Effects of Yoga Nidra on mental wellness during the immediate postpartum period

ABSTRACT

Introduction:

Depression affects women more than men, particularly during pregnancy and the postpartum period. While many women are hesitant to use pharmacotherapy due to concerns about side effects and financial constraints, it becomes imperative to explore alternative therapies like Yoga Nidra, known for reducing stress and anxiety. This study aims to evaluate the impact of Yoga Nidra on mental health during the postpartum period.

Objectives and Methods:

The objective was to assess the psychological state of postpartum women and the effect of Yoga Nidra on the same. This quasi-experimental study was conducted in a rural-based tertiary care center in central Gujarat. A total of 100 participants, 50 postpartum women in the control group and 50 in the intervention group, were enrolled in the study. The Generalized Anxiety Disorder-7 (GAD-7) and Edinburgh Postnatal Depression Scale (EPDS) questionnaires were administered to the participants at the beginning of the study. The intervention group received eight sessions of Yoga Nidra, each lasting 30 min. At discharge, both groups were administered EPDS again. The data was analyzed using STATA 14 software (STATA 14 Software (StataCorp LLC)).

Results and Conclusion:

Mean baseline EPDS scores were 12.62 ± 4.6 and 13.76 ± 6.2 in the intervention and control groups, respectively. On average, there was 5.48 units (reduction) improvement in EPDS scores in the intervention group (P < 0.0001) and a 1.5-unit worsening (increase) in the control group (P < 0.0001) at the end of the study. The difference was significant between the groups (+6.98 units, P < 0.0001), thereby concluding that Yoga Nidra is a promising non-pharmacological therapy that can be used to manage immediate postpartum anxiety and depressive symptoms.

Introduction

Globally, it has been estimated that 5% of adults suffer from depression, with women being affected more than men.[1] Pregnancy is a period of transition, with immense physiological and psychological stress, in a woman’s life. They are vulnerable to anxiety and depression during the childbearing age and in the immediate postpartum period.[2] Perinatal depression is typically defined as a non-psychotic depressive episode of mild to major severity that occurs during pregnancy or the postnatal period.[3] The prevalence of postpartum depression (PPD) in the United States, the United Kingdom, and Australia ranges from 7% to 20%. In resource-constrained countries, it is around 25% and may be as high as 60%.[4,5,6] A meta-analysis conducted in 2017 showed that the prevalence of postpartum depression among Indian mothers is 22%, and the factors affecting it are financial burden, domestic violence, marital conflicts, and a lack of social support.[7] It is one of the most common complications of pregnancy and has a significant impact on maternal and neonatal/infant mortality and morbidity.[8,9] Early recognition and effective intervention in the immediate postpartum period have a beneficial effect on treating or preventing postpartum depression.[3]

Patients often express reluctance to start and/or adhere to pharmacotherapy; instead, they prefer to seek alternative therapies and treatment options, often due to the fear of adverse effects of medication on the fetus and newborn baby and financial constraints.[10,11] Complementary and alternative medicine can help manage a variety of disorders. Yoga Nidra is one of the non-pharmacological therapeutic modalities that is being increasingly recognized as an intervention for deep relaxation, which helps attain complete relaxation of the body physically, mentally, and emotionally.[12] It is practiced by lying down in a supine position (Shavasana) and following the instructions given by the instructor (live or recorded). The practice includes awareness of the body, awareness of breathing, and visualization. Randomized controlled trials evaluating the effects of Yoga Nidra on patients with menstrual disorders and cervical cancer have reported significant improvement in anxiety and depressive symptoms.[12,13]

Several non-pharmacological interventions, like yoga and yogic relaxation, have been tested for reducing stress, anxiety, and depression symptoms in patients with different conditions and have been proven to significantly improve symptoms. However, the effects of those interventions on perinatal mental health and postpartum depression have been unexplored. The objective of the study is to assess the baseline anxiety and depression symptoms in postpartum women and evaluate the impact of Yoga Nidra on the postpartum mental health of women during their postpartum hospital stay.

Methods

This quasi-experimental study was conducted in the postpartum ward of a rural-based tertiary care medical center in central Gujarat over a period of 7 months.

All the postpartum females admitted to the postpartum ward, irrespective of their type of delivery, were approached for the study, and those who gave consent were included in the study. Complicated delivery cases like mothers with eclampsia, pre-existing mental illness, or postpartum hemorrhage were excluded from the study. Two questionnaires were used in the study, a previously validated Gujarati version of the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder 7 (GAD 7), for assessment of postpartum depression symptoms and anxiety, respectively.[14,15,16] The Gujarati version of GAD-7, openly available on the web, was administered to the patients.[17]

The sample size was calculated based on pilot data collected from a past study conducted in the same department.[16] Assuming the standard deviation (SD) of the EPDS score for the control group as 6 units and that for the intervention group as 4 units, considering the clinically important difference in the mean EPDS score to be 3 units, a type I error of 0.05, and the power of the study as 80%, the calculated sample size was 46 participants per group. The calculation was done using the WINPEPI software. The study sample consisted of 100 participants (50 in the intervention group and 50 in the control group), who were enrolled after their delivery at Shree Krishna Hospital. Mothers who delivered during the first week of the month were selected for the intervention group. Further, the control group participants were enrolled after a week’s gap: mothers who delivered in the third week of the month to avoid any contamination of the intervention group in the control group.

All the participating mothers in the intervention group and the control group were administered the GAD-7 and EPDS questionnaires. Assistance was provided to the participants if they had difficulty understanding the questions and the options in the EPDS or GAD-7. A Yoga Nidra session was then administered to the intervention group, one in the morning and one in the evening, by providing them with an audio script recorded by one of the investigators for four consecutive days. The session lasted for 30 min. A total of eight Yoga Nidra sessions were conducted for the participants in the intervention group. No intervention was conducted for the control group. At the time of discharge, all the participants (both the control group and intervention group) were again requested to answer the EPDS questionnaire. The steps for the Yoga Nidra intervention are mentioned in Table 1.[18]

Table 1.

Step for conducting a Yoga Nidra session

Step	Description
1	Preparation: All the participants were asked to lie down in a comfortable position: Shavasana, flat with palms facing upwards along the body, preventing contact with the other parts of the body. They had to close their eyes but were instructed to remain awake.
2	Yoga Nidra was started with the chanting of OM three times.
3	Sankalpa (resolve): The participants were asked to mentally affirm to themselves a personal resolution, known as “Sankalpa.” For example, for postpartum women – her child was growing well, she was having a good recovery from delivery, she was having a good flow of milk, etc.,
4	Rotation of consciousness: The participants were asked to contract and relax each muscle of the body in a systematic manner, by which the whole body would be relaxed, and, as a result, the mind would be automatically relaxed.
5	Breath awareness: The participants were asked to breathe consciously for 25 repetitions, visualizing the flow of breath in and out of the nostrils, through the throat and chest, and the abdomen and navel.
6	Participants were asked to experience the opposite types of feelings, like extreme heat, extreme cold; happiness and sadness; love and hatred, etc.,
7	Visualization: Participants were taken on a trip through imagination, a location, like a garden with flowers, different smells, an ocean, the flight of our body over the earth, flowing along with the water of a river, a visit to a temple, the ringing of holy bells, etc., and took a mental ride of those places, spending some time in the pleasing imagination.
8	Sankalpa (resolve): As the participants became increasingly aware of themselves, their body, and their surroundings, they were asked to repeat step 3 and remember their resolution, but this time with unwavering commitment, belief, and an optimistic mindset.
9	They were instructed to slowly open their eyes and breathe normally. Recite OM and get up after some time.

At the end of the study, the average change in the EPDS score of the intervention group compared to the control group was assessed using an independent sample ‘t’ test on the score difference of the post and pre-EPDS score for individuals. EPDS score of more than 10 was considered the cutoff for depressive symptoms.[14] The data were entered in Microsoft Excel and analyzed using STATA 14 statistical software (STATA 14 Software (StataCorp LLC)).

Results

Baseline characteristics of the intervention and control groups are shown in Table 2 (n = 50 each in the control and intervention groups). Baseline EPDS and GAD-7 scale scores and post-intervention EPDS scores across the intervention and control groups are shown in Table 3.

Table 2.

Baseline characteristics of participants

	Intervention (A) (n=50)	Control (B) (n=50)	P
Age distribution of the mothers
≤20 years	7	5	0.80
21-30 years	35	38
31-40 years	7	7
>40 years	1	0
Parity-wise distribution
1	20	17	0.31
2	24	21
>2	6	12
Type of delivery
Normal vaginal	21	23	0.84
LSCS	29	27
Sex of the child in present delivery
Female	30	25	0.42
Male	20	25
GAD-7 at baseline
No anxiety	20	29	0.11
Anxiety	30	21

GAD-7=Generalized Anxiety Disorder 7

Table 3.

Edinburgh Postnatal Depression Scale (EPDS) Assessment

	Intervention group	Control group (no intervention administered)	P
Pre-intervention EPDS score (mean (SD))	12.62 (4.61)	13.76 (6.22)	0.30
Post-intervention EPDS score (mean (SD))	7.17 (2.75)	15.26 (5.47)	<0.0001
P	<0.0001	<0.0001	-
Mean difference EPDS (SD)	-5.48 (2.44)	1.5 (2.06)	<0.0001
Median difference EPDS (IQR)	-6.0 (3.25)	1.0 (3.00)
Minimum/maximum difference EPDS	-10/0	-2/+8.0
GAD-7 score	9.06 (4.63)	7.12 (3.53)	0.021

GAD-7=Generalized Anxiety Disorder 7, EPDS=Edinburgh postnatal depression scale

Baseline assessments showed that anxiety symptoms were present in 60% and 42% of participants in the intervention and control groups, respectively. Baseline EPDS scores were 12.62 ± 4.6 and 13.76 ± 6.2 (P = 0.30) in the intervention and control groups, respectively.

At baseline assessment, in the intervention group, 35 participants had an EPDS score of ≥10, and eight participants had answered question number 10 positively (Did you think of harming yourself at any time?), while post-intervention, only 10 participants had EPDS scores ≥10, and none had answered question number 10 positively. At baseline assessment, in the control group, 37 participants had an EPDS score ≥10 during, and 43 had ≥10 during the post-intervention phase assessment (the control group was not given any intervention). One participant had answered question number 10 positively, and the answer remained the same during the post-intervention assessment. The participant was offered psychiatric help but refused due to personal reasons.

While observing the baseline vs. post-intervention difference in both groups by paired T tests, there was a +5.48 unit improvement (reduction) in EPDS in the intervention group and a −1.5 unit worsening (increase) in the control group. The difference was significant between the groups (+6.98 units, P < 0.0001). This indicates that the intervention (Yoga Nidra) effectively reduced the depressive symptoms in participants in the intervention group during the immediate postpartum period.

Discussion

The use of complementary alternative medicine techniques is being increasingly explored and accepted by people all over the world, especially for palliative care, pain management, and improving mental health. In this pilot study, we proposed to evaluate the effectiveness of a deep relaxation method, Yoga Nidra, on the mental health of postpartum women admitted to the hospital during the immediate postpartum period. The study showed a significant reduction in depressive symptoms among the participants who practiced Yoga Nidra when compared to those in the control group who did not [Table 3].

Most of those studies explore the use of techniques like yoga and meditation, and very few studies have focused on Yoga Nidra. When it comes to women’s health and maternal health, several studies have tried to evaluate the impact of yoga and/or Yoga Nidra. Two randomized controlled trials evaluating the impact of Yoga Nidra on general well-being, anxiety, and depression in patients with menstrual irregularities showed a significant reduction in anxiety and depression in the intervention group.[19,20] A longitudinal study conducted in 2021 among post-menopausal participants reported that Yoga Nidra is an effective non-pharmacological technique for improving general well-being.[21] Studies have also shown the positive impact of yoga (not Yoga Nidra) on the management of stress, anxiety, and depression symptoms during the postpartum period.[22,23] These studies very well show the positive impact of yoga and/or Yoga Nidra on mental health, but this is one of the first pilot studies to report its use for the management of postpartum depression.

Yoga Nidra, being a subset of yoga, has various other reported benefits that could be of clinical importance in the perinatal period. It has been observed that mothers of premature infants or those who are not able to produce enough breast milk are more prone to stress and anxiety in the postpartum period. Evidence suggests that yoga and deep relaxation as complementary therapies can help increase prolactin and oxytocin levels in the postpartum period and increase breast milk production.[24,25] The use of Yoga Nidra has been found to be effective in managing stress-related conditions like hypertension.[26] A study conducted in 2009 evaluating the use of Yoga Nidra on diabetes control reported that over a three-month period, participants in the intervention group (oral hypoglycemics with Yoga Nidra) significantly improved blood glucose control and associated symptoms of diabetes when compared to the control group.[27] This could help care providers manage patients in resource-limited settings with a high prevalence of pregnancy-induced hypertension. As this technique of yogic sleep induces deep relaxation, it could also be used to help patients improve their sleep during the stressful postpartum period. The potential explanation for the beneficial effects of yoga and yogic relaxation techniques includes, but is not limited to, increased vagal activity (greater sympathetic control) and changes in brain wave activity (increase in alpha, beta, and theta waves and reduction in delta waves), which lead to improved memory and concentration.[28]

Management of perinatal mood disorders including postpartum depression often falls within the continuum of primary care, where incorporating the use of complementary alternative medicine techniques can be recommended to patients when they are reluctant to accept pharmacotherapy or due to financial constraints. The practice has been shown to be effective in mild to moderate symptoms of stress, anxiety, and depression, but could also be used for patients with severe symptoms as an add-on therapy [Table 3]. It can also be potentially used to manage chronic diseases as an add-on therapy. Although this study involved a hospital-based intervention, the practice of Yoga Nidra, like yoga, can be done independently at home just by following pre-recorded instructions that are freely available on the internet, making it highly accessible. This could also be used in regions where patients are from lower sociodemographic sections, as most of the resources regarding Yoga Nidra are free to access. Even though our current study shows promising results, it has certain limitations. The study was conducted within a short period of time and participants received only eight Yoga Nidra sessions. There was no follow-up post-discharge. To evaluate the long-term benefits, robust randomized controlled trials with long-term follow-up are needed. Due to discrepancies in the electronic health records, not all participants had socio-demographic data recorded and hence could not be used to test for relevant associations.

Conclusion

The high incidence of postpartum depressive and anxiety symptoms in our study population accentuates the need for accessible and affordable interventions that can be integrated into routine postpartum care. Yoga Nidra presents a promising non-pharmacological approach to the management of depression symptoms during the immediate postpartum period. Primary care physicians can not only help with screening and early detection of postpartum depression but also administer this intervention and monitor its response. Integration of Yoga Nidra into perinatal care may be a valuable intervention, especially for mothers who may be reluctant to receive pharmacological treatments due to concerns about adverse drug reactions.

Ethical clearance

The study was approved by the Institutional Ethics Committee H M Patel Center for Medical Care and Education, approval letter number IEC/HMPCMCE/69/FACULTY/245/16. A written consent was taken from all the participants before enrollment into the study.

IRB approval

The study was approved by the Institutional Ethics Committee H M Patel Center for Medical Care and Education, approval letter number IEC/HMPCMCE/69/FACULTY/245/16.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.