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EFFECTIVENESS OF RELAXATION PROGRAMME
ON INISTITUTIONALISED WOMEN WITH
PREGNANCYINDUCED HYPERTENSION
Thesis submitted in partial fulfilment for the Award
of Degree of Doctor of Philosophy in Nursing
By
SREEDEVI J
VINAYAKA MISSIONS UNIVERSITY
SALEM, TAMILNADU, INDIA
SEPTEMBER, 2014
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VINAYAKA MISSIONS UNIVERSITY
DECLARATION
I,SREEDEVI J, declare that the thesis entitled Effectiveness
of Relaxation Programme on Institutionalized Women with
Pregnancy Induced Hypertension, submitted by me for the
Degree of Doctor of Philosophy is the record of work carried out
me during the period from April 2008 to April 2014 under the
guidance of Dr. Sr. Anne Jose and has not formed the basis for
the award of any degree, diploma, associate-ship, fellowship, titles
in this or any other University or other similar institution of higher
learning.
Place: Kozhikode Signature of the Candidate
Date: 24-09-2014Sreedevi J
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VINAYAKA MISSIONS UNIVERSITY
CERTIFICATE BY THE GUIDE
I, Dr. Sr. Anne Jose, certify that the thesis entitled
EFFECTIVENESS OF RELAXATION PROGRAMME ON
INISTITUTIONALISED WOMEN WITH PREGNANCY INDUCED
HYPERTENSION submitted for the Degree of Doctor of
Philosophy by Mrs. Sreedevi J.is the record of research work
carried out by her during the period from April 2008 to September
2014 under my guidance and supervision and that this work has
not formed the basis for award of any degree, diploma, associate-
ship, fellowship or other titles in this University or any other
University or institution of higher learning.
Signature of the Supervisor with designation
Place
Date
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ACKNOWLEDGEMENT
The investigator is very much thankful to God Almighty for
leading in the correct path by his boundless guidance and blessings to
complete this research endeavour to a wrathful one.
As in the proverb “it takes a village to raise a child”, many
individuals play important roles in the production of one’s doctoral thesis
research, and I want to acknowledge several people in my “village” for
their considerable contributions throughout my doctoral studies.
It is the investigator’s bounden duty to express at the outset,
heartiest gratitude to Dr. Sr. ANNE JOSE, former Professor, Govt.
College of Nursing, Kottayam for the inspirations, valuable suggestions,
support and excellent guidance for the successful completion of this
thesis.
The most profound and sincere gratitude to the management of
Vinayaka Missions University for their kind and overwhelming support to
help me successfully to complete doctoral study.
My sincere thanks to Dr.V.RajendranPh D, Dean, Research
Department, Vinayaka Missions University for his valuable guidance
and support in a number of ways to complete this study.
The investigator owes her sincere gratitude to all the pregnant
women who were willing to participate in the study.
The investigator’s heartfelt thanks to Prof. Valsa K Panicker,
Principal, Govt. College of Nursing, Thiruvananthapuram and
Prof. Nirmala L., Principal, Govt. College of Nursing, Kozhikode for their
constant encouragement and support for the completion of her study.
The investigator is deeply indebted to Mrs. Lali K.S.,
Asso. Professor, Govt. College of Nursing, Kozhikode for her constant
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moral support, critical guidance, valuable suggestions and inspirations
throughout this venture.
The investigator extends her respectful appreciation to
Dr. Reetha Devi V.S., Former Professor, Govt. College of Nursing,
Kozhikode for her enormous support and priceless suggestions that
guided to the fruitful completion of this study.
The researcher expresses her gratitude and thanks to
Dr. Umadevi C., Professor and Head of the Department of Obstetrics
and Gynaecology, Medical College Hospital, Kozhikode for permitting to
conduct the study in the department.
The investigator owes her sincere gratitude to all experts who
validated the tool.
The researcher expresses her heartfelt gratitude to
AcharyanUnniraman Master and his team, Pathanjali Yoga and
Research Institute, Kozhikode for his valuable suggestions, content
validity of research programme and rendering his voice for Malayalam
translation of relaxation programme.
The investigator is deeply indebted to the Sister in charge and
Staff of Antenatal and Postnatal wards, Labour room and Neonatal ICU,
Institute of Maternal and Child Health, Kozhikode for their cooperation
and participation for the successful completion of the study.
The investigator expresses her special thanks to Dr.Biju George,
Assistant Professor in Community Medicine, Medical College,
Kozhikode and Mr. GirishBabu, Asst. Professor, Department of
statistics, Govt. Arts and Science College, Kozhikode for the help
rendered in statistical analysis.
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She is thankful to all her teachers, friends and library staff of
Govt. College of Nursing, Kozhikode, Staff Medical College Library,
Kozhikode and staff of Learning Resource Centre, Medical College,
Kozhikode and all well-wishers who helped for the successful
completion of the study.
The researcher acknowledges the inspiration and help given by
her colleagues and all the Nursing students of Govt. College of Nursing,
Kozhikode.
I owe my sincere thanks to M/s Prayag computers for shaping
and printing my thesis.
Finally, I want to acknowledge the support of all my family and
friends throughout this journey; particularly Mrs. Jayalakshmi P.V,
Mr.PavithranRayaroth, Mr.Ashfaq K, Mrs.Smitha P.S and
Sr. Lissa Paul whose friendship during this journey has meant so much;
my mother Indira , my aunt Anandavally, sister Sheeba, sister in-law
Soorya and my brothers Shajilal, and Anoopraj, brother-in law
Radhakrishnan for their unwavering love, support and belief in me; My
daughter Astha and niece Anshika, Anjana and Archana for their
curious minds, joyous spirits, and laughter as we all “went to school”;
and last, but by no means least, my husband Jitendra Sharma, for his
patience, perspective, support and love.
SREEDEVI J
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ABSTRACT
The present study is aimed to evaluate the effect of relaxation
programme on stress, coping and pregnancy out- come among women
with pregnancy induced hypertension.
Objectives of the study were:
1. To assess the level of stress experienced by women with PIH
before and after relaxation programme.
2. To assess the coping strategies used by women with PIH before
and after relaxation programme.
3. Evaluate the effect of relaxation programme on level of stress of
women with PIH
4. Evaluate the effect of relaxation programme on coping strategies of
women with PIH
5. Evaluate the effect of relaxation programme on pregnancy
outcome of women with PIH
6. Find out the association between level of stress and selected
variables: age, obstetric score, family history of PIH and family
history of hypertension of women with PIH.
7. Find out the association between coping strategies and selected
variables: age, obstetric score, family history of PIH and family
history of hypertension of women with PIH.
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8. Find out the association between stress, coping and pregnancy
out- come of women with PIH.
An evaluative approach with quasi experimental, pre- test post-
test control group design was used. Eight hypotheses were formulated
and tested. The conceptual frame work of the study was based on Betty
Newman’s system model (1972).
The dependent variables were: stress, coping and pregnancy
outcome among women with pregnancy induced hypertension. The
independent variable was relaxation programme.
Five measuring instruments were used in this study to evaluate the
effectiveness of relaxation programme among women with PIH. Of
these, semi structured interview schedule on socio demographic and
clinical data, observation checklist to determine the physiological
indicators and pregnancy outcome were developed by the investigator
and a four point rating scale, DASS ( Lovibond and Lovibond,1995) to
assess stress level and Jalowic coping scale for coping strategies
(A.Jalowic,1987) were standardised scales.
The study conducted on 400 women with pregnancy induced
hypertension in Institute of Maternal and Child Health (IMCH)
Kozhikode. A purposive sampling technique was adopted for selection
of sample. The experimental and control group were not different in
their pre-test scores.
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The relaxation programme was administered through audio CD
arranged in the sequence of deep breathing, progressive muscle
relaxation and guided imagery in Malayalam with necessary instructions
to the experimental group by the investigator from Monday to Friday in
the morning and evening for four weeks. A post- test was administered
to both groups to assess stress and coping strategies and pregnancy
outcome was measured through records.
The collected data were analysed by computing paired and
independent t tests and Chi square. The findings of the study were:
1. The mean post test scores in the experimental group was
significantly higher than that their pre-test scores with regards to:
• Stress, t (200)=30.56,p<0.05
• Coping strategies, t(200)=54.24,p<0.05
2. The mean post test scores in the experimental group were
significantly higher than the mean post-test score of control group
with regards to:
• Stress, t (400) =30.51, p<0.05
• Coping strategies, t (400) =50.4, p<0.05
3. The mean post- test pregnancy outcome score in the
experimental group was significantly higher than the mean post-
test pregnancy score of control group with regards to:
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• Maternal outcome in terms of
Labour, χ2 =70.55, p<0.05
Type of delivery, χ2 =42.93, p<0.05
Complications, χ2 =20, p<0.05
Blood pressure, χ2 =50.04, p<0.05
Proteinuria, χ2 =96.47, p<0.05
Oedema, χ2 =60.58, p<0.05
• Neonatal outcome in terms of
Birth weight, χ2 =18.96, p<0.05
Apgar score, χ2 =102.15, p<0.05
Complications, χ2 =13.8, p<0.05
Still birth, χ2 =4.37, p<0.05
4. There was no significant association between stress and selected
variables among women with pregnancy induced hypertension in
the control and experimental group at 0.05 level. There were four
selected variables:
a. With regard to age, there were three groups, <20, 20-29 and >30
years. The F value was 0.253 p 0.77 which showed no
significance.
b. With regard to obstetric score, there were four groups, gravida,
para, live and abortion.
� The F value for gravida was 2.40 p=0.06 showed no
significance.
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� The F value for para was 1.74 and p=0.158 showed no
significance
� For live F=3.84, p=0.022 showed significance.
� F value for Abortion was 2.47 and p=0.06 showed no
significance.
c. There were no statistically significant association between stress
and History of PIH in the family (F=0.19,p=0.84) and family history
of hypertension (F=1.311,p=0.19)
5. There were no statistically significant association between coping
and selected variables (p=>0.05).
6. There were no statistically significant association between stress
and pregnancy outcome among control group except in birth
weight (F=6.4, p=0.002) and APGAR score (F=3.62,p=0.02) in
control group and found absence of association among
experimental group (p=>0.05).
7. There were no statistically significant association between coping
and pregnancy outcome among women with PIH in both groups
(p=>0.05).
The findings of the present study revealed that the
relaxation programme is highly significant to relieve stress, adapt
useful and effective coping strategies and positive pregnancy
outcome among women with pregnancy induced hypertension.
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LIST OF CONTENTS Chapter Title Page no
I INTRODUCTION 1
II REVIEW OF LITERATURE 11
Need and significance 40
Objectives and hypotheses 47
Theoretical frame work 53
III METHODOLOGY 59
IV ANALYSIS AND INTERPRETATION 87
V DISCUSSION, SUMMARY AND
CONCLUSION 187
Bibliography 225
Appendices 247
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LIST OF TABLES
Table Title Page no
1 Distribution of high risk cases in IMCH,
Kozhikode. 45
2 Details of Data Collection Instruments Used
in the Study 72
3 Plan of analysis of collected data 86
4 Frequency and percentage distribution of socio
personal variables among women with PIH 89
5
Frequency, percentage and chi square
distribution of clinical data among women with
PIH among experimental and control group
100
6
Frequency, percentage and chi square
distribution of history of disease complicating
among women with PIH
108
7 Distribution of means of the pre post pulse
rates among experimental group 121
8 Weekly average difference in mean pre and
post respiratory rate in experimental group 122
9 Weekly average difference in pre and post
systolic blood pressure in experimental group 123
10 Weekly average difference in pre and post
diastolic blood pressure in experimental group 124
11
Comparison of pre -test mean score of level of
stress among women with PIH between
experimental group and control group before
intervention
125
12
Comparison of post -test mean score of level
of stress among women with PIH between
experimental group and control group after
intervention
126
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Table Title Page no
13
Comparison of pre -test post- test mean score
of coping strategies among women with PIH
between experimental group and control group
131
14
Comparison of pre -test post –test mean score
of coping strategies of sub scales among
women with PIH between experimental group
and control group
132
15
Significance of difference in the mean pre- test
score of stress in the experimental and control
group
143
16
Significance of difference in the mean post-
test stress score in the experimental and
control group after relaxation programme.
144
17
Significance of difference in mean pre and
post- test stress score in the experimental
group
145
18
Significance of difference in the mean pre- test
score of coping in the experimental and control
group
146
19
Significance of difference in mean post- test
coping score of women with PIH in the
experimental and control group after relaxation
programme
147
20
Significance of difference in the mean pre- test
post- test coping score in the experimental
group after relaxation programme
148
21
Significance of difference between mean pre
and post-test score on selected physiological
variables among women with PIH in
experimental group
149
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Table Title Page no
22
The Chi square value computed on pregnancy
outcome score in terms of maternal outcome
in the experimental group and control group
after relaxation programme
151
23
The Chi square value computed on pregnancy
outcome score in terms of neonatal outcome in
the experimental group and control group
after relaxation programme
153
24
Association between stress and selected
variables among women with pregnancy
induced hypertension
155
25
Association between coping and selected
socio personal variables among women with
PIH
157
26
Association between maternal out-come in
terms of labour and selected variables among
women with PIH in experimental group
159
27
Association between maternal out-come in
terms of type of delivery and selected
variables among women with PIH in
experimental group
160
28
Association between maternal out-come in
terms of complications and selected variables
among women with PIH in experimental group
161
29
Association between maternal out-come in
terms of blood pressure and selected variables
among women with PIH in experimental group
162
30
Association between maternal out-come in
terms of oedema and selected variables
among women with PIH in experimental group
163
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Table Title Page no
31
Association between maternal out-come in
terms of protein urea and selected variables
among women with PIH in experimental group
164
32
Association between neonatal out-come in
terms of birth weight and selected variables
among women with PIH in experimental group
165
33
Association between neonatal out-come in
terms of Apgar score and selected variables
among women with PIH in experimental group
166
34
Association between neonatal out-come in
terms of complications and selected variables
among women with PIH in experimental group
167
35
Association between neonatal out-come in
terms of still birth/IUD and selected variables
among women with PIH in experimental group
168
36
Association between maternal out-come in
terms of labour and selected variables among
women with PIH in control group
169
37
Association between maternal out-come in
terms of type of delivery and selected variables
among women with PIH in control group
170
38
Association between maternal out-come in
terms of complications and selected variables
among women with PIH in control group
171
39
Association between maternal out-come in
terms of blood pressure and selected variables
among women with PIH in control group
172
40
Association between maternal out-come in
terms of protein urea and selected variables
among women with PIH in control group
173
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Table Title Page no
41
Association between maternal out-come in
terms of oedema and selected variables
among women with PIH in control group
174
42
Association between neonatal out-come in
terms of birth weight and selected variables
among women with PIH in control group
175
43
Association between neonatal out-come in
terms of Apgar score and selected variables
among women with PIH in control group
176
44
Association between neonatal out-come in
terms of complications and selected variables
among women with PIH in control group
177
45
Association between neonatal out-come in
terms of still birth/IUD and selected variables
among women with PIH in control group
178
46
Association between post stress and
pregnancy outcome among women with PIH in
control group
179
47
Association between post stress and
pregnancy outcome among women with PIH in
experimental group
180
48
Association between post-test coping score
and maternal outcome in terms of type of
delivery among women with PIH in control
group
181
49
Association between post-test coping score
and neonatal outcome in terms of birth weight
among women with PIH in control group
182
50
Association between post-test coping score
and neonatal outcome in terms ofapgar score
among women with PIH in control group
183
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Table Title Page no
51
Association between post-test coping score
and maternal outcome in terms of type of
delivery among women with PIH in
experimental group
184
52
Association between post -test coping score
and neonatal outcome in terms of birth weight
among women with PIH in experimental group
185
53
Association between post-test coping score
and neonatal outcome in terms of apgar score
among women with PIH in experimental group
186
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LIST OF FIGURES
Figures Title Page no
1 Theoretical framework for the study 57
2 Schematic Representation of Study 63
3 Schematic presentation of data collection process 85
4 Frequency distribution based on age among
women with PIH 91
5 Percentage distribution of monthly income among
women with PIH 92
6 Percentage distribution based on religion among
women with PIH 93
7 Percentage distribution based on occupation
among women with PIH 94
8 Percentage distribution based on support system
among women with PIH 95
9 Percentage distribution based on family structure
among women with PIH 96
10 Percentage distribution based on leisure time
activities among women with PIH 97
11 Percentage distribution based on place of
residence among women with PIH 98
12 Percentage distribution based on history of any
recent stressful events among women with PIH 99
13 Percentage distribution based on reason for
admission among women with PIH 102
14
Percentage distribution based on time of diagnosis
of PIH in present pregnancy among women with
PIH
103
15 Percentage distribution based on history of drug
intake among women with PIH 104
16 Percentage distribution based on family history of
hypertension among women with PIH 105
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Figures Title Page no
17 Percentage distribution based on family history of
PIH among women with PIH 106
18 Percentage distribution based on history of PIH in
previous pregnancy among women with PIH 107
19 Percentage distribution based on history of foetal
loss among women with PIH 109
20 Percentage distribution based on presence of
headaches among women with PIH 110
21 Percentage distribution based on presence of
pitting oedema among women with PIH 111
22 Percentage distribution of presence of eye
symptoms among women with PIH 112
23 Percentage distribution based on presence of
epigastric pain among women with PIH 113
24 Percentage distribution based on presence of
nausea and vomiting among women with PIH 114
25 Percentage distribution based on body weight
among women with PIH 115
26 Percentage distribution based on weight gain
during pregnancy among women with PIH 116
27 Percentage distribution based on height among
women with PIH 117
28 Percentage distribution based on number of foetal
movements per 12 hours among women with PIH 118
29 Percentage distribution based on sleep pattern
among women with PIH 119
30 Percentage distribution based on antenatal check-
ups among women with PIH 120
31
Percentage distribution based on level of stress
among women with PIH in the experimental and
control group after relaxation programme
127
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Figures Title Page no
32 Mean distribution based on level of stress among
women with PIH in the experimental and control
group
128
33
Percentage distribution based on depression,
anxiety and stress among women in the
experimental and control group before relaxation
programme
129
34
Percentage distribution of Post relaxation
depression, anxiety and stress in experimental and
control group
130
35
Mean distribution based on coping score among
women with PIH in the experimental and control
group
133
36 Percentage distribution based on labour among
women with PIH in experimental and control group 134
37
Percentage distribution based on type of delivery
among women with PIH in experimental and
control group
135
38
Percentage distribution based on maternal
complications among women with PIH in
experimental and control group
136
39 Percentage distribution based on blood pressure
among women with PIH in experimental and
control group
137
40 Percentage distribution based protein urea among
women with PIH in experimental and control group 138
41 Percentage distribution based on oedema among
women with PIH in experimental and control group. 139
42 Percentage distribution based on birth weight
among women with PIH in experimental and
control group
140
43 Percentage distribution based on APGAR score
among women with PIH in experimental and
control group
141
44 Percentage distribution based on neonatal
complications among women with PIH in
experimental and control group
142
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CHAPTER I
INTRODUCTION
Pregnancy is an important event, one of the great honour’s and
God’s gift to woman, for this woman is respected everywhere. It is
surrounded by many positive values ranging from enhancement of the
self- esteem to social approval. The highest value placed on the woman
in most societies is the role as mother which make the motherhood as
central to woman’s life. Pregnancy and childbirth is a great event in the
life of every woman for which she aspires and longs for, with great
expectation. She has fantasies about pregnancy and motherhood.
Pregnancy is a time of growth and hope. Pregnancy is not only a
biological event but also an adaptive process. This period is a time of
physical and psychological preparation for birth and parenthood.
Pregnant woman perceive it as a period of happiness in anticipation of
motherhood. Becoming a parent is considered as one of the
maturational milestones of woman’s life. Pregnant woman carry the
foetus safely till delivery and adjust to sacrifices the motherhood
demands. Women hope for a smooth journey in pregnancy without any
complication and a normal foetal development.
Pregnancy is a state of carrying one or more off springs, known
as an embryo or foetus inside the womb of a female. Pregnancy is a
period of profound physical and physiological transformation. Many
changes in maternal physiology occur during this period. Even though
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these are more apparent in the reproductive organs it involves other
system such as in the cardiovascular, hematologic, metabolic, renal and
respiratory, endocrine systems too. Maternal physiological changes in
pregnancy are the normal adaptations that a woman undergoes during
pregnancy to better accommodate the embryo or foetus and ensures
the foetusgrow properly and receives adequate nutrition.
Pregnancy is a complex phenomenon which includes
physiological,psychological and social changes, especially for the first
one. It is always relatedwith changes in psychological functioning of
pregnant women and associated withambivalence, frequent mood
changes, varying from anxiety, fatigue, exhaustion,sleepiness, and
depressive reactions to excitement as pregnancy causes many
changesin body appearance, activity and sexuality. Pregnancy is
identified as a potentstressor.
The psychological changes also depend upon whether the
pregnancy wasplanned or unplanned, wanted or unwanted, becoming
pregnant after a long periodor after medical intervention like IVF,
changes in the role, changes in therelationships, fear of being a good
parent, fear of problems associated with thepregnancy or the baby, fear
of childbirth and lack of support and being alone, theamount of help the
couple might expect to receive in raising the child, the type
ofrelationship whether stable or transient with the partner, pressure from
the partneror family to become pregnant.Life stress, perceived social
2
support in relations between stress andsymptoms during pregnancy
reveal influences of socio-demographic factors (i.e., socioeconomic
status, age, parity), stress (partner conflict and life events), andsocial
support on symptoms of anxiety and depression. Women who reported
lowlevels of social support showed stronger relations between stress
and symptomsthan women who reported high levels of social support,
indicative of a mediatingeffect of social support (Glazier, Elgar,
Goel,Holzapfel. 2004).
During pregnancy many changes occur in women's self-concept.
Womenmay feel having lost some control over their lives. The changes
in their self-imageand the shift in focus from themselves to the needs of
the foetus and unfamiliarterritory of pregnancy and early motherhood
create stress. As first-time mothersstart to undergo a transition at in
their pregnancy, they face difficult periods bothearly in the pregnancy
and after the birth, and have unmet need for support in thoseperiods
(Darvill, Skirton and Farrand, 2010).
The neuroendocrine mechanism plays an important role in
physiology ofstress during pregnancy. The increased production of
several stress hormones,including adrenaline and cortisol, enable the
mother to cope with stress caused bythe physiological changes which
occur as a normal part of pregnancy inducedphysiological stress. As
long as these remain within manageable parameters, theycontribute to
the well-being. Whenthe parameters are exceeded, they
3
becomestressors, involving the alarm or flight-or-fight response, the
resistance and theexhaustion stages. The resistance stage causes an
increase in production ofendocrine hormones such as cortisol and
thyroxin, which maintain the adjustmentto the continued presence of the
stress. The exhaustion or ‘‘burnout’’ stage occurswhen these resources
are exhausted, eventually weakening several body systemsincreasing
morbidity and mortality.
Pregnancy and childbirth are special events in women’s lives and
indeed, in the lives of their families. This can be a time of great joy and
joyful anticipation. It can also be a time of fear, suffering and even
death. Even though pregnancy is not a disease; but a normal
physiological process, it is associated with certain risks to the health
and survival both for woman and foetus she bears. These risks are
common in every society and every setting.
Maternal death and disability are the leading causes of healthy
life years lost for developing country women of reproductive age,
accounting for more than 28 million disability adjusted life years
(DALYS) lost and at least 18% of the burden of disease in these
women. For each woman who dies, an estimated 100 women
survivechildbearing but suffer from serious disease, disability or
physical damage caused by pregnancy related complications (WHO,
2006).“Maternal mortality is a neglected tragedy and it has been
neglected because those who suffer are neglected people with least
4
power and influence, they are the poor, the rural peasants and above all
women”(Mehler, 1987).
In most women pregnancy is almost uneventful. Unfortunately
for some mothers this most thrilling experience leads to fatal tragedies
of mother and baby. WHO estimates that out of 5,29,000 maternal
death reported globally each year, 1,36,000 (25.7%) was contributed by
India. Among these 16% are due to pregnancy related complications
(WHO, 2004).
Every minute of every day a woman dies of pregnancy related
complications. For every woman who dies at least thirty others develop
chronic debilitating problems. It is estimated that every year nearly 3-4
million new-born dies within the first week of their life and for every new
born baby that dies another is still born. That is the black picture of
motherhood and childbirth. These women and babies die for the same
reason that is poor health and inadequate care during pregnancy and
childbirth (WHO, 2001).
Pregnant women still die from four major causes: severe
bleeding after childbirth, infections, hypertensive disorders, and unsafe
abortion. Every day, about 1000 women died due to these
complications in 2008. Out of the 1000, 570 lived in sub-Saharan Africa,
300 in South Asia and five in high-income countries. The risk of a
woman in a developing country dying from a pregnancy-related cause
5
during her lifetime is about 36 times higher compared to a woman living
in a developed country (WHO,2010).
Pregnancy induced hypertension or gestational hypertension is
considered to be a major cause of maternal and foetal morbidity and
mortality. Gestational hypertension used to be named “Pregnancy
Induced Hypertension” or PIH and considered to be a relatively benign
condition. The old name was a source of confusion because it was used
to denominate all forms of hypertension during pregnancy. Also, the
condition is not benign and pregnancy outcomes in gestational
hypertension are worse than in mild pre-eclampsia (Buchbinder, 2002).
Hypertensive disorders occur in 6 to 8 % of all pregnancies and
are the second leading cause of maternal mortality in developing
countries and accounting for 15%-18% of deaths (Morris et al, 2005).
In the United Kingdom, fewer than ten women will die each year
from pre-eclampsia but this remains a relatively common cause of death
in pregnancy in the developed world. Only about two in two thousand
women will have an eclamptic convulsion but the associated maternal
mortality is two per cent (Douglas, 2008).
Worldwide, in recent decades, hypertensive disorders of
pregnancy is one of the leading causes of both maternal and perinatal
morbidity and mortality. 5-8 per cent of all pregnancies, preeclampsia
and hypertensive disorders of pregnancy are major causes of maternal,
foetal and neonatal morbidity worldwide (Mudaliar, 2005).
6
In India, the incidence of PIH ranges from 5-15%. In the primi, it
is 16% whereas in multiparas it is 7 per cent, maternal mortality is by
10% to 15%. Prenatal mortality and morbidity is 15% to 25%. In public
hospitals number of antenatal mothers with PIH is 40% that is 8 patients
out of 20 patients. In 1998 more than 146320 cases of PIH were
diagnosed (Sheheena, 2009).
For the year 2003, maternal mortality rate for India was 301 per
100,000 live births. This means more than 78,000 women die each year
due to pregnancy related causes. In 2003 the early neonatal mortality
rates in Kerala was 30 per 1000 live births (Govt. of India, 2005).
The Kerala Federation of obstetrics and gynaecology did a
preliminary survey of maternal deaths in Kerala through its members. A
data on 105 deaths have been collected. The leading causes of death
were haemorrhage in 23 patients and hypertensive disorders of
pregnancy in 13 patients (Paily, 2004).
Hypertensive disorders of pregnancy act as a leading cause of
maternal death. PIH leads to preterm labour, eclampsia, Haemolysis
Elevated Liver Enzymes and Low Platelets (HELLP) syndrome which
contribute significantly to the maternal mortality and morbidity. This also
results in prematurity, still birth, neonatal mortality and morbidity
(NHBPEP, 2002). The incidence of PIH in primigravida is3 to 7 per cent,
whereas in multigravida it is 0.8-2.6% and the chances of recurrence of
PIH in women in their subsequent pregnancy is one third. Age, family
7
history of hypertension, family history of PIH, and poor socio-economic
status are risk factors of developing PIH (Flack et al. 2002).
Hypertensive disorders remain the most significant and
intriguing unsolved problems in obstetrics. In the society the role of
mother as a citizen and in nurturing the young ones to an apt citizen is
unique. Every maternal death is an avoidable tragedy. If mother dies it
is not only a catastrophe to the child but also for the rest of the family.
Blood pressure is defined as the product of cardiac output and
peripheral vascular resistance or both influenced by a variety of factors
(Kaplan, 2002) including when in pregnancy measurement occurs
(Brown et al., 1998; Halliganet al., 1993; Hermida, Ayala and Iglesias,
2001). Cardiac output is a function of heart contractility and heart rate,
while vascular resistance relates to resistance to blood flow in the blood
vessels. Depending on the aetiology of the hypertension in pregnancy
and how long it has been present, cardiac output or peripheral vascular
resistance or both may be elevated (Beevers, Lip and O'Brien, 2001;
Bosio, McKenna, Conroy and O'Herlihy, 1999, cited by Moffat,2008).
The experience of pregnancy itself is stressful event, having the
pregnancy classified as high risk increases the level of maternal
distress (Janga, 2005). Prenatal maternal stress is an indicator of
adverse birth outcomes (Lobel, Kaminer and Mayer, 2000). PIH is a
pregnancy specific syndrome with a clinical continuum rangingfrom mild
to severe form. It has a dual impact on mother and foetus. The
8
complication of PIH is manifold which ranges from maternal death to
maternal complications like cerebral haemorrhage, liver damage, renal
failure, DisseminatedIntraCoagulopathy, HELLP and pulmonary
oedema. PIH can result not only in life threatening complications but
also pre-term induction of labour leading to induced prematurity to the
foetus. PIH poses great threat to the foetus by way of intra uterine
growth retardation (IUGR) and foetal death (Flack et al 2002). If PIH is
diagnosed at twenty weeks of gestation itself the woman has to struggle
throughout the pregnancy period which requires close monitoring and
hospitalization. This has a devastating role in the health status of the
patient. Hence the permanent objective in PIH management is to
ensure a safe delivery without any complications.
During the last decade evidence suggested that, pregnancy
induced hypertension poses risk to both mother and foetus but a
women’s risk continues long after the baby is born. This means
hypertensive disorders of pregnancy, pre-eclampsia in particular are
associated with future hypertension and cardiovascular events like
ischemic death, myocardial infarction, ischemic heart failure, stroke and
transient ischemic attack (American Heart Association, 2005).
Sandan (1998) reported that women with gestational
hypertension are at risk for progression to severe hypertension,
pre eclampsia or eclampsia. The risks are increased with lower
9
gestational age at the time of diagnosis. Therefore these patients
require close observation of maternal and foetal conditions
The prevalence of intrauterine growth retardation is 10% for all
pregnancies and 25 % or higher for mothers with hypertensive
disorders.
Maternal stress and anxiety were found to be the predictors of
adverse pregnancy outcomes including low birth weight and
prematurity. A consistent increase in the frequency of IUGR, preterm
delivery and LBW were noted among the infants of women with high
baseline levels of psychological distress and low levels of social
support.
Size at birth is related to future health and therefore pre
eclampsia may result in future adult disease of the baby. This included
an increased risk of hypertension and diabetes when they become
adults (Barker, 1990).
The common non pharmacological therapies given during
antenatal period to alleviate stress, depression and anxiety are
massage, muscle relaxation, breathing technique, music therapy, aroma
therapy, herbal therapy, yoga, guided imagery, meditation and
psychotherapy.
10
CHAPTER II
REVIEW OF LITERATURE
Literature review involves the systematic identification, scrutiny and
summary of written materials which contain information on a research
problem.
2.1 The review of literature is presented under the following
headings.
2.1.1 Literature on PIH related to incidence,causes and outcome.
2.1.2 Literature on stress during pregnancy
2.1.3 Literature on stress and coping strategies
2.1.4 The effects of relaxation on stress
2.1.5 The effects of relaxation on coping
2.1.6 Literature on pregnancy outcome of PIH
2.1.1Literature on PIH related toincidence,causes and outcome
Hypertension is generally defined as blood pressure greater
than or equal to 140/90 mm Hg, using a mercury sphygmomanometer
and with a diastolic pressure based on Korotkoff phase V sounds
(Canadian Hypertension Education Program, 2003; World Health
Organization-International Society of Hypertension [WHO-ISH], 1999).
The presence of hypertension in pregnancy may be due to one or more
conditions: pre-eclampsia/eclampsia, gestational hypertension, chronic
hypertension, or pre-eclampsia superimposed on pre-existing chronic
11
hypertension. Standardization of classifications has been endorsed and
use of internationally-accepted definitions encouraged by the
International Society for the Study of Hypertension in Pregnancy
(ISSHP) (Brown, Lindheimer, de Swiet, Van Assche, and Moutquin,
2001; Davey and MacGillivray, 1988). Acute blood pressure elevation
may also occur in relation to cardiovascular reactivity or stress
response, some of which is known as white-coat hypertension. Although
blood pressure alone, at least via conventional means, is not a strong
predictor of adverse pregnancy outcomes (Zhang, Klebanoff, and
Roberts, 2001). It is still the most common sign clinicians use to monitor
hypertensive pregnancy and is relied on as a surrogate clinical marker
(Shennan and Halligan, 1999,cited by Moffat,2008).
A blood pressure measurement of more than or equal to 140/90
mm of Hg or an increase in arterial pressure of 20 mm of Hg, taken on
two occasions, at least six hours apart, but within one week or a single
reading of diastolic blood pressure more than 105 mm of Hg is
zconsidered as hypertension in pregnancy(Banashree Das 2003).
Pre-eclampsia is a multi-system disorder, characterized by
abnormal vasoconstriction of maternal blood vessels and increased
peripheral vascular resistance, leading to reduced organ perfusion,
increased blood pressure, and proteinuria (Dekker and Sibai, 2001;
Khalil and Granger, 2002); ranging from mild to severe, and can result
in negative sequelae as hypertensive crisis, abruption placenta,
12
intravascular disseminated coagulopathy, liver or renal failure,
cerebrovascular haemorrhage, coma and/ or eclampsia (seizures).
Prevalence rates are reported as between 7% to 10%, with maternal
mortality rates three times higher and perinatal mortality five times
greater than in the general pregnant population (Witlin and Sibai, 2001).
Hypertension in pregnancy is defined as BP≥ 140/90 mm of Hg
recorded six hours apart.Gestational hypertension is hypertension
occurring after twenty weeks of gestation without proteinuria. It is the
mildest form of presentation in the spectrum of pregnancy induced
hypertension (Friedman, 2003).
Nelson and Ester (1996) reported that Gestational Hypertension
usually recur in subsequent pregnancies, becomes more severe with
increase in age. Gestational Hypertension is the most frequent cause of
Hypertension during pregnancy. The incidence ranges between 6 to
18% in nulliparous and 6-8% in multipara (Knuist,1998).
A retrospective study to determine the maternal risk factors and
the outcome on mothers and neonates in developing hypertension
complicating pregnancies was conducted in Saudi Arabia (Abdul-Azize
and Associated, 2003). The results demonstrated that preeclampsia
was detected on a high percentage and 30% of women delivered
prematurely compared to healthy controls.Spontaneous vaginal
deliveries were less frequent in women with preeclampsia compared to
healthy controls. Placental abruption was the most common maternal
13
complications. The findings of perinatal outcome showed staggering
figures on still births and early neonatal deaths.
Pattinsonetal (1998) described the results of conservative
management in 34 patients who had severe pre eclampsia before 28
weeks. The patients were managed by bed rest, antihypertensive,
intensive foetal and maternal monitoring. Eleven patients presented
before 24 weeks, all of them resulting in perinatal deaths, and the
remaining 34 were between 24 and 37 weeks gestation with (38%)
resulting in a surviving infant. Maternal complications included three
cases (9%) of pulmonary oedema and one case (3%) with pleural
effusion.
Pre-eclampsia is not simply high blood pressure in pregnant
woman, but rather a multisystem disease affecting virtually every organ
system. Deficient placental implantation, poor placental perfusion and
reduced systemic organ perfusion are key elements in the pathology of
PIH (Roberts, 1993).
According to Johenning(1992), there is international debate
concerning the most appropriate end point for estimation of diastolic
blood pressure in pregnant women. Physicians in US use Korot-Koff
phase 5 (disappearance of sounds) while in England and Australia
recommend phase 4 (muffling).
Magee (2004) reported that a careful history of PIH should
include whether women have symptoms such as urinary disturbances,
14
epigastric pain and headaches. Sometimes nausea or even vomiting
can be a presenting feature. However,at least 50% of women even with
severe disease will be asymptomatic.
Mattar (2000) stated that oedema is neither sufficient nor
necessary to confirm the diagnosis of pre eclampsia. Oedema is a
common found in normal pregnancy and approximately one third of
eclamptic women never demonstrate the presence of oedema.
Hauth (2010) reported thatgestational hypertension is
considered seriously when it is associated with persistent headaches,
epigastric or right upper quadrant pain plus nausea and vomiting, foetal
growth restriction or with abnormal liver enzymes and the absence
orpresence of proteinuria.
The patient is usually seen remote from complaining of
epigastric pain or right upper quadrant pain (65%) some will have
nausea and vomiting (50%) and others will have no specific syndrome
like symptoms. Hypertension and proteinuria may be absent or slightly
abnormal. Physical examination will demonstrate right upper quadrant
tenderness and significant weight gain with oedema (Schwartz, 1993).
Criteria for diagnosis of pre-eclampsia include systolic blood
pressure 160 mm Hg or diastolic 110 mm of Hg; proteinuria 2-4+by
dipstick method on at least two random catch samples; Altered renal
function test or oliguria ≤500ml/24 hours of urine output, elevated liver
enzymes, generalized oedema or weight gain of at least 5 pounds in
15
one week; nausea and vomiting, persistent severe headache, visual
disturbances, epigastric pain. A weight gain of more than 1 kg per week
in last trimester is ominous (Salhan, 2007).
According to Mudaliar (2005) the average weight gain
throughout whole pregnancy is usually 8.12 kg. More important than the
total gain in weight during pregnancy is the rate at which this weight is
put on.A gain of five pounds in one week is cited as a warning sign of
pre-eclampsia. However rapid weight gain occurs in pregnancy and in
one group of women who became eclamptic only 10% manifested this
rapid weight gain (Cherley, 1998).
Headaches are usually present in severe forms of pre-eclampsia.
The pain may be occipital or frontal may be pulsatile or dull, many occur
simultaneously with visual symptoms, and may frequently be intense,
especially when preceding the onset of convulsions.
Preeclampsia is the commonest cause of iatrogenic prematurity
accounting for 15% of all premature births and approximately one in five
low birth weight infants < 1500g.
As family history in a first degree is strongly related to pre
eclampsia, this illustrates the significant genetic influence. Pre
eclampsia is more common in first pregnancies and even miscarriage or
termination of pregnancy will provide some reduction in risk(Strickland,
1999).
16
Approximately 1/3 women with gestational hypertension have a
substantial increase in poor maternal and perinatal outcome when
compared with normotensive women. They have increased incidence of
pre-term delivery and admission to neonatal ICU(Buchbinder et al.,
2002).
Shear and associates (2005) conducted a retrospective study in
Canada on PIH and its outcome on pregnancy among women with
severe preeclampsia. It was found that the majority of foetus born to
155 mothers subjected to the study had severe IUGR and they
concluded thatearly onset pre eclampsia is particularly involved with
placental insufficiency and more than half of babies from before 34
weeks will be growth restricted.
Yunsig et al. (2003) analysed the outcome of PIH in 255 women
at Turkey. The findings of the study revealed that out of 255 cases 138
patients were found to have severe preeclampsia. The delivery route
was vaginal in the case of 105 patients and caesarean section in that of
150 patients. Intra uterine foetal demise was observed in 24 cases and
perinatal mortality rate was found to be 144/1000 births.
• Literature on stress during pregnancy
Stress and anxiety have become so much a part of daily
experience that we fail to notice its harmful effects. It can build up
gradually over days, weeks and months until we emotionally recognize
symptoms of emotional or behavioural disturbance. There are both
17
physical and cognitive effects of stress. Physical effects include tight
muscles, rapid and shallow breathing, increased BP and heart rate,
adrenaline secretion and sweating. Cognitive effects can include
difficulty in concentrating and memory problems. It is necessary to
develop techniques to manage stress so that it doesn’t build to harmful
levels (Barrey, 2004).
David (1994) reported that several stress factors among
hospitalized pregnant women. They are separation from family
environment, patientstatus, worriesabout their own health, about
outcome of pregnancy and living conditions in hospital.
Women who are judged to have high-risk pregnancy report more
stress and anxiety than do women with a low-risk pregnancy (Da Costa
et al., 1999; Heaman, 1998; Leeners, Neumaier, Kuse, Bonzel, and
Rath, 2002; Yali and Lobel, 1999). A combination of stressors, including
the complication itself, heightened vigilance, a high-risk label,
uncertainty, and additional health monitoring and surveillance all may
serve as stressors in their own right, and can potentially raise anxiety
(Kemp and Page, 1986; Mercer and Ferketich, 1988; Reading, 1983).
Release of catecholamine and maternal vasoconstriction resulting from
physiologic arousal can restrict oxygen and nutrients to the fetus
(Copper et al., 1996), while fetal exposure to high levels of stress
hormones via the hypothalamic-pituitary-adrenal axis may contribute to
18
low birth weight and preterm birth (Challis et al., 2000; Sandman et al.,
1994; Wadwha et al., 1996).
Barbara (2005) reported that stress due to anxiety and fear can
also increase blood pressure. Longtime stress is beyond one’s control
allow the body to no recuperation time and can disable the body’s
natural ability to fight disease.
A descriptive co–relationalstudy identified that, women with
complicated pregnancies perceive their overall risk and risk for special
pregnancy outcome as significantly higher than women with
uncomplicated pregnancies. Stateanxiety and biomedical risk were
positively related to perception of risk (Gofton,2001).
Women are particularly susceptible to high blood pressure
during pregnancy and this is an especially dangerous time to have it. It
can develop through both external stress and the special physical
demands of carrying a child. Whatever the cause pregnancy induced
hypertension needs to be carefully monitored as around 5% of cases
develop into pre-eclampsia, a very dangerous condition. Stress plays an
important rolein high blood pressure and this complicates pregnancy
because pregnancy is often an extremely stressful period (Jan oliver,
2008).
Enhanced levels of stress, anxiety and depressed mood have
been found in pregnancy and these emotional states are associated
with altered physiological parameters. For example, when experiencing
19
stress or mental health problems, pregnant women’s peripheral
physiology is characterized by an up regulated activity of the
hypothalamic-pituitary—adrenal (HPA) axis. The HPA is one of the
primary stress systems in humans and regulates the release of
glucocorticoids such as cortisol whereas the sympathetic-adrenal-
medullary (SAM) system, a second important regulator of human stress
reactivity, releases the catecholamine norepinephrine (NE) and
epinephrine (E).During pregnancy, catecholamine levels have been
found to be elevated in women with occupational stress.Assessment of
E and NE is relatively uncommon during pregnancy since they need to
be measured in blood plasma and have half-lives of only about 2 min in
circulation. Indirectly, SAM activity can be assessed by measuring blood
pressure and heart rate changes (de Weerth andGuttel, 2005).
Studies have suggested that prenatal stress may be associated
with a spectrum of adverse pregnancy outcomes, including preterm
birth and low birth weight babies and other complications in mothers
(Hobelet al, 2008).
A body of recent epidemiologic research suggests that stressors
related to pregnant women’s employment are associated with
development of pre-eclampsia. A prospective cohort study of 717
women (Landsbergis and Hatch, 2000) showed positive associations
between psychosocial work stress and PIH. In another study, women
20
who worked outside the home were significantly more likely to develop
pre-eclampsia than those who didn’t (Higgins et al., 2002).
A prospective follow-up study was conducted to find out
the association between psychological stress during pregnancy
andstillbirth. Information was collected from 19282 singleton pregnant
women.Women with complications during pregnancy such as diabetes,
hypertension, vaginal bleeding, immunization and imminent preterm
delivery were excluded but the result was unchanged for still birth.They
conclude that psychological stress during pregnancy was associated
with an increased risk of stillbirth
(Wisborg, Barklin, Hedegaardand Henriksen).
Lydon, Dunne, Owens, Avalos, Sarma, O'Connor, Nestor and
McGuire (2012) examined the psychosocial profile of 25 women with
gestational diabetes mellitus (GDM) and compared them to 25 non-
diabetic pregnant women. Data collected through Pregnancy
Experiences Scale (PES), the Depression, Anxiety Stress Scale
(DASS), the Problem Areas in Diabetes Scale (PAID-5) and the
Perceived Social Support Scale (PSSS). The GDM group reported a
significantly greater ratio of pregnancy 'hassles' to pregnancy 'uplifts'.
The GDM group also had a significantly higher depression score.
Elevated levels of diabetes-related distress were found in 40% of
women with GDM. Study indicates that the experience of GDM appears
to be associated with increased psychological distress in comparison to
21
the experience of non-diabetic pregnant women. This may indicate the
need for psychological screening in high risk pregnancy and the
provision of psychological support to cope up with pregnancy specific
stress.
YaliandLobel(1999) investigated coping and distress among
high risk pregnant women.The association between coping and
pregnancy-specific distress was examined in 167 pregnant women at
high risk. Women were experienced moderately high levels of distress
about preterm delivery, physical symptoms, labor and delivery, weight
gain, and having an unhealthy baby. They managed the demands and
challenges of pregnancy through prayer and positive appraisal as best
coping methods.The investigators found that age of woman, income,
education, and parity were significantly associated with ways of coping.
Coping by avoidance, preparation for motherhood, and substance use
were associated with greater distress, whereas coping by positive
appraisal was associated with less distress.
Daniells, Grenyer, Davis, Coleman, Burgess, and Moses (2003)
examined anxiety levels of women diagnosed with gestational diabetes
and to compare these with glucose-tolerant (GT) .The sample consisted
of 50 each and the result revealed that women with GDM had a higher
level of anxiety at the time of the first assessment when compared with
GT women.
22
Nisha (2006) conducted a study on effect of music therapy on
physiological indicators and stress level among women with PIH at
Kozhikode. The findings revealed that the subjects experienced moderate
level of stress and also music therapy found significantly effective in reduction
of stress (t=12.6,p<0.05) among experimental and control group.
A retrospective study conducted by Black (2007) on psychological
stress, preeclampsia/gestational hypertension symptoms, confidence in self-
monitoring, well-being, and perceived social support with
preeclampsia/gestational hypertension disease progression in one hundred
postpartum women with PIH. The findings revealed that psychological stress
was significantly higher (p=0.04) in women with PIH. Worsening/severe
preeclampsia/gestational hypertension was associated with increasing
psychological stress and a higher number of preeclampsia/gestational
hypertension symptoms.
Brigitte, Peruka, Sabine, Ruth Stiller, and Werner (2007) investigated
the correlation between emotional stress during pregnancy and the risk for
PIH. A self-administered questionnaire comprising obstetrical and
psychosocial questions was completed by 725 patients and 880 controls
matched for age, parity, nationality, and educational level. The results
revealed that emotional stress during pregnancy was associated with a 1.6-
fold increased risk for PIH and the investigator concluded that psychosocial
interventions to reduce emotional stress during pregnancy may help to
decrease the risk to develop PIH.
22a
Sudha (2000) explored and assessed the levels of stress and its
manifestation and different stressors in women with PIH and identified the
coping strategies used by women with PIH in response to stress. The coping
strategies were assessed by Jalowiec coping strategies and the findings
revealed that the mean percentage score was higher in the area of optimistic
(13.72%) coping strategies as compared to other coping strategies. The
standard deviation (± 0.56) computed between coping strategies shows that
fatalistic coping scores were apparently more dispersed in comparison with
other coping strategies.The effectiveness of Jalowiec coping strategies was
found in all eight coping strategies.The study concluded that coping was
effective only with adequate support.
A study aimed to describe psychological consequences, interventions
and outcomes in a population of women from a tertiary centre during February
2004 to April 2007, 141 women with a history of PIH were referred to the
medical psychologist. Obstetrical history, reason for referral to medical
psychologist, medical psychological conclusion after intake, treatment and
outcome were evaluated. Results showed that the referral was mainly for
dysfunctional coping. Most women were Caucasian primiparous who
delivered preterm by ceserean section of growth-restricted infants. Twenty-
two women received therapy, one was referred to a medical social worker, did
not need therapy. The main interventions were psycho-education (n = 18),
supportive techniques (n = 10), increasing autonomy techniques (n = 8) and
eye movement desensitisation and reprocessing (n = 7). Duration between PE
and consultation of medical psychologist was significantly related to the
number of sessions (p < 0.01, Pearson correlation = 0.609).( Yvonne,
Petrouschka, and Johanna .,2009).
22b
A study included two groups of women--100 women with PIH and 100
of women with normal course of pregnancy, which were tested using two
questionnaires concerning pregnancy as a stressful event and using
strategies for coping with stress.Women with PIH experience pregnancy in a
more stressful way than women with regular course of pregnancy. However, it
is necessary to point out that respondents of both groups thought that
pregnant women seek attention from everyone from their environment, and
that their husbands/partners should pay special attention to them during
pregnancy. The importance of relationship between partners during
pregnancy and the emotional life of pregnant woman has been also examined
by other researchers. These data suggest that pregnancy is an emotionally
vulnerable period during which women demand special attention from the
environment and especially from their husbands/partners. In view of using
particular strategies to cope with stress, certain differences have been
registered between the two groups of women. Namely, women with PIH utilize
much more the mechanism of seeking social support and much less the
mechanism of positive redefinition, compared with women with normal course
of pregnancy. The investigator concluded that the psychosocial approach,
pregnancy may be considered as a specific state of high emotional tension,
which can represent a potent stressor. In the frame of specific reactions to
stress, pregnancy as a stress-inducing situation may lead to transformation of
emotional tension to biochemical and vegetative response, and thus
contribute to onset of pregnancy-induced hypertension( Bjelica, 2004).
22c
A study was carried out to identify the correlation between stress
and risk for hypertensive disease in pregnancy. A questionnaire on
obstetrical and psychosocial aspects was collected from 725 study
group and 880 controls. Homogeneity of sample was assured by
matching age, parity, nationality, and educational level. Findings of the
study revealed thatemotional stress during pregnancy was associated
with increased risk forhypertensive disease in pregnancy. The study
concluded that psychosocial interventions to reduce emotional stress
during pregnancy may help to decrease the risk to develop hypertensive
disease (Brigitte, Wagner, Kuse, Stiller, and Rath, 2007).
• Literature on stress and coping strategies
Coping hasbeen defined as "cognitive and behavioural efforts to
manage specific external and/or internal demands thatare appraised as
taxing or exceeding the resources of the person" (Lazarus and
Folkman, 1984).Coping by this definition involves the interaction
betweenthe person and his or her environment, and it isreasonable to
expect variation among people in their predispositions to cope in
particular ways. Because optimismaffects both how people look at the
world (appraisal)and their behaviour in it (effort), it is a likely candidate
to influence coping behaviours and thereby affect adjustment.Coping
strategies are thought to consist of both cognitions and behavioursthat
are directed at managing a problem and its attendant negative
emotions. In a transactional scheme, stressors arise because of a
23
perceived shortfall of resources needed to deal with a problem, once
the resources have been developed, the situation is no longer perceived
as stressful-unless the situation somehow becomes altered and the
routines are no longer adequate (Webb, 1999).
To obtain information regarding the responses to stress and the
degree of stress experiences, a sample of 120 pregnant adolescents
was given three measures of stress: the State TraitAnxiety Inventory
(STAI), the Sources of Stress Inventory, and the Pregnant
Adolescent/Adolescent Mother Stress Measure. A majority of the
respondents reported experiencing dysphoric affect in response to
stress. Specific coping strategies for dealing with stress were employed
infrequently and were viewed as minimally effective. When coping
strategies were used, those employed were more often adaptive (e.g.,
relaxation, distraction) than maladaptive (DianeAnda et.al, 1993).
• The effects of relaxation on stress
Stress is often defined as the psychological and physiological
condition that we experience when we perceive a situation as
threatening or demanding (Jacobson, 1963).Science had already
proven that stress is a causative or aggravating factor in many common
diseases. According to him when doing progressive muscle relaxation
therapy, our body will be at ease, adrenaline levels are low, breathing is
deep, BP is low, blood vessels are dilated and immune responses are
doing its work properly (Smith, 2007).
24
Stress and anxiety have become so much a part of daily
experience that we fail to notice its harmful effects. It can build up
gradually over days, weeks and months until we emotionally recognize
symptoms of emotional or behavioural disturbance. There are both
physical and cognitive effects of stress. Physical effects include tight
muscles, rapid and shallow breathing, increased heart rate and blood
pressure, adrenaline secretion and sweating. Cognitive effects can
include difficulty in concentrating and memory problems. It is necessary
to develop techniques to manage stress so that it doesn’t build to
harmful levels (Barrey, 2004).
The interest in complementary and alternative therapies has
increased significantly in past fifteen years. Complementary therapies
are those therapies used in addition to conventional treatment
recommended by the person’s health-care provider (Pelletier, 2000).
There are many benefits of being able to induce relaxation
response in our body. Some benefits include reduction of generalized
anxiety, prevention of cumulative stress, increased energy, improved
concentration, reduction of physical problems and increased self -
confidence (Bourne, 2000).
According to John Astin and Shapiro (2003) there is
considerable evidence that an array of mind/body therapies can be
used as an effective adjustment to conventional medical treatment for a
number of clinical conditions. Literature was reviewed to examine the
25
efficiency of representative psychosocial mind body therapy intervention
including relaxation, cognitive behavioural therapy, imagery, meditation
etc. Isometric contraction and relaxation of large muscle groups of face,
neck, hands, shoulder, back, stomach, thighs and leg muscles for 30’ to
1 minute each exercise for total of 25-30 minutes.
According to Lambert (2000), progressive muscle relaxation
technique is a technique where an individual tense and relax one at a
time, all major muscle groups of the body. The idea is to tense each
muscle group hard for 10 seconds & then let it go suddenly. Then give
15-20 minutes to relax and become aware of contrast between feeling
of relaxation and how it felt when tensed. Then move on to next muscle
group until whole body is worked through. Often it is helpful to have
some quiet gentle music in background, regular physical exercise helps
reduce stress.
Chellammal (2004) reported that progressive muscle relaxation
technique reduces preoperative anxiety. Study findings showed that
there is a significant reduction in anxiety on pre and post-test
experience. Progressive muscle relaxation techniques are helpful in
reducing anxiety.
Jacqueline (2002) studied autogenic training technique on both
visual imagery and body assessments to move a person into a state of
deep relaxation. The person imagines a peaceful place and focus on
different physical sensations moving from feet to the head. For example
26
one might focus on warmth and heaviness in limbs, natural breathing or
a calm heartbeat.
There is accumulating evidence that pregnancy is accompanied
by hypo responsivity to physical, cognitive, and psychological
challenges. This study evaluates autonomic blunting extends to
conditions designed to decrease arousal. Physiological and
psychological responsivity to an 18-min guided imagery relaxation
protocol in healthy pregnant women during the 32nd week of gestation
(n=54) and non-pregnant women (n=28) was measured. Data collection
included heart period, respiratory sinus arrhythmia, tonic and phasic
measures of skin conductance, respiratory period, and self-reported
psychological relaxation. The findings support non-specific blunting of
physiological responsivity during pregnancy (Di Pietro, Mendelson,
Williams and Costigan, 2012).
According to Woods (2002) progressive muscle relaxation
technique helps to achieve and maintain ideal body weight – a key goal
to fight pregnancy induced hypertension. Regular practice of deep
progressive muscle relaxation technique for 20-30 minutes on a daily
basis can produce over time a general feeling of relaxation and well-
being that benefits every year of life.
A recent controlled clinical trial compared infertile women
receiving either group support or cognitive behavioural therapy together
with relaxation training. With a control group receiving only usual care
27
for infertility, Relaxation training included meditation, progressive
muscle relaxation, guided imagery and Yoga. The three arm trial found
that women receiving either group support or cognitive behavioural
therapy in conjunction with relaxation training were more likely to
become pregnant than the control group during a one year follow up
(Domar, 2000).
According to Kreydin (1999), prenatal relaxation techniques and
massage therapy is a common modality used by expecting woman
during pregnancy. Body work therapy like relaxation techniques can
bring relaxation and an improved sense of well-being to a pregnant
woman.
A study conducted by the University of Toronto (2002) relaxation
and BP in pregnancy (REBIP) to identify the effectiveness of relaxation
technique on blood pressure in Hypertensive pregnant woman. Day
time ambulatory mean arterial pressure both systolic and diastolic and
heart rate is taken and maternal anxiety have been checked. This study
carefully indicates that relaxation methods can reduce blood pressure
and anxiety for people with pregnancy induced hypertension.
Women are particularly susceptible to high blood pressure
during pregnancy and this is an especially dangerous time to have it. It
can develop through both external stress and the special physical
demands of carrying a child. Whatever the cause pregnancy induced
hypertension needs to be carefully monitored as around 5% of cases
28
develop into pre-eclampsia, a very dangerous condition. Stress plays a
large part in high blood pressure and this complicates matters because
pregnancy is often an extremely stressful time (Oliver, 2008).
Esch and colleagues (2003) reviewed the therapeutic use of
relaxation response in 154 stress related disease in the U.S. The results
demonstrated that relaxation response is an appropriate tool to
counteract stress related disease process in immunological,
cardiovascular and neuro degenerative disorders. These techniques
may also serve as primary or secondary means of prevention.
Relaxation can be successfully applied to pregnant women with
Pregnancy Induced Hypertension. There is significant decrease in mean
arterial pressure in a relaxation training group from entry into study to
one week prior to as opposed to increased blood pressure levels in a
bed rest (Somers, 1999).
A pre-test-post-test experimental design with a convenience
sample of 60 subjects was used to examine the effects of a relaxation
with guided imagery protocol on anxiety, depression, and self-esteem in
primiparas during the first 4 weeks of the postpartum period. The results
showed that the experimental group had less anxiety and depression
and greater self-esteem than did the control group at the end of the
period. Positive correlations were obtained between anxiety and
depression; negative correlations between self-esteem and anxiety and
depression (Ree, 1995).
29
A study to investigate the effect of applied relaxation to reduce
anxiety and perceived stress in women with PIH. The findings
suggested that beneficial effect of relaxation on reducing perceived
stress in pregnant women with PIH (Bastani and Varfari, 2007).
`A prospective study was undertaken to determine the effect of
breathing and meditation on the birth outcomes of high risk pregnancy
on 335 women in Bangalore (Narendran, 2005). The results of the study
revealed that the number of babies with birth weight >3500gms were
significantly higher in the experimental group than control group.
Preterm deliveries were significantly lower and complications like IUGR
and PIH were also significantly lower in experimental group.
Janke (1999) conducted a quasi-experimental study to examine
the effect of PMR on 107 women with preterm labour. The results
revealed that experimental group had significantly longer gestation and
larger new-borns when compared to the control and non-adherent
group. The investigator recommended that being the low cost of the
intervention, it should be offered to all women at risk.
An exploratory study was conducted to examine the effect of an
eight week psycho physiological stress reduction programme on 21
German participants with chronic physical, psychosomatic and
psychological illness (Majundar and co-workers, 2002). The report
shows that overall intervention lead to high levels of adherence to the
30
meditation practice and lasting effect on reduction of symptoms.
Positive complementary effect with psychotherapy was also found.
Weber (1996) did a study to investigate the effects of relaxation
exercises on stress level on 39 subjects by state Trait Anxiety
inventory.Relaxation exercises such asPMR, meditative breathing,
guided imagery, soft music etc. were employed to promote
relaxation.The finding shows a significant reduction in anxiety
level.Thus,PMRwas helpful in reducing stress.
Jeanne (2008) reported that the body’s natural relaxation
response is a powerful antidote to stress. Relaxation techniques such
as deep breathing, visualization, progressive muscle relaxation,
meditation, and yoga can help you activate this relaxation response.
When practiced regularly, these activities lead to reduction in our
everyday stress levels.
Relaxation techniques can reduce negative responses to stress
and help you enjoy a better quality of life. Relaxation techniques are a
great way to help one quest for stress management. Relaxation is not
just about peace of mind or enjoying a hobby. Relaxation is a process
that decreases the wear and tear of life’s challenges on your mind and
body (Earnest, 2006).
Creating the experience of relaxation is vital to offset the harmful
effects of receiving stress on the body. Through the regular practice of
relaxation techniques one can begin to reverse this cumulative
31
damaging process, and engage the body’s amazing possibility for self-
healing. PMR is also known as a guided body scans and is a very
valuable stress relief technique (Sandi, 2008).
Bastani et al. (2006) conducted a randomized control trial on
110 Iranian primi gravid women to determine the effect of relaxation
education on anxiety and pregnancy outcome such as low birth weight,
preterm birth and surgical delivery. The findings revealed that there
were significant reductions in low birth weight, caesarean section and
/or instrumental extraction among experimental group compared with
control group.
A good relaxation technique is an anti-stress weapon to help you
deal with any stressful situation as it arises. Stress reduction exercise
uses progressive muscle relaxation focus on slowly tensing and relaxing
muscle groups. This helps to focus on the difference between muscle
tension and relaxation, and to become more aware of physical
sensations (Jane, 2008).
Relaxation techniques encompass a wide variety of stress
management methods for slowing down the body and stilling the mind.
Meditation, PMR, breathing exercises and guided imagery are
relaxation techniques used in clinical settings to help patients regulate
their reactions to stress and achieve overall wellbeing. The relaxation
response is characterized by decreased BP heart rate, respiratory rate,
32
O2 consumption, muscle tension as well as increased alpha wave brain
activity (Romesh, 2005).
A controlled clinical trialshows the differences in perceptions of
physical and mental energy and positive and negative mood states
throughpractising breathing and relaxationand visualization techniques.
Result showed that a significantly greater increase in perceptions of
mental and physical energy and feelings of alertness and enthusiasm
compared with the relaxation and visualization groups (Wood 1998).
Jallo et al (2009)investigated the effects of relaxation-guided
imagery (R-GI) on perceived stress, anxiety, and corticotrophin-
releasing hormone (CRH) levels. A controlled randomized experimental
design with two groups selected. Study measures included the
Perceived Stress Scale, STA Inventory, and plasma CRH levels
collected at three time points. The findings support that the R-GI
intervention reduces anxiety, daily stress levels and reduce preterm
birth.
Kavitha(2009) conducted a study on effectiveness of guided
imagery on women with PIH. 30 women admitted in Madurai Medical
College Hospital were selected using purposive sampling technique.
Intervention on guided imagery was administered using the audio CD
for 20 minutes two times a day for 5 days.Findings revealed that the
mean blood pressure had reduced significantly.
33
Guided imagery provides an alternate focus of attention, and when that
focus is relaxation, increases a sense of emotional and cognitive calm (Fors
et al., 2002; Harvey & Payne, 2002; Lee &Olness, 1996; Lyles et al., 1982;
McCaffery, 1990), thereby eliciting a psychophysiological relaxation response
among women with PIH (Achterberg, 1985; Baider et al., 2001; Baider et al.,
1994; Butcher & Parker, 1988; Esplen et al., 1998; Hammer, 1996; McCaffery,
1990; Sheikh et al., 2002). Additionally, the calm and relaxation response that
guided imagery provides may serve as a coping strategy for the mother.
Potentially this intervention could influence both sympatho-adreno medullary
system (SAM) and hypothalamic-pituitary- adrenal (HPA) systems and
provide counterbalance thus benefiting peripheral vascular resistance and
blood pressure.Hence guided imagery is beneficial as a relaxation technique
in high risk pregnancies.(Steptoe, 1988; Titlebaum, 1988, cited by Moffat,
2008).
Gisha (2005) evaluated effect of relaxation therapy on level of stress
and physiological outcome of women with PIH. The findings revealed that
there was significant reduction in stress level among experimental group than
that of control group (t=12.2, p<0.001) and there was significant reduction in
mean blood pressure and other physiological markers such as headache,
proteinurea and weight among experimental group after relaxation therapy.
Reshma (2008) conducted a study on effect of relaxation therapy on stress
and physiological parameters among women with PIH. The sample of 30
antenatal mothers with 30- 38 weeks of gestation were included in the study.
The relaxation therapy was administered for 30 minutes daily for 2 weeks.
The findings revealed that there was a significant positive change in mean of
33a
pre therapy scores of physiological parameters and mean of post therapy
scores. There was significant reduction in the stress level after relaxation
therapy (t=12.4, p 0.000<0.05). The study concluded that relaxation therapy is
effective in coping stress among women with PIH.
Neethu and Sumathi (2014) conducted a study to assess the
effectiveness of Benson’s relaxation therapy on stress and coping among 30
mothers with high risk pregnancy. The findings of the study depicted that the
evidence of significant difference between pre and post-test values of stress
and coping after intervention. (Stress, t=37.7; coping, t=29.1 and p=0.000).
Rauchfuss, Enderwitz , Maier and Frommer (2012) conducted a study on
experience of pregnancy for women with pregnancy-induced hypertension.
Results revealed that a weak expression of their emotions was observed.
Additionally, the majority of women reported a rather disturbed relationship
with their physicians. Stress and PIH are intertwined. This is presented in the
literature available about this subject. Qualitative research produces only
contextual and subjective evidence; nevertheless this is the most concrete
base that one can obtain. Only a readiness to deal with conflicts developing
during pregnancy and the expression of also negative emotions towards
relevant third persons would be helpful to cope with one's own negative
feelings. The concluded that the practical impact on care for women with PIH
is awareness for their underlying conflicts, weak emotional expressivity and
provision of an adequate supply of psychological support.
33b
Thangamani (2009) conducted a study on blood pressure before
and after the Bensons relaxation therapy among PIH mothers in
selected hospitals, Salem. The results revealed that there was a
significant reduction in mean systolic blood pressure.
Reviewsof studiesshowthat the effects of relaxation techniques
during pregnancy positively associated with maternal and foetal
outcome among women with high risk pregnancy. Identifying pregnant
women at risk and instituting relaxation programme early in pregnancy
especially in high risk condition improve obstetric and developmental
outcomes for both the mother and her foetus (Fink, Urech,Caveltand
Alder, 2010).
Effect of relaxation on coping
Kushnir, Friedman andEhrenfeld(2012) evaluated the effects of
listening to selected music while waiting for a caesarean section on
emotional reactions, on cognitive appraisal of the threat of surgery, and
on stress-related physiological reactions.A total of 60 healthy women
waiting alone to undergo an elective caesarean section for medical
reasons only were randomly assigned either to an experimental or a
control group. An hour before surgery they reported mood, and threat
perception. Vital signs were assessed by a nurse. The experimental
group listened to preselected favourite music for 40 minutes, and the
control group waited for the operation without music. At the end of this
period, all participants responded to a questionnaire assessing mood
34
and threat perception, and the nurse measured vital signs.Women who
listened to music before a caesarean section had a significant increase
in positive emotions and a significant decline in negative emotions and
perceived threat of the situation when compared with women in the
control group who exhibited a decline in positive emotions, an increase
in the perceived threat of the situation, and had no change in negative
emotions. Women who listened to music also exhibited a significant
reduction in systolic blood pressure compared with a significant
increase in diastolic blood pressure and respiratory rate in the control
group. Listening to favourite music immediately before a caesarean
section may be a cost-effective, emotion-focused coping strategy.
• Literature on pregnancy outcome of PIH
Five to eight percentage of all pregnancies, preeclampsia and
hypertensive disorders of pregnancy are major causes of maternal, fetal
and neonatal morbidity worldwide. Hypertension is a sign of pre
eclampsia and both conditions may create morbidity. Foetal and
neonatal consequences include IUGR, still birth and severe prematurity
due to delivery for maternal indications (Chang, 2004).
A population based study conducted by Ananth, Cande, Basso
and Olgabto examine trends in stillbirth and neonatal mortality related to
PIH in the USA between 1990 and 2004.Results showed that PIH
increased from 3% in 1990–1991 to 3.8% in 2003–2004. In both
periods, PIH was associated with a higher risk of stillbirth and neonatal
35
death and observed that the increased risk of PIH-related stillbirth was
higher in women having their second or higher-order births compared
with women having their first birth. The findings conclude that a
substantial burden of stillbirth and neonatal mortality is associated with
PIH, especially among multiparous women.
Krabbendam et al examined the association between stress and
pregnancy outcome.A prospective cohort study of 5511 pregnancies
was conducted in 2001-03 in the Netherlands. The results support a
direct relationship between perceived stress and adverse pregnancy
outcome. Demographic variables may explain the association between
psychosocial stress and pregnancy outcome to a significant degree.
Bastani et al. (2006) conducted astudy to determine effect of
relaxation education in anxious pregnant women in their first pregnancy
on birth weight, preterm birth, and surgical delivery
rate.Theexperimental group received routine prenatal care along with 7-
week applied relaxationtraining sessions, while the control group
received only routine prenatal care. Result revealed that significant
reductions in low birth weight, caesarean section, and/or instrumental
extraction were found in the experimental group compared with the
control group. The findings suggest beneficial effects of nurse-led
relaxation education sessions during the prenatal period.
The adverse perinatal outcome are higher in severe gestational
hypertension than in mild pre-eclampsia, i.e. in women who have
36
gestational hypertension or pre-eclampsia increased rate of pre-term
delivery and delivery of small for gestational age infants.
Yadav, Saxena, Yadav, and Gupta (2004) conducted a case
controlled prospective study of 250 cases of hypertension complicating
pregnancy and 400 normal pregnant women to determine the effect of
hypertension on maternal and foetal outcome. The study was carried
out at the Department of Obstetrics and Gynaecology, Safdarjang
Hospital, New Delhi. The analysis of the data concluded that maternal
hypertension was associated with increased incidence of preterm
delivery, labour induction, caesarean section, still birth and overall
perinatal mortality compared to control group.
A cross-sectional analytical study was conducted by Buga and
Lumu (2002) to determine the complications and perinatal outcome in
patients with hypertensive disorders of pregnancy and found that
Hypertensive Disorders of Pregnancy were a major cause of maternal
and perinatal morbidity and mortality.
Jantasingand Tanawattanacharoen(2005) conducted a study to
determine perinatal and maternal outcomes in severe preeclamptic
women between 24-33-week gestations and compared the outcomes
between expectant and aggressive management.The outcomes were
analysed according to the gestational age on admission (< 28 weeks'
and > or = 28 weeks' gestation). The result shows that the perinatal
morbidity and mortality were significantly high in the gestational age <28
37
weeks group. There were 11 perinatal deaths, 8 in those managed at <
28 weeks and 3 in those managed at 28-29 weeks' gestation (p < 0.05).
Maternal morbidities were similar among both groups. The study
concluded that delivery at earlier weeks of pregnancy increases
neonatal morbidity and mortality in severe preeclamptic women.
Fatemeh,Marziyeh, Nayereh, Anahitaand Samira evaluated
maternal and perinatal outcome in nulliparous women in 2008 and
compared for maternal and perinatal outcomes. The results revealed
that maternal and foetal-neonatal complications mostly appear in
pregnancy complicated with hypertension.
Stress in pregnancy predicts earlier birth and lower birth weight.
The authors investigated whether pregnancy-specific stress contributes
uniquely to birth outcomes compared with general stress, and prenatal
health behaviours. Main outcome measures were Gestational age at
delivery, birth weight, preterm delivery (<37 weeks), and low birth
weight (<2,500 g). Results showed that alatent pregnancy-specific
stress factor predicted birth outcomes better than latent factors
representing state anxiety and perceived stress.They concluded that
pregnancy-specific stress contributed directly to preterm delivery and
indirectly to low birth weight(Lobel et al, 2008).
Prenatal psychosocial predictors of infant birth weight and length
of gestation were investigated in a prospective study of 120 Hispanic
and 110 White pregnant women. Hypotheses specifying that personal
38
resources (mastery, self-esteem, optimism), prenatal stress (state and
pregnancy anxiety), and socio-cultural factors (income, education,
ethnicity) would have different effects on birth outcomes were tested
using structural equation modelling. Results confirmed that women with
stronger resources had higher birth weight babies whereas those
reporting more stress had shorter gestations. Resources were also
associated with lower stress, marital status,ethnicity, income and
education, and first time mothers(Rini, Dunkel, Wadhwa and Sandman
1999).
Mulder et al evaluatedthe existing evidence of comparable
effects of prenatal stress on human pregnancy and child
development.Result revealed that pregnant women with high stress are
at increased risk for spontaneous abortion and preterm labour and
malformed or growth-retarded baby. These problems might be reduced
by specific stress reduction programmes.
39
Need and Significance of the Study
One of the great wonders of nature is the growth of a foetus
within the womb of mother. The growth and development of the baby
dependent on thehealth and nutrition of the mother because she is the
seed and the soil for nurturing the baby for a period of nine
months,according to Meharban Singh(2001).
PIH is a chronic illness which is developed only during
pregnancy. It can be controlled by regulation of diet, relaxation by
avoiding stress, early identification and medication, monitoring blood
pressure level, rest, and urine testing for the presence of albumin and
by making some adjustment in life styles (Mani, 2003).
Pregnancy in itself is a stressful period, full of anxiety, hope, fear
of outcome and death. High risk pregnancies like PIH add up to it in the
way of increased stress effect on physical, physiological, psychological,
diet modification and bed rest. Diagnosis of PIH adds up to the stress of
being pregnant and coping mechanisms seen to fail (Pasquali, Arnold
and Alesi, 1985). Mothers experience fear, anxiety, despair, loneliness,
isolation and various other stressful psychological experiences. Natural
anxiety is an everyday phenomenon, with a motivating function that
mobilizes resources for the adaptation of the individual to new
situations. When anxiety cases are simpler, superposition of symptoms
is higher, as well as the lack of specificity in the clinical condition. In this
40
sense, anxiety and depression maybe part of the general “stress
process”.
Stress is present in confinement and immobilization. Women
experience profound changes in emotional, social and cognitive status.
Women with PIH may advocate for bed rest, experience sensory
deprivation or overloads due to immobilization which are stressors that
are intervene with each other. Associate with immobilization and
oedema of PIH are often changes in body image as well as normal
bodily functions such as breathing, urinating and defecating.
The women with PIH never subjected to great worries about their
physiological alteration, growing foetus and outcome of pregnancy. The
long term hospitalization had an added effect to the disease condition.
Moreover they suffer from sleep disturbances and mood fluctuations.
For instance antihypertensive drugs will cause foetal complications like
IUGR (Chobain et al, 2003).
The end result of pregnancy induced hypertension is decreased
perfusion, resulting ischemia particularly to placenta, liver, kidney and
brain. The foetus may be significantly impaired by decreased utero-
placental perfusion. In case of longstanding hypertension, the foetus is
at increased risk for mortality and morbidity such as IUGR.
Vijayakumar et.al (2003) conducted a survey with the objective of
determining the causes of maternal deaths at the Institute of Maternal
and Child Health (IMCH), Calicut for the years 2000-2002.The records
41
of IMCH were analyzed and conclusions were drawn from the
documented facts. The total number of deaths recorded in the three
years of study was 60. Of the total number of deaths it was noted that
90.2% of the women were from rural areas, the rest 9.8%was from
urban areas. Almost 90%of the mothers who succumbed to various
complications came from rural areas after initially receiving treatment
from various local hospitals and being referred to the IMCH when the
condition of the patients gets worsened. It was noted that among the
maternal deaths, 43.3% were primigravidae, the rest being multi
gravidae. 3.3% of the women had a confirmed history of previous
termination ofpregnancy.1.6% of the women had a previous abortion.
Among the cases it was noted that 65%of the fetuses were still born
and the rest of the 35% were relatively well neonates. The causes of
deaths in the mothers were uncontrolled PIH and eclampsia-68.3%,
uncontrolled haemorrhage-30%, jaundice-10%, anaemia-3.3%,cardiac
arrest-5% and rupture uterus-5% (overlapping figures are seen due to
multiple causes being attributed to some of the patients). The
predominant causes of maternal death are PIH and eclampsiawhich
warrant unique intervention strategies right from the sub center level to
the tertiary care hospital.
According to the annual statistics of IMCH (2007), the total
number of PIH in IMCH Kozhikode is 1719 (7.5%). Among these cases,
mild hypertension are 1376, severe hypertension 198, hypertension
42
complicating pregnancy 55, eclampsia 59, HELLP 29 and acute fatty
liver of pregnancy 2 cases. This emphasizes the significance of PIH in
this setting. Kerala’s healthcare and organizational setup of health
service are unique and comparable to the standards of developed
countries. In spite of all these advancements PIH act as a potent threat
to the women. Hence the predominance of PIH in maternal mortality
warrants unique intervention strategies.
Since the treatment with antihypertensive drugs produces
adverse effects on the foetus, the nurses must choose simple,
conservative, nonintrusive methods which meet little resistance from
other health professionals. Researchers had brought to light the
promising effect of non-pharmacological interventions like relaxation
therapy, guided imagery and music therapy in normalising the
physiological alterations and stress. Progressive relaxation studies had
shown that the relaxation is effective in lowering blood pressure of
persons with chronic hypertension (Boback, 1987). At this juncture a
non-pharmacological method of treatment which is both conducive to
the patients’ health and economy needs to be advocated. Even though
the effects of relaxation programme on blood pressure, stress, pain and
anxiety were widely expressed, little explorations were done in PIH.
In integrating complementary and alternative therapy, Herbert
Benson established a model for stress induced high blood pressure.
43
Procedures evolved some changes as autogenic training and
progressive muscle relaxation (Herbert-Benson, 1998).
Disease and illnessparticularly blood pressure is initiated and
aggravated by 80% of stress. Measures of relieving blood pressure are
to carry out progressive muscle relaxation; tensing each muscle group
than thinking that muscles are heavy comfortable, relaxed, warm,
smooth at ease, calm and breathe deeply (Gayle Kimball, 2007).
Apart from the side effects of antihypertensive, relaxation
techniques and rest in hospital or home setting is helpful for continued
evaluation and treatment of patient. This will increase the blood flow
promoting diuresis, increases uterine blood flow and improve placental
perfusion and reduce blood pressure.
Relaxation exercises are simple, safe or economic. They help in
preventive and promotive aspects of health and illness where as long
term drug consumption for hypertension can have side effects upon
human system and it also involve heavy cost (Howley, 2003).
44
Prevalence of high risk cases in IMCH during 2007 to 2010
Table 1
Distribution of high risk cases in Institute of Maternal and Child
Health, Kozhikode.
According to table 1,PIH is second prevalent high risk case
among the total deliveries during the past four years and the percentage
was increased from 8 to 9.6.It shows the severity of this disease among
pregnant women admitted in this institution.
PIH is one of the leading causes of maternal mortality and
morbidity in IMCH. Moreover, the investigator during her clinical
experience realised that most of the women with PIH belong to younger
age groups; its impact on the loss of life is irreplaceable. Pregnancy is a
long-term process and women with PIH have to wave through the entire
S No
Particulars 2007 % 2008 % 2009 % 2010 %
1 PIH 1610 8 1398 8 1472 9.2 1924 9.6
2 GDM 639 3.2 568 3.3 747 4.6 591 4.7
3 Anaemia 743 38.3 6435 36.9 5986 37.2 4436 34.9
4 Heart Disease
163 0.81 173 0.99 157 0.98 141 1.1
5 Abruption 218 1.1 234 1.3 135 0.84 190 1.5
6 Placenta previa
139 0.69 150 0.86 149 0.93 135 1.1
7 Atonic PPH 73 0.36 79 0.45 46 0.29 28 0.22
8 Traumatic PPH
23 0.11 28 0.16 20 0.12 18 0.14
9 Total Deliveries
20206 - 17454 - 16081 - 12699 -
10 Maternal Death
20 - 11 - 10 - 10 -
11 MMR - 100.41 - 63.21 - 62.27 - 78.95
45
period without complications. By considering the high risk status of
pregnancy, age of the woman and concerns foetal health, a non-
pharmacological measure like relaxation programme will be helpful to
minimize the complications. The relaxation programmes like guided
imagery, progressive muscle relaxation and deep breathing – all simple,
safe, low cost measure without any side effects that can be practised by
women with PIH of all strata and positively influence the outcome of
pregnancy on women with PIH. Keeping conducive internal and external
maternal environment is necessary to help the foetus get a healthy stay
inside the womb. Viewing this, the investigator developed a keen
interest in reducing maternal stress and anxiety during pregnancy
through the relaxation programme, thereby keeping the mother and
foetus/ new born emotionally and physically healthy.
Statement of the Problem:
A study to evaluate the effectiveness of relaxation programme
on level of stress, coping strategies and pregnancy outcome among
women with pregnancy induced hypertension, admitted in the Institute
of Maternal and Child Health, Kozhikode.
Title of the Study: Effectiveness of relaxation programme on
institutionalised women with pregnancy induced hypertension.
46
Objectives of the study
1. To assess the level of stress experienced by women with PIH
before and after relaxation programme.
2. To assess the coping strategies used by women with PIH before
and after relaxation programme.
3. Evaluate the effect of relaxation programme on level of stress of
women with PIH.
4. Evaluate the effect of relaxation programme on coping strategies
of women with PIH.
5. Evaluate the effect of relaxation programme on pregnancy
outcome of women with PIH.
6. Find out the association between level of stress and selected
variables: age, obstetric score, family history of PIH and family
history of hypertension of women with PIH.
7. Find out the association between coping strategies and selected
variables: age, obstetric score, family history of PIH and family
history of hypertension of women with PIH.
8. Find out the association between stress, coping strategies and
pregnancy out-come of women with PIH.
Hypotheses
H1- There will be significant difference between the mean post- test
stress score of women with PIH in experimental and control group after
the relaxation programme.
47
H2 - There will be significant difference between the mean pre and post-
test stress scores of women with PIH in experimental group after the
relaxation programme
H3 - There will be significant difference between the mean pre and post
test score of coping strategies of women with PIH in experimental group
after the relaxation programme.
H4 -There will be significant difference between the mean post test
score of coping strategies of women with PIH in the control and
experimental group after the relaxation programme.
H5 -There will be significant difference in the mean score of pregnancy
outcome among women with PIH in the control and experimental group
after the relaxation programme.
H6-There will be significant association between stress and selected
variables: age, obstetric score, family history of PIH and family history of
hypertension in the control and experimental group.
H7-There will be significant association between coping and selected
variables: age, obstetric score, family history of PIH and family history of
hypertension in the control and experimental group.
H8-There will be significant association between stress, coping and
pregnancy out- come among women with PIH.
Operational Definitions
Effectiveness: According to Oxford dictionary (1992), effectiveness
refers to achieving the intended result. In the present study it refers to
48
determining the extent to which relaxation programme has achieved the
desired effects. It is measured in terms of stress, use of coping
strategies and pregnancy outcome among women with PIH and which
can be measured by maternal stress scale -Depression Anxiety Stress
Scale (DASS), coping scale (Jalowiec coping scale) and pregnancy
outcome scale.
Relaxation programme: Refers to the group of relaxation measures
which bring the body and mind to a state of relaxation which includes
the following.
a. Progressive muscle relaxation
b. Deep breathing exercises
c. Guided imagery
The effect of which can be measured by maternal stress scale (DASS),
coping scale (Jalowiec coping scale) and pregnancy outcome scale.
Stress: According to Selye (1964) stress is defined as a person’s
adaptive response to a stimulus that places excessive psychological or
physical demands on that person.
In this study stress refers to clinically significant emotional state
as depression, anxiety and stress that disturbs the normal physiological,
psychological functioning and homeostasis of the women with PIH,
finally cause major damage to the mood, health of the mother and
foetus and measured by DASS (Lovinbond and Lovinbond, 1995)
before and after relaxation programme at 30-36 weeks of pregnancy.
49
Coping strategies: Coping strategies is defined as the specific cognitive
and behaviour methods used to deal with stressors.
In this study coping strategies are the specific cognitive and
behaviour methods adopted by women with PIH to deal with stressors
as measured by Jalowiec Coping Scale (JCS) (A.Jalowice, 1987)
Pregnancy outcome: In this study pregnancy outcome refers maternal
and neonatal outcome.
Maternal outcome includes labour, type of delivery, and development
of complications during delivery, blood pressure, proteinuria and
oedema.
Neonatal outcome: Birth weight and Apgar score and
development of complications during delivery and still birth.
Pregnancy induced hypertension (PIH): It is a syndrome complex
characterised by development of hypertension to the extent of 140/90
mm of Hg or more with oedema or proteinuria or with both induced by
gravid state after 20 weeks of gestation in previously normotensive
women.
Women with pregnancy induced hypertension: Refers to pregnant
women of gestational age 30-34 weeks who are admitted with
pregnancy induced hypertension.
Selected variables: In this study selected variables refer to the age,
obstetric score, family history of PIH and family history of hypertension
of women with PIH.
50
Assumptions of the study.
1. Pregnancy is maturational crisis
2. Pregnancy is a stressful condition.
Pregnancy is a time of many changes. Woman’s body, emotions
and the life of family are changing. She may welcome these changes,
but they can add new stresses to her life. Feeling stressed is common
during pregnancy. But too much stress can make her uncomfortable.
Stress can make to have trouble sleeping, have headaches, lose
appetite or overeat. High levels of stress that continue for a long time
may cause health problems, like high blood pressure and heart disease.
During pregnancy, this type of stress can increase the chances of
having a premature baby (born before 37 weeks of pregnancy) or a low-
birth weight baby (weighing less than 5½ pounds). Babies born too
soon or too small are at increased risk for health problems. The causes
of stress are different for every woman, but here are some common
causes during pregnancy .Some women may feel serious stress about
pregnancy. They may be worried about miscarriage, the health of their
baby or about how they’ll cope with labour and birth or becoming a
parent.
3. Stress is cumulative which endangers the health of the mother and
foetus.
4. Stress affects the pregnancy outcome of women with PIH:
51
Maternal stress and anxiety during pregnancy has been
associated with shorter gestation and higher incidence of preterm
birth,smaller birth weight and length andincreased risk of miscarriage
5. The intensity of stress affects adaptation mechanism: Prenatal
maternal stress predicts a variety of adverse physical and
psychological health outcomes for the mother and baby.
6. Women cope with stress during pregnancy but avoidant coping
behaviours or styles and poor coping skills in general are associated
with high risk pregnancy, preterm birth and infant development
(Christine and Christine,2011)
7. Women will be able to express stress, coping as per response to the
tools used to measure them.
8. Antenatal health status of woman influences the post natal maternal
health and neonatal wellbeing.
9. Early detection and management of antenatal health problems
significantly reduce mortality and morbidity among mothers and
neonates.
10. Individual is viewed as holistic adaptive system.
11. Relaxation enhances the sense of well- being.
52
THEORETICAL FRAMEWORK
The theoretical framework for this study is based on Betty
Neuman’s system model (1980) as depicted in figure 1.
The four major concepts identified by Neman are the Human
beings, environment, health and nursing.
The human being is viewed as an open system that constantly
interacts with both internal and external environmental forces and
stressors. Neuman views the individual as a complete system of which
its sub parts are interrelated. The sub parts are the physiological,
psychological, socio-cultural, developmental and spiritual factors.
Neuman defines environment as all the internal and external
factors or influences that surround the client or client system. The
internal environment exists within the client system. The external
environment exists outside the client system. Neuman identifies a third
environment, the created environment, which represents the open
system exchange of energy with both the internal and external
environments. Stressors are present both within and outside of the
system and have the potential for causing system instability.
Neuman identifies health as optimal system stability or the
optimal state of wellness. The client system moves towards wellness
when more energy is available than this is needed and toward illness
53
when more energy is needed than available. Death occurs when the
energy needed to support life is not available.
According to Neuman, the major concern of nursing is to help
the client system to attain, maintain or retain system stability. This may
be accomplished through accurate assessment of both the actual and
potential effect of stressor invasion and assisting the client system to
make those adjustments necessary for optimal wellness.
Neumann used a total person approach incorporating the holistic
concept and an open system approach. She developed her health care
system to provide a unifying focus for defining a problem definition and
for better understanding of the client in interaction with the environment.
The major concepts she identified are basic structure, stressors,
flexible line of defence, line of resistance, degree of reaction and
prevention as intervention and reconstitution.
According to Neumann, all life is characterized by the on-going
interplay of balance and imbalance with the organism. Wellness exists
when all the parts and subparts are in harmony with the client.
Application of theory in present study
Stressors are environmental forces that may alter the system
stability. The woman with pregnancy induced hypertension is in
dynamic interaction with the various tension producing stimuli. The
stressors can be interpersonal, intrapersonal and extra personal.
54
Impaired physiological variables of Pregnancy induced hypertension
constitute the major stressors in present study.
Stressors are stimuli which might penetrate the clients’ both
flexible and normal line of defence resulting in either positive or
negative outcome. The system of the client consists of a core of basic
structure, energy resources surrounded by three concentric circles. The
basic structure of the individual consists of physiological, psychological,
socio-cultural and spiritual factors.
Normal line of defence is a state of equilibrium of the individual
or state of adaptation, the individual has maintained overtime.
The line of resistance and flexible line of defence protect the
client from stressors. The line of resistance represents the internal
factors which help the client to defend against stressors.
In the present study the socio-demographic status, clinical
status, stress level, previous history of PIH can affect the physiological
variables of women with PIH.
According to Neuman, the quantity of reactionis caused the
system’s instability from stressors who invade the normal line of
defence. In this study reaction is the level of stress, ineffective coping
strategies adopted and negative pregnancy outcomes.
Neumann related three levels of prevention to nursing.
According to her the nursing intervention can begin when a stressor is
55
identified. The interventions are purposeful actions to help the client to
retain or maintain system stability. In this study relaxation programme is
the intervention. The relaxation programme is administered twice for
daily four weeks.
The goal of nursing is to keep the client stable. So maintenance
of stability requires interactions that re- directed towards counteracting
movement towards a stressful state. These include primary, secondary
and tertiary prevention. Here the nursing intervention at secondary and
tertiary prevention level is relaxation programme, the focus of the study.
Relaxation programme can strengthen the normal line of defence so
that the normalization or reduction in blood pressure, proteinuria and
normal pregnancy outcome. The client also experiences decreased
stress and adopted effective coping strategies. By strengthening normal
line of defence and thereby strengthening lines of resistance helps to
prevent stressors from affecting the central core or basic structure and
thus helps to maintain system stability. Thus system stability denotes
the effect of relaxation programme.
Reconstitution is the state of adaptation to stressors. In this study,
reconstitution is achieved by practicing relaxation programme and is
evidenced by the improvement of physiological variables, reduction
instress level, effective coping and positive outcome of pregnancy
among women with pregnancy induced hypertension.
56
[Type a
quote
from
Intrapersonal stressors
• Extremes of age
• Family history of
hypertension
• History of high risk
condition in previous
pregnancy
• Diagnosis of PIH
• Fetal outcome in previous
pregnancy
Interpersonal stressors
• Marital status
• Educational status
• Occupational status
• Income
Extra personal stressors
• Environmental
factors
• Place of residence
• Support system Reconstitution: Maintenance of stability
Primary
prevention
o Prevention of
stressors
o Effective coping
o Prevention of
complications
Secondary
prevention
o Early detection
and treatment of
PIH
o Stress reduction
o Effective coping
o Prevention of
Tertiary prevention o Prevention of
complications
o Maintenance of
optimum level of
health among
women with PIH
and normal
pregnancy outcome
Rela
xatio
n p
rogra
mm
e
Under
study
STRESSORS
Women with
PIH
Figure 1 :Theoretical framework of the study based on Betty Neuman’s System Model
57
Delimitations
• The study is confined to women with pregnancy induced
hypertension admitted in antenatal wards of the institute of
maternal and child health during the period of data collection.
• The study is evaluating the effect of relaxation programme
irrespective of antihypertensive medications and diet used by
women with pregnancy induced hypertension.
• The stress and coping strategies measured by woman’s
expression of stress to the DAS scale and coping strategies as
per response to Jalowiec coping scale.
• The pregnancy outcome measured as maternal and neonatal
outcome.
Summary
This chapter has covered the review literature, need and
significance of the study, statement of the problem, title of the study,
objectives, hypothesis, operational definition and theoretical frame work.
58
CHAPTER III
RESEARCH METHODOLOGY
The present study aimed at evaluating the effect of relaxation
programme on level of stress, coping strategies and pregnancy
outcome of women with PIH admitted in IMCH, Kozhikode.
Research Approach
An evaluative approach was found to be useful to achieve the
objectives of the present study. Evaluation research is the utilization of
scientific research methods and procedures to evaluate a programme,
treatment, practice or policy; it uses analytical means to document the
worth of an activity (Wood and Haber, as cited in Jose. A,2005).
An evaluative research is the specific use of scientific method for
the purpose of making an evaluation. Evaluation is the process of
determining the value or amount of success in achieving a pre-
determined objective. In the present study, the investigators objective is
to evaluate the effect of relaxation programme on level of stress, coping
strategies and pregnancy outcome of women with pregnancy induced
hypertension. As the effectiveness of relaxation is scientifically
determined, the difference between pre and post test score should be
find out, an evaluative approach is considered more appropriate.
According to Suchman, there are six essential steps to follow for
evaluative research. The first step is identification of the goals to be
evaluated.The goal identified for the present study was to develop and
59
test the effectiveness of relaxation programme on stress coping and
pregnancy outcome among women with PIH.
The second step is the analysis of the problem with which the
activity must cope.In the present study the problems were identified by
an extensive review of literature, informal interview with high risk
pregnant women, the experts in the field of psychology, obstetrics and
gynaecology and on the basis of researcher’s clinical experience in the
field.
The third step identified is description and standardization of the
activity. In the present study the activity was the relaxation
programme.The three different techniques of relaxation programme
developedand translated to Malayalam. And programme was recorded
in an audio compact disc.
The fourth step is to measure the degree of change that takes
place. For that three measuring instruments were developed and two
were selected to measure the variables under the study before and after
the intervention.
The fifth step is to determine whether the observed change is
due to the activity alone or some other cause. A quasi-experimental
design with pre-test post-test control group design was adopted to
determine whether the observed change was due to the administration
of relaxation programme alone.
60
The next step is to identify the durability of the effects.
Considering this step, a post test was conducted after four weeks of
relaxation programme on stress, coping and pregnancy outcome.
ResearchDesign
The research design adopted for the study was quasi-
experimental; using pre-test, post-test control group design (Fig.2).This
design is similar to experimental design except that it lacks
randomization. The quasi – experimental designs are used frequently
because they are practical,feasible and generalizable. The designs are
more adaptable to the real world practice setting than controlled
experimental designs. In addition, for some hypotheses this design may
be the only way to evaluate the effect of the independent variable of
interest (Campbell and Stanley, 1972).
The weakness of this design involves mainly the inability to
make clear cause and effect statements. However, if the researcher can
rule out any plausible alternative explanations for the findings, such as
studies can lead to furthering knowledge about casual relationships.
Researchers have several options for ferreting out these alternative
explanations. They may control them ‘a priori’ by design or control them
statistically(Campbell and Stanley, 1972).
According to Campbell and Stanley, pre-test post-test control
group design is one of the most wide spread design in educational
research involving an experimental group and a control group both
61
given a pre-test and a post-test. The assignment of treatment to one
group or the other is assumed to be random and under the
investigator’s control. The more similar the experimental and the control
group are in their recruitment, and the more the similarity is confirmed
by the scores on the pre-test, the more effective this control become.
Assuming that these conditions are approximated for internal validity,
we can regard this design as controlling the main effects of history,
maturation testing and instrumentation and experimental mortality.
The present study was conducted in a tertiary level hospital
setting with high risk group of pregnant women, randomization was
found impossible. However, the wards selected randomly for assigning
relaxation programme. Also the two groups were not different
statistically on pre- test scores.
The factors jeopardizing internal validity such as history,
instrumentation, selection bias and experimental mortality were
controlled in the study by adopting the following measures.
History: No other relaxation programme similar to the intervention was
offered to the experimental group or control group during the data
collection period.
Instrumentation: The same tools were used for both groups before and
after the programme and were administered under the similar
conditions.
62
Fig 2 Schematic Representation of Study
Population Sample Dependent
variables Instruments Pre test
Independent
variable Post -test 1 Post-test 2
Women
with PIH
Experimental
200
Control 200
1.Stress
2.Coping
strategies
3.Pregnancy
outcome
-do-
• Depression
Anxiety Stress
scale
• Coping scale
• Observation
checklist on
pregnancy
outcome
-do-
Day 2 of
1st Week
Day 1 of
1stweek
Relaxation
programme
Duration twice
daily for 4
weeks
--------------
One day
after
intervention
-do-
Follow up for
observation of
pregnancy
outcome after
delivery
-do-
63
Experimental mortality: The respondents who were present throughout
the study were only included in the final analysis.
2.2. Variables under study
Independent variable
The independent variable is relaxation programme which was
developed and administered by the investigator.
Dependent variables
The dependent variables were
• Stress
• Coping strategies
• Pregnancy outcome in terms of maternal and neonatal outcome.
Setting of the study
Thestudy was conducted in the Institute of Maternal and Child
Health (IMCH) Kozhikode. It is a 740 bedded tertiary level hospital
exclusively for women and children in which 380 beds were allotted to
the maternity clients, attached to Government Medical
College,Kozhikode. There is an average admission of 40-60 antenatal
women per day and about 80 to 100 deliveries are taking place. There
are four wards allotted for antenatal women and one ward is for
postnatal mothers. Out of four antenatal wards two wards were
assigned randomly as experimental and two as a control. There are six
units of Obstetrics and Gynaecology functioning in all days rotationally
and antenatal women those who required were admitted in these wards.
64
In the labour room complex, there is separate area available for
conducting high risk deliveries. IMCH is selected for the study as it
caters to a large number of populations from both rural and urban areas
of five districts of NorthKerala i.e. Wayanad,Kasaragod, Kannur,
Malappuram and Kozhikode. This hospital has advanced facilities for
managing high risk casesand the ample availability of samples, among
the high risk pregnancies. Pregnancy induced hypertension is more
prevalent, coupled with the investigator’s familiarity and access to the
hospital motivated the investigator to help the women with PIH to
enhance their health and infant’s health by adopting appropriate
relaxation programme.
Population
The population of the present study consisted of women with
pregnancy inducedhypertension.
Sample
The sample consists of women with pregnancy induced
hypertension admitted in antenatal wards of IMCH, Kozhikode.
Sample size
The researcher selected400 women (control – 200 and
experimental – 200) who are fulfilling the criteria.
Sampling Technique
Non probability purposive sampling technique was used in the
present study. In purposivesampling, subjects are included in the study
65
because the researcher conveniently chose subjects who fulfil the
needed criteria at the right place and at right time.
Criteria for sample selection
Inclusion criteria
Women with PIH admitted in antenatal wards of IMCH, Kozhikode who
are:
• Willing to participate in the study.
• Gestational age 30-34 weeks.
• Blood pressure up to 160/110 mm of Hg.
• Hearing acuity (natural or compensated through use of
hearingaids) that was adequate to hear verbal and audio taped
instructions.
Exclusion criteria
• Severe PIH – BP above 160/110 mm of Hg.
• Women with multiple pregnancy and high risk pregnancy other
thanPIH.
• Documented psychotic illness, with or without current use of
antipsychotic medication.
Data Collection Instruments
After reviewing the enormous number of literature related
pregnancy induced hypertension and its management, assessment of
stress and coping during pregnancy and the effect of relaxation
programme, unpublished and published, through Medline search
66
thefollowing tools were identified and used in the study (Table 2
presents the details of data collection instruments).
Tool I: Semi structured interview schedule on socio-personal data of
women with PIH.(Appendix A)
Collection of a detailed data base is essential, so that effective
problem oriented planning of patient care can be established.
Interviewing is a well-established method of data collection and can be
used effectively to gather truthful information about individual.
A semi structured interview schedule developed by the
investigator to obtainverbal responses of women with PIHand consists
of ten items regarding socio personal data.
Validity of the scale: Content validity of the tool was established from
eleven experts. There was 100% agreement on all items.
Tool II: Observation check list to assess the clinical and physiological
variables of women with PIH.(Appendix B)
In a high-risk (at-risk) pregnancy, the mother, foetus, or neonate
is at increased risk of morbidity or mortality before or after delivery.Risk
assessment is part of routine prenatal care. Risk is also assessed
during or shortly after labour and at any time that events may modify
risk status. Risk factors are assessed systematically because each risk
factor presents increases overall risk. High-risk pregnancies require
close monitoring to lower neonatal morbidity and mortality rates. Hence
the investigator developed an observation checklist to identify the
67
physiologicaland clinical status of women with PIH.Observation check
list includes of 30 items.Eleven experts had validated the content of this
tool. According to expertsview, this tool has two sections. Section I has
24 items for assessing the clinical data and section II has physiological
variables consisting of 3 items.
Tool III: Depression Anxiety Stress Scale(DASS) assesses the level of
stress among women with PIH (Lovibond and Lovibond,
1995).(AppendixC )
During the transition to pregnancy, women especially with high
risk condition commonly question their self-worth. Tremendous inner
turmoil may resultfromquestions about identity and can sometimes lead
to a personal crisis.Personal or emotional problems may bemanifested
as global psychological distress, somatic distress, anxiety, low self-
esteemor depression (Grace, 1997).
The stress evaluated in this study refers to “natural stress” as an
everyday phenomenon, witha motivating function that mobilizes
resources for theadaptation of the individual to new situations. When
stress cases are simpler, superposition of symptoms is higher, as well
as the lack of specificity in the clinical condition. In this sense, anxiety
and depression maybe part of the general “stress process”. Hence the
investigator with the help of experts and guide, select the
Depression,Anxiety Stress Scale(DASS) to assess stress among
women with PIH.DASS is a standardised tool developed by
S.H.Lovibond and P.F. Lovibond. The DASS is as set of self–report
68
scale to define, understand and to measure the clinically significant
emotional state as depression, anxiety and stress. DASS constituted
with 42 items scored from 0 to 3.The score of DASS are rated as
normal 9,7 14,mild as10-13,8-9, 15-18, moderate as 14-20,10-14.19-25
and severe as 21-27,15-19,26-33 and extremely severe as 28+,20+,37+
for depression, anxiety and stress respectively. The reliability coefficient
was 0.91 for depression, 0.84 for anxiety and 0.90 for stress. The DASS
has previously been tested in several studies.
The Malayalam translation of tool was made. A forward-
backward translation technique was followed with the help of English
and Malayalam language experts.
Tool IV: Jalowiec’s coping scale (JCS) to identify the coping strategies
of women with PIH (Jalowiec,1987).
Stress disturbs the equilibrium of the body. It affects physically,
emotionally andmentally. When individuals experience stress or face
demanding situation, they adopt ways ofdealing with it, as they cannot
remain in a continued state of tension. How the individual dealswith
stressful situations is known as ‘coping’. There are two major targets of
coping: changing ourselves or changing our environment. Coping refers
to a person’s active efforts to resolvestress and create new ways of
handling new situations at each life stage (Erikson, 1959). The process
by whicha person attempts to manage stressfuldemands is called
“Coping Strategies”. Based on these the investigator identified atool
developed by Dr. Anne Jalowiecand was used to identify the coping
69
strategies of women with PIH. The JCS is based on Lazarus and Folk
man’s theory of stress and coping. JCS has been designed to measure
how people cope with various types of physical, emotional and social
stressors. The JCS measures the use and effectiveness of 60 cognitive
and behavioural coping strategies in a stressful situation. The items
describe cognitive and behavioural efforts in response to stress are
grouped into eight coping dimensions.
• Confrontative• Fatalistic• Emotive
• Palliative • Supportive• Self-reliant
Item responses are rated on a four-point scale from 0 (never
used) to 3 (often used) and a scale of helpless from 0 (not helpful) to 3
(very helpful). The higher score, the more coping effort involved. The
higher total coping score the more alteration between different coping
strategies.
Reliability: Total use- Cronbach alpha .88 and effectiveness-.91.
The Malayalam translation of tools was made. A forward-
backward translation technique was followed with the help of English
and Malayalam language experts.
Tool V: Pregnancy outcome scale to assess the maternal and neonatal
outcome of women with PIH.(Appendix D)
Pregnancy complications and obstetric and neonataloutcomes
are usually high in high risk cases. Considering these facts the
researcher developed a tool which is useful toidentify factors that may
be responsible for the increasein adverse birth outcomes among
70
women with pregnancy induced hypertension.It is an observation
checklist developed by investigator. It includes maternal and neonatal
outcome observation. Maternal outcome includes BP, proteinuria, and
type of delivery, labour, and development of complications during
delivery and maternal death.
Neonatal outcome includes birth weight, APGAR score,
complications and still birth/IUD.
Validity: Content validity was obtained from 12 experts from the field of
Obstetrics and Gynaecology and Neonatology.
Reliability:Reliability was assessed byCronbachalpha .84.
71
Table 2
Details of Data CollectionInstruments Used in the Study
Name of the tool
Variables Measured
Selected/ developed
by investigator
No. of items
Reliability Validity
Established
Depression Anxiety
Stress Scale (DASS)
(SH Lovibond&PF
Lovibond) 2004
Stress
Selected
42
0.84
Chronbach Alpha
Content Construct
Jalowiec
Coping
Scale
(Dr.AnneJalwi
ec, 2003)
Coping
Strategies
Selected
60
0.91
Chronbach
Alpha
Content
Construct
Pregnancy
outcome
scale
Maternal
and
neonatal
out- come
Developed
9
0.84Chronb
ach
Alpha
Content
Observation
Check list
Clinical and
Physiological
variables
Developed
27
0.83 & 0.93
Chronbach
Alpha
Content
Demographic
Performa
Socio-
personal
variables
Developed
10
-
Content
RELAXATION PROGRAMME (Appendix E)
The stimulus complex confronting the individual has rarely been
conceptualized in terms of the nature of the coping demands it poses
for thatindividual, and intervention strategies have often been
72
formulated to match those demands. Problem and emotional focused
coping mechanism are both useful under the appropriate circumstances
in facilitating adjustment to stressors associated with disease and health
care (Humphrey et al., 1998; D’zurilla and Sheedy, 1991) stress
managementprograms may be categorized into five basicformats:
progressive muscle relaxation,meditation, biofeedback, cognitive-
behavioural skills training, and visualization. A combination of
thesetechniques may be applied during stress management
interventions to achieve moreeffective reduction (Goldman and Wong,
1997; Gregson and Looker, 1994). Relaxation programmes are effective
techniques for reducing stress. These exercises help you to feel less
tense and more relaxed. The result is a great sense of physical and
emotional well-being. Helping patients learn relaxation techniques to aid
stress reduction and management is based on the concept of the mind-
body connection. Whatever relaxes the musculature, produces mental
relaxation and vice versa. The relaxation response can reduce existing
distress and eventually ameliorate its effect. Progressive muscle
relaxation is a simple and effective way to help patients learn how to
relax. By releasing both physical and mental tension, relaxation restores
our mind and body to a balanced state. Breathing exercises and
progressive relaxation soothe the body. Guided imagery and
visualization install peace of mind, especially when combined with
physical relaxation. Striking a balance is the key.The relaxation
programme includes Jacobson’s progressive muscle relaxation,
73
breathing exercise and guided imagery for 45 minutes. Progressive
muscle relaxation is a mind-body technique that involves slowly tensing
and then relaxing each muscle group in the body. Typically used to
tame stress, progressive muscle relaxation is said to increase
awareness of the sensations associated with tension (and, in turn, help
you identify and deal with the physical effects of everyday stress).
Indeed, a number of studies shows that regular practice of progressive
muscle relaxation may help keep stress in check (as well as treat
stress-related health problems like insomnia and anxiety).Breathing
exercises, a fundamental component of mind and body practices, have
been proven to activate the body’s relaxation response. Additionally,
breathing exercises can help control the body’s reaction to stress by
balancing its “fight or flight” response and relaxation response.
Incorporating breathing exercises such as the one can improve
physiological factors like blood pressure, heart rate and muscle
relaxation, which in turn may help to manage anxiety, improve
concentration, sleep sounder or improve immune system.Visualization
is a relaxation technique; you form mental images to take a visual
journey to a peaceful, calming place or situation. During visualization,
try to use as many senses as you can, including smell, sight, sound and
touch.One of the benefits of visualization is that you can use mind
visualization to distract yourself from stressful thoughts. When you are
worrying about something that you cannot change, you can use
visualization to distract yourself and get some stress relief. Use
74
pleasant imagery, something that feels peaceful and serene. If you
imagine relaxing at the ocean, for instance, think about the smell of salt
water, the sound of crashing waves and the warmth of the sun on your
body (cited in Rajeswari,2008)
An audio compact disc of relaxation programme was prepared
based on consultation with psychologist and yoga teacher.
The programme aimed to relax the mind and body, relieve stress
and cope with the stressful situation effectively among women with
pregnancy induced hypertension.
Objectives: 1.To relieve stress
2. To cope with the stressful situation effectively
3. To relax the body and mind.
4. To enhance subjective well-being.
Steps
1. Conducive environment
Quiet and free of distracting noise
The women will be kept physically comfortable
2. Frequency
The women will be assisted to perform relaxation programme with the
investigator twice a day i.e. morning and evening for45mts through an
audio-tape for 4 weeks.
75
3. Appropriate dress
Comfortable and loose fitting clothes should be worn.
Don’t wear lenses.
4. Check Blood Pressure before starting the programme and 30 mts.
after the programme.
General instructions before and during muscle relaxation
technique:
• Instructions should be simple and clear.
• Easily understood by literate and illiterate people and give them
clear picture to cooperate during the whole procedure.
• Sit down on the bed as comfortable as possible. Keep body loose
light free.
• Be calm and comfortable.
• Avoid stray thoughts.
• Avoid extra movements of the body.
• During the part of exercise cycle, tense the muscles tightly and
hold for slow count of 5-7 seconds.
• Repeat each exercise three times.
• During the relaxation part of exercise cycle, relax the muscle
quickly and completely. Let your mind relax and appreciate how
relaxed the muscles are feeling.
• Try to keep all other muscles relaxed as you exercise specific
muscle groups.
76
• Relax by taking three deep breaths, inhaling through nose and
exhaling through mouth after each step. Completely relax for 30
sec. to a minute between each step.
• As you exercise from head to toe, observe changes like lightness
and soothening of sensation.
• Now make your body completely free... loose… light… and…
free.
• Let us begin our exercise.
Progressive muscle relaxation
Duration -15mts.
Procedure
1. Facial muscles
a) Tense muscles of face by wrinkling the forehead, frowning
and squinting the eyes. Then relax.
b) Clench your teeth. Relax.
c) Purse your lips. Relax.
d) Push tongue to the roof of your mouth.
e) Lift your eyebrows with your eyes still closed.
f) Relax completely.
2. Neck and shoulders
a) Bend head back, then forward so that the chin touches the
chest.
b) Tense shoulders by tightening and shrugging the shoulders.
77
c) Relax completely.
3. Tense chest muscles by taking a deep breath and hold it for 5-7
seconds.
4. Hands
a) Clench fist separately and feel the tension.
b) Clench both fists together.
c) Relax completely.
5. Lower arms
a) Make a fist and bend arms up at the elbow with your right
arm, then repeat with your left arm.
b) Relax completely.
6. Upper arms
a) Stretch out your right arm in front of you as if you are reaching
for something, and then relax.
b) Then repeat with left arm.
c) Relax completely.
7. Back
a) Arch your back.
b) Relax completely.
8. Thighs and buttocks
a) Tense both thigh muscles and buttocks by squeezing
together.
b) Relax completely.
78
9. Lower legs
a) Point toes towards your head, then away from your head.
b) Relax completely.
10. Toes
a) Curl toes up.
b) Relax completely.
BREATHING EXERCISES
Duration-10 mts.
Procedure
- Maintain a comfortable position.
- Keep the mouth closed.
- Place both hands comfortably.
- Take slow deep breaths (feeling of the lung expansion).
- Take in deep breath through nose, hold the breath count for 10-0
numbers in mind, and breathe very slowly through mouth.
- Release the tension.
- Feel to flow the oxygen to your body
- Relax the body.
- Practice this exercise 2-3 times/mts. for 5mts.
GUIDED IMAGERY
Duration – 20 mts
Procedure:
Now draw attention to the vision before you.
79
You will see each of the objects closely and clearly before you.
Just imagine an exciting day-break. Can’t you hear the birds chirping
and twittering in the branches? (Back ground music) Look at those
lovely hill-tops, dimly perceivable, through the thin veneer of the
enshrouding fog pierced by the golden rays of the rising sun. You will
certainly enjoy the marvellous spectacle which lifts you to the ecstatic
echelons of blissfulness (back ground music).
Now turn your eyes on to that stream which cascades down the
hills splashing drops like pearls and see how it gently moves along the
valley, purling to the pebbles it flows over. Sauntering along the bank of
the stream, you are now entering an open grass land. Stay there for a
while, charmed by the beautiful sights and sounds nature lays before
you for your delight and enjoyment (back ground music). Listen to the
amours chant of the feathered choir and the murmurs’ buzz of
butterflies. And from you are now entering a beautiful garden arrayed
with rows of fragment flowers. Exhilarated by the exciting spectacle of
the golden drops of dew trickling down the petals and the colourful
butterflies dancing around the flowers, you are now moving forward
(back ground music).Yonder is a lake and now you are on the shore of
that lake. Your eyes now meet the blooming lotuses, the swans that
swim about and the golden fishes (back ground music).Now focus
attention on your own body. Don’t you feel that each organ of your body
now experiences a condition of ecstasy? Now concentrate on the baby
80
growing on your womb. Imagine sucking its finger and gently kicking
against the walls of your womb.
In fact this is a very serene and blissful state. Now you are being
provided with enough oxygen in all your limbs and thus being lifted to an
extremely salubrious condition. Both the mind and body now experience
a condition of celestial bliss. Pray that you may be able to transmit this
pleasant and relieving experience, you are now going through in to
other individual’s also. Now descent from this euphoria world of
imagination in your own work-a-day world and slowly rise up.
• Massage the hands, face, chest, abdomen and legs and sides of
the head.
• Keep smiling.
• Relax whole body completely, Keep eyes closed for about two
minutes and let ourselves remain in the same relaxed position.
• Open your eyes and enjoy the renewed energy. Feel relaxed and
refreshed.
• Sit up, stretch and standup slowly.
The content validity of the relaxation programme was done by 12
experts and translated in toMalayalam.
Pre testing: All the tools and relaxation programme were administered
to 40 women with PIH to check clarity of language. They have not
expressed any doubts.
81
Pilot Study:
The investigator conducted a pilot study after getting permission
from the ethics committee of Medical College, Kozhikode, formal
administrative permission from the Superintendent and Head of the
department of Obstetrics and Gynaecology, IMCH, Kozhikode.The
study was conducted atIMCH; Kozhikode from 1-01-2011to31-3-
2011.Forty women with PIH satisfying the selection criteria were
selected.Twenty of them were assigned to experimental group and
twenty were in the control group. After obtaining informed consentfrom
the women, pre- test was administered to both groups. The
experimental group were subjected to relaxation programme for five
days for four weeks in the morning between 7a.m to 9 am and evening
between 5p.m to 7pm for forty five minutes duration. The relaxation
programme through an audio CD played to women in a quiet room and
instructed to assume comfortable position and close their eyes for
relaxation.Their physiological variables were assessed in the morning
before relaxation and in the evening 20 minutes after the relaxation
programme.
Ethical issues:
A formal discussion was held with Head of the Department,
Obstetrics for conducting a study on women with pregnancy induced
hypertension. The research protocol was submitted to the institute
ethics committee for ethical clearance and approval. Permission was
82
received to select study subjects and to collect required information
from them.
Data Collection Process
The data collection process started from April 2011 to April
2012.The setting of study was IMCH, Kozhikode where six units are
functioning under Obstetric department with approximately 300
antenatal women admitted in three antenatal wards.The investigator
personally approached the women with pregnancy induced
hypertension admitted in the antenatal wards. Subjects were selected
as per inclusion criteriaand to establish good rapport, the investigator
greeted the subjects in a friendly manner and seen that they were
comfortably seated. Experimental group were selected from third and
fifth floor whereas control group was selected from first and second floor
of antenatal wards to avoid contamination.
The selected subjects were explained the purpose, nature and
duration of the study and alsopromised to keep up confidentiality. A
written consent was obtained individually. Given adequate time for them
to feel at ease and started the interview as pleasant conversation.
Questions were asked one by one and the responses were recorded in
the interview schedule. The stress rating and coping scales were given
for rating their responses. The investigator was careful to direct the
women towards necessary and relevant responses and thus to prevent
unnecessary explanations and information. Physiological variables and
83
clinical data were also obtained. After the pre- test explanation was
given to experimental group regarding relaxation programme.
The relaxation programme includes Jacobson’s progressive
muscle relaxation; deep breathing exercise and guided imagery for 40
minutes were prepared in Malayalamand recorded in an audio C.D. This
audio C D was played in a quiet room where a small group of four to
five women with PIH were seated comfortably after assessing their
physiological variable. They were instructed to follow the instructions
and perform accordingly by closing their eyes. The relaxation
programme was provided for 5 days twice daily, in between 7 a.m. to 9
a.m. in the morning and between 5 p.m. to 7p.m.in the evening for four
weeks. In the evening Physiological variables were re-assessed. A
post-test was done at the end of the fourth week for both groups. Then
subjects were followed and assessed for pregnancy outcome. No drop
outs were in the study period and all the subjects in the experimental
group were satisfied with the relaxation programme they received. Both
groups were received routine care.
84
Fig .3 : Schematic presentation of data collection process
2.13. PLAN FOR DATA ANALYSIS
Descriptive statistics was used to arrange the data in a scientific
way. Inferential statistics was used to test the hypotheses. Data were
analysed using the Statistical package for the social sciences (SPSS
85
version 16). p value of <0.05 and more than that was considered
significant.
Table- 3: Plan of analysis
Method Type of
statistics Purpose
Descriptive
Frequency,
percentage, mean,
standard deviation
Assess the sample
characteristicsand study variables
Inferential
statistics
Paired ‘t’ test
Compare the study variables
before and after the interventional
within the group
Independent ‘t’ test
Compare the study variables
before and after the intervention
between the groups
Chi square
• Assess the homogeneity of
samples between the groups
• Identify the association between
stress, coping strategies,
pregnancy outcome and selected
variables
• Identify the association between
stress, coping and pregnancy
outcomes
ANOVA Associate background variables
with selected outcome variables
86
CHAPTER IV
ANALYSIS AND INTERPRETATION
This chapter deals with the analysis and interpretation of the
collected data to assess the effectiveness relaxation programme on
stress, coping and pregnancy outcome among women with pregnancy
induced hypertension. Analysis and interpretation of the data obtained
from 400 women with pregnancy induced hypertension admitted in the
antenatal wards of Institute of Maternal and Child health, Kozhikode
was done through an integrated system of computer programme. The
software package used for statistical analysis is SPSS 16 version.
All items in the tools were coded and transferred to a master
data sheet for computer programming. All the information was directly
entered to the computer.
The responses are tabulated and analysed under the following
headings.
SECTION I:Distribution of the sample based on socio personal
data
SECTION II: Distribution of sample based on clinical data
SECTION III : Distribution of sample based on physiological data
87
SECTION IV:
A: Distribution of sample based on stress score
B: Distribution of sample based on coping score
C: Distribution of sample based on pregnancy outcome
SECTION V:
A: Effect of relaxation programme on stress
B. Effect of relaxation programme on coping
C. Effect of relaxation programme on physiological variables.
D. Effect of relaxation on pregnancy outcome
SECTION VI:
A. Association between stress and selected variables
B.Association between coping and selected variables
C. Association betweenpregnancy outcome and selected variables
88
Section I: Distribution of socio personal variables of women
with PIH in the experimental and the control group
Table 4 Frequency and percentage distribution of socio
personal variables among women with PIH(n=400)
NS-Not significant at the level p=0.05
Socio personal variables
Control group Experimental
group χ
2 value
df p
value f % f %
Age in years <19 60 30 61 30.5
0.651 2 0.72NS 20-29 95 47.5 88 44 30 & above 45 22.5 51 25.5 Monthly income < Rs.1500 106 53 117 58.5
2.685 2 0.26NS Rs.1501-3000 85 42.5 79 39.5 Rs.3001-4500 9 4.5 4 2 Education
Primary 43 21.5 52 26.0
1.922 4 0.75NS
Higher secondary
96 48.0 94 47.0
College level 42 21.0 40 20.0 Technical 4 2.0 4 2.0 Professional 15 7.5 10 5.0 Illiteracy 0 0 0 0 Occupation Housewife 159 79.5 170 85
5.10 3 0.16NS Manual labor 7 3.5 3 1.5
Government 11 5.5 14 7 Private 23 11.5 13 6.5 Religion Hindu 98 49 102 51
4.589 2 0.101NS Christian 39 19.5 52 26 Muslim 63 31.5 46 23 Support system Adequate 181 90.5 171 85.5
2.367 1 0.12NS
Inadequate 19 9.5 29 14.5 Family structure Nuclear 183 91.5 186 93
0.315 1 0.575NS
Joint/extended 17 8.5 14 7
89
Table 4 shows the distribution of socio personal variables among
women with PIH in the experimental and the control group. Majority of
women in both groupswere belonged to in the group of 20-29 years of
age. Less than fifty percentages of women in both group had secondary
level of education.
On the basis of family income,majority of women in both groups
falling under lower income group (Rs.1500 per month).Majority of
women in both groups were house wives.
With respect to religion, majority of the control group49% and51%
in the experimental groupswere Hindus, 26% in the experimental and
19.5% in the control group were Christians and Muslims were only 23%
in the experimental and 31.5% in the control group.
85.5% in the experimental group and 90.5% in control group had
adequate support system.
Considering types of family, 93% in the experimental group and
91.5% in the control group belonged to nuclear family.
On the basis of leisure time activities, watching TV was the
leisure time activity among majority of subjects in the experimental
(51.5%) and in the control group (94, 47%).
Regardingarea of residence,80% in the experimental group and
75% in the controlgroup were residing in rural area. 20% in the
experimental group and 25% in the control group living in urbanarea.
90
Considering stressful events in the past, 93% in the experimental
group and 91% in the control group had no history of stressful
events.Theχ2 valuerevealed homogeneity between the groupswith
respectto the socio personal variables among women with PIH
Figure 4:Frequency distribution based on age among women with
PIH(n=400)
91
Fig 5:Percentage distribution of monthly income among women
with PIH (n=400)
92
Fig.6:Percentage distribution based on religion among women with
PIH (n=400)
93
Fig. 7: Percentage distribution based on occupation among women
with PIH (n=400).
94
Fig.8:Percentage distribution based on support system among
women with PIH (n=400).
95
Fig.9: Percentage distribution based on family structure
among women with PIH (n=400).
96
Fig.10: Percentage distribution based on leisure time activities
among women with PIH (n=400).
97
Fig.11: Percentage distribution based on place of residence among
women with PIH (n=400
98
Fig.12: Percentage distribution based on history of any recent
stressful events among women with PIH (n=400).
99
Section II: Distribution of sample based on clinical data Table 5 Frequency, percentage and chi square distribution of clinical data
among women with PIH among experimental and control group (n=400)
Variables Control group
Experimental group
χ2
value df
p value
f % f %
Obstetric score Gravida
Primi 44 22 38 19
1.136 3 0.768
NS
Second 87 43.5 94 47
Third 54 27 50 25
Fourth & above 15 7.5 18 9
Para
Primi 66 33 58 29
1.088 3 0.780
NS
Second 109 54.5 119 59.5
Third 16 8 14 7
Fourth & above 9 4.5 9 4.5
Live
0 85 42.5 80 40
0.531 2 0.767
NS 1 100 50 107 53.5
2 15 7.5 13 6.5
Abortion
0 156 78 155 77.5
1.625 3 0.654
NS 1 19 9.5 17 8.5 2 22 11 27 13.5
3 3 1.5 1 0.5
Gestational age
30wks 38 19 44 22
5.586 4 0.232
NS
31wks 48 24 52 26 32wks 16 8 6 3
33wks 72 36 76 38
34 wks 26 13 22 11 NS-Not significant at the level p=0.05
100
Table 5 reveals the distribution of clinical data among women with PIH
in the experimental and control group. In this regard, obstetric score as
gravid, para, live and abortion were included.
On the basis of gravid,less than 50% in both groupsbelonged to
second gravida.More than half of the women were, 54.5% in
experimental and 59.5% in control, belonged to second para.Majority of
the samples in both groups (78% in experimental and 77.5% in control)
had no history of abortions and only 1.5% in experimental and 0.5% in
control group had three abortions.
Regarding gestational age,38% in the experimental group
and36% in the control group were at 33 weeks of gestation and only
3%in the experimental and 8%in the control group were at 32 weeks of
gestation.
101
Fig. 13: Percentage distribution based on reason for
admission among women with PIH (n=400).
Figure 13 shows that 91% of sample in the
experimental group and 92.5% in control group were admitted for
safe confinement and only 9% in the experimental and 7.5% in the
control group were admittedfor evaluation of pregnancy induced
hypertension.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
safe
confinement
Evaluation of
PIH
Reason for admission
Experimental
Control
102
Fig.14: Percentage distribution based on time of diagnosis of
PIH in present pregnancy among women with PIH(n=400)
It is revealed from the figure 14 that, among the sample half of
the subjects in both groups were diagnosed as pregnancy induced
hypertension during 26-30 weeks of gestation,30% were during 20-25
weeks and only 20% were diagnosed during 31-34 weeks of gestation
in both groups.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
20-25 weeks 26-30 weeks 31-36 weeks
pe
rce
nta
ge
Gestational weeks
Experimental
Control
103
Fig.15: Percentagedistribution based on history of drug intake
among women with PIH(n=400)
Figure 15show that51.50% in experimental group and55% in control
grouphad no history of drug intake and 48.5% in experimental and 45%.
in control group had history of drug intake to treat PIH.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
yesNo
Pe
rce
nta
ge
Histroy of drug intake
Exprimental
control
104
Fig.16: Percentage distribution based on family history of
hypertension among women with PIH(n=400)
Figure 16 indicates family history of hypertension, 78% in the
experimental and 74% in the control group had no family history of
hypertension.
yesNo
22%
78%
26%
74%
Family history of hypertension
Experimental Control
105
Fig. 17: Percentage distribution based on family history of PIH
among women with PIH(n=400)
According to figure 17, more than half of the sample in
both group had no family history of pregnancy induced hypertension.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
YesNo
Family history of PIH
Experimental
Control
106
Fig. 18: Percentage distribution based on history of PIH in
previous pregnancy among women with PIH (n=400)
Figure 18 show that 31.5% in experimental and 33.5%
in control group had history of pregnancyinduced hypertension in
previous pregnancy. More than half among sample in experimental
(68.5%) and control(66.5%) had no such history.
0%
10%
20%
30%
40%
50%
60%
70%
YESNo
History of PIH in previous pregnancy
Experimental
control
107
Table 6:
Frequency, percentage and chi square distribution of history of
disease complicating among women withPIH (n=400)
Item Control group
Experimental group
χ2
value df
p value
f % f %
Diseases
Yes 93 46.5 84 42 0.821 1 0.365NS
No 107 53.5 116 58
Gestational hypertension
Yes 19 9.5 19 9.5 0 1 1NS
No 181 90.5 181 90.5
Preeclampsia
Yes 44 22 41 20.5 0.134 1 0.714
NS
No 156 78 159 79.5
NS-Not significant at the level p=0.05
The above table shows that more than half of the sample in both
group had no history of disease complicating pregnancy,9.5% subjects
in both group had the history of gestational hypertension (GIH),20.5% in
experimental and 22% in the control group had history of PIH.
108
Fig. 19: Percentagedistribution based on history of foetal loss
among women with PIH(n=400)
The above diagram reveals the foetal loss in previous pregnancy. It
waspresent only 11% in the experimental and 13.5% in the control
group.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
yes No
History of foetal loss
Experimental
Control
109
Fig.20: Percentage distribution based on presence of headaches
among women with PIH. (n=400)
According to figure 20, severe headache was present
among 57% in experimental and 52% in control group, mild head ache
among 31% and 32% and there was no head ache in 12% of the
experimental and 16% of control group.
0%
10%
20%
30%
40%
50%
60%
severe Mild No
Head Ache
Experimental
Control
110
Fig.21: Percentage distribution based on presence of pitting
oedema among women with PIH (n=400)
Figure 21shows that half of the sample in both groups had
pitting oedema of 2cm depth,29.5% in both groups had oedema with
1cm deep,9%in experimental and 8.5% control group presented with
3cm deep and 11.8% and 12.5% had no pitting oedema in the
experimental and control group respectively.
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
3mm 2mm 1mm No oedema
Pitting oedema
Experimental
Control
111
Fig. 22:Percentage distribution based on presence of eye
symptoms among women with PIH(n=400)
According to the above diagram,70% in the experimental and
69.5% in the control group had no eye symptoms, whereas 30% had
flashes around their eyes in the experimental and control group. None
of the samples had severe eye symptoms like blindness and blurring of
vision.
0%
10%
20%
30%
40%
50%
60%
70%
80%
No Flashes
Eye symptoms
Experimental
Control
Column1
112
Fig.23: Percentage distribution based on presence of epigastric
pain among women with PIH(n=400)
The data in the figure 23 indicates that majority (89% and
87.5%) of sample in both groups had no epigastricpain andonly 11% in
the experimental and 12.5%in the control group had pain after
takingfood.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
After food No
Epigastric pain
Experimental
Control
113
Fig.24: Percentage distribution based onpresence of nausea and
vomiting among women with PIH (n=400)
Figure 24 reveals that nausea and vomiting was present only among
48.5% in experimental and 45% in control group.
0%
10%
20%
30%
40%
50%
60%
Absent Present
Nausea and Vomiting
Experimental
Control
114
Fig. 25: Percentage distribution based on body weight among
women with PIH(n=400)
The above figure indicated that half of the samples in
both groups had body weight ranging between 56 to 65 kg.None of the
sample belonged to underweight,that is less than 45 kg.
45-55 kg 56-65 kg >65 kg
38.50% 50.50%11%
34.50%52%
13.50%
Body weight
Control
Experimental
115
Fig. 26: Percentagedistribution based on weight gain during
pregnancy among women with PIH(n=400)
It is referred from the above diagram that,70% in the
experimental group and 69.5% in the control grouphad more than 0.5 kg
weight gain.
0%
10%
20%
30%
40%
50%
60%
70%
>0.5kg <0.5kg
70%
30%
69.50%
30.50%
Weight gain during pregnancy
Experimental
Control
116
Fig. 27: Percentage distribution based on height among women
with PIH(n=400)
From the above diagram it is evident that 69% subjects
in experimental and 67.5% in control group belonged to 151-160cm
height, 22.% and 25% belonged to 161 -170cm and below 10% only
belonged to less than 150cm height in both groups.
0%
10%
20%
30%
40%
50%
60%
70%
80%
<151 cm 151-160 cm 161-170 cm
Height in centimeters
Experimental
Control
117
Fig 28: Percentage distribution based onnumber of foetal
movements per 12 hours among women with PIH(n=400)
According to figure 28 the foetal movements felt more
than 10 per 12 hours among majority of sample in both groups, 12% in
experimental group and 15.5% in the control group felt the foetal
movements less than 10 per 12 hours and none of the sample felt more
than 10 per 12 hours.It indicate that majority of sample had normal
foetal movements.
<10/12 hours>10/12hours
12%
88%
15.50%
84.50%
Foetal movements
Experimental Control
118
Fig.29: Percentage distribution based on sleep pattern among
women with PIH.(n=400)
The above diagram shows that most of the samples in
both groups had interupted sleep,only 29.5% in experimental group and
27% in the control group had sound sleep andonly 1.5%in experimental
and 4% in control had insomnia.Interupted sleep and insomnia may
affect the health of the women especially during pregnancy.
29.50%
68%
1.50%
27%
69%
4%
8-10 hours Interrupted Sleep Insomnia
Sleep pattern
Experimental Control
119
Fig. 30: Percentage distribution based on antenatal check-ups
among women with PIH(n=400)
The above bar diagram shows that 12% of the sample in
both groups had irregular antenatal check-ups even though the majority
(88%) had regular check-ups.Irregular antenatal check- ups lead to
difficulty in identifying the complications like PIH among pregnant
women.Among the sample 100% in both groups had foetal heart rate
and urine out- put within normal limits.
Section III: Distribution of weekly average difference in scores of
physiological data in experimental group
This section deals with distribution of weekly average
scores of physiological data in the experimental group.
0%
20%
40%
60%
80%
100%
RegularIrregular
Antenatal Checkup
Experimental
Control
120
Table 7:
Distribution of means of the pre post pulse rates among
experimental group (n=200)
Week Days
Pulse Rate Paired t
value P-value PRE Post
Mean SD Mean SD
1
1 81.50 4.10 82.20 5.56 -1.78 0.077NS
2 81.05 5.43 80.30 3.49 2.40 0.017*
3 80.50 4.91 78.90 3.88 4.92 <0.001**
4 79.20 2.86 78.60 4.16 2.67 0.008*
5 77.40 4.35 75.60 5.10 6.36 <0.001**
2
1 81.76 4.14 82.12 5.14 -1.02 0.307NS
2 80.97 5.07 80.12 3.32 2.71 0.007*
3 80.61 4.74 78.76 3.96 5.68 < 0.001**
4 79.22 2.72 78.82 4.08 1.75 0.082NS
5 77.68 4.37 75.81 4.90 6.77 < 0.001**
3
1 81.01 3.93 78.84 3.04 6.15 < 0.001**
2 80.13 5.04 78.60 3.31 3.75 < 0.001**
3 79.31 5.45 78.66 3.34 1.50 0.136NS
4 78.79 3.49 78.34 4.19 2.15 0.033*
5 77.04 4.22 74.96 5.19 7.31 < 0.001**
4
1 78.79 3.14 78.78 3.26 0.03 0.976NS
2 78.77 3.09 78.84 3.04 -0.22 0.826NS
3 78.81 3.18 78.60 3.31 0.72 0.470NS
4 78.75 3.15 78.66 3.34 0.29 0.776NS
5 78.52 3.45 78.41 3.52 0.35 0.727NS
NS- Not Significant at p=0.05 level; *- Significant at p=0.05 level; ** -Significant at p=0.001
level
Table 7 shows the average mean difference in the pre
and post pulse rate in the experimental group. It is inferred that the pre
and post pulse rate was significantly different in the first three weeks but
121
was not significant after the 3rd week of the study period.There is great
difference in the first and fourth week pulse rate. It seems that effect of
relaxation achieved at fourth week and no abnormality was detected
during fourth week.
Table 8:
Weekly average difference in mean pre and post respiratory rate in
experimental group (n=200)
Week Days
Respiratory rate Paired t
value P-value PRE Post
Mean SD Mean SD
1
1 14.90 1.95 14.90 2.15 0.00 1.000NS
2 14.90 2.15 13.50 1.66 9.37 < 0.001**
3 14.00 1.79 13.70 1.82 2.67 0.008**
4 13.90 1.73 13.30 1.31 5.42 < 0.001**
5 12.90 1.18 13.40 1.69 -3.55 <0.001**
2
1 14.89 1.98 14.82 2.09 0.45 0.307NS
2 14.90 2.23 13.52 1.73 8.98 < 0.001**
3 14.07 1.80 13.58 1.73 4.48 < 0.001**
4 13.80 1.74 13.29 1.28 4.64 < 0.001**
5 12.91 1.20 13.32 1.58 -3.11 0.002*
3
1 14.70 1.93 13.14 1.13 9.92 < 0.001**
2 14.22 1.22 13.20 1.33 7.85 <0.001**
3 13.45 1.46 13.15 1.28 2.21 0.028*
4 13.72 1.61 13.10 1.22 5.58 <0.001**
5 12.81 1.00 13.28 1.71 -3.05 0.003*
4
1 13.29 1.15 13.28 1.14 0.09 0.932NS
2 13.26 1.14 13.14 1.13 1.07 0.286NS
3 13.28 1.14 13.20 1.33 0.67 0.506NS
4 13.18 1.16 13.15 1.28 0.25 0.801NS
5 13.14 1.26 13.20 1.33 -0.43 0.671NS
NS- Not Significant at p=0.05 level; *- Significant at p=0.05 level; ** -Significant at p=0.001 level
From the above table 8 inferred that the weekly average difference
in the pre and post-test respiratory rate in the experimental group.
There is statistically significant difference was found during first, second
and third week. Even though there is no statistically significant
difference was found during fourth week, there is slight difference was
122
found between pre post mean (pre-13.14, post 13.2) score in the
experimental group. Hence it is evident that the relaxation programme is
helpful in maintaining respiratory rate of women with PIH.
Table 9:
Weekly average difference in pre and post systolic blood pressure
in experimental group (n=200)
Week Days
SBP Paired t
value
P-
value PRE Post
Mean SD Mean SD
1
1 137.50 9.44 137.90 9.81 -0.95 0.342NS
2 134.40 8.73 131.80 7.84 5.89 <0.0001***
3 128.80 8.47 127.50 7.68 3.34 0.001**
4 131.00 7.49 127.50 9.44 8.52 < 0.001**
5 124.70 8.79 125.30 9.47 -2.33 0.021*
2
1 136.35 9.63 136.64 9.95 -0.67 0.506NS
2 134.19 9.00 130.98 7.95 7.13 < 0.001**
3 128.23 8.11 126.90 7.79 3.36 0.001**
4 130.98 7.95 127.35 10.15 8.60 < 0.001**
5 124.62 9.35 125.18 10.07 -2.06 0.04*
3
1 120.17 8.09 119.73 8.05 1.70 0.091NS
2 120.17 8.09 119.68 8.02 1.93 0.050*
3 122.70 8.19 124.00 8.39 -2.36 0.019*
4 123.21 8.34 121.72 7.90 3.34 0.001**
5 118.35 7.35 119.60 8.01 -4.56 <0.001**
4
1 120.13 8.48 120.03 8.12 0.82 0.416NS
2 119.88 8.02 119.73 8.05 1.34 0.18NS
3 119.68 7.96 119.68 8.02 0.00 1.000NS
4 119.73 7.93 119.90 7.94 -1.18 0.241NS
5 119.78 8.02 119.40 7.87 0.58 0.565NS
NS- Not Significant at p=0.05 level; *- Significant at p=0.05 level; ** -Significant at p=0.001 level
123
Table 9 shows the average difference in the systolic blood pressure
(SBP) in pre and post- test. It was significantly different in the first three
weeksand there is no statistically significant differenceinSBP during 4th
week (t=0.58,p=0.5), but the SBP among experimental group was
maintained within normal limits. It seems that the effect of relaxation
programme achieved and shows that there was a significant role of the
relaxation programme to reduce the SBP of the study subjects.
Table 10:
Weekly average difference in pre and post diastolic blood pressure
in experimental group (n=200)
Week Days
DBP Paired
t value P-value PRE Post
Mean SD Mean SD
1
1 89.50 4.99 89.50 5.91 0.00 1.000NS
2 87.40 5.35 86.30 5.82 3.52 0.001**
3 83.80 6.49 84.90 4.93 -2.54 0.012*
4 83.30 4.54 82.30 6.06 2.70 0.008*
5 81.30 5.16 79.40 4.44 7.55 < 0.001**
2
1 90.15 5.63 89.95 6.38 0.63 0.528NS
2 87.82 6.13 86.24 6.00 4.42 < 0.001**
3 83.98 6.67 85.23 4.91 -2.88 0.004*
4 83.03 5.26 82.06 6.76 2.49 0.014*
5 80.88 5.74 79.03 4.98 7.37 < 0.001**
3
1 79.96 5.34 79.66 5.15 1.86 0.065NS
2 79.96 5.34 79.86 5.52 0.56 0.574NS
3 80.54 6.01 82.20 6.00 -4.23 < 0.001**
4 79.90 4.55 78.38 4.65 5.69 <0.001**
5 78.41 4.55 77.76 3.98 3.04 0.003*
4
1 79.92 5.44 79.92 5.19 0.00 1.000NS
2 79.66 5.15 79.66 5.15 0.00 1.000NS
3 80.57 5.82 79.86 5.52 1.34 0.182NS
4 79.74 5.09 79.59 5.15 1.97 0.050*
5 79.63 5.16 77.80 4.00 4.31 <0.001**
NS- Not Significant at p=0.05 level; *- Significant at p=0.05 level; ** -Significant at p=0.001
level
124
According to table 10, the average difference in the diastolic
blood pressure (DBP) in pre and post- test. It was significantly different
in the first three weeks and statistical difference was found on the fifth
day of the fourth week. This shows that there was a significant role of
the relaxation programme to reduce the DBP of the study subjects.
SECTION IV:A:Distribution of the sample based on the level of
stress
This section deals with distribution of level of stress
among women with PIHbetween experimental group and control group
before and after intervention.
Table11
Comparison of pre-test mean score of level of stress among
women with PIH between experimental group and control group
before intervention (n=400)
Group Level of
stress Score
Obtained
score f % Mean SD
Min Max
Experimental
group
No 0-30
Mild 31-40
Moderate 41-59
Severe >60 84 114 200 100 112.9 10.34
Control
group
No 0-30
Mild 31-40
Moderate 41-59
Severe >60 77 126 200 100 111.58 11.34
Table 11 highlights the pre -test mean score of level of stress between
experimental and thecontrol group. The experimental group had a mean
score of112.9 and control grouphad 111.58.There was no
125
statistically significant differencein the level of stress between groups
(t=1.2,p=0.22)
Table 12:
Comparison of post -test mean score of level of stress among
women with PIH between experimental group and control group
after intervention (n=400)
Group
Level
of
stress
Score
Obtained
score f %
Mea
n SD
Min Max
Experimental
group
No 0-30 16 30 10 5 25.30 4.29
Mild 31-40 31 40 20 10 36.75 2.97
Moderate 41-59 41 58 85 42.5 46.57 4.02
Severe >60 62 128 84 42 82.76 9.89
Control
group
No 0-30
Mild 31-40
Moderate 41-59
Severe >60 77 126 200 100 111.94 11.17
Table 12 depicts that the post -test mean score of level of stress
among women with PIH between the experimental and the control
groups. The experimental group had a mean of 59.73 and control group
had a mean of111.94.Agreater reduction was observed in the level of
stress in the experimental groupin comparison to control group.
126
Fig.31: Percentage distribution based on level of stress among
women with PIH in the experimental and control group after
relaxation programme (n=400)
5
10
43 42
0 0 0
100
0
20
40
60
80
100
120
No Mild Moderate Severe
Level of stress
experimental
control
127
Fig.32: Mean distribution based on level of stress among women
with PIH in the experimental and control group (n=400)
112.9
59.73
111.58 111.94
0
20
40
60
80
100
120
pre test post test
Mean stress score of women with PIH
Experimental Control
128
Fig.33: Percentage distribution based on depression, anxiety and
stress among women in the experimental and control group before
relaxation programme.(n=400)
Figure33, show that the depression, anxiety and stress
present in its severe form among 100% of sample in experimental group
whereas in the control group 43% had severe depression, 77% had
anxiety and 34.5% had stress before intervention.
0
20
40
60
80
100
120
Depression Anxiety Stress Depression Anxiety Stress
Experimental Control
Normal
Mild
Moderate
Severe
129
Figure 34: Percentage distribution of Post relaxation depression,
anxiety and stress in experimental and control group.(n=400)
From the above figure it is evident that depression,
anxiety and stress reduced to 43%, 77% and 34.5% in experimental
group whereas in control group it was increased from 43% to 100 in
depression, 77% to 100 in anxietyand 34.5% to 99.5% in stress .Hence
it is understood that the relaxation programme helped the women in the
experimental group to relax.
0
10
20
30
40
50
60
70
80
90
100
De
pre
ssio
n
An
xie
ty
Str
ess
De
pre
ssio
n
An
xie
ty
Str
ess
Experimental Control
Normal
Mild
Moderate
Severe
130
Section IV: B: Distribution of sample based on coping strategies
This section deals with distribution of coping strategies
among women with PIH between experimental group and control group
before and after intervention.
Table 13:
Comparison of pre -test post- test mean score of coping strategies
among women with PIH between experimental group and control
group (n=400)
Group
Usefulness Effectiveness Total
Mean SD Mean SD Mean SD
Experimental
Pre test 81 5.64 50.57 4.95 131.6 8.34
Post test 48.59 4.6 119.92 5.73 168 7.27
Control
Pre test 80.85 6.02 49.22 4.73 130.01 7.45
Post test 81.49 4.88 49.87 5.44 131.26 7.44
Table 13 depicts the pre- test post- test coping score between
the experimental and the control group. The total coping score for the
experimental group was131.6 and the control group had total coping
score of 130.01,which reveals absence of statistical significance in the
coping score between groups before intervention. After
intervention,there is an apparent difference in the mean score of coping
betweenexperimental group and control group. Hence it is evident that
the relaxation programme is best technique to cope the stress
effectively.
131
Table 14:
Comparison of pre -test post –test mean score of coping strategies
of sub scales among women with PIH between experimental group
and control group (n=400)
Sub scale variables N Mean SD
t
value
P
value
Confrontive Experimental 200 7.83 2.39
2.263 0.024* Control 200 7.27 2.51
Evasive Experimental 200 10.92 2.18
2.198 0.029* Control 200 10.44 2.23
Optimistic Experimental 200 7.54 1.39
0.932 0.352NS Control 200 7.42 1.29
Fatalistic Experimental 200 3.03 1.14
1.727 0.085NS Control 200 2.83 1.17
Emotive Experimental 200 3.62 1.15
0 1NS Control 200 3.62 1.18
Palliative Experimental 200 6.25 1.39
0.898 0.37NS Control 200 6.13 1.28
Supportant Experimental 200 5.23 2.32
0.669 0.504
NS Control 200 5.07 2.31
Self-reliant Experimental 200 6.38 1.32
0.518 0.605NS Control 200 6.45 1.38
NS- Not Significant at p=0.05 level; *- Significant at p=0.05 level
The above table shows that the sub scale of coping strategies among
women with PIH in the control group and experimental
group.Confrontive(t=2.26,p=0.024)and evasive (t=2.19,p=0.029) coping
dimension have statistical significance. Even though there is no
statistical significance in other dimensions, there is effective coping
among women with PIH in experimental group (table 13) than control
group.
132
Fig .35: Mean distribution based on copingscore among women
with PIH in the experimental and control group (n=400)
0
20
40
60
80
100
120
140
160
180
pre test post test
131.6
168.5
131.01 131.26
Mean coping score of women with PIH
Experimental Control
133
SECTIONIV
C:DISTRIBUTIONOF SAMPLE BASED ON PREGNANCY OUTCOME
This section deals with sample distribution based on maternal and
neonatal outcome among experimental and control groups.
A. Pregnancy outcome in terms of maternal outcome
Figure 36: Percentage distribution based on labour among women
with PIH in experimental and control group (n=400)
From the figure 36, it is noticed that 83.5% in experimental group and
43% in control group had term labour. Pre- term labour occurred only in
16.5% among experimental group but it was 57% in control group. It
seems that relaxation programme helped to relax and thus the women
with PIH in experimental group delivered at term.
134
Figure 37: Percentage distribution based on type of delivery
amongwomen with PIH in experimental and control group (n=400)
It is evident from the figure that the type of delivery was normal
among 79.5% in experimental group and only 48% in control group. In
experimental group only 17% had undergone LSCS but it was 43% in
control group. Out of 400 samples, 3.5% and 9% had instrumental
delivery in experimental and control group respectively. The relaxation
programme may be helped to reduce the rate of operative and
instrumental deliveries among women in experimental group than
control group.
135
Figure 38: Percentage distribution based on maternal
complications among women with PIH in experimental and control
group (n=400)
Figure 39 reveals the maternal complications during delivery among
women with PIH in the experimental and control group.In experimental
group only 8% developed complications but in the control group it was
24.5%. It is interpreted that relaxation programme helps to maintain the
physiological parameters, thus the complications during delivery was
decreased among women with PIH in the experimental group.
136
Figure 39: Percentage distribution based on blood pressureamong
women with PIH in experimental and control group (n=400)
According to figure 39, blood pressure status of women with
PIH in the experimental and control group after delivery. The data show
that 84.5% in the experimental group and 51.5% in the control group
had normal blood pressure after delivery. Only 15.5% in experimental
group had high blood pressure, whereas 48.5% in control group had
high blood pressure after delivery. It seems that effect of relaxation
programme helps to maintain the blood pressure among majority of
women with PIH in experimental group,
137
Figure 40: Percentage distribution based proteinureaamong
women with PIH in experimental and control group (n=400)
The above diagramshows the presence ofproteinurea
among women with PIH in the control and experimental group. In the
experimental group, 88% had no protein urea, 59% in the control group
had presence of protein urea after delivery. It appears that the
relaxation programme helps to maintain physiological parameters
(proteinurea) among women with PIHin experimental group.
88
12
41
59
0
10
20
30
40
50
60
70
80
90
100
Absent Present
Pe
rce
nta
ge
Protienuria
Experimental
Control
138
Figure 41: Percentage distribution based on oedemaamong
women with PIH in experimental and control group. (n=400)
From figure 41, it is evident that oedema was absent
among 84% in experimental and 47% in control group. Only 16% in the
experimental and 53% in control group had oedema after delivery. It is
interpreted that the effect of relaxation programmecan help to keep the
physiological status in most of the women with PIH in the experimental
group, thus 84% had no oedema.
84
16
47
53
0
10
20
30
40
50
60
70
80
90
Absent Present
Pe
rce
nta
ge
Edema
Experimental
Control
139
B. Pregnancy outcome in terms of neonatal outcome
Figure 42: Percentage distribution based on birth weightamong
women with PIH in experimental and control group.(n=400)
The above figure shows that 61.5% in experimental and
49% in control group had normal birth weight (2.5-3.5kg).48% in control
group had babies with less than 2.5 kg birth weight; this was only 29%
in experimental group. Babies with more than 3.5kg birth weight were
present among 9.5% in experimental group and only 3% in control
group.Maintaining the infants’ birth weight within the normal rangemay
be achievedby theexperimental group through relaxation programme.
140
Figure 43: Percentage distribution based onAPGAR scoreamong
women with PIH in experimental and control group (n=400).
From the figure 43 it is evident that 88% of babies in the
experimental group had normal APGAR score (8-10) whereas in control
group it was only 40%. Apgar score in the range of 4-7 was present in
10.5% experimental group and 40.5% in control group. Severe distress
(Apgar score-0-4) was present among 19.5% in the control group and it
was only 1.5% in the experimental group. This indicated that effect of
relaxation programme may be helped to maintain the normal respiratory
status among 88% babies in the experimental group.
141
Figure 44: Percentage distribution based on neonatal
complicationsamong women with PIH in experimental and control
group.(n=400).
The bar graph shows the neonatal outcome in terms of
neonatal complications among experimental and control group. Among
3.5% in experimental group hadneonatal complications, and in control
group it was 14%. This findingindicated that the relaxation programme
benefitted to decrease the neonatal complications among neonates of
women with pregnancy induced hypertension in experimental group.
142
Section V
A: Effect of relaxation on level of stress.
This section deals with the effect of relaxation programme on
level of stress.In order to evaluate the effect of relaxation programme,
following null hypothesis was formulated and tested at the level of
0.05level.
H01:Meanscores of stress in the experimental and control
groupbetween the p will have nosignificant difference.
H02: There will be no significant difference between the mean pre and
post stress of women with pregnancy induced hypertension in
experimental group, the data was subjected to t test and findings were
presented in the table.
Table 15
Significance of difference in the mean pre- test score of stress in
the experimental and control group (n=400)
Group Mean SD t value p value
Experimental 112.90 10.339
1.130
0.259NS Control 111.67 11.316
NS not significant
Table 15 depicts that the obtained t value of pre-test scores of
stress in the experimental and control group. The data show that there
is no statistical significance in the pre-test score among both
143
group(t=1.130,p>0.001).Hence the null hypothesisH01 is
accepted showing no significant difference was found between groups
on level of stress.
Table 16
Significance of difference in the mean post- test stress score in the
experimental and control group after relaxation programme.
(n=400)
Group Mean SD t value p value
Experimental 59.73 21.467
-30.098
0.0001*** Control 111.39 11.330
*** Significant at < p=0.001 level
Table16highlights the post -test mean score of stress in the
experimental and the control groups. The experimental group had mean
score of 59.73 and the control group had a mean score of 111.39.
There was a highlysignificant reduction in stress among the
experimental group compared to the control group at P<0.001
(t=30.09).The two groups were not different in pre-test scores (Table
17).The null hypothesisH02 is thereforerejected and it isinterpreted that
the women with PIH who have undergone relaxation programme have
significantly reduced their stress compared to those who have not
undergone the programme. The relaxation programmewas effective in
relieving stress among women with pregnancy induced hyper tension.
144
Table 17
Significance of difference in mean pre and post- test stress score in
the experimental group. (n=200)
**significant at p=0.001level.
It is inferred from table 17 that there is statistically
significant difference in the mean pre and post- test stress score of
experimental group (t=30.56, p<0.001). The mean post- test score of
the experimental group is significantly reduced than their pre-test mean
score. On the basis of this findings, the null hypothesis H02 is rejected
and interpreted that the women with PIH who have undergone
relaxation programme showed significant difference in their post- test
stress score comparedto their pre-test stress score. The relaxation
programme was effective in relieving stress among women with PIH.
B : Effect of relaxation on coping
This section deals with the effect of relaxation programme on
coping.In order to evaluate the effect of relaxation programme, following
null hypothesis was formulated and tested at the level of 0.05level.
H03: There will be no significant difference between the mean scores
of coping in the experimental and control group, the data was subjected
to independent sample t test and findings were presented in the table
Group Mean SD t value p value
Pre test 112.90 10.339 30.564 0.001**
Post test 59.73 21.467
145
H04:No significant difference between the mean pre and post
copingscorein experimental group will be there.The data was subjected
to paired t test and findings were presented in the table
Table 18
Significance of difference in the mean pre- test score of coping
in the experimental and control group. (n=400)
Group
Usefulness Effectiveness Total t
valv
e
df p
value Mean SD Mean SD Mean SD
Experimental 81.02 5.64 50.57 4.95 131.6 8.34 0.28 398 0.77NS
Control 80.85 6.02 49.22 4.73 130.07 7.75
NS not significant Table 18 depicts that the obtained t value of pre-test scores of
coping in the experimental and control groupis not statistically
significant different (t=0.283,df=398,p>0.05). The null hypothesis H03 is
accepted showing that there is nostatistical difference in the coping
score among experimental and control group.
146
Table 19
Significance of difference inmean post- test coping scoreof women
with PIH in the experimental and control group after relaxation
programme. (n=400)
Coping
Strategies Group Mean SD
t
value p value
Usefulness
Experimental 48.59 4.60
69.5 0.0001***
Control 81.49 4.85
Effectiveness
Experimental 119.94 5.72
125.2 0.0001***
Control 49.87 5.44
Total
Experimental 168.5 7.27
50.4 0.0001***
Control 131.26 7.47
***significant at p=0.0001 level
Table 19 indicated that there is statisticallysignificant
difference in the mean coping score of experimental and control groups
(t=50.4, p<0.01). That is, the experimental group scored significantly
higher in the pot test compared to the control group. The two groups
were not different in pre-test coping score (Table 20). Hence thenull
hypothesis is rejected and it is interpreted thatthe women with PIH who
have undergone relaxation programme have scored significantly higher
in the post test on coping score compared to those who have not
undergone relaxation programme.The relaxation programme was
effective in adopting useful coping strategies among women with PIH.
147
Table 20 Significance of difference in the mean pre- test post- test coping
score in the experimental group after relaxation programme(n=200)
Coping Mean SD t value df p value
Usefulness 32.43 6.75 67.85 199 0.001**
Effectiveness -69.34 7.36 -133.18 199 0.001**
Total score -36.90 9.62 -54.24 199 0.001**
**- significant at p<0.001) According to table20,it is evident that there is statistically significant
difference in the pre- test post -test mean score of coping among
women with PIH in experimental group after relaxation programme
(t=54.24,p=0.001).The null hypothesis H04 is thus rejected and it is
interpreted that the relaxation programme was effective in adopting
useful coping strategies among women with PIH.
SECTION V C: Effect of relaxation on physiological variables
In order to evaluate the effect of relaxation programme
on physiological variables among women with PIH in the experimental
group, the following hypothesis was stated and tested at 0.001 levels.
H05: There will be no significant variation in the weekly score of
physiological variables in the experimental group.
In order to find out the significant variation in the weekly scores of
physiological variable in the experimental group, the data was subjected
totest and the findings presented in the table21.
148
Table 21:
Significance of difference between mean pre and post-test score on
selected physiological variables among women with PIH in
experimentalgroup (n = 200)
Weekily average difference of pre and post values of selected physiological variables
Variables Weeks Mean Std.
Deviation Minimum Maximum F -value P-value
Pulse difference
1st -.81 4.505 -14 22
14.341 0.0001** 2nd -.33 4.746 -14 22
3rd -1.36 5.293 -18 12
4th -.07 4.431 -14 14
Respiratory Rate difference
1st -.36 2.028 -8 6
13.684 0.0001**
2nd -.42 1.935 -8 4
3rd -.59 2.152 -8 6
4th -.04 1.726 -6 6
SBP difference
1st -1.28 5.727 -20 20
29.757 0.0001** 2nd -2.49 8.079 -38 30
3rd -.14 7.467 -30 30
4th -.09 4.414 -20 20
DBP difference
1st -.58 4.944 -10 10
0.806 0.491NS 2nd -.49 6.090 -20 20
3rd -.82 4.949 -30 20
4th -.54 4.476 -20 16
**- significant at p<0.001); NS- not significant
Table 21 depicts the weekly average mean
scores of physiological variables (pulse, respiration, SBPand DBP)
among women with PIH in the experimental group. The findings show
that there is a significant difference between the mean pre and post-
test scores of the experimental group (p=0.0001level) except in DBP
(p=>0.05 level). The null hypothesis H05 is therefore rejected and it is
interpreted thatthe relaxation programme effective in maintaining
149
physiological variables that is very important to maintain the health of
mother and foetus in women with pregnancy induced hypertension.
D: Effect of relaxation on pregnancy outcome among women with
pregnancy induced hypertension.
This section deals with the effect of relaxation programme on
pregnancy outcome.
In order to evaluate the effect of relaxation programme on
pregnancy outcome in terms of maternal and neonatal outcome,
following null hypothesis was formulated and tested at the level of
0.05level.
H06.(a): There will be no significant difference in the mean score of
maternal outcome among women with PIH in the control and
experimental group after the relaxation programme.
H06.(b): There will be no significant difference in the mean score of
neonatal outcome among women with PIH in the control and
experimental group after the relaxation programme.
150
A .Maternal outcome
Table 22:
The Chi square value computed on pregnancy outcome score in
terms of maternal outcome in the experimental group and control
group after relaxation programme (n=400)
**significant at p=0.001,***significant at p=0.0001 level.
Maternal outcome variables
Experimental Control χ
2 value df p
value f % f %
Labour
Term 167 83.5 86 43 70.565 1 0.001**
Preterm 33 16.5 114 57
Type of delivery
Normal 159 79.5 96 48
42.938 2 0.0001
*** Instrumental 7 3.5 18 9
L S C S 34 17 86 43
Complications
Present 16 8 49 24.5 20.005 1
0.0001***
Absent 184 92 151 75.5
Blood pressure
Normal 169 84.5 103 51.5 50.046 1
0.0001***
High 31 15.5 97 48.5
Proteinuria
Present 24 12 118 59 96.473 1
0.0001***
Absent 176 88 82 41
Oedema
Present 32 16 106 53 60.582 1
0.0001***
Absent 168 84 94 47
151
Table 22 shows the pregnancy outcome in terms of maternal outcome
in Labour, type of delivery, complications, blood pressure, proteinuria
and oedema among women with PIH in the experimental and control
group. The findings revealed that 83.5% labour at term in experimental
group and it was only 43% in control group. But pre- term labour rate
was higher among control group (57%) than experimental group
(16.5%). Majority of subjects in the experimental (79.5%) had normal
delivery whereas in control group it was 48%. 43% had LSCS in the
control and it was very low in the experimental group (17%). 9%
subjects had instrumental delivery in control group and only 3.5%
subjects in the experimental group had instrumental delivery. Regarding
complications, majority of subjects in both groups had no complications
(92% experimental, 75.5% control). Blood pressure was normal among
84% in experimental group whereas in the control group it was only
51.5%. Proteinuria and oedema was absent among 88% and 81% in
experimental, 41% and 47% in control group respectively. The findings
are statistically significant in all areas of maternal outcome (p=<0.001).
Therefore, H06(a) is rejected and it is interpreted that the relaxation
programme is effective in positive pregnancy outcome in terms of
maternal outcome (Labour, type of delivery, complications, blood
pressure, proteinuria and oedema) among women with pregnancy
induced hypertension.
152
B. Neonatal outcome
Table 23:
The Chi square value computed on pregnancy outcome score in
terms of neonatal outcome in the experimental group and control
group after relaxation programme (n=400)
Neonatal outcome variables
Experimental Control χ
2
value df p value
f % f %
Birth weight
<2.5 kg 58 29 96 48
18.965 2 0.0001*** 2.5-3.5kg 123 61.5 98 49
>3.5 kg 19 9.5 6 3
Apgar score
0-4 3 1.5 39 19.5
102.151 2 0.0001*** 4-7 21 10.5 81 40.5
8-10 176 88 80 40
Complications
Present 7 3.5 28 14
13.808 1 0.0001***
Absent 193 96.5 172 86
Still birth
No 197 98.5 189 94.5
4.737 1 0.030*
Yes 3 1.5 11 5.5
***significant at p=0.0001 level and * at p<0.05.
The data in table 23 show the chi square value computed on neonatal
outcome in terms of birth weight, APGAR score, complications and still
birth among women with PIH in experimental and control group. The
153
findings show that in the experimental group, 61.5% had normal birth
weight (2.5-3.5kg) neonates whereas in control group it was only
49%.Among the subjects, 29% in the experimental and 49% in the
control group had below normal birth weight (<2.5kg) babies and the
birth weight was more than 3.5kg in 9.5% and 3% among experimental
and control group respectively.Regarding Apgar score, 88% in
experimental and 40% in control group had the normal score (8 -10),
Mild distress was observed (4-7 score) in 10.5% in experimental
and40.5%in control group.Severe respiratory distress(score0-4) was
present 1.5% in experimental group and it was 19.5% in control group.
Majority of neonates in both groups (96.5% in experimental and 86% in
control group) had no complications. The χ2value computed are highly
significant in all areas (p=<0.05). The null hypothesis H06 (b)is
therefore rejected and inferred that the relaxation programme is
effective in positive neonatal outcome among women with PIH
SECTION VI
A:Association between stress and selected variables among
women with PIH.
The following hypothesis was stated to identify association between
stress and selected variables.
154
H08. There is no significant association between stress and selected
variables among women with pregnancy induced hypertension in the
control and experimental group at 0.05 level.
Table 24:
Association between stress and selected variables among women
with pregnancy induced hypertension (n=400)
Selected variables N Mean Sd Min Max F
value p
Age in years
<19 121 111.9 10.8 81 126
0.25 0.77NS
20-
29 183 112.1 11.1 77 141
30 and
above 96 112.9 10.6 87 135
Gravida
1 82 112.0 11.2 84.0 126.0
2.40 0.06NS 2 181 113.7 10.1 77.0 141.0
3 104 110.7 11.7 84.0 135.0
4 33 109.7 10.3 81.0 126.0
Para
0 124 132.1 7.3 111.0 145.0
0.82 0.48NS 1 228 130.7 8.3 105.0 144.0
2 30 130.6 8.3 114.0 144.0
3 18 131.2 7.4 119.0 141.0
Live
0 165 110.5 11.3 81.0 126.0
3.84 0.02** 1 207 113.6 10.5 77.0 141.0
2 28 112.3 9.8 94.0 125.0
Abortion
0 311 112.8 10.4 77.0 141.0
2.47 0.06NS 1 36 113.0 12.2 84.0 135.0
2 49 108.3 12.1 81.0 126.0
3 4 110.5 9.7 101.0 123.0
History of
PIH in the
family
Yes 180 112.17 11.03 - -
0.19 0.84NS
No 220 112.33 10.74 - -
Family history
of
hypertension
Yes 96 111.0 10.4 -
- 1.31 0.19NS
No 304 112.6 11.0 - -
*significant at p=0.05 level and NS- not significant
155
Table 24 shows that the association between stress and socio
personal variables (age, obstetric score,history of PIH in family and
family history of hypertension) among women with PIH in experimental
and control group.The f value of pre -test stress scores of subjects with
respect to age (f=0.253,p>0.05) obstetric score except in live status,
history of PIH in the family(t=0.19,p>0.05)and family history of
hypertension (t=1.31,p>0.05) are not statistically significant. Findings
revealed that stress and socio personal variables (age, obstetric score,
history of PIH in family and family history of hypertension) are not
associated.Therefore the null hypothesis, H08is accepted and it is
interpreted that socio personal variables are not a significant factor to
determine stress among women with PIH.
SECTION VI
B: Association between coping and selected variables among
women with PIH.
The following hypothesis was stated to identify association between
coping and selected variables.
H09. There is no significant association between coping and selected
variables among women with pregnancy induced hypertension in
experimental and control group at 0.05 level.
156
Table 25
Association between coping and selected socio personal variables
among women withPIH (n=400)
Selected variables N Mean SD Min Max F
value
p
value
Age in years
<19 121 131.9 7.1 113 144
1.72 0.17NS 20-29 183 130.3 8.5 111 145
30 and
above 96 131.8 8.0 105 143
Gravida
1 82 131.6 7.1 114 144
1.18 0.31NS 2 181 130.5 8.3 112 143
3 104 132.2 8.2 105 145
4 33 130.5 7.6 114 141
Para
0 124 132.1 7.3 111 145
0.82 0.48 NS 1 228 130.7 8.3 105 144
2 30 130.6 8.3 114 144
3 18 131.2 7.4 119 141
Live
0 165 132.0 7.3 111 145
1.48 0.22 NS 1 207 130.5 8.5 105 144
2 28 130.9 8.2 114 141
Abortion
0 311 130.8 7.9 112 144
2.23 0.08 NS 1 36 131.8 9.0 105 144
2 49 133.3 7.4 111 145
3 4 125.0 8.2 114 133
History of
PIH in the
family
Yes 180 130.64 8.17 - -
1.15 0.24 NS No 220 131.57 7.83 - -
Family
history of
hypertension
Yes 96 130.1 7.8 - -
1.49 0.13 NS No 304 131.5 8.0
NS- not significant
157
Table 25 presents the association between coping
strategies and selected socio personal variables (age, obstetric score,
history of PIH in family and family history of hypertension) among
women with PIH in experimental and control group. The f value of pre -
test coping scores of subjects with regard to age (f=1.72,p>0.05)
obstetric score, history of PIH in the family(t=1.15,p>0.05) and family
history of hypertension (t=1.49,p>0.05) are not statistically significant.
Findings revealed that coping and selected socio personal variables
(age, obstetric score, history of PIH in family and family history of
hypertension) are not associated. Therefore the null hypothesis, H09 is
accepted and it is interpreted that socio personal variables are not a
significant factor with regard to coping among women with PIH.
SECTION VI B: Association between pregnancy outcome and
selected variables among women with PIH
The following hypothesis was stated to identify association between
pregnancy outcome and selected variables.
H010. There is no significant association between pregnancy outcome
and selected variables among women with pregnancy induced
hypertension in the experimental groupand control at 0.05 level.
158
Table 26:
Association between maternal out-come in terms of labour and
selected variables among women with PIH in experimental group
(n=200)
Selected variables Maternal out come Labour
Term Pre term χ2 value
N % N % df P
Age in years
<19 54 88.5 7 11.5
4.42 2 0.10 20-29 68 77.3 20 22.7
30 and
above 45 88.2 6 11.8
Gravida
1 38 86.4 6 13.6
1.06
3 0.78NS 2 70 80.5 17 19.5 3 46 85.2 8 14.8 4 13 86.7 2 13.3
Para
0 56 84.8 10 15.2
1.8
3 0.61NS 1 89 81.7 20 18.3 2 15 93.8 1 6.3 3 7 77.8 2 22.2
Live
0 74 87.1 11 12.9 1.36 2 0.5NS 1 81 81 19 19
2 12 80 3 20
Abortion
0 130
83.3 26 16.7
0.64
3 0.88NS 1 16 84.2 3 15.8 2 18 81.8 4 18.2 3 3 100 0 0
History of PIH in the
family
Yes 75 88.2 10 11.8
2.4 1 0.12
No 92 80 23 20
Family history of
hypertension
Yes 55 87.3 8 12.7 0.96 1 0.32
No 112
81.8 25 18.2
NS- not significant at p=0.05 level
The above table shows that there is no association between
maternal out-come in terms of labour (term and pre term) and selected
variables among women with PIH in the experimental group.
159
Table 27:
Association between maternal out-come in terms of type of
delivery and selected variables among women with PIH in
experimental group (n=200)
Selected variables
Maternal out come Type of Delivery
Normal Instrumental Caesarean χ2 value N % N % N % df P
Age in years
<19 48 78.7 2 3.3 11 18
7.5 4 0.94N
20-29
70 79.5 4 4.5 14 15.9
30 and
above 41 80.4 1 2 9 17.6
Gravida
1 37 84.1 0 0 7 15.9
3.13 6 0.79N 2 70 80.5 3 3.4 14 16.1 3 41 75.9 3 5.6 10 18.5 4 11 73.3 1 6.7 3 20
Para
0 57 80.3 1 1.5 12 18.2
3.19 6 0.78N 1 83 79.8 4 3.7 18 16.5
2 13 81.3 1 6.3 2 12.5 3 6 66.7 1 11.1 2 22.2
Live
0 70 82.4 1 1.2 14 16.5 6.02 6 0.19N 1 70 79 4 4 17 17
2 10 66.7 2 13.3 3 20 Abortion
0 126 80.7 5 3.2 25 16
1.32 6 0.92N 1 14 73.7 1 5.3 4 21.1 2 17 77.3 1 4.2 4 18.2 3 2 66.7 0 0 1 33.3
History of PIH in the family
Yes 68 80 3 3.5 14 16.5 0.29 2 0.98N
No 91 79.1 4 3.5 20 17.4
Family history of hypertension
Yes 35 72.5 2 4.5 7 15.9 0.21 2 0.89N
No 124 72.5 7 3.2 27 17.3
NS- not significant at p=0.05 level
The findings of table 27indicates that there is no significant
association between type of delivery (Normal, Instrumental and
caesarean delivery) and selected variables (P>0.05).
160
Table 28:
Association between maternal out-come in terms of complications
and selected variables among women with PIH in experimental
group (n=200)
Selected variables
Maternal out come Complications
Present Absent
N % N % χ
2 value
df p
value
Age in years
<19 3 4.9 58 95.1
4.3 2 0.11N 20-29 11 12.5 77 87.5
30 and above
2 3.9 49 96.1
Gravida
1 3 6.8 41 93.2
0.92
3 0.82N 2 6 6.9 89 93.1
3 5 9.3 49 90.7 4 2 13.3 13 86.7
Para
0 6 9.1 60 90.9
0.35 3 0.94N 1 8 7.3 101 92.7 2 1 6.3 15 93.8 3 1 11.1 8 88.9
Live
0 8 9.4 77 90.6
0.4 2 0.81N 1 7 7 93 93
2 1 6.7 14 93.3
Abortion
0 11 7.1 145 92.9
3 3 0.39N 1 2 10.5 17 89.5 2 2 9.1 20 90.9 3 1 33.3 2 67.7
History of PIH in the family
Yes 7 8.2 78 91.8 0.01
1 0.91N
No 9 7.8 106 92.2 Family history
of hypertension
Yes 6 9.5 57 90.5 0.29 1 0.59N
No 10 7.3 127 92.7
N-Not significant at p=0.05 level
Table 28 shows no association between maternal out come in
terms of complications and selected variables among women with PIH
in experimental group.
161
Table 29:
Association between maternal out-come in terms of blood
pressure and selected variables among women with PIH in
experimental group (n=200)
Selected variables
Maternal out come Blood pressure
Normal High N % N % χ
2 value df P
Age
<19 53 86.9 8 13.1
0.95 2 0.62N 20-29 75 85.2 13 14.8
30 and
above 41 80.4 10 19.6
Gravida
1 39 88.6 5 11.4
0.88 3 0.82N 2 72 82.8 15 17.2 3 45 83.3 9 16.7 4 13 86.7 2 13.3
Para
0 58 87.9 8 12.1
1.1 3 0.77N 1 91 83.5 18 16.5 2 13 8.3 3 18.8 3 7 77.8 2 22.2
Live
0 74 87.1 11 12.9 1.87 2 0.39N 1 84 84 16 16
2 11 73.3 4 26.7
Abortion
0 131
84 25 16
0.64 3 0.88N 1 16 84.2 3 15.8 2 19 86.4 3 13.6 3 3 100 0 0
History of PIH in the
family
Yes 73 85.9 12 14.1 0.21 1 0.64N
No 96 83.5 19 16.5
Family history of
hypertension
Yes 38 86.4 6 13.6 0.15 1 0.69N
No 131
84 25 16
N-Not significant at p=<0.05 level
Table 29 refers the findings of association between maternal out
come in terms of blood pressure and selected variables among women
with PIH in experimental group. The findings indicate that there is no
162
significant association between blood pressure and selected variables
(P>0.05).
Table 30:
Association between maternal out-come in terms of oedema and
selected variables among women with PIH in experimental group
(n=200)
Selected variables
Maternal out come Oedema
Present Absent N % N % χ
2 value df P
Age
<19 52 85.2 9 14.8
0.66 2 0.71N 20-29 75 85.2 13 14.8
30 and
above 41 80.4 10 19.6
Gravida
1 39 87.9 5 11.4
1.13 3 0.76N 2 72 82.8 15 17.2 3 44 81.5 10 18.5 4 13 86.7 2 13.3
Para
0 58 87.9 8 12.1
1.98 3 0.57N 1 91 83.5 18 16.5 2 12 75 4 2.5 3 7 7 2 22.2
Live
0 73 85.9 12 14.1 1.49 2 0.47N 1 84 84 16 16
2 11 73.7 4 26.7
Abortion
0 130 83.3 26 16.7
0.71 3 0.87N 1 16 84 3 15.8 2 19 86.4 3 13.6 3 3 100 0 0
History of PIH in the
family
Yes 72 84.7 13 15.3 0.05 1 0.81N
No 96 83.5 19 16.5
Family history of
hypertension
Yes 37 84.1 7 15.9 0.00 1 0.98N
No 131 84 25 16
N-Not significant at p=<0.05 level
Data presented in table 30shows no association between
maternal out come in terms of oedema and selected variables among
women with PIH in experimental group.
163
Table 31:
Association between maternal out-come in terms of protein urea
and selected variables among women with PIH in experimental
group (n=200)
Selected variables
Maternal out come Protein urea
Present Absent df p value N % N % χ
2 value
Age in
years
<19 55 90.2 6 9.8
0.49 2 0.78N
20-29 76 86.4 12 13.6 30 and above
45 88.2 6 11.8
Gravida
1 40 90.9 4 9.1
0.45 3 0.92N
2 76 87.4 11 12.6 3 47 87 7 13 4 13 86.7 2 13.3
Para
0 59 89.4 7 10.6
1.01 3 0.79 N
1 96 88.1 13 11.9
2 14 87.5 2 12.5 3 7 77.8 2 22.2
Live
0 76 89.4 9 10.6
1.07 2 0.58N 1 88 88 12 12 2 12 80 3 20
Abortion
0 137 87.8 19 12.2
0.71 3 0.87N
1 17 89.5 2 10.5 2 19 86.4 3 13.6 3 3 100 0 0
History of PIH in the family
Yes 75 88.2 6 13.6
0.08 1 0.93N No 101 87.8 18 11.5
Family history of hypertension
Yes 38 86.4 6 11.5
0.14 1 0.7N No 138 88.5 13.6
N-Not significant at p=<0.05 level
According to table 31, no association was found between
maternal out come in terms of protein urea and selected variables
among women with PIH in experimental group (P>0.05).
164
Table 32:
Association between neonatal out-come in terms of birth weight
and selected variables among women with PIH in experimental
group (n=200)
Selected variables
Neonatal out come
Birth weight <2.5kg 2.5-3.5kg >3.5kg
N % N % N % χ
2 valu
e df p
Age in
years
<19 11 18 46 75.4 4 6.6 8
4 0.06N
20-29 33 37.5 46 52.3 9 10.2 30 and above
14 27.5 31 60.8 6 11.8
Gravida
1 14 31.8 27 61.4 3 6.8 1
6 0.98N 2 24 27.6 54 62.1 9 10.3
3 16 29.6 32 59.3 6 11.1 4 4 26.7 10 66.7 1 6.7
Para
0 21 31.8 40 60.6 5 7.6
0.96
6 0.98 N 1 30 27.5 68 62.4 11 10.1 2 4 25 10 62.5 2 12.5 3 3 33.3 5 55.6 1 11.1
Live
0 25 29.4 53 62.4 7 8.2
0.71 4 0.94N 1 28 28 62 62 10 10
2 5 33.3 8 53.3 2 13.3
Abortion
0 45 28.8 96 61.5 15 9.6
0.46
6 0.99N 1 6 31.6 11 57.9 2 10.5 2 6 27.3 14 63.6 2 9.1
3 1 33.3 2 66.7 0 0 History of
PIH in the
family
Yes 23 27.1 54 63.5 8 9.4
0.29 2 0.86N
No 35 30.4 69 60 11 9.6
Family history of hyperten
sion
Yes 11 25 29 65.9 4 9.1
0.49 2 0.77N
No 47 30.1 94 60.3 15 9.6
N-Not significant at p=<0.05 level
165
The findings in the table 32shows maternal outcome in terms of birth
weight and selected variables among women reveals no association
between neonatal in PIH in experimental group (P>0.05).
Table 33:
Association between neonatal out-come in terms of Apgar score
and selected variables among women with PIH in experimental
group (n=200)
Selected variables
Neonatal out come Apgar score
0-4 4-7 8-10 χ2
value df
p value N % N % N %
Age in
years
<19 1 1.6 4 6.6 56 91.8
4.35
4
0.36N
20-29 2 2.3 13 14.8 73 83 30
and above
0 0 4 7.8 47 92.2
Gravida
1 2 4.5 5 11.4 37 84.1
4.2
6
0.64N
2 1 1.1 8 9.2 78 89.7 3 0 0 6 11.1 48 88.9 4 0 0 2 13.3 13 86.7
Para
0 2 3 8 12.1 56 84.8
2.18
6
0.9N
1 1 0.9 10 9.2 98 89.9 2 0 0 2 12.5 14 87.5 3 0 0 1 11.1 8 88.9
Live
0 2 2.4 10 11.8 73 85.9
1.35
4
0.85N 1 1 1 9 9 90 90 2 0 0 2 13.3 13 86.7
Abortion
0 3 1.9 137 87.8 137 87.8
2.56
6
0.86N
1 0 0 17 89.5 17 89.5 2 0 0 20 90.9 20 90.9 3 0 0 1 33.3 2 67.7
History of PIH in the
family
Yes 1 1.2 8 9.4 76 89.4
0.3
2
0.85N No 2 1.7 13 11.3 100 87
Family history of
hypertension
Yes 0 0 4 9.1 40 90.9 1 2 0.6N
No 3 1.9 17 10.9 136 87.2
N-Not significant at p=<0.05 level
166
Table 33projects no association between neonatal out come in
terms of Apgar score and selected variables among women with PIH in
experimental.
Table 34:
Association between neonatal out-come in terms of complications
and selected variables among women with PIH in experimental
group (n=200)
Selected variables
Neonatal out come Neonatal complications
Present Absent
N % N % χ
2 value
df p value
Age in years
<19 1 1.6 60 98.4
0.93 2 0.62N 20-29 4 4.5 84 95.5 30 and above
2 3.9 49 96.1
Gravida
1 3 6.8 41 93.2
2.4 3 0.49N 2 3 3.4 84 96.6 3 1 19 53 98.1 4 0 0 15 100
Para
0 3 4.5 63 95.5
1.13 3 0.77N 1 4 3.7 105 96.3 2 0 0 16 100 3 0 0 9 100
Live
0 3 3.5 82 96.5 0.61 2 0.73N 1 4 4 96 96
2 0 0 15 100
Abortion
0 6 3.8 150 96.2
1.13 3 0.76N 1 1 5.3 18 94.7 2 0 0 22 22 3 0 0 3 100
History of PIH in the family
Yes 3 3.5 82 96.5 0
1
0.98N
No 4 3.5 11 96.5
Family history of
hypertension
Yes 1 2.3 43 97.7 0.25 1 0.61N
No 6 3.8 150 96.2
N-Not significant at p=<0.05 level
The findings in the table 34 reveals no statistically significant
association between neonatal out come in terms of complications and
167
selected variables among women with PIH in experimental group was
(P>0.05).
Table 35:
Association between neonatal out-come in terms of still birth/IUD
and selected variables among women with PIH in experimental
group (n=200)
Selected variables
Neonatal out come Still birth/IUD
Present Absent χ2
value
df p
value N % N %
Age in years
<19 1 1.6 60 98.4
1.1
2
0.56N
20-29
2 2.3 86 97.7
30 and above
0 0 51 100
Gravida
1 2 4.5 42 95.5
3.88
3
0.27N
2 1 1.1 1 1.1 3 0 0 54 100 4 0 0 15 100
Para
0 2 3 64 97
0.8
3
0.6N
1 1 9 108 99.1 2 0 0 16 100
3 0 0 9 100
Live
0 2 2.4 83 97.6
0.81
2
0.66N 1 1 1 99 99 2 0 0 15 100
Abortion
0 3 1.9 153 98.1
0.85
3
0.83N
1 0 0 19 100
2 0 0 22 100 3 0 0 3 100
History of PIH in the family
Yes 1 1.2 84 98.8
0.1
1
0.74N No 2 1.7 113 98.3
Family history of
hypertension
Yes 0 0 44 100 1.6
3
0.69N
No 3 1.9 153 98.1
N-Not significant at p=<0.05 level
168
From table 35, the findings reveals that no association between
neonatal out come in terms of still birth/IUD and selected variables
among women with PIH in experimental group was not statistically
significant (P>0.05).
Table 36:
Association between maternal out-come in terms of labour and
selected variables among women with PIH in control group
(n=200)
Selected variables
Maternal out come Labour
Term Pre term
N % N % χ
2 value
df p
value
Age in years
<19 15 25 45 75
12 2 0.02* 20-29
51 53.7 44 46.3
30 and above
20 44.4 25 55.6
Gravida
1 19 50 19 50
0.99 3 0.8NS 2 39 41.5 55 58.5
3 21 42 29 58 4 7 38.9 11 61.1
Para
0 27 46.6 31 53.4
0.46 3 0.92NS 1 49 41.2 70 58.8 2 6 42.9 8 57.1 3 4 44.4 5 55.6
Live
0 35 43.8 45 56.3 0.79 2 0.67NS 1 44 41.1 63 58.9
2 7 53.8 6 46.2
Abortion
0 68 43.9 0 0
2.5 3 0.45NS 1 8 47.1 18 66 2 9 33.3 9 52.9 3 1 100 87 56.1
History of PIH in the
family
Yes 38 40 57 60 0.66 1 0.41NS
No 48 45.7 57 54.3
Family history of
hypertension
Yes 19 36.5 33 63.5 1.19 1 0.27 NS
No 67 45.3 81 54.7
*significant at p=0.05Level,NS- not significant at p=<0.05 level
169
The above table shows that there is no association between
maternal out-come in terms of labour (term and pre term) and selected
variables among women with PIH in the control group except in age
(p=<0.05).
Table 37:
Association between maternal out-come in terms of type of
delivery and selected variables among women with PIH in control
group (n=200)
Selected variables
Maternal out come
Type of Delivery
Normal Instrumen
tal Caesarea
n χ
2 valu
e N % N % N % df p
value
Age in years
<19 16 26.7 10 16.7 34 567
18.8 4 0.001** 20-29
53 55.9 4 4.2 38 40
30 and above
27 60 4 8.9 14 31.1
Gravida
1 21 53.3 2 5.3 15 39.5
1.8 6 0.93N 2 44 46.8 9 9.6 41 43.6
3 27 48 5 10 21 42 4 7 38.9 2 11.1 9 50
Para
0 30 51.7 4 6.9 24 41.4
1.3
6 0.97N 1 55 46.2 11 9.2 53 44.5 2 7 50 2 14.3 5 35.7 3 4 44.4 1 11.1 4 44.4
Live
0 40 50 6 7.5 34 42.5 1.6
4 0.8N 1 49 45.8 10 9.3 48 44.9 2 7 53.8 2 15.4 4 30.8
Abortion
0 76 49 14 9 65 41.9
2.7 6 0.84N 1 9 52.9 1 5.9 7 41.2 2 10 37 3 11.1 14 51.9 3 1 10 0 0 0 0
History of PIH in the
family
Yes 42 44.2 8 8.4 45 47.4 1.41 2 0.49N
No 54 51.4 10 9.5 41 39
Family history of
hypertension
Yes 21 40.4 5 9.6 26 50 1.67 2 0.43N
No 75 50.7 13 8.8 20 40.5
** Significant at p=0.001,NS- not significant at p=<0.05 level.
170
Table 37 shows the association between maternal out come in
terms of type of delivery and selected variables among women with PIH
in control group. The findings indicated that there is significant
association between type of deliveryand age at p=0.001 level. Other
variables have no significant association.
Table 38:
Association between maternal out-come in terms of complications
and selected variables among women with PIH in control group
(n=200)
N-Not significant at p=0.05 level,*significant at p=0.01 level
Selected variables
Maternal out come Complications
Present Absent χ2
value
N % N % df P value
Age in years
<19 8 13.3 52 86.7
8.8 2 0.01* 20-29 32 33.7 63 66.3 30 and above
9 20 36 80
Gravida
1 12 31.6 26 68.4
1.31 3 0.72N 2 22 23.4 72 76.6
3 11 22 39 78 4 4 22.2 14 77.8
Para
0 16 27.6 42 72.4
1.24 3 0.74N 1 29 24.4 90 75.6 2 3 21.4 11 78.6 3 1 11.1 8 88.9
Live
0 21 26.3 59 73.8 0.71 2 0.69N 1 26 24.3 81 75.7
2 2 15.4 11 84.6
Abortion
0 38 24.5 117 75.5
3.82 3 0.28N 1 5 29.4 12 70 2 5 18.5 22 81.5 3 1 100 0 0
History of PIH in the family
Yes 23 24.2 72 75.8 0.008 1 0.92N
No 26 24.8 79 75.2 Family history
of hypertension
Yes 11 21.2 41 78.8 0.42 1 0.51N
No 38 25.7 110 74.3
171
Table 38 shows the no association between maternal out come in
terms of complications and selected variables among women with PIH
in control group except in age(P<0.05).
Table 39:
Association between maternal out-come in terms of blood
pressure and selected variables among women with PIH in control
group (n=200)
Selected variables Maternal out come Blood pressure Normal
High χ2
value df p value
N % N %
Age in years <19 17 28.3 43 71.7 19
2 0.0001***
20-29 56 58.9 39 41.1 30 and
above
30 66.7 15 33.3
Gravida
1 21 55.3 17 44.7 0.78
3 0.85N
2 47 50 47 50 3 27 54 23 46 4 8 44.4 10 55.6
Para
0 31 53.4 27 46.6 1.24
3 0.74N
1 59 49.6 60 50.4 2 8 57.1 6 42.9 3 5 55.6 4 44.4
Live
0 41 51.3 39 48.8 0.71
2 0.69N 1 53 49.5 54 50.5 2 9 30.8 4 30.8
Abortion
0 81 52.3 74 47.7 2.59
3 0.45N
1 10 58.8 7 41.2 2 11 40.7 16 59.3 3 1 100 0 0
History of PIH in the family
Yes 45 47.4 50 52.6 1.23
1 0.26N No 58 55.2 47 44.8
Family history of hypertension
Yes 23 44.2 29 55.8 1.48
1 0.22N No 80 54.1 68 45.9
N-Not significant at p=0.05 level,***significant at p=0.0001 level
172
Table 39 shows no association between maternal out come in terms of
blood pressure and selected variables among women with PIH in
control group except in age(P<0.05).
Table 40:
Association between maternal out-come in terms of protein urea
and selected variables among women with PIH in control group
(n=200)
Selected variables
Maternal out come Protein urea
Present Absent χ2
value
N % N % df P
Age in
years
<19 15 25 45 75
9.9 2 0.007* 20-29 48 50.5 47 49.5 30 and above
19 42.2 26 57.8
Gravida
1 17 44.7 21 55.3
0.69 3 0.87N 2 38 40.4 56 59.6 3 21 42 29 58 4 6 33.3 12 66.7
Para
0 25 43.1 33 56.9
0.36 3 0.97N 1 48 40 71 59.7 2 6 42.9 8 57.1 3 3 33.3 6 66.7
Live
0 33 41.3 47 58.8 0.17 2 0.91N 1 43 40.2 64 59.8
2 6 46.2 7 53.8
Abortion
0 64 41.3 91 58.7
2.3 3 0.5N 1 8 47.1 9 52.9 2 9 33.3 18 66.7 3 1 100 0 0
History of PIH in the
family
Yes 36 37.9 59 62.1 0.72 1 0.39N
No 46 43.9 59 56.2
Family history of
hypertension
Yes 18 34.6 34 65.4 0.42 1 0.277N
No 64 43.2 84 56.8
N-Not significant at p=0.05 level
Table 40 shows no association between maternal out come in
terms of protein urea and selected variables among women with PIH in
control group except in age (p<0.05).
173
Table 41:
Association between maternal out-come in terms of oedema and
selected variables among women with PIH in control group
(n=200)
Selected variables
Maternal out come Oedema
Present Absent χ
2 value
N % N % df P value
Age
<19 16 26.7 44 73.3
14.2 2 0001*
*
20-29 53 55.8 42 44.2 30 and
above 25 55.6 20 44.4
Gravida
1 20 52.6 18 47.4
1.03 3 0.79N 2 43 45.7 51 54.3 3 24 48 26 52 4 7 38.9 11 61.1
Para
0 29 50 29 50
0.40 3 0.93 N 1 54 45.4 65 54.6 2 7 50 7 50 3 4 44.4 5 55.6
Live
0 38 47.5 42 52.5 0.31 2 0.85N 1 49 45.8 58 54.2
2 7 53.8 6 46.2
Abortion
0 74 47.7 81 52.3
2.4 3 0.47N 1 9 52.9 8 47.1
2 10 37 17 63 3 1 100 0 0
History of PIH in the
family
Yes 41 43.2 54 56.8 1.07 1 0.3N
No 54 56.8 52 49.5
Family history of
hypertension
Yes 21 40.4 31 59.6 1.2 1 0.26N
No 73 49.3 75 50.7
N-Not significant at p=<0.05 level
According to table 41, the findings of association between
maternal out come in terms of oedema and selected variables among
women with PIH in control group was not statistically significant
(P>0.05) except with regard to age (0.001).
174
Table 42:
Association between neonatal out-come in terms of birth weight
and selected variables among women with PIH in control group
(n=200)
Selected variables
Neonatal out come Birth weight
<2.5kg 2.5-3.5kg >3.5kg χ2
value
N % N % N % df P value
Age in years
<19 16 26.7 43 71.7 1 1.7
20.5 4 0.0001*
**
20-29 53 55.8 37 38.9 5 5.3 30 and
above 27 60 18 40 0 0
Gravida
1 21 55.3 16 42.1 1 2.6
2.1 6 0.9N 2 44 46.8 48 51.1 2 2.1
3 24 48 24 48 2 4 4 7 38.9 10 55.6 1 5.6
Para
0 30 51.7 26 44.8 2 3.4
3.17 6 0.78 N 1 55 46.2 61 51.3 3 2.5 2 7 50 7 50 0 0 3 4 44.4 4 44.4 1 11.1
Live
0 40 50 38 47.5 2 2.5
1.76 4 0.78N 1 49 45.8 55 51.4 3 2.8 2 7 53.8 5 38.5 1 7.7
Abortion
0 76 49 75 48.4 4 2.6
3.2 6 0.77N 1 9 52.9 7 41.2 1 5.9 2 10 37 16 59.3 1 3.7 3 1 100 0 0 1 100
History of PIH in the
family
Yes 42 44.2 50 52.6 3 3.2 1.04 2 0.59N
No 54 51.4 48 45.7 3 2.9
Family history of
hypertension
Yes 21 40.4 29 55.8 2 3.8 1.67 2 0.43N
No 75 50.7 69 46.6 4 2.7
N-Not significant at p=<0.05 level,***significant at p=0.0001 level
The findings in the table 42 reveals that there is association between
neonatal out come in terms of birth weight and selected variables among
women with PIH in control group was not statistically significantexcept for
age (P<0.05).
175
Table 43:
Association between neonatal out-come in terms of Apgar score
and selected variables among women with PIH in control group
(n=200)
Selected variables
Neonatal out come Apgar score
0-4 4-7 8-10 χ2
value df
p value N % N % N %
Age in
years
<19 8 13.3 18 30 34 56.7
15.5 4 0.004*
20-29 25 26.3 37 38.9 33 34.7 30
and abov
e
6 13.3 26 57.8 13 28.9
Gravida
1 10 26.3 14 36.8 14 36.8
3.17 6 0.78N 2 18 19.1 37 39.4 39 41.5 3 8 16 24 48 18 36 4 3 16.7 6 33.3 9 50
Para
0 13 22.4 23 39.7 22 37.9
2.56 6 0.86N 1 23 19.3 46 38.7 50 42 2 2 14.3 8 57.1 4 28.6 3 1 11.1 4 44.4 4 44.4
Live
0 17 21.3 32 40 31 38.8 3 4 0.55N 1 21 19.6 41 38.3 45 42.1
2 1 7.7 8 61.5 4 30.8
Abortion
0 31 20 63 40.6 61 39.4
2.6 6 0.85N 1 3 17.6 8 47.1 6 35.3 2 5 18.5 9 33.3 13 48.1 3 0 0 1 100 0 100
History of PIH in the
family
Yes 19 20 34 35.8 42 44.2 1.8 2 0.4N
No 20 19 47 44.8 38 36.2
Family history of
hypertension
Yes 10 19.2 18 34.6 24 46.2 1.26 2 0.53N
No 29 19.6 63 42.6 56 37.8
N-Not significant at p=<0.05 level
From table 43, the findings reveals that the association between
neonatal out come in terms of Apgar score and selected variables
among women with PIH in control group was not statistically significant
(P>0.05) except with age (0.004).
176
Table 44:
Association between neonatal out-come in terms of complications
and selected variables among women with PIH in control group
(n=200)
N-Not significant at p=<0.05 level
The findings in the table 44 reveals that the association between
neonatal out come in terms of complications and selected variables
among women with PIH in control group was not statistically significant
(P>0.05).
Selected variables
Neonatal out come Neonatal complications
Present Absent
N % N % χ
2 value
df p value
Age in years
<19 5 8.3 55 91.7
0.93 2 0.62N 20-29 17 17.9 78 82.1
30 and
above 6 13.3 39 86.7
Gravida
1 3 6.8 41 93.2
2.4 3 0.49N 2 3 3.4 84 96.6 3 1 1.9 53 98.1 4 0 0 15 100
Para
0 3 4.5 63 95.5
1.13 3 0.77N 1 4 3.7 105 96.3
2 0 0 16 100 3 0 0 9 100
Live
0 3 3.5 82 96.5 0.61 2 0.73N 1 4 4 96 96
2 0 0 15 100
Abortion
0 6 3.8 150 96.2
1.13 3 0.76N 1 1 5.3 18 94.7 2 0 0 22 22 3 0 0 3 100
History of PIH in the
family
Yes 3 3.5 82 96.5 0 1 0.98N
No 4 3.5 11 96.5
Family history of
hypertension
Yes 1 2.3 43 97.7 0.25 1 0.61N
No 6 3.8 150 96.2
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Table 45:
Association between neonatal out-come in terms of still birth/IUD
and selected variables among women with PIH in control group
(n=200)
Selected variables
Neonatal out come Still birth/IUD
Present Absent χ2
value df p value
N % N %
Age in years
<19 1 1.7 59 98.8
2.4 2 0.29N 20-29 7 7.4 88 92.6
30 and above
3 6.7 42 93.3
Gravida
1 3 7.9 35 92.1
3.88 3 0.27N 2 5 5.3 89 94.7 3 3 6 47 94 4 0 0 18 100
Para
0 4 6.9 54 93.1
0.86 3 0.83N 1 6 5 113 95 2 1 7.1 13 92.9 3 0 0 9 100
Live
0 5 6.3 75 93.8 0.84 2 0.65N 1 6 5.6 101 94.4
2 0 6.3 13 100
Abortion
0 9 5.8 146 94.2
0.25 3 0.96N 1 1 5.9 16 94.1 2 1 3.7 26 96.3
3 0 0 1 100
History of PIH in the family
Yes 5 5.3 90 94.7 0.02 1 0.88N
No 6 5.7 99 94.3
Family history of
hypertension
Yes 49
94.2 140 94.6 0.1 1 0.92N
No 3 5.8 8 5.4
N-Not significant at p=<0.05 level
From table 45, the findings reveals that absence of association
between neonatal out come in terms of still birth/IUD and selected
variables among women with PIH in control group .
From the above tables, it is interpreted that there is significant
association between ageand pregnancy out- come among women with
PIH. Other variables had no association. The null hypothesis H010 is
thereforepartially accepted.
178
SECTION VI
D: Association between post stress and pregnancy outcome
among women with PIH.
Table 46:
Association between post stress and pregnancy outcome among
women with PIH in control group
(n=200)
Variables Sum of
squares Mean square df f value p value
Type of delivery
Between groups 1166.06 583.03 2
4.712 0.010* Within groups 24377.29 123.74 197
Total 25543.35 199
Birth weight
Between groups 1558.56 779.28 2
6.40 0.002** Within groups 23984.79 121.75 197
Total 25543.35 199
APGAR score
Between groups 906.502 453.25 2
3.62 0.028* Within groups 24636.85 125.06 197
Total 25543.35 199
Neonatal complications
Between groups 133.37 133.37 1
1.03 0.30 Within groups 25409.97 128.33 198
Total 25543.35 199
*significant at p=<0.05 level Table 46 shows that the association between stress and
pregnancy outcome in terms of maternal and neonatal outcome among
women with PIH .The findings reveals that there is highly significant
association(f=4.712, p=0.01) betweenstress and pregnancy outcome –
maternal outcome in terms of type of delivery and neonatal outcome in
terms of birth weight and apgar(f=6.40,p=0.002,f=3.62,p=0.028).It is
179
interpreted that maternal stress affect the type of delivery,neonatal birth
weight and apgar score of neonate among women with PIH in control
group.
Table 47: Association between post stress and pregnancy outcome among
women with PIH in experimental group (n=200)
Variables Sum of squares
Mean square
df f value p value
Type of delivery Between groups
57.09 28.54 2 0.06 0.94NS
Within groups 91650.77 465.23 197
Total 91707.87 199 Birth weight
Between groups
464.44 232.22 2
0.50 0.60NS
Within groups 91243.43 463.16 197 Total 91707.87 199
APGAR score Between groups
61.84 30.92 2 0.06 0.93NS
Within groups 91646.03 465.2 197 Total 91707.87 199
Neonatal complications Between groups
58.74 58.74 1 0.12 0.72NS
Within groups 91649.13 462.87 198
Total 91707.87 199
Ns –not significant at p=<0.05 level
Table 47 shows that the association between stress and pregnancy
outcome in terms of maternal and neonatal outcome among women
with PIH.The findings reveal no statistically significant
associationbetween stress and pregnancy outcome (p=>0.05) in
experimental group. Findings of the table 47 revealed that maternal
stress affect the type of delivery,neonatal birth weight and apgar score
of neonate among women with PIH in control group. It is interpreted that
180
women with PIH who have undergone relaxation programme managed
the stress and therefore resulted in a positive pregnancy outcome.
SECTION VI
E: Association between post-test coping score and pregnancy
outcome among women with PIH
Table 48:
Association between post-test coping score and maternal
outcome in terms of type of delivery among women with PIH in
control group (n=200)
Coping
Sum of
Square
s
Mean
Square df F
p
value
Usefulness
Between Groups 0.926 .463 2
.019 .981NS Within Groups 4691.05 23.812 197
Total 4691.98 199
Effectiveness
Between Groups 24.627 12.313 2
.413 .662NS Within Groups 5867.99 29.787 197
Total 5892.60 199
Total
Between Groups 6.665 3.333 2
.069 .933NS Within Groups 9506.61 48.257 197
Total 9513.28 199
NS- Not significant at p=<0.05 level
Table 48 indicated that the association between coping and
pregnancy outcome in terms of maternal and neonatal outcome among
women with PIH .The findings reveals absence of association between
coping and pregnancy outcome in terms of type of delivery in control
group.
181
Table 49:
Association between post-test coping score and neonatal outcome
in termsof birth weight among women with PIH in control group
(n=200)
Coping Sum of
Squares
Mean
Square df F
p
value
Usefulness
Between Groups 1.060 .530 2
.022 .978NS Within Groups 4690.92 23.812 197
Total 4691.98 199
Effectiveness
Between Groups 38.008 19.004 2
.639 .529NS Within Groups 5854.61 29.719 197
Total 5892.62 199
Total
Between Groups 23.280 11.640 2
.242 .786NS Within Groups 9490.00 48.173 197
Total 9513.28 199 199
Not significant at p=<0.05 level
Table 49 shows that the association between coping and
pregnancy outcome in terms of neonatal outcome (birth weight) among
women with PIH.The findings reveals that no statistically significant
association (p=>0.05) between coping and pregnancy outcome.
182
Table 50:
Association between post-test coping score and neonatal outcome
in terms of apgar score among women with PIH in control group
(n=200)
Coping Sum of
Squares
Mean
Square df F
p
value.
Usefulness
Between Groups 11.941 5.971 2
.251 .778 NS Within Groups 4680.039 23.757 197
Total 4691.980 199
Effectiveness
Between Groups 37.219 18.609 2
.626 .536NS Within Groups 5855.401 29.723 197
Total 5892.620 199
Total
Between Groups 2.905 1.452 2
.030 .970NS Within Groups 9510.375 48.276 197
Total 9513.280 199
NS-Not significant at p=<0.05 level.
Table 50 presents the association between coping and pregnancy
outcome in terms of neonatal outcome (apgar score) among women
with PIH in control group.The findings highlight absence of association
between coping and pregnancy outcome.
183
Table 51:
Association between post-test coping score and maternal outcome
in terms of type of delivery among women with PIH in experimental
group (n=200)
Coping Sum of
Squares
Mean
Square df F
p
value
Usefulness
Between Groups 47.840 23.920 2
1.130 .325 Within Groups 4170.715 21.171 197
Total 4218.555 199
Effectiveness
Between Groups 1.865 .933 2
.028 .972 Within Groups 6547.690 33.237 197
Total 6549.555 199
Total
Between Groups 45.885 22.942 2
.431 .651 Within Groups 10494.115 53.270 197
Total 10540.000 199 199
NS-Not significant at p=<0.05 level.
Table 51 shows no association between post coping and
maternal outcome in terms of type of delivery among women with PIH
in experimental group.
184
Table 52:
Association between post -test coping score and neonatal
outcome in terms of birth weight among women with PIH in
experimental group (n=200)
Coping Sum of
Squares
Mean
Square df F
p
value
Usefulness
Between Groups 64.772 32.386 2
1.536 .218 Within Groups 4153.783 21.085 197
Total 4218.555 199
Effectiveness
Between Groups 13.857 6.929 2
.209 .812 Within Groups 6535.698 33.176 197
Total 6549.555 199
Total
Between Groups 32.516 16.258 2
.305 .738 Within Groups 10507.484 53.337 197
Total 10540.000 199
NS-Not significant at p=<0.05 level.
Findings in the table 52 show absence of association between
post coping and neonatal outcome in terms of birth weight among
women with PIH in experimental group.
185
Table 53:
Association between post-test coping score and neonatal outcome
in terms of apgar score among women with PIH in experimental
group (n=200)
Coping Sum of
Squares
Mean
Square df F p value
Usefulness
Between
Groups 15.442 7.721 2
.362 .697 Within Groups 4203.113 21.336 197
Total 4218.555 199
Effectiveness
Between
Groups 17.942 8.971 2
.271 .763 Within Groups 6531.613 33.155 197
Total 6549.555 199
Total
Between
Groups 57.356 28.678 2
.539 .584 Within Groups 10482.644 53.211 197
Total 10540.000 199
NS-Not significant at p=<0.05 level.
It is evident from table 53 that there is no significant association
betweenpost coping and neonatal outcome in terms of apgar score
among women with PIH in experimental group.
Summary
This chapter dealt with the analysis and interpretation of findings
of the study. Both descriptive and inferential statistics were used to
analyse the data. All the null hypotheses were tested to find out the
differences and association.
186
CHAPTER V
DISCUSSION, SUMMARY AND CONCLUSION
Pregnancy is a period of enormous physiological and
psychosocial adaptation, often producing increased stress and
emotional distress. Psychological factors have an important role to play
in the development of stress rather physiological changes in normal
pregnancy. High risk pregnancy contributes additional psychological
and physiological stress to pregnant women. Hypertension is one of the
common complications within pregnancy and contributes significantly to
maternal and perinatal morbidity and mortality. Significant increase in
the levels of stress hormones may compromise the health of both
mother and foetus. Complementary and alternative therapiesare
increasingly popular among pregnant mothers who can be used safely
to deal with physiological as well as psychological depression,
anxietyand stress. One of thecomplementary therapies is relaxation
programme which includes progressive muscle relaxation, breathing
exercises and guided imagery. Visualization and guided imagery work
in connection between brain and the involuntary system. Visual images
can influence both voluntary and involuntary nervous system. Therefore
stimulating the brain through imagery can have a direct effect on both
the nervous and endocrine systems, ultimately producing changes in
immune and other body systems. An exercise increases the efficiency
187
of the heart and slows the respiratory rate, improves fitness, lowers
blood pressure, promotes relaxation, reduces stress and anxiety. It also
serves to improve coordination, range of motion, posture, concentration,
sleep and digestion. Hence incorporating breathing, progressive muscle
relaxation and guided imagery help to enhance the body and achieve a
state of balance and harmony between body and mind. When applying
this to women with PIH help to attain a harmonious state so that
physiological status can be maintain within normal limits and reduce
stress, anxiety and depression, effectively cope with disease condition
and achieve a positive pregnancy outcome in terms of maternal and
neonatal outcome.
This chapter dealswith discussion on the findings based on
statistical conclusion of the study. The findings are discussed in relation
to the objectives and hypotheses of the study.
The present study evaluated the effectiveness of relaxation
programme on stress, coping and pregnancy outcome among women
with PIH admitted in institute of maternal and child health, Kozhikode.
Thedata were collected from 400 women with pregnancy induced
hypertension (200 in experimental group and 200 in control group).
The objectives of the study were
1. To assess the level of stress experienced by women with PIH before
and after relaxation programme.
2. To assess the coping strategies used by women with PIH before and
after relaxation programme.
188
3. Evaluate the effect of relaxation programme on level of stress of
women with PIH
4. Evaluate the effect of relaxation programme on coping strategies of
women with PIH
5. Evaluate the effect of relaxation programme on pregnancy outcome
of women with PIH
6. Find out the association between level of stress and selected
variables: age, obstetric score, family history of PIH and family history
of hypertension of women with PIH.
7. Find out the association between coping strategies and selected
variables: age, obstetric score, family history of PIH and family history
of hypertension of women with PIH.
8. Find out the association between stress, coping and pregnancy out-
come of women with PIH.
The findings of the study revealed a significant decrease in the
level of stress, significant improvement in using coping strategies and a
positive pregnancy outcome of experimental group after relaxation
programme.
The conceptual framework of the present study was based on Betty
Neuman’s system model (1980) is a nursing theory based on the
client’s relationship to stress, the reaction to stress, and reconstitution
factors that are dynamic in nature. The core of the model consists of
energy resources (normal temperature range, genetic structure,
response pattern, organ strength or weakness, ego structure, and
189
knowns or commonalities) that are surrounded by several lines of
resistance, the normal line of defence, and the flexible line of defence.
The lines of resistance represent the internal factors that help the
patient defend against a stressor, the normal line of defence represents
the person's state of equilibrium, and the flexible line of defence depicts
the dynamic nature that can rapidly alter over a short period of time.
The purpose of the nurse is to retain this system's stability through the
three levels of prevention. Primary prevention is to protect the normal
line and strengthen the flexible line of defence. Secondary prevention
aimed to strengthen internal lines of resistance, reducing the reaction,
and increasing resistance factors. Tertiary prevention helps to readapt
and stabilize and protect reconstitution or return to wellness following
treatment. In the present study the relaxation programme helped to
strengthen the flexible line of defence, strengthen internal resistance
and readapt and stabilize the system. The relaxation programme was
found to be effective for relieving stress, adapting useful and effective
coping strategies and helped to achieve a positive pregnancy outcome
in terms of maternal and neonatal outcome among women with
pregnancy induced hypertension, thus justifying the selection of system
model as the conceptual frame work for the study
190
Discussion on the findings related to each variable is given below.
Level of stress experienced by women with PIH before and after
relaxation programme.
The study showed 100% (200) in the experimental group and
100% (200) inthe control group had severe stressin the pre-test. No
significant difference was found between groups on stress. The pre-test
mean score of stress (Table 11) in the study group was 112.9 and in the
control group the overall stress was 111.58 which reveals absence of
statistical significant in the stress score between group.In the present
study, all the study subjects in the experimental and control group were
experienced severe stress before relaxation programme
(t=1.130,p>0.001).The findings of the study were consistent with
findings of the study done by Rajeswari(2008) on level of stressduring
pregnancy. The mean score was 49.47 in the study group and in the
control group it was 48.38,reveals absence of statistical significant in
the stress score between groups. These findings were consistent with
the findings on prevalence of stress during pregnancy obtained by
Rondo, Ferreira, Nogueira, Ribeiro, Lobert and Artes (2003).
In the post-test 20 (10%) in the experimental group had mild
stress, 43% had moderate stress and 42% in the experimental group,
whereas100% in the controlgroup had severe stress.The study findings
were consistent with the findings of thestudy done by Dumas Reid,
Wolfe, Griffin (2005) and the result showed that stress wasprogressively
191
worse over time; women in rural areas were less likely to develop
stressduring pregnancy.
The findings of present study are consistent with findings of study
conducted by Paul (2005) revealed that there was moderate level of
stress among all samples before relaxation therapy and the mean
stress score was significantly lower than that of control group after
relaxation therapy (t=12.23, p <0.001). The study findings
ofSurendranreveals that stress score was moderate among both group
and it was significantly lower in the experimental group than that of
control group (t=12.67,p<0.05) after therapy. The present study also
reveals that the stress score of experimental group was significantly
lower than that of control group (t=-30.098, p<0.05) after the relaxation
programme. The finding supports the findings of Raddi (2000) who
found that majority of women (64.6%) had moderate level of stress
(mean 57.07, SD6.59).
The present study findings supported by a recent study on
psychosocial stress during pregnancy in a diverse urban sample found
that 78% experienced low-to-moderate antenatal psychosocial stress
and 6% experienced high levels (Woods S. M, Melville J. L, Guo Y, et
al. 2010).The findings of the present study show that there was a highly
significant reduction in the mean difference of the stress between
experimental and the control groups at the level of p <0.001.
192
The finding of the present study is supported by the study done
by Vieten and Astin (2008), eightweekmindfulness-based intervention
done during pregnancy showed significantlyreduced anxiety and
negative affect at p=0.05 level during the third trimester in comparison
to those who did not receive theintervention. The brief and non-
pharmaceutical nature of this intervention makes it apromising effect
during pregnancy.
The findings of the study conducted by Jallo, Bourguignon,
Taylor, Ruiz,Goehler on the bio behavioural effects of relaxation guided
imagery on maternal stress. The findings show that State anxiety
significantly decreased over time in the R-GI group, and it increased
over time in the usual-care (UC) group. The R-GI group had significant
decreases in NRSS scores before and after using R-GI. There were no
significant differences in CRH levels between groups over time. These
findings are consistent with findings of present study that the stress is
higher among women with PIH before relaxation and it was significantly
lowered after relaxation programme among the experimental group.
Coping strategies used by women with PIH before and after
relaxation programme.
The findings of the present study reveals there was no difference
in the coping strategies used by the women with pregnancy induced
hypertension in experimental group and control group before relaxation
programme (t=1.216,p=0.22) (t=0.283, df =398, p>0.05).
193
Yali and Lobel (1999) conducted a study to find out the
association between coping and pregnancy-specific distress. They
examined 167 pregnant women at high medical risk. A population-
appropriate coping inventory and prenatal distress measure were
administered in mid-pregnancy (mean of 24 weeks gestation). Subjects
experienced moderately high levels of distress about preterm delivery,
physical symptoms, labour and delivery, weight gain, and having an
unhealthy baby. They most frequently coped with the demands and
challenges of pregnancy through prayer and positive appraisal Socio
demographic variables including age, income, education, and parity
were significantly associated with ways of coping. Coping by avoidance,
preparation for motherhood, and substance use were associated with
greater distress, whereas coping by positive appraisal was associated
with less distress. These effects differed somewhat when levels of
global, non-specific distress were controlled. The present study is also
corroboration with the above findings.
Marion and Clauson conducted study on uncertainty and stress in
women hospitalized with high-risk pregnancy.The purpose of this
descriptive correlation study was to describe how women hospitalized
with high-risk pregnancy perceive the uncertainties and stress of their
situations. A sample consisting of 58 hospitalized antepartum women in
a tertiary maternity hospital completed the Uncertainty Stress Scale-
High-Risk Pregnancy Version 48 hours after admission and at the time
of discharge, when going home undelivered. Uncertainty at admission
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was found to be moderately low for 86% of the women, and was
significantly lower at the time of discharge. Higher levels of uncertainty
were positively correlated with higher levels of stress from the
uncertainty in this sample. Women who stayed longer in the hospital
reported higher uncertainty. These results have implications for the
assessment support; teaching, and discharge planning provided by
nurses during antepartum hospitalization. These results are supporting
the findings of present study.
The present study findings go along with the findings of a study
conducted by Lise and Segerstrom (2006) on relation between
dispositional optimism and better adjustment to diverse stressors may
be attributable to optimism's effects on coping strategies. Dispositional
optimism was found to be positively associated with approach coping
strategies aiming to eliminate, reduce, or manage stressors or
emotions, and negatively associated with avoidance coping strategies
seeking to ignore, avoid, or withdraw from stressors or emotions. Effect
sizes were larger for the distinction between approach and avoidance
coping strategies than for that between problem and emotion-focused
coping. Meta-analytic findings also indicate that optimists may adjust
their coping strategies to meet the demands of the stressors at hand,
and that the optimism-coping relationship is strongest in English-
speaking samples.
195
Jada, Hamilton and Lobel (2008) conducted a study on types,
patterns, and predictors of coping with stress during pregnancy .The
present study investigated coping in early, mid-, and late pregnancy in
321 ethnically and socioeconomically diverse women of varying medical
risk. The goal was to determine how women cope with stress across
pregnancy and to explore the association of coping with maternal
characteristics, stress perceptions, disposition, and social support.
Factor analysis of the Revised Prenatal Coping Inventory revealed three
distinct types of coping: Planning-Preparation, Avoidance, and Spiritual-
Positive Coping. Spiritual coping was used most frequently during
pregnancy; avoidant coping was used least often. As hypothesized, use
of spiritual coping and avoidance differed across pregnancy. Planning
was used more consistently across time. Multivariate regression
analyses revealed that the strongest predictors of planning were high
optimism and pregnancy-specific distress. Avoidance was most strongly
predicted by high state anxiety and pregnancy-specific distress. Greater
religiosity and optimism were the strongest predictors of spiritual coping.
These results add to a body of evidence that women use distinctive and
varied strategies to manage stress prenatally. They also suggest that
coping is responsive to changing demands across pregnancy and
reflective of women's characteristics, perceptions, and social situations.
These findings are consistent with the present study findings.
196
There are several study findings supported the findings of the
present study. Mayor (2001) conducted a study to examine the coping
styles and strategies used by the pregnant women (71 participants)
shows that the optimistic coping style (emotion focused) was strategy
the most often used by 75%of the young women. Specific optimistic
strategies included thinking positively seeing good side of the situation
and keeping a sense of humour while the remaining 25% of the sample
used confrontation coping style (problem focused) with coping
strategies such as handling one step at a time.
Effect of relaxation programme onlevel of stress.
The finding of the study revealed that the pre-test relaxation score
(t=1.130, p=0.259) on level of stress was significantly higher than the
post relaxation scores (t=-30.098, p= 0.0001). This shows that,
relaxation programme had reduced level of stress in women with PIH.
The effect of relaxation therapy on the level of stress and
physiological parameter among antenatal mother with mild pregnancy
induced hypertension was studied and the findings revealed that the
mean of pre-relaxation score was significantly higher than the mean of
post relaxation scores(Reshma, 2008). Kerstin Weidner et.al (2010)
examined whether a short-term psychosomatic intervention during
pregnancy had effects on characteristics of labour and delivery as well
as on the long-term course of anxiety, depression and physical
complaints in pregnant in-patient women. All gynaecological and
obstetric inpatients of a university hospital, who had either exhibited
197
complications during their pregnancy or were considered high-risk
pregnancies, were examined. Symptoms of anxiety and depression
(HADS) and physical symptoms (GBB) were assessed by standardised
questionnaires. Women with elevated scores on either the HADS or the
GBB were randomly assigned to either a treatment group, which had
received a psychosomatic intervention or an untreated control group. Of
the n = 238 women who were assessed during their stay in our
hospital, n = 135 were included in the follow-up 1-year later. The
findings showed that more than one-third of the participants (38.7%)
had elevated scores of anxiety, depression and/or physical symptoms.
The psychosomatic intervention had a significant effect on anxiety
scores (p = 0.006).Findings suggest that a short-term psychosomatic
intervention can have a positive long-term effect on anxiety
symptoms.These findings support the present study results that the
relaxation programme had significant effect on stress among women
with PIH (t=30.5,p=0.0001).
The findings of present study is supported by the results of study
conducted by Isabelle Marc et.al (2011),who assessed the benefits of
mind-body interventions during pregnancy in preventing or treating
women’s anxiety and in influencingperinatal outcomes. Randomized
control trials, involving pregnant women of any age at any time from
conception to one month after birth, comparing mind-body interventions
with a control group. Mind-body interventions include: autogenic
training, biofeedback, hypnotherapy, imagery, meditation, prayer, auto-
198
suggestion, tai-chi and yoga. Control group includes: standard care,
other pharmacological or non–pharmacological interventions, other
types of mind-body interventions or no treatment at all. They included
eight trials (556 participants), evaluating hypnotherapy (one trial),
imagery (five trials), autogenic training (one trial) and yoga (one trial)
and have reported results individually for each study. Compared with
usual care, imagery and autogenic training have a positive effect on
anxiety and depression among women with pregnancy. The present
study findings also reveal that the relaxation programme is highly
beneficial for relieving stress among women with PIH.
A pre-test-post-test experimental design with a convenience
sample of 60 subjects was used to examine the effects of a relaxation
with guided imagery protocol on anxiety, depression, and self-esteem in
primiparas during the first 4 weeks of the postpartum period. The results
showed that the experimental group had less anxiety and depression
and greater self-esteem than did the control group at the end of the
period. Positive correlations were obtained between anxiety and
depression; negative correlations between self-esteem and anxiety and
depression. All findings were significant at the 0.05 level (Ree, 1995).
Effect of relaxation programme on coping strategies among
women with PIH.
Pregnancy induced hypertension is pregnancy specific medical
complication impose high risk to mother and her baby. This condition
199
produce severe stress and sometimes ineffective coping worsen the
condition. Mind body interventions promote the mother to adopt better
coping in stressful situation.The present study finding revealed that the
relaxation programme effective in using better coping strategies among
women with PIH (t=-54.p=0.001). These findings are supported by the
study finding ofKushnir, Friedman, Ehrenfeld and Kushnir (2012)
thatassessed the effects of listening to music on emotional reactions
and coping before caesarean section. Women who listened to music
before a caesarean section had a significant increase in positive
emotions and a highly significant decrease in negative emotions and
perceived fear of the situation when compared to control group. The
results also revealed that asignificant change in blood pressure among
experimental group compared to control group. The authors conclude
that administering music therapy before surgery significantly reduce
negative emotions and help the women to cope such situations
effectively.
Mahboubeh, Abediyan, Mehdi Ahmadi, Pahlavanzadeh, and
Hassanzadeh (2010) studied to determine the effect of relaxation on the
infertile women's stress score. This was a semi-experimental and
clinical trial study. Participants randomly divided into two groups. At the
beginning, the stress scores were assessed in both groups using
Newton's infertility stress questionnaire. The participants’ stress scores
were evaluated and then, the relaxation technique was implemented on
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the intervention group. This technique was performed in twelve
sessions. All the questionnaires were completed under supervision of
the researcher after embryo was transferred to the uterus (after 2
weeks) and before conducting the pregnancy test. The findings shows
that the total stress score did not have a significant difference in groups
before the intervention whereas significant difference was observed in
stress scores between the two groups after the intervention at
p=<0.05level. Stress score was higher in the control group in compared
with the intervention group. Relaxation technique can reduce the stress
score in infertile women as a complementary and alternative medicine
method. The findings of present study also reveal that relaxation
technique reduces the stress.
A study conducted to evaluate psychological changes in women
of three minority ethnic groups in a program of psychosocial services
that promoted positive cognitive adaptation to childbearing throughout
pregnancy and the postpartum period. In this prospective longitudinal
study, both cognitive adaptation and generalized stress were measured
at each trimester of pregnancy as well as after birth and 3 months
postpartum. The mean scores at each time are first compared with first
trimester scores for women in the program and then with scores for
comparable women in a cross-sectional sample tested before the
program. For women in the program, results of the psychological
adaptation measures and the stress measures had improved from their
first trimester value by the time of birth. Stress levels of women in the
201
program were less than for women in the corresponding comparison
sample from the third trimester on. Enhanced perinatal services that
include interventions and monitoring strategies aimed at improving the
cognitive adaptation of women to childbearing are important in
promoting stress reduction in women and infants (Affonso et al., 1999).
Effect of relaxation programme on pregnancy outcome among
women with PIH
Kimberly June Nylen (2009) studied to examine the association
between maternal distress during pregnancy and infant reproductive
outcomes. It was hypothesized that women who report high levels of
distress during pregnancy would be more likely to experience adverse
reproductive outcomes. An additional goal of the study was to examine
the hypothesis that social support and coping style moderate the
association between prenatal maternal distress and birth outcomes.
This study utilized a prospective, longitudinal design. Pregnant women
(N = 257) completed self-report questionnaires and clinical interviews at
two time points during pregnancy. Following delivery, birth weight, week
of delivery, head circumference, and Apgar score were extracted from
medical records. Results suggested that women who were clinically
depressed during pregnancy were more likely to experience adverse
birth outcomes. In addition, maternal stress, anxiety, and depression
were best conceptualized as one general “distress” factor, which did not
predict variance in birth outcomes over and above demographic
variables. Significant interactions between maternal distress and social
support, as well as maternal distress and coping emerged as predictors
202
of birth outcomes. Results suggest that women with high levels of
stress, who also have small support networks, are at higher risk of
adverse birth outcomes than women with large networks, who were
relatively insulated from effects of higher distress. The findings of
present study explore similar results.
Narendran, Nagarathna, VivekNarendran, Gunasheela and
Nagendra (2005) identified the efficacy of Yoga on pregnancy outcome
on antenatal women between 18 and 20 weeks of pregnancy. Yoga
practices, including physical postures, breathing, and meditation were
practiced by the yoga group one hour daily, from the date of entry into
the study until delivery. The control group walked 30 minutes twice a
day (standard obstetric advice) during the study period. Birth weight and
gestational age at delivery were primary outcomes. Results showed that
the number of babies with birth weight ≥2500 grams was significantly
higher, preterm labour was significantly lower,complications such as
isolated intrauterine growth retardation and pregnancy-induced
hypertension with associated IUGR were also significantly lower in the
yoga group. The findings of the present study also consistent with these
results. The present study findings reveal that the pregnancy outcome
(maternal) in terms of labour (t=70.5,p=0.001),type of delivery
(t=42.9,p=0.001), complications (t=20,p=0.0001) blood pressure (t=50,
p=0.0001) proteinurea (t=96.43,t=0.0001) and oedema
(t=60.5,p=0.0001) were statistically significant.
203
The above findings are contradicted by the study done by Pagel,
Smilkstein, RegenandMontano (1990) on social and psychological
stress factors which influence pregnancy outcome such as birth weight,
gestational age, 1 and 5 min APGAR scores confirmed that the life
events stress accounted for significant variation in both 1 minute and
5minute APGAR scores, birth weight, gestational age at birth.
Association between level of stress, coping, pregnancy outcome
and selected variables: age, obstetric score,family history of PIH,
family history of hypertension of women with PIH.
The study findings of Reshma (2008) shows that, there was no
significant association between pre therapy scores of level of stress and
the selected variables, The present study findings also reveal that there
is no association between stress and selected variables such as age,
obstetric score, family history of PIH and family history of hypertension
among women with PIH. Similar results were found in the studies
conducted by Nisha (2006),Gisha (2005) and Raddi (2009) that there
was no significant association between stress and selected variables.
Sable and Deborah conducted a study on impact of perceived
stress, major life events and pregnancy attitudes on low birth.Women
who had a very low birth weight baby most frequently said they almost
always perceived stress during their pregnancy (25%). Perceived stress
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was also higher among women who a moderately low birth weight baby
(21%) than among those who had a normal-birth-weight baby (16%).
Similarly, several measures of negative pregnancy attitudes or
intentions (such as pregnancy denial and unhappiness about the
pregnancy) were more common among women who had a low birth
weight baby than among the others. There is some basis to believe,
however, that maternal emotional distress is associated with poor
pregnancy outcomes. An early study of stress and social support found
a relationship between stress, social support and adverse pregnancy
outcomes. In that study, however, the dependent variable was a
composite of various birth outcomes and could not be used to isolate
risks for low birth weight or preterm delivery. Three recent
examinationsof stress and low birth weight each had different findings,
measured stress differently and analysed different risk factors. One
used a 28-item psychosocial assessment scale with five separate
subscales, one of which measured “stress” (although the authors did
not describe how stress was defined).Among nearly 2,600 women
studied, stress was significantlyrelated to both low birth weight and
preterm delivery, but not to intrauterine growth retardation. In the
present study pregnancy out come in terms of neonatal outcome (birth
weight) and stress has statistically significant association
(p<0.05).Findings revealed that maternal stress affect the neonatal birth
weight.
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The findings of the study by Reshma revealed that the mean of
pre therapy scores on blood pressuresignificant positive change in the
mean pre therapy and post therapy scores of physiological parameters
of antenatal mothers with mild PIH. The present study findings also
suggest that there is significant difference in the physiological
parameters of experimental group before and after relaxation
programme.
SUMMARY
Significant findings of the study
The present study evaluated the effect of relaxation programme
on stress; coping and pregnancy out- come among women with
pregnancy induced hypertension. The objectives, hypotheses and major
findings of the study were:
Objectives
1. To assess the level of stress experienced by women with PIH
before and after relaxation programme.
2. To assess coping strategies used by women with PIH before and
after relaxation programme.
3. Evaluate the effect of relaxation programme on level of stress
among women with PIH
4. Evaluate the effect of relaxation programme on coping strategies
among women with PIH
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5. Evaluate the effect of relaxation programme on pregnancy
outcome among women with PIH
6. Find out the association between level of stress and selected
variables: age, obstetric score, family history of PIH, family history
of hypertension of women with PIH.
7. Find out the association between coping strategies and selected
variables: age, obstetric score, family history of PIH, family history
of hypertension of women with PIH.
8. Find out the association between pregnancy out come and
selected variables: age, obstetric score, family history of PIH,
family history of hypertension of women with PIH.
Hypotheses
H01.There will be no significant difference between the mean post- test
stress score of women with PIH in experimental and control group after
the relaxation programme.
H02. There will be no significant difference between the mean pre and
post- test stress scores of women with PIH in experimental group after
the relaxation programme
H03. There will be no significant difference between the mean pre and
post test score of coping strategies of women with PIH in experimental
group after the relaxation programme.
H04. There will be no significant difference between the mean post test
score of coping strategies of women with PIH in the control and
experimental group after the relaxation programme.
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H05. There will be no significant difference in the mean score of
pregnancy outcome among women with PIH in the control and
experimental group after the relaxation programme.
H06. There will be no significant association between stress and
selected variables: age, obstetric score, family history of PIH and family
history of hypertension in the control and experimental group.
H07. There will be no significant association between coping and
selected variables: age, obstetric score, family history of PIH and family
history of hypertension in the control and experimental group.
H08. There will be no significant association between stress, coping and
pregnancy out- come among women with PIH.
An evaluative approach with quasi experimental, pre- test
post- test control group design was used. Eight hypotheses were
formulated and tested. The conceptual frame work of the study was
based on Betty Newman’s system model (1972).
The dependent variables were: stress, coping and pregnancy
outcome among women with pregnancy induced hypertension. The
independent variable was relaxation programme.
Five measuring instruments were used in this study to
evaluate the effectiveness of relaxation programme among women with
PIH. Of these, semi structured interview schedule on socio
demographic and clinical data, observation checklist to determine the
physiological indicators and pregnancy outcome were developed by the
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investigator and a four point rating scale, DASS ( Lovibond and
Lovibond,1995) to assess stress level and Jalowic coping scale for
coping strategies (A.Jalowic,1987) were standardised scales.
The study conducted on 400 women with pregnancy induced
hypertension in Institute of Maternal and Child Health (IMCH)
Kozhikode. A convenient sampling technique was adopted for selection
of sample. The experimental and control group were not different in
their pre-test scores.
The relaxation programme was administered through audio CD
arranged in the sequence of deep breathing, progressive muscle
relaxation and guided imagery in Malayalam with necessary instructions
to the experimental group by the investigator from Monday to Friday in
the morning and evening for four weeks. A post- test was administered
to both groups to assess stress and coping strategies and pregnancy
outcome was measured through records.
Results
The major findings of the present study are discussed under the
following headings-
1. Socio personal characteristics of women with PIH
• Among the sample, 30% of subjects belonged to less than 20
years of age in both group.
• Out of the 400 women,half of the sample in both group belonged to
low income group.
• Majority of samples in both groups were housewives.
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• Support system was adequate for majority of the subjects in both
groups.
• Family structure of the sample was nuclear type in 91.5% in
experimental and 93% in control group.
• Most of the samples in bothgroups (47% in experimental and
51.5% in control) were watching TV as their leisure time activities.
• Majority of subjects in both groups belonged to rural residents.
• Majority of women in both groups had no history of stressful events
Distribution of sample based on clinical data
• Below 50% of women in both groups belonged to second gravid,
whereas 54.5%in theexperimentaland 59.5% in the control group
belonged to second para.
• No history of abortion was reported among majority of samples in
both groups.
• Regarding gestational age, in the experimental group 38% and
36% in the control group were 33 weeks of gestational age and
only 3% in the experimental and 8% in the control group were 32
weeks of gestation, 22% and 19% in 30 weeks and 26% and 24%
in 31 weeks of gestational age among women in experimental
group and in control group respectively.
• Majority of sample were admitted for safe confinement as reason
for hospital admission and only 9% and 7.5% in respective
groupswere admittedfor evaluation of pregnancy induced
hypertension.
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• Among the samples, half of the subjects were diagnosed as
pregnancy induced hypertension during 26-30 weeks of
pregnancy, 30% were during 20-25 weeks and only 20% were
diagnosed during 31-36 weeks of pregnancy in both groups.
• Out of 400 samples, 51.50% in experimental group and55% in
control group had no history of drug intake. Among subjects, 78%
in the experimental and 74% in the control group had no family
history of hypertension
• Among subjects 31.5% in experimental and 33.5% in control group
had history of pregnancy induced hypertension in previous
pregnancy. More than half among sample in experimental (68.5%)
and control (66.5%) had no such history.
• More than half of the sample in both group had no history of
disease complicating pregnancy
• Among the sample only 11% in the experimental and 13.5% in the
control group had the history of foetal loss in the previous
pregnancy.
• Severe head ache was present among 57% of subjects in
experimental and 52%in control group.
• Most of the sample had pitting oedema of 2cm depth in both
groups.
• Nausea and vomiting was present only among 48.5% in
experimental and 45% in control group
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• Among samples,69.5% in the control group and 70% in
experimental group had more than 0.5 kg weight gain during
pregnancy.
• Majority of samples in both groups had foetal movements felt more
than 10 per 12 hours.
• Most (68% and 69%) of the sample in both group had interrupted
sleep.
• 12% of the samples had irregular antenatal check -ups even
though the majority (88%) had regular check-ups
3. Distribution of sample based on stress score
• All the samples had severe level of stress before relaxation
programme.
• After four weeks of intervention 5% of women in the experimental
group have no stress, 10% with mild stress,43% with moderate
stress and 42% had severe stress.
• Depression, anxiety and stress present in its severe form among
100% of sample in experimental group whereas 43% of sample
had severe depression, 77% had anxiety and 34.5% stress in
control group.
• Depression, anxiety and stress reduced to 43%, 77% and 34.5%
in experimental group whereas in control group it was 100%
(depression and anxiety) and 99.5% (stress).
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4. Distribution of samples based on coping
• The total score on coping strategies used by the women in
experimental and control group were 111 and 105 in pre- test. In
post-test, the total score in experimental group was increased to
187 and control group it was 111.
5. Distribution of samples based on pregnancy outcome
� Maternal outcome:
• 83.5% in experimental group and 43% in control group had term
labour. Pre-term labour occurred only in 16.5% among
experimental group but it was 57% in control group.
• Type of delivery was normal among 79.5% in experimental group
and only 48% in control group. In experimental group only 17%
had undergone LSCS but it was 43% in control group. Regarding
instrumental deliveries, 3.5% in experimental and 9% in control
group had instrumental deliveries.
• Maternal complications were present only 8% in experimental
group and 24.5% in control group.
• Among samples, 84.5% in the experimental group and 51.5% in
the control group had normal blood pressure. Only 15.5% in
experimental group had high blood pressure whereas 48.5% had
high blood pressure after delivery.
• Oedema was absent among 84% in experimental and 47% in
control group.
� Neonatal outcome:
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• Normal birth weight (2.5-3.5kg) was observed among 61.5% in
experimental and 49% in control group.48% in control group had
babies with less than 2.5 kg birth weight, this was only 29% in
experimental group. Babies with more than 3.5kg birth weight were
present among 9.5% in experimental group and only 3% in control
group.
• Apgar score with in normal range(8-10) was present in babies
among 88% in the experimental group , whereas in control group it
was only 40%. Severe distress was seen among 19.5% in the
control group and it was only 1.5% in the experimental group.
• The neonatal complications present among 14% in control group
but it was only 3.5% in experimental group.
6. Effect of relaxation on level of stress
• Therewas no statistical significance in the obtained t value of pre-
test scores of stress in the experimental and control group
(t=1.21,p>0.05) showing that there is no difference in the stress
level score between experimental and control group
• There is a significant difference in the mean post- test stress score
of experimental and control group (t=-30.098, p<0.05). It indicates
that the relaxation programme is effective in relieving stress among
women with pregnancy induced hyper tension.
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7. Effect of relaxation on coping
• The obtained t value of pre-test scores of coping in the
experimental and control group is not statistically significant
(t=0.283,df=398,p>0.05) showing that there is no difference in the
coping score among experimental and control group
• It is evident that there is statistically significant difference in the
pre- test post -test mean score of coping in experimental group
after relaxation programme (p=0.001). So the relaxation
programme is effective in adopting useful and effective coping
strategies among women withPIH.
8. Effect of relaxation on physiological variables
• There is statistical difference in the weekly average scores of
physiological variables (pulse, respiration and systolic blood
pressure, p=0.0001level) except in diastolic blood pressure
(p>0.05 level).It seems that relaxation programme is effective in
maintaining physiological variables among women with PIH.
9. Effect of relaxation on pregnancy outcome
• The maternal outcome among women with PIH were highly
significantin terms of labour, type of delivery, complications, blood
pressure, proteinuria and oedemaat 0.001 level
• The neonatal outcome is statistically significant among women with
pregnancy induced hypertension except in terms of still birth
(p>0.05)
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10. Association between stress,coping, pregnancy outcome and
selected variables.
There were four selected variables.
• With regard to age, there were three groups, <20, 20-29 and >30
years. The F value was 0.253 p 0.77 which showed no
significance.
• With regard to obstetric score, there were four groups, gravida,
para, live and abortion. The F value for gravida was 2.40 p=0.06
showed no significance.
• The F value for para was 1.74 and p=0.158 showed no significance
• For live F=3.84, p=0.022 showed significance.
• F value for Abortion was 2.47 and p=0.06 showed no significance.
• There were no statistically significant association between stress
and History of PIH in the family (F=0.19,p=0.84) and family history
of hypertension (F=1.311,p=0.19)
• There is no statistically significant association between coping and
selected variables among women with PIH
• Pregnancy out come in terms of neonatal outcome (birth weight)
and stress has statistically significant association
(F=6.4,p=0.002).Findings revealed that maternal stress affect the
neonatal birth weight.
• There is significant association between Apgar score and stress
among women with PIH in control group (F=3.62,p=0.02).
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Recommendations
1. Complementary therapies should be incorporated with allopathic
medicine in caring women with pregnancy and child birth
problems especially in high risk cases where medicine may
harm the baby and for that relaxation programme can be
effectively utilized.
2. Relaxation programme should be included in all antenatal care
setting, so that stress related to pregnancy can be relived and
effective coping will be achieved.
3. Health professionals involved in caring women during pregnancy
and child birth should be given training in relaxation technique
so that they can provide suitable relaxation technique to their
clients.
4. In high risk antenatal care more emphasis should be given for
psychological well- being. Health care personnel should be
made aware of the fact that along with physical and
physiological balance psychological well- being is also
important in case of relieving stress among high risk antenatal
women.
5. The audio CD on relaxation programme made available in
antenatal, intra-natal and postnatal care setting so that without
sparing heath care professional the programme can be
implemented to a large population to achieve relaxation.
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Suggestions for future study
1. 1 A similarstudy can be replicated at another setting.
2. A similar study can be conducted on a larger sample and for
longer duration
3. So that effect on pregnancy outcome in all aspects can be
evaluated.
4. A comparative study can be conducted to evaluate the
effectiveness of relaxation programme and other complimentary
therapy.
5. A similar study can be conducted in other high risk pregnancies.
6. A similar study can be conducted on large sample by using
probability sampling technique.
7. A study can be conducted to compare theeffectiveness of the
intervention between normal mothers and high risk mothers
using Betty Neuman’smodel.
8. Effect relaxation on stress and biochemical markers can be
assessed.
9. A similar study on primigravidae can be conducted at different
gestational weeks.
10. Transcultural studies can be done to assess the stress,
pregnancy outcome and coping and effect of various relaxation
interventions.
11. Knowledge, practice and attitude on relaxation programme
among health care team members can be studied.
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Limitations of the study
1. Sampling technique being non probability purposive,
generalization of findings is limited.
2. Relaxation therapy was limited to 45 minutes in the morning and
evening for five days for four weeks due to high attrition rate of
the samples.
3. Effect of relaxation on physiological variables evaluated only in
the experimental subjects during the programme.
4. The investigator could not control the effect of antihypertensive
drugs due to ethical reasons.
5. The researcher had no control over the pregnancy outcome
such as gestation ageat birth, mode of delivery, birth weight and
other complications, because it may beinfluenced by other
factors such as nutritional, familial, and genetic factors.
6. Measurement of psychological components is complex and very
difficult, yet the baseline value for stress and coping among the
participants were all the above the population based mean, thus
confirms that this population also was in fact distressed.
Because psychological distress has associated with adverse
pregnancy outcome, the findings raise the possibility of the
benefits of relaxation programme might clinically meaningful.
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Strength of the study
The study was challenging process to the investigator. Client
centred assistance was provided during the relaxation programme. The
relaxation programme was scheduled to their convenience in the
morning and evening, which included both relaxation and group
interactions. The literature provided and substantiated that the
complementarytherapies are commonly used as the intervention.The
audio on relaxation programme on small group basiswas perceived as
one of the effectivemethods to relax their mind and body and improve
their pregnancy outcomes in terms of maternal and neonatal outcomes.
Nursing implications
The findings of the study have implications for nursing practice,
nursing education, nursing research and nursing administration.
Nursing practice: Pregnancy induced hypertension is one of the high
risk pregnancies in which a great deal of psychological alteration take
place with prime manifestation in blood pressure. Women with PIH also
suffer a great deal of stress. Researchers prove that stress can
aggravate the blood pressure. Relaxation programme plays a major role
in the alleviation of stress. Relaxation programme restores
psychological and physiological well-being. So the provision of
relaxation programme in the clinical setting for women with PIH helps in
improving the physical and psychological outcome. This can be given
as individual or group therapy. As pregnancy, labour, purperium is
220
stress full development states this therapy will be beneficial in all these
settings.
The present study throws light on the fact that PIH is more
among the younger group of primi status with low socio economic
background. This young productive group has to be taken care with the
available resources and low cost treatment modality. Hence it is
imperative to adopt relaxation programme along with pharmacological
measures as a routine treatment strategy in IMCH setting as well as in
other settings.
The integrated perspectives of nursing incorporate the use of
relaxation programme in therapeutic settings and are beneficial not only
to the patients but also to the health professionals. Researches prove
that relaxation programme could increase the work efficiency through
stress relief. So relaxation programme can be used in all clinical
settings.
The nursing practice expanding to an independent profession
they can practice relaxation programme with no side effect is more
beneficial to their clients. The holistic nursing gives much attention to
relaxation programme and strongly believes that relaxation can bring
back harmony into the whole self by eliminating that ,which is causing
disharmony and has the power to heal the body and mind.
The current concept of management of mild PIH is providing rest
and careful monitoring in the home setting. Relaxation programme
221
through an audio CD, in home care setting helps to provide an added
effect to psychological and physical status.
As the stress is common phenomenon in day to day life and it is
increasing in day by day, measures to overcome these are essential.
This present study finding shows that PIH patients had stressed and
relaxation programme had beneficial effect. Relaxation programme is
cost effective and can be practiced in home itself. The community
health nurse can disseminate this knowledge among the society so that
they can practice the same in community setting.
Nursing education: Nursing curriculum should be equipped with
knowledge and skill to hatch out perspective nurses to assist client and
community developing their potential. By introducing these innovating
practices in the curriculum the diversification of the nursing role can be
enhanced.
Nursing curriculum should give emphasis on psychological
aspects like stress associated with high risk pregnancy. The curriculum
should include the importance of alternative therapy and its principles. It
should also contain the provision for practising relaxation programme in
their clinical experience.
Nursing personnel working in various health care setting should
be given in service training regarding relaxation programme and its use.
Staff development programme should be provided to up-date the
knowledge, improving the skill of nurses regarding the current
perspectives and management options of PIH. With prompt
222
assessment, counselling and advocacy skills nurses can contribute to
the early detection and treatment of pregnancy induced hypertension so
as to facilitate a better maternal and foetal outcome.
Nursing administration: Nursing administration should keep abreast
with importance of complimentary devices in the area of nursing
practice that would improve the nursing profession. It is high time to
acquaint the nurses with high power of relaxation programme. The
nursing administrators should take initiatives in implementing,
maintaining and making necessary policy for instituting relaxation
programme. It is the nursing administrators who should inculcate among
the subordinates a liking for the latest treatment modalities including
relaxation programme that will promote enthusiasm in the subordinates
in adopting new health care practices. To enhance the latest knowledge
in the field of alternative therapies the administrators of nursing service
and education should take necessary arrangements in this area.
Nursing research: Although much research has been done on the
effect of relaxation on hypertension, its effect on pregnancy induced
hypertension has to be explored further. The nurses should take the
initiative to conduct more studies on stress and pregnancy outcome
among high risk pregnancies. Administrators should provide necessary
arrangement to conduct researches in the clinical setting so that
evidence based practice can be utilised for comprehensive patient care.
223
Conclusions: An integrated approach to relaxation during pregnancy is
safe. It improves pregnancy outcome in terms of neonatal and maternal
outcomes among women with PIH, with no increased complications.
The relaxation programme can be implemented in the clinical setting by
the staff nurses to promote emotional and physical well -being among
women with high risk pregnancies. These are the best complimentary
therapy, cost effective and simple to practice even by the health
personnel.
224
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