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Archives of Gynecology andObstetrics ISSN 0932-0067 Arch Gynecol ObstetDOI 10.1007/s00404-012-2227-4

Effects of massage therapy and presence ofattendant on pain, anxiety and satisfactionduring labor

Seyedeh Hamideh Mortazavi, SiavashKhaki, Rayhaneh Moradi, KazemHeidari & Seyedeh Fatemeh VaseghRahimparvar

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Arch Gynecol ObstetDOI 10.1007/s00404-012-2227-4

Author's personal copyMATERNAL-FETAL MEDICINE

EVects of massage therapy and presence of attendant on pain, anxiety and satisfaction during labor

Seyedeh Hamideh Mortazavi Siavash Khaki Rayhaneh Moradi Kazem Heidari Seyedeh Fatemeh Vasegh Rahimparvar

Received: 23 July 2011 / Accepted: 9 January 2012 Springer-Verlag 2012

AbstractPurpose To investigate the eVects of massage and pre-senting an attendant on pain, anxiety and satisfaction dur-ing labor to clarify some aspects of using an alternativecomplementary strategy.Methods 120 primiparous women with term pregnancywere divided into massage, attendant and control groupsrandomly. Massage group received Wrm and rhythmic mas-sage during labor in three phases. After 30 min massage ateach stage, pain, anxiety and satisfaction levels were evalu-ated. Self-reported present pain intensity scale was used tomeasure the labor pain. Anxiety and satisfaction were mea-sured with the standard visual analog scale.Results Massage group had lower pain state in second andthird phases (p < 0.05) in comparison with attendant groupbut reversely, the level of anxiety was lower in attendantgroup in second and third phases (p < 0.05) and satisfactionwas higher in massage group in all four phases (p < 0.001).The massage group had lower pain and anxiety state inthree phases in comparison with control group (p < 0.05).Data analysis of satisfaction level showed higher values infour phases in massage group compared with control

(p < 0.001) and comparison of attendant and control groupsshowed higher satisfaction in attendant group in phases 2, 3and 4 as well (p < 0.001). Duration of active phase waslower in massage group (p < 0.001).Conclusions Findings suggest that massage is an eVectivealternative intervention, decreasing pain and anxiety duringlabor and increasing the level of satisfaction. Also, the sup-portive role of presenting an attendant can positively inXu-ence the level of anxiety and satisfaction.

Keywords Anxiety Attendant Labor support Massage therapy Pain Satisfaction

Introduction

Using the various alternative ways such as massage therapyin developed countries, it is no wonder that the percentageof cesarean section decreases. As the World Health Organi-zation recommends that this rate should not be higher than1015%, as well as the rate of morbidity and mortality ofinfants after delivery [1]. Child birth is a painful and stress-ful event in a woman life which is accompanied withfatigue, fear and negative feelings and as labor proceeds,the state worsens [2, 3]. Whereas the labor pain is sharp andposses fast progression, several analgesics are being used.But none of them, alone, can manage the pain adequatelydue to the diVerent proved side eVects [4, 5]. Administrat-ing alternative methods can also lead to mothers satisfac-tion. Mothers always seek a way to relieve the severe painso in this case using appropriate touching methods seems tobe useful and make them feel more relaxed [6, 7], therefore,beside the analgesic, labor pain can be controlled by alter-native ways. Massage is one of these methods which canlead to relaxation, relieves muscle spasm and decreases

S. H. Mortazavi S. KhakiStudents ScientiWc Research Center, School of Medicine, Tehran University of Medical Science, Tehran, Iran

R. Moradi S. F. Vasegh Rahimparvar (&)Department of Midwifery, School of Nursing and Midwifery, Tehran University of Medical Science, Nosrat St. Tohid sq, Tehran, Irane-mail: vaseghrh@tums.ac.ir

K. HeidariDepartment of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran123

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Author's personal copyanxiety. It is thought that massage can work through twodiVerent pathways: by blocking the pain impulses byincreasing the A-Wbers transfer and also by stimulating theendorphins to be released locally [8]. It is a fact that aspressure Wbers are longer and they have more protectivemyelin membrane, the pressure from massage overcomesthe transmission of painful impulses to the brain. In previ-ous studies, reduction in systolic pressure has been shownas one of the relieving eVects of massage [9]. Massage as avery useful sensory stimuli is not only the most usedmethod used, but also one of the most pleasant andaccepted ways to reduce the pain in most of the diseases[10]. Aromatherapy and massage can considerably decreasethe anxiety so that they can be considered as a supplemen-tary care during labor [11, 12]. Previous studies report thatmothers receiving massage during labor felt less anxietyand pain in their back and feet and have been more relaxedwhereas after receiving massage, decrease in heart rate andthe pattern of relaxation in EEG have been shown [13].Massage is shown to have some remarkable eVects oninfants as well. Preterm neonates showed less distress pat-terns and term neonates demonstrated more increase ingrowth in their Wrst month of age [14]. For decreasing anxi-ety during labor and also increasing satisfaction during andafter labor, presenting an attendant, one who is accompa-nied with mother during the whole labor and provides theown support (doula), seems to be appropriate as a nonmedi-cal approach. In this instance, shorter length of labor,decreasing cesarean section rate, lower needing for epiduralanesthesia, greater cervical dilation, lower percentage offetal distress and higher neonatal Apgar scores are reportedby articles as the beneWts of using a doula (a trained atten-dant) during labor [15, 16]. A few studies are undertaken toinvestigate the deWnite eVects of massage and presenting anattendant on such parameters during labor. Also the eVec-tiveness of massage is diVerent in various nations due to thediVerent sensitivity to pain and alternative ways. In thisstudy, diVerent eVects between presence of attendant andmassage therapy on pain, anxiety and satisfaction in pri-miparous pregnant are investigated.

Materials and methods

The current work was done in November 2009 till April2010 at Baharlou university hospital in Tehran, Iran. TheInstitutional Review Board approval was granted by theResearch Ethic Committee of Tehran University of MedicalSciences. A written informed consent form was preparedfor each subject and the researchers introduced the generalpurposes of the procedure for each group.

120 primiparous women between 16 and 36 years andmean age of 23 with the following properties were selected:

experiencing a normal pregnancy without any complica-tions, term pregnancy at the time of admission (gestationalage between 37 and 42 weeks) and cervical dilatation of nomore than 4 cm. Exclusion criteria were needing to cesar-ean section for any medical reason and also Oxytocin infu-sion to accelerate or augment labor progression. Womenwho met the criteria were entered the study until the wholenumber of samples were fulWlled. Then, the subjects wererandomly divided into three equal groups: massage group,attendant group and control group (40 in each group). Sam-ples of each group were entered the study on the separatedintermittent days of the week. None of the groups wasaware of the presence of the others groups. The subjects incontrol groups took the standard obstetrics care in eachphase as well as the other groups.

Firm and rhythmic massage was given to the massagegroup for 30 min in three phases: latent phase (34 cm cer-vical dilation), active phase (57 cm cervical dilation), anddeceleration phase (810 cm cervical dilation). For summa-rization, these phases were considered as Wrst, second andthird phases, respectively. Before massage started, motherswere encouraged to close their eyes and breathe deeply toconcentrate on the massage. Massages included shoulderand back massage, abdominal eZeurage and sacral pres-sure. The type of massage was selected based on motherspreference. After 30-min massage at each phase, threeparameters of pain, anxiety and satisfaction levels wereevaluated. Furthermore, satisfaction was measured 30 minafter delivery (considered as phase 4).

In the attendant group, the laboring womans attendantaccompanied her during the whole labor. Three parameterswere assessed in attendant and control groups as well asmassage group.

Self-reported present pain intensity (PPI) scale was usedto measure the labor pain. PPI is a scale of 05: 0, no pain;1, mild pain; 2, moderate pain; 3, distress; 4, severe pain;and 5, intolerable pain [17]. Anxiety was measured with thestandard visual analog scale (VAS). This scale consists of a10-cm horizontal line deWne no anxiety at the left and worstanxiety at the right. Subjects were asked about their level ofanxiety during labor and the high scores showed theincrease in the level of anxiety. Satisfaction was measuredwith the same scale, but in this case high values showedincrease in the level of satisfaction [18]. The duration ofactive phase was calculated in hour in each group and com-pared between groups.

Results

Demographically subjects were the same and there were nosigniWcant diVerences in age, education and occupation(Table 1).123

Arch Gynecol Obstet

Author's personal copyIn massage group, based on mothers preference, 91.7%(n = 25) received sacrum massage, 2.5% (n = 3) shouldermassage, 0.8% (n = 1) eZeurage massage (a light strokingmovement used in massage) and 5% (n = 6) the combina-tion of massages. Mean active phase length was 2.6 h(SD = 0.95 h) in massage group, 5.7 h (SD = 1.89 h) inattendant group and 7.5 h (SD = 1.87 h) in control group.The duration of active phase was signiWcantly lower inmassage group (p < 0.001). The massage group had signiW-cantly lower pain state in the latent, active and decelerationphases generally (p < 0.05). The characteristics of painstate in phases 1, 2 and 3 in various groups, respectively,are shown in Figs. 1, 2, and 3. Pain was signiWcantly lowerin massage group, comparing with attendant in second andthird phases (p < 0.05) but on the contrary, anxiety statewas lower in attendant group in second and third phases(p < 0.05) and the Wrst phase anxiety was signiWcantlylower in massage group. Between massage and attendantgroups, satisfaction had higher values in all four phases inmassage group (p < 0.001). Between massage and controlgroups, the pain state was signiWcantly lower and satisfac-tion level was signiWcantly higher in the massage group inall phases (p < 0.05, p < 0.001, respectively) and also anxi-ety was signiWcantly in lower state in phases 1, 2 and 3 inmassage group (p < 0.05). Between attendant and controlgroups in phases 2, 3 and 4, satisfaction state was signiW-cantly higher in attendant group (p = 0.000) and the level ofpain and anxiety showed signiWcant decrease in second andthird phases in attendant group (p < 0.05, p = 0.000, respec-tively).

Although the median of anxiety score in massage groupwas lower than control group, but from the Wrst to the thirdphase, trend of anxiety in massage group was ascending(p = 0.000) But in attendant and control group, it wasdescending (p = 0.000, p = 0.46, respectively). The medianof satisfaction score was higher in massage group as com-pared to attendant, but generally the trend of satisfaction inboth groups was ascending (p = 0.000) and the median ofsatisfaction score was the lowest in control group, mean-

while the trend in control group was descending in Wrstthree phases with an ascending pattern in the fourth phasewhich was signiWcant (p = 0.000).

Table 1 Demographic data of the participants Variable Massage group Attendant group Control group P Value

Age 23.12 (SD = 3.17) 22.45 (SD = 3.45) 23.50 (SD = 4.24) 0.431Occupation 0.870

Housewife 39 (97.5%) 38 (95%) 37 (97.5%)Employee 1 (2.5%) 2 (5%) 3 (2.5%)

Education 0.110Illiterate 0 (0%) 1 (2.5%) 3 (7.5%)

Arch Gynecol Obstet

Author's personal copyDiscussion

The Wndings of this work revealed that massage, as a saferelieving method, can adequately eVect on some insepara-ble properties of labor such as pain and decline them appro-priately. In this case, Khodakarami et al. [19] showed thatthe mean pain intensity, which was assessed by VAS, wassigniWcantly lower in women receiving massage duringlabor compared with control group. Also they commentedthat massage therapy can reduce the medical interventionand analgesic usage during labor and signiWcantly lower theduration of the Wrst stage of delivery [19]. Another study byKimber et al. [20] claims that massage therapy accompany-ing relaxation technique from late pregnancy to the birth isa supportive procedure which should be involved with largetrials to assess the diVerences in self-reported pain, mea-sured by VAS.

Another massage intervention by Chang et al. [21] clari-Wed that administrating massage in the intervention groupcannot change the characteristics of pain during labor but itcan positively inXuence on pain intensity and reduce thisaspect at latent and active phase of cervical dilation.

Another study in 2006 showed that a regular massage ofmore than 14 days increases the threshold of the pain byinteraction between oxytocin and opioid nerves [22].

In our study the attendant group had statistically lowerlevel of anxiety among all. In this instance, Latifses et al.[23] stated that massage is more eVective than doing noth-ing during labor to decrease the level of anxiety and alsoField et al. [13] showed that mothers receiving massageduring labor experience lower level of anxiety Chang et al.[24], demonstrated that using massage therapy during anormal labor performed by the mothers partner, is an eVec-tive intervention to decrease the values of pain and anxiety.A study in 2005 stated that massaging and relaxing by

partners are eVective ways to reduce anxiety. The partnersin that study were taught to massage their spouses twotimes a week for 20 min. Ultimately, the result showed asigniWcant decrease in the level of anxiety [23].

Our research showed that presenting an attendant whoprovides the emotional supports during the whole laborwould be eVective in lowering pain and anxiety, meanwhilealtering the experience of giving birth to a more pleasantone. In case of presenting an attendant, Campbell et al. [15]indicated that the additional support by a female from thefamily or friend can signiWcantly shorten the length of laborin the intervention group (accompanying with an atten-dant), greater cervical dilation at the time of epidural anes-thesia, and leads to higher neonatal Apgar scores at both 1and 5 min another randomized controlled trial suggestedthat the presence of a doula (trained labor attendant) cansigniWcantly decrease the rate of cesarean section and theneed for epidural analgesia for both procedures with diVer-ent proved side eVects in mothers and the infants. Thus, themother and her male partners perspective about the pres-ence of the doula during the whole labor were both positive[25]. In this research, the active phase length was depen-dently lowered by massage therapy and attendant presence.Other studies also have reported that presenting doulaand using massage as an intervention lower the length oflabor [16].

Obviously, massage and attendant could inXuence on thelevel of satisfaction signiWcantly meanwhile impressing theanxiety and satisfaction trend in a positive manner. Changet al. [21] also noted that massage by the mothers partnerduring the labor improves the mothers and surprisingly hermale partners satisfaction from the labor process.Improved sense of satisfaction with child birth followingmassage as a pain relief in labor process was commented inother studies too [20].

As preliminary results, the data revealed signiWcantdecreasing eVects of massage therapy on pain and anxietyof primiparous women during labor which can be consid-ered as a beneWcial nonmedical approach in obstetrics prac-tice. Besides, by a supportive presence of an attendant, painand anxiety will subside noticeably. Thus, the presence of amember of family serves encouragement, security and psy-chological assurance for the laboring mother. Throughthese strategies, women will feel safe and experience deliv-ery as a non-stressful physiological event and their level ofsatisfaction will improve. Considering the low power of thegroups due to small sample size in this study, more studiesneed to be done in larger groups and various nations to sub-stantiate these Wndings more exclusively and achieve aunanimous agreement.

Acknowledgments This research has been supported by StudentsScientiWc Research Center of Tehran University of Medical Sciences

Fig. 3 Pain at phase 3 in three study groups123

Arch Gynecol Obstet

Author's personal copyand health Services grant. The authors would also want to acknowl-edge Baharlou hospital, as the educational hospital of Tehran Univer-sity of Medical Sciences for providing all the assistance andcooperation for this research.

ConXict of interest None.

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