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The Effect of Foot Reflexology on the Anxiety Levels of Women in Labor


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Objectives: This research was conducted to analyze the effect of foot reflexology on the anxiety levels of women during labor. Design, setting and subjects: The study was conducted as a semiexperimental study. It was conducted with 154 nulliparous pregnant women who applied to a maternity unit of a state hospital in the north-western part of Turkey to give birth. Interventions: Foot reflexology was applied once to the pregnant women in the experimental group when cervical dilation was 3-4 cm. The treatment was applied to the right foot and left foot reflex points for 15 min, for a total of 30 min. The data in the study were collected using the "Pregnant Women Introductory Information Form" and the "Spielberger State-trait Anxiety Inventory" (STAI TX-1). In evaluating the data, number, percentage, Chi-square, independent samples t-test, and repeated measure analysis of variance test were used. Main outcome measures: The mean scores of the STAI TX-1 were used to analyze the results. Results: The mean STAI TX-1 scores were measured before reflexology, in the latent and active phases of labor and early in postpartum period (four times in total). The mean STAI TX-1 scores were higher in the experimental group than in the control group (p < 0.001). The mean STAI TX-1 scores postreflexology application (when cervical dilation was 3-4 cm) and during the active phase of the labor (when cervical dilation was 6-8 cm) of the pregnant women in the experimental group were lower than those of the control group (respectively p = 0.010, p < 0.001). In the experimental group, there was no statistically significant difference between the mean STAI TX-1 scores pre- and postreflexology (p = 0.820). The mean STAI TX-1 scores in the early postpartum period were similar in the experimental and control groups (p = 0.080). Conclusion: Foot reflexology was found to have a positive effect in lowering the total anxiety scores of the pregnant women. Reflexology is a noninvasive and economical method, which may be used by health professionals to reduce problems during labor. A decrease in anxiety experienced at birth improves women's positive birth experiences, promotes a secure mother-infant attachment, and protects postpartum mental health.
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The Effect of Foot Reflexology on the Anxiety Levels
of Women in Labor
Zu¨ mru¨ t Yılar Erkek, MSc, PhD
and Songul Aktas, PhD
Objectives: This research was conducted to analyze the effect of foot reflexology on the anxiety levels of
women during labor.
Design, setting and subjects: The study was conducted as a semiexperimental study. It was conducted with
154 nulliparous pregnant women who applied to a maternity unit of a state hospital in the north-western part of
Turkey to give birth.
Interventions: Foot reflexology was applied once to the pregnant women in the experimental group when
cervical dilation was 3–4 cm. The treatment was applied to the right foot and left foot reflex points for 15 min,
for a total of 30 min. The data in the study were collected using the ‘‘Pregnant Women Introductory Information
Form’’ and the ‘‘Spielberger State-trait Anxiety Inventory’’ (STAI TX-1). In evaluating the data, number,
percentage, Chi-square, independent samples t-test, and repeated measure analysis of variance test were used.
Main outcome measures: The mean scores of the STAI TX-1 were used to analyze the results.
Results: The mean STAI TX-1 scores were measured before reflexology, in the latent and active phases of
labor and early in postpartum period (four times in total). The mean STAI TX-1 scores were higher in the
experimental group than in the control group ( p<0.001). The mean STAI TX-1 scores postreflexology ap-
plication (when cervical dilation was 3–4 cm) and during the active phase of the labor (when cervical dilation
was 6–8 cm) of the pregnant women in the experimental group were lower than those of the control group
(respectively p=0.010, p<0.001). In the experimental group, there was no statistically significant difference
between the mean STAI TX-1 scores pre- and postreflexology ( p=0.820). The mean STAI TX-1 scores in the
early postpartum period were similar in the experimental and control groups ( p=0.080).
Conclusion: Foot reflexology was found to have a positive effect in lowering the total anxiety scores of the
pregnant women. Reflexology is a noninvasive and economical method, which may be used by health pro-
fessionals to reduce problems during labor. A decrease in anxiety experienced at birth improves women’s
positive birth experiences, promotes a secure mother–infant attachment, and protects postpartum mental health.
Keywords: foot reflexology, nullipar, labor, anxiety, midwife, midwifery care, Turkey
The meaning of the word ‘‘anxiety’’ is worry, fear, and
curiosity. The process of labor causes anxiety in pregnant
women as a result of a number of factors.
In particular,
nulliparous pregnant women experience this anxiety to a
greater extent. In the studies of Parvathi and colleagues,
51.66% of nulliparous women were found to have moderate
anxiety about labor.
Increased anxiety during birth affects maternal and fetal
health negatively and leads to many obstetric and psychi-
atric problems. Women who have anxiety about labor show
a decreased release of oxytocin and increased level of
adrenaline. As a result, uterine contractions are irregular and
ineffective. Labor becomes longer and more difficult. An-
xiety also reduces the release of endorphins, and the preg-
nant women thus experience more pain.
The stimulation
of the sympathetic system due to pain, stress, and anxiety
Department of Midwifery, Gaziosmanpasxa University, Tokat, Turkey.
Faculty of Health Sciences, Department of Obstetrics and Women Health Nursing, Karadeniz Technical Universty,
Trabzon, Turkey.
Volume 24, Number 4, 2018, pp. 352–360
ªMary Ann Liebert, Inc.
DOI: 10.1089/acm.2017.0263
causes an increase in adrenocorticotropic hormone (ACTH),
cortisol, epinephrine, and norepinephrine levels. The mother’s
uterine blood flow decreases and metabolic acidosis occurs.
All of these cause severe fetal–obstetric complications such
as reduced oxygenation of the fetus due to the prevention of
uteroplacental circulation, fetal metabolic acidosis, preterm
labor, fetal hypoxia, and meconium aspiration.
In addition,
a high level of anxiety leads to the desire for a cesarean birth,
postpartum depression, posttraumatic stress disorder, sexual
dysfunction, inadequate mother–infant attachment, breast-
feeding problems, and neonatal neglect.
Today, various methods are used to prevent adverse
events related to birth anxiety and reduce the anxiety of
women during delivery.
One of these methods is reflexol-
ogy. Reflexology is a practice that leads to the formation of
electrochemical messages as a result of the stimulation of
nerve points with specific techniques. In this practice, the
organs associated with the neurons are stimulated to reduce
tension, stress, and to maintain the balance of the body.
In addition, reflexology opens the nerve pathways that are
overloaded with sensory stimuli, leading to the release of
endorphins and enkephalins, which are at least five times
more analgesic than the morphine.
In obstetric practice,
it has been stated that reflexology is effective in the in-
duction of oxytocin release, the initiation and regulation of
uterine contractions, relaxation during contractions, in re-
ducing the level of pain and anxiety, and in shortening the
duration of delivery.
Smitha and Bindu found that
foot reflexology reduced birth pain,
McNeill et al. found
that the need for analgesia is lower in primiparous pregnant
women who have had reflexology
and Dolation et al.
found that it shortens labor pains and the duration of labor.
Hanjani et al. and Mirzaee and Kaviani found that foot re-
flexology during delivery significantly reduces the anxiety
levels of the pregnant women.
Controversially, some
studies found that reflexology had no significant effect on
the process of giving birth.
Reflexology is cheap and noninvasive. The widespread use
of this practice at birth by all health professionals, especially by
midwives, has the potential to contribute to the reduction of
maternal anxiety and fear of pregnancy, to decrease the need
for analgesia in parallel to this, to increase intrapartum and
postpartum well-being and to decrease the per capita cost
burden. At the same time, the contact experienced during re-
flexology also has a therapeutic effect by establishing a bond
between the pregnant woman and health professionals.
In the literature, it has been emphasized that the level of
evidence in studies on reflexology in the field of obstetrics is
not sufficient and that more studies with higher quality ev-
idence are needed.
This study was designed to meet this
need. It was conducted to analyze the effect of foot reflex-
ology on the anxiety felt by women during labor.
Materials and Methods
Study design
The study was a semiexperimental study with no invasive
intervention. Foot reflexology was given to the pregnant
women in the experimental group, while foot reflexology
was not given to the pregnant women in the control
group. The study was conducted in the delivery room and
obstetrics ward of a state hospital in the northwestern part of
Turkey. There were two rooms with two beds and two ob-
stetric tables in the obstetrics ward. Twelve midwives and
six obstetrics doctors were working in this ward at the time
of the study. Vaginal deliveries of low-risk pregnant women
were mostly performed by midwives.
Ethical statement
Before the study, written approval was obtained from the
Ethics Committee (No: 14-KAEK-188) and written per-
mission was obtained from the hospital, in which the study
was to be conducted. In addition, both verbal and informed
written consent were obtained from the participants.
Participants: universe and sample of the study
According to the sample power analysis, two independent
groups with 95% confidence interval, alpha =0.05, 80%
power and medium-effect size were created for the inde-
pendent samples t-test. A total of 154 nulliparous women,
77 in the experimental group and 77 in the control group,
were included in the sample of the study.
Inclusion criteria. Women with a low-risk pregnancy, no
complications in the present or previous pregnancies, no ma-
ternal medical illness, no previous maternal morbidity or history
of mortality, no deficiencies in fetal developmental, and no
abnormal results in the laboratory and screening tests throughout
the pregnancy.
In the hospital in which the study was con-
ducted, the ‘‘Pregnancy Risk Determination Form’’, which is
recommended by the Turkish Ministry of Health, was used.
Exclusion criteria. Women who had had any complica-
tions related to pregnancy or labor, including edema in the feet
and ankle regions, varicosis, wounds, lesions, masses, callus
and tinea pedis; and pregnant women who took narcotic an-
algesics or sedatives. In addition, the ‘‘Pregnant Women In-
troductory Information Form’’ asked for information about
situations of risk which could affect the anxiety levels of the
pregnant women during labor, such as sexual abuse, physical
violence, a known psychiatric disorder, substance dependence,
and vaginismus. Pregnant women with one or more of these
risks were excluded.
Study protocol
The pregnant women were randomly selected to provide
objectivity in the inclusion of subjects into the experimental
(n=77) and control (n=77) groups. Pregnant women who
applied to the hospital on Mondays, Wednesdays, and Fridays
were included in the experimental group, while the pregnant
women who applied to the hospital on Tuesdays, Thursdays,
and Saturdays were included in the control group. A maxi-
mum of three pregnant women were analyzed in one day.
The study was conducted with a total of 188 pregnant
women who were in conformity with the study criteria.
During the application, 34 pregnant women (18 of them in the
experimental group, 16 of them in the control group) were
excluded for different reasons (fetal distress, cesarean section,
prolonged delivery, development of complications, a request
to leave the study, and cervical dilation by hand). The number
of samples was then maintained as 154 by the inclusion of
new subjects in the place of those who had left (Fig. 1).
The ‘‘Pregnant Women Introductory Information Form’
and ‘‘Spielberger State-Trait Anxiety Inventory’’ (STAI TX-I)
were used in the study. The data collection forms prepared
were given to the sample group after a trial application with
10 pregnant women who fitted the research criteria to deter-
mine the functioning of the data collection forms.
Personal information form
The ‘‘Pregnant Women Introductory Information Form’
was developed by the researchers based on the related lit-
erature and expert opinion. This form contained nine ques-
tions, including sociodemographic characteristics (age,
education, marital status, etc.) and pregnancy and obstetrical
history. The form was given to the pregnant women when
they felt well using the face-to-face interview technique
during the latent phase of birth (1–3 cm dilation) in the
delivery room. Forms were filled in by the pregnant women.
State-Trait Anxiety Inventory
This is a Likert-type scale, developed by Spielberger et al.
in 1964 to measure the state-trait anxiety levels of normal and
abnormal individuals. The adaptation of the scale to Turkish
was done by O
¨ner and LeCompte.
The STAI TX-1 contains
20 items and statements which require that the individual
describe how he/she feels in a particular situations. The in-
dividual is asked to answer considering his/her own feelings
about the condition experienced. The scale has ordered and
reversed statements. The minimum score that can be gained
from the scale is 20, while the highest score is 80. Anxiety
ating the scale, it is accepted that there is no anxiety for a
score below 36, mild anxiety for a score between 37 and 42,
and high anxiety for a score of 42 or above.
Application of reflexology
Foot reflexology was performed by one of the re-
searchers after 42 h of foot reflexology training. The con-
tent of the training consisted of theoretical and practical
information. The researcher had also completed a study
about reflexology.
The necessary information about the application of re-
flexology was explained to the pregnant women beforehand.
The technique was applied in the delivery room where the
pregnant woman was. During the reflexology, the women lay
on their left sides in the bed. The back and extremities were
supported with pillows to provide a comfortable position.
Foot reflexology was given when cervical dilation was 3–
4 cm and was consistently applied to each leg for 15min, for
a total of 30 min. If a woman did not want to continue the
application or any maternal (change in vital signs, pain,
cramping, etc.) or fetal complications (tachycardia, brady-
cardia, increased fetal movements) were encountered, the
application was terminated. Manual reflex points on the feet
for anxiety are as follows: (1) solar plexus; (2) pituitary gland
and hypothalamus reflex points; (3) shoulders and back reflex
spots; (4) heart; (5) large intestine reflex points; (6) heel
(sciatic); and (7) spinal cord (Fig. 2).
Spielberger State-Trait Anxiety Inventory
The STAI TX-1 was first applied to pregnant women
in the experimental group who were in the latent phase
FIG. 1. Flowchart of preg-
nant women participating
in the survey.
(cervical dilation 3–4 cm). The second application was made
immediately after the foot reflexology, the third application
was made in the active phase (cervical dilation 6–8 cm), and
the fourth application was made in the early postpartum
period (postpartum second hour). In the control group, the
second application was made 30 min after the first applica-
tion. Other applications were made in the same time frame
with the experimental group. The STAI TX-1 was used in
the study, because the cause of anxiety in the birth is usually
specific to that situation. Mc Vicar et al. analyzed anxiety,
cortisol, and melatonin levels after reflexology therapy and
found that reflexology significantly reduced state anxiety but
did not alter persistent anxiety (anxiety without an objective
The steps in applying the STAI TX-1 in the control
and experimental groups are shown in Figure 3.
In the study, the experimental group and the control group
were treated equally by the researcher at every stage of labor,
except for the use of foot reflexology. Healthcare profes-
sionals (the midwife and obstetrician) in the hospital provided
standard care and interventions for both groups. These include
treatments and activities such as induction, enema, amniot-
omy, vaginal examination, fetal monitorization, follow-up of
vital signs, fundal pressure, episiotomy, perineal care, fundus
massage, and education for the mother and infant. During
pregnancy no analgesia was given to the pregnant women.
In the study, follow-up of the labor and the delivery itself
were carried out by the midwives. All pregnant women
(experimental and control groups) were nursed by a single
midwife (vaginal examination, enema application, etc.)
until cervical dilation was 4 cm. After cervical dilation had
reached 4cm, the pregnant woman was transferred to another
room in the same ward and was followed up by another
midwife until the first 2 h after birth. During labor, all follow-
up and care of the pregnant women were provided by two
midwives (one midwife for before cervical dilation was 4 cm,
one midwife for after cervical dilation was 4 cm). However, a
doctor intervened the process if a complication developed in
the pregnant woman or fetus during labor. Pregnant women
who required the intervention of a doctor were excluded from
the scope of the study.
Statistical analysis
The data were analyzed using the SPSS 22.0 package
program. The comparison of the introductory and obstetric
characteristics of the pregnant women in the experimental
and control groups was made by the Chi-Square test. It was
found that the mean scores of STAI TX-1 were parametric
as a result of the Kolmogorov–Smirnov Test. Comparisons
between the groups were made by the Student tand, two-
way analysis of variance (ANOVA) tests (for independent
groups) and repeated measure ANOVA test in groups (for
dependent groups). All analyses were made for a 95%
confidence interval and p<0.05 was accepted as statisti-
cally significant.
As shown in Table 1, it was found that the majority of the
pregnant women in the experimental and control groups were
middle school graduates, housewives, had a median income,
had been married for 9–18 months, had become pregnant
willingly, and were at 40th week of their pregnancies. The
pregnant women were found to be similar in terms of their
introductory characteristics ( p=0.852, p=0.550, p=0.193,
p=0.470, p=0.483, p=0.642, p=0.100, and p=0.810 re-
spectively) except for residence ( p=0.050) (Table 1).
When the mean STAI TX-1 scores of the experimental and
control groups were analyzed, it was found that the mean
scores of the experimental group were 47.57 9.68 before the
application, 47.77 9.38 after the application, 54.64 9.45 in
the active phase, and 33.89 7.37 in the early postpartum
period. The total anxiety score was found to be 45.97 6.43.
The mean scores of the control group were 47.819.33 before
the application, 51.72 9.99 after the application, 60.32 8.14
in the active phase, and 35.92 7.23 in the early postpar-
tum period. The total anxiety score was determined to be
48.94 6.05. There was no significant difference between
mean STAI TX-1 scores before the application and in the early
postpartum period in the experimental and control groups
(before application p=0.870, postpartum period p=0.080).
Furthermore, the difference between the experimental and
control groups was statistically significant in terms of the
means of the total STAI TX-1 scores ( p<0.001) (Table 2).
To determine the origin of statistical difference, a binary
comparison was made with the paired sample ttest with the
FIG. 2. Anxiety reflex points (figure organized by re-
searchers in computer environment). Manual reflex points
on the feet for anxiety; (1) solar plexus, (2) pituitary gland
and hypothalamus reflex points, (3) shoulders and back re-
flex points, (4) heart, (5) large intestine reflex points, (6)
heel (sciatic), and (7) spinal cord.
FIG. 3. Application steps of STAI TX-I.
STAI TX-I, Spielberger State-Trait Anxiety
Table 1. Comparison of the Experimental and Control Groups According to Descriptive Characteristics
Experimental group (n=77) Control group (n=77)
Test and p-valueNumber % Number %
Age w
18–23 56 72.7 55 71.4 df =1
24–29 21 27.3 22 28.6 p=0.852
Education status
Primary school graduate 21 27.3 20 26.0
Middle school graduate 31 40.3 33 42.9 w
High school graduate 21 27.3 16 20.8 df =3
University graduate 4 5.1 8 10.4 p=0.550
Profession w
Housewife 74 96.1 70 90.9 df =1
Officer 3 3.9 7 9.1 p=0.193
Village 18 23.4 32 41.5 w
Province 27 35.1 21 27.3 df =2
County 32 41.5 24 31.2 p=0.050
Financial status perception
Poor 6 7.8 10 13.0 w
Medium 49 63.6 43 55.8 df =2
Good 22 28.6 24 31.2 p=0.470
Duration of marriage w
9–18 Months 52 67.5 56 72.7 df =1
19 Months [25 32.5 21 27.3 p=0.483
Willingness to pregnancy w
Will 75 97.4 74 96.1 df =1
Not will 2 2.6 3 3.9 p=0.642
Gestational week
37 Weeks 6 7.8 9 11.7 w
38 Weeks 18 23.4 12 15.6 df =4
39 Weeks 9 11.7 21 27.3 p=0.100
40 Weeks 29 37.7 24 31.2
41 Weeks 15 19.5 11 14.2
Abortus status w
Yes 10 13.0 11 14.2 df =1
No 67 87.0 66 85.8 p=0.810
Table 2 not being seen. In the control group, the difference
between the mean STAI TX-1 scores for the pre- and
postapplication periods (t:-5.85, p<0.001), for the post-
application period and active phase (t:-7.93, p<0.001),
and the active phase and early postpartum period (t:18.12,
p<0.001) were statistically significant. In the experimental
group, there was no statistically significant difference
between pre- and postapplication (t:-0.227, p=0.820),
there was a statistically significant difference between
postapplication and the active phase (t:-6.80, p<0.001),
and there was a statistically significant difference between
the active phase and early postpartum period after appli-
cation (t:15.86,p<0.001) in terms of mean STAI TX-1
The purpose of the study was to analyze the effect of
applying foot reflexology in the latent phase of labor. In this
study, mean STAI TX-1 scores were similar in the experi-
mental and control groups before the application of reflex-
ology ( p=0.870) (Table 2). This result was predicted,
because the sociodemographic and obstetric characteristics
of the pregnant women in two groups (Table 1) and the
times at which anxiety levels were measured were similar.
These aspects of the experimental and control groups are
homogeneous, and they are therefore important in showing
the effects of reflexology on anxiety.
Extreme anxiety at birth triggers a ‘‘fight or flight’’ re-
action. This response strengthens the painful stimuli from
the uterus and cervix and makes the pain more intense.
This pain and anxiety may be reduced with the positive
effects of reflexology. Reflexology alleviates muscle
spasms, gives a feeling of relaxation, and stops the neural
transmission of the pain message to the brain. Thus, the
level of pain decreases. Reduced severity of pain leads to
decreased anxiety.
The alleviation of the anxiety of
a pregnant women during birth ensures that she can ef-
fectively cope with labor pains and experience birth as a
positive experience.
In this study, the STAI TX-1 scores of the pregnant
women were measured four times: in the prereflexology
period, the latent phase of birth, the active phase of birth,
and at the second hour of the postpartum period. The mean
STAI TX-1 scores as the sum of the four measurements
were lower in the experimental group compared with the
control group. This decrease was statistically significant
(p<0.001) (Table 2). According to this finding, it can be
suggested that foot reflexology applied in the latent phase
has a positive effect on lowering the total anxiety score.
Hanjani et al.
found that foot reflexology applied to pri-
miparous women for 40 min at birth decreased their level of
anxiety compared with that of the control group ( p<0.05).
Mirzaee and Kaviani
found that the anxiety levels of the
pregnant women who were given reflexology at labor were
lower compared with those of the control group (p<0.05).
Smith et al.
compared six meta-analytical studies on
massage, reflexology, and other manual methods in pain
management at birth, and it was found that massage and
reflexology were effective in decreasing the labor pain and
reducing women’s anxiety and that they had a positive
birth experience ( p<0.05). The findings of these studies
are similar to the findings of our study. However, only one
was measured in three steps (after application, in the active
phase and at the first 2 h postpartum) in this study.
In this study, the mean scores of the STAI TX-1 changed
according to the stages of labor and the research group
(experimental or control). The mean STAI TX-1 scores of
the subjects in the experimental group did not change after
reflexology ( p=0.820), but they increased after application
of the reflexology in the active phase ( p<0.001) (Table 2).
The increase in the pregnant women’s anxiety after reflex-
ology is thought-provoking. This result indicates that the
increase in medical interventions (induction, frequent vagi-
nal examination, electronic fetal monitoring [EFM], the
restriction of oral intake, and movement, etc.) given to the
pregnant women may increase their anxiety and reduce
the efficacy of reflexology as labor progresses. Induction,
EFM, and vaginal touch during vaginal birth are often per-
formed as a routine in nulliparas in Turkey.
These appli-
cations, the nearness of giving birth, and nulliparity in the
study group may have further increased the anxiety.
Table 2. Comparisons of Spielberger State-Trait Anxiety Inventory Point Scales in Groups
Measure time
Experimental group Control group
and p-valueMean SD
Mean SD
Preapplication (latent phase) 47.57 9.68 47.81 9.33 t=0.16, p=0.870
Postapplication 47.77 9.38 51.72 9.99 t=2.52, p=0.010
Active phase 54.64 9.45 60.32 8.14 t=3.39, p<0.001
Early postpartum period 33.89 7.37 35.92 7.23 t=1.72, p=0.080
45.97 6.43 48.94 6.05 t=2.95, p<0.001
The statistical difference was found significant p<0.05.
The statistical difference was found significant, p<0.001 (p=0.000 was evaluated as p<0.001).
Standard deviation.
Student ttest.
Repeated measures ANOVA (analysis of variance).
It is the sum of the mean STAI TX-1 (Spielberger State-Trait Anxiety Inventory TX-1) scores measured four times in the latent and
active phases of birth, in the first second hour of the postpartum period and before reflexology.
On the contrary, it is also an important finding that the
level of anxiety after application and in the active phases
was lower in the experimental group compared with the
control group ( p=0.010 and p<0.001 respectively) (Table 2).
This finding suggests that reflexology decreases the anxiety
of pregnant women in the active and latent phases when
compared with the women in the control group. This effect
of reflexology is pleasing.
At a look at Table 2 in the study, it is seen that in the
active phase of the pregnant women in the experimental
group, the anxiety scores increased after reflexology, but
the anxiety scores were lower than those of the control
group. This result suggests that reflexology may have
positively contributed to the prevention of an increase in
anxiety in the active phase.
A high level of maternal anxiety during labor decreases
the release of endorphin, prolactin, and oxytocin hor-
mones, and increases the cortisol and ACTH levels of the
mother. This condition affects mother–infant attachment,
breastfeeding, and the mental state of mothers in the early
postpartum period.
Coates et al. reported that mothers
with high maternal stress and anxiety did not welcome
their babies and that they had more postpartum distress.
The reduction of the anxiety of the pregnant woman at
mother and the infant in the postpartum period. This study
investigated the effect of reflexology applied in the latent
phase on maternal anxiety in early postpartum period (first
2 h). In the early postpartum period, the mean STAI TX-1
scores of the mothers in both the experimental and control
groups were lower compared to those in the active phase of
labor ( p=0.080) (Table 2).
In the study, the anxiety of the mothers in the postpartum
period decreased in both the experimental and control
groups compared to the active phase of labor. This suggests
that reflexology has no effect at this period (for the exper-
imental and control groups p<0.001). The completion of the
birth process, reduced pain, the bonding of mother and in-
fant, and the relationship between them may decrease the
mothers’ anxiety levels. This is an expected positive result.
Reflexology that is only given once in the latent phase may
not be very effective in reducing anxiety in the postpartum
period and the effect of this practice may weaken over time.
Hattan et al.
reported that only one application of relax-
ation methods is not as effective as regular sessions and that
such interventions should be repeated in individuals. There
are limited studies in the literature that show the effect of
or the ineffectiveness of reflexology on the
anxiety in the postpartum period.
There are very few studies in the literature that analyze
the effect of foot reflexology on anxiety during labor. For
this reason, this discussion was performed in a limited
Strengths and limitations of the study
The originality of the study, the similarity of the socio-
demographic and obstetric characteristics of the pregnant
women in the experimental and control groups, the sample
containing low-risk pregnant women, the standard care
and follow-up for both groups, and the limited studies on
the subject are strong aspects of this study. In addition, it is
thought that this study will make contribution to facilitating
the transition from the intrapartum to the postpartum period
and motherhood by decreasing the anxiety of the pregnant
women during labor.
The limitations of the study are that all the pregnant
women were nulliparous and the reflexology was applied
only once to the experimental group. In addition, the
possible effect of some individual characteristics of the
pregnant women and their histories (e.g., trauma) on their
anxiety was not sufficiently excluded.
Recommendations for clinical practice
Applying reflexology not only in the latent phase of
labor but also in the later phases of labor (active phase,
transition phase, etc.) may be more effective in reduc-
ing anxiety.
Reducing and eliminating factors that may negatively
affect the anxiety of the pregnant women increases the
effect of reflexology. These factors can be divided into
two groups: factors regarding health professionals
(their attitudes and behaviors, etc.), and factors re-
garding the delivery environment (number of people
in the labor room, noise, etc.).
It is recommended that reflexology should be widely
practiced by midwives and obstetricians working in
delivery wards.
Reflexology should be used as an evidence-based in-
dependent midwifery practice after specific training has
been given.
Suggestions for further studies
It is recommended that qualitative studies be conducted
involving the emotions, thoughts, and attitudes of preg-
nant women/mothers about receiving reflexology during
Studies should be conducted with larger populations.
It is recommended that monitoring studies for reflex-
ology be conducted.
Foot reflexology given to pregnant women had the posi-
tive effect of reducing the total anxiety score in the exper-
imental group compared with the control group. When
reflexology was used to try to reduce the anxiety scores of
the experimental group in the latent and active phases, there
was no effect. However, the anxiety scores of the experi-
mental group in the latent and active phases were lower than
those of the control group.
According to all these results, foot reflexology during
labor can be used to reduce anxiety in pregnancy. A more
widespread use of this practice and at different stages of
labor may increase the effectiveness of this intervention.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Songul Aktas, PhD
Faculty of Health Sciences
Department of Obstetrics
and Women Health Nursing
Karadeniz Technical Universty
Trabzon 6100
... The number of older people who suffered from hypertension and lived in Kalumpang PHC working area was 127 people. Erkek and Aktas (2018) and Kaze et al. (2017) also found that the prevalence of older people who experienced hypertension followed by anxiety was higher in urban areas. In determining the subjects, the researchers got the participants list from monthly health check-ups (MHC). ...
... This study's results are consistent with a study by Alimohammad et al. (2018), which indicates a tendency for differences in anxiety levels in patients receiving therapeutic foot massages before and after the intervention (30.00 ± 3.74 decreased to 21.86 ± 1.68). A study also shows a significant decrease in the intervention group's anxiety levels when baseline data compared to post-intervention data (Yllar Erkek & Aktas, 2018). The study is also supported by the results of Eguchi et al. (2016), which shows a significant decrease in anxiety levels in the intervention group compared to baseline (41.1-38.0). ...
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Background Globally, the prevalence of hypertension, especially in older people, is relatively high and increasing annually. In addition to hypertension, many older people also experience anxiety. Interventions are needed to reduce blood pressure and overcome anxiety, one of which is foot massage. Objective To determine the effect of foot massage on reducing blood pressure and anxiety in older people with hypertension. Method This study was a one-group pre-test–post-test design with a time-series design for measuring blood pressure and assessing the degree of anxiety after foot massage intervention for 12 sessions. Thirty older people with hypertension and anxiety participated in this study. Results A significant decrease in anxiety was observed after the 6th and 12th sessions of foot massage intervention ( P < 0.05). A significant decrease was observed in systolic blood pressure after the 12th intervention compared to baseline and 8th intervention ( P < 0.05). Conclusion Foot massage intervention is effective in reducing blood pressure and anxiety in older people with hypertension.
... The required sample was determined with the independent t-test using G* power software free 42 with an estimated effect size of 0.65 as the reduction in anxiety scores measured via the Spielberger State-trait Anxiety Inventory in the intervention group was compared to the control group. 18,[43][44][45] The total number was 184 with 92 in each group after an adjustment of (20%) for those who gave no response and/or dropped out. However, the sample size was further inflated when the primigravidae encountered, in the early recruitment, and expressed a high preference for pain relief, and thus a higher attrition rate was anticipated, and an increased possibility of participants that can turn into a cesarean section delivery was noted. ...
... This positive impact in lowering anxiety has also been observed in studies in Iran and Turkey in which foot reflexology was reported to decrease the anxiety on Spielberger State-Trait Anxiety Inventory. 44,58 Similarly, other studies that used sacral massage, massage, and the presence of an attendant as an intervention also reported lower anxiety in the intervention group. 43,56,60 The same mechanism of action via the stimulation of the parasympathetic nervous system, along with the release of endorphin, encephalin, and enkephalin, cumulatively decreases the heart rate and the release of stress hormones, and correspondingly increases feelings of calmness in the body. ...
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Background: Labor pain and anxiety are important concerns during labor, especially among the primigravidae. It may increase the duration of labor, increase stress hormones, and affect maternal and new-born related outcomes. This study examined the effectiveness of combined breathing exercises, foot reflexology, and massage (BRM) interventions on labor pain, anxiety, labor duration, stress hormone levels, maternal satisfaction, maternal vital signs, and the new-born's APGAR scores. Participants and methods: This single-blind-parallel randomized controlled trial (RCT) was conducted at the Maternity and Children Hospital (MCH), Makkah, Saudi Arabia, by recruiting primigravidae aged 20 to 35 years, without any medical complications, and who were block-randomized at six-centimeter cervical dilation and stratified by intramuscular pethidine. The intervention is BRM compared to standard care. The labor pain was measured via present behavioral intensity (PBI) and visual analogue scale (VAS), and the anxiety was measured via Anxiety Assessment Scale for Pregnant Women in Labor (AASPWL). The secondary outcomes were duration of labor, maternal stress hormone levels, maternal vital signs, maternal satisfaction, fetal heart rate, and APGAR scores. All outcomes were measured at multiple time-points during and after contraction at baseline, during BRM intervention, at 60, 120, and 180 minutes post-intervention. Generalized linear mixed models were used to estimate the intervention effects over time. Results: A total of 225 participants were randomized for the control (n = 112) and intervention group (113). BRM lowered the labor pain intensity at 60 minutes after intervention during (1.3 vs 3.5, F = 102.5, p < 0.001) and after contraction (0.4 vs 2.4, F = 63.6, p < 0.001) and also lowered anxiety (2.9 vs 4.2, F = 80.4, p < 0.001). BRM correspondingly lowered adrenocorticotropic (ACTH) (133 vs 209 pg/mL, p < 0.001), cortisol (1231 vs 1360 nmol/mL, p = 0.003), and oxytocin (159 vs 121 pg/mL, p < 0.001). It also shortened the labor duration (165 vs 333 minutes, p < 0.001), improved vital signs, which resulted in higher APGAR scores, and increased maternal satisfaction. Conclusion: The labor unit management could consider adopting BRM as one of the non-pharmacological analgesia for healthy women in labor. Trial registration: ISRCTN87414969, registered 3 May 2019.
... The results obtained were encouraging and significant, but their power was low [12,13]. Many publications report on the use of FRin obstetrics [14,15], surgery [16], cardiology [17,18], pediatrics [19,20], hematology [21], radiology [22], and orthopedics [23], with significant results. However, there were none on palliative care. ...
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Background In palliative care, the relief of discomfort is sought by an overall approach, combining prescribed medication and additional therapies, such as foot reflexology (FR). The main objective of this study was to assess the feasibility of FR in a population of inpatients in a palliative care unit (PCU).The precariousness of the patients led us to perform a feasibility study and not a cohort study from the outset. Its secondary objective was to assess the impact of an FR session on some symptoms of discomfort (anxiety, pain, troubled sleep, and psychological distress). Methods This is a feasibility study designed as a randomized controlled two-arm therapeutic trial. One arm tested FR, the other an active control, massage therapy (MT). The evaluators were blinded. Results FR was feasible for 14 patients out of the 15 included in the FR group (95% CI [68%; 100%]). These patients were in the palliative care phase of cancer, motor neuron disease, or terminal organ failure. Concerning the symptoms of discomfort, ESAS sleep quality score was on average 3.9 (± 2.5) before a session in the FR group. It was improved to an average of 3 (± 2.3) on the day after the session (effect-size = 0.38 [0.03; 0.73]). Conclusion This study confirms the feasibility of an FR session for patients hospitalized in a PCU. It resulted in a slight improvement in sleep quality. For other discomfort symptoms such as anxiety, pain and distress, FR yielded a non-significant improvement. Significant results would have needed a larger cohort.
Amaç: Araştırma, doğum eyleminde olan kadınların yaşadıkları ağrı ile baş edebilmek için bildikleri nonfarmakolojik yöntemleri sorgulamak ve bu yöntemlerden hangilerini tercih ettiklerini belirlemek amacıyla yapılmıştır. Yöntem: Tanımlayıcı olarak tasarlanan araştırmanın evrenini 01.07.2019- 01.03.2020 tarihleri arasında Adıyaman ilindeki bir hastanenin doğumhane servisine yatışı yapılan 250 kadın oluşturmuştur. Örneklem seçiminde gelişigüzel örnekleme yöntemi kullanılmıştır. Araştırmaya, doğum eylemi başlamış, gebelik haftası term olan, vajinal doğum planlanan, kendisinde-bebeğinde herhangi bir sağlık sorunu bulunmayan, tek fetüse sahip, tedavi gebeliği olmayan gebe kadınlar dahil edilmiştir. Veri toplama aracı olarak Katılımcı Bilgi Formu kullanılmıştır. Verilerin analizinde yüzde, ortalama, standart sapma, Kruskal Wallis Testi ve Mann Whitney U Testleri kullanımıştır. Bulgular: Araştırmada kadınların doğum ağrısına yönelik tercih ettikleri nanfarmakolojik yöntemler incelendiğinde; sırasıyla en fazla pozisyon değişikliği (%93.6), bele masaj (%76), sosyal destek (62.8), doğum topu (%47.2), müzik dinleme (%40.4), sacruma masaj (%34.8), aromaterapi (%26), perine masajı (%14.8), yoga/meditasyon (%11.2), sıcak uygulama-perineal sıcak uygulama (%9.6), soğuk uygulama (%8.8), acupres (%6), akupunktur (%4), hipnoz (%2.8), İntradermal Steril Su Enjeksiyonu (%2), Transkütanöz Elektriksel Sinir Stimulasyonu (%0.8) yöntemlerini tercih ettikleri saptanmıştır. Sonuç: Araştırmamızda kadınların tamamının doğum ağrısını azaltmak amacıyla herhangi bir nanfarmakolojik yöntemi tercih ettikleri anlaşılmaktadır. Doğum eyleminde kadını rahatlatan nanfarmakoljik yöntemlerin, doğumhanelerde uygulanması, gebelerin doğum eylemini daha memnun tamamlamalarına olanak sağlayacaktır.
Many women and individuals assigned female at birth experience sexual assault or abuse in their lives leading to sexual trauma. In this article, we review the effects of sexual trauma and resulting chronic stress on the body and during the perinatal period. Maternal, fetal, and neonatal health implications are discussed. Routine screening for sexual assault and violence can assist with early identification and intervention. A variety of modalities and methods for managing the effects of sexual trauma have been identified, including pharmacologic treatment, psychotherapy, complementary and alternative medicine, and shared decision-making. Further research regarding different treatments is essential to find additional tools to aid clinicians providing care to this vulnerable population. When nurses care for individuals with a history of sexual trauma, incorporating trauma-informed care can help prevent retraumatization and promote a healthy perinatal experience.
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Background: The factors related to the satisfaction of women during labour vary widely. Pain relief is one of the fundamental weaknesses, so it could influence the rating of the rest of the satisfaction items. The use of Transcutaneous Electrical Nerve Stimulation (TENS), like a non-pharmacologic pain relief approach, is a safe and effective technique used during childbirth. Measure for Testing Satisfaction (COMFORTS) scale is a specific questionnaire that includes the most important factors associated with the relation between mother satisfaction and the childbirth experience Aim: to analyse factors influencing satisfaction in pregnant women during labour and its relationship with pain management. Design: A randomized and double-blind controlled trial was conducted. All participants completed the satisfaction scale immediately after childbirth. Methods: A total of 63 participants were randomly assigned to one Transcutaneous electric nerve stimulation (TENS) device to relieve the pain, with different dose in each patients group. This was measured with two scales; the satisfaction level was measured with the COMFORTS scale and pain was measured with the Visual Analogue Scale (VAS). Results: the total satisfaction scale mean score was 171.03 (SD 19.69) with an individual item mean of 4.28. Women who expressed a low level of satisfaction had experienced severe pain. A lower degree of satisfaction was observed in women with severe pain (3.03 ± 1.1) than in women with moderate pain (4.53 ± 0.7). Women who have had more than one delivery presented the highest level of satisfaction, followed by nulliparous and those who have had a previous pregnancy. Conclusions: Overall, high level of satisfaction during labour was obtained; we recommend the use of Transcutaneous electrical nerve stimulation for pain relief to improve general satisfaction. Trial registration: ID: NCT03137251. First registration: 02/05/2017 Protocol:
This book discusses human–computer interaction (HCI) which is a multidisciplinary field of study which aims at developing and implementing tools and techniques to attain an effective and efficient interaction between the humans (the users) and computers. In recent years, there is an increase of interest of HCI researchers and practitioners in the inclusion of gaze gestures which can greatly enhance the communication between the human user and the computer, as well as other more “physical” communication involving all what can be learned from movements of the human body, from face, hand, leg, foot, etc., to the whole body movement, even extending to the involvement of groups of agents, even society. These explicitly human-centric issues in the development, design, analysis, and implementation of the HCI systems are discussed in the book. A comprehensive state of the art is given complemented with original own proposals. As opposed to more traditional formal and IT based analyses, the discussion is here more focused on relevant research results from psychology and psychophysiology, and other soft, cognitive, etc., sciences. Remarks on the relevance of affective computing are also mentioned.
What does the future hold for motion-based interaction methods? Will increasingly popular concepts and inventions, such as immersive virtual reality, hasten their already rapid development? Or will they be supplanted by other solutions, such as interfaces capable of reading brain activity directly, or those that recognize voice commands? Neither of these require movement. Each enables new perspectives for both users and technology, but also carry many risks. The development of technologies related to the recording of movement, such as immersive virtual reality, is also of high importance for other branches of science, including psychology. To date, no solution has facilitated the analysis of human behaviors by psychologists in such a detailed manner, nor in such natural environments.
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Reflexology is basically a study of how one part of the human body relates to another part of the body. Reflexology practitioners rely on the reflexes map of the feet and hands to all the internal organs and other human body parts. They believe that by applying the appropriate pressure and massage certain spots on the feet and hands, all other body parts could be energized and rejuvenated. This review aimed to revisit the concept of reflexology and examine its effectiveness, practices, and the training for reflexology practitioners. PubMed, SCOPUS, Google Scholar, and SpringerLink databases were utilized to search the following medical subject headings or keywords: foot massage, reflexology, foot reflex-otherapy, reflexological treatment, and zone therapy. The articles published for the last 10 years were included. Previous systematic reviews failed to show concrete evidence for any specific effect of reflexology in any conditions. Due to its non-invasive, non-pharmacological complementary nature, reflexology is widely accepted and anecdotal evidence of positive effect reflexology in a variety of health conditions are available. Adequate training for practitioners is necessary to ensure the consistency of service provided.
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Reflexology is a technique used widely as one of non-pharmacological pain management techniques. The present study aimed to review and determine the effect of foot reflexology on anxiety, pain and outcomes of the labor in primigravida women. This clinical trial study was conducted on 80 primigravida mothers who were divided randomly into an intervention group (Foot reflexology applied for 40 min, n=40) and control group (n=40). The pain intensity was scored immediately after the end of intervention and at 30, 60 and 120 min after the intervention in both groups, based on McGill Questionnaire for Pain Rating Index (PRI). Spielberger State-Trait Anxiety Inventory (STAI) was completed before and after intervention in both groups. Duration of labor phases, the type of labor and Apgar scores of the infant at the first and fifth minute were recorded in both groups. Descriptive and inferential statistics methods (t-test and chi-square test) were applied in analyzing data. Application of reflexology technique decreased pain intensity (at 30, 60 and 120 min after intervention) and duration of labor as well as anxiety level significantly (P<0.001). Furthermore, a significant difference was observed between two groups in terms of the frequency distribution of the type of labor and Apgar score (P<0.001). Results of this study show that reflexology reduces labor pain intensity, duration of labor, anxiety, frequency distribution of natural delivery and increases Apgar scores. Using this non-invasive technique, obstetricians can achieve, to some extent, to one of the most important goals of midwifery as pain relief and reducing anxiety during labor and encourage the mothers to have a vaginal delivery. © 2015 Tehran University of Medical Sciences. All rights reserved.
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The aim of this interventional correlational study is to compare the effects of foot reflexology (FR) and connective tissue manipulation (CTM) in subjects with primary dysmenorrhea. DESIGN: A total of 30 participants having primary dysmenorrhea completed the study. Data, including demographics (age, body-mass index), menstrual cycle (age at menarche, menstrual cycle duration, time since menarche, bleeding duration), and menstrual pain characteristics (intensity and duration of pain, type and amount of analgesics), were recorded. Effect of dysmenorrhea on participants' concentration in lessons and in sports and social activities was assessed by using the visual analog scale. Participants rated their menstruation-related symptom intensity through the Likert-type scale. FR was applied to 15 participants for 3 days a week and CTM was performed on 15 participants for 5 days a week. Treatments were performed during one cycle, which started at the third or fourth day of menstruation and continued till the onset of next menstruation. Assessments were performed before treatment (first menstruation), then after termination of the treatment because of the next menstruation's onset (second menstruation), and ∼1 month after at the consecutive menstrual period (third menstrual cycle). RESULTS: Time-dependent changes in duration and intensity of pain along with analgesic amount show that both treatments provided significant improvements (p < 0.05) and no superiority existed between the groups (p > 0.05). A similar result was obtained in terms of time-dependent changes in concentration in lessons and difficulty in sports and social activities due to dysmenorrhea. Menstruation-related symptoms were found to be decreased after treatment and in the following cycle with both treatments (p < 0.05) where no difference existed between the groups (p > 0.05). CONCLUSION: Both FR and CTM can be used in the treatment of primary dysmenorrhea and menstruation-related symptoms as these methods are free from the potentially adverse effects of analgesics, noninvasive, and easy to perform.
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Background: Women can experience a range of psychological problems after birth, including anxiety, depression and adjustment disorders. However, research has predominantly focused on depression. Qualitative work on women’s experiences of postnatal mental health problems has sampled women within particular diagnostic categories so not looked at the range of potential psychological problems. The aims of this study were to explore how women experienced and made sense of the range of emotional distress states in the first postnatal year. Methods: A qualitative study of 17 women who experienced psychological problems in the first year after having a baby. Semi-structured interviews took place in person (n = 15) or on the telephone (n = 2). Topics included women’s experiences of becoming distressed and their recovery. Data were analysed using Interpretative Phenomenological Analysis (IPA). Themes were developed within each interview before identifying similar themes for multiple participants across interviews, in order to retain an idiographic approach. Results: Psychological processes such as guilt, avoidance and adjustment difficulties were experienced across different types of distress. Women placed these in the context of defining moments of becoming a mother; giving birth and breastfeeding. Four superordinate themes were identified. Two concerned women’s unwanted emotions and difficulties adjusting to their new role. “Living with an unwelcome beginning” describes the way mothers’ new lives with their babies started out with unwelcome emotions, often in the context of birth and breastfeeding difficulties. All women spoke about the importance of their postnatal healthcare experiences in “Relationships in the healthcare system”. “The shock of the new” describes women’s difficulties adjusting to the demands of motherhood and women emphasised the importance of social support in “Meeting new support needs”. Conclusions: These findings emphasise the need for exploration of psychological processes such as distancing, guilt and self-blame across different types of emotional difficulties, as these may be viable target for therapeutic intervention. Breastfeeding and birth trauma were key areas with which women felt they needed support with but which was not easily available.
In the early postnatal period, the differences in the plasma levels of stress hormones and glucose were investigated in healthy neonates born by normal vaginal delivery (VD) and elective cesarean section (C/S) whose mothers were healthy. Forty term neonates were included in the study (20 VD, 20 C/S). The plasma adrenocorticotrophic hormone (ACTH), growth hormone (GH), prolactin, and glucose levels of neonates were measured at 0., 4., and 24. hours. The plasma ACTH values were found higher in newborn born by VD. Serum cortisol levels did not different at 0. and 4. hours in each group, but it was observed higher in neonates delivered by VD at 24. hours. Prolactin and GH levels were equal in neonates delivered by VD and C/S. The blood glucose levels were found lower in newborns delivered by C/S at 0. and 4. hours.The-difference of blood glucose levels between the two groups disappeared at 24. hours. The higher plasma ACTH values in newborns delivered by VD than delivered by C/S lead us to think that the VD delivery caused more stress to the newborns. The plasma cortisol. GH, and prolactin levels were not affected by delivery type. The blood glucose level was found lower in neonates delivered by C/S during early postnatal period, but these babies were able also to keep glucose homeostasis in the levels of VD babies.