The role of massage therapy in postpartum depression and functional recovery: A randomized controlled trial

Authors

Abstract

Aim Postpartum period is a critical time for women’s physical and psychological recovery. Non-pharmacological interventions such as massage therapy may support maternal well-being by reducing depressive symptoms and enhancing functional capacity. The aim of this study was to investigate the effects of classical massage applied to mothers in the early postpartum period on functional status and depression, and to evaluate the contribution of massage as a supportive care method.
Materials and Methods This randomized controlled study was registered at ClinicalTrials.gov (NCT06539858). A total of 28 postpartum women were randomly assigned to either an intervention group (n=14) or a control group (n=14). The intervention group received a 45-minute classical massage (waist, neck, back) once a week for four weeks. The control group received no additional care. Outcomes were measured using the Edinburgh Postnatal Depression Scale (EPDS) and the Inventory of Functional Status After Childbirth (IFSAC). Data were analyzed using non-parametric tests (Mann-Whitney U, Wilcoxon) due to non-normal distribution.
Results In the intervention group, a significant decrease in EPDS scores was found (p=0.014), along with a non-significant improvement in IFSAC scores (p=0.072). In the control group, functional status improved significantly (p=0.025) without significant changes in depression scores (p=0.154). No significant differences were found between groups in EPDS or IFSAC scores (p>0.05).
Discussion Massage therapy may reduce depressive symptoms in early postpartum mothers and supports functional recovery trends. Sociocultural influences may explain unexpected functional gains in the control group. Larger-scale studies are recommended to explore outcomes across different postpartum populations and birth experiences.

Keywords

Introduction

The first six months after birth are called the postpartum period [1]. Postpartum depression is defined as depression that occurs within the first month after birth [2]. Although the highest risk period is the first year after birth, the risk of developing this depression continues for approximately two years [3–5]. The rate of postpartum depression in mothers in Turkey varies between 6.3% and 50.7% [6]. With the increase in responsibilities in mothers after birth, depression, stress, sleep problems and unmet basic needs increase. Studies conducted in recent years have shown that more than just the mother’s depression needs to be treated [7]. The postpartum period is a period when mothers are more sensitive and various psychological problems occur. This period affects not only the mother but also the baby’s psychological state indirectly. The incompatibilities experienced delay the acquisition of the sense of motherhood and responsibilities [8, 9]. One of the biggest reasons for the emergence of depression is the lack of support provided to the mother. The depression level develops positively with the support provided by the mother’s close circle [1]. In this process, the physical characteristics of the mother are prioritized, while other functional characteristics are overlooked.
The mother needs to be in a state of full functionality, which includes self-care, care of the baby and other family members, as well as social and professional requirements [10]. In the first weeks after discharge, decreases in the functional status of mothers may be observed due to their responsibilities at home [11]. Massage therapy is one of the easiest methods recommended instead of drug treatment for problems seen in mothers during the breastfeeding period. Massage therapy, considered a complementary or alternative treatment, is seen to relax mothers by creating relaxation in their muscles and to have a positive effect on psychological problems [12]. In studies conducted on mothers in the postpartum period, the healing effects of massage application have been observed [13–15]. These positive improvements can be stated as a decrease in depressive thoughts and an increase in serotonin and dopamine levels [16]. The aim of this study is to investigate the effects of massage application on functional status and depression in women who have given birth.
This study was based on the hypothesis that classical massage applied during the postpartum period would reduce depressive symptoms and improve the functional status of mothers. Massage is a safe, accessible, and non-pharmacological intervention that can support psychological well-being in postpartum women [17]. Short-term massage sessions provided by a partner or healthcare staff may enhance emotional resilience and sleep quality [18].
Therefore, the hypotheses were formulated as follows:
H1: Classical massage applied during the early postpartum period significantly reduces Edinburgh Postnatal Depression Scale (EPDS) scores in the intervention group compared to the control group.
H2: Classical massage applied during the early postpartum period improves Inventory of Functional Status After Childbirth (IFSAC) scores in the intervention group compared to the control group.
These hypotheses are consistent with Domínguez-Solís et al. (2021), who emphasized the effectiveness of non- pharmacological interventions in reducing postpartum anxiety and depression.

Materials and Methods

Study Population and Sampling: The study universe consisted of adult women aged 20-40 years who applied to Yalova University Physiotherapy and Rehabilitation Application and Research Center between February and August 2024 and were in the first 6 months of postpartum. Women who had conditions contraindicated to massage were excluded. A total of 28 women met the criteria and were included in the study. Participants who met the inclusion criteria of the study were randomized into intervention and control groups through a randomization application used with free access. The study was completed with a total of 28 participants divided into two groups: an Intervention (n=14) and a Control (n=14).
Data Collection Tools
Participants were included in the study through invitation and announcement. The intervention group received a 45-minute classic massage of the waist, back, and neck with baby oil once a week for 4 weeks. The control group was not treated. Participants’ information was collected using a data recording form. Functional status was measured with the Postpartum Functional Status Inventory(Bulguroglu et al., 2023), and depression status was measured with the Edinburgh Postnatal Depression Scale (EPDS). The evaluations were administered to all participants twice: at the beginning of the study and the end of the 4 weeks.
Edinburgh Postnatal Depression Scale (EPDS): It is a validated self-assessment tool evaluating the emotional states of mothers in the last 7 days.The scale, which was adapted into Turkish by Engindeniz et al. [19], is a self-assessment type, four- point Likert-type scale consisting of 10 items. The answers, consisting of four options, are scored between 0 and 3; the lowest score that can be obtained from the scale is 0, and the highest score is 30. In the evaluation, items 1, 2, and 4 are scored as 0, 1, 2, 3, while items 3, 5, 6, 7, 8, 9, and 10 are scored in reverse as 3, 2, 1, 0.
Inventory of Functional Status After Childbirth (IFSAC): It was prepared considering the time spent by the mother after birth. It consists of a total of 5 sections and 36 questions. Each question is scored between 1-4. In the first section, housework, in the second section, social activities, in the third section, baby care, in the fourth section, daily life and in the fifth section, work life are questioned. A low score indicates a decrease in functional status. Validity and reliability have been proven by Özkan et al. [20].
Evaluation of Data
Statistical analyses were performed using SPSS version 24.0. The conformity of variables to normal distribution was examined using Kolmogorov-Smirnov and Shapiro-Wilk tests. Participants’ age, body weight, height, and BMI were characteristics that did not conform to a normal distribution, both within the group and in total; therefore, categorical variables are presented by giving median and minimum-maximum values (Table 1). The control of whether categorical data were distributed similarly between the two groups was evaluated using the Chi-Square test, and the data were found to be similar between the two groups. Since the primary hypothesis of the study, examining the effect of massage on the functional status and depression of mothers, was not met, the analysis was conducted using the Mann-Whitney U test in independent groups. Since within- group assumptions were not met, the Wilcoxon signed-rank test was employed. A p value of < 0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Yalova University (Date: 2024-06-03, No: 2024/3).

Results

Demographic Information of Participants
Demographic information of the 28 participants, all of whom were recent birth women, who met the inclusion criteria and completed the study are presented in Table 1.
Depression and Functional Status Results
The intergroup significance assessment of the difference created before and after the isolation intervention, as measured by the Edinburgh Postnatal Depression Scale, and the functional impairment intervention, as measured by the Postpartum Functional Status Inventory, was conducted using the Mann-Whitney U test. The results are presented in Table 2. There was no significant difference in the EPDS and IFSAC results in the intergroup assessments.
The significance of the intragroup difference after changes in depression and functional status was analyzed using the Wilcoxon test. The results are presented in Table 3. A significant decrease in the score differences depending on the results (p=0.014). Despite the increase in functional status scores of the intervention group, a non-significant result was obtained (p = 0.072). While there was no significant difference in the scores within the control range, a significant difference was found in the increase in functional status scores (p = 0.025).

Discussion

This study examined the effects of classical massage therapy on depression and functional status in early postpartum mothers. The observation of a significant decrease in depression levels in the intervention group is parallel to many studies in the literature. For example, Hidayati et al. reported that endorphin massage applied to women with postpartum depression significantly reduced EPDS scores [12]. Similarly, Imura reported an improvement in the mothers’ mental state after aromatherapy massage [15]. These studies support the effect of massage therapy in reducing depressive symptoms. These results align with the study by Ko and Lee (2014), which found that five days of 20-minute back massages significantly improved sleep quality, indirectly supporting psychological well- being in postpartum women.
In another study conducted on women who had cesarean delivery, participants were divided into 3 groups: massage (20-minute connective tissue massage), standard care, and individual attention. Relaxation increased in the massage group compared to the other groups, while pain and stress levels decreased [20]. In a study conducted on 100 women who had normal birth, mothers were divided into two groups: intervention and control. The intervention group experienced a significant improvement in anxiety scores immediately after a 20-minute back massage applied in a sitting position and the next morning [18]. Kenyon reported that a 20-minute back massage can provide psychological relief [21]. In a study conducted by Lee and Ko., 60 women who had a normal delivery who received massage experienced less back pain [22].
A systematic review by Domínguez-Solís et al. (2021) also found that partner-supported massage and other non pharmacological interventions led to significant reductions in postpartum depression and anxiety [23]. Interventions involving personal contact and psychosocial support had the greatest effect sizes, suggesting that the classical massage intervention in our study likely contributed through similar mechanisms. While the massage intervention led to a reduction in depressive symptoms, its effect on functional status was not statistically significant. Similarly, Ko and Lee (2014) did not measure daily activities but focused on sleep quality. Functional status is a multidimensional construct influenced by social and environmental factors. Domínguez-Solís et al. (2021) emphasized that interventions involving partner participation and psychoeducation were more successful in enhancing functional outcomes.
The fact that the effect on functional status was not significant in our study is consistent with similar results reported by Bulguroğlu et al. [24]. In their study, no significant effect of physical activity on functional level was found in the postpartum period. However, some studies, such as those by Bagherinia et al. [10], have reported that educational interventions have a positive effect on functionality, suggesting that massage alone may not be sufficient.
The unexpected functional improvement observed in the control group may indicate the effect of sociocultural or environmental support factors. Bingöl and Tel emphasized that social support is an important factor affecting the level of depression [1]. Therefore, the higher environmental support levels of individuals in the control group may explain this improvement.
When the functional status of the mother was assessed after undergoing whole body massage therapy, it was observed that there was no significant improvement in her functional status. No significant difference was found in their ability to care for themselves and their babies [25]. In our study, no significant results were observed in the intervention group; however, an increase was noted in the functional status of the control group. We believe that the significant improvement observed in the control group may be attributed to differences in the sociocultural, physical, and economic status of the mothers, or to the presence and influence of supporters. Another important point of the study is that all mothers were included regardless of the type of delivery. However, Simonelli et al. reported that connective tissue massage was effective in women who had undergone a cesarean section, drawing attention to the fact that the type of delivery may have different effects on psychological and physical well-being [13]. This situation suggests that the type of delivery should be controlled for in future studies.

Limitations

This study has several limitations. First, the study was conducted in a single center, which may not represent diverse sociocultural and healthcare settings. Second, participants were not stratified based on type of delivery (vaginal or cesarean), which could affect both psychological and functional recovery outcomes. Finally, long-term effects of massage therapy were not assessed, as the follow-up was limited to four weeks.

Conclusion

This study supports the use of classical massage as an effective intervention for reducing postpartum depression. However, improvements in functional status may require a multidisciplinary and multi-component approach. Future studies should consider the effects of partner support, delivery type, and social environment with larger sample sizes and more comprehensive designs.

References

1. Yilmaz Bingol T, Tel H. Postpartum dönemdeki kadınlarda algılanan sosyal destek ve depresyon düzeyleri ile etkileyen faktörler [Perceived social support and depression levels and affecting factors in postpartum women]. Gulhane Med J.2007;50(4):267-72.
   Article PubMed Google Scholar
2. Segal DL. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). In: Weiner IB, Craighead WE, editors. The Corsini Encyclopedia of Psychology. Hoboken (NJ): John Wiley & Sons; 2010. p. 87-93.
   Article PubMed Google Scholar
3. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to mothers II: report of the second national U.S. survey of women’s childbearing experiences. J Perinat Educ. 2007;16(4):9-17.
   Article PubMed Google Scholar
4. Parry BL, Haynes P. Mood disorders and the reproductive cycle. J Gend Specif Med. 2000;3(5):53-8.
   PubMed Google Scholar
5. Manfredi G, Lazanio S, Kotzalidis GD, Ruberto A, Girardi P, Tatarelli R. Postpartum depression without delivering a child? Acta Psychiatr Scand. 2005;112(3):233-6.
   PubMed Google Scholar
6. Durukan E, Ilhan MN, Bumin MA, Aycan S. 2 Hafta-18 aylık bebeği olan annelerde postpartum depresyon sıklığı ve yaşam kalitesi [Prevalence of postpartum depression and quality of life in mothers with babies aged 2 weeks to 18 months]. Balkan Med J. 2011;28(4):385-93.
   PubMed Google Scholar
7. Forman DR, O’Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Dev Psychopathol. 2007;19(2):585-602.
   PubMed Google Scholar
8. Righetti-Veltema M, Conne-Perreard E, Bousquet A, Manzano J. Postpartum depression and mother-infant relationship at 3 months old. J Affect Disord. 2002;70(3):291-6.
   Article PubMed Google Scholar
9. Basdas O, Efe YS, Erdem E, Ozdemir A, Gunes T, Ozturk A. Anne bebek bağlanmasını etkileyen faktörler [Factors affecting mother-infant bonding]. YOBU Fac Health Sci J. 2022;3(2):130-6.
   Article PubMed Google Scholar
10. Bagherinia M, Mirghafourvand M, Shafaie FS. The effect of educational package on functional status and maternal self-confidence of primiparous women in postpartum period: a randomized controlled clinical trial. J Matern Fetal Neonatal Med. 2017;30(20):2469-75.
    Article PubMed Google Scholar
11. Fawcett J, Tulman L, Myers ST. Development of the inventory of functional status after childbirth. J Nurse Midwifery. 1988;33(6):252-60.
    PubMed Google Scholar
12. Hidayati H, Barlianto W, Baktiyani SCW. Postpartum depresyonlu kadınlarda endorfin masajının Edinburgh Doğum Sonrası Depresyon Ölçeği (EDPS) ve β-endorfin seviyesi üzerine etkileri [Effects of endorphin massage on B-endorphin level and Edinburgh Postnatal Depression Scale (EPDS) score in women with postpartum blues]. Cukurova Med J. 2014;39(3):512-6.
    Article PubMed Google Scholar
13. Simonelli MC, Doyle LT, Columbia MA, Wells PD, Benson KV, Lee CS. Effects of connective tissue massage on pain in primiparous women after cesarean birth. J Obstet Gynecol Neonatal Nurs. 2018;47(5):591-601.
    Article PubMed Google Scholar
14. Putri M, Suryantara B, Nasution SS, Kebidanan M, Guna S, Yogyakarta B. Effect of effleurage massage technique with postnatal massage technique on afterpains in postpartum mothers. Sci Midwifery. 2023;11(2):374-80.
    Article PubMed Google Scholar
15. Imura M. The psychological effects of aromatherapy-massage in healthy postpartum mothers. J Midwifery Womens Health. 2006;51(2):148-53.
    Article PubMed Google Scholar
16. Bilgic D, Daglar G, Ozkan SA, Kadioglu M. Postpartum depresyonda tamamlayıcı ve alternatif tedaviler [Complementary and alternative treatments in postpartum depression]. J Women’s Health Nurs. 2016;2(2):13-35.
    PubMed Google Scholar
17. Ko YL, Lee HJ. Randomized controlled trial of the effectiveness of using back massage to improve sleep quality among Taiwanese insomnia postpartum women. Midwifery. 2014;30(1):60-4.
    Article PubMed Google Scholar
18. Jahdi F, Mehrabadi M, Mortazavi F, Haghani H. The effect of slow-stroke back massage on the anxiety levels of Iranian women on the first postpartum day. Iranian Red Crescent Med J. 2016;18(8):e34270.
    Article PubMed Google Scholar
19. Engindeniz AN, Küey L, Kültür S. Edinburgh Doğum Sonrası Depresyon Ölçeği Türkçe formu geçerlilik ve güvenilirlik çalışması [Validity and reliability of the Turkish form of the Edinburgh Postnatal Depression Scale]. Bahar Semp. 1996;1(1):51-52.
    PubMed Google Scholar
20. Ozkan S, Sevil U. Doğum sonrası fonksiyonel durum envanterinin geçerlilik güvenilirlik çalışması [Validity and reliability study of the Postpartum Functional Status Inventory]. TSK Koruyucu Hekimlik Bülteni. 2007;6(3):199-208.
    PubMed Google Scholar
21. Kenyon M. Randomized controlled trial on the relaxation effects of back massages for puerperants on the first post-partum day. Jpn J Nurs Sci. 2015;12(2):87-98.
    PubMed Google Scholar
22. Lee HJ, Ko YL. Back massage intervention for relieving lower back pain in puerperal women: a randomized control trial study. Int J Nurs Pract. 2015;21(S2):32-7.
    PubMed Google Scholar
23. Dominguez-Solis E, Lima-Serrano M, Lima-Rodriguez JS. Non-pharmacological interventions to reduce anxiety in pregnancy, labour and postpartum: a systematic review. Midwifery. 2021;102(103126).
    PubMed Google Scholar
24. Bulguroglu HI, Bulguroglu M, Gevrek PTC. Investigation of the effects of physical activity level on functionality level and quality of life in the postpartum period. J Health Popul Nutr. 2023;42(1):1-6.
    PubMed Google Scholar
25. Aizar E, Asiah DN. Postpartum massage and functional status of mothers in Medan. Bull Farmatera. 2018;3(1):1-6.
    PubMed Google Scholar

Declarations

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →

About This Article