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��ࡱ�>��	�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������Y�	�R���bjbj[�[�z�9�
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\g�*������������$�������Pt�<�C>�����"8Z!L�"��=�=�=�=�=�=�=$EE��G>�=9�N#""N#N#�=����4�=$,$,$,N#Z����R<L$,N#�=$,$,�v:|�;�������3�kK������'b�:><>0C>;~9H
*9H$�;9H��;�N#N#$,N#N#N#N#N#�=�=$,N#N#N#C>N#N#N#N#��������������������������������������������������������������������9HN#N#N#N#N#N#N#N#N#Rd:	Title: Effects of yoga intervention on mental and physical health during pregnancy
Authors: 
Hsiao-Ling Huang1, Ling-Li Wang2, Chien-Ming Tsao3, Shu-Chin Tung4, City C. Hsieh4,5
Affiliations:
1Department of Healthcare Management, Yuanpei University, Hsinchu, Taiwan
2One Yoga Studio, Hsinchu, Taiwan 
3Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan 
4Department of Health and Leisure Management, Yuanpei University, Hsinchu, Taiwan 
5Department of Physical Education, National Tsing Hua University, Hsinchu, Taiwan 
Corresponding author:
City C. Hsieh, Ph.D. 
Department of Physical Education, National Tsing Hua University, Hsinchu, Taiwan 
P. O. Box, 10-95, Hsinchu, Taiwan, 300
E-mail:  HYPERLINK "mailto:chsieh@" chsieh@mail.nd.nthu.edu.tw 
Phone: +886-3-521-3132 
Fax: +886-3-562-6262

Effects of yoga intervention on mental and physical health during pregnancy
Abstract
Purpose: The purpose of this study was to investigate the effects of yoga intervention during pregnancy on depression, sleep quality, discomfort, maternal weight, pelvic floor muscle strength, labor duration, and gestational age in primiparous women, as well as birth weight and height of the infant.
Methods: Eighty gynecology outpatients were selected (control group, 40; yoga group, 40) and evaluated. A yoga intervention program was implemented from 29 weeks of gestation to prior to birth, with each session lasting 60 minutes per day, 3 days per week for 10-11 weeks. Participants were re-evaluated after delivery. 
Results: The depression score for pregnant women in the yoga group decreased significantly compared to the control group (p < .05). Sleep quality in the yoga group was significantly better than the control group (p < .05), and discomfort was significantly attenuated in the yoga group (+8.2%) compared to the control group (+60.9%). The increase in maternal weight during pregnancy was significantly lower in the yoga group (+24.98%) than in the control group (+30.66%), while pelvic floor muscle strength was significantly higher in the yoga group (-28%) than the control group (-45%) (p < .05). Furthermore, the duration of the first stage, second stage, and total labor were significantly shorter in the yoga group (p < .05). There was no significant difference in the gestational age of the pregnant women between the two groups and no significant differences in the birth weight and height of the infant between the two groups.
Conclusions: This study indicates that a yoga intervention could be beneficial for mental and physical health during pregnancy without a negative impact on the size of the newborn.

Keywords: Depression, Sleep quality, pregnanCY discomforts, pelvic floor muscle strength, labor duration
Introduction
Pregnancy is a very precious and important event and can be one of the happiest periods in the life of a woman. However, pregnancy is associated with profound anatomical and physiological changes, and is a unique state of physiological stress that necessitates both mental and physical adaptation. The traditional advice in China has been for pregnant women to refrain from initiating strenuous exercise programs. 
This advice was given because exercise could result in an increase in core body temperature during pregnancy, increased potential for congenital anomalies, and fluctuations in the delivery of oxygenated blood and energy substrates to the developing fetus given the increased energy demands of maternal skeletal muscle, leading to disorders in fetal growth (13). However, the risks associated with the of lack of physical activity during pregnancy also need to be considered by pregnant women and their care providers, including the loss of physical fitness, excessive maternal weight gain, greater risk of pregnancy-induced hypertension or diabetes mellitus, development of varicose veins, deep vein thrombosis, and low back pain, as well as poor psychological adjustment to the physical changes of pregnancy (39).

Most pregnant women do not exercise regularly and do not meet the standard set by the American College of Obstetricians and Gynecologists for the minimum amount of exercise needed to stay healthy during pregnancy. A study by Tung et al. (37) reported that 84% of pregnant women in Taiwan do not exercise regularly. Nearly four fifths (n = 526, 76.0%) of subjects did not exercise regularly before pregnancy, whereas 42.9% of subjects who did exercise previously continued exercising regularly after becoming pregnant. Among those who were inactive before pregnancy, 10.1% began exercising after becoming pregnant. In contrast, 57.1% of subjects who had been active before pregnancy stopped exercising regularly after becoming pregnant. Overall, it was found that subjects decreased the amount (minutes x times/week) of exercise they performed during pregnancy compared with the pre-pregnancy amount. The American College of Obstetricians and Gynecologists suggests that pregnant women with uncomplicated pregnancies should be encouraged to continue to engage in physical activity, and not be in a state of confinement (1). Yoga may be the optimal mode of exercise for pregnant women, especially in the third trimester when other more vigorous forms of exercise are discouraged. Yoga is derived from the Sanskrit term yuj, which means �to yoke or to join together.� It is an ancient system of physical and mental practice that originated in South Asia during the Indus Valley civilization. Yoga can be defined as a series of stretching exercises and postures (asanas) combined with deep breathing (pranayama) and meditation, which aim to unite the mind, body, and soul (15). Yoga is perceived as a way to develop and maintain a healthy mind and body and has become a popular mode of exercise among adults, and presumably during pregnancy.
The National Center for Complementary and Integrative Health (NCCIH) reported that yoga is a mind and body practice with historical origins in ancient Indian philosophy (27). Previous research has suggested that yoga is effective for improving function and reducing chronic low back pain (35), as well as lowering salivary cortisol levels and improving emotional well-being and fatigue scores (3). Studies also suggest that practicing yoga might have other health benefits such as lowering heart rate and blood pressure, and may also help to relieve anxiety, depression, and insomnia (27). 
A recent systematic literature review found that yoga interventions are generally effective at reducing anxiety and depression in pregnant women (33). In addition to anxiety and depression, pregnant women experience a greater degree of disturbed sleep, such as more awakenings, longer periods of wakefulness at night, and lower sleep efficiency than non-pregnant women. Previous studies have reported improved sleep and diminished fatigue in pregnant women who participate in yoga; however, Beddoe et al. (9) and Ko et al. (22) reported contradictory results. Beddoe et al. (9) completed a study using actigraphy and the General Sleep Disturbance Scale, and found that women who began mindfulness yoga in the second trimester had improvements in sleep, while women who received the intervention in the third trimester did not. Ko et al. (22) assessed sleep via a Fatigue Symptoms Checklist and found that the decrease in fatigue post yoga/exercise intervention was not significant. Sun et al. (36) conducted a study on the effects of a prenatal yoga program on the discomforts of pregnancy and maternal childbirth self-efficacy in Taiwan. All members of the experimental group were asked to watch a prenatal yoga videotape and practice the exercises at home at least three times a week, starting after the first yoga practice session and continuing for a period of 12�14 weeks. They found that women who took part in the prenatal yoga program reported significantly fewer complaints of discomfort than the control group.
The strength of the pelvic floor muscles (PFM) is decreased after childbirth, and vaginal delivery is accepted as the major cause of pelvic floor damage (2). One possible reason for choosing a cesarean delivery may be a fear of sexual dysfunction caused by the loss of PFM strength (17). Cesarean delivery has often been assumed to protect postpartum sexual function because it avoids trauma to the genital tract (5). However, studies have yet to examine the effect of a yoga intervention on PFM strength. In another pregnancy study, in which the yoga program involved six 1-h sessions (12), the yoga group had lower levels of maternal discomfort during labor and 2 h post-labor, and they experienced less pain than the control group. The yoga group also had a shorter duration of the first stage of labor as well as a shorter total duration of labor.
Although the benefits of yoga on mental and physical health have been highlighted, there have been no original studies investigating the effects of a yoga intervention on the holistic mental and physical health of primiparous women and their infants. Therefore, the purpose of this study was to investigate the effects of a yoga intervention during pregnancy on depression, sleep quality, discomfort during pregnancy, maternal weight, PFM strength, labor duration, and gestational age in primiparous women, as well as the birth weight and height of the infant.
Methods
Subjects 
This study had a quasi-experimental design. The Committee on Human Research at the University of Yuanpei, Taiwan, approved this study. Participation was voluntary. Each subject was assured that her data would be kept anonymous and confidential and participants were free to withdraw from the study at any time without repercussions. To maintain anonymity and confidentiality, completed data were given code numbers, kept in a locked file, and viewed only by investigators. The eligible primiparous women were between 28 and 29 weeks gestation when the intervention began. Gestational age was determined from the last menstrual cycle and was verified by ultrasound scan measurements when appropriate. 
The inclusion criteria for participants were as follows: (1) at least 20 years old, (2) singleton pregnancy, (3) no major obstetric or medical pregnancy complications according to the prenatal checklist, (4) planning a hospital birth, (5) normal extremities and able to perform exercise activities, (6) able to listen, speak, read, and write in Chinese, and (7) had not undertaken yoga or regular exercise for at least one year. Women who had multiple gestations, worked night shifts, had diagnosed depression, major longstanding sleep issues, a diagnosed sleep disorder, or planned a caesarean section, according to their medical records and self-reported data, were excluded. Subjects were recruited from the prenatal clinic of a large urban hospital in Hsinchu County, Taiwan. Informed consent was obtained from all women participating in the study. The nursing staff offered various prenatal education sessions, depending on gestation. All subjects received standard obstetric care. Ultimately, this study included 40 subjects in the yoga group and 40 subjects in the control group.

Yoga Intervention
Upon completion of pre-intervention testing, subjects participated in either the yoga intervention group or control group. The yoga intervention program was implemented from 29 weeks gestation until just prior to birth, with each session lasting 60 minutes per day, 3 days per week for 10-11 weeks, including a warm-up (10 minutes), the main exercises (40 minutes), and a cool down (10 minutes). The yoga intervention took place at a yoga studio and was designed and coached by a prenatal yoga specialist who had a master�s degree in exercise physiology and was a certified instructor in prenatal yoga, fitness, aerobics, and personal training. She had more than 10 years of experience in teaching prenatal and postnatal yoga, and had been a physical education instructor at a university in Taiwan. The yoga intervention incorporated the key asanas, the salient breathing techniques, relaxation poses (Shava Asana), and meditation. The yoga intervention program is described in Table 1.
 Measurements
The following demographic characteristics were collected: maternal age, weight, height, education, occupation, and gestational age, as well as the birth weight and height of the infant. 

Depression
Depression was assessed using the Beck Depression Inventory for Level of Depression, which is the most widely used tool for the self-assessment of level of depression for the purposes of clinical research (7). The questionnaire consists of 21 questions, each of which features 4 response options for questions related to the previous 2 weeks. A higher score for this questionnaire indicates a greater level of depression. The Chinese version of the Beck Depression Inventory possesses acceptable psychometric properties (34). The assessment of the Beck Depression Inventory was conducted at 28-29 weeks gestation, prior to the yoga intervention, and at the last prenatal visit at 38- to 40-week gestation. 

Sleep Quality
Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). The Chinese version of the PSQI has also been used extensively for a sleep quality study in dialysis patients in Taiwan (30). This self-administered questionnaire was applied in order to assess sleep quality during the previous 1-month period. The answers to seven components (each scored from 0 to 3) are calculated to provide the following information: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep-inducing medication, and level of daytime dysfunction (10). From the sum of the seven component scores, the global PSQI score can be calculated (0�21). A patient with a global PSQI score e" 5 is considered to be a poor sleeper and a patient with a value of < 5 is considered to be a good sleeper. The assessment of the PSQI was conducted at 28-29 weeks gestation, prior to the yoga intervention, and at the last prenatal visit at 38-40 weeks gestation.

Discomfort during Pregnancy 
The Pregnancy Discomfort Questionnaire (36) was used in this study. The questionnaire includes questions describing symptoms of discomfort such as back pain, varicose veins, cramps, edema of the ankles, hemorrhoids, headache, sleep disturbances, and fatigue, among others. Each item is scored on a five-point scale ranging from �very severe� (five points) to �none� (one point). There are 20 items in the questionnaire. Total scores ranged from 20 to 100. Previous research has demonstrated good internal consistency reliability and test-retest reliability of the Discomforts of Pregnancy Questionnaire in a Taiwanese population (36). In the study by Sun et al. (36), Cronbach�s alpha coefficient for the questionnaire was 0.84. The assessment of the Discomforts of Pregnancy Questionnaire was conducted at 28-29 weeks of gestation, prior to the yoga intervention, and at the last prenatal visit at 38-40 weeks gestation.

PFM strength
PFM strength was measured as a maximum voluntary contraction (MVC) using a perineometer. The sensor diameter was 26 mm wide and it was connected to the unit via an 80-cm plastic tube. The unit measured pressure in cm H2O. A standardized test procedure as described by van der Walt et al. (38) was used. The balloon catheter was compressed by an estimated 10% to allow for air expansion at body temperature and then connected to the silicon tubing of the PeritronTM 9300 perineometer (Cardio Design, Australia). The subject inserted the balloon sensor up to a mark, so that the middle of the balloon sensor was 3.5 cm from the introitus. The subject was instructed to contract the PFM as hard as possible and then to relax without pressing the perineum downwards. Strength measurements were accepted as correct when the gynecologist assessed that no visible co-contraction of the hip adductors, gluteals, or rectus abdominis muscles (posterior pelvic tilt) took place and the catheter was drawn inwards while the participant performed the PFM strength test (38). All evaluations of PFM strength were assessed by a single gynecologist at 28-29 weeks gestation prior to the yoga intervention and again at 4 weeks postpartum. 

Labor duration
For this study, the duration of the first stage of labor was calculated as the number of minutes between 3 cm of cervical dilation with regular uterine contractions until complete dilation (10 cm). The second stage of labor was defined as the time between full dilation of the cervix and delivery. The term �total duration of labor� was used for stages 1 and 2 combined (19). 

Data Analysis
Statistical analyses were performed using SPSS 18.0 (IBM Corp., Armonk, NY, USA). Data were calculated and presented as numbers and percentages or means and standard deviations. The independent group t-test was used to compare maternal age, weight, and height between the two groups; the duration of the first stage, second stage, and total labor; gestational age; and the birth weight and height of the infants. The chi-square test was used to compare educational level and occupation. The primary analyses compared changes from pre-intervention to post-intervention and between the yoga and control groups by using univariate analysis of covariance (ANCOVA) procedures in which the post-test value was the dependent variable, and the pre-test value of the same variable was the covariate. ANCOVA was performed for the change in depression, sleep quality, discomfort, maternal weight, and PFM strength from pre-test to post-test between the two groups. Statistical significance was defined as a p-value less than .05. Results
The demographic characteristics of the study subjects are shown in Table 2. The independent group t-test was used to compare maternal age, weight, and height between the two groups, while the chi-square test was used to compare educational level and occupation. There were no significant differences in these demographic characteristics between the yoga and control groups.

ANCOVA was performed for the change in depression, sleep quality, discomfort, maternal weight, and PFM strength from pre-test to post-test between the two groups. Table 3 shows the changes in mental health indicators between the two groups. The change in depression for pregnant women in the yoga group (-29.10%) from pre-test (18.90 � 6.50 points) to post-test (13.40 � 4.30 points) was significantly greater than that of the control group (-2.27%) from pre-test (17.65 � 5.80 points) to post-test (17.25 � 5.60 points). In addition, the change in sleep quality for women during pregnancy in the yoga group (+9.35%) from pre-test (4.98 � 2.42 points) to post-test (5.44 � 2.65 points) was significantly lower than the change in the control group (+76.76%) from pre-test (5.12 � 2.86 points) to post-test (9.05 � 3.42 points). Moreover, the change in discomfort for women during pregnancy in the yoga group (+8.18%) from pre-test (37.90 � 7.46 points) to post-test (41.00 � 8.13 points) was significantly lower than the change in the control group (+35.08%) from pre-test (38.70 � 9.13 points) to post-test (52.28 � 10.14 points).

The Table 4 shows the changes in physical indicators between the two groups. The change in maternal weight during pregnancy in the yoga group (+24.98%) from pre-test (53.95 � 5.43 kg) to post-test (67.43 � 5.88 kg) was significantly lower than the change in the control group (+28.97%) from pre-test (53.25 � 6.37 kg) to post-test (68.68 � 6.31 kg). Additionally, the change in PFM strength in the yoga group (-26.47%) from pre-test (44.58 � 7.34 cm H2O) to post-test (32.78 � 7.67 cm H2O) was significantly lower than the change in the control group (-44.68%) from pre-test (43.48 � 8.18 cm H2O) to post-test (24.05 � 6.03 cm H2O). The independent group t-test was used to analyze the difference in the duration of the first stage, second stage, and total labor, and gestational age, as well as the birth weight and height of the infants between the two groups. This study found that the duration of the first stage of labor was significantly shorter in the yoga group (332.00 � 83.02 min) than the control group (421.95 �1 05.01 min), and the duration of the second stage of labor was significantly shorter in the yoga group (32.00 � 9.01 min) than in the control group (57.00 � 12.00 min) as well. Table 4 also shows no significant difference in the gestational age of the pregnant women between the two groups and no significant differences in the birth weight and height of the infants.

Discussion
Changes in mental health indicators
Perinatal depression is common, with prevalence rates for major and minor depression as high as 20% during pregnancy (29). Pregnant women who obtain a high depression score should receive follow-up care and be provided with appropriate interventions for managing emotions to help them regain their mental health. Yoga could be a good intervention to promote mental health during pregnancy. This study found that the depression score for pregnant women in the yoga group decreased significantly compared to the control group. This is consistent with previous reports on the experiences of pregnant women with depression following yoga practice (25). The depressive symptoms were reduced in 55% of the yoga group participants as compared to 11% of the control group participants (25). Yoga offers the benefits of moderate intensity exercise and relaxation, while also contributing to improved sleep, and reducing fatigue and stress levels (32). Field and Diego (16) also pointed out that yoga appears to stimulate pressure receptors under the skin which, in turn, leads to enhanced vagal activity and reduced cortisol. The decrease in depression may be related to changes in brain waves and decreased cortisol levels achieved through yoga postures. This study indicates that a yoga intervention could be beneficial for the reduction of depression levels in pregnant women.
The physiologic and biochemical changes in pregnancy may place women at risk for developing specific sleep disorders. Hung et al. (18) revealed that the prevalence of pregnancy-associated sleep disturbance (PSQI score > 5) is 65.5%. The mean score of the global PSQI was 7.25 � 3.43, indicating that the participating pregnant women reported mild sleep disturbance in general. Trend analyses of PSQI scores indicated a linear trend, with a gradual decline in sleep quality as the pregnancy progressed. Sleep quality differed by trimester, such that women in later pregnancy experienced poorer sleep quality. This study also found the same trend in the control group. The sleep quality at the post-test (38-40 weeks of gestation) in the control group was significantly poorer than the pre-test (28-29 weeks of gestation), while there were no significant differences from pre-test to post-test in the yoga group. Furthermore, the change in sleep quality for women during pregnancy in the yoga group (+9.35%) from pre-test (4.98 � 2.42 points) to post-test (5.44 � 2.65 points) was significantly lower than the changes in the control group (+76.76%) from pre-test (5.12 � 2.86 points) to post-test (9.05 � 3.42 points). This study indicated that a yoga intervention could be beneficial for sleep quality in pregnant women. In a sample group with chronic insomnia, yoga led to improvements on virtually every sleep measure, including sleep efficiency, total sleep time, sleep onset latency, number of awakenings, and sleep quality measures according to sleep-wake diaries (20). Beddoe et al (9) studied the effects of mindful yoga on sleep in 15 pregnant women and found that women who received the intervention in the second trimester had significantly fewer awakenings and less perceived sleep disturbance at post-test than at pre-test. Those who began yoga during the third trimester ironically had poorer sleep over time. The use of actigraphy and the General Sleep Disturbance Scale in the Beddoe et al. study and the use of the PSQI for sleep quality assessment in our study may have led to different results with regard to sleep quality in the third trimester. Although this study showed that a yoga intervention could improve sleep quality in the third trimester, more studies are necessary to clarify this association. 
The results of this study revealed that the discomfort that women experience during pregnancy was significantly attenuated in the yoga group (+8.2%) than in the control group (+60.9%). This result is consistent with previous studies (12, 36). Chuntharapat et al. (12) reported that women who received a series of yoga sessions during mid and late pregnancy had higher levels of maternal comfort during labor and two hours after birth. In addition, Sun et al. (36) found that women who took part in the prenatal yoga program reported significantly fewer pregnancy discomforts than the control group. The gentle stretching that occurs while performing yoga positions (asanas) helps relieve the musculoskeletal discomforts of pregnancy and prepares the pelvic and lower extremity muscles for childbearing. The breathing and relaxation techniques of yoga promote improved respiratory capacity that alleviates pregnancy-related shortness of breath and enhances breathing during labor (26). Thus, the finding that the yoga group manifested lower investigator-observed pregnancy discomforts than the control group would be expected.

Changes in physical health indicators
One of the most important changes during pregnancy is in the metabolism of the mother, which results in a normal weight gain during pregnancy of approximately 11.4�15.9 kg (31). This creates a risk for maternal overweight, obesity, and complications to maternal health status, although an additional increase in maternal weight offers an energy reserve so that the mother can later feed her baby. The present study showed that the women of the yoga group gained less weight (13.48 � 1.72 kg) than those of the control group (15.43 � 1.24 kg). It should be noted that, according to our results, the weight gain of the pregnant women in the yoga and control groups is considered normal for a healthy pregnancy. To date, few studies have examined the effect of a yoga intervention on maternal weight gain during pregnancy, although studies have found that yoga interventions are generally effective for reducing body weight (23, 24). Regular yoga practice was significantly associated with weight loss by overweight participants according to an observational study of 15,550 participants aged 53�57 years (23). Moreover, after a four-day residential yoga training program followed by one hour of home practice daily for 14 weeks, one study found a significant loss in average body weight by 1.78 kg among participants with risk factors for coronary artery disease (24). Yoga is a mode of physical activity containing of various postures (asanas), breathing, and meditation skills. Yoga practice could result in energy expenditure. Therefore, the results of this study demonstrate that yoga interventions can attenuate maternal weight gain during pregnancy. 
The PFM consist of two muscular layers, the pelvic diaphragm and the urogenital diaphragm (the striated muscles and the external genital muscles in the perineal membrane). The muscular layers form a structural support; a fast and strong contraction of the PFM ensures continence during an abrupt increase in abdominal pressure (14). One study showed that PFM strength decreases after vaginal delivery, while another showed that it is not affected in women who deliver by cesarean section (2). Baytur et al. (6) investigated the particular role of the method of delivery and strength of the PFM in the sexual function of women and found that PFM strength was significantly lower in the vaginal delivery group than in the cesarean delivery and nulliparous groups. Fortunately, Nielsen et al. (28) reported the trainability of the pelvic floor and found that women had regained antenatal pelvic floor contraction pressures by 8 months after vaginal delivery if antenatal instruction on how to perform pelvic floor exercises was provided. In contrast, a group of women who were taught pelvic floor exercises before delivery regained their antenatal PFM strength. The present study was the first to investigate the effect of yoga practice on PFM strength during and after pregnancy in women planning vaginal delivery. Our study found that PFM strength in the control group (-45%) was significantly decreased (p < .05) compared to the yoga group (-28%). This result indicates that a yoga intervention during pregnancy could attenuate the decrease in PFM strength due to vaginal delivery. This may be attributed to the breathing exercises and the role of some of the yoga poses in strengthening the PFMs. This outcome could provide a basis for advocating for vaginal delivery. More studies are needed to assess whether it is possible to regain PFM strength by 8 months postpartum by performing strengthening exercises before delivery using a yoga intervention. 
In terms of labor duration, the findings of this study showed that the yoga group demonstrated a shorter duration of the first stage, second stage, and total labor compared to the control group. These results are somewhat similar to prior findings that showed that women who received a series of yoga sessions during mid and late pregnancy had a significantly shorter duration of the first stage of labor and the total duration of labor than the study control group (12). However, our finding of a shorter duration of the second stage of labor in the yoga group is in conflict with the findings of Chuntharapat et al. Studies of the effects of yoga interventions on the duration of labor are rather limited. Nevertheless, Beckmann and Beckmann (8) found that nulliparous women who exercised regularly had significantly shorter first and second stages of labor than did non-exercising nulliparous women. The shorter labor duration in the yoga group may be attributed to various postures (asanas), breathing, and meditation skills that improve PFM contraction and enhance breathing during labor. Further research is needed to examine the effect of yoga intervention on the duration of the second stage of labor. 
Carlo (11) reported that gestational age is the common term used during pregnancy to describe how far along the pregnancy has progressed. It is measured in weeks, from the first day of the woman's last menstrual cycle to the current date. A range from 38 to 42 weeks defines a normal pregnancy. Infants born before 37 weeks are considered premature. Infants born after 42 weeks are considered postmature. This study showed no significant difference in the gestational age of the pregnant women between the yoga group (39.05 � 0.81 wk) and control group (38.88 � 0.92 wk). This is in accordance with the study by Kim et al. (21). They conducted a study to evaluate whether pregnant women performing a combination of Western relaxation therapy and Eastern yoga and meditation would exhibit a decreased maternal and neonatal adverse response associated with delivery, and did not observe statistical differences between the experimental group (39.4 � 0.9 wk) and control group (39.5 � 0.9 wk). It should be noted that, according to the results of both studies, the gestational age of the pregnant women in the experimental and control groups was considered normal for a healthy pregnancy. Finally, no significant differences in the birth weight and height of the infants were found between the two groups. These findings are consistent with previous studies on yoga practice by pregnant women (21) and resistance exercise training (4). The results of this study suggest that yoga intervention does not have a negative impact on the birth weight and height of the infant.
Conclusion
The purpose of this study was to investigate the effects of yoga intervention during pregnancy on the holistic mental and physical health of primiparous women and their infants. According to the results of this study, yoga intervention can improve depression, sleep quality, and discomfort during pregnancy, which indicates that yoga intervention could be beneficial for mental health during pregnancy. In addition, yoga intervention can also attenuate maternal weight gain, decrease in PFM strength, and labor duration, which indicates that yoga intervention could also be beneficial for physical health during pregnancy. This study suggests that yoga intervention does not have a negative impact on the size of the newborn because no significant differences in the birth weight and height of the infants were found between the two groups. The findings presented in this study provide additional evidence of the benefits of yoga intervention during pregnancy for the maternal�fetal unit.

Acknowledgments
This work was supported by the National Science Council, Taiwan, NSC 100-2410-H-134 -016. We thank Yi-Chin Sun for assistance with the questionnaires. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. 
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the ethics committee of human research at the university of Yuanpei, Taiwan. Informed consent was obtained from all individual participants included in the study.
Conflict of interest: The authors declare that they have no conflict of interest.

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