
pregnant women because compared with other physical activity it confirmed eligibility of each woman for the study by asking her
has relatively low exercise intensity and poses low risks of or her doctors. Then, the researcher explained the study contents,
accidental falling and hard contact with other persons. The practice schedule, and ethical consideration to each woman by using
of yoga combines poses (asana), breathing (pranayama), and written information.
meditation (diyana). Hatha yoga is a style of yoga that focuses on
gentle poses that resemble animals and plants, which stretch and 2.3. Study schedule
loosen whole body. Using psychological and physiological
measures, many previous reviews of non-pregnant populations At recruitment, written consent was obtained after the
suggested that yoga has reduced stress.9 explanation about the study. Subsequently, participants filled
Previous studies using psychological measurements reported out a questionnaire survey, which included demographic data,
that performing yoga during pregnancy decreases perceived stress, such as employment status; educational history; and information
anxiety and depressive symptoms and improves quality of life.10 In concerning alcohol, tobacco, and medications that could influence
addition, some previous studies suggested that yoga has reduced saliva secretion. The questionnaires were collected again at time 1
the risk of obstetric complication, such as preterm birth and low and time 2 to record the changes in participants’ demographic
birth weight.10,11 The underlying mechanism might be the data. Other demographic data were obtained from the participants’
alleviation of physiological stress response.4,5 Recently, Ber- medical charts, including age, gestational weeks, and health status.
shadsky et al.12 and Newman et al.13 have shown a significant After the first survey at recruitment, participants started to attend
reduction of salivary cortisol concentration after yoga participation a yoga class and practice yoga at their home by using a digital video
among healthy pregnant women in the USA and UK, respectively. disc (DVD). They continued to practice yoga until they delivered.
However, the effects of yoga on pregnant Japanese women have Outcome assessments before and after yoga session at time 1 and
not been demonstrated. Moreover, it is not been clarified how yoga time 2 were conducted between May and December 2013. The
during pregnancy will affect SAM-axis activity in the pregnant outcome assessment included the measurements of stress
women. By clearing the effects of yoga on HPA- and SAM-axis responses; salivary cortisol, salivary alpha-amylase (a-amylase),
activity, yoga can be proposed to pregnant women as one of the and subjective mood which was obtained using the profiles of
techniques which alleviate the stress responses during pregnancy. mood states (POMS)14.
Therefore, this study aimed to verify the immediate effects of yoga
on physiological stress responses, which include HPA- and SAM- 2.4. Outcome variables and the assessment protocol
axis activity during pregnancy, combined with psychological
measurements. We hypothesized that physiological stress re- 2.4.1. Physiological stress response
sponse was alleviated and subjective mood improved after
participation in yoga class. 2.4.1.1. Salivary cortisol. Cortisol is a stress hormone that reflects
the HPA axis activity. Cortisol exists in unbound and protein-
bound forms in serum. Unbound cortisol in saliva reflects both the
2. Participants, ethics, and methods total and the free cortisol in serum.15 Salivary cortisol follows the
diurnal circadian rhythm in which it increases rapidly after
2.1. Design and setting waking, and then decreases slowly over the course of the day.16
Salivary cortisol reactivity to stress is maintained during
One group pre–post test design was adopted. Participants pregnancy.17 Additionally, salivary cortisol concentration ele-
practiced yoga from 18–22 gestational weeks until birth. vates as pregnancy progresses.18
Participants’ stress responses were measured before and after Participants used 5-cm straw to collect 2-ml saliva from under
yoga classes at two time points to assess how one yoga session their tongue and deposited the saliva into a polypropylene tube.
decreases stress at different phases of their pregnancy. The first Within 4 h after collection, the saliva samples were frozen at -
assessment was scheduled for 27–32 gestational weeks (time 1), 80 8C. All samples were assayed for salivary cortisol in duplicate
in the middle of the study period. The second assessment was using a salivary enzyme immunoassay (EIA) kit (Salimetrics, State
scheduled for 34–37 gestational weeks (time 2), near the College, LA, USA) within 4 months after the collection. The plates
conclusion of the study period. The study was conducted at a were assayed photometrically at 450 nm using a plate reader (Bio-
university hospital in Tokyo, Japan, between March and Rad, 680XR, CA, USA). Average intra- and inter-assay coefficients of
December 2013. variation were 3.2% and 6.2%, respectively.

Please cite this article in press as: Kusaka M, et al. Immediate stress reduction effects of yoga during pregnancy: One group pre–post
test. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.003
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2.4.1.2. Salivary a-amylase. Salivary a-amylase, which reflects bended forward during exhalation for deeper stretches. During
SAM-axis activity, is often used as a non-invasive and alternative the meditation, participants closed their eyes in supine or lateral
biomarker to norepinephrine.19 Salivary a-amylase follows a positions and meditated with the guided imagery provided by the
diurnal course that is opposite to the diurnal course of cortisol; instructor. Yoga was practiced on yoga mats, at a comfortable
salivary a-amylase decreases sharply after waking, and then temperature, and accompanied by the relaxation music. Partici-
increases gradually.20 Salivary a-amylase reactivity to stress pants were offered to participate in yoga classes as often as
attenuates during the third trimester.17 Some cross-sectional possible.
studies have suggested that salivary a-amylase concentration When participants attended their first yoga class, they received
decreases from the first to third trimester.17,20 DVD which contained the same program as the yoga class. They
Alpha-amylase concentration was measured using a salivary were asked to practice yoga 3 times a week at their homes. They
amylase monitor (NIPRO Corporation, Osaka, Japan). The biosensor recorded the times of their practices, and noted comments on their
consists of a disposable test strip and the main unit that has a physical conditions and emotions before and after the practice in
digital display. The test strip contained a reagent paper infused the original record sheet provided by researchers. Participants
with 2-Chloro-4-nitrophenyl-4-galactopyranosylmaltoside (Gal- attended the yoga classes and were given the yoga DVD without
G2-CNP). Saliva was collected using the strip by placing it under charge. Moreover, as a token of gratitude for participation in the
the participants’ tongue for 30 s. After the strip was inserted into study, they were provided with a 500-yen (approximately five
the main unit, Gal-G2-CNP began to be metabolized. Subsequently, dollars) bookstore gift certificate three times; that are at
the color density of the reagent paper in the strip was measured recruitment, time 1, and time 2.
photometrically at 430 nm, and the salivary a-amylase value was
displayed.21 2.4.5. Ethical considerations
The study protocol was approved by the Ethical Committee of
2.4.2. Psychological stress response the Graduate School of Medicine of The University of Tokyo (No.
3812). Additionally, this study was registered as a clinical trial
2.4.2.1. Mood. Mood was assessed to determine various aspects of (study ID: UMIN 000008607). The participants received explana-
psychological stress responses. Momentary mood was measured tions of the purpose and contents of the study, the voluntary nature
using the Japanese version of the POMS-65 scale14. The POMS scale of their participation, the risks and benefits of exercise during
consists of six mood dimensions: Tension-Anxiety, Depression, pregnancy, and privacy considerations. Written consent was then
Anger-Hostility, Fatigue, and Confusion, which are negative mood obtained from each participant and her partner or other family.
dimensions, as well as Vigor, which is a positive dimension of Participants were approved for yoga by their doctors with written
mood. Participants rated each item on a 5-point Likert scale that permissions.
ranged from 0 (not at all) to 4 (extremely), based on their feeling at During the study period, the health status of each participant
the assessment. The validity and reliability of the Japanese version was monitored by the researchers and medical staffs using the
were confirmed.14 The mean values of Cronbach’s a in this study participant’s medical chart. Participants received blood pressure
were as follows: 0.88 for Tension-Anxiety, 0.88 for Depression, checks and were asked about their condition before and after yoga
0.92 for Anger-Hostility, 0.93 for Fatigue, 0.76 for Confusion, and classes. Further, the heart rate of each participant’s fetus was
0.91 for Vigor. checked using a Doppler fetal monitor before and after classes.
Participants were instructed not to practice yoga at their homes
2.4.3. Assessment protocol when they were in a poor state of health.
Before and after yoga classes that were designated for outcome
assessments at time 1 and 2, one researcher first collected the 2.4.6. Statistical analysis
POMS scales and then the saliva samples. To avoid the influences Participants’ demographic data were presented as mean and
of food on stress response, participants were asked to refrain from Standard Deviation or n (%). Total times of yoga practice at home
consuming food for 1 h before the saliva collection. Additionally, were noted by using the records of participants. Yoga class
participants were asked to drink nothing except water after their participation was recorded by researchers. Frequency of yoga
last meals. Saliva samples were collected more than 10 min after practice was calculated as the sum of yoga classes and practice at
the participants had rinsed their mouths with water. Samples home divided by the total intervention period of yoga.
were collected at scheduled times to reduce the influence of We compared the concentrations of salivary cortisol and
diurnal changes in salivary cortisol and a-amylase. Before the a-amylase before and after each class using the paired t-test. The
class, participants were assessed between 13:30 and 14:00. POMS scores were compared using the Wilcoxon rank-sum test.
Afterwards, participants practiced yoga for 60 min (14:00–15:00). We also calculated the percentage of women who showed a
Following the class, the participants were assessed again (15:00– decrease in salivary cortisol and a-amylase concentrations and
15:30). POMS scores of negative dimensions. The percentage of women
who showed an increase in POMS vigor scores was also calculated.
2.4.4. Intervention Statistical analyses were performed using the Statistical Package
For the present study, the prenatal yoga classes were conducted for Social Sciences for Windows Version 22 (SPSS Japan Inc.,
at the hospital twice a month on weekdays. Researchers and a yoga Japan). For all statistical tests, Two-tailed p-values less than 0.05
instructor held the classes. The instructor for the yoga classes was were considered statistically significant. Moreover, we calculated
certificated by the Japan Maternity Fitness Association, which the effect size of one yoga session on salivary cortisol and
developed the Hatha yoga program for pregnant women. Each a-amylase concentration (effect size d) and POMS scores (effect
class lasted 60 min, consisting of 15 min of warm-up, 40 min of size r). Effect size d in this study was Cohen’s d adjusted for the
poses, and 5 min of meditation and breathing. During the warm- correlation between values before and after yoga classes, which
up, participants stretched their whole bodies in a sitting position. was calculated by using G*power22. The reference values for
Then, participants practiced 7–8 yoga poses, took a 5-min break, evaluating effect size d were as follows; 0.20 was ‘‘small’’, 0.50 was
and subsequently practiced 7–8 more poses with guided instruc- ‘‘medium’’, and 0.80 was ‘‘large’’.23 The reference values for
tion. All poses were coordinated with breathing. To avoid halting evaluating effect size r were as follows; 0.10 was ‘‘small’’, 0.30 was
breath, participants bended backward during inhalation and ‘‘medium’’, and 0.50 was large.23

Please cite this article in press as: Kusaka M, et al. Immediate stress reduction effects of yoga during pregnancy: One group pre–post
test. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.003
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4 M. Kusaka et al. / Women and Birth xxx (2016) xxx–xxx

Using power estimated with values of physiological measure-


ments in previous studies, we calculated required sample size.
Studies examining yoga’s effects on salivary cortisol24 and
a-amylase25 among healthy adults have Cohen’s d values of
0.51 and 0.65, respectively. Thus, the required number of
participants for the analysis would be 33 and 21 women,
respectively (p < 0.05 and 80% power).

3. Results

Fig. 1 shows the flow chart of study recruitment and


participation. Of the 328 women who were screened for the study
eligibility, 247 women were excluded because they did not meet
the eligibility criteria. The remaining 81 women were recruited,
and 60 agreed to participate (participation rate: 74.1%).
Of the 60 initial participants, 53 and 46 women continued
participation at time 1 and time 2, respectively. Seven dropped out
by time 1: two were at risk of premature delivery, 2 had fetal
growth retardation (FGR), 2 transferred to another hospital, and 1
refused to continue to participate. Seven more participants
dropped out by time 2: four were at risk of premature delivery,
1 was restricted from exercising because of forelying umbilical
cord, 1 refused to continue, and 1 delivered her child prematurely.
Of those who continued to participate, 44 and 35 women
participated in the outcome assessments at time 1 (44/53: 83.0%)
and time 2 (35/46: 76.0%), respectively. Thus, the final response Fig. 1. Flow chart of study recruitment and participation.
rate was 54.3% (44/81) and 43.2% (35/81) at time 1 and 2,
respectively. Nine and 11 women could not participate in the
outcome assessment at time 1 and time 2, respectively. The main 66) at time 1 and 2, based on self-report. Thus, the mean (range)
reason for their absenteeism was reported as ‘‘for their work’’ at frequency of yoga practice was 2.7 (0.4–6.0) and 2.4 (0.4–6.2)
time 1 and ‘‘for personal schedule conflicts’’ at time 2. The median times a week, respectively, based on self-report. No woman
number of participants in yoga classes, which included women consumed alcohol, tobacco, and medicines that would influence
who did not participate in outcome assessment at that time, was salivary secretion.
13 [range: 4 (at the end of the study) to 17]. The changes in salivary cortisol and a-amylase concentrations
Table 1 presents the participants’ demographic characteristics. and the POMS scores before and after the yoga classes were
The mean age of participants at recruitment was 34.4 years (35.0 presented in Table 2 (time 1) and Table 3 (time 2). The mean
years at time 1 and 35.1 years at time 2). At recruitment, 75.0% of salivary cortisol concentration declined significantly after each
the participants had graduated from the university or graduate yoga class [time 1: 0.36–0.26 mg/dL (p < 0.001), time 2: 0.32–
university. At least half of the participants worked at time 1 and 2 0.26 mg/dL (p = 0.001)]. The effect size d of yoga on salivary cortisol
(66.7% and 50.0%, respectively). At time 2, 85.8% of the analyzed was large. The mean salivary a-amylase concentration also
participants did not work including 15 (42.9%) women who had decreased significantly following each class [time 1: 72.2–
obtained maternity leave. Participants had attended mean (range) 50.8 kU/L (p = 0.001), time 2: 70.6–52.7 kU/L (p = 0.006)]. The
of 3.2 (2–5) and 5.3 (3–8) yoga classes at time 1 and time 2, effect size d of yoga on salivary a-amylase was medium. The
respectively. Mean (range) total times of yoga practice at home percentage of women who showed a decrease in salivary cortisol
(times) before outcome assessment were 12.9 (1–35) and 23.4 (1– and a-amylase concentrations were 75.0% and 63.6% at time 1 and

Table 1
Participants’ demographic characteristics.

Baseline (n = 60) time 1 (n = 44) time 2 (n = 35)

Variables Mean SD Mean SD Mean SD

Gestational weeks (weeks) 19.9 1.4 28.5 1.5 35.2 0.9


Age (years) 34.4 4.1 35.0 4.4 35.1 4.3
Participation in yoga
Total times of participation in classes (times) – 3.2 0.9 5.3 1.3
Total times of yoga practice at home (times) – 12.9 8.4 23.4 18.1
Total intervention period of yoga (days) – 44.7 13.7 90.1 13.6
Frequency of yoga practice a (times/week) – 2.6 1.3 2.3 1.5

n % n % n %

Working
Yes 40 66.7 22 50.0 5 14.2
No 20 33.3 22 50.0 30 85.8
Education
University, graduated university 45 75.0 32 72.7 25 71.4
High school, technical school, two-year college 15 25.0 12 27.3 10 28.5

SD, standard deviation.


a
The sum of yoga classes and practice at home, divided by the total intervention period of yoga.

Please cite this article in press as: Kusaka M, et al. Immediate stress reduction effects of yoga during pregnancy: One group pre–post
test. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.003
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Table 2 healthy pregnant women. We found that their salivary cortisol and
The changes in the salivary cortisol and a-amylase concentrations and the profiles
of mood states (POMS) scores before and after the yoga classes at time 1 (n = 44).
a-amylase decreased and their subjective mood improved after
yoga classes.
Pre-test Post-test pa db

Mean SD Mean SD 4.1. The stress reduction effects of yoga


Salivary 0.36 0.16 0.26 0.10 <0.001 0.97
cortisol (mg/dL) 4.1.1. Effects on physiological stress response
Salivary 72.2 45.8 50.8 26.5 0.001 0.60 Some previous studies, which investigated populations other
a-amylase (kU/L) than pregnant women, have shown reductions in salivary
Pre-test Post-test pc r cortisol24,26 and a-amylase25 concentrations following yoga. In
POMS original Median IQR Median IQR
addition, some studies12,13 have recently shown a significant
score reduction of salivary cortisol concentration after yoga participation
among healthy pregnant women in USA and UK, respectively. The
Tension-Anxiety 7.5 4.25–11.0 3.0 1.0–7.75 <0.001 0.75
Depression 3.5 0.3–7.0 0.0 0.0–2.75 <0.001 0.71 reduction in salivary cortisol that was observed in the present
Anger-Hostility 4.0 1.0–8.5 0.0 0.0–4.75 <0.001 0.71 study shows the reproducibility of results of these previous studies
Fatigue 9.0 4.0–13.0 3.5 1.0–9.0 <0.001 0.68 in a different country and race. Moreover, the present study is the
Confusion 7.0 4.25–10.0 3.0 3.0–6.0 <0.001 0.74
first to reveal a reduction of salivary a-amylase concentrations
Vigor 12.0 7.25–16.0 15.0 11.0–19.75 <0.001 0.59
after yoga classes among pregnant women. The results indicate
SD, standard deviation; IQR, inter-quartile range. that both HPA- and SAM-axis activations are alleviated by yoga.
a
Salivary cortisol and a-amylase concentrations were compared using the
Three components of yoga may reduce stress response. First,
paired t-test.
b
Effect size d adjusted with the correlation between pre and post values. body muscles tension could be loosened by various poses. Second,
c
POMS scores were compared using the Wilcoxon-rank sum test. it is suggested that slow and deep breathing lead to control the
autonomic nervous activity. Third, while meditating, participants
were especially conscious of their breathing and mind, allowing
70.6% and 73.5% at time 2, respectively. With respect to the median greater relaxation.
of the POMS scores, Trait-Anxiety, Depression, Anger-Hostility, However, some cautions are warranted regarding the interpre-
Fatigue, and Confusion significantly decreased after the yoga tation of the reduction in salivary cortisol concentration that was
classes at both time 1 and time 2. The percentage of women who observed in this study; indeed, this change may include reductions
showed a decrease in POMS negative mood dimensions at time 1 resulting from both the yoga intervention and the normal, gently
were as follows: 77.2%, tension-anxiety; 65.9%, depression; 77.2%, decreasing diurnal pattern. However, the changes in cortisol
anger-hostility; 81.8%, fatigue; and 79.5%, confusion. The percent- observed in this study were larger than the diurnal decrease
age at time 2 were as follows: 60.0%, tension-anxiety; 57.1%, reported by a previous study16. In addition, the salivary a-amylase
depression; 48.6%, anger; 74.3%, fatigue, and 68.6%, confusion. The concentration in this study reduced against the diurnal increase.
median Vigor scores also significantly increased. The effect size r of Accordingly, our results suggest that the reductions in salivary
yoga on mood scales was medium to large. The percentage of cortisol and a-amylase were mainly caused by yoga.
women who showed an increase in POMS vigor scores were 70.5%
and 62.9% at time 1 and 2, respectively. 4.1.2. Effects on psychological stress response
Few studies have assessed the short-term effects of exercise on
4. Discussion the mood of pregnant women. Polman et al.27 investigated the
mood of pregnant women using the POMS scale, and showed the
This study investigated the immediate physiological and improvement of mood after water- and studio-based exercises.
psychological stress reduction resulting from yoga performed by The present study also showed that the scores of all negative
dimensions decreased, while Vigor improved significantly. These
Table 3 results suggest that yoga is effective for improving mood during
The changes in the salivary cortisol and a-amylase concentrations and the profiles pregnancy. However, women with psychiatric disorders were not
of mood states (POMS) scores before and after the yoga classes at time 2 (n = 35).
included in this study. The participants’ scores are low in some
Pre-test Post-test pa db of the negative mood dimensions, especially in depression and
Mean SD Mean SD anger-hostility. Thus, the changes might not be clinically signifi-
cant. In addition, participants might have filled out the desired
Salivary 0.32 0.12 0.26 0.10 0.001 0.99
cortisol (mg/dL)c
answer on POMS scales because the study objectives could be
Salivary 70.6 37.0 52.7 34.7 0.006 0.74 perceived by them.
a-amylase (kU/L)c
Pre-test Post-test pd r 4.2. Evaluation of baseline concentration of salivary cortisol and
alpha-amylase before yoga classes
POMS original Median IQR Median IQR
score
Salivary cortisol concentrations before yoga classes were
Tension-Anxiety 7.0 4.0–11.0 3.0 2.0–6.0 0.001 0.54
Depression 1.0 0.0–4.0 0.0 0.0–2.0 0.001 0.56
almost as high as those in normal daily life observed in previous
Anger-Hostility 1.0 0.0–5.0 0.0 0.0–1.0 0.003 0.49 studies.16,28,29 In contrast, the salivary a-amylase concentrations
Fatigue 9.0 4.0–12.0 3.0 0.0–7.0 <0.001 0.67 observed in the present study were higher than the concentrations
Confusion 7.0 4.0–8.0 3.0 3.0–6.0 <0.001 0.65 observed in several previous studies of pregnant women.17,20 In
Vigor 11.0 9.0–13.0 13.0 11.0–17.0 0.007 0.46
a Japanese study that used the same amylase monitor as the
SD, standard deviation; IQR, inter-quartile range. present study, mean  SD salivary a-amylase concentrations was
a
Salivary cortisol and a-amylase concentrations were compared using the 42.5  34.1 kU/L among 104 pregnant women before health checkups
paired t-test
b
Effect size d adjusted with the correlation between pre and post values.
by midwives.30 The the high values of a-amylase in this study can
c
n = 34. partly been explained by the characteristics of salivary a-amylase,
d
POMS scores were compared using the Wilcoxon-rank sum test. that is, a large variation in concentration across individuals.

Please cite this article in press as: Kusaka M, et al. Immediate stress reduction effects of yoga during pregnancy: One group pre–post
test. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.003
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6 M. Kusaka et al. / Women and Birth xxx (2016) xxx–xxx

Additionally, the collection times and gestational weeks of partici- Conflicts of interest
pants differed across studies. Therefore, mean a-amylase concentra-
tions may vary across studies. All the authors declare no conflicts of interest in this work.

4.3. Study limitations Acknowledgement

This study has several limitations. First, it was conducted at a This work was supported by the Foundation for Total Health
single university hospital. Perhaps in consequence, participants Promotion, 2012; and the JSPS KAKENHI Grant Numbers 23792638
were older and were more commonly employed the general and 25293451. We thank the staff and instructors of the Japan
Japanese population. Moreover, the participants in this study were Maternity Fitness Association for offering the yoga program.
limited to primiparous women because stress response may vary
between primiparas and multiparas. Therefore, caution is war-
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Please cite this article in press as: Kusaka M, et al. Immediate stress reduction effects of yoga during pregnancy: One group pre–post
test. Women Birth (2016), http://dx.doi.org/10.1016/j.wombi.2016.04.003