Explore 17 (2021) 463 468

Contents lists available at ScienceDirect

Explore
journal homepage: www.elsevier.com/locate/jsch

Original Research

Effects of self-acupressure on pregnancy-related constipation:

A single-blind randomized controlled study
€ l, MD, PhD, Assistant Professorb,2
Ayça Şolt Kirca, PhD, Assistant Professora,1,*, Derya Kanza Gu
a
Kırklareli University School of Health, MidwiferyDepartment Kırklareli, Turkey
b
Medipol University School of Medicine Health, Gynecology and Obstetric Department, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Article History: Objectives: This study aimed to demonstrate that acupressure could be used to relieve the symptoms of con-
Received 2 June 2020 stipation during pregnancy.
Revised 14 July 2020 Design: Single-blind randomized controlled trial
Accepted 23 July 2020
Setting: Private Medipol Nisa Hospital, Istanbul, Turkey
Intervention: This trial including 120 women aged
20 years was conducted from November 2019 to Febru-
Keywords:
ary 2020. The participating women who were in the 1st, 2nd or 3rd trimester of their pregnancy, had single-
Self-acupressure
ton pregnancy and had a complaint of constipation were randomized into the acupressure (n = 75) and
Constipation
Pregnancy
control groups (n = 75). The women in the acupressure group applied 15 min of self-acupressure to the TH-6
Education acupuncture point twice a day for one week. The women in the control group received no intervention
treatment.
Main outcome measures: Constipation levels of the participants in the two groups were assessed before and
after the procedure using the Constipation Severity Instrument
Results: In the present study, after the application of self-acupressure, the severity of constipation decreased
significantly in the acupressure group compared to the control group (before treatment: 41.36 § 6.5 vs.
37.56 § 6.17 respectively, after treatment: 26.08 § 7.93 vs. 36.88 § 5.93, respectively, p < 0.01)
Conclusion: Although it is safe to use medical drugs in constipation associated with pregnancy, can’t reduce it
to the extent desired. This study's evidence indicates that self-administered acupressure can effectively alle-
viate the symptoms of constipation in clinical practice.
© 2020 Elsevier Inc. All rights reserved.

Introduction progesterone during pregnancy. Other factors influencing constipa-

In pregnancy, among gastrointestinal system (GIS) complaints,
constipation is second only to nausea.3,4 In their systematic review,
Rungsiprakan et al. (2015) determined that the prevalence of consti-
pation during pregnancy ranges from 11% to 44%.1 The results of a
study conducted in Turkey found the prevalence of constipation
among pregnant women to be 38.8% 47%.5,6 Several factors are
responsible for the development of constipation during pregnancy. In
pregnancy, the internal abdominal pressure is increased, and the
muscles (anal sphincters and levator ani muscle) that are primarily
responsible for the defecation process and supporting the pelvic
organs and the urethra are subjected to structural changes.4 Another
factor in decreasing bowel movements is the increase in the hormone
* Corresponding and First author, Kirklareli University School of Health, Midwifery
Department Kirklareli, Turkey.
E-mail addresses: aycasolt@hotmail.com (A. Ş. Kirca), deryakanza@yahoo.com
(D. Kanza Gu € l).
1
Orcid 0000-0001-6733-5348
2
Orcid 0000-0001-8879-9299
tion during pregnancy are the enlargement of the uterus, decreased
physical activity, stress, consumption of iron and calcium supple-
ments, inadequate fluid intake, and changes in diet.3,7 9 In their pro-
spective study, Van Brummen et al. (2006) found that pregnant
women in the first trimester (8.9%) suffered more constipation prob-
lems than women in their third trimester (4.5%).10 In Derbyshire
et al.’s (2006) study, the feeling of both difficulties in defecating and
incomplete emptying of the bowel was found to be high in all trimes-
ters of pregnancy.11 In a study conducted by Shamim and Begum
(2019) with 332 pregnant women, 62.3% of participants suffered
from pregnancy-related constipation.12
Although exercise, increased dietary fibre, and consuming more
water are recommended to alleviate constipation during pregnancy,
pharmacological drugs (laxatives) are often used for therapeutic pur-
poses,3,13 but the administration of these drugs may have negative
effects on the health of both mother and baby.3,14,15 Therefore, com-
plementary and alternative medicine has drawn more attention,
especially in recent years. Many women prefer to use non-pharmaco-
logical methods, such as acupuncture, acupressure, aromatherapy,

https://doi.org/10.1016/j.explore.2020.07.004
1550-8307/© 2020 Elsevier Inc. All rights reserved.
464
A. Ş. Kirca and D. Kanza Gu
homoeopathy, and herbal laxatives instead of pharmaceuticals.16 19
Acupressure is one of these methods. Acupressure is a manipulative
treatment method that ensures the essential balance of life energy
(Qi) through applied pressure on more than 365 and 2000 acupunc-
ture points via 14 main energy pathways (meridians) on the
skin.20,22,42 Qi is the vital energy found everywhere in the universe
and also all individuals are born with qi. The meridians like the
branches of a tree. The meridians provide that direct the flowing of
Qi all around the body.22 If qi is disrupted, the body fails to maintain
balance then diseases may occur. Acupressure helps to establish bal-
ance by helping the regulation of blood circulation and providing the
necessary qi energy for the body. Also, acupressure promotes the bal-
anced by releasing of many chemicals, such as beta-endorphin, sero-
tonin, dopamine, and adrenaline, into the blood.20 22,40,41 After that
when the body restores balance, pain, constipation, nausea, vomiting
and the other symptoms will reduce.20 23,25
Acupressure is an easy-to-apply, non-invasive, cost-effective, and
safe method that can be applied by a specialist or by a patient after
being taught the technique.23,24 A review of previous studies in the
literature revealed that acupressure application increased the intesti-
nal motility of tested individuals and improved the symptoms of
constipation.2,19,25 27 There are several acupressure points (LIV3,
ST36, SP15, CV12, CV4, ST25, SP14, ST37, and TH-6) related to reduc-
ing constipation symptoms.19,25,29,30 In the current study, the Triple
Heather Meridian (TH-6) acupressure point (which in four finger-
widths above the wrist on the back of the forearm) was chosen
because it is easy to find, and the pregnant women can apply self-
acupressure on this point. In the literature review, although a consid-
erable amount of research can be found devoted to the investigation
of how acupressure reduces constipation in women with chronic
constipation, patients undergoing hemodialysis, and patients with
Fig.. 1. Diagram showing the recruitment of pregnant women and progression throughout the trial.
€ l / Explore 17 (2021) 463 468
cancer,19,25,27,28 no attention has been paid to the application of acu-
pressure to reduce pregnancy-related constipation or to teaching this
practice so the person can perform it on herself. With regard to these
few evidence, we hypothesized that the woman's ability to perform
this application by herself may have reduce the need for laxatives
used to eliminate constipation, and this will enable the woman to
perceive her health improve and develop a perception of self-
healing.21,24
This single-blind randomized controlled experimental study was
intended to evaluate the effects of self-acupressure on pregnant
women's self-reported constipation symptoms in Turkey.
Methods
Research design and participants
The study was conducted as a single-blind randomized controlled
trial. The study population included pregnant women who presented
to the maternity outpatient clinics of the private Medipol Nisa Hospi-
tal in Istanbul, between November 9, 2019, and February 29, 2020,
for pregnancy follow-up. The average number of pregnant women
who presented to the hospital was 600 per month. The appropriate
sample size for the study was calculated using G*Power software
(version 3.1.9.3). Because there were no studies in previous literature
of the application of acupressure to reduce constipation during preg-
nancy, the Cohen standard effect size (between medium and large
effect) determined the sample size for the study to be 0.55. Thus,
according to the two-sided hypothesis, standard effect size: 0.55,
Type I margin of error 0.05, power analysis 0.80 (a = 0.05,
1 b = 0.80) and a one-to-one distribution of the groups, the minimal
sample size was calculated as 106 (n = 53 for each group). To allow
 € l / Explore 17 (2021) 463 468
A.Ş. Kirca and D. Kanza Gu
for losses during the study, it was decided to include 75 people in
each group. After excluding 23 participants who had used laxatives
and seven who withdrew, the results for the remaining 120 pregnant
women were analyzed (Fig. 1).
Pregnant women who met the inclusion criteria were included in
the study. Participants were randomly assigned to the acupressure
(Group 1) and the control (Group 2) groups with a simple random num-
ber generator program (https://stattrek.com/statistics/random-number-
generator.aspx). In the program, given the number of participants to be
included in the sample and the number of groups, the box with the min-
imum value was numbered “1,” and the box with the maximum value
was numbered “2.” Then, the "allow duplicate entries" box was selected
as "True." Finally, “set the seed” value was set to 1. According to the ran-
dom numbers table at the end of the procedure, the first entry was “2.”
Therefore, the first volunteer was assigned number 2 (control group).
The second entry was "2." Hence, the second volunteer was also
assigned number 2 (control group), and so on. Volunteer No. 150 was
assigned the 150th number in the list, which was "1," so the 150th vol-
unteer was assigned to the acupressure group (Group 1).
The midwives and gynaecologists working in outpatient clinics
were different every day. To prevent bias, a midwife working in the
outpatient clinic that day but not involved in the study oversaw the
participants in filling out the Maternal Information Form and the
Constipation Severity Instrument (CSI) one week before and one
week after the week of treatment. The obstetrician and the midwife
working in the outpatient clinic that day were informed about the
purpose of the study and the procedure of acupressure application.
But the obstetrician and the midwife who administered the question-
naires did not receive details about the TH-6 point and its effects. The
obstetrician did not know which group (acupressure or control) the
participating pregnant women were assigned, thus, avoiding psycho-
logical influences on either group of participants minimized the pla-
cebo effect. Mobile phone interviews were conducted by the
researcher, the pregnant women who met the study criteria and
assigned to the experimental group were told on which day they will
receive training. Thus, experiment and control groups never met
each other. Also, the participants were informed about the purpose
of the study and the procedure of acupressure application. But the
participants did not receive details about the TH-6 point and its
effects. The acupressure specialist and the pregnant women in the
acupressure group first met during the training.
In the retrospective power analysis using the G*Power software after
data collection, the power was calculated as 100% for the acupressure
and control groups based on the mean scores for the CSI and 5% alpha
margin of error. The sample size of the study was considered sufficient.
Inclusion criteria: Pregnant women between ages 20 and 40 years,
in any trimester of gestation, with a singleton pregnancy, being pri-
mipara or multipara, and scoring
37 on the CSI scale were included
(To ensure that the degree of constipation problems in the test group
and the control group would be similar, the scale’s mean score was
calculated, and only women scoring higher than the mean were
included in the study).
Exclusion criteria: Women with a chronic disease, such as diabe-
tes, hypertension, thyroid disorders, chronic constipation, sigmoid
colon (enlarged or colon resection), and the like, those taking the
medication regularly, those with verbal communication difficulties,
with current use of pharmacological or non-pharmacological meth-
ods to reduce constipation, and those undergoing psychiatric treat-
ment (pharmacotherapy or psychotherapy) were excluded.
Data collection tools
Maternal Information Form: The form, prepared by the research-
ers based on relevant literature, consisted of 10 items regarding the
participants’ socio-demographic characteristics, diet, daily water con-
sumption, and participation in sports activities.
465
Constipation Severity Instrument (CSI): The CSI, developed by
Varma et al. (2008), is used to assess defecation frequency, intensity,
problems/difficulty in defecating, and symptoms of constipation.31
The scale is divided into three sections: obstructive defecation,
colonic inertia, and pain. The minimum and maximum scores possi-
ble in each of the three sections are 0 to 28, 0 to 29, and 0 to 16,
respectively; therefore, the lowest and highest possible total scores
are 0 and 73, respectively. There is no cutoff point for the scale—an
increasing score reflects increasing severity of constipation. Kaya and
Turan confirmed the validity and reliability of the Turkish version of
the CSI in 2010.32 The Cronbach’s alpha value of the scale was 0.92
both in the original study and in the present study.
Data collection procedure
Maternal Information Form and CSI: To prevent bias, a midwife
who was working in the outpatient clinic but not involved in the
study administered the completion of the forms, which took approxi-
mately 20 min. All pregnant women who met the inclusion criteria
were informed about the procedures to be performed before the
application of treatment. They were further advised that they could
withdraw from the study at any time, and they signed the informed
consent forms. Researcher registered a list of the groups.
Acupressure application steps for Group 1: The participants who
had been assigned to the study group were taken to a private training
room in the outpatient clinics and divided into groups of two or three
women. Illustrated brochures containing information about acupres-
sure were handed out to the participants, and they watched a short
video recorded by the researcher on how to perform acupressure.
Then, the researcher who had been trained in acupressure demon-
strated to the participants on which point, how often, and how to
apply pressure on her body. Due to the location of the TH-6 point
(four finger-widths above the wrist on the back of the forearm,
Fig. 3), the use of an acupressure wristband, magnets, or other devi-
ces is not practical; therefore, the participants were trained to apply
pressure using only their fingers and with sufficient force to see a col-
our change in their nail bed colour. Finally, the women were allowed
to find the point and practice the technique on their own. Training
the acupressure group and practicing the technique took approxi-
mately 40 45 min. It should be mentioned that, due to the location
of the TH-6 point, acupuncture was not performed to minimize inva-
sive applications during pregnancy and to allow the women to con-
tinue taking part in routine prenatal care.
Number, time, duration, type, and technique of the application:
The researcher demonstrated how to find the TH-6 point. The partici-
pants were told to apply acupressure on both points for 15 min twice
a day, in the morning and evening, for a week (40 45 s of heating
and massaging, then 2.5 min of pressure, and 30 s of rest). The partic-
ipants were asked to be alone in a quiet room for the application and
to use a stopwatch during the application. If ıt is necessary, the par-
ticipants were provided phone numbers enabling them to contact
the researchers 24/7.
Application steps for the control group: Because participants in
the control group could not use pharmacological or non-pharmaco-
logical methods, they did not undergo any intervention. They were
given the phone numbers of the two researchers whom they could
contact at any time, day or night, or advised to come to the hospital,
if necessary, in case their condition became serious.
The pre- and post-application CSI scores of the participants in both
groups were evaluated statistically (one week before initiating was
identified as CSI-1, one-week post-procedure was identified as CSI-2).
Data analysis
The IBM SPSS v.23 (SPSS, Inc., Chicago, IL, USA) software package
was used to analyze descriptive statistics, numbers, percentages,
466 € l / Explore 17 (2021) 463 468
A. Ş. Kirca and D. Kanza Gu

arithmetic mean, and standard deviation. The results of the Shapir- Table 2
o Wilk test demonstrated that the scores derived from the scale Intra- and inter-group comparisons of the mean CSI scores obtained by the partici-
pants in the acupressure and control groups.
were normally distributed. The Chi-square test was used to compare
the categorical data. In the comparison of the groups the first, miss- Acupressure Group Control Group (n = 75) t* P2
ing value analysis was performed. Loss data were estimated with (n = 75)
both EM and Regression analysis and similar results were obtained. CSI-1 41.36 § 6.5 37.56 § 6.17 t = 3.673 <0.001
Finally, the analysis was completed. While the independent samples CSI-2 26.08 § 7.93 36.88 § 5.93 t= 9.449 <0.001
t-test was used for inter-group comparisons, the dependent samples t** t = 15.013 t = 1.256
P1 <0.001 .213
t-test was used for the intra-group comparisons. The Mann Whit-
ney U test was used for comparison of data with non-normal distri- t* = Independent samples t-test, t** = Dependent samples t-test.
bution. To present the results of the analysis, median values p1: Comparison of CSI-2 results completed with Expectation-Maximization (EM)
method with CSI-1 results,.
(minimum-maximum) were used for the data with non-normal dis- p2: Comparisons between groups
tribution, mean § standard deviation was used for data with normal CSI: Constipation Severity Scale
distribution, and frequency (percentage) was used for the categori- CSI-1: Before intervention, CSI-2: After intervention.
cal data. A p-value of < 0.05 was established as statistically signifi-
cant. Our analyses were based on the ‘Intention to Treat (ITT)’ high-fibre foods, amount of fluid intake, duration and intensity of
principle. participation in physical activity (sports) (p > 0.05, Table 1).
In the present study, the results of intra-group and inter-group com-
parisons of constipation levels of the participants in the acupressure
Ethical considerations group, who underwent acupressure intervention, and of participants in
the control group, who did not assess twice using the CSI tool, are given
_
Approval for the study was obtained from Istanbul Medipol Uni- in Table 2. The intra-group comparisons of the CSI scores of the partici-
versity Clinical Researches Ethics Committee (Reference number: pants in the acupressure group demonstrated that their post-application
10,840,098 604.01.01-E.60992, Decision number: 928, Date:8/11/ mean score (26.08 § 7.93) was lower than their pre-application mean
2019). All the procedures were performed by rules about studies score (41.36 § 6.5) and that the difference was highly significant
involving human participants by considering the ethical standards of (p < 0.001, Table 2). As for the control group, there was no statistical dif-
the institutional and/or national research committee. ference between their pre- and post-study CSI scores (37.56 § 6.17 and
36.88 § 5.93, respectively) (p > 0.05, Table 2).
Results The inter-group comparisons of the CSI scores demonstrated that
the pre-application mean CSI score of the participants in the acupres-
The findings of the study are charted below in Tables 1 and 2, and sure group (41.36 § 6.5) was significantly higher than that of the par-
Fig. 2: ticipants in the control group (37.56 § 6.17) (p < 0.001, Table 2).
Comparison of the women’s socio-demographic and descriptive However, the post-application means CSI score of the participants in
characteristics reveal that the two groups were similar in terms of the acupressure group (26.08 § 7.93) was significantly lower than
age, educational status, employment status, number of pregnancies, that of the participants in the control group (36.88 § 5.93)
gestational age, type of diet (principal and snacks), a diet including (p < 0.001, Table 2, Fig. 2).

Table 1
Comparison of the socio-demographic and descriptive characteristics (the number of meals, amount of water consumed, duration of sports) of the groups

Acupressure Group (n=75) (min-max) Control Group (n=75) (min-max) Total Group (n=150) (min-max) Test Statistics p*
Age 30 (22 - 41) 29 (21 - 40) 30 (21 - 41) U= 2453 0.175

n % n % n % X2 p**

Number of Pregnancy
Primiparous 38 50.7 46 61.3 84 56
Multiparous 37 49.3 29 38.7 66 44 1.732 0.188
Trimester
1.trimester 21 28 19 25.3 40 26.7
2.trımester 19 25.3 27 36 46 30.7 2.054 0.358
3.trımester 35 46.7 29 38.7 64 42.7
Education status
Primary education 9 12 7 9.3 16 10.7 3.132 0.20
High school 45 60 55 73.3 100 66.7 9
University 21 28 13 17.3 34 22.7
Work status
Housewife 48 64 52 69.3 100 66.7 0.481 0.786
Self-employment 14 18.7 12 16 26 17.3
Officer 13 17.3 11 14.7 24 16
Fibre food
Yes 48 64 42 56 90 60 1.000 0.317
No 27 36 33 44 60 40
Active sports
Yes 37 49.3 31 41.3 68 45.3 0.986 0.325
No 38 50.7 44 58.7 82 54.7
Number of main meals 3 (2 - 4) 3 (2 - 5) 3 (2 - 5) U_2703 0.570*
Number of snacks 2 (0 - 4) 2 (1 - 3) 2 (0 - 4) U=2737 0.743*
Water (glass) 3 (1 - 6) 3 (2 - 5) 3 (1 - 6) U=2570 0.339*
Sport (hour) 7 (2 - 0) 7 (2 - 0) 7 (2 - 0) U=2539 0.258*
* Mann Whitney U test
** Chi-square test statistics
 € l / Explore 17 (2021) 463 468
A.Ş. Kirca and D. Kanza Gu
Fig.. 2. Average and number deviation graph of the total scores before and after the procedure according to the groups.
Discussion
This study, to the best of the authors’ knowledge, is the first trial
ever, carried out to evaluate the efficacy of acupressure in partici-
pants with constipation during pregnancy. As a result of this random-
ized controlled study, acupressure applied to TH-6 acupuncture point
reduced the symptoms of constipation during pregnancy. The results
were discussed within the framework of the results of other studies
in which acupressure and acupuncture were applied to pregnant
women experiencing constipation.
The similarity of the groups in terms of their socio-demographic
and descriptive characteristics (age, number of pregnancies, trimes-
ter, educational status, working status, a diet including high-fibre
foods, amount of fluid consumed, and active participation in sports)
supports the reliability of the study. The results are similar to those of
other national and international studies.6,11,12,33 36
In the present study, the CSI scores of the participants who applied
self-acupressure dropped significantly compared to those of the control
group. In a study conducted with 30 women, Chen et al. (2013)
reported that constipation symptoms decreased significantly in women
who received electro-acupuncture treatment compared to women who
did not.26 According to the results of Shin and Park’s (2016) randomized
controlled study conducted with 52 women with constipation effects
from chemotherapy for breast cancer, constipation symptoms decreased
significantly in the participants who were administered auricular acu-
pressure, compared to participants in a control group.27 In Chen et al.'s
Fig.. 3. TH-6 acupuncture point.
467
(2017) experimental study conducted with 56 female patients with
functional constipation, difficulty in defecating, and diminished quality
of life who underwent acupuncture were significantly improved, com-
pared to a control group.37 According to the results of a randomized
controlled experimental study in which Zhou et al. (2019) administered
28 sessions of electro-acupuncture to 415 of 822 women suffering from
chronic constipation, the application regulated bowel movements of the
women with serious functional constipation, enabling them to defecate
more comfortably and not experience further constipation problems for
12 weeks after the treatment.19 In their randomized controlled study,
Yang et al. (2019) applied auricular acupuncture to 120 primiparous
puerpera who underwent cesarean section and found that the incidence
of constipation in these women was lower than in women who did not
undergo auricular acupuncture.38 The results of the present study are
consistent with those of similar studies.
Results of various studies conducted to date have supported the
use of acupressure, which is among the traditional and alternative
therapy methods for the treatment of diseases. In the literature, it
has been reported that no complications detract from the effective-
ness and reliability of this method. In the present study, application
of self-acupressure to the TH-6 point by the participant’s controlled
intestinal peristalsis and gastrointestinal system functions increased
production and re-secretion of body fluid, and increased blood,39
which contributed to a significant drop in their CSI scores. Therefore,
acupressure can be recommended as an effective method to reduce
the symptoms of pregnancy-related constipation.
Limitations
The results of this randomized controlled study apply only to the
women surveyed, and they cannot be generalized to other women.
The first limitation of the study was that the training took longer
than planned. The researcher demonstrated how to apply self-acu-
pressure to the TH-6 point to each participant individually. Due to
the location of the TH-6 point, it took a long time for the participants
to find exactly where to apply the pressure during training. The sec-
ond limitation is that the study was performed voluntary; all the
women recruited volunteered to participate in the study, which
increased the duration of the study. The third limitation was the rela-
tively small sample size. The fourth limitation of the study was to not
apply any method to the participants in the control group. Therefore,
the interview time with this group was shorter than the experimen-
tal group. The fifth limitation was that the time allocated to the
468
A. Ş. Kirca and D. Kanza Gu
application was limited to one week because in Turkey, the use of
non-pharmacological treatments is uncommon, and it was believed
that and if longer time had been allocated to the application, the par-
ticipants might have wanted to abandon the study to use pharmaco-
logical methods. Therefore, it is recommended that future studies be
planned for long term treatment and should include larger study
groups. Besides, the provision of training on non-pharmacological
methods to women by midwives/nurses/gynaecologists in prenatal
classes may increase interest and acceptance of non-pharmacological
treatment methods. The strength of this study was the participants
were not informed what the TH-6 point serves to avoid creating a
placebo effect.
Conclusions
The study data indicate that CSI scores decreased in pregnant
women who were taught how to apply self-acupressure, and this
practice was an effective intervention to relieve the symptoms of
constipation during pregnancy. Training of pregnant women by
healthcare professionals (midwives, nurses, and gynaecologists) in
the clinic on how to apply self-acupressure can help them relieve
symptoms of constipation without resorting to pharmacological
methods. Because the location of the area where the application of
acupressure for constipation is performed is easy to find, it is recom-
mended that acupressure should be applied to these points.
Declaration of Competing Interest
The authors have no conflicts of interest to disclose.
Informed consent
In the data collection phase, written permission was obtained
from Private Medipol Nisa Hospital. After explaining the purpose and
objective of the study, written consents of the participants were
obtained.
References
1 Rungsiprakarn P, Laopaiboon M, Sangkomkamhang US, Lumbiganon P, Pratt JJ.
Interventions for treating constipation in pregnancy. Cochrane Database Syst. Rev..
2015(9).
2 Blane R, Blagrave P. Management of Constipation In Long-Term Care: the impor-
tance of a multidisciplinary approach. Can. Nurs. Home. 2011;22(4):16–18.
3 Trottier M, Erebara A, Bozzo P. Treating constipation during pregnancy. Can. Family
Phys.. 2012;58(8):836–838.
4 Shin GH, Toto EL, Schey R. Pregnancy and postpartum bowel changes: constipation
and fecal incontinence. Am. J. Gastroenterol.. 2015;110(4):521.
5 Kılıçarslan S. Sociodemographic characteristics. Health Qualities and Anxiety Levels
of Third-Trimester Pregnant Women Living in Edirne. Trakya University Faculty of
Medicine Department of Family Medicine MA ThesisEdirne; 2008.
6 Kaya R. The State of the Prevalence of Constipation in Pregnancy and Its Relation With
the Quality of Life. Aydın: Adnan Menderes University, Institute of Health Sciences
Department of Midwifery MA Thesis; 2018.
7 Cullen G, O'Donoghue D. Constipation and pregnancy. Best Pract. Res. Clin. Gastroen-
terol.. 2007;21(5):807–818.
8 Prather CM. Pregnancy-related constipation. Curr. Gastroenterol. Rep.. 2004;6
(5):402–404.
9 Constipation Wald A. diarrhoea, and symptomatic haemorrhoids during preg-
nancy. Gastroenterol. Clin. North Am.. 2003;32(1):309–322. vii.
10 van Brummen HJ, Bruinse HW, van de Pol G. Defecatory symptoms during and after
the first pregnancy: prevalences and associated factors. Int. Urogynecol. J. Pelvic
Floor Dysfunc.. 2006;17:224–230.
11 Derbyshire E, Davies J, Costarelli V, Dettmar P. Diet, Physical inactivity and the
prevalence of constipation throughout and after pregnancy. Matern. Child Nutr..
2006;2(3):127–134.
€ l / Explore 17 (2021) 463 468
12 Shamim S, Begum A. Functional constipation in pregnancy; need to furnish some
more emphasis. Ann. Abbasi Shaheed Hospital .Karachi Med. Dental Coll.. 2019;24
(2):96–102.
13 Body C, Christie JA. Gastrointestinal diseases in pregnancy: nausea, vomiting,
hyperemesis gravidarum, gastroesophageal reflux disease, constipation, and diar-
rhoea. Gastroenterol. Clin.. 2016;45(2):267–283.
14 Blaker P, Wilkinson M. Chronic constipation: diagnosis and current treatment
options. Prescriber. 2010;21(9):30–45.
15 Liu LW. Chronic constipation: current treatment options. Can. J. Gastroenterol..
2011;25. Suppl B 22B 8B [PubMed: 22114754].
16 Miyoung C, Euysoon C. A Comparison between the effects of aroma massage and
meridian massage on constipation and stress in women college students. J. Korean
Acad. Nurs.. 2011;41(1).
17 Samavati R, Ducza E, Hajagos-To  th J, Gaspar R. Herbal laxatives and antiemetics in
pregnancy. Reproductive Toxicol.. 2017;72:153–158.
18 Peckham EJ, Cooper K, Roberts ER, Agrawal A, Brabyn S, Tew G. Homeopathy for
treatment of irritable bowel syndrome. Cochrane Database Syst. Rev.. 2019(9).
19 Zhou J, Liu Y, Zhou K, et al. Electroacupuncture for women with chronic severe
functional constipation: subgroup analysis of a randomized controlled trial.
Biomed. Res. Int.. 2019. https://doi.org/10.1155/2019/7491281.
20 Gao D. The Encyclopedia of Chinese medicine. Spain: Carlton Books; 1997.
21 Tsay SL, Chen ML. Acupressure and quality of sleep in patients with end-stage renal
disease: a randomized controlled trial. Int. J. Nurs. Stud.. 2003;40:1–7.
22 Schlaeger JM, Gabzdyl EM, Bussell JL, et al. Acupuncture and acupressure in labor. J.
Midwifery Womens Health. 2017;62(1):12–28.
23 Dibble SL, Champan J, Mack KA. Shin AS Acupressure for nausea: results of a pilot
study. Oncol. Nurs. Forum.. 2000;27(1):41.
24 Maa SH, Tsou TS, Wang KY, Wang CH, Lin HC, Huang YH. Self-Administered acu-
pressure reduces the symptoms that limit daily activities in bronchiectasis
patients: pilot study findings. J. Clin. Nurs.. 2007;16(April):794–804.
25 Abbasi P, Mojalli M, Kianmehr M, Zamani S. Effect of acupressure on constipation in
patients undergoing hemodialysis: a randomized double-blind controlled clinical
trial. Avicenna J. Phytomed.. 2019;9(1):84.
26 Chen CY, Ke MD, Kuo CD, Huang CH, Hsueh YH, Chen JR. The Influence of electro-
acupuncture stimulation to female constipation patients. Am. J. Chin. Med. (Gard
City N Y). 2013;41(02):301–313.
27 Shin J, Park H. Effects of auricular acupressure on constipation in patients with
breast Cancer receiving chemotherapy: a randomized control trial. West. J. Nurs.
Res.. 2018;40(1):67–83.
28 Wang PM, Hsu CW, Liu CT, Lai TY, Tzeng FL, Huang CF. Effect of acupressure on consti-
pation in patients with advanced cancer. Support. Care Cancer. 2019;27(9):3473–3478.
29 WHO. Standard Acupuncture Point Locations in the Western Pacific Region. World
Health Organization, Manila Philippines; 2008.
30 Tindall J, Jarmey C. Acupressure For Common Ailments. Gai Books Ltd, London and
Stroud, Published by Simon&Schuster: New York; 1991.
31 Varma MG, Wang JY, Berian JR, Patterson TR, McCrea GL, Hart SL. The constipation
severity instrument: a validated measure. Dis. Colon Rectum. 2008;51(2):162–172.
32 Kaya N, Turan N. Reliability and validity of constipation severity scale. Turkiye Klini-
kleri J. Med. Sci.. 2011;31(6):1491.
33 Farghali MM, Abdelazim IA, Awadalla AM, et al. Effect of progesterone therapy ver-
sus diet modification on constipation during pregnancy. J. Basic Clin. Reprod. Sci..
2016;5(2):82–87.
lar S, Hisar KM. The Efficacy of Education and Counseling Service For Preventing
34 Çag
Constipation Given to Pregnant Woman Who Applied to Family Health Centers.
Gu€ mu€ şhane Univ. J. Health Sci.. 2018;7(1):156–163.
35 Hestiantoro A, Baidah PA. The Prevalence and risk factors of constipation in preg-
nancy. Indonesian J. Obstetrics .Gynecol. 2018;6-2:84–88.
36 Sehhatti F, Hughes C, Mirghafourvand M, Azan ZA. The Effect of short-term foot
reflexology in improving constipation symptoms during pregnancy: a two-armed,
randomized controlled trial. Int. J. Women's Health .Reprod. Sci.. 2020;8(1):4726.
37 Chen L, Jin X, Jiang X, Wang C, Shi Y, Wang L. Acupoint embedding for female func-
tional constipation: a randomized controlled trial. Zhongguo zhen jiu= Chinese Acu-
puncture & Moxibustion. 2017;37(7):717–721.
38 Yang GY, Chen QZ, Fu HY, Chen CH. Effect of auricular acupuncture on postpartum
rehabilitation of primipara with cesarean. Zhongguo zhen jiu= Chinese Acupuncture
& Moxibustion. 2019;39(7):717–720.
39 Li MK, Lee TF, Suen KP. Complementary effects of auricular acupressure in relieving
constipation symptoms and promoting disease-specific health- related quality of
life: a randomized placebo-controlled trial. Complement. Ther. Med.. 2014;22:266–
277.
40 Beal MW. Acupuncture and acupressure: applications to women’s reproductive
health care. J. Nurse Midwifery. 1999;44(3):217–230.
41 Tsay SL. Acupressure and fatigue in patients with end-stage renal disease: a ran-
domized controlled trial. Int. J. Nurs. Stud.. 2004;41:99–106.
42 Mirbagher-Ajorpaz N, Adib-Hajbaghery M, Mosaebi F. The effects of acupressure on
primary dysmenorrhea: a randomized controlled trial. Complement. Ther. Clin. Prac-
tice. 2014;17(1):33–36.