Is Massage Beneficial for Pregnant Women and their Infants?

By Bridget S. Bongaard MD, FACP, Fellow in Integrative Medicine; Director of the Integrative Medicine Service Line, CMC-Northeast Medical Center in Concord, NC; she reports no financial relationship relevant to this field of study.

When we idealistically think of being pregnant, despite facing the hardships of labor and delivery of our new child, it is a vision of hopefulness, happiness, and expectations for a happy event. The path of the pregnant woman is, however, not so prosaic, and the reality of the stresses on her body and psyche are multifold. Her body undergoes a massive physical change, creating weight shifts to areas not normally used to support this physical load, as well as potentially disturbing changes in body image. The hormonal changes in women sometimes lead to low energy levels, and personal questions can arise regarding the woman's ability to be a good mother, or to be able to successfully complete the pregnancy with the delivery of a healthy infant.

Initial romantic thoughts are also tempered by the life settings of the mother. Whatever environmental stresses are currently ongoing with her immediate family, job, or responsibilities for other children may also create a significant psychological and physical burden for the woman. This can be alleviated by significant support from her partner, family, or friends; however, not all women have optimal support, leading to stress, which may precipitate the development of anxiety/depression in the expectant mother and affect the infant she is carrying. Depressed pregnant women have altered neurotransmitters (elevated stress hormones consisting of cortisol and norepinephrine levels, and low levels of countering serotonin and dopamine).1 These women are at higher risk for abortion, pre-eclampsia, preterm labor, intrapartum complications, and low birth weight, as well as post natal problems, such as depression, infant feeding problems, and perception of the infant as being fussy, hungry, or demanding.1

The infant is integrally a part of the mother and the stresses she encounters during pregnancy, as well as after birth. For instance, the development of the infant's circadian rhythm is established before birth, and by the third trimester of pregnancy, fetal diurnal rhythms are entrained to the maternal day-night rhythms.2 If the mother is depressed, her newborn infant may exhibit depression-like symptoms and have the same levels of stress hormones as did the mother.1 The infant's personal development is dependent upon optimal bonding between mother and baby. Post-partum disturbances of the maternal-infant relationship are quite common, and are present in 22% of peri-natal psychiatric referrals and in 29% of mothers diagnosed with post-natal depression.3 These disorders run the gamut of a sad spectrum of bonding delay (ambivalence, or loss in maternal response), rejection (threatened or established), or pathological anger/impulse control (resulting in handling the baby roughly with contemplation to harm or even deliberate attempts to kill her infant).3 The effects of this lack of normal bonding (lack of affection and stimulation) can last up until 18 months of age, and it has been shown that the children of women with postnatal depression later perform substandardly in terms of both behavior and intelligence.4

Effects of Massage on Depressed Pregnant Women

Massage therapy significantly alters the biochemistry of the mother not only short term following the massage, but also over the course of serial massage therapy treatments, with marked reduction in cortisol, determined in salivary gland samples.5 Dopamine, like serotonin, reduces depression and its stress effects.5 In a study done by Field and colleagues, 32 depressed adolescent mothers received two, 30-minute massage or relaxation therapy sessions per week, over a 5-week study period. In the randomized, controlled trial, both groups reported a reduction in anxiety following their first and last sessions; however, only the massage group showed behavioral and stress hormone improvements, including a decrease in anxious behavior, pulse, and salivary cortisol levels. Urinary cortisol levels remained diminished following the 5-week intervention period for the massage therapy group.6

Fujita and colleagues did a study to evaluate the effects of infant massage on their mothers' mood status. This randomized, controlled trial contained 39 post partum mothers who were evaluated at baseline and again after 3 months of baby massage using salivary cortisol levels and psychological measurements of depression and vigor (profile of mood states, or POMS). Baby massage positively affected the mood status of the mothers, but there were no significant differences in salivary cortisol levels at 3 months time.7

Another study by Field et al on 84 depressed pregnant women recruited during the second trimester and randomly assigned to progressive muscle relaxation, a control group, or massage therapy group consisting of two 20-minute weekly massages by their significant others. Results were interesting in that not only did the massage group report lower levels of both anxiety and depressed mood, they also experienced less back and leg pain by the end of the 16 week study.1 Higher levels of maternal salutary neurotransmitters (dopamine and serotonin) were found, as well as conversely lowered stress hormones (cortisol and norepinephrine). This may have contributed to an additional benefit noted in the trial, that being the better neonatal outcome for the massage group in terms of lesser incidence of both prematurity and low birth weight.

In another trial, depressed mothers of preterm infants were studied and divided into two groups: ones who massaged their babies and the others, who watched their babies being massaged. Both groups of mothers had lower depressive scores; however, only the group who actually massaged their premature infants had lower anxiety scores.8

Oxytocin is another critical CNS neurotransmitter for maternal and child health. Across mammalian species, it is noted to promote maternal bonding behavior. A small controlled study done by Glover and colleagues looked at a cohort of post partum depressed women attending an infant massage class, and found that the study group had improved infant interaction, as well as less depressive symptoms, compared to the control group who received training in infant care. The mechanism of action was postulated to be increases in maternal plasma oxytocin concentrations occurring with massage, thereby potentially promoting the bonding relationship with the infant.4

Other Areas of Potential Benefit Due to Massage Therapy

The sleep behavior of 50 normal and low birth weight (LBW) light preterm infants was studied by Kelmanson and Adulas in St. Petersburg, Russia.9 Babies were enrolled at 2 months after birth and were matched with a control group. The study group received massage intervention consisting of gentle rubbing and stroking, as well as passive and kinesthetic movements of the limbs by professionals until the child was 8 months of age. Study group infants were found to have less likelihood of snoring during sleep, required less feeding on awakening at night, and appeared more alert during the day. There was no difference in sleep behavior between those born at full term and those at preterm in the massage group. It was, therefore, suggested that massage might be a valuable approach to reducing sleep-disordered breathing and improving sleep quality in LBW infants.

Others have commented on the potential benefits of using massage in preterm or LBW babies. Dr. Beachy noted that when infant massage therapy is properly applied to preterm infants in the neonatal intensive care unit (NICU), they respond with increased weight gains, improved developmental scores, and earlier discharge from the hospital.10 This study also found that parents of preterm infants and their families benefited by performing the infant massage themselves, as it enhanced their bonding with the child and increased confidence in their parenting skills. In a Korean Nursing study of preterm infants using 10-minute massages twice daily for 10 days, it was discovered that the massage group had higher vagal tone after massage compared with the control group, and also significantly higher scores for awake state and motor activity. The authors concluded that massage therapy might enhance optimal physiological responses and behavioral organization of premature infants, and the nurses could use this to promote the infant's capacity to respond positively to their environment.11

Using Massage in Perinatal Care

Adding essential oils is promoted as another way of providing a satisfying massage therapy experience. In a study by Imura and colleagues, healthy post partum mothers, having delivered normal full term infants, were given a 30-minute aromatherapy massage on the second post partum day. Compared with the non-massage control group, the post treatment scores significantly decreased for the Maternity Blues Scale, the Sate-Anxiety Inventory, and all except one of the Profile of Mood Subscales. Scores increased in the Profile of Mood-States-Vigor subscale and the Approach Feeling toward Baby subscale. Conflict Index of Avoidance/Approach Feeling towards Baby subscale scores significantly decreased, with the overall outcomes indicating less depression, better energy level, and better maternal-infant bonding interactions.12

Bastard and Tiran note that antenatal anxiety has been linked to changes in the maternal hypothalamic-pituitary-adrenal axis, which can affect fetal development and potentially have lasting effects on the child's development.13 Their observation that psychotherapy and antidepressant treatment does not always effect long-term improvement led to their recommendation that midwives should incorporate aromatherapy and massage into their practices, but also encouraged further research to definitively establish efficacy and cost effectiveness .

As described in one study, labor pain can be impacted by massage therapy, in that massaged mothers reported a decrease in depressed mood, anxiety, as well as pain. They also showed less anxiety and agitated activity, as well as a more positive affect following the first massage during labor. Interestingly, the massaged mothers had significantly shorter labors, a shorter hospital stay, and less post partum depression.14

Nabb and colleagues established a massage program for women and their birth partners from 36 weeks gestation through labor and delivery. The intervention was developed on the basis of reports citing that repeated massage sessions over a 14-day period increase the pain threshold through an interaction between oxytocin and opioid receptors. Repeated massage-like stimulation induced long-term effects on nociception, an apparent contribution by oxytocinergic mechanisms.15 Recordings were made at 90 minutes post partum and showed significant reduction in perceived pain in both nulliparous and multiparous women groups.16 These data were compared to pain scales collected 2 days post partum, and were still lower than the control group. This finding could have the potential for significantly reducing the need for pharmacological analgesia in labor.15

Hur and colleagues investigated the effect of delivery nursing care using essential oils on labor stress response, labor anxiety, and post partum status anxiety for primiparous women. The study authors randomized 48 nulliparous women with full-term, uncomplicated pregnancies into experimental and control groups. Twenty-four hours after delivery, postpartum maternal anxiety level was assessed and correlated to measurements of plasma epinephrine and norepinephrine from cord blood. The experimental group demonstrated significantly lower levels of the two neurotransmitters; however, no significant difference was found between the two groups with regard to anxiety during labor or postpartum.

Conclusions

While many of the studies cited had positive outcomes both for the mother and the infant (either full term or preterm/LBW), it is noted that the majorities of the studies are small and flawed. No harm was reported, however, and massage therapy did have beneficial effects on hormones influencing stress, together with positive effects on sleep, crying, and mother-infant bonding. The findings provide tentative evidence to support recommending infant and perinatal massage, especially in high-risk groups, such as depressed mothers or LBW infants. Larger, methodologically sound trials are encouraged.

References

1. Field T, et al. Massage therapy effects on depressed pregnant women. J Psychosom Obstet Gynaecol. 2004;25:115-122.

2. Ferber S, et al. Massage therapy by mothers enhances the adjustment of circadian rhythms to the nocturnal period in full-term infants. Developmental and Behavioral Pediatrics. 2002;25:410-415.

3. Klier CM. Mother-infant bonding disorders in patients with postnatal depression: The Postpartum Bonding Questionnaire in clinical practice. Arch Womens Ment Health. 2006;9:289-291.

4. Glover V, et al. Benefits of infant massage for mothers with post natal depression. Semin Neonatol. 2002;7:495-500.

5. Field T, et al. Cortisol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci. 2005;115:1397-1413.

6. Field, T, et al. Massage and relaxation therapies' effects on depressed adolescent mothers. Adolescence. Vol. 31(124) 1996;903-911.

7. Fujita M, et al. Effect of massaging babies on mothers: Pilot study on the changes in mood states and salivary cortisol level. Complement Ther Clin Pract. 2006;12:181-185, Epub 2006 Mar 13.

8. Feijo L, et al. Mothers' depressed mood and anxiety levels are reduced after massaging their preterm infants. Infant Behav Dev. 2006;29:476-480.

9. Kelmanson IA, Adulas EI. Massage therapy and sleep behaviour in infants born with low birth weight. Complement Ther Clin Pract. 2006;12:200-205.

10. Beachy JM. Premature infant massage in the NICU. Neonatal Netw. 2003;22:39-45.

11. Lee HK. The effect of infant massage on weight gain, physiological and behavioral responses in premature infants. Taehan Kanho Hakhoe Chi. 2005;35:1451-1460.

12. Imura M, et al. The psychological effects of aromatherapy-massage in healthy postpartum mothers. J Midwifery Womens Health. 2006;51:e21-e27.

13. Bastard J, Tiran D. Aromatherapy and massage for antenatal anxiety: its effect on the fetus. Complement Ther Clin Pract. 2006;12:48-54.

14. Field T, et al. Labor pain is reduced by massage therapy. J Psychosom Obstet Gynaecol. 1997;18(4) 286-291.

15. Nabb MT, et al. Does regular massage from late pregnancy to birth decrease maternal pain perception during labour and birth?-A feasibility study to investigate a programme of massage, controlled breathing and visualization, from 36 weeks of pregnancy until birth. Complement Ther Clin Pract. 2006;12:222-231.

16. Hur MH, et al. Effects of delivery nursing care using essential oils on delivery stress response, anxiety during labor, and postpartum status anxiety. Taehan Kanho Hakhoe Chi. 2005;35:1277-1284.