EFFECTIVENESS OF RELAXATION PROGRAMME ON ... · Signature of the Supervisor with designation Place Date iii . ACKNOWLEDGEMENT The investigator is very much thankful to God Almighty

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

i


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

ii


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

iii

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

iv

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.

v

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

vi

ABSTRACT

The present study is aimed to evaluate the effect of relaxation

programme on stress, coping and pregnancy outcome 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



vii

8. Find out the association between stress, coping and pregnancy

outcome 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.

viii

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:

ix

• 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.

x

� 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.

xi

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

xii

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

xiii

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


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


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

xiv

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


terms of type of delivery and selected

variables among women with PIH in

experimental group

160

28


terms of complications and selected variables

among women with PIH in experimental group

161

29


terms of blood pressure and selected variables


162

30


terms of oedema and selected variables


163

xv

Table Title Page no

31


terms of protein urea and selected variables


164

32

Association between neonatal out-come in

terms of birth weight and selected variables


165

33


terms of Apgar score and selected variables


166

34




167

35


terms of still birth/IUD and selected variables


168

36


terms of labour and selected variables among

women with PIH in control group

169

37


terms of type of delivery and selected variables

among women with PIH in control group

170

38




171

39


terms of blood pressure and selected variables


172

40


terms of protein urea and selected variables


173

xvi

Table Title Page no

41


terms of oedema and selected variables


174

42


terms of birth weight and selected variables


175

43


terms of Apgar score and selected variables


176

44




177

45


terms of still birth/IUD and selected variables


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


and neonatal outcome in terms of birth weight


182

50


and neonatal outcome in terms ofapgar score


183

xvii

Table Title Page no

51


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


185

53


and neonatal outcome in terms of apgar score


186

xviii

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


9 Percentage distribution based on family structure


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

xix


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


pitting oedema among women with PIH 111

22 Percentage distribution of presence of eye

symptoms among women with PIH 112


epigastric pain among women with PIH 113


nausea and vomiting among women with PIH 114

25 Percentage distribution based on body weight


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


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

xx


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


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


control group

140

43 Percentage distribution based on APGAR score


control group

141

44 Percentage distribution based on neonatal

complications among women with PIH in

experimental and control group

142

xxi

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

1

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



2. To assess the coping strategies used by women with PIH before



women with PIH.

4. Evaluate the effect of relaxation programme on coping strategies

of women with PIH.


outcome 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 outcome 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

outcome

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


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.


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.


7. Back

a) Arch your back.


8. Thighs and buttocks

a) Tense both thigh muscles and buttocks by squeezing

together.


78

9. Lower legs

a) Point toes towards your head, then away from your head.


10. Toes

a) Curl toes up.


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


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


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


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


119

Fig. 30: Percentage distribution based on antenatal check-ups


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 output 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


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


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


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


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


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)



-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


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


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


69.5 0.0001***

Control 81.49 4.85

Effectiveness


125.2 0.0001***

Control 49.87 5.44

Total


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 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


H06.(b): There will be no significant difference in the mean score of

neonatal outcome among women with PIH in the control and


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 preterm 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.


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


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


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


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


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


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


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


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


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


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


Yes 75 88.2 6 13.6

0.08 1 0.93N No 101 87.8 18 11.5


Yes 38 86.4 6 11.5

0.14 1 0.7N No 138 88.5 13.6


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


Yes 45 47.4 50 52.6 1.23

1 0.26N No 58 55.2 47 44.8


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


(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


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


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


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


(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


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


(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


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


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


(n=200)


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


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

177

Table 45:

Association between neonatal out-come in terms of still birth/IUD


(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


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


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 outcome 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


6.40 0.002** Within groups 23984.79 121.75 197

Total 25543.35 199

APGAR score


3.62 0.028* Within groups 24636.85 125.06 197

Total 25543.35 199

Neonatal complications


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


.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


.022 .978NS Within Groups 4690.92 23.812 197

Total 4691.98 199

Effectiveness


.639 .529NS Within Groups 5854.61 29.719 197

Total 5892.62 199

Total


.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:


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


.251 .778 NS Within Groups 4680.039 23.757 197

Total 4691.980 199

Effectiveness


.626 .536NS Within Groups 5855.401 29.723 197

Total 5892.620 199

Total


.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


1.130 .325 Within Groups 4170.715 21.171 197

Total 4218.555 199

Effectiveness


.028 .972 Within Groups 6547.690 33.237 197

Total 6549.555 199

Total


.431 .651 Within Groups 10494.115 53.270 197

Total 10540.000 199 199


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


Coping Sum of

Squares

Mean

Square df F

p

value

Usefulness


1.536 .218 Within Groups 4153.783 21.085 197

Total 4218.555 199

Effectiveness


.209 .812 Within Groups 6535.698 33.176 197

Total 6549.555 199

Total


.305 .738 Within Groups 10507.484 53.337 197

Total 10540.000 199


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:


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


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


2. To assess the coping strategies used by women with PIH before and

after relaxation programme.

188


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


variables: age, obstetric score, family history of PIH and family history

of hypertension of women with PIH.


variables: age, obstetric score, family history of PIH and family history


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


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


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

194

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

200

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

204

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 outcome among women with

pregnancy induced hypertension. The objectives, hypotheses and major

findings of the study were:

Objectives



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


4. Evaluate the effect of relaxation programme on coping strategies


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outcome among women with PIH


variables: age, obstetric score, family history of PIH, family history



variables: age, obstetric score, family history of PIH, family history


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


207

H05. There will be no significant difference in the mean score of

pregnancy outcome among women with PIH in the control and


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 outcome 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

208

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.

210

• 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:

213

• 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).

216

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.

217

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.

218

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.

219

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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EFFECTIVENESS OF RELAXATION PROGRAMME ON ... · Signature of the Supervisor with designation Place Date iii . ACKNOWLEDGEMENT The investigator is very much thankful to God Almighty