Effect of Benson Relaxation Technique on Blood Pressure and Anxiety among Women with Pregnancy Induced Hypertension.

Background : Pregnancy induced hypertension is a major public health issue in both developed and developing countries, contributing to high perinatal mortality rates . Aim : To assess effect of Benson’s relaxation technique on blood pressure and anxiety among women with Pregnancy Induced Hypertension. Design : Quasi-experimental design was adopted in this study. Setting : It conducted at antenatal Unit of Women Health Hospital, Assuit University. Sample : Purposive sample of 50 women with pregnancy induced hypertension. Tools : Tool (I) Structured interviewing questionnaire, Tool (II) Blood pressure recording Sheet &Tool (III) Hospital Anxiety Scale (HAS) Results : There is statistically significant difference between pre & post implementation regarding blood pressure and anxiety levels with p-value .000. Conclusion : Benson relaxation technique was an effective intervention to control blood pressure and reduce anxiety levels for women with pregnancy-induced hypertension. Recommendations : Nursing staff should include Benson relaxation techniques in the nursing care plan for pregnant women with PIH.


Introduction
Pregnancy induced hypertension (PIH) is a significant contributor to both maternal and perinatal death and morbidity.It accounts for 18% of all maternal fatalities worldwide and impacts 4.2% of women in Egypt.The citation is from Suhartono et al. (2022).The World Health Organization and the American College of Obstetrics and Gynecology classify pregnancyinduced hypertension (PIH) into three groups.The first group is gestational hypertension, which occurs after the 20th week of pregnancy or within the first 24 hours after delivery.This type of hypertension is characterized by the absence of proteinuria and edema.Preeclampsia is a condition that typically occurs after the 20th week of pregnancy or within 2 weeks after delivery.It is characterized by high blood pressure (≥ 140/90 mmHg), proteinuria (excessive protein in the urine, > 300 mg/L), elevated levels of serum creatinine (> 30 mg/mmol), and edema (swelling).
Eclampsia, on the other hand, is a more severe form of preeclampsia that is accompanied by neurological symptoms such as seizures, hyperreflexia (exaggerated reflexes), headache, visual disturbances, or coma.(Arce-López et al., 2022) Maternal problems associated with Pregnancy-Induced Hypertension (PIH) include eclampsia, shock, and bleeding.Meanwhile, the potential dangers to the fetus include stillbirth, stunted growth in the womb, lack of oxygen, and being born prematurely.The citation is from Gupta et al. in 2023.Furthermore, a prevalent emotional issue that might occur during a pregnancy with a significant risk is anxiety, which is a reaction to feeling unsafe or endangered (Chan et al., 2020).
Anxiety is characterized as a state of worry or discomfort regarding anything that has an unpredictable result, and it has the capacity to coexist with, cause, or provoke despair.Pregnant women exhibit a higher vulnerability to anxiety, with a prevalence ranging from 15% to 23%, in contrast to a range of 3% to 5% in women who are not pregnant (Sayed et al., 2022

Research design:
A quasi-experimental design with pre and post-test was adopted to accomplish the stated aim.

Operational definitions
Pregnancy-Induced Hypertension (PIH): is operationally defined in this study as elevated blood pressure levels (> 140/90 mmHg) occurring after the 20th week of pregnancy.
Benson's Relaxation Therapy: is delineated in this study as Dr. Benson's recommended systematic and consistent breathing practices, steps, and techniques aimed at substantially reducing blood pressure.This involves easing the tension in the muscles surrounding constricted blood vessels through a regimen of 20-minute sessions, administered three times a day over a period of three days.

Study setting:
The research was conducted at the Antenatal Unit of Women's Health Hospital, specializing in high-risk pregnancies.The Women's Health Hospital provides the services to the whole Upper Egypt region.It is a six-story building with five floors designated for governmental entry and one floor designated for private entry.

Study Sample:
Purposive sampling was employed, involving a selection of 50 women diagnosed with Pregnancy-Induced Hypertension (PIH) and hospitalized.

Sample size calculation
The sample size was calculated using (Epiinfo statistical package, version 7.2, designed by the CDC (Centre for Disease Control and Prevention) with 80 percent power, a value of 2.5 is chosen at the acceptable limit of precision (D) at 95 percent confidence level (C1), with expected prevalence 10%, worst acceptable 25%.

Inclusion criteria:
• Women with Pregnancy-induced hypertension • No other medical issues.
• No psychiatric disorders •Hospitalized for at least three consecutive days

Tools of data collection:
Three tools were used to collect the data:

Tool (I): Structured interviewing questionnaire:
It divided into two parts as follows: 1 st Part: included personal data such as the woman's age, education, occupation, residency.

Tool (III): Hospital Anxiety Scale (HAS):
This scale was inspired by (Zigmond& Snaith ,1983) and adopted by researcher to assess anxiety level of women with pregnancy induced hypertension.It was a 14-item scale with two subscales, one to measure anxiety and one to measure depression.The researcher used only the anxiety subscale that consisted of seven items.
Where women were asked to choose one of four responses for each item graded from 0 to 3. The total score of 21 was divided into four categories.

Ethical consideration:
The Assuit University Faculty of Nursing's Research Ethics Committee approved the study with code No.
(1120240688).The participants were informed that their participation was entirely voluntary.The study's aim was explained to all participants by the researcher.They were assured that all obtained data would be kept confidential and used solely for the study.Prior to enrollment, the women gave verbal informed consent.

Pilot study:
A pilot sample of 10% of the participants (5 women) was taken to assess the questionnaire's clarity, integrity, and to calculate the duration required for collecting the data.There was no modification, and the pilot sample was included in the overall sample. Fieldwork:

Procedures
The study took place over four months from September 2023 to December 2023 and was divided into four phases: planning and preparation, assessment, implementation, and evaluation.

1-Planning &Preparation phase
During this phase, the researcher conducted a

2-Assessment phase
In this phase, each woman was interviewed face to face for 30 minutes to assess basic data using the developed interviewing questionnaire; as personal data, obstetric history and pre-test Blood pressure recording Sheet & Hospital Anxiety Scale (HAS) were also assessed face to face to obtain pretest blood pressure and anxiety level.

3-Implementation phase
While each woman was watching a video, the researcher demonstrated Benson relaxation technique for each woman individually.The woman then asked to apply it again.The Benson relaxation technique was implemented using the steps outlined below.
1-Sit in a comfortable position.
4-Gradually relax all of muscles, beginning with toes and feet and progressing to the entire body 5-Take naturally and slowly breaths through nose to inhale from three to five seconds, pause from three to five seconds, repeat the targeted words or phrases silently as she exhales from three to five seconds.
The preceding steps were repeated for 10-20 minutes.Benson relaxation was performed twice daily, three hours apart, for three days in a row.

4-Evaluation phase
To assess effect of Benson relaxation technique on blood pressure and anxiety, Blood pressure & anxiety levels were evaluated after completing the sessions of the three days using the same tools.

Table (1):
Displays the studied women's personal data.It reveals that nearly half (48%) of the women were between the ages of 30 and 35.
The mean age was 29.5 ±5.8.In terms of residence, more than two-thirds (80%) of the studied women live in rural areas.When it comes to education, nearly half (40%) of the women have a secondary education.Furthermore, more than two-thirds (72%) of women are unemployed.

Table (2):
Reveals the obstetric history and clarifies that (50%) of the studied women had gravida between 3 -4 and (60%) of the studied women had para between 3-4 and 3to 4 living children.(**) highly statistically significant difference Where the majority of the women have moderate and severe level of anxiety in pre-implementation while in post-implementation nearly two thirds of the women have normal level of anxiety.
This was consistent with (Ibrahim et al.,2022) who noted a statistically significant disparity in anxiety levels between the study and control groups with (P =0.000*).
Also (Ibrahim et al.,2019)  • To ensure that the findings are more generalizable, future studies should be done on a larger number of participants and a wider geographical region.

2
nd Part: included Obstetric history as number of paras, gravida, abortion, stillbirths, living children & weeks of gestations.Tool (II): Blood pressure recording Sheet: It was made by the researcheres to evaluate blood pressure.
comprehensive review of both domestic and global literature, along with many studies pertaining to the subject of the study, utilizing various sources such as publications, online resources, academic journals, and magazines.This also facilitated the development of research instruments.A film and instructional resources were developed to disseminate information about PIH (Pregnancy-Induced Hypertension) and the specific procedures included in the Benson relaxation technique.In order to ensure the effective implementation of the Benson relaxation technique, the researcher sought instruction and training from a mental relaxation therapist on how to properly execute the technique.

Figure ( 1 ):
Figure (1): Shows that history of pregnancy induced hypertension and polyhydramnios were the most common risk factors for pregnancy induced hypertension in the studied women (50%), (32%) respectively.

Figure ( 3
Figure (3): Shows a highly statistically significant difference in women's anxiety level in pre-and post-test p-value 0.000.
Figure 1: Percentage distribution of the studied women according to their risk factors for pregnancy induced hypertension (N=50).

Figure 3 :
Figure 3: Percentage distribution of women's total anxiety level in pre-test and post-test (N=50).Discussion discovered that those who acquired Benson relaxation techniques experienced a more substantial decrease in anxiety compared to those who did not.Also (Mohammadi & Parandin .,2019)who did their research in Iran and observed that integrating the Benson relaxation technique (BRT) with a brief psycho-educational intervention (BPI) can assist pregnant women minimize unfavorable psychological manifestations such as anxiety and stress.This result can be linked to muscle relaxation boosting the release of natural opioids (endorphins), which alleviate anxiety and mental stress in pregnant women.ConclusionThe Benson relaxation technique demonstrated efficacy as an intervention for women with pregnancy-induced hypertension in terms of blood pressure regulation and anxiety alleviation.Recommendations• Benson relaxation techniques should be incorporated in the nursing care plan for pregnant women experiencing PIH.• Nurses should receive training in the form of workshops and seminars to educate them on the benefits of the Benson relaxation technique and how to apply it.

Song et al.,2023).
Ginsberg et al. (2023)trated that pregnancy anxiety adversely affects the overall health of the growing fetus and accelerates the occurrence of postnatal depression.system,which is responsible for the "fight or flight" response, and enhance the response of the parasympathetic nervous system, which is responsible for the "rest and digest" response.The main objectives of this approach are to decrease arousal and induce a state of calmness, often achieved through techniques such as regulating breathing, alternating muscle tension and relaxation, or focusing the mind on positive ideas.The citation is fromGinsberg et al. (2023).H0: Benson's relaxation technique will not have any effect on blood pressure and anxiety levels among women with PIH H1: Women with PIH will have lower post-test mean systolic and diastolic blood pressure scores than pre -test mean scores following Benson relaxation technique H2: Women with PIH will have lower post-test mean anxiety scores than pre -test mean scores following Benson relaxation technique