A true experimental study to assess the effectiveness of holistic self-care approach on clinical parameters, psychological stress, wellbeing, among antenatal mothers with pregnancy-induced hypertension admitted in antenatal ward at SRM Medical College Hospital and Research Centre

Abstract

BACKGROUND:

Pregnancy-related hypertension diseases are a global concern. Pregnancy-induced hypertensive problems affect 5–8% of pregnant women worldwide. Maternal and neonatal morbidity and mortality are primarily caused by pre-eclampsia and eclampsia. Five to seven percent of pregnancies end in pre-eclampsia, which manifests as proteinuria and hypertension.

MATERIALS AND METHODS:

A study with a pretest–posttest control group design was conducted among 80 antenatal mothers (40 control and 40 experimental) with pregnancy-induced hypertension (PIH) at SRM Medical College Hospital and Research Centre. The intervention included education on dietary changes, walking, leg and foot exercises, awareness of PIH warning signs, and Mitchell’s relaxation techniques, administered for 7 consecutive days. Clinical parameters, stress (Perceived Stress Scale), and wellbeing (WEMWBS) were measured before and after the intervention.

RESULTS:

In the experimental group, stress scores slightly decreased (39.80 to 39.30; P = 0.096) and wellbeing modestly improved (44.53 to 45.33; P = 0.104). Significant reductions were noted in clinical parameters post intervention. Systolic BP dropped from 126.85 to 117.13 mmHg, and diastolic BP from 81.90 to 73.25 mmHg (P = 0.000). The pulse rate decreased from 90.28 to 75.80 bpm, and the respiratory rate from 21.49 to 19.05 (P = 0.000). This suggests the holistic self-care approach effectively improved clinical outcomes in PIH mothers.

CONCLUSION:

A holistic self-care approach significantly improved clinical parameters and psychological wellbeing in antenatal mothers with PIH, with reduced vital signs and stress levels in the intervention group.

Introduction

Pregnancy is a really enjoyable experience for women. Women are excited when they learn they are pregnant and plan for their future child with care and delight. Although pregnancy is a natural process, it does not come without complications. However, pregnancy-induced hypertension (PIH) is the most common health problem that can make this historic occasion challenging.[1]

Pregnancy hypertension is characterized by a blood pressure of 140/90 mmHg or above, recorded on two occasions with a minimum interval of 6 hours. Elevated systolic and diastolic blood pressures are key indicators of PIH. PIH arises after 20 weeks of gestation in individuals who had normal blood pressure. PIH occurs in approximately 5–8% of all pregnancies. Although the cause of PIH is unknown, certain risk factors are known to increase the risk. These include young women with their first pregnancy, pregnant women younger than 20 years and older than 40 years, pregnant women with multiple fetuses, pregnant women with diabetes, pregnant women with preexisting hypertension or preeclampsia or PIH, and pregnant women with preexisting renal disease.[2]

PIH is the greatest cause of maternal and fetal complications, resulting in morbidity and mortality. The World Health Organization reports that one woman dies every 7 minutes due to pregnancy-related hypertension problems. Fetal effects include intrauterine growth restriction, premature delivery, fetal suffering, and death. A cohort study found that preterm babies born to PIH women had greater neonatal and infant death rates compared to normotensive women. Mother may experience seizures, stroke, and hepatic and renal failure.[3]

In 2015, 99% of deaths occurred in undeveloped regions. During pregnancy, there are four types of hypertensive disorders: chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and preeclampsia with chronic hypertension. There are two phases to the pathophysiologic processes that underlie this sickness. The initial phase is characterized by decreased placental perfusion, most likely caused by aberrant placentation with reduced trophoblast invasion and inadequate uterine spiral artery remodeling. The maternal systemic symptoms, which include thrombotic, metabolic, and inflammatory reactions that alter vascular function and may endanger several organs, constitute the second stage.[4]

Preeclampsia is the greatest cause of maternal and newborn death and morbidity worldwide, with the majority of cases occurring in underdeveloped nations. The disease is typically identified in late pregnancy by the presence of elevated blood pressure, proteinuria, and/or edema. Preventing any disease process requires understanding its prevalence, etiology, and pathophysiology.[5]

Although early medication is very beneficial in managing hypertension crises and newborn problems, it does not always affect disease progression. Stressors that women face throughout their lives, particularly during pregnancy, can have an impact on their physical, spiritual, and emotional wellbeing. Relaxation practices, such as breathing exercises, can help reduce stress and stabilize blood pressure. Breathing methods employed in Lamaze sessions can be useful in lowering anxiety or stress.[6]

Other maternal short-term problems include central nervous system dysfunction, liver damage, thrombocytopenia, acute disseminated intravascular coagulation (DIC), oliguria, pulmonary edema, cerebrovascular accidents, and placental abruption. In one study of 4188 women with preeclampsia, 6% experienced one or more systemic problems.[7]

Compared to late-onset PE, PIH-associated problems are more common in early-onset PE (<gestational week 32). According to a comparison study, the rates of perinatal problems are the same for women with PE and those with superimposed PE. Women with superimposed PE, on the other hand, were far more likely to experience problems from the intervention, including delivery before gestational week 34, cesarean delivery, and admission to the neonatal intensive care unit.[8]

In terms of long-term health risk, several studies have shown that women with PIH are more likely to develop various illnesses later in life, including hypertension, cardiovascular disease, diabetes mellitus, and renal disease. A study of 3593 women who had preeclampsia during their first singleton pregnancy found a strong correlation between pregnancy-related hypertensive disorders and later hypertension-related diseases.[9]

Hypertensive diseases of pregnancy, including chronic hypertension, with or without superimposed preeclampsia/eclampsia, gestational hypertension, HELLP syndrome, and preeclampsia with or without severe symptoms or eclampsia, provide a considerable risk of morbidity to both mother and fetus. Although effective prenatal treatment with close observation to detect indicators of pre-eclampsia and quick delivery to limit or avoid harmful effects has generated reduced morbidity and death, they nevertheless persist. While hypertension itself presents problems throughout pregnancy, unfavourable effects from progression to preeclampsia/eclampsia are the principal concern.[10]

Both immobilization and confinement cause stress. Women’s emotional, social, and cognitive statuses undergo significant changes. PIH is a high-risk condition that suggests a risk to the health of the fetus or the mother during pregnancy.[11]

Psychosocial, culture, and environmental stressors during pregnancy are known to have negative effects on the health of the mother and fetus, and new research indicates that the effects of prenatal stress may last for generations. Although some early studies showed minimal stress effects on pregnancy, most human studies show that mild, moderate, and severe stress can have negative influences on pregnancy outcome and the behavioural and physiological development of offspring.[12] Prenatal stress can range from severe (such as trauma) to moderate (such as life event changes) to mild (such as experiencing daily hassles).[12]

The hypothalamic-pituitary-adrenal (HPA) axis is still developing during fetal life, making it vulnerable to the effects of prenatal programming. The fully developed HPA axis controls numerous homeostatic systems in the body, including the immune, reproductive, cardiovascular, metabolic, and central nervous systems, and it mobilizes the body’s physical and psychological resources in response to stress. Programming of this system during fetal life is suggested as a main method by which early experiences are connected to later health outcomes, given the central involvement of the HPA axis in numerous survival activities and the connections between dysregulation of the HPA axis and disease.[13] It represented in Figure 1.

Figure 1.

Pathogenesis of pregancy – induced hypertension

A woman’s pregnancy is a unique moment for her and her family. During this time, a pregnant woman’s body, emotions, and family life undergo numerous changes. Pregnant women’s lives are frequently made more stressful by these developments. Stress can be detrimental to a pregnant woman, though, if it reaches uncomfortable levels. It can result in headaches, backaches, anxiety, and exhaustion. A prolonged period of excessive stress can lead to potentially dangerous health issues like heart disease, high blood pressure, and weakened immunity to infectious diseases.[14]

According to the World Health Organization (2019), pregnancy-related hypertension illnesses account for 35% of maternal mortality. Pregnancy-related hypertension affects 5–15% of pregnancies and is linked to morbidity in both the mother and the unborn child. Primigravidae have a 16% incidence of PIH, multigravida a 7% incidence, and 70% of PIH cases have secondary preeclampsia. Pregnancy-related hypertension diseases are thought to be responsible for between 62,000 and 77,000 deaths annually, or 18.1% of all maternal deaths. According to reports, 8–10% of pregnancies in India resulted in PIH. Across Kerala, PIH is responsible for 45.5% of deaths, compared to 21.92% across India.[15]

It is acknowledged that deep breathing and relaxation techniques greatly aid pregnant women in preparing for the difficulties and discomforts of childbirth. The fetus benefits from the application of breathing and relaxation techniques. The effect of relaxation techniques on hypertension is the subject of numerous studies. The findings showed that all relaxation techniques, particularly progressive muscle relaxation, were successful in lowering blood pressure.[16]

The current researcher was interested in evaluating the impact of relaxation therapy on stress reduction and, consequently, blood pressure decreases among antenatal mothers with PIH to enhance mothers’ skills with competency.

Materials and Methods

Study design and setting

This true experimental study was conducted from January 2025 to July 2025 at SRM Medical College Hospital and Research Centre, under the supervision of the Department of OBG.

Study participants and samplings

The study recruited 80 antenatal mothers diagnosed with mild to moderate PIH. Eligibility was based on the following criteria: gestational age between 18 and 38 weeks, aged between 18 and 40 years, and the ability to comprehend and follow instructions. Mothers with complications such as diabetes, renal or cardiac disorders, bleeding disorders, and multiple pregnancies were excluded.

The sample size was determined using standard formulae to achieve 80% power at a 95% confidence level, accounting for potential attrition. Participants were selected using a simple random sampling technique. The final sample was divided equally into an experimental group (n = 40), which received the holistic self-care intervention, and a control group (n = 40), which received routine hospital care. Informed consent was obtained from all participants prior to their inclusion.

The formula used for calculating the sample size was

P1Q1 + P2Q2 (Z_α + Z_β) ²/(P1-P2)2

The estimated sample size for the study = 35

10% of attrition is expected.

The final sample size is = 35 + 3 = 38.

The final sample size is rounded to 40.

So, for 2 groups (40 + 40 = 80) samples.

Sample sizes required

Hence, the sample size for the control group is 40 and that for the experimental group is 40. There were a total of 80 samples. It represented Tables 1 and 2.

Table 1.

Formula

Z α		1.96 (95% confidence)
Z β		0.84 (80% power of the test)
P1 (Previous study findings)		50.33%
P2 (Expected level of improvement)		20.17%
Q1 (1 – P1)		49.67%
Q2 (1 – P2)		79.83%

Table 2.

Sample size

		Sample size
Sample size 1 (n1):		40
Sample size 2 (n2):		40
Total sample size (both groups)		80

Data collection tools and techniques

Data were collected using a structured tool developed by the investigator and validated by subject experts. The pretest was assessed by using a perceived stress rating scale, the Warwick Edinburgh Mental Well-being scale, and clinical parameters (blood pressure, pulse rate, and respiration rate) were assessed on the 1^st day of the data collection. Following the pretest, the study’s intervention, the Holistic self-care approach, indicates management of PIH mothers with health education on dietary changes, to eat balanced diet with less salt, consume less than 5 grams of salt per day, walking exercise for 5 minutes, leg and foot exercise, educating mothers about warning signs of PIH, followed by teaching Mitchell’s relaxation techniques to the PIH antenatal mothers, was provided for 7 days in the morning and evening. After the 7^th day, the same questionnaire assessed the posttest. The collected data were tabulated and interpreted with descriptive and inferential statistics.

Statistical analysis

The collected data were coded, entered, and analysed using SPSS version 25. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used to describe the demographic and clinical characteristics of the participants. To assess the effectiveness of the holistic self-care intervention, inferential statistical methods were applied.

Paired t-tests were used to compare the pretest and post-test values within the experimental and control groups to identify changes over time. Independent t-tests were employed to compare the mean differences in clinical parameters, stress levels, and wellbeing scores between the experimental and control groups. Chi-square tests were used to explore associations between selected categorical variables. Furthermore, Pearson’s correlation analysis was performed to examine the relationship between psychological stress and mental wellbeing scores.

All tests were two-tailed, and a P value of less than 0.05 was considered statistically significant. This comprehensive statistical approach ensured accurate interpretation of the impact of the holistic self-care approach on maternal health outcomes in antenatal mothers with PIH.

Ethical consideration

This study was approved by the institutional research committee, SRM Medical College Hospital and Research Centre, and the institutional ethics committee approved the study (IEC- ST1024-1713). The study was registered with the Clinical Trials Registry of (India (EC/NEW/INST/2022/2933).

Results

The study recruited 80 antenatal mothers diagnosed with mild to moderate PIH. The results demonstrated statistically significant improvements in clinical and psychological outcomes in the experimental group compared to the control group. In the experimental group, systolic blood pressure decreased from a pretest mean of 126.85 ± 1.03 mmHg to a post-test mean of 117.13 ± 0.97 mmHg (P = 0.000), while the diastolic blood pressure reduced from 81.90 ± 1.78 mmHg to 73.25 ± 1.63 mmHg (P = 0.000). The pulse rate showed a significant reduction from 90.28 ± 1.41 bpm to 75.80 ± 1.11 bpm (P = 0.000), and the respiratory rate dropped from 21.49 ± 0.55 to 19.05 ± 0.32 (P = 0.000).

Regarding psychological measures, the mean stress score in the experimental group decreased from 39.80 (SD = 1.682) to 39.30 (SD = 2.041), with a P value of 0.096, indicating a reduction though not statistically significant. The wellbeing score showed an increase from 44.53 (SD = 2.386) to 45.33 (SD = 2.314), with a P value of 0.104. While these psychological outcomes were not statistically significant, the trends suggest a positive direction influenced by the intervention. The data are tabulated in Tables 3 and 4.

Table 3.

Correlation between psychological stress and wellbeing in the control group

(Karl Pearson’s coefficient of correlation)
Test		n		Mean		SD		r		P
Stress		40		39.30		2.041		-0.601		0.000
Well-being		40		45.33		2.314

**P<0.01 (Significant at the 1% level)

Table 4.

Correlation between psychological stress and wellbeing in the experimental group

Karl Pearson’s coefficient of correlation
Test		n		Mean		SD		r		P
Stress		40		26.23		2.041		-0.821		0.000
Well-being		40		61.65		2.314

**P<0.01 (Significant at the 1% level)

In contrast, the control group did not show significant improvements in any of the measured variables. These findings support the effectiveness of the holistic self-care approach in improving key clinical outcomes and potentially enhancing psychological wellbeing among antenatal mothers with PIH.

Discussion

The study revealed that the majority of antenatal mothers in both groups were aged 24–29 years, Hindu by religion, and from nuclear families. Most were housewives with education up to degree level. In terms of maternal variables, a higher proportion were primiparous and had no family history of hypertension. The pretest findings showed both groups had severe stress, moderate wellbeing, and elevated clinical parameters. Post-test results in the experimental group showed significant improvements in systolic and diastolic BP, pulse, respiratory rate, stress levels, and wellbeing scores after the holistic self-care intervention. Statistical analysis confirmed highly significant differences in clinical and psychological outcomes between pre- and post-tests in the experimental group. There was a significant association between “occupation” and stress levels in the control group and “type of marriage” with stress in the experimental group. Maternal variables like gravida, parity, and family history were significantly associated with stress in the control group. A strong negative correlation was found between psychological stress and wellbeing in both groups. Thus, Hypothesis RH1 and RH2 were accepted, proving the effectiveness of the holistic self-care approach. The data are tabulated in Tables 5 and 6.

Table 5.

Frequency and percentage distribution of demographic variables of antenatal mothers with pregnancy-induced hypertension

Demographic Variables
Demographic Variables		Class		No. of mothers in
				Control group		%		Experimental group		%
Age in years		18-23		12		30%		13		33%
		24-29		17		43%		15		38%
		30-35		11		28%		12		30%
		>35		0		0%		0		0%
Religion		Hindu		21		53%		19		48%
		Christian		12		30%		15		38%
		Muslim		7		18%		6		15%
		Any other		0		0%		0		0%
Type of family		Nuclear family		27		68%		22		55%
		Joint family		13		33%		18		45%
Income per month		10000-15000		10		25%		8		20%
		1500l-20000		14		35%		19		48%
		Above 20000		16		40%		13		33%
Type of Marriage		Consanguineous		0		0%		14		35%
		Non-Consanguineous		40		100%		26		65%
Education		Primary		7		18%		8		20%
		Secondary		8		20%		8		20%
		Higher secondary		10		25%		9		23%
		Degree		15		38%		15		38%
Occupation		House wife		26		65%		23		58%
		Laborer		6		15%		6		15%
		Self-employed		0		0%		0		0%
		Private employee		8		20%		11		28%

Table 6.

Frequency and percentage distribution of maternal variables among mothers with pregnancy-induced hypertension

Maternal Variables		Class		No. of mothers in
				Control group		%		Experimental group		%
Gravida		Primi mother		22		55%		22		55%
		Multi mother		18		45%		18		45%
Parity		1		22		55%		22		55%
		2		18		45%		18		45%
		>2		0		0%		0		0%
Family history of hypertension		Yes		8		20%		16		40%
		No		32		80%		24		60%
Weeks of Gestation		28-32		11		28%		16		40%
		33-37		17		43%		16		40%
		> 38		12		30%		8		20%
Previous history of hypertension		Yes		5		13%		7		18%
		No		13		33%		12		30%
		Primi mother		22		55%		21		53%

Furthermore, the absence of adverse effects and high participant compliance underscore the acceptability of the intervention. Given the growing interest in complementary and integrative health approaches, this study adds value to the literature by demonstrating tangible improvements in maternal health outcomes through a simple, non-invasive, cost-effective strategy. The findings of this study substantiate the role of holistic self-care as a beneficial adjunct to routine clinical management of PIH. It promotes a proactive, wellness-oriented model of antenatal care that supports both physical and mental health. The study is consistent with the study done by Sumathi C (2025) on evaluation of the effectiveness of progressive muscle relaxation therapy on level of stress among PIH mothers. A quantitative, quasi-experimental nonequivalent design was used to assess the effectiveness of progressive muscle relaxation therapy on stress among 60 mothers with PIH. Participants were selected using nonprobability purposive sampling. The pretest mean stress scores were 20.06 ± 9.44 and 19.50 ± 9.23, which reduced to 11.10 ± 5.46 and 8.96 ± 0.27 in the post-test. The paired t test value (t = 1.246) was statistically significant at P < 0.001 and P < 0.05 levels. The study concluded that progressive muscle relaxation therapy was effective in reducing stress among hypertensive pregnant mothers.[17]

Limitations and recommendations

At the same time as our study gives precious insights, it has boundaries in general because of its true-experimental design. This study was conducted in a single tertiary care hospital and involved a relatively short intervention period of 7 days, which may limit its generalizability and long-term impact assessment. Despite these limitations, the intervention demonstrated strong clinical effectiveness in reducing blood pressure and enhancing maternal wellbeing. Future research studies should include long-term follow-up and consider larger, multicenter populations, longer follow-up durations, and inclusion of fetal and neonatal outcomes to fully capture the benefits. Healthcare providers should be encouraged to incorporate holistic self-care modules into routine antenatal programs to promote safe, cost-effective, and empowering care strategies for expectant mothers.

Conclusion

In conclusion, our study reveals that a structured, holistic self-care approach is an effective complementary strategy in the management of PIH. The intervention significantly improved clinical parameters such as blood pressure, pulse rate, and respiratory rate, indicating better physiological control. Although psychological improvements were not statistically significant, the observed positive trends suggest potential benefits for mental wellbeing. This approach promotes self-responsibility, empowerment, and engagement in antenatal care. It is simple and cost-effective and can be integrated into routine maternal health services to enhance both physical and emotional health outcomes. Further studies are encouraged to confirm long-term efficacy and extend applicability.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.