Effect of acupressure and reflexology on pregnancy constipation: a quasi-experimental study

Abstract

Background

Constipation is one of the most common complaints during pregnancy. A significant percentage of pregnant women report that this constipation occurs or worsens during pregnancy. Nowadays, the use of complementary medicine treatments to control or reduce constipation is of particular importance. The aim of this study was, therefore, to compare the effects of acupressure and reflexology on constipation in pregnant women.

Methods

In this quasi-experimental study, 90 pregnant women who had visited three health centres in Birjand, Iran, for 4 weeks in 2021 were randomly selected and assigned to three groups: acupressure (n = 30), reflexology (n = 30) and control (n = 30). The Constipation Assessment Scale (CAS) for pregnancy was completed before the intervention and in the first, second, third and fourth weeks after the intervention (twice a week), while the control group received usual care.

Results

The average severity of constipation decreased significantly over time after the start of the intervention in both the acupressure and reflexology groups (P < 0.05). In the control group, the average severity of constipation decreased significantly in the first, second and third weeks after the intervention, but increased significantly in the fourth week (P < 0.05). The average reduction in the severity of constipation over the course of the study was significantly higher in the pregnant women in the acupressure group than in the reflexology group and the control group, and higher in the reflexology group than in the control group (P < 0.05).

Conclusions

Both acupressure and reflexology had significant effects on reducing the severity of constipation during pregnancy. However, the alleviating effect of acupressure was greater than that of reflexology.

Trial registration Registered at the Iranian registry of clinical trials, with code No. IRCT20210626051706N1 in 2021-12-20.

Introduction

Every year there are more than two hundred million pregnancies worldwide [1]. The physical and psychological changes associated with pregnancy affect all organs; however, the most common changes occur in the digestive system [2, 3]. Nausea, vomiting, heartburn and constipation are among the most common digestive problems experienced by women during pregnancy [4]. Constipation, the second most common digestive problem in pregnant women, which is associated with feelings of dissatisfaction in those affected, requires attention and care [5]. The global prevalence of constipation during pregnancy is 32.4%, with the first trimester being the most affected at 21.1%, the second trimester at 34% and the third trimester at 30.3% [6].

Several factors are involved in the development of constipation during pregnancy. However, the main cause of constipation in pregnancy is a combination of hormonal and mechanical factors that affect the digestive system [6].

Various treatments are used to treat constipation, including fiber intake, concomitant medications, laxatives, gastro kinetic agents, bile acid transport inhibitors, physical activity, and probiotics [7].

Despite the common treatments for constipation in pregnancy, it is better to take as little medication as possible due to sensitivity during pregnancy [8]. One of the most effective non-pharmacological measures to prevent and treat constipation is the use of complementary and alternative medicine (CAM), which may be safer than the usual drug treatments. There are many types of CAM, including acupuncture, electroacupuncture, transcutaneous electrical nerve stimulation, acupuncture stimulation and acupressure [9].

Acupressure is one of the therapeutic and palliative approaches that can be used by physicians, nurses and even the patients themselves, and has a positive impact on patient care and support. The characteristics of acupressure include that the pressure is applied with the fingers, that no drugs, needles or other means need to be used, that it is easy to learn and apply, and that there are no negative physical effects even if the treatment is incomplete [10, 11]. Acupressure is the application of pressure to specific areas of the body along the energy meridians identified and used by traditional Chinese medicine [12]. When applied to specific points, acupressure has the effect of increasing gastrointestinal motility and digestive fluids. It is also used to relieve and prevent constipation as it stimulates the sacral nerve which regulates defecation [13]. It has been reported that acupressure may have positive effects in the treatment of constipation during pregnancy [14].

Another alternative treatment method that is likely to have an effect on constipation is reflexology, which involves firmly massaging specific areas of the body. Reflexology is based on the fact that there are reflex points on the soles of the feet and hands that correspond to every part of the body, including muscles, nerves, glands and bones. These reflexes are located on the soles of the feet, the toes and the insides and outsides of the feet. Therefore, there are different types of reflexology treatments, one of which is foot reflexology [15–17].

By pressing the corresponding reflex point, electrochemical nerve stimuli are activated, which are accompanied by stimulation of the nervous system, the peripheral nervous system is activated and a message is sent. This message is transmitted to the central nervous system via afferent neurons in a ganglion. The message that passes through the ganglion is transmitted via afferent neurons to specific organs or glands, and thus a response to this message is generated. By stimulating inactive areas or calming over-activated areas, reflexology contributes to the balance of all systems in the body [7].

Various studies have demonstrated the effectiveness of reflexology and acupressure in the treatment of constipation [18]. However, to our knowledge, no study has compared the effects of these two methods on the severity of constipation in pregnancy. Both reflexology and acupressure are considered non-pharmacological measures of Chinese alternative medicine that are simple, easy, cheap and non-invasive. According to the points considered in this study, both reflexology and acupressure are techniques that can be performed by patients themselves. Therefore, this study was conducted with the aim of comparing the effects of acupressure and reflexology on the severity of constipation in pregnancy in health centers in Birjand, Iran.

Materials and methods

Study design and participants

The study population of this single-blind quasi-experimental study was all pregnant women who suffered from constipation in pregnancy from March to May 2021 and contacted the health centers of Birjand, Iran. This study was approved by the ethics code IR.BUMS.REC.1399.504 of Birjand College of Medical Sciences and the code for the clinical trial was IRCT20210626051706N1.

In this study, research ethics were observed based on the Declaration of Helsinki (meaning that subjects were free to accept or decline participation in the study after being informed of the objectives of the study, and that informed consent was obtained from them and the benefits of participating in the study were explained to them. Participants could withdraw from the study at any time during the study if they decided to stop for any reason and this would not affect the services provided to them.

Their details are completely confidential and they can find out about the results of the study after the study has finished if they wish). Inclusion criteria included constipation of moderate or high severity (score ≥ 9 on the Constipation Assessment Scale (CAS) for pregnancy) in the last 3 days, singleton pregnancy and gestational age of 12–32 weeks. In addition, subjects with a history of hemorrhoid surgery or other surgery related to the colon, a history of gastrointestinal diseases such as hepatitis, ulcerative colitis and irritable bowel syndrome (IBS), diabetes, hypothyroidism, anxiety, death of relatives in the last 2 months, drug addiction, taking medications that cause or aggravate constipation, and taking bowel-stimulating medications were excluded from the study.

The sample size was calculated using a standard formula and based on the results of the study by Ghaffari et al. [19]. The mean severity of constipation in the intervention group was 13.20 ± 7.56 before the intervention and 6.94 ± 4.80 after the intervention. With a 95% confidence level, 22 participants were required in each group. In addition, based on the post-intervention mean constipation severity in the intervention (6.94 ± 4.80) and control (16.3 ± 8.00) groups, a sample size of 11 participants per group was calculated. However, to enhance the study's reliability, 30 participants were included in each group.

Initially, three health centers (These centers are located in the west to south of Birjand city, and about 8000 people are covered by these centers, and all three centers are among the main and most visited centers in the city) with similar cultural, social, and economic characteristics were non-randomly selected from among the available centers. Then, using simple random sampling without replacement (lottery method), each center was assigned to one of the study groups. This approach was intended to prevent the transfer of study experiences among participants in different groups. Subsequently, in each group, eligible participants who met the inclusion and exclusion criteria were enrolled through convenience sampling.

Data collection

The data collection instrument comprised a questionnaire in two parts:

• A.Demographic information, including: mother’s age, education level, employment status, number of pregnancies, history of constipation, gestational age (GA), body mass index (BMI) before pregnancy, weight gain during pregnancy, iron consumption, milk consumption, fluid consumption per day, number of regular walks per day, average number of hours of sleep per day and night, and family income.
• B.
  The CAS for pregnancy: this scale is a valid scientific tool that includes eight characteristics, such as frequency of bowel movements, hard stools, anal pain during bowel movements, duration of straining, abdominal distension and bloating, feeling of incomplete defecation, feeling of fullness and pressure on the pelvis, and failure to defecate within 72 h. The desired score is calculated based on a five-point Likert scale from zero to four as follows for each characteristic:

  • Frequency of bowel movements: once or twice a day (0), twice a week (1), once a week (2), less than once a week (3), less than once a month (4);
  • Hard stools, anal pain on defecation, failure to defecate within 72 h: never (0), rarely (1), sometimes (2), most of the time (3), always (4);
  • Duration of straining: less than 5 min (0), 5–10 min (1), 10–20 min (2), 20–30 min (3), more than 30 min (4);
  • Flatulence and bloating, incomplete defecation, bloating and pelvic pressure: none (0), mild (1), moderate (2), severe (3), very severe (4).

The final score is calculated from the sum of the above and 32 points. Based on the total score obtained, the severity of constipation is divided into four ranges. A score of 0–8 indicates no problem or a mild problem, a score of 9–16 indicates a relatively to moderately severe problem, a score of 17–24 indicates a severe problem and a score of 25–32 indicates a very severe problem [20]. The reliability of this questionnaire was reported to be 0.84 in the study by Ghaffari et al. [19] using the test–retest method with an interval of about 24 h, indicating the stability of the instrument over time.

The CAS for pregnancy was completed before the intervention and in the first, second, third and fourth week after the intervention (twice a week).

Intervention

Acupressure and reflexology were performed by a researcher trained in acupressure and reflexology. All phases of the study were controlled and finally approved by the project management of Birjand College of Medical Sciences.

In the acupressure group, the two points of Li 11 (Qu Chi) on both hands and the two points of ST36 (Zu San Li) on both feet (4 points in total) were massaged for 16 min during 12 sessions (3 sessions per week) using their own thumb puller with a pressure of 3–4 kg. In this way, each point on each side was pressurized for 4 min. The pressure was calibrated with a digital scale.

In the reflexology group, participants were asked to sit on a chair in a quiet and bright room to relax completely. They were then asked to place one foot on top of the other foot and, after gently massaging the foot, hold the heel with the left hand and then use the back of the right fist to pull on the sole of the foot from the area of the 2nd interphalangeal joint to the area of the large and small intestine from top to bottom with an alternating pressure of 4–5 kg. This measure was repeated for each foot for 8 min (16 min in total) for 12 sessions (3 sessions per week).

The control group received the usual care of the center (nutrition and care instructions). It should be noted that in both the acupressure and reflexology groups, the usual nutrition and care instructions were given in addition to the aforementioned interventions.

All participants in the acupressure group (n = 30) and the reflexology group (n = 30) performed acupressure and reflexology for 16 min per session, 3 sessions per week, totaling 48 min per week and 576 min, or 9.6 h, throughout the study period.

During the course of the study, participants were contacted twice a week to remind them of the intervention and to check for any complications and any problems or questions regarding the pregnancy or the intervention and to complete the checklist. If they missed more than one appointment for any reason, they were excluded from the study. It should be noted that all participants completed all phases and none of them dropped out of the study.

Statistical analysis

Central and dispersion indices were used for quantitative variables and number and percentage were used for qualitative variables. To test the homogeneity of the groups in the demographic characteristics, chi-squared, Fisher’s exact, one-way analysis of variance (ANOVA), Tukey’s post hoc, Kruskal–Wallis, and Mann–Whitney U tests were used. Due to the normal distribution of the data (using the Kolmogorov–Smirnov test), repeated measures ANOVA, Tukey’s post hoc, and Benferoni post-hoc tests were used. To control for heterogeneous variables, a marginal model using the GEE (generalized estimating equations) approach was employed. Depending on the type of response variable, the model used an identity link function for the constipation severity score and an ordinal logistic link for the intensity of constipation. The data were analyzed using SPSS v. 19 and the significance level was considered P < 0.05.

Results

In this study, 90 pregnant women with pregnancy constipation were examined in three groups: acupressure (n = 30), reflexology (n = 30) and control (n = 30). Finally, statistical analyzes were carried out on 90 pregnant women. None of the subjects were excluded from the study and no side effects were observed during the study period.

The demographic data of the study subjects in the three groups are listed separately in Tables 1, 2, 3.

Table 1.

Frequency distribution of demographic characteristics in pregnant women of three studied groups

Variable	Acupressure (n = 30)		Reflexology (n = 30)		Control (n = 30)		Test statistic	P value
	Frequency	Percentage	Frequency	Percentage	Frequency	Percentage
Educational stage
Lower than diploma	2	6.7	2	6.6	0	0.0	6.01*	0.20
Diploma	15	50.0	14	46.7	22	73.3
Associate degree or higher	13	43.3	14	46.7	8	26.7
Occupation
Homewife	13	43.3	18	60.0	20	66.6	4.47*	0.35
Home jobs	11	36.7	6	20.0	5	16.7
Employee	6	20.0	6	20.0	5	16.7
Iron consumption
No	4	13.3	8	26.7	7	23.3	1.74*	0.42
Yes	26	86.7	22	73.3	23	76.7
Dairy consumption
0–1 glass a day	10	33.3	9	30.0	8	26.7	0.56*	0.97
2–3 glasses a day	16	53.3	18	60.0	18	60.0
More than 3 glasses a day	4	13.3	3	10.0	4	13.3
Amount of regular walking per day
No activity	5	16.7	3	10.0	4	13.3	9.60**	0.13
Half-hour	13	43.3	10	33.3	9	30.0
One hour	12	40.0	11	36.7	16	53.4
More than an hour	0	0.0	6	20.0	1	3.3
Family income
Less than adequate	3	10.0	5	16.7	5	16.7	0.79**	0.81
Adequate	27	90.0	25	83.3	25	83.3
History of constipation
No	25	83.3	28	93.3	30	100.0	5.47**	0.07
Yes	5	16.7	2	6.7	0	0.0
History of constipation in previous pregnancies
No	17	56.7	17	56.7	17	56.7	0.00**	1.00
Yes	13	43.3	13	43.3	13	43.3

*: Chi−squared test

**: Fisher’s exact test

Table 2.

Evaluation of the normality of the distribution of research variables

Variable	Acupressure		Reflexology		Control
	Z-score	P value	Z-score	P value	Z-score	P value
Mother’s age	1.04	0.23	1.10	0.18	0.62	0.84
Gestational age	1.00	0.27	0.78	0.57	0.71	0.70
BMI before pregnancy	0.53	0.94	0.68	0.75	0.83	0.49
Weight gain	1.74	0.005	2.50	< 0.001	2.13	< 0.001
Gravida	1.29	0.07	1.50	0.02	1.89	0.002
Fluid consumption per day	1.08	0.20	1.13	0.16	1.86	0.002
Average number of hours of sleep per day and night	1.06	0.21	1.28	0.08	1.18	0.13
Severity of constipation
Before the intervention	0.99	0.28	1.07	0.20	1.06	0.21
First week after the intervention	0.97	0.30	0.95	0.33	0.80	0.55
Second week after the intervention	0.88	0.42	1.02	0.25	0.78	0.57
Third week after the intervention	0.81	0.53	0.65	0.79	0.72	0.67
Fourth week after the intervention	0.86	0.45	0.61	0.85	0.79	0.56

Table 3.

Comparison of demographic characteristics in pregnant women of the three studied groups

Variable	Acupressure	Reflexology	Control	Test statistic	P value	Post-hoc test’s result
	Mean ± SD	Mean ± SD	Mean ± SD
Mother’s age	28.47 ± 5.00	26.83 ± 4.65	27.43 ± 4.15	0.96*	0.39	–
Gestational age	6.48 ± 20.37	5.37 ± 20.03	6.08 ± 23.77	3.56*	0.03	A–C: P = 0.08 R–C: P = 0.05
BMI before pregnancy	3.13 ± 24.53	3.03 ± 27.49	3.02 ± 29.79	7.63*	0.001	A–R: P = 0.001 A–C: P = 0.02
Weight gain	0.63 ± 2.13	0.45 ± 2.27	0.50 ± 2.40	3.07**	0.22	–
Gravida	0.80 ± 1.90	0.70 ± 1.70	0.59 ± 1.83	1.21**	0.55	–
Fluid consumption per day(glass)	1.25 ± 5.03	1.10 ± 4.20	1.12 ± 5.17	11.49**	0.003	A–R: P = 0.01 R–C: P = 0.001
Average number of hours of sleep per day and night	0.98 ± 7.07	0.87 ± 7.00	0.96 ± 7.63	4.11*	0.02	R–C: P = 0.03

*: One−way ANOVA

**: Kruskal–Wallis test

Table 1 shows that the frequency distribution of the variables education level, occupation, iron consumption, dairy consumption, regular walk per day, family income, history of constipation and history of constipation in previous pregnancies showed no significant differences (P > 0.05).

According to Table 2, the significance level for the variables weight gain, gravida and fluid consumption was < 0.05 in at least one of the three groups studied. This leads to the conclusion that the variables mentioned do not have a normal distribution, but the other study variables do have a normal distribution.

Table 3 shows that the variables age, weight gain and gravida did not differ significantly in the three groups studied (P > 0.05), but the variables gestational age, BMI, fluid consumption per day and number of hours of sleep per day and night showed a significant difference (P < 0.05). More specifically, the average gestational age and the average number of hours of sleep per day and night were significantly higher in the control group than in the reflexology group (P < 0.05). The average BMI in the acupressure group compared to the other two groups studied (P < 0.01) and the average fluid consumption per day were significantly lower in the reflexology group than in the other two groups studied (P < 0.01) (Fig. 1).

Fig. 1.

Process study of design

According to Table 4 and Fig. 2, there was no significant difference in the average severity of constipation before the intervention and in the first and second weeks after the intervention in the three groups studied (P > 0.05). However, a significant difference was observed in the third and fourth weeks after the intervention (P < 0.001). More specifically, the average severity of constipation was significantly lower in the acupressure and reflexology groups than in the control group at the third and fourth weeks after the intervention (P < 0.001).

Table 4.

Comparison of the average severity of constipation before the intervention, and in the first, second, third, and fourth weeks after the intervention

Stage	Acupressure	Reflexology	Control	P value of ANOVA	Tukey’s post-hoc test’s result
	Mean ± SD	Mean ± SD	Mean ± SD
Before the intervention (t0)	2.04 ± 12.10	2.08 ± 11.07	2.12 ± 11.73	0.16	NS
First week after the intervention (t1)	2.12 ± 11.77	2.46 ± 10.67	2.26 ± 11.45	0.16	NS
Second week after the intervention (t2)	2.03 ± 10.03	2.68 ± 10.05	2.32 ± 11.28	0.07	NS
Third week after the intervention (t3)	2.33 ± 7.38	2.52 ± 8.82	2.43 ± 11.08	< 0.001	A–C: P < 0.001 R–C: P = 0.001
Fourth week after the intervention (t4)	2.01 ± 3.62	2.13 ± 4.12	2.28 ± 11.83	< 0.001	A–C: P < 0.001 R–C: P < 0.001
P value of repeated measures test	< 0.001	< 0.001	0.002	–	–
Benferoni post-hoc test’s result	t0–t1: P = 0.02 t0–t2: P < 0.001 t0–t3: P < 0.001 t0–t4: P < 0.001 t1–t2: P < 0.001 t1–t3: P < 0.001 t1–t4: P < 0.001 t2–t3: P < 0.001 t2–t4: P < 0.001 t3–t4: P < 0.001	t0–t1: P = 0.03 t0–t2: P < 0.001 t0–t3: P < 0.001 t0–t4: P < 0.001 t1–t2: P = 0.02 t1–t3: P < 0.001 t1–t4: P < 0.001 t2–t3: P < 0.001 t2–t4: P < 0.001 t3–t4: P < 0.001	t0–t1: P = 0.03 t0–t2: P = 0.03 t0–t1: P = 0.01 t2–t4: P = 0.01 t3–t4: P = 0.003	–	–

Fig. 2.

Comparison of the average severity of constipation before the intervention, and in the first, second, third, and fourth weeks after the intervention

According to Table 4 and Fig. 2, there was no significant difference in the average severity of constipation before the intervention, and in the first and second weeks after the intervention in the three studied groups (P > 0.05); however, a significant difference was observed at the third and fourth weeks after the intervention (P < 0.001). More specifically, the average severity of constipation in the third and fourth weeks after the intervention was significantly lower in the acupressure and reflexology groups than in the control group (P < 0.001).

As shown in Table 4, the mean severity of constipation during pregnancy was significantly different in all three groups studied at different timepoints (P < 0.05). More specifically, the average severity of constipation in the two groups with acupressure and reflexology decreased significantly over time after the start of the study (P < 0.05). In other words, the average severity of constipation in the first week after the intervention compared to before the intervention, in the second week compared to the first week and before the intervention, in the third week compared to the first and second weeks and before the intervention, and in the fourth week compared to the first week and before the intervention.

In the control group, the average severity of constipation significantly decreased in the first, second and third weeks after the intervention compared to before the intervention (P < 0.05); however, the average severity of constipation decreased in the fourth week after the intervention (P < 0.01).

According to Table 5, there was no significant difference between the average changes in the severity of constipation of the three groups studied before and in the first week after the intervention (P = 0.86); however, the average changes in the severity of constipation before the intervention, and in the first, second, third and fourth weeks after the intervention in the acupressure group compared to the reflexology and control groups (except for the average changes in the second and third weeks with the fourth week in the acupressure and reflexology groups) was significantly higher (P < 0.05). In other words, the severity of constipation has decreased more in the acupressure group compared to the two reflexology and control groups. In addition, the results showed that the average changes in the severity of constipation in the reflexology group were significantly higher than the control group before the intervention, and in the first, second, third and fourth weeks after the intervention (except for before the intervention and the first week with the second week after the intervention) (P < 0.05).

Table 5.

Comparison of the average changes in severity of constipation before the intervention, and in the first, second, third, and fourth weeks after the intervention

Changes	Acupressure	Reflexology	Control	P value of ANOVA	Tukey’s post-hoc test’s result
	Mean ± SD	Mean ± SD	Mean ± SD
Before the intervention, and the first week after the intervention	− 0.33 ± 0.76	− 0.40 ± 0.98	− 0.28 ± 0.69	0.86	NS
Before the intervention, and the second week after the intervention	− 2.07 ± 1.66	− 1.02 ± 1.57	− 0.45 ± 1.08	< 0.001	A–R: P = 0.02 A–C: P < 0.001
Before the intervention, and the third week after the intervention	− 4.72 ± 2.09	− 2.25 ± 2.15	− 0.65 ± 1.34	< 0.001	A–R: P < 0.001 A–C: P < 0.001 R–C: P = 0.004
Before the intervention, and the fourth week after the intervention	− 8.48 ± 2.36	− 6.95 ± 2.36	1.36 ± 0.10	< 0.001	A–R: P = 0.02 A–C: P < 0.001 R–C: P < 0.001
The first and second weeks after the intervention	− 1.73 ± 1.79	− 0.62 ± 1.41	− 0.17 ± 0.96	< 0.001	A–R: P = 0.009 A–C: P < 0.001
The first and third weeks after the intervention	− 4.38 ± 2.28	− 1.85 ± 2.30	− 0.37 ± 1.22	< 0.001	A–R: P < 0.001 A–C: P < 0.001 R–C: P = 0. 01
The first and fourth weeks after the intervention	− 8.15 ± 2.31	− 6.55 ± 2.85	1.21 ± 0.38	< 0.001	A–R: P = 0.02 A–C: P < 0.001 R–C: P < 0.001
The second and third weeks after the intervention	− 2.65 ± 1.42	− 1.23 ± 1.71	− 0.20 ± 0.78	< 0.001	A–R: P < 0.001 A–C: P < 0.001 R–C: P = 0.01
The second and fourth weeks after the intervention	− 6.42 ± 1.79	− 5.93 ± 2.97	1.12 ± 0.55	< 0.001	A–C: P < 0.001 R–C: P < 0.001
The third and fourth weeks after the intervention	− 3.77 ± 1.65	− 4.70 ± 2.49	1.25 ± 0.75	< 0.001	A–C: P < 0.001 R–C: P < 0.001

Since some demographic variables (gestational age, BMI, fluid consumption per day and the average number of hours of sleep per day and night) were not homogeneous in the two groups, we performed a final comparison according to Table 6, taking into account their effects as well as the effect of time. Controlling for the above variables, the severity of constipation was reduced by 3.52 units in the acupressure group compared to the control group and by 3.32 units in the reflexology group compared to the control group. The results also showed that the severity of constipation decreased significantly over time (P < 0.001).

Table 6.

Effect of acupressure and reflexology on pregnancy constipation after controlling the variables of gestational age, BMI, fluid consumption per day, and average number of hours of sleep per day and night by linear marginal model

	Variable	Parameter	Standard error	Test statistic	P value
Intervention group (baseline: control group)	Acupressure	− 3.52	0.56	39.39	< 0.001
	Reflexology	− 3.32	0.56	34.77	< 0.001
Time		− 1.57	0.14	111.6	< 0.001
BMI		− 0.01	0.06	0.05	0.82
Gestational age		− 0.05	0.04	1.71	0.19
Fluid consumption per day		− 0.03	0.19	0.02	0.89
Average number of hours of sleep per day and night		− 0.20	0.21	0.94	0.33

According to Table 7, the odds of experiencing more severe constipation in the acupressure and reflexology groups were 94% and 92% lower, respectively, than those in the control group (OR = 0.06 and 0.08).

Table 7.

Severity of pregnancy constipation after controlling the variables of gestational age, BMI, fluid consumption per day, and average number of hours of sleep per day and night by ordinal logistic marginal model

	Variable	Coefficient	Standard error	P value	Odds ratio (OR)	Confidence interval (CI)
Intervention group (baseline: control group)	Acupressure	− 2.82	0.72	< 0.001	0.06	0.01	0.24
	Reflexology	− 2.50	0.71	< 0.001	0.08	0.02	0.33
Time		− 1.38	0.19	< 0.001	0.25	0.17	0.37
BMI		0.01	0.06	0.80	1.01	0.91	1.14
Gestational age		0.00	0.03	0.96	1.00	0.94	1.06
Fluid consumption per day		0.02	0.14	0.91	1.02	0.77	1.34
Average number of hours of sleep per day and night		-0.14	0.20	0.49	0.87	0.59	1.29

Severity of pregnancy constipation: scores less than 8: mild, scores between 9 and 16: moderate, scores between 17 and 24 [20]: severe, and scores above 25: very severe

Discussion

The results of the present study showed that in both the acupressure and reflexology groups, the average severity of constipation decreased significantly over time after the start of the intervention. In the control group, the average severity of constipation decreased significantly in the first, second and third weeks after the intervention compared to before the intervention, but increased significantly in the fourth week. The average reduction in the severity of constipation over the course of the study was significantly higher in the pregnant women in the acupressure group than in the reflexology and control groups, and higher in the reflexology group than in the control group. Traditional Chinese Medicine (TCM) is a collection of practices that have been used for hundreds of years in China and other parts of the world to prevent and treat disease [21]. TCM has been used in numerous studies to treat many conditions, including constipation, anxiety, nausea, depression, insomnia, cancer and even strokes. Acupressure and reflexology are considered non-pharmacological methods for the treatment of constipation [21–26]. Although researchers do not yet understand the exact mechanism of acupressure and reflexology, their acceptance is growing, because they are inexpensive and do not require specialized equipment [10, 11].

By applying acupressure to specific points of the digestive tract, gastrointestinal motility and digestive juices can be increased. It is also used to relieve and prevent constipation as it stimulates the sacral nerve, which regulates bowel movements [13].

In line with the results of the present study on the effect of acupressure on pregnancy constipation, the results of Abd-El Rahman et al. [14] in women with pregnancy constipation in the period of 2–6 weeks after natural labour showed that both the acupressure and control groups had a significant improvement in the severity of constipation. However, this improvement was significantly greater in the acupressure group. Finally, this study mentions that acupressure combined with walking and general care of the digestive system leads to a reduction in the severity of constipation in the postpartum period [14]. The results of the study by Kirca et al. [27] also showed that after the application of acupressure, the severity of constipation was significantly reduced in the intervention group compared to the control group. In this context, Abbasi et al. [28] investigated the effect of acupressure on constipation in patients with chronic kidney disease undergoing haemodialysis and showed that acupressure had a significant positive effect on the number of defecations and improvement in stool quality. Ghiyasvandian et al. [29] investigated the effect of acupressure on defecation in patients undergoing skeletal traction and concluded that after the intervention there was a statistically significant difference in the average state of defecation between the two control and acupressure groups and that defecation was relatively easy for most people in the intervention group.

Reflexology also activates the nervous system by applying pressure to the reflex point, activating electrochemical nerve impulses and the peripheral nervous system, and sending a message to the central nervous system, which is then transmitted to specific organs or glands, resulting in an appropriate response according to the message sent. Reflexology contributes to the balance of all body systems by stimulating inactive areas or calming overactive areas [7].

In line with the results of the present study on the effects of foot reflexology on constipation in pregnancy, the results of the study by Anjoman et al. [30] on the effect of foot reflexology on constipation in pregnancy showed that 97% of women reported improvement at the end of the 6-week intervention and 67% of women were satisfied with foot reflexology for improving symptoms of constipation. The results of the study by Ghaffari et al. [19] on the effect of foot reflexology on the severity of constipation in pregnancy showed that there was a significant difference in the average severity of constipation in the intervention group before and after the intervention, while no significant difference was found in the control group. In the study by Esmaeil Pour et al. [31], which investigated the effect of foot reflexology on the severity of constipation in older women, the difference in the average severity of constipation was statistically significant in both the intervention and control groups at the end of the first to sixth weeks. The effect of the intervention, therefore, already started in the first week after the intervention. Woodward et al. [32] investigated the effect of reflexology on idiopathic constipation in 19 women whose constipation was confirmed by the Rome II criteria in a prospective single-group study and showed that constipation partially improved in 94% of participants following a reflexology intervention (weekly for 6 weeks, each session 35–45 min). The patients' need to use laxatives was also reduced. Finally, the results showed that reflexology can increase peristaltic waves, leading to the treatment of constipation, improvement of quality of life and reduction of stress and depression in women [32].

Although in the above studies the study population, the assessment tool and the duration of the intervention are different, the results obtained are consistent with the results of the present study, which present the positive effects of acupressure and reflexology on reducing the severity of constipation.

Various studies have demonstrated the effectiveness of foot reflexology and acupressure in the treatment of constipation. However, to our knowledge, there is no study comparing the effects of these two methods on the severity of constipation in pregnancy. However, Aydinfard et al. (2016) compared the effectiveness of foot reflexology and abdominal massage on the severity of constipation in patients hospitalized in the orthopedic department and showed that there was a statistically significant difference between the intervention groups and the control group in terms of the average severity of constipation from day 3 to day 6. In addition, the effect of foot reflexology was stronger than the effect of abdominal massage [33]. The results of this study are somewhat consistent with the results of the present study, which show the positive effect of both interventions on reducing the severity of constipation. However, in the study by Aydinfard et al. (2016), the effect of foot reflexology was greater than that of abdominal massage in reducing the severity of constipation, but in the present study, acupressure had a greater effect than reflexology.

This difference is probably due to the fact that in the study by Aydinfard et al. (2016) the massage was applied to the abdominal area, whereas in the present study the massage was applied to two Li 11 (Qu Chi) points on both hands and two ST36 (Zu San Li) points on both feet.

According to the studies mentioned, acupressure and reflexology, therefore, led to an improvement in constipation.

There is also no consensus that these two methods are superior to each other, and the best method for them is selected based on the individual characteristics of the patients. However, according to the results of the present study, which showed that constipation improved more in the acupressure group than in the reflexology group, this difference is probably due to their mechanism of action. Acupressure regulates the body’s energy channels and can have a more general, simultaneous effect with its action, while reflexology focuses on stimulating specific points in different parts of the body that affect a specific organ, and the accuracy in selecting the point and the accuracy in performing the technique requires more precision in this method.

The comparative investigation of the effects of acupressure and reflexology on the severity of constipation in pregnant women, which has not been done in other studies, is one of the strengths of this study. In addition, the interventions in this study are designed to be self-administered, so that the implementation of these interventions to reduce constipation will not involve excessive costs for the patients. The limitations of the present study include the seasonal restriction of patients' diet, the reduction of visits of pregnant mothers to the health centers due to the COVID-19 pandemic and the implementation of this study in a single city. It was also noted that the study was single-blinded, that people could not be randomized, that the questionnaires were based on self-report and that the follow-up period was short. The need for studies with longer follow-up periods is suggested. The cultural and social context may limit generalizability. Therefore, a more detailed and comprehensive study is recommended.

Conclusion

In conclusion, both acupressure and reflexology as non-pharmacological measures of TCM, which are simple, easy, cheap and non-invasive methods, were effective in reducing constipation in pregnancy in the present study. Moreover, the effect of acupressure was greater than that of foot reflexology. Therefore, these measures are recommended to reduce the severity of pregnancy constipation considering the conditions and status of the patients.

Author contributions

Conceptualization: [FJB, MT]; methodology: [FJB, MT, HBT]; formal analysis and investigation: [FJB,FS, MT]; writing—original draft preparation: [FJB, MT]; writing—review and editing: [FJB, FS, HH, HBT, MT]; Supervision: [MT].

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by Birjand University of Medical Science’s Research Ethics Committee (Approval ID: IR.BUMS.REC.1399.504). All participants were informed of the purposes and procedures of the study and verbal and written consent were obtained. All methods were carried out in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.