Breastfeeding mothers health benefits such as reducing postpartum bleeding, maintain spacing, prevent breast cancer and ovarian cancer. A mother who will give breast milk to her baby is a demand that feel heavy so will result in psychological disorders such as anxiety (increased cortisol levels). In an effort to increase breast milk production and expenditure to be smooth to use conventional and non-conventional therapies.
Analyzing the effect of effleurage back massage and hypnobreastfeeding against cortisol levels and production in the mother during childbirth.
This research uses research quasy experiment with pretest and post-test with control group design, research was conducted pre-test in the intervention group was given massage effleurage back hypnobreastfeeding and control groups were given massage effleurage back for 7 days on the variables to be studied and then measured the levels of cortisol and milk production before and after the intervention.
There is a significant difference in the effect of effleurage back massage hypnobreastfeeding in the intervention group and the control group were given back effleurage massage for 7 days on cortisol levels and milk production.
Massage effleurage and hypnobreastfeeding effectively to decrease cortisol levels and increased milk production in mothers during childbirth.
Keywords: Effleurage back massage, Hypnobreastfeeding, puerperal
Mother's Milk (ASI) is one - the only source of nutrients naturally produced by humans, breast milk contains good nutritional composition and bioactive components nonnutritive for the development of a healthy baby is recommended by the American Academy of Pediatrics (AAP).[1, 2]According to the World Health Organization (WHO) Breast milk is the perfect natural food which has the advantage of a lifetime, beneficial breast milk as the baby's first immunization to reduce newborn mortality, early childhood development, healthy brain development.[1, 3]
Breastfeeding mothers health benefits such as reducing postpartum bleeding, maintain spacing, prevent breast cancer and ovarian cancer. It is estimated that breastfeeding can prevent approximately 823,000 child deaths and 20,000 deaths from breast cancer each year, but still there are mothers who do not breast feed the baby because of a problem when trying to breastfeed her baby.[3, 4]
According to data from the United Nations Children's Fund (UNICEF) today globally who are exclusively breastfed infants under 6 months of age were 41% and only 2 of the 5 infants who were breastfed exclusively. The target set by the WHO in 2025 the achievement of exclusive breastfeeding is 50%.[5] Coverage of breastfeeding in the city of Bengkulu in 2017 was 2,096 people (61.2%), the scope of exclusive breastfeeding in 2017 has decreased compared to 2016 as many as 874 people in 2015 to 61.4% and as much as 77.9%.6This coverage is below standard national coverage of 80%. Community Health Center West Rim is a public health center in the city of Bengkulu at the lowest exclusive breastfeeding coverage, from 178 the number of babies exclusively breastfed infants given only 33 infants (18.5%).[6]
Research Helen et al stated that there are several reasons mothers do not breastfeed among other medical reasons, milk is not enough, the anxiety about the production of milk. Milk production is less and slow exit is one factor inhibiting the mother not to breastfeed their babies.[7] Results of the research showed health workers Isroni husband and was instrumental in the provision of exclusive breastfeeding. [8] The decline in the proportion of exclusive breastfeeding because breast milk is not smooth expenditure so that the needs of breastfeeding their babies are not met and not enough reason not confident a mother to breastfeed her baby. [9, 10]
A mother who will give breast milk to her baby is a demand that feel heavy so will result in psychological disorders such as anxiety.[11] Research Nurul Kamariyah that the psychological condition of the mother will affect lactation, the mother will breastfeed should prepare a psychological condition.[12] Maternal anxiety levels in the puerperal influence on the volume of milk berkurangya, causing dissatisfaction with the infant while breastfeeding.[13]
High anxiety will affect prolactin levels and 1 of 5 nursing mothers with depressive symptoms will interfere with the process of breastfeeding.14 Someone under stress will stimulate the HPA-axis so that it will happen secretion of Corticotropin releasing factor (CRF) from the hypothalamus, followed by increased adenocorticotropin hormone (ACTH) resulting in increased secretion of cortisol by the adrenal glands.15 Mother during childbirth will experience postpartum blues period marked by changes in mood, anxiety, dizziness and sad feelings arise, it will increase cortisol levels which would delay or prevent the release of oxytocin during lactation and potentially interfere with the milk letdown reflex.[16]
Studies done by Ike Mardiati at Hospital Dr. Sudirman Kebumen that during 2017 there were 375 maternal lactation primiparous impaired due to anxiety as many as 115 people (30.7%). EM frilian research results Bentel mention breastfeeding mothers anxiety levels primiparity 36.62% compared with 16.38% multiparous mothers.[17]
Breast milk production is influenced by the hormone prolactin, which is secreted by the anterior pituitary gland that stimulated Prolactin-releasing hormone (PRH) which is located in the hypothalamus, while strongly influenced by the hormone prolactin, oxytocin hormone in milk production.[18]The hormone oxytocin causes the muscle fibers that surround the alveoli crimped gland which causes the flow of milk in the breast, causing the sensation to squirt milk out of the nipple.[19]
In an effort to increase breast milk production and expenditure to be smooth to use conventional and non-conventional therapies, traditional therapies using drugs - drugs that can be administered to nursing mothers, among others metoclopramide and domperidone.[20] Domperidone is a drug that is often given to lactating mothers and safe for babies but have side effects in the mother such as headache, diarrhea, abdominal cramps, dry mouth, thirst and tachyarrhythmia.[20] Some supplements are in the form of extracts and processed into food growing - plants such as leaves katuk, cumin, beans, papaya, banana can increase milk production and has been studied benefits to increase milk production. [8, 21]
Non-conventional therapies are commonly used are massage oxytocin, engineering Marmet, effleurage, back massage, massage can stimulate endorphin posterior hypothalamus and anterior pituitary sections that induce relaxation and comfort the body.22 Massage is a method that is simple, practical and does not cause tension but will cause stimulation massage the skin surface gently, relaxes the muscles, tendons, ligaments and fascia systematically to give the sensation of relax and kesaluran nerve flow of breast milk in both breasts.[23, 24]
Massage is an alternative method sedrehana, inexpensive, non-invasive, effective and no side has the advantage of the recovery of the body, massage can increase serotonin hormone that lowers cortisol levels and increasing dopamine, which can reduce anxiety.[25, 26]
Non-conventional therapies in addition to massage that can be done to reduce anxiety and increase the productionwith hypnobreastfeeding. Hypnobreastfeeding is a method of relaxation to balance the body and mind that makes the mother to be relaxed, calm and relaxed. Research conducted Luftiana Puspita Sari said there was no significant difference production between the intervention and control groups were given a combination of oxytocin and hypnobreastfeeding massage with p value => 0.05.[27]
Based on research Sheyla Najwatul that an increase of the volume of milk by 32% and 58% decrease in stress levels in mothers given electrical acupoint compared with massage therapy. Massage therapy is done with techniques effleurage massage the back and breast area for 14 days postpartum mothers.
Studies conducted by funda Kosova mention a back massage is done for 15 minutes massage group impairment noraadrenalin level compared with the group not given a massage with p value <0.05. Massage before breastfeeding can provide tranquility effect on the mother during childbirth so as to decrease the hormone noraadrenalin.[25] Research conducted by Elvika show the results that rolling massage method (back) to enhance comfort and provide relaxation in the mother so as to increase the volume of milk for their stimulation of reflexes in the formation of breast milk.
Based on the results Arkha Rosyaria that method Woolwich and rolling massage (back) at the same time effectively influence the hormone prolactin to increase milk production. Sustainable Nove research results showed that elevated levels of the hormone oxytocin can be done with oxytocin massage methods that affect the production of milk.
Analyzing the effect of effleurage back massage and hypnobreastfeeding against cortisol levels and milk production in mothers during childbirth.
Analyzing the cortisol levels before and after intervention with hypnobreastfeeding back effleurage massage in the mother during childbirth.
Analyzing milk production before and after the intervention and hypnobreastfeeding back effleurage massage in the mother during childbirth.
Analyze differences in cortisol levels before and after the massage intervention efflurage back and hypnobreastfeeding during childbirth.
Analyze differences in milk production before and after the massage intervention efflurage back and hypnobreastfeeding during childbirth.
This research uses quasy experimental research with pretest and post-test with control group design, research was conducted pre-test in the intervention group was given back effleurage massage hypnobreastfeeding and control groups were given back effleurage massage for 7 days on the variables to be studied. On day 8 post-test performed on the intervention group and the control group.
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| Age20-35 Years | 20 | 100 | 28.25 ± 6.265 | 20 | 100 | 26.55 ± 4.045 | 0,071 |
| parityprimiparasmultiparas | 1010 | 5050 | 1.55 ± 0.759 | 128 | 6040 | 1.70 ± 0.801 | 0.719 |
| WorkWorkDoes not work | 812 | 4060 | 1.40 ± 0.503 | 713 | 3565 | 1.35 ± 0.489 | 0.534 |
Table 1. Shows the results of the frequency distribution of age, parity and occupation of respondents. Homogeneity test was obtained p value for all variable> 0.05, meaning that neither age, parity and work the respondent had the same variant or homogeneous.
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| Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |
| 1 (Pre) | 6.40 ± 1.090 | 4.25 ± 0.910 | 11.25 ± 1.251 | 6.25 ± 1.209 | 3.95 ± 1.050 | 12.05 ± 1.050 |
| 2 | 6.10 ± 1.021 | 4.50 ± 0.761 | 11.15 ± 1.268 | 5.95 ± 1.099 | 3.65 ± 0.671 | 12.05 ± 1.050 |
| 3 | 5.90 ± 0.852 | 4.55 ± 1.231 | 12.15 ± 1.755 | 5.90 ± 1.210 | 4.65 ± 1.531 | 11.85 ± 1.182 |
| 4 | 10.10 ± 1.165 | 9.10 ± 1.165 | 13.80 ± 2.587 | 5.95 ± 1.191 | 4.35 ± 1.040 | 12.00 ± 1.076 |
| 5 | 10.80 ± 1.005 | 10.20 ± 1.240 | 13.85 ± 2.661 | 5.90 ± 1.119 | 4.30 ± 1.342 | 11.70 ± 0.923 |
| 6 | 11.35 ± 0.933 | 11.05 ± 0.999 | 13.60 ± 2.798 | 6.00 ± 1.170 | 3.75 ± 0.639 | 11.45 ± 1.123 |
| 7 | 11.70 ± 0.733 | 12.05 ± 1.099 | 17.15 ± 0.988 | 10.95 ± 0.887 | 10.40 ± 1.635 | 13.50 ± 2.724 |
| (Post) | 12.30 ± 0.571 | 12.15 ± 0.671 | 17.00 ± 0.858 | 10.85 ± 0.813 | 10.85 ± 1.226 | 16.00 ± 0.858 |
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0,000 | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 |
Table 2 above shows that there are significant differences in the frequency of breastfeeding, BAK and the amount of sleep a day 1 (before) until the last day (after) in the intervention group and the control group with p value <0.05. To find such a significant time difference posthoc wilxocon test results can be seen in the table below.
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| day 1 | day 2 | 0.186 | 0,201 | 0.686 | 0,084 | .109 | 0,964 |
| day 3 | 0.166 | 0.257 | 0.096 | 0,084 | 0.056 | .545 | |
| day 4 | 0,000 | 0,000 | 0,001 | 0.107 | .190 | 0.868 | |
| day 5 | 0,000 | 0,000 | 0,001 | 0,084 | 0,302 | 0.222 | |
| day 6 | 0,000 | 0,000 | 0,018 | 0.059 | 0.317 | .120 | |
| day 7 | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 | 0,021 | |
| day 8(Post) | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 | |
Posthoc test results indicate the intervention group differences in the frequency of breast-feeding, and sleep significant BAK occur started the 3rd day until the last day, while the control group there were significant differences from day 6 until the last day. Differences Frekuesi breastfeeding, BAK and lamamya sleep in intervention and control groups before and after treatment.
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| prolactin | meanSD | 328.8016.356 | 131.4044.785 | 0,000 | 296.75140.608 | 187.0583.445 | 0,000 |
| PSAS | meanSD | 84.8016.367 | 54.054.861 | 0,000 | 82.6515.557 | 68,008.956 | 0.009 |
| suckle | meanSD | 6,401,095 | 12,30.571 | 0,000 | 6.251,209 | 10.850,813 | 0,000 |
| BAK | meanSD | 4.25.910 | 12,15.671 | 0,000 | 3.951,050 | 10.851.226 | 0,003 |
| Sleep | meanSD | 11.251.251 | 17.000.858 | 0,002 | 12.051,050 | 16.000.858 | 0,000 |
Table 5 above shows a significant difference or significant levels of cortisol, PSAS, frequency of breastfeeding, BAK and duration of sleep before and after treatment in the intervention group and the control group (value <0.05).
Differences in levels of cortisol, PSAS, frequency of breastfeeding, BAK and duration of sleep between the intervention and control groups.
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| cortisol PostCortisol Δ | 159.23165.05 | 71.8581,498 | 0,0470.038 |
| PSAS | 61.03 | 10.024 | 0,000 |
| suckle | 11.58 | 1,010 | 0,000 |
| BAK | 11.50 | 1,177 | 0,000 |
| Sleep | 16.03 | .987 | 0,003 |
Table 5 shows differences meaningful or significant Yag between the intervention and control groups either of cortisol, PSAS value, frequency of breastfeeding, BAK and duration of sleep with p value <0.05.
Results of research and analysis of the characteristics of the mother during childbirth can be interpreted from age, parity and work. The frequency distribution postnatal maternal age in this study with a range of 20-35 years. Based on the age of the respondent's age characteristics of the average age of the group and hypnobreastfeeding back effleurage massage with massage group effleurage no life characteristics mean difference between groups. In statistical research findings indicate the age of the respondents in this research the same / equivalent.
One of the factors that can affect the reproductive health of a person is a minor. Age will determine maternal health is the condition of pregnancy, childbirth and the postnatal and breastfeeding. According to research Mitrami 2017 that less than 20 years of age are not ready in terms of physical and social in dealing with pregnancy and childbirth will affect the postnatal and breastfeeding.
In this study, the age of respondents aged 20 to 35 years, someone with adult will be better prepared physically, mentally and socially for pregnancy, childbirth and the postpartum period in preparation for breastfeeding her baby.
Parity is a factor that can influence the levels of cortisol and mother's milk production during the postpartum period. Mothers most often experience anxiety primiparous compared with multiparous mothers during parturition and lactation. In this study, primiparous mothers in the intervention group of 10 people and multipara 12 people in the control group there were 12 primiparous and multiparous 10 people. Anxiety in the mother during childbirth will affect milk production.17 Primiparous mothers do not have a new and changed role of a teenager becoming a mother demanded provide nutritional intake baby so it will affect the psychological mother.
In this study, there are 8 0rang working mothers and 12 people out of work in the intervention group, while the control group, there were 7 people are employed and 13 orng yng not work. Another factor that can influence the levels of cortisol and milk production in mothers during childbirth is a job. Working mothers will have fatigue that affects the physical and psikologia and time constraints to give breast milk to her baby.
The results of this study showed that cortisol levels prior to treatment on his back effleurage massage group and hypnobreastfeeding average gained 328.80 ng / ml and at the back effleurage massage group gained an average of 296.75 ng / ml. Cortisol levels after treatment on his back effleurage massage group and hypnobreastfeeding obtained average value of 131.40 ng / ml and at the back effleurage massage group 187.05.
During postnatal mother may be experiencing anxiety caused insomnia, pain, fatigue and problems with breastfeeding. A new mothers to breastfeed their babies will be prosecuted properly so baby nutrient requirements are met, it can cause psychological disorders such as anxiety. [65]Treatment of the puerperal period has not been widely available to address issues that affect anxiety. Massage effleurage back and hypnobreastfeeding is an effective, simple, inexpensive and non-invasive to reduce anxiety on the first day postpartum.
Massage is the manipulation of soft tissue structures that can give a sense of calm and a psychological influence by increasing the morphine endogenous hormones such as endorphins, enkefalindan dinorphin as well as lower levels of stress hormones such as cortisol.
Cortisol is produced by the body in the zone fasciculata by their metabolism that is associated with stress, when the stressor is received excessive then secreted CRF will be increased so that the increase rangasangan pituitary and secretion of cortisol by the adrenal glands will increase as well. The concentration of the hormone cortisol in normal conditions will be released at least every heart and in the morning cortisol values were 50 ng / ml to 230 ng / ml.
The results are consistent with research conducted in primiparous postpartum mothers in Semarang given massages decreased cortisol 74.82 ng / ml. Massage manage system noraadrenalin, massage can stimulate sensory afferent fibers in the skin that affects the body and pikiran.relaksasi in the puerperium can decimate the activity of the sympathetic nervous system and reduce the level of anxiety.
This study shows that massage effleurage back and hypnobreastfeeding in 7 days can lower the level of anxiety and cortisol levels mother during childbirth. Therefore midwives and nurses use effleurage back massage and hypnobreastfeeding on postpartum mother to give relaxation that will lower cortisol levels and anxiety of the mother.
These results indicate the production of milk in the back effleurage massage group and hypnobreastfeeding as measured by frequency of breastfeeding before intervening with an average value of 6.40 and after the intervention 12,30. BAK baby before intervening with an average value of 4.25 and 12.15 after intervention and after the intervention. Infant sleep duration before the intervention and after the intervention 17.00 11.25.
The results of the study in the control group were given back effleurage massage obtained an average value of 6.25 frequency of breastfeeding before the intervention and after the intervention 10.85. BAK infants with an average value of 3.95 and 10.85 setelh intervention. Old baby sleeping with an average value of 12.05 before the intervention and after the intervention 16,00 then this shows a significant difference with p-value <0.05.
Puerperal mother on the first day will undergo psychological changes such as anxiety, sadness and fatigue, it will affect milk production. Breast milk is the main food for the newborn abyi, because breast milk contains antibodies, immune substances that can prevent entry of infection into the baby's body.
Massage techniques effleurage done on the back will provide sensory stimulation to the nerves of the spine as a neurotransmitter will stimulate the medulla oblongata which immediately sent a message to the posterior hypothalamus to secrete oxytocin hypofise that secrete breast milk.
Hypnobreastfeeding technique begins with the preparation of the body, mind and soul, comfortable environment for supportive therapy. Mom took a deep breath, exhale, close your eyes and relax the body by relaxing the muscles from head to toe. Mothers are given confidence in him to be able to provide breast milk to their babies, beliefs with positive affirmations in the mother will increase the production and flow of milk. Hypnobreastfeeding stimulate the brain to release neurotransmitters that the brain chemical found encphalin and endorphins that serve to enhance the mood so that it can change a person's acceptance of the pain or other physical symptoms.
This study proves that the mother during childbirth as normal vaginal delivery after effleurage back massage for 20 minutes and hypnobreastfeeding shown to increase milk production. This study is in line with research conducted elvika massage / massage is an effective supportive therapy to reduce physical discomfort and improve mood disorders, reduction of discomfort in breastfeeding mothers will help the process of lactation.
Results of statistical analysis of significant difference between the levels of the hormone cortisol and hypnobreastfeeding effleurage massage p-value of 0.000 (p-value 0.05) with the difference in the average value of 131 (Standard deviation 44.785), while the control group were given massage effeleurage before and after intervention p-value of 0.05 (p-value <0.05) with an average value of 187.05 (standard deviation 83.445). Differences in average values before treatment and after treatment 159.23 (standard deviation of 71.858 with p value of 0.047 (p value <0.05).
The hormone cortisol is an important regulator in humans, free cortisol in the blood have a negative feedback on the release cortikotropin hormone releasing hormone (CRH) from the hypothalamus. CRH will descend through the veins of the portal system to the anterior pituitary hypothalamus that stimulates ACTH. At the time of the psychological condition of someone experiencing anxiety will increase cortisol levels.
In this study, examination using blood serum cortisol levels in the morning and examined by ELISA. Blood serum for inspection more accurate and precise than the saliva, hair and urine in assessing increased levels of cortisol in the body.
Cortisol levels after being given a massage intervention and hypnobreastfeeding effeleurage significant decline, in line with the research feresteh jahdi that give a touch of massage therapy to improve blood circulation and muscle relaxation will create comfort and reduce anxiety16, So as to lower cortisol levels in the mother during childbirth.
Research is conducted conducted by Agustina 2016 that aromatherapy massage aromatherapy proven to reduce cortisol levels and increase milk production in postpartum women primapara in Semarang. So it is advisable to give a massage to every woman in the puerperium-feeding.
These results indicate that an increase in milk production in intrvensi group effleurage back massage and hypnobreastfeeding seen from ferekuensi breastfeeding p-value 0.000 (standard deviation of 1,010) with an average value of 11.58. Nlai baby BAK frequency average of 11.50 with a p-value of 0.000 (standard deviation of 1.177) and the long sleep of infants with an average value of 16.03 p-value 0.003 (standard deviation of 0.987). In the intervention group increased milk production in the third day and the control group increased milk production on the day to six.
Mother on the first day post partum lactation caused seing experiencing less smooth expenditures have not breastfed or breastfed discharge. Milk production is less or later would cause the mother did not breastfeed her baby so that the baby does not get enough food intake and infants. How many factors that affect milk production, among others such as the mother's age at birth, occupation, parity, nutrition, rest patterns, breast care and psychological factors.
In this study, milk production was measured using observation sheet that includes the frequency of breastfeeding, BAK baby and infant sleep duration during the visit ask respondents to provide intervention. Enough milk production can be judged from the baby's weight, frequency, BAK dabn CHAPTER babies, old sleeping baby, the baby's skin color, mother's breast is taut before feeding and become mushy after breastfeeding her baby.
Handling the lack of milk production in mothers during childbirth include medical and non-medical methods, medical methods to give medicines that contain chemicals and can sometimes cause side effects in the mother and baby.
Non-medical methods one of which is to give a massage to the backs and special hypnoterapi for nursing mothers as hypnobreastfeeding. The use of this method to provide a relaxing effect and stimulation on the back that will merangang sensory nerves of the skin surface can stimulate the parasympathetic nerve to mengelaurkan hormone prolactin and oxytocin that milk production smoothly.23,
Research conducted by Patel 2012, massage is an alternative to non-pharmacological therapy in improving milk production as measured by weight gain, the amount of BAK old baby and infant sleep after feeding.23 In line with less research Morhen 2012 which shows the results of massage can increase the production of lactation, the reduction of NO and increased ACTH and β- endorphin.
In research increase milk production can be concluded that massage effeluerage and hypnobreastfeeding conducted in the mother during childbirth can lower cortisol levels so that mothers feel more comfortable and increase milk production. Through massage or stimulation to the spinal medulla oblongata neurostransmitter will stimulate directly send messages to the hypothalamus in the posterior pituitary hormone oxytocin to mengeluarakan that ASI expenditure to be smooth.
Effleurage back massage intervention and hypnobreastfeeding proven to reduce the level of cortisol in the mother during childbirth.
Effleurage back massage intervention and hypnobreastfeeding proven effective in improving milk production in mothers during childbirth.
There was a significant difference in lowering cortisol levels between the groups back and hypnobreastfeeding effleurage massage with effleurage back massage group.
For postpartum mothers can use effleurage massage your back and hypnobreastfeeding as non-medical alternative method to increase milk production and the level of anxiety, this method is very secure, sedrehana, inexpensive, non-invasive, effective and no side. This method can also be carried out by her husband and family, while hypnobreastfeeding can be done by the mother after the technique taught by the therapist.
Expected to implement using effleurage massage your back and hypnobreastfeeding to deal with lactation.
For hospital and midwife practice Mandiri
For researchers selanjunya.
This research can be continued using other variables related denag milk production and the level of anxiety such as nitric oxide (NO) or β-endorphin (BE), increasing the number of samples and respondents with post Sectio Cesarean.
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