EUROX 19 (2023) 100214

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology: X
journal homepage: www.journals.elsevier.com/european-journal-of-obstetrics-and-gynecology-and-
reproductive-biology

Effectiveness of antenatal yoga in reducing intensity of labour pain: A

systematic review and meta-analysis
Deenadayalan Boopalan a, Venugopal Vijayakumar b, Poornima Ravi c,
Poonguzhali shanmugam d, Bincy Kunjumon e, Maheshkumar Kuppusamy f, *
a
Senior Research Fellow, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
b
Department of Yoga, Govt. Yoga & Naturopathy Medical College & Hospital, The Tamilnadu Dr. MGR Medical University, Chennai, India
c
Senior Research Fellow, Sri Ramachandra Institute of Higher Education and Research. Chennai, India
d
Department of Community medicine, Govt. Yoga & Naturopathy Medical College & Hospital, The Tamilnadu Dr. MGR Medical University, Chennai, India
e
Department of Community Medicine, SRM Medical College Hospital and Research Centre, SRMIST, Chennai, India
f
Department of Physiology, Govt. Yoga & Naturopathy Medical College & Hospital, The Tamilnadu Dr. MGR Medical University, Chennai, India

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

Keywords: Background: Yoga during pregnancy was found to be beneficial in various aspects of pregnancy including pain
Yoga management during the time of labour. The current systematic review and meta-analysis aims to assess the
Antenatal yoga effectiveness of antenatal yoga practices in reducing pain during the time of labour.
Delivery outcome
Methods: We searched electronic databases such as PubMed, Embase, Cochrane Library, and Web of Science, till
Pain
Meta-analysis
January 2023. Randomized controlled trials (RCTs) which measured the effects of antenatal yoga practices on
pain management during labour were included. The main outcome was the pain intensity measured with any
validated questionnaire. The methodological quality of included studies was evaluated by using a risk-of-bias
assessment tool developed by the Cochrane Collaboration. For the effect size, standardized mean differences
(SMDs) with a 95% confidence interval (CI) were generated with a random effect model using R software
(version 4.2.2).
Results: Eight studies including 576 antenatal women between the age of 14 and 40 years were included. Results
of this meta-analysis showed that yoga is effective in reducing labour pain (SMD: − 1.34 95% of CI: − 1.86,
− 0.81) with significant heterogeneity among the studies (I2 73%, p < 0.0008).
Conclusion: Antenatal yoga can be a promising intervention in the field of obstetrics to reduce the intensity of
labour pain. However, we are still in need of RCT with a large sample size to confirm the reliability of the present
meta-analysis.

Background delivery of placenta and recovery (1–4 h postpartum). Pain originates

from different sites during labour which includes uterine contraction,
Labour is a normal physiological process of delivering a baby to the dilatation of the cervix and stretching of pelvic floor muscles. Pain
external world and the pain experienced by the women during labour experienced by women during labour is influenced by maternal position,
and childbirth is a complex phenomenon [1]. Pain is a unique individual anxiety, fear, stress, pain tolerance, and social support [4]. Several
experience, and the pain experienced by women varies widely pharmacological and non-pharmacological interventions were used
depending upon the sensory and affective perception [2]. Labour pain is effectively to manage pain in labour. Pharmacological management for
a combination of unpleasant sensory, perceptual, and emotional expe­ labour pain involves the usage of opioid drug, epidural, inhaling anal­
riences which is associated with autonomic, physiological, emotional, gesic and combined spinal epidurals. However, pharmacological in­
and behavioural responses [3]. Labour usually involves three stages, terventions are associated with adverse effects such as nausea, vomiting
namely, effacement and dilatation of the cervix, delivery of baby, and and dizziness. At times, it may also lead to incidences of instrumental

* Correspondence to: Department of Physiology, Government Yoga and Naturopathy Medical College and Hospital, Chennai 600106, India.
E-mail addresses: [email protected] (D. Boopalan), [email protected] (V. Vijayakumar), [email protected] (P. Ravi), dr.
[email protected] (P. shanmugam), [email protected] (B. Kunjumon), [email protected] (M. Kuppusamy).

https://doi.org/10.1016/j.eurox.2023.100214
Received 1 April 2023; Received in revised form 22 June 2023; Accepted 4 July 2023
Available online 5 July 2023
2590-1613/© 2023 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D. Boopalan et al. European Journal of Obstetrics & Gynecology and Reproductive Biology: X 19 (2023) 100214

Identification of studies via databases and registers Identification of studies via other methods
Identification

Records identified from Records identified from:

Records removed before
Databases Websites (n =18)
screening:
[PubMed/MEDLINE, Organisations (n = 5)
Duplicate records removed
Embase, Cochrane Library, Citation searching (n = 4)
(n =98)
CINAHL] (n =174)

Records screened Records excluded

(n = 76) (n =52)

Reports sought for retrieval Reports not retrieved Reports sought for retrieval Reports not retrieved
(n = 24) (n = 5) (n =11) (n = 6)
Screening

Reports assessed for eligibility Reports assessed for eligibility Reports excluded:
(n = 19) Reports excluded: (n = 5) Yoga and pregnancy
Article in Korean (n =1) outcomes (n =1)
Meta-analysis and systematic Yoga and pain (n = 2)
Review (n=3) Yoga and psychological
Review article (n =6) parameters in pregnancy
Cochrane review (n =2) (n =1)
.

Studies included in review

Included

(n = 7)
Reports of included studies
(n =1)
Total (n=8)

Fig. 1. PRISMA flow chart of study selection.

delivery, fetal distress, caesarean section, urinary incontinence, motor heading term (Mesh) and key words are used: “Yoga” [Mesh], “Yoga” OR
nerve blockade, hypotension and fever [3]. Available evidences have “Prenatal Yoga” AND “labour pain”[Mesh], “Labour Pain” OR “Delivery
documented that the non-pharmacological interventions such as, Pain”. Only articles published in English language is included for the
breathing exercises, relaxation techniques and massage reduce labour meta-analysis. In addition, references from included studies and perti­
pain intensity during the active phase of labour [5]. Similarly, other nent review articles were searched to identify other studies meeting the
non-pharmacological interventions such as essential oils, acupressure, selection criteria. The present systematic review and meta-analysis was
music therapy, aromatherapy, perineal massage [6] and yoga are conducted and reported as per the Preferred Reporting Items for Sys­
commonly used to manage labour pain as well [7–9]. Stress and anxiety tematic Reviews and Meta-Analyses (PRISMA) guidelines [13].
are common problems faced during pregnancy, which could directly
impact the course of pregnancy and even labour. Mind-body in­
Study selection
terventions such as hypnotherapy, tai-chi, auto-suggestion, meditation,
reflexology [10] and yoga are proven to be beneficial in the manage­
Two authors (DB, PR) independently identified articles eligible for
ment of anxiety during pregnancy [7]. Yoga is a widely used mind body
review and meta-analysis. Randomized controlled trials (RCTs) exam­
intervention technique, gaining attention in recent times, concerned to
ining the effects of antenatal yoga practices on pain management during
its beneficial effect during pregnancy and labour. Yoga not only com­
labour were included. Articles that met the following (PICO) criteria
prises of asanas, but also pranayama, mudra, meditation and also
were screened.
relaxation practices that are documented to be useful during pregnancy
[11]. Child birth is associated with stress response and production of
(1) Participants: Pregnant women with age above (≥14 years).
catecholamine affects labour process [12]. Yoga is documented to be
(2) Intervention: Yoga is the primary intervention, which includes
beneficial in reducing pain and stress while also preparing the mind of
components such as asanas, pranayama, relaxation techniques,
pregnant women for labour. Although the recommendation of yoga for
Om chanting, and meditation.
antenatal care and labour ease has been reported previously, there is a
(3) Comparison: Pregnant women receiving standard care or any
need for a comprehensive assessment. Hence, the objective of the pre­
other interventions apart from yoga.
sent systematic review and meta-analysis is to evaluate the impact of
(4) Outcome: The studies that assessed labour pain as an outcome
antenatal yoga in reducing labour pain.
measure were included.

Methodology
Exclusion criteria
Data sources and searches
Participants with twin pregnancy, gestational hypertension, gesta­
For the current systematic review and meta-analysis, PubMed, tional diabetes mellitus and high-risk pregnancy were excluded. Articles
Embase, Cochrane Library and Web of Science, CINAHL and Google written in languages other than English were also excluded. Studies
Scholar were systematically searched for the article published from using other interventions or therapies in addition to yoga were not
inception through January, 2023. The following medical subject included.

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D. Boopalan et al. European Journal of Obstetrics & Gynecology and Reproductive Biology: X 19 (2023) 100214

Table 1
Characteristics of included studies.
First Author Country Study Design Participants with Intervention details Outcome measures Findings
(Year) sample size

Chuntharapat Thailand Randomized 18 − 35 years Yoga asanas, chanting om, State-Trait Anxiety Inventory; Practice of 30 mins of yoga, at
et al., 2008 Controlled primigravid women 66 breathing awareness, yoga The visual analogue scale total least thrice for 10 weeks
[18] Trial (Yoga group-33; nidra, and dhyana 60-min comfort (VASTC); facilitates in maternal comfort,
control group-33) practice sessions at Maternal comfort decreasing pain during labour,
the26–28th, 30th, 32nd, questionnaire (MCQ); and 2 h post-delivery and
34th, 36th, and 37th week of The visual analogue sensation shortening length of labour
gestation. of pain scale(VASPS); The pain
behavioural observation scale
(PBOS)
Martins et al., Brazil Randomized 14–40 years of age, asanas, breathing, VAS, lumbar pain provocation yoga decreased pain intensity
2014 [19] Controlled 12–32 weeks of meditation and relaxation test, posterior pelvic pain in lumbar and posterior pelvic
Trial gestation. yoga group provocation test region
− 21 and control group
− 24
Jahdi et al., Iran Randomized sixty primiparous 1-hour supervised yoga Labour pain and discomfort Yoga during pregnancy may
2017 [15] Controlled women, aged 18–35 class, three times a weekly, level measured using a Visual reduce pain of labour and
Trial years starting at 26 weeks Analogue Scale improved adequacy of
gestation. childbirth.
Karnasih 2018 Indonesia Randomized 22 (Yoga group-11; asanas, chanting om, VAS at 2–4 cm of cervical In yoga group-duration of
[13] Controlled control group-11) dhyana, yoga nidra and dilatation second and third stage of labour
Trial breathing awareness was decreased, labour pain
score decreased, C- section
decreased
Bolanthakodi India Randomized 150 (Yoga group-75; 30-min practice sessions at Alleviation of labour pain was in yoga group decrease in
et al., 2018 Controlled control group-75) 30th, 32nd, 34th, 36th, assessed by using numerical oxytocin augmentation,
[16] Trial primigravida, 20–35 37th, 38th, and39th weeks pain intensity scale(NPIS), intravenous analgesics, in
years of age, pain behaviour observational number of vaginal deliveries,
gestational age of scale(PBOS),and maternal length of labour shortened,
30weeks delivery comfort questionnaire tolerance of pain is better in
study group
Mohyadin et al., Iran Randomized 84 (Yoga group-42; six 60-min training sessions State-Trait Anxiety Inventory, Practicing yoga during
2021 [14] Controlled control group-42) for every 2 weeks from week labour pain - Visual Analogue pregnancy mayreduce women’s
Trial primigravida, above 18 26 of pregnancy and Scale (VAS) anxiety during labour
years of age. continued until 37 weeks of
gestation.
Rahayu et al., Indonesia Non- 59 primigravida modified Iyengar yoga Degree of anxiety- Hamilton Iyengar yoga in primigravida
2023 [12] randomized females (Yoga group- weekly once with 90 min of Scale Rating for Anxiety women was beneficial in
experimental 30; control group-29) duration for three months (HSRA) labour pain - Visual reducing labourpain and
study with 20–35 years of Analogue Scale (VAS) anxiety.
age.
Esencan and Turkey Randomized 90 (Yoga group-30; yoga and meditation for State Trait Anxiety Inventory Yoga and meditation are
Rathfisch Controlled control group-60) 60 min two times a week for (STAI) Wijma Delivery effective methods for reducing
(2023)[19] Trial primiparous pregnant 10 weeks. Expectancy/Experience pain and fear perception and
women Questionnaire, increasing self-efficacy and
Childbirth Self-Efficacy Scale vaginal delivery rates during
(CBSEI) Short Form Wijma the labour
Delivery Expectancy/
Experience Questionnaire
Version B,
visual analogue scale (VAS) for
pain.

Data extraction and quality assessment Statistical analysis

Data was independently extracted by two authors (DB, PR) using a The mean (i.e.) VAS differences between experimental and control
standardized protocol and reporting form. Disagreements were resolved groups were estimated. Standardized mean difference (SMD) and 95%
by arbitration, and consensus was reached after discussion. The confidence interval (CI) were calculated to determine the effect size
following information was extracted: study characteristics (study name, using random effect model. The I2 statistics and Cochran Q test was used
authors, publication year, Country of origin, sample size, study design, to assess heterogeneity. Analysis was done with metafor package in R
intervention details, outcome measures, and findings), study sample statistical software version 4.2.2.
characteristics (mean age and sex), main exposure (antenatal yoga) and
main outcome (Visual analogue scale (VAS) - labour pain). Two in­ Results
vestigators assessed (DB and PR) the methodological quality of the
included studies as recommended by the Cochrane handbook of Literature selection
assessing risk of bias in a randomized trial. Domains such as random
sequence generation, allocation concealment, blinding of participants We identified 201 potential articles from the initial literature search.
and personnel reporting, blinding of outcome assessment, other sources After reading title, abstract and removing duplicates, 178 articles were
of bias, incomplete outcome and data selective outcome is assessed in all excluded by three independent authors. Of those, 23 potential articles
the included studies [10]. were retrieved after carefully reading through the full text, out of which
8 articles were included for review and 7 articles were included for the

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D. Boopalan et al. European Journal of Obstetrics & Gynecology and Reproductive Biology: X 19 (2023) 100214

Fig. 2. Effect of antenatal yoga on labour pain.

Fig. 3. Funnel plot of the meta-analysis.

meta-analysis (Fig. 1).

Literature characteristics
Fig. 4. Risk of bias summary.

Table 1 shows the literature characteristics of the included studies.

Out of 8 studies, two studies [14,15] was done in Indonesia, two studies reporting. More than half of the study rated low risk in incomplete
[16,17] in Iran, rest in India [18,19], Thailand [20] and Brazil [21]. Out outcome data. Regarding blinding of outcome assessment and selective
of those eight included studies, six studies [14,16–20] done on primi­ reporting four studies had low risk and in rest of the studies it was un­
gravida mothers. The age of the participants ranges from 14 to 40 years. clear (Figs. 4 and 5).
Maximum sample size was 75 in both study and control group, while the
minimum sample size was 11 in both groups. Intervention of study Discussion
group involved practice of asanas, pranayama, dhyana, relaxation, Om
chanting, and Yoga nidra. Minimum duration of intervention was Yoga, a popular mind-body medicine, is frequently recommended for
30 min and maximum duration was 1 h. Most commonly used param­ pregnant women. The aim of this systematic review and meta-analysis
eters for assessment in all the studies was visual analogue scale. was to examine the published evidence on antenatal yoga, with a spe­
cific focus on its effectiveness in reducing the intensity of labour pain.
The current systematic review and meta-analysis revealed evidence that
Meta- analysis antenatal yoga can reduce labour pain during delivery. In a recent meta-
analysis investigating the effects of prenatal yoga on childbirth pain, five
Seven RCTs with 462 participants reported the pain intensity studies involving a total of 581 women were analyzed. The findings
through VAS. The pooled results (Fig. 2) showed that yoga is effective in demonstrated a significant reduction in labour pain associated with
reducing labour pain (SMD: − 1.34 95% of CI: − 1.86, − 0.81) with sig­ prenatal yoga, as indicated by a standardized mean difference (SMD)
nificant heterogeneity among the studies (I2 =73%, p < 0.0008). Due to value of − 1.05 (95% confidence interval: − 1.45 to − 0.65; z = 5.15;
the small number of studies, we could not execute the initially planned P < 0.01). These results are consistent with our own findings, high­
sensitivity analysis. Findings from Egger test (p = 0.59) and symmetry lighting the beneficial impact of prenatal yoga in alleviating pain during
of the funnel plot (Fig. 3) demonstrated that there is no significant labour [22]. However, that review only considered studies from
publication bias exists in this study. PubMed, EMBASE, and Cochrane databases. Our systematic review, on
the other hand, stands out by including studies from Web of Science,
Risk of bias assessment CINAHL, and Google Scholar. Moreover, we conducted a comprehensive
literature search up to January 2023, ensuring that our review is
Majority of the studies rated low risk in random sequence generation, up-to-date is one of the strengths of this current review. All the included
allocation concealment and other sources of biases. Majority of the studies provided at least one of these yogic interventions like asanas,
studies rated high risk in blinding of participants and personnel

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D. Boopalan et al. European Journal of Obstetrics & Gynecology and Reproductive Biology: X 19 (2023) 100214

Fig. 5. Risk of bias graph.

pranayama, mudra, relaxation techniques and yoga nidra. However, the protocol to confirm our findings. We also hypothesis that, prenatal yoga
duration, frequency, outcomes and age groups varied widely. Through practise can reduce the number of augmentations of labour and
this meta-analysis, we postulate that yoga could be used as an effective caesarean sections.
non pharmacological intervention in the management of labour pain.
Studies reported that practice of yoga reduces intensity of the labour Ethical approval
pain, shortens the length of the labour, decreased number of caesarean
section, oxytocin augmentation, usage of intravenous analgesics, Not applicable.
improved rates of vaginal birth and tolerance to pain [23,24]. Previous
meta- analysis and systematic review on antenatal yoga found that yoga CRediT authorship contribution statement
can reduce generalized body pain, lumbo-pelvic pain, rate of pre-term
labour, intra-uterine growth retardation, low birth weight and preg­ All authors have accepted responsibility for the entire content of this
nancy related complications [24–26]. Moreover, practice of yoga brings manuscript and approved its submission.
positive birth experience and greater satisfaction with pain relief.
Antenatal yoga can also reduce stress, depression, and psychologically Research funding
prepares the women for labour [27]. During pregnancy and labour, body
undergoes several physiological and psychological changes[12]. Man­ None declared.
agement of pain through yogic intervention involves both physical and
psychological factors [28]. The practice of asanas strengthens the body
Declaration of Competing Interest
and improves flexibility, in addition, asanas also influences secretion of
hormone from endocrine gland [29,30]. Practice of pranayama and
The authors declare that they have no known competing financial
breathing awareness brings mindfulness, regulates autonomic balance
interests or personal relationships that could have appeared to influence
and also alleviates stress [23]. During the practice of yoga nidra and
the work reported in this paper.
dhyana, their positive perception towards effective management of la­
bour pain influences women in attaining better control over pain and
Acknowledgments
also induces deeper state of relaxation [20,31]. According to
fear-tension-pain cycle, fear and tension can adversely affect the prog­
None.
ress of labour and also increases the intensity of the labour pain [32].
Yoga can effectively manage pain by alleviating stress, fear and tension
associated with labour. No adverse events were reported in any of the Informed consent
studies. However, due to the limited numbers of included studies, the
relatively very small overall population, high heterogeneity no strong Not applicable.
suggestions can be made regarding safety of the intervention.
Though this review revealed positive results for yoga, there are References
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