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The Effect of Foot Reflexology on the Anxiety Levels
of Women in Labor
Zu¨ mru¨ t Yılar Erkek, MSc, PhD
1
and Songul Aktas, PhD
2
Abstract
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
Introduction
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.
1
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.
2
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.
3–5
The stimulation
of the sympathetic system due to pain, stress, and anxiety
1
Department of Midwifery, Gaziosmanpasxa University, Tokat, Turkey.
2
Faculty of Health Sciences, Department of Obstetrics and Women Health Nursing, Karadeniz Technical Universty,
Trabzon, Turkey.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE JACM
Volume 24, Number 4, 2018, pp. 352–360
ªMary Ann Liebert, Inc.
DOI: 10.1089/acm.2017.0263
352
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.
4–12
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.
7,8,10,13
Today, various methods are used to prevent adverse
events related to birth anxiety and reduce the anxiety of
women during delivery.
3
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.
14–16
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.
17–22
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.
14–17,23–27
Smitha and Bindu found that
foot reflexology reduced birth pain,
25
McNeill et al. found
that the need for analgesia is lower in primiparous pregnant
women who have had reflexology
17
and Dolation et al.
found that it shortens labor pains and the duration of labor.
15
Hanjani et al. and Mirzaee and Kaviani found that foot re-
flexology during delivery significantly reduces the anxiety
levels of the pregnant women.
23,24
Controversially, some
studies found that reflexology had no significant effect on
the process of giving birth.
27,28
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.
29,30
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.
27,31
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.
32
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).
EFFECT OF FOOT REFLEXOLOGY IN LABOR 353
Measurements
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.
33
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
levelissaidtoincreasewithanincreaseinscore.Inevalu-
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.
33,34
Interventions
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.
35
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).
14,15,18,19,36
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.
354 YILAR ERKEK AND AKTAS
(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
cause).
37
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.
Results
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 47.81–9.33 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.
14,15,18,19,34
EFFECT OF FOOT REFLEXOLOGY IN LABOR 355
FIG. 3. Application steps of STAI TX-I.
STAI TX-I, Spielberger State-Trait Anxiety
Inventory.
Table 1. Comparison of the Experimental and Control Groups According to Descriptive Characteristics
Characteristics
Experimental group (n=77) Control group (n=77)
Test and p-valueNumber % Number %
Age w
2
=0.03
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
2
=2.09
High school graduate 21 27.3 16 20.8 df =3
University graduate 4 5.1 8 10.4 p=0.550
Profession w
2
=1.71
Housewife 74 96.1 70 90.9 df =1
Officer 3 3.9 7 9.1 p=0.193
Residence
Village 18 23.4 32 41.5 w
2
=5.81
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
2
=1.46
Medium 49 63.6 43 55.8 df =2
Good 22 28.6 24 31.2 p=0.470
Duration of marriage w
2
=0.49
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
2
=0.20
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
2
=7.68
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
2
=0.05
Yes 10 13.0 11 14.2 df =1
No 67 87.0 66 85.8 p=0.810
*
p<0.05.
356 YILAR ERKEK AND AKTAS
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
scores.
Discussion
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.
14–17,38
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.
23
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
24
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.
39
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
sessionofreflexologywasappliedtotheexperimental
group(inthelatentphase)andtheeffectofthisonanxiety
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.
40
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
Test
d
and p-valueMean –SD
c
Mean –SD
c
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
a
Active phase 54.64 –9.45 60.32 –8.14 t=3.39, p<0.001
b
Early postpartum period 33.89 –7.37 35.92 –7.23 t=1.72, p=0.080
Total
f
45.97 –6.43 48.94 –6.05 t=2.95, p<0.001
b
F=109.21
e
F=149.3
e
p<0.001
b
p<0.001
b
a
The statistical difference was found significant p<0.05.
b
The statistical difference was found significant, p<0.001 (p=0.000 was evaluated as p<0.001).
c
Standard deviation.
d
Student ttest.
e
Repeated measures ANOVA (analysis of variance).
f
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.
EFFECT OF FOOT REFLEXOLOGY IN LABOR 357
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.
41
Coates et al. reported that mothers
with high maternal stress and anxiety did not welcome
their babies and that they had more postpartum distress.
42
The reduction of the anxiety of the pregnant woman at
laborcontributestoanimprovedstateofhealthofboththe
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.
43
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
reflexology
44
or the ineffectiveness of reflexology on the
anxiety in the postpartum period.
45
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
manner.
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
labor.
Studies should be conducted with larger populations.
It is recommended that monitoring studies for reflex-
ology be conducted.
Conclusion
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
Turkey
E-mail: songulbora@mynet.com;
saktas@ktu.edu.tr
360 YILAR ERKEK AND AKTAS
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