Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, Autumn 2020, 127, 12–25

LITERATURE REVIEW

Effect of antenatal yoga on adverse psychological

outcomes in pregnancy
A. Yeboah
Physiotherapy Department, Worthing Hospital, Worthing, UK

Abstract
Pregnancy is a time when expectant mothers may experience mental health issues
for the first time, and stress, anxiety and depression are common. These conditions
have been associated with both poor birth outcomes and an increased risk of post-
natal depression. Stress levels have also been shown to have a negative impact on
musculoskeletal conditions in pregnancy. It has been proposed that the benefits of
yoga as a method of stress relief could extend to the ante-­ and postnatal periods.
The aim of this literature review was to explore the available evidence for the
use of yoga in the management of stress, anxiety and depression in pregnancy,
and to propose suggestions for further research in this field. A literature search
was conducted using all the search engines on the Healthcare Databases Advanced
Search online resource. Specific inclusion criteria yielded nine papers that were
of sufficient quality to be included. The study group sizes ranged from 46 to 122
participants. Interventions were variable with respect to the duration and frequency
of yoga practice. Depression, anxiety and stress were measured using validated
outcome measures, including the State-Trait Anxiety Inventory assessing state and
trait, and the Edinburgh Postnatal Depression Scale. No adverse events were re-
ported, and the outcomes demonstrated decreases in anxiety and depression scores.
In conclusion, antenatal yoga may be an effective method of managing stress, anxi-
ety and depression in pregnancy, but there is too much inconsistency within studies
to draw any strong conclusions. Therefore, larger-­scale, high-­quality studies with
consistent interventions are needed.
Keywords: adverse psychological outcomes, antenatal, pregnancy, prenatal, yoga.

Introduction include generalized anxiety, obsessive–compul-

The physical and emotional changes that occur sive behaviour, social anxiety and post-­traumatic
during pregnancy have been well-­ documented stress disorder (AWHONN 2015). Many people
(Wang et al. 2004; Vleeming et al. 2008; NICE are aware of postnatal depression, but there is
2014). A combination of hormonal and anatomi- less knowledge of depression during pregnancy,
cal changes can lead to musculoskeletal (MSK) and the prevalence of anxiety during and after
complaints such as low back pain (LBP) and pregnancy (Mind 2020). It has been established
pelvic girdle pain (PGP), which affect 50% and that a history of mental health problems during
20% of the pregnant population, respectively pregnancy is one of the factors that is associated
(Vleeming et al. 2008; Katonis et al. 2011). with postnatal depression (NHS 2018). Research
On an emotional level, poor perinatal mental carried out into the effects of depression and
health is a significant problem; depression and anxiety in pregnancy has also demonstrated a
anxiety are the most common presentations, link to brain development in the newborn that
and have prevalences of 12% and 13%, respec- can extend to child- and adulthood, and this has
tively (NICE 2014). Perinatal anxiety disorders been associated with anxiety, depression and
behavioural problems including attention deficit
Correspondence: Andrea Yeboah, Specialist Physiotherapist, hyperactivity disorder (Glover 2016).
Pelvic, Obstetric and Gynaecological Team, Physiotherapy
Department, North Wing, Worthing Hospital, Lyndhurst Road, Mental health problems in pregnancy can be
Worthing BN11 2DH, UK (e-­mail: andrea.yeboah@nhs.net). managed by psychological therapy or medication
12 © 2020 Pelvic, Obstetric and Gynaecological Physiotherapy
 Antenatal yoga and adverse psychological outcomes in pregnancy
(NICE 2014). The need for medication is dealt term under which the majority of yoga practices
with on a case-­ by-­case basis, and will depend fall, with the term hatha meaning “force or deter-
on the severity of the current symptoms and the mined effort” (Iyengar 2001, p. 4). More specific
patient’s past medical history. It is known that styles of yoga include Ashtanga Yoga, Iyengar
medication taken in pregnancy can cross the Yoga, hot yoga, and antenatal or pregnancy yoga.
placenta, and therefore, affect the baby. It has In the UK, there are a number of pregnancy
been reported that anticonvulsants increase the and postnatal yoga teaching organizations, in-
risk of spina bifida and learning difficulties, and cluding Birthlight, Sitaram Partnership and Yoga
antidepressants can predispose the baby to heart Mama. These and others have evolved since
problems and high blood pressure (NICE 2014). 2000, leading to the growth of antenatal yoga
However, the same guideline highlights that do- classes. Such classes have a strong focus on
ing without medication can run the risk of wors- asana (posture) and pranayama (rhythmic control
ening mental health problems and becoming un- of breath), which can increase energy levels, im-
well, which also poses a risk for the baby. There prove sleep and strengthen the body (Dinsmore-­
has been a historic lack of integrated physical Tuli 2010). Guidelines from the British Wheel of
and mental healthcare in the perinatal period, and Yoga (BWY) pertaining to the practice of antena-
also a paucity of specialist services to support tal yoga previously specified that women should
women who become unwell during this time (PHE wait until week 16 of pregnancy before practis-
2019). However, media awareness has increased ing yoga, but these now state that there is no
in recent years, and patient support groups such evidence of an increased risk of miscarriage, al-
as APNI (the Association for Post Natal Illness) though women should seek a pregnancy-­specific
and the PANDAS (Pre And postNatal Depression class where possible (BWY 2016). Similarly,
Advice and Support) Foundation have also been the UK National Health Service (NHS) guide-
established to support affected women. lines also do not impose any specific restrictions
Exercise in pregnancy has numerous physical with respect to the first trimester. In addition, the
and psychological benefits for both the mother BWY set out safety guidelines in regard to class
and her unborn child. Maternal benefits docu- content and appropriate asana. Practitioners opt-
mented by the Department of Health and Social ing to set up pregnancy-­specific classes will gen-
Care (DHSC) include a reduction in hypertensive erally have antenatal yoga continuing profession-
disorders, improved cardiovascular fitness, less al development (CPD) qualifications. However,
gestational weight gain and a reduction in the risk the field is poorly regulated, and many teachers
of gestational diabetes (DHSC 2019). The DHSC without specialist training will continue to allow
also reports low-­to-­moderate evidence that exer- pregnant women to join their classes. This can
cise may reduce the risk of depression in preg- have implications for the safety and well-­being
nancy, and includes yoga and Pilates within their of a woman and her unborn child.
list of physical activities that are recommended Previous systematic reviews have investigated
during pregnancy. the benefits of yoga with respect to: the mental
The popularity of yoga is evident: studies have health of women who have been diagnosed with
reported­an increase in the use of complemen- breast cancer (Cramer et al. 2017); mind–body
tary and alternative medicine by almost half of interventions during pregnancy to manage anxi-
all women of reproductive age with hypnosis, ety (Marc et al. 2011); and relaxation therapy for
relaxation and yoga being the most widely prac- preterm labour (Khianman et al. 2012). Overall,
tised examples (Sullivan & McGuiness 2015). these reviews have reported positive results in
With respect to prenatal yoga, there is also a sig- the reduction of stress and anxiety, but highlight-
nificant media influence, with celebrities promot- ed the need for further research. It is possible
ing the positive physical and mental benefits of that yoga could be beneficial for mothers during
regularly practising this form of exercise (Rossi pregnancy, and thus, have a positive impact on
2014). mental health and well-­being.
One of the six orthodox systems of Indian phi- Yoga is thought to influence pathophysiologi-
losophy, this practice stems from the Yoga Sutras, cal processes through a number of mechanisms;
a classical work by a sage known as Patañjali. In for example, by reducing sympathetic over­
his work, he refers to the eight limbs or stages activity and increasing parasympathetic activity
of yoga, four of which include posture, rhythmic (Pilkington et al. 2016). These processes could
control of the breath, concentration and medita- facilitate a reduction in cortisol and, therefore,
tion (Iyengar 2001). Hatha Yoga is the umbrella stress levels, and also boost immune function by
© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy 13
A. Yeboah
increasing immunoglobin A (IgA) and salivary α-­ abstracts, a study that only examined labour
amylase levels. outcomes, and a paper that investigated yoga in
The objectives of the present literature review the management of pregnancy-­ related LBP and
are to explore the evidence to support the claims PGP.
that antenatal yoga can help in the management A number of literature review critique meth-
of adverse psychological outcomes, especially ods were considered, including the Consolidated
stress, anxiety and depression in pregnancy. The Standards of Reporting Trials (CONSORT 2010)
author also aims to draw these studies together in and the Critical Appraisal Skills Programme
order to provide a reference point for both health (CASP) checklists (CASP 2018). Having re-
professionals and other researchers who are in- viewed the CASP criteria, this checklist was
terested in this area of health. chosen because it met the desired standards.
Information extracted from the papers included:
the randomization process and patient analysis;
Materials and methods
blinding of patients and study personnel; analysis
A literature search was conducted four times
of group interventions; treatment effect and local
between October and November 2018, and then
application; and the risk-­to-­benefit ratio of the
rerun in October 2019. The keywords used
intervention. The outcome measures used includ-
in the title and abstract search criteria were
ed: physiological markers, i.e. cortisol, IgA and
“yoga”, “pregnancy”, “antenatal”, “prenatal”,
salivary α-­amylase, tested before, during and/or
“depression”, “anxiety” and “stress”. The terms
following the yoga intervention; and a number
“pregnan*(pregnant)”, “prenatal”, “pre-­natal”,
of self-­reporting questionnaires (see Table 1). All
“ante-­natal” and “antenatal” were linked us-
the selected papers passed the initial screening
ing “OR” to ensure that no terminology was
questions, and therefore, it was deemed appropri-
missed. All Healthcare Databases Advanced
ate to continue with the CASP checklist and sub-
Search (HDAS) databases were incorporated
sequently include these in the literature review.
in the search. These included AMED, BNI,
Figure 1 is a Preferred Reporting Items
CINAHL, Embase, HBE, HMIC, MEDLINE and
for Systematic Reviews and Meta-­Analyses
PsycINFO. Because this is a new area of re-
(PRISMA) flowchart (Moher et al. 2009;
search, only papers written in the past 10 years
PRISMA 2009) illustrating the search strategy,
were included. This also ensured that the present
and the process of selecting and eliminating
literature review was based on current evidence.
studies.
The search criteria were further specified as
follows: randomized controlled trials (RCTs) or
studies of similar quality, full-­text articles writ- Results
ten in English, and yoga intervention to include Of the nine studies included in the present lit-
physical postures in addition to meditation/ erature review, three were conducted in the
pranayama from peer-­reviewed journals. These USA, three in India, and one each in Taiwan,
criteria were especially important in order to Japan and the UK; the sample sizes ranged from
ensure rigour, validity and reliability. The initial 46 (Davis et al. 2015) to 122 (Satyapriya et al.
searches yielded 44 papers, seven of which met the 2009). Six studies recruited women with no cur-
criteria, and the subsequent search yielded eight rent depressive or anxiety disorders (Satyapriya
new papers, but none of these met the inclusion et al. 2009, 2013; Bershadsky et al. 2014;
criteria. Secondary referencing from three litera- Newham et al. 2014; Chen et al. 2017; Hayase
ture reviews identified four further papers with & Shimada 2018). The remainder involved
potential, and two of these were subsequently women who were already suffering from anxi-
included. One of these studies (Rakhshani et al. ety and/or depression (Field et al. 2013; Davis
2012) used alternative keywords in line with the et al. 2015), or were classified as having high-­
high-­risk pregnancy bias of the paper, which ex- risk pregnancies (Rakhshani et al. 2012). The
plains why it was missed in the initial searches. majority of studies did not recruit women until
The search also identified papers that provided they were in their second or early third trimester
useful information and possible topics for further (range = 16–28/40), although one enlisted them at
research, but did not directly meet the search cri- 12–19 weeks’ gestation (Bershadsky et al. 2014),
teria. These included five systematic reviews, a and in the case of Rakhshani et al.’s (2012) re-
trial with a single-­treatment-­group design, a pilot search conducted with high-­ risk pregnancies,
study with a very small study size, conference before 12 weeks. The age of the participants
14 © 2020 Pelvic, Obstetric and Gynaecological Physiotherapy
 Antenatal yoga and adverse psychological outcomes in pregnancy
Table 1. Summary of outcome measures
Outcome measure Abbreviation Description
State-­Trait Anger Expression STAXI Psychological test based on 10 questions that measures the intensity
Inventory of anger in individuals, and their disposition to experience angry
feelings; consists of a four-­point Likert scale ranging from (1)
“almost never” to (4) “almost always”; based on emotional state at a
particular time
State-­Trait Anxiety Inventory STAI Forty questions based on a four-­point Likert scale; measures
anxiety about an event (state anxiety) or anxiety level as a personal
characteristic (trait anxiety); higher scores correlate with higher
anxiety levels up to a maximum score of 30; mothers who score ≥ 13
are likely to be suffering from depressive illness
Positive and Negative Affect PANAS Two, 10-­item scales measuring positive and negative affect; each item
Schedule is measured on a five-­point scale from (1) “not at all” to (5) “very
much”; results are based on symptoms recorded over the past week
Edinburgh Postnatal Depression EPDS Ten-­question self-­rating scale to identify patients at risk of perinatal
Scale depression; results are based on symptoms recorded in the past 7 days
Hospital Anxiety and Depression HADS Used to determine the levels of anxiety and depression that an
Scale individual is experiencing; the 14-­item scale is split between
those relating to either anxiety or depression; results are based on
symptoms recorded over the past week
Center for Epidemiologic Studies CES-­D Twenty questions based on a four-­point Likert scale ranging from (0)
Depression Scale “rarely or none of the time” (< 1 day per week) to (3) “most or all
of the time” (6–7 days per week); results are based on feelings and
behaviour recorded over the past week
International Physical Activity IPAQ Consists of a set of four questionnaires that can be completed by
Questionnaire telephone or self-­administration; used to obtain data on health-­related
physical activity over the past 7 days
Pregnancy Experiences PEQ Addresses pregnancy-­specific stressors and concerns in pregnancy;
Questionnaire consists of 41 questions rated on a three-­point scale, with higher
scores indicating higher stress levels; results based on severity
recorded in the past month
Profile of Mood States POMS Consisting of 12 items on depression; rated on a five-­point scale
ranging from (0) “not at all” to (4) “extremely”
Relationship Questionnaire Consists of 12 items on a four-­point Likert scale; measures positive
(i.e. sense of support and care) and negative aspects of relationships,
including anxiety and irritability
Wijma Delivery Expectancy/ WDEQ Measures the feelings and thoughts that women have at the prospect
Experience Questionnaire of labour and delivery; rated on a scale from 1 to 6, with higher
scores indicating greater fear of childbirth
Structured Clinical Interview SCID Instrument designed to be administered by a mental health
for DSM-­IV professional to diagnose mental health; depending on the type of
patient, assessment time ranges from 30 min to 2 h

was variable (range = 18–45 years). However, Randomization was carried out by reliable and
Rakhshani et al. (2012) recruited women who tested methods, including block randomization
fell within their high-­risk criteria specification using the Clinstat program (St George’s Hospital
of < 20 years or > 35 years. A summary of the Medical School, London, UK) and online random
papers can be found in Table 2. number generators. Control groups were accord-
The interventions researched in the nine papers ingly assigned to either treatment as usual (TAU)
were all exclusively based on yoga. Experienced (Newham et al. 2014; Davis et al. 2015; Chen
teachers led the classes, but a variety of ap- et al. 2017; Hayase & Shimada 2018), standard
proaches were employed. The styles included: prenatal exercises (Satyapriya et al. 2009, 2013;
a generic hatha approach, which was followed Rakhshani et al. 2012) or a leaderless social sup-
in five of the studies, including Newham et al. port group (Field et al. 2013), and no interven-
(2014) and Bershadsky et al. (2014); the integrat- tion (Bershadsky et al. 2014). Treatment as usual
ed approach to yoga therapy (IAYT) (Rakhshani varied from simple stretches (Satyapriya et al.
et al. 2012; Satyapriya et al. 2013); and modified 2013) to standard care and self-­reported conven-
Ashtanga yoga (Davis et al. 2015). All authors tional antenatal exercises, which were described
specified that their chosen style was specifically as walking for a 30-­min period in both the morn-
adapted to the pregnant population, and that in- ing and afternoon (Rakhshani et al. 2012).
formed consent had been obtained from the in- The intervention periods ranged from an 8-­
tervention and control groups. week yoga programme (Newham et al. 2014) to
© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy 15
A. Yeboah

Records identified through Additional records identified

database searches through other sources
(n = 57) (n = 4)

Records left after duplicates removed

(n = 56)

Relevant records Records excluded

screened (n = 27)
(n = 36)

Studies included in critical

analysis
(n = 9)

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-­Analyses

(PRISMA) flowchart demonstrating the literature search strategy (Moher et al.
2009; PRISMA 2009).

from 20 weeks’ gestation until delivery (Hayase (Relationship Questionnaire). These and the re-
& Shimada 2018). Yoga sessions varied in mainder used are described in more detail in
length from 20 min (Field et al. 2013) to 1.5 h Table 1. Four studies measured levels of salivary
(Bershadsky et al. 2014). Additional home prac- cortisol, IgA and salivary α-amylase (Bershadsky
tice was addressed in three papers (Field et al. et al. 2014; Newham et al. 2014; Chen et al.
2013; Davis et al. 2015; Hayase & Shimada 2017; Hayase & Shimada 2018).
2018). This was consolidated by Davis et al. Bershadsky et al. (2014) recruited 38 primipa-
(2015) and Field et al. (2013) through the use rous women (primiparas) who were practising
of a home DVD, although the expectation in yoga during pregnancy from two yoga studios
the latter study appeared to be for women to in California, USA, and a much smaller control
engage in home study only after the interven- group of 11 from an ongoing unrelated study
tion. Satyapriya et al. (2009, 2013) used home of perinatal depression. These authors acknowl-
practice as part of their intervention, and relied edged that this small sample size may have lim-
on telephone calls and an activity diary to en- ited the statistical power to establish differences
sure compliance. Bershadsky et al. (2014) were between the two groups. Furthermore, the high
the only authors who used follow-­up assessment attrition rate in this paper, on which the authors
for up to 2 months into the postnatal period. did not comment, may have affected the validity
The remainder of the studies were limited to of the study. Assessments measuring cortisol lev-
the pregnancy period only. The locations of the els, affect and depressive symptoms were carried
interventions were primarily hospital-­ based set- out in early and mid-­pregnancy, and < 2 months
tings, although Newham et al. (2014) held their postpartum, before and after a 90-­min yoga ses-
classes in a Sure Start centre, and Bershadsky sion. The participants in the control group were
et al. (2014) ran their classes in a yoga studio. younger and less educated, had a lower income
Two papers did not specify the location of the in- and were less likely to be white, but exhibited
tervention (Field et al. 2013; Davis et al. 2015). no difference in their symptoms of depression or
The majority of studies used self-­reported psy- affect at the onset of the study. Bershadsky et al.
chological outcome measures, including those (2014) showed lower mean salivary cortisol lev-
specific to anxiety [State-­Trait Anxiety Inventory els on yoga days (P < 0.01), but no change in
(STAI) assessing state (STAI-­State) and trait levels over time. Insufficient saliva samples were
(STAI-­Trait)], depression [Edinburgh Postnatal available to test differences between the groups.
Depression Scale (EPDS)] and relationships The yoga group also showed a greater immediate
16 © 2020 Pelvic, Obstetric and Gynaecological Physiotherapy
 Table 2. Characteristics of the studies included in the literature review: (RCT) randomized controlled trial; (PIH) pregnancy-­induced hypertension; (GDM) gestational diabetes mellitus;
(IUGR) intrauterine growth restriction; (SGA) small for gestational age; (CES-­D) Center for Epidemiologic Studies Depression Scale; (STAI) State-­Trait Anxiety Inventory; (STAXI)
State-­Trait Anger Expression Inventory; (PEQ) Pregnancy Experiences Questionnaire; (HADS) Hospital Anxiety and Depression Scale; (IAYT) integrated approach to yoga therapy; (TAU)
treatment as usual; (HCP) healthcare professional; (EPDS) Edinburgh Postnatal Depression Scale; (STAI-­State) STAI state subscale; (STAI-­Trait) STAI trait subscale; and (IgA) immuno-
globulin A
Reference Location Study design Sample Outcome measures Results Conclusion/recommendations
Satyapriya et al. Bengaluru, RCT 122 healthy women Parasympathetic and Parasympathetic tone Yoga reduces perceived
(2009) India Yoga and deep relaxation recruited between weeks sympathetic tone and sympathetic tone stress and improves adaptive
or standard prenatal 18/40 and 20/40 at increased and decreased, autonomic response to stress
exercises for 1 h per day prenatal clinics respectively, following in healthy pregnant women
guided relaxation
(P < 0.001)
Rakhshani et al. Bengaluru, RCT 68 high-­risk women PIH, GDM, IUGR, SGA Significantly fewer Yoga can potentially be
(2012) India 1 h of yoga three times and newborns with low cases of all conditions an effective therapy for
a week from week 12/40 Apgar scores measured reducing the hypertensive-­

© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy

to 28/40 related complications of
pregnancy and improving
foetal outcomes
Field et al. Miami, FL, RCT 92 women with prenatal CES-­D, STAI, STAXI Lower CES-­D, STAI Yoga may be an effective
(2013) USA 12 weeks of 20-­min yoga depression from two and relationship scores; and STAXI scores, and intervention for reducing
sessions or leaderless prenatal ultrasound clinics cortisol, oestriol and improved relationship depression and anxiety;
social support group at a large university progesterone levels scores; cortisol decreased further research is needed
medical centre after each session, to look at the effect on
oestriol and progesterone rates of prematurity and low
levels decreased after birthweight, as well as any
the last; anxiety and long-­term effects
depression lower for both
groups at postpartum
follow-­up
Satyapriya et al. Bengaluru, RCT 96 primiparas or PEQ, STAI and HADS Anxiety and depression Yoga reduces anxiety,
(2013) India 16 weeks of the IAYT multiparas recruited at significantly reduced depression and pregnancy-­
and control group week 20/40 following intervention related uncomfortable
practising simple both between and within experiences
stretching exercises groups
Bershadsky et al. CA, USA Yoga group and control 38 primiparas recruited Cortisol levels, affect and Greater immediate Prenatal yoga may improve
(2014) group (not randomized) from two yoga studios depressive symptoms improvement in current mood, and may
90-­min yoga session contentment and negative be effective in reducing
effect (P < 0.05); few postpartum depressive
signs of postnatal symptoms
depression a few months
postpartum (P < 0.05)
Continued/

17
Antenatal yoga and adverse psychological outcomes in pregnancy
18
A. Yeboah

Table 2. (Continued)
Reference Location Study design Sample Outcome measures Results Conclusion/recommendations
Newham et al. Manchester, RCT 59 primiparas between Questionnaire assessing Lowered state anxiety Antenatal yoga seems to be
(2014) UK 8 weeks of prenatal hatha weeks 20/40 and 24/40 state, trait, pregnancy-­ and cortisol levels after a useful for reducing women’s
yoga, sessions adopted specific anxiety and single session anxieties about childbirth,
a themed approach; depression; stress and preventing increases in
women in the TAU group hormone assessments depressive symptoms
could make their own
arrangements, if desired
Davis et al. CO, USA RCT 46 primiparas and EPDS, and STAI-­State Antenatal yoga feasible, Antenatal yoga is feasible,
(2015) 8-­week yoga intervention multiparas via HCP and STAI-­Trait but the reduction in but the reduction in anxiety
or TAU referral and community negative effect was the and depression is less
advertisement only significant difference robust than the reduction in
between groups; the negative effect
reduction in anxiety
and depression was less
robust
Chen et al. Taipei, Longitudinal, prospective 94 primiparas and Salivary cortisol and IgA Short-­term reductions Prenatal yoga significantly
(2017) Taiwan RCT multiparas from a levels collected at 16, 20, in salivary cortisol and reduced pregnant women’s
Two, weekly yoga prenatal clinic at 24, 28, 32 and 36 weeks IgA levels, but long-­term stress and enhanced their
sessions of 70 min 16 weeks’ gestation effects on IgA only immune function
between weeks 16/40 and
36/40, or routine prenatal
care
Hayase & Shimada Osaka, Prospective longitudinal 38 women in a yoga Heart rate variability, Positive correlation Practicing yoga activates
(2018) Japan study group and 53 in a control salivary α-amylase and between the number the parasympathetic nervous
60-­min yoga sessions group; the yoga group night-­time sleep duration of classes attended and system during the third
with advice to perform attended maternity classes night-­time sleep duration trimester of pregnancy,
15 min of daily yoga between weeks 20/40 and (P < 0.05) consolidating sleep during
practice 23/40 the night and decreasing
α-amylase levels, which
indicates a reduction in stress

© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy

 Antenatal yoga and adverse psychological outcomes in pregnancy
improvement in contentment and negative effect group attrition were not specified, although it
(P < 0.05), and fewer signs of postnatal depres- could be speculated that this was a result of their
sion (P < 0.05) a few months postpartum. participation in yoga elsewhere.
Chen et al. (2017) recruited a larger cohort of Satyapriya et al. (2013) recruited 96 women
94 primiparous and multiparous women from a aged between 20 and 35 years with at least one
prenatal clinic at 16 weeks’ gestation. The par- living child at 20 weeks of normal pregnancy in
ticipants were assigned by block randomization order to examine the effect of the IAYT on anxi-
to: a control group (routine prenatal care); or ety, depression and well-­being. The intervention
two, 70-­ min sessions of yoga a week between period was 16 weeks, and incorporated poses
16-­ and 36-­weeks’ gestation, and had to attend taught in small groups for 2 h a day, 3 days a
85% of the total number offered. This study had week for a month, then 1 h a day independ-
a low attrition rate, and the authors specified that ent practice consolidated with refresher classes.
those who left cited migration or medical rea- In contrast, the control group practised simple
sons. Sessions were taught by a former midwife stretching exercises. Significantly, three women
who had trained as a yoga instructor, and the from the control group moved to the antenatal
hatha-­style class was designed for women in the yoga group, leading to dropouts within the study,
second and third trimesters. The outcomes meas- and this was acknowledged by Satyapriya et al.
ured were effects on salivary cortisol and IgA (2013) as a limitation. The assessment tools used
levels, which were collected at 16, 20, 24, 28, 32 were the Pregnancy Experiences Questionnaire
and 36 weeks’ gestation. Participant groups did (PEQ), the STAI-­State, the STAI-­Trait and the
not differ significantly, but the gestational age Hospital Anxiety and Depression Scale (HADS),
was greater and infant birth weight larger in the which demonstrated that anxiety and depression
yoga group (P < 0.001). A short-­term reduction in were significantly reduced following interven-
salivary cortisol (P < 0.001) and increases in IgA tion both between groups (Mann–Whitney U-­test
levels (P < 0.001) were noted after yoga practice, P < 0.001) and within groups (Wilcoxon signed-
but there were only long-­term effects on IgA lev- rank test P < 0.001).
els (P = 0.018), potentially indicating short-­term Another paper by Satyapriya et al. (2009) with
decreases in stress and long-­term improvements a similar intervention to the above study exam-
in immune function. ined the efficacy of the IAYT on perceived stress
The study by Newham et al. (2014) involved and heart rate variability. A combination of phys-
59 primiparas who were > 18 years of age. The ical postures and breathing techniques was spe-
participants were recruited at their ultra­ sound cifically developed for healthy pregnant women.
scan between weeks 20 and 24 of gestation. They The authors concluded that the IAYT reduces
were randomly assigned to 8 weeks of prenatal perceived stress more than standard prenatal ex-
hatha yoga classes taught by a BWY-­accredited ercises by 18–20 weeks’ gestation, and found
antenatal teacher, or TAU. The yoga sessions that parasympathetic and sympathetic tone were
adopted a themed approach, and included infor- increased and decreased, respectively, following
mation about the common ailments of pregnancy, guided relaxation (P < 0.001). Satyapriya et al.
optimal foetal positioning, the different stages of (2009) did not appear to address the difference in
labour and pelvic floor muscle exercises. Newham contact between the two groups, or take into ac-
et al. (2014) specified that women in the TAU count the fact that an increase in this could have
group could make their own arrangement to par- influenced the treatment effect. Furthermore, the
ticipate in alternative yoga groups if desired, and study did have a high attrition rate of > 20% in
27% did this. Further detail with respect to TAU both the yoga and control groups.
was not specified. Mood profiles did not differ Hayase & Shimada (2018) recruited: 38 pri-
between the groups at baseline. A questionnaire miparas and multiparas, who were attending ma-
assessing state, trait and pregnancy-­specific anxi- ternity yoga classes at a Japanese hospital be-
ety and depression, and stress hormone assess- tween 20 and 23 weeks’ gestation; and a matched
ments were completed at the first and last ses- control group of 53, who received no interven-
sions of the course. The outcomes demonstrated tion. The intervention involved a weekly 60-­min
lowered state anxiety and cortisol levels after a yoga session, and advice to perform 15 min of
single session, and a consistent effect over time. daily yoga practice. The outcomes evaluated at
Two women dropped out of the yoga group in 20–23, 28–31 and 36–40 weeks’ gestation were
comparison to six who withdrew from the control heart rate variability and salivary α-­amylase. The
group. The reasons for the relatively high control authors found significant outcomes with respect
© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy 19
A. Yeboah
to parasympathetic nervous system activation in the participants should follow the DVD at home
the group practising yoga, and a positive correla- at the end of the study, there appeared to be no
tion between the number of classes attended and expectation that they should do this during the
night-­time sleep (P < 0.05). Hayase & Shimada course of the study. The authors did not address
(2018) acknowledged that the small sample size the possibility that group intervention could also
was a limitation of their study. The fact that they have been a factor in the positive mental health
did not address attrition is also an issue. outcomes in the control group. Work commit-
In contrast to the previous studies, which in- ments were cited as the primary reason for the
cluded normal pregnancies among the inclusion significant dropout rate in both yoga and social
criteria, Rakhshani et al. (2012) recruited 68 support groups.
high-­risk primiparas and multiparas within the The last study to involve women who were
first 12 weeks of gestation, and investigated the already depressed and anxious was Davis et al.
effects of yoga in the prevention of pregnancy (2015), who assigned participants to either an 8-­
complications. Their inclusion criteria included a week yoga intervention or TAU. These authors
history of poor obstetric outcomes and a body used a score of ≥ 9 on the EPDS, ≥ 25 on the
mass index of > 30. The intervention group at- STAI-­State and ≥ 35 on the STAI-­Trait as a di-
tended a total of 28 sessions based on the IAYT agnosis of depression/anxiety. The authors based
used by Satyapriya et al. (2009, 2013) between their intervention on the traditional Ashtanga
13 and 28 weeks’ gestation, and the control group vinyasa system, and provided an antenatal yoga
received standard care plus additional walking instructional video for home practice. The two
in the morning and afternoon. The attrition rate groups had similar baseline demographic and
was significant in both groups, but more so in clinical characteristics, and included primiparas
the yoga group (35%), largely because some and multiparas. As was the case in the other
participants moved away. This could have in- studies, the TAU group lost four of the 23 par-
fluenced the outcomes, but was not cited by the ticipants to follow-­up as a result of these wom-
authors as a limitation of the study. Rakhshani en pursuing regular yoga practice. Davis et al.
et al. (2012) attributed the lower attrition rate in (2015) concluded that antenatal yoga was a
the control group to the fact that women who viable intervention, but acknowledged that the
had moved out of the area could continue to evidence for yoga in the reduction of anxiety and
walk, whereas yoga participants could no long- depression was less robust because the only sig-
er attend the class. Positive outcomes of the nificant difference between the groups was with
study for mothers and babies included decreased regard to the reduction in negative affect.
incidences of hypertension (P = 0.018), pre-­
eclampsia (P = 0.042), gestational diabetes melli-
tus (P = 0.049) and intrauterine growth restriction Discussion
(P = 0.05). The papers identified in the present literature
Field et al. (2013) conducted a study that in- search that met the eligibility criteria were pre-
volved 46 women who met the diagnostic cri- dominantly undertaken in North America and
teria for depression on the Structured Clinical Asia, and only one UK study was included.
Interview for DSM-­IV (SCID). On average, the Although the pool of research was limited, most
participants were recruited from two ultrasound notably in the UK, it is certain that yoga, in-
clinics at 22 weeks’ gestation. The authors did cluding prenatal yoga, has seen a growth in
not specify whether the population group con- popularity in the Western world in recent years.
sisted of primiparas or multiparas. They exam- One study reported that practice in the USA
ined yoga and social support, and found that the has nearly doubled over a 4-­year period (YJYA
yoga group demonstrated decreased depression, 2016). Therefore, it is likely that there will be
anxiety, anger, and back and leg pain after each a trend towards further research, which is dem-
session, in contrast to those receiving social sup- onstrated by the fact that all but one of these
port. However, both groups showed significant papers were published after 2011.
changes with respect to depression, anxiety, anger As discussed in the introduction, the teachings
and relationship outcomes across the period of of Patañjali stress the importance of the eight
treatment. The 12-­week intervention period con- stages that must be achieved in order to embrace
sisted of 20-­min sessions involving basic poses, the philosophy and way of life of yoga. Although
which Field et al. (2013) employed in order to many Westerners commit to regular yoga prac-
increase compliance. Although they specified that tice, they do not necessarily follow or indeed
20 © 2020 Pelvic, Obstetric and Gynaecological Physiotherapy
 Antenatal yoga and adverse psychological outcomes in pregnancy
know much about this philosophy. Because of its of home practice in the studies by Satyapriya
strong connections with Hinduism, yoga has been et al. (2009, 2013), Davis et al. (2015) and
known to alienate some religious groups, includ- Hayase & Shimada (2018) would have been less
ing Muslims, Christians and Jews, and demonic reliable, and potentially affected both the internal
inferences have been made by prominent religious and external validity of associated papers. This
figures (Jones 2018). This issue was addressed also brings into question the ethics of discourag-
by Rakhshani et al. (2012), who identified some ing women from engaging in physical exercise,
initial reluctance to practising yoga expressed an activity that can have significant health ben-
by Muslims and Christians in their study group. efits in pregnancy. This issue was addressed in
Although they reported that this did not influence the study by Newham et al. (2014), who allowed
retention, it may have influenced the level of ini- women in their control group to practice yoga,
tial interest in the project. However, the other but requested that they document their exercise
studies did not discuss this limitation, which may regime. Unfortunately, as these authors acknowl-
have affected recruitment and retention. edged, this would have influenced the fidelity of
The papers differed significantly with respect the comparison groups, and consequently, the
to the interventions involved. Overall, those stud- internal validity of their reporting. The control
ies carried out in Asia favoured a more labour-­ group interventions also varied significantly in
intensive approach, and therefore, required more other papers. Whereas Bershadsky et al. (2014)
commitment on the part of the students than their specifically used a control group who were not
Western counterparts. This is probably because practising prenatal yoga or relaxation, Satyapriya
the practice has long been embedded in Asian et al. (2009, 2013) allowed simple stretching
culture. The contrast can be seen when the 20-­ exercises and standard prenatal workouts, and
min yoga sessions taught by Field et al. (2013) Rakhshani et al. (2012) included a 30-­min walk
over a 12-­week period are compared to the inte- in the morning and afternoon in their programme.
grated yoga approach of Satyapriya et al. (2009, Once again, these interventions may have influ-
2013), who advocated 1 h of daily practice over enced internal validity. It is also significant that
a 16-­week period. the yoga groups in the Bershadsky et al. (2014)
There was some variation in the styles of yoga and Hayase & Shimada (2018) papers were re-
reported in the papers. The hatha and IAYT styles cruited from women currently practising yoga:
taught in the majority of studies shared similari- these groups may have been biased as a result
ties in the outlines of the classes described, and of existing expectations about the benefits of
were all adapted for the pregnant population. yoga. Direct comparisons were not possible be-
However, Davis et al. (2015) favoured a tradi- cause of differences in the outcome measures
tional Ashtanga style that, although modified used.
for pregnancy, is usually a more flowing, ener- One significant difference between the studies
getic practice. This choice of a more vigorous was that six involved women who were experi-
approach is somewhat surprising considering encing a “normal pregnancy”, and four studied
the high-­risk population recruited to this study. participants with existing depression and anxi-
However, the group did enjoy a reduction in neg- ety, or high-­risk pregnancies. It is interesting
ative effects, although these were not as signifi- that Rakhshani et al. (2012) recruited women
cant as those seen in other studies. Davis et al. prior to the 12 weeks’ gestation mark, when risk
(2015) also addressed the possibility of medical of miscarriage is still high and anxiety levels
complications. However, only one was noted, may have been especially heightened. This may
and this was reported by the participant as being have influenced the extent to which the partici-
linked to potential infection and not the interven- pants responded to a yoga intervention. It could
tion itself. It should be noted that the themes ad- be hypothesized that women with no depressive
dressed by Newham et al. (2014) in the classes or anxiety symptoms are better placed to com-
that they taught in addition to yoga practice may mit to regular yoga classes, and therefore, may
have increased the self-­efficacy of the women, achieve better outcomes. However, the problems
thereby influencing their results. However, it is experienced by the participants with existing de-
likely that elements of these themes may have pressive symptoms, and those who fell into the
been addressed in other classes without a specific high-­risk category, may have made them more
structure. motivated to engage with a potentially benefi-
The classes described in the studies could be cial intervention. Alternatively, low mood may
closely monitored. In contrast, the self-­reporting have been a factor in dropout rates as a result of
© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy 21
A. Yeboah
demotivation brought about by depression. Both a number of participants dropping out of the
groups achieved statistically significant outcomes, control groups in two studies, and commenc-
leading Rakhshani et al. (2012) to conclude that ing a yoga programme (Rakhshani et al. 2012;
yoga is beneficial for both populations. Satyapriya et al. 2013). Previous yoga experience
Financial incentives were paid to partici- would also have influenced participants’ motiva-
pants in three of the studies (Field et al. 2013; tion and expectations of the intervention.
Bershadsky et al. 2014; Davis et al. 2015). Rakhshani et al. (2012) specifically investi-
Women may face significant financial burdens in gated the feasibility of implementing a yoga in-
the ante-­and postnatal periods, and this incen- tervention in a hospital setting. They determined
tive could have contributed to lower stress levels that this is a suitable environment with regard
than those who were self-­funding. This may have to the ease with which: the research staff car-
made the participants in these studies not only ried out the intervention; and the class responded
more motivated, but also likely to respond more to the exercises taught. Although this issue was
favourably to the intervention, which could have not specifically addressed in the other studies, no
affected both the internal and external validity of significant implementation issues were reported.
these papers. The only shortcoming mentioned was the inter-
Psychological outcome was the predominant action between groups, which may have contrib-
method of assessment used within the papers. uted to the desire for non-­yoga groups to cross
The most commonly cited outcomes in five out of over to the intervention group (Rakhshani et al.
nine studies were the STAI-­State and STAI-­Trait 2012; Satyapriya et al. 2013).
scales. Otherwise, there was significant variation One finding that all the studies had in common
in terms of the outcome measures used includ- was that no adverse safety issues came about as
ing the Positive and Negative Affect Schedule, a result of the interventions. This is supported
SCID, PEQ, and HADS. Because the outcome by literature reviews by Gong et al. (2015) and
measures employed varied so significantly, it was Sheffield & Woods-­Giscombé (2016), and also
not possible to make a direct comparison of the by Polis et al. (2015), who examined foetal re-
results obtained, and this makes the development sponses to 26 yoga postures and reported no
of a coherent picture of the efficacy of yoga in negative outcomes.
the studies reviewed challenging.
The four papers that investigated physiologi-
cal markers with saliva samples had to rely on Limitations
participants adhering to the rather rigid pre-­ The present literature search was limited to
collection instructions, which included avoiding the HDAS and subsequent secondary refer-
alcohol for 24 h, and not eating, brushing teeth encing. It must be acknowledged that a more-
or consuming caffeine products within 2 h of sa- comprehensive search that included grey lit-
liva collection. Adherence to these instructions erature (e.g. conference presentations and yoga
could certainly potentially affect the internal va- journals) might have brought to light additional
lidity of these studies. All four found that the interesting and relevant studies. Since the field
intervention groups had significantly lower lev- of yoga is a developing area, it is also possi-
els of cortisol, the primary stress hormone, and ble that new research could have been published
salivary α-amylase after practising yoga. Chen in the time that elapsed since the last search in
et al. (2017) also reported higher levels of the October 2019.
antibody blood protein IgA (P < 0.001). With respect to the study interventions, dif-
With respect to internal validity, it was not pos- ferences in the style of yoga, duration of in-
sible to blind either the participants or the thera- put, intensity of practice and location of the
pists because of the nature of the intervention. intervention may have influenced the outcomes.
However, the majority of studies specified that Similarly, population groups varied with respect
their assessor was blinded. The exceptions were to their obstetric history, demographics and so-
Bershadsky et al. (2014) and Davis et al. (2015), cioeconomic background. However, despite these
who did not address this issue. Perhaps influ- significant differences, the implementation of the
enced by media promoting the positive effects yoga practice itself, as opposed to the specific
of yoga, intervention expectations may have in- content, appeared to be the most significant fac-
creased the likelihood of women already feeling tor since positive outcomes were reported in all
more positive at the beginning of a programme. the papers reviewed. Baseline levels of anxi-
Furthermore, this may also have contributed to ety and depression also differed significantly,
22 © 2020 Pelvic, Obstetric and Gynaecological Physiotherapy
 Antenatal yoga and adverse psychological outcomes in pregnancy
ranging from no history or current symptoms of managing anxiety, stress and depression in preg-
anxiety to having an existing diagnosis, which nancy, but the interventions, population groups
confounded the results once again. A further and outcome measures used in the nine papers
limitation within those studies involving women were too variable to allow any strong conclu-
with existing depression was that different diag- sions to be drawn. This supports the findings
nostic criteria for depression were used. of other authors (Marc et al. 2011; Gong et al.
Methodological shortcomings were also identi- 2015; Sheffield & Woods-­Giscombé 2016; Joly
fied, particularly with respect to the small sam- 2017), who have concluded that, although the
ple sizes, which meant that the groups may not initial results in this area of research are prom-
have been large enough to achieve statistical sig- ising, there is a need for further research.
nificance. The recruitment process was biased in Some additional benefits of yoga have been
several studies, notably those in which the par- established by current studies. Joly (2017) re-
ticipants were pooled from those already prac- ported an increase in optimism and self-­efficacy,
tising yoga (Bershadsky et al. 2014; Hayase & but acknowledged the need for further research
Shimada 2018). Another major limitation was the into types of yoga and level of input. Kinser
inability to apply a double-­blind design, which is et al. (2017) investigated yoga-­ based approach-
the ideal standard for an experiment (Polgar & es for LBP and PGP, and demonstrated positive
Thomas 2013). outcomes in addition to positive effects on de-
The outcome measures used were mainly fo- pression, stress and anxiety, findings that were
cused on self-­reporting, which very much relies also supported by Field et al. (2013). Low back
on factors such as honesty, current mood, intro- pain and PGP are associated with sick days, and
spective ability and comprehension. Whereas the impose a financial burden on those affected.
STAI-­State and STAI-­Trait require information Therefore, it can be hypothesized that choosing
based on the subject’s present mood, the ma- an activity that can address both these issues
jority of measures employed involve responses might be particularly effective. Future studies
based on the preceding week, and are based on should also address the cause-­and-­effect relation-
an average score rather than a snapshot repre- ship between stress and anxiety and MSK issues
sentation, which may have given a different per- in pregnancy, and subsequent management with
spective. The physiological markers that were a yoga intervention. This type of intervention
reported in a minority of studies had the advan- would also demand that yoga instructors receive
tage of providing objective measurements, and it specialist training in order that they could modi-
will be important to continue such evaluations in fy poses, and give appropriate advice to women
subsequent studies and combine these with self-­ with MSK complaints in their classes.
reported outcomes. However, the disadvantage The literature search undertaken for the pre-
of the outcome measures, was that these relied sent study revealed only one RCT undertaken in
on patient compliance with pre-­sample collection the UK. The remainder were conducted on dif-
guidelines. ferent continents, and the consequent cultural
It is possible that the control group was in- differences compromise any attempt at making a
fluenced by the benefits of yoga promoted in direct comparison. The analysis was made more
media coverage, and governmental and antenatal difficult by the lack of homogeneity among the
clinic recommendations. The ethics of restricting papers critiqued, and factors such as inclusion
access within the pregnant population to such a criteria, sociodemographic status, psychological
potentially beneficial mode of exercise should profile and the intervention itself all affect the
also be considered. internal and external validity of the research.
In order to establish a reliable body of evi-
dence, large multicentre studies are needed that
Conclusion and implications for further involve highly trained yoga teachers carrying out
research comparable interventions. These should employ
Public awareness of perinatal mental health has the same outcome measures, and the control
increased in recent years, leading to better di- groups should have a similar level of contact to
agnosis and treatment pathways for women the participants who take part in the interven-
suffering from anxiety and depression in preg- tion. This calls for more collaborative working
nancy and the postpartum period (NICE 2014). with yoga centres and hospital settings keen to
The present literature review demonstrates that carry out further research. It is also important
antenatal yoga may be an effective method of that yoga governing bodies and teacher training
© 2020 Pelvic, Obstetric and Gynaecological Physiotherapy 23
A. Yeboah
centres work together in order to standardize the Bershadsky S., Trumpfheller L., Kimble H. B., Pipaloff D.
teaching of antenatal yoga. & Yim I. S. (2014) The effect of prenatal Hatha yoga on
affect, cortisol and depressive symptoms. Complementary
The settings chosen for the interventions var-
Therapies in Clinical Practice 20 (2), 106–113.
ied between the studies, but the majority were British Wheel of Yoga (BWY) (2016) BWY Guidelines
carried out in a hospital environment. This can for Teaching Yoga in Pregnancy. [WWW document.]
facilitate recruitment, referral and multidiscipli- URL https://www.bwy.org.uk/pdf/1474017548BWY%20
nary team involvement if required. However, Guidelines%20for%20Teaching%20Yoga%20in%20
Pregnancy.pdf
some women may feel that this is medicalizing
Chen P.-­J., Yang L., Chou C.-­C., et al. (2017) Effects of pre-
the intervention, and therefore, there is also an natal yoga on women’s stress and immune function across
argument for conducting classes in community pregnancy: a randomized controlled trial. Complementary
settings, which could include antenatal centres in Therapies in Medicine 31 (April), 109–117.
the community. With the significant financial bur- Consolidated Standards of Reporting Trials (CONSORT)
den that the NHS is currently facing, it is difficult (2010) CONSORT 10 Checklist of Information to Include
When Reporting a Randomised Trial. [WWW document.]
to implement services that will eat into hospital URL http://www.ijo.in/documents/01CONSORT_SS.pdf
budgets. However, perinatal mental health prob- Cramer H., Lauche R., Klose P., et al. (2017) Yoga for
lems cost the UK £8.1 billion each year (Bavetta improving health-­related quality of life, mental health
et al. 2014), and therefore, effective preventative and cancer-­related symptoms in women diagnosed with
measures are crucial. Consequently, it is impor- breast cancer. Cochrane Database of Systematic Reviews,
Issue 1. Art. No.: CD010802. DOI: 10.1002/14651858.
tant that we are able to provide sufficient high-­
CD010802.pub2.
quality evidence to justify interventions. Lastly, Critical Appraisal Skills Programme (CASP) (2018) CASP
the postnatal period is a particularly important Randomised Controlled Trial Checklist. [WWW document.]
time for new mothers because this is when they URL https://casp-­uk.net/wp-­content/uploads/2018/01/CASP-­
forge lasting bonds with their babies. We should Randomised-­Controlled-­Trial-­Checklist-­2018.pdf
all strive to make this period as stress-­ free as Davis K., Goodman S. H., Leiferman J., Taylor M. &
Dimidjian S. (2015) A randomized controlled trial of
possible, and thereby, minimize the risk of post- yoga for pregnant women with symptoms of depres-
natal depression. Therefore, it is important that sion and anxiety. Complementary Therapies in Clinical
studies investigate the effect of antenatal yoga Practice 21 (3), 166–172.
in the postnatal period in order to justify further Department of Health and Social Care (DHSC) (2019)
intervention. Physical Activity for Pregnant Women. [WWW docu-
ment.] URL https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/
Acknowledgements file/829894/5-­physical-­activity-­for-­pregnant-­women.pdf
Dinsmore-­Tuli U. (2010) Yoga for Pregnancy and Birth.
I would like to acknowledge Dr Nikki Fairchild,
Hodder Education, London.
my supervisor during my studies at the Field T., Diego M., Delgado J. & Medina L. (2013) Yoga
University of Chichester, Chichester, UK. She is and social support reduce prenatal depression, anxi-
a senior lecturer at the School of Education and ety and cortisol. Journal of Bodywork and Movement
Sociology, University of Portsmouth, Portsmouth, Therapies 17 (4), 397–403.
Glover V. (2016) A Stressful Pregnancy Matters – It Can
UK. Her research interests include exploring
Affect a Baby’s Genes. [WWW document.] URL https://
classroom practices in early childhood educa- life.spectator.co.uk/articles/a-­stressful-­pregnancy-­matters-­
tion and care, and developing and extending en- it-­can-­change-­a-­babys-­genes/
gagement with qualitative research methodolo- Gong H., Ni C., Shen X., Wu T. & Jiang C. (2015)
gies and methods. Nikki supports and mentors Yoga for prenatal depression: a systematic review and
postgraduate students who create publications meta-­analysis. BMC Psychiatry 15: 14. DOI: 10.1186/
s12888-­015-­0393-­1
and conference presentations in their chosen Hayase M. & Shimada M. (2018) Effects of maternity
fields. yoga on the autonomic nervous system during pregnan-
cy. The Journal of Obstetrics and Gynaecology Research
44 (10), 1887–1895.
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Westwood M. (2014) Effects of antenatal yoga on ma- Andrea Yeboah is a pelvic, obstetric and gy-
ternal anxiety and depression: a randomized controlled
naecological physiotherapist. She began her
trial. Depression and Anxiety 31 (8), 631–640.
Pilkington K., Gerbarg P. L. & Brown R. P. (2016) Yoga career at St Mary’s Hospital in London, and
therapy for anxiety. In: The Principles and Practice of subsequently worked for 7 years in a num-
Yoga in Health Care (eds S. B. S. Khalsa, L. Cohen, T. ber of London NHS and private hospitals be-
McCall & S. Telles), pp. 95–113. Handspring Publishing, fore moving to Western Sussex Hospitals NHS
Edinburgh. Foundation Trust. Andrea was awarded the
Polgar S. & Thomas S. A. (2013) Introduction to Research
in the Social Sciences, 6th edn. Churchill Livingstone,
University of Bradford Postgraduate Certificate
Edinburgh. in Physiotherapy in Women’s Health in 2008,
Polis R. L., Gussman D. & Kuo Y.-­H. (2015) Yoga in and completed her pregnancy yoga teacher train-
pregnancy: an examination of maternal and fetal re- ing in 2010. This literature review was written
sponses to 26 yoga postures. Obstetrics and Gynecology as part of the Writing for Publication module
126 (6), 1237–1241.
at the University of Chichester in 2018–2019.
Preferred Reporting Items for Systematic Reviews and
Meta-­Analyses (PRISMA) (2009) PRISMA Flow Andrea is continuing her research into antenatal
Diagram. [WWW document.] URL http://www.prisma-­ yoga as part of a 1-­ year clinical improvement
statement.org/PRISMAStatement/FlowDiagram.aspx scholarship at Worthing Hospital, where she is
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