Yoga during Pregnancy: A ReviewShilpa Babbar, M.D. 1 Agatha C. Parks-Savage, Ph.D. 2 Suneet P. Chauhan, M.D. 1

1Department of Obstetrics and Gynecology, Eastern Virginia MedicalSchool, Norfolk, Virginia

2Department of Family Medicine, Eastern Virginia Medical School,Norfolk, Virginia

Am J Perinatol 2012;29:459464.

Address for correspondence and reprint requests Shilpa Babbar,M.D., 845 Fairfax Avenue, Suite 544, Norfolk, VA 23507(e-mail: babbars@evms.edu).

Yoga is derived from the Sanskrit term yuj, which meansto yoke or to join together, and it can be defined as asystem of stretching exercises and postures (asanas) com-bined with deep breathing (pranayama) and meditation,with the aim to unite the mind, body, and soul.1 Yoga isperceived as a way to develop and maintain a healthy mindand body and has become a popular means of exerciseamong adults, and presumably during pregnancy. In 2008,15 million Americans reported they practiced yoga.2 Apossible reason for its popularity is that yoga has healthbenefits in reducing stress, anxiety, depression, chronicpain syndromes (arthritis, chronic low back, migraineheadaches), and chronic conditions such as hypertensionand diabetes in adults.1 However, there is little knownabout the potential benefits, if any, of yoga amongthe obstetric population. Thus, it is understandable whyAmerican College of Obstetricians and Gynecologists(ACOG) in the committee opinion entitled Exercise duringPregnancy and the Postpartum Period3 does not mentionthe word yoga.

The objective of this systematic review was to identifyclinical trials that assessed peripartum outcomes while prac-ticing yoga. We also critically reviewed the methodologicalquality among the studies identified to help improve futureresearch in this field.

Materials and Methods

An electronic literature search was conducted on PubMedfrom January 1970 to January 2011. To identify the pertinentarticles we utilized a combination of the following terms:yoga and pregnancy, childbirth, postpartum, lacta-tion, breast-feeding, pregnancyweight loss, postpartumweight loss, pregnancy depression, postpartum depres-sion, cesarean section, postpartum pain control, andprenatal yoga.

We included randomized and nonrandomized controlledtrials that specifically stated that the interventionwas yoga oryoga-based exercise during pregnancy or the postpartumperiod. Non-English publications, those discussing the concept

Keywords

yoga pregnancy exercise prenatal

Abstract The purpose of this review article is to evaluate the peripartum outcomes of yoga duringpregnancy, including the postpartum period and lactation. The PubMed database wasanalyzed from January 1970 to January 2011. We identified five prospective observa-tional studies (n 575) and three randomized clinical trials (RCTs; n 298), whichwere analyzed separately. The nonrandomized trials indicated a significant reduction inrates of preterm labor (p < 0.0006), intrauterine growth retardation (p

of yoga without any data analysis, case reports, and abstractswere excluded. Studies that focused on reviewing and com-paring complementary alternative medicine (CAM), such asacupuncture, aromatherapy, biofeedback, hypnosis, and mas-sage, were also excluded. Last, we excluded studies that did notfocus on pregnancy, yoga, or the postpartum period.

Since the CONSORT (Consolidated Standard of ReportingTrials) statement was published in 1996, randomized clinicaltrials (RCTs) published after this year were evaluated forcompliance with these guidelines.4 The CONSORT score5 isderived from the identification of 50 separate items that theRCT should describe in the article and assigns 2 points ifpresent and 0 if absent. The CONSORT score is expressed as apercentage of total points.

Results

Our search of the PubMed database found a total of 53publications during the 42-year period. Of these publications,we screened and excluded 45 (85%) reports for the followingreasons: conceptual discussion without data (n 14), notyoga or yoga-based (n 11), no abstracts available (n 6),CAM review (n 5), non-English (n 5), and those articlesnot related to pregnancy (n 4). There were no relevantarticles focusing on the postpartum period or lactation(Fig. 1).

We identified eight publications that met our inclusioncriteria, which underwent a full text review and are the focusof this report. Half of the studies were conducted in India(n 4), followed by United States (n 2) and one each fromThailand and Taiwan. Of the eight publications reviewed, fivewere prospective observational study (Table 1)610 andthree were randomized clinical trials (Table 2).1113

The study design of the five observational reports variedwith two pre- and postintervention (yoga)8,9 and three casecontrols, with the latter group either walking for the sameduration6,7 or receiving routine care.10 The total sample sizeof these five reports was 575 (range 15 to 335). The outcomeof interests varied, and significant differences are listedin Table 1.610

For the three RCTs, the intervention was yoga and thecontrol group was either routine prenatal care11 or standardprenatal exercises.12,13 The total sample size was 298 (range74 to 122).With all three trials, the examiner was not blindedto which arm the women were randomized. All three trialshad positive results, showing that yoga during pregnancydecreases the duration of labor, improves maternal comfortduring childbirth,11 decreases stress during the antepartumperiod,12 and improves quality of life during pregnancy.13 Thecalculated CONSORTscores ranged from 42 to 70% (Table 2).

Discussion

With the rise of obesity in the United States, exercise is animportant part of a healthy lifestyle. Approximately one-thirdof adult women in the United States are obese. Research hasshown that obese women are at an increased risk for severalpregnancy complications including gestational hypertension,

preeclampsia, gestational diabetes, and increased cesareansection rate.16 Before conception, obstetricians should informwomen of the possible complications of obesity and encour-age these women to undertake a weight reduction programincluding diet, exercise, and behavior modifications.16

Exercise is also a pivotal part of pregnancy, especially foroverweight and obese women. According to ACOG,17 exercisehas beneficial effects during pregnancy. It helps to reducecommon symptoms of pregnancy such as backaches, consti-pation, bloating, and swelling. It may also help prevent ortreat gestational diabetes.17 Considering how common ex-cessive weight gain and retention are during pregnancy,18

exercise during pregnancy may prevent or reduce it. In 2002,ACOG released its latest recommendations on exercise, whichencourages 30minutes or more of moderate exercise a day onmost, if not all, days of the week.3 Although the committeeopinion specifies what exercise not to do (i.e., scuba diving,horseback riding, ice hockey, soccer, basketball, gymnastics,downhill skiing, and vigorous racket sport),3 it does notmake recommendations on which type of exercise toperform for maximum benefit. Thus, clinicians may beuncertain about recommendations of exercises that are gain-ing acceptance.

Yoga is a constellation of slow dynamic and static move-ments, focused breathing, and controlled stretching of skele-tal muscles. Its popularity has increased in the United Stateswith 15 million adults practicing this exercise in 2008.2

Traditional goals of childbirth education have been to reducepain and anxiety through relaxation techniques that havetheir roots in yoga,19 but its benefits during pregnancyremain uncertain. Thus, a review of the published report onthe topic is useful.

There are three findings of this review. First, there arelimited published data on yoga during pregnancy. An elec-tronic search covering 42 years yielded 53 publications on thetopic as compared with a PubMed search with the termsexercise, pregnancy, which provided 3105 citations forreview. A possible reason for the paucity of publications onyoga during pregnancy is that it is practiced infrequently.According to the National Health and Nutrition ExaminationSurvey,20 among the nine exercises commonly done duringpregnancy, walking was themost popular (41%) and yogawasranked fourth, being practiced by only 7%. Other possiblereasons for lack of publications include origin of the exercisein an Eastern country, insufficient funding, lack of interest,inadequate knowledge of the benefits of yoga, or unaccept-ability of yoga as a valid form of exercise.

The second finding of the review is that the observationalstudies and randomized trials have demonstrated an im-proved quality of life13 by decreasing stress,8,12 anxiety,8

and sleep disturbances9with yoga practice during pregnancy.The possible biological plausibility of the finding is thatduring pregnancy, stressors activate the hypothalamic-pitui-tary-adrenal axis,21 and yogic relaxation techniques reducesympathetic tone and improve sympathovagal balance.22

Despite the significant improvements and physiological ex-planations, we caution about the generalizability of thesefindings because the studies are hampered by poor study

American Journal of Perinatology Vol. 29 No. 6/2012

Yoga during Pregnancy Babbar et al.460

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design, and the evaluator of the outcomes was not blinded tothe intervention.

Of note, an observational study7 from India reported thatcompared with a control patient who walked a half-hourtwice a day, a woman who practiced yoga 1 hour daily wassignificantly less likely (19% versus 30%, respectively) to havea newborn weighing less than 2500 g. We do not think

currently there is sufficient evidence that yoga decreasesthe likelihood of low birth weight because there are severalmaternal and fetal factors that influence the rate of pretermbirth and growth restriction,23,24 which are the two leadingreasons for aweight

Table

1Non

rand

omized

TrialswithYo

gadu

ring

Preg

nanc

y

FirstAuthorof

Publication

(Yea

r,Country)

Sample

Size

andPo

pulation

YogaInterven

tion,Comparison

Interven

tion,an

d/orControl

Group,Duration

Outcomes

Mea

sured

Resu

ltsan

dConclusions

Naren

dran

etal6

(200

5,India)

12

1(68yo

gagrou

p,53

control)

18

20wkpreg

nant

withab

norm

alDop

pler

velocimetry

scores

ofum

bilicala

nduterinearteries

Yo

gaexercises,

brea

thing

tech

niqu

es,an

dmed

itation

Con

trol:walke

d

htw

iceada

y

1hda

ily,from

timeof

recruitm

ent

tode

livery

Birthou

tcom

esmeasuredby

:

Bloo

dpressure

IUGR

Dop

pler

velocimetry

scores

ofum

bilical

anduterinearteries

Mod

ean

dge

stationa

lag

eof

delivery

Birthweight

Asignificant

increa

sein

birthweigh

tto

250

0g(p