Widyawati MN, et al. Belitung Nursing Journal.

2016 August;2(4):48-57
Accepted: 12 August 2016
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© 2016 Belitung Nursing Journal

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ORIGINAL RESEARCH ISSN: 2477-4073

EFFECT OF MASSAGE AND AROMATHERAPY ON STRESS

AND PROLACTIN LEVEL AMONG PRIMIPAROUS
PUERPERAL MOTHERS IN SEMARANG, CENTRAL JAVA,
INDONESIA

1,2* 1 1 1
Melyana Nurul Widyawati , Soeharyo Hadisaputro , Anies , Ariawan Soejoenoes
1
Doctoral Program of Medical Science and Health, Diponegoro University, Semarang, Indonesia
2
Postgraduate Midwifery Program, Semarang Health Polytechnic, Semarang, Indonesia

*Correspondence:
Melyana Nurul Widyawati, S. SiT, M.Kes.
Postgraduate Midwifery Program, Semarang Health Polytechnic, Jl. Tirto Agung, Pedalangan, Banyumanik,
Kota Semarang, Jawa Tengah, Indonesia (50268). Mail: [email protected]

ABSTRACT
Background: Exclusive breastfeeding in Semarang during the past five years remains low. Only 20 to 64% of
mothers were breastfed exclusively in 2010-2012. The incidence of postpartum blues was reported by 29.9%
mothers, and mostly (56.6%) was primiparous.
Objective: This study aims to determine the effect of Loving Massage, aromatherapy, and a combination of
Loving Massage and aromatherapy on stress levels, and changes in levels of prolactin in primiparous puerperal
in Semarang.
Method: A true experimental study with a randomized pretest-posttest control group design. Cluster random
sampling was used to select 12 health centers from the 37 health centers in Semarang. A random assignment
with a sealed envelope was performed to divide study participants into four groups; loving massage group,
aromatherapy group, and a combination group of loving massage and aromatherapy, and a control group. A total
of 52 primiparous puerperal mothers was involved, with 13 mothers were distributed equally in each group.
Results: Loving Massage, aromatherapy, and a combination of Loving Massage and aromatherapy effectively
changed mother’s stress and prolactin levels. Effectiveness of each treatment assessed from the average
difference in scores before and after treatment. Combination of Loving Massage and aromatherapy had proven
as the most effective treatment in reducing stress levels (11.61 ± 6.76), and increasing prolactin level (83.13 ±
6.41 ng/ml).
Conclusions: Loving Massage & Aromatherapy shown to lower the levels of stress, and can increase the levels
prolactin in postpartum primiparous. Therefore, it is recommended to provide Loving Massage therapy and
aromatherapy to postpartum primiparous mothers.

Key words: Loving massage, aromatherapy, stress, prolactin.

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INTRODUCTION often erratic in postpartum mothers can be
United Nations Children's Fund improved by inhaling jasmine oil. In
(UNICEF) reported that started feeding on addition, oil Foeniculum vulgare/Fennel/
the first day after birth can reduce the risk Fennel Oil contains antioxidants, can help
of neonatal mortality up to 45%.1 In reduce anxiety, increase the flow of milk,
addition, exclusive breastfeeding was and it can be used as galactagogue
found effective in preventing infant (increases the supply of breast milk).
mortality up to 13% - 15%.2 Nevertheless, Moreover, phytoestrogens contained in
having their first experience, primiparous Fennel can support the growth of breast
mothers are susceptible to depression tissue.7
during the postpartum as a result of the Postpartum period is recognized as
complex pressures of high anxiety, lability vulnerable to affective disorders,
feelings, and feeling of guilt. The especially depression postpartum. In
postpartum mothers who are depressed contrast, the prevalence and clinical
tend to be too late to initiate breastfeeding presentated stress levels and milk
or choose to stop breastfeeding and production during the postpartum period
therefore, tend to have low prolactin have not received much attention for
levels, both in milk and in serum.3 Low research. Data show that the obsessive-
levels of the prolactin hormone give compulsive disorder, stress and anxiety
unfavorable effects on milk production.4,5 disorders were higher in postpartum
Postpartum women are also at risk women than in the general population.8
for inflammation which naturally rise Loving massage and aromatherapy are
began in the last trimester of pregnancy expected to help postpartum mothers to
and these changes will continue in the gain the feeling of relaxation and increased
postpartum period. Study showed that comfort that can affect the increase in milk
mothers with postpartum depression production as well as maternal and infant
experienced acute stress and inflammatory immune system. The interaction that
responses withstand failure, had higher occurs between these therapies have
levels of IL-6 and TNF-α higher in mutually synergistic effect as between the
response to an acute stressor than two can be mutually augmented by the
postpartum mothers who are not therapeutic work without adding to the ill
depressed. They are also less sensitive to effects or reduce them.
glucocorticoids which can usually resolve This study aims to determine the
the inflammatory response system.3 The effect of Loving Massage, Aromatherapy,
study also showed that aromatherapy and a combination of Loving Massage and
massage therapy can reduce anxiety and Aromatherapy on stress levels, and
stress, as well as beneficial to the immune changes in levels of prolactin in
system.6 primiparous puerperal in Semarang, which
Given the previous study was expected to increase the coverage of
evidences, this research applied Loving exclusive breastfeeding. The novelty of
Massage and Aromatherapy mixture of this research can be observed from the
jasmine and fennel oils which the result of nature of the treatments given: (1) Loving
local processing plants native to Indonesia. massage technique, which had never been
Studies reported that jasmine oil has a studied before is a massage technique
stimulating effect on the function of the modifications designed by the researchers
nervous system, increasing positive in this study. The technique combines
emotions, and improve mood. Mood that is massage with effluarage techniques,

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petrissage, accupressure, and love 7th day after birth, up to four weeks
kneading with the concept of holistic postpartum.
body-mind-spirit connection through The combination treatment of
touching; (2) a mixture of aromatherapy Loving massage and aromatherapy Fennel
fennel and jasmine had never been studied / Fennel and Jasmine / Jasmine was given
before; (3) a combination of massage with as a combination of massage with a
aromatherapy Loving fennel and jasmine duration of 50 minutes, using sunflower oil
have not been investigated before. with additional aromatherapy Fennel /
Fennel and Jasmine / Jasmine (each 3
METHODS drops in 100 ml sunflower oil) once a
It was a true experimental study week for four weeks. Total giving massage
with a randomized pretest-posttest control four times beginning on the 7th day after
group design. Cluster random sampling birth, up to four weeks postpartum. The
was employed to select 12 health centers control group was given standard
from the 37 health centers in Semarang. A treatment in the postpartum care service,
random assignment with a sealed envelope including the examination of signs - vital
was performed to divide study participants signs, diagnose the perceived complaints
into four groups; loving massage group, (fever, shortness of breath, abdominal
aromatherapy group, combination of pain, severe headache, blurred vision,
loving massage and aromatherapy group, breast pain, swelling in the breasts, sore
and a control group. nipples, swelling in hands, swelling in the
The subject of this research was face, swelling in the limbs, severe
postpartum primipara mothers who agreed bleeding, vaginal discharge that smells),
to receive the treatment, and has met the nutrition, defecation, micturition, and
inclusion and exclusion criteria of the breastfeeding patterns. Blood sampling in
study. The subjects were given the the control group performed at the same
treatment, each treatment is divided into 4 time as the treatment group.
groups, loving massage group, The stress levels of mothers in the
aromatherapy group, combination of treatment group were measured using
loving massage aromatherapy group, and DASS (depression anxiety and stress
control groups. A total of 52 primiparous scale) on the 7th day post partum prior to
puerperal mothers were involved, with 13 the treatment, and after obtaining four
mothers were distributed equally in each times the treatment on day 28 postpartum.
group. There was no drop out reported Likewise, the stress levels of mothers in
during the study period. the control group were also measured
Loving massage treatment using using the same methods on the 7th day
sunflower oil was given with a duration of post partum and 28 days post partum.
50 minutes each time once a week for four Prolactin serum was measured using DRG
weeks at the beginning on the 7th day after Prolactin ELISA, and laboratory analyzes
birth, up to four weeks postpartum. were performed at the GAKY Laboratory
Aromatherapy treatment Fennel/ Fennel of Medical Faculty of Diponegoro
and Jasmine / Jasmine (each 3 drops in University Semarang. Measurement of
100 ml of water) was given by inhalation prolactin levels in the treatment and
using a diffuser for 30 minutes. control group was performed on the 7th
Aromatherapy inhalation was given every day of post partum at 10.00 am, and after
week for four weeks at beginning on the obtaining the treatment at 11:00 am.
Different test analysis between treatment

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groups were analyzed by One Way Anova, Faculty Research Ethics Committee
by setting up a p value> 0.05. Diponegoro University Semarang.
The therapists were midwives who
have been trained in providing treatment RESULTS
for primiparous puerperal mothers. Data Respondents’ characteristics
collection in the experimental group was The subject of this research was
retrieved by researchers, assisted by nine postpartum primipara mothers who agreed
midwives certified competent as to receive the treatment, and has met the
enumerators who previously given special inclusion and exclusion criteria of the
training for four days. Ethical approval of study. They were women at reproductive
this study was obtained from Medical age 20-35 years old and primiparous.

Table. 1 Respondents’ characteristics

Groups
Total
Variable X1 X2 X3 C
F % f % F % f % f %
Age
20-25 7 53,8 9 69,2 7 53,8 7 53,8 30 57,7
26-30 2 15,4 3 23,1 4 30,8 4 30,8 13 25,0
31-35 4 30,8 1 7,7 2 15,4 2 15,4 9 13,3
Total 13 100 13 100 13 100 13 100 52 100
Education
Primary 2 15,4 1 7,7 0 0,0 1 7,7 4 7,7
First secondary 2 15,4 1 7,7 2 15,4 3 23,1 8 15,4
Secondary 8 61.5 8 61,5 10 76,9 7 53,8 33 63,5
Higher education 1 7,7 3 23,1 1 7,7 2 15,4 7 13,5
Total 13 100 13 100 13 100 13 100 52 100
Occupation
Housewife 6 46,2 7 53,8 8 61,5 8 61,5 29 55,8
Private employee 6 46,2 5 38,5 3 23,1 4 30,8 18 34,6
Civil servant 1 7,7 1 7,7 1 7,7 0 0,0 3 5,8
Business owner 0 0,0 0 0,0 1 7,7 1 7,7 2 3,8
Total 13 100 13 100 13 100 13 100 52 100
BMI
Underweight 0 0 2 15,4 0 0 1 7,7 3 5,8
Normal 6 46,2 3 23,1 6 46,2 8 61,5 23 44,2
Overweight 1 7,7 4 30,8 0 0 3 23,1 8 15,4
Obese 6 46,2 4 30,8 7 53,8 1 7,7 18 34,6
Total 13 100 13 100 13 100 13 100 52 100

Table 1 shows that more than half In terms of education, the vast
(57 percent) of primiparous mothers were majority of respondents (63 percent)
at the youngest age group (20-25). Among attained secondary education. The
the intervention and control groups, proportion of mothers who completed
mothers at the second groups (given secondary level at all groups is also
aromatherapy intervention) have the equally distributed that most mothers have
highest proportion of younger mothers similar educational background.
than others. Mothers at the third and Nevertheless, it should be noted that more
control group are more likely to be older mothers in the third and control group (15
primiparous.

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and 23 percent, respectively) completed group three and control group have higher
only first secondary. proportion of housewife compared to the
Aside from education, socio- first and second group.
economic background of mothers in this Other basic characteristic that
study can be seen from their occupation. relevant to be considered for this study is
Table 1 shows that most mothers in the Body Mass Index or BMI. Generally, most
intervention and control group shared mothers (44 percent) were categorized as
similar characteristics in terms of their having normal BMI. Nevertheless, it
occupation. The vast majority (55 percent) should be noted that about a third of
of respondents were housewife and private mothers were obese. When comparison
employee (35 percent). Looking at the made among the four groups, it showed
proportion distribution of occupation that more mothers in the third group were
among four groups, it can be seen that obese.
reported no symptoms of stress, whilst 30
Stress level percent experienced medium stress level.
The study found, among primipara There were only 7 percent of mothers in
mothers who received loving massage this group reported acute stress level.
treatment, all of them (13 persons) Among mothers in the control group, the
reported medium to severe stress level proportion of mothers who experienced
(acute, chronic), as shown in Table 2. stress showed no significant difference
After applying loving massage treatment, before and after the treatment.
the proportion of mothers who reported
acute and chronic stress declined, from Prolactin levels
30.8 percent to 15.4 and 7.7 percent Table 3 shows the mean
respectively. difference in prolactin level of mothers in
Similarly, of 13 mothers who the intervention group. Prior to the
received aromatherapy, about a third were intervention, the mean level of prolactin
experiencing medium stress level, whilst was varying; 197.65 ng/mL in loving
the other 60 percent experienced acute and massage group; 209.70 ng/mL in
chronic stress level. After the treatment, aromatherapy group; 195.35 ng/mL in
the proportion of mothers who had severe combined aromatherapy and massage, and
stress symptoms was significantly 181.35 ng/mL in control group.
decreased to “not stress” (46 percent), After the treatment, among those
medium (30 percent), and acute (15 who received loving massage, the mean
percent). There were only 7 percent of prolactin level elevated from 197.65 to
mothers in aromatherapy treatment who 248.79 ng/mL. Of mothers who received
were reported in chronic stress level. aromatherapy, prolactin level was slightly
Prior to treatment, more mothers increased from 209.70 to 200.68 ng/mL
in the third group (combined loving whilst combination of loving massage and
massage and aromatherapy) showed severe aromatherapy resulted in an increment of
stress level than the first two groups. More prolactin level from 195.35 to 278.48
than half (53 percent) of the subject ng/mL. Mothers in the control group
reported acute stress level while 30 percent showed a decreased in prolactin level from
was reported at medium stress level and 181.35 to 168.54 ng/mL.
another 15 percent was in chronic The highest increase in the average
condition. After the treatment, the majority level of the prolactin hormone difference
of mothers in this group (53 percent) occurs in the combination group Loving

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Massage & Aromatherapy (83.13 ± 6.41 ng/mL). This suggests that the
ng/mL) followed by Loving Massage combination treatment Loving Massage &
treatment group (69.14 ± 6.60 ng/mL), Aromatherapy was the most effective way
Aromatherapy (-9.01 ± 1, 38 ng/mL ), and to increase prolactin levels for primiparous
finally the control group (-12.81 ± 5.14 puerperal.

Table 2. Stress level of postpartum primipara mothers before and after treatment

Group Stress level Before treatment After treatment

F % F %
Loving massage Not stress 0 0.0 4 30.8
Mild 0 0.0 2 15.4
Medium 5 38.5 4 30.8
Acute 4 30.8 2 15.4
Chronic 4 30.8 1 7.7
Total 13 100.0 13 100.0
Mean 29.92 19.38
Mean difference -10.54
SD 6.267
p-value 0.001**
Aromatherapy Not stress 0 0,0 6 46,2
Mild 0 0,0 0 0,0
Medium 4 30,8 4 30,8
Acute 4 30,8 2 15,4
Chronic 5 38,5 1 7,7
Total 13 100.0 13 100.0
Mean 30.77 19.31
Mean difference -11.46
SD 8.521
p-value 0.001**
Loving Massage Not stress 0 0,0 7 53,8
Aromatherapy Mild 0 0,0 1 7,7
Medium 4 30,8 4 30,8
Acute 7 53,8 1 7,7
Chronic 2 15,4 0 0,0
Total 13 100.0 13 100.0
Mean 28.54 16.92
Mean difference -11.62
SD 6.764
p-value 0.001**
Control Not stress 0 0,0 0 0,0
Mild 0 0,0 1 7,7
Medium 4 30,8 5 38,5 52  
Acute 6 46,2 5 38,5
Chronic 3 23,1 2 15,4
Total 13 100.0 13 100.0
Mean 29.85 27.85
Mean difference -2
SD 2.025
p-value 0.343

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 Table 3. Prolactin level differences of postpartum primipara mothers before
and after treatment

Group N Prolaction level (ng/mL)

Mean SD Min Max
Loving Massage Before treatment 13 197,65 48,79 120,28 258,30
After treatment 13 248,79 87,16 106,86 386,67
Aromatherapy Before treatment 13 209,70 80,28 65,26 317,77
After treatment 13 200,68 102,69 54,33 357,91
Loving Massage Before treatment 13 195,35 68,52 128,12 353,14
Aromatherapy After treatment 13 278,48 58,93 176,78 377,21
Control Before treatment 13 181,35 60,48 52,38 259,83
After treatment 13 168,54 73,22 36,08 272,59

DISCUSSIONS The combination of loving

Statistical analysis showed that massage and aromatherapy effect was even
Loving Massage that was given four times more significant when it was seen from the
in 4 weeks with a duration of 50 minutes decline in the number of respondents53  who
each session significantly influenced the experience severe stress. The combination
reduction of stress levels with average of massage and aromatherapy mechanism
differences (± SD) 10.54 ± 6.27 whilst in reduced the hormones of stress, namely
the second group, mothers who were given cortisol and aromatherapy, and stimulated
aromatherapy intervention with diffuser the production of endorphins that provides
for 30 minutes also showed a decreased in the relaxing effect to reduce stress more
the stress level of 11.46 ± 8.52 in average. than in a massage or aromatherapy
In the third group, primiparous puerperal treatment only.
mothers who received a combination of Aromatherapy used in this research
interventions Loving Massage & was the essential oil of fennel and jasmine.
Aromatherapy, showed a significantly Jasmine essential oil stimulates the body to
decrease in their stress level with an release endorphins which are natural
average difference of 11.61 ± 6.76. Unlike painkillers and mood enhancer, thus
mothers in the intervention group, mothers making the body becomes relaxed.9 The
in the control group experienced only a mechanism of reduction in stress levels
slight difference in their stress level during may be related to modulation of the
the study period. sympathetic and parasympathetic nervous
The decrease in stress levels was systems. Aromatherapy can reduce the
found highest in the combination group activity of the sympathetic nervous system
Loving Massage & Aromatherapy. It can and increase the activity of the
be understood because the stimulation of parasympathetic nervous system which can
pressure receptors are innervated by vagal lead to relaxation of the body and reduce
afferent fibers, which ultimately lead to the stress levels.10
limbic system, including the structure of In the control group, stress levels
the hypothalamus that is involved in the of the mothers were also decreased,
regulation of the autonomic nervous although in a very minimal level. The
system and the secretion of cortisol. result was in accordance with studies that
reported mothers who do not work at risk

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of postpartum depression is 10 times and stimulation via receptors olfactori to
greater than working mothers.3 All increase prolactin.
respondents are primiparas that in this case The results of this study
the adjustment to the new role is more corresponds to the result of similar study
difficult than in multiparous. In the on postpartum mothers by Pamuji in 2014
absence of specific interventions in women regarding the effect of a combination of
both with regard to both physical and Woolwich massage methods and
psychological, the mother will tend to be endorphine massage. The study found, the
more easily stressed.11 According to the treatment given may increase the prolactin
results, the hypothesis of Loving massage, hormone levels and the volume of milk.13
Aromatherapy, and the combination of Various studies also found that stimulation
Loving Massage Aromatherapy can lower to release prolactin also can be done with
stress levels in primiparous puerperal is breast massage, nipple cleaning, and
acceptable. breastfeeding early and regularly.14,15 The
On the other hand, the combination prolactin hormone stimulates cells in the
of massage and aromatherapy proved to alveoli to produce milk. The more of the
have the most significant effect, since it prolactin hormone, the milk production
affects through three channels body increases. Among breastfeeding mothers,
systems simultaneously, namely a prolactin will be decreased under stress,
combination of receptors mechanical psychic influence, anesthesia, and
physically through massage directly on the surgery.16,17 In this case, the psychological
skin, the mechanism of aromatherapy condition of nursing mothers determines
through the skin which is absorbed by the the success of exclusive breastfeeding.
epidermis, and the working mechanism of Since stress condition can inhibit the
aromatherapy to stimulate the olfactory production of prolactin hormone, therefore
receptors in the nose through several holistic therapies that provide
neurotransmitters stimulate parts of the relaxation sensation to mothers can be
brain.6,12 suggested: massage therapy, acupuncture,
According to the results, the yoga, exercise, relaxation, hypnosis, music
hypothesis of loving massage, and the therapy and aromatherapy.18,19
combination of loving massage Limitations of this study were
aromatherapy can increase prolactin levels related to the threat of internal validity:
in primiparous puerperal is acceptable, but (1) Bias history; that it is possible
the hypothesis of aromatherapy can some respondents at the primiparous
increase prolactin levels in primiparous puerperal period have frequently obtained
puerperal is rejected. Aromatherapy had no massage therapy prior the intervention that
significant effect in increasing prolactin may affect the dependent variable.
levels was possibly due to the lack of Therefore, the changes in the dependent
physical stimulation. Studies found, in variable are not entirely due to treatment
order to stimulate prolactin level, or experimentation, but also influenced by
stimulation through mechanical receptors the previous experience of the study
physically through massage directly on the subjects in terms of massage and
skin is needed because stimulation via aromatherapy.
receptors olfactori allegedly less impact on (2) Selection bias; in this case, it is
increasing prolactin.6 This requires further related to the selection of members of the
research related to comparative experimental group and the control group.
effectiveness of mechanical stimulation In other words, the changes in the

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dependent variable not only because of the Psychoneuroendocrinology.
effect of treatment, but also due to the 2007;32(2):133-139.
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Phytochemical and pharmacological
given.
review on Foeniculum Vulgare. 2013;
4(3):327 – 41. . International Journal of
CONCLUSION Pharmaceutical Sciences.
Loving Massage & Aromatherapy 2013;4(3):327-341.
were proven as an effective method to 8. Ross LE, McLean LM, Psych C.
reduce stress levels either separately or in Anxiety disorders during pregnancy and
a combination. The study noted the postpartum period: a systematic
aromatherapy only could not increase review. depression. 2006;6(9):1-14.
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massage and aromatherapy is AH. Foeniculum vulgare Mill: a review
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pharmacology, contemporary
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application, and toxicology. BioMed
eventually will increase milk production. research international. 2014;2014.
10. Duan X, Tashiro M, Wu D, et al.
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Cite this article as: Widyawati MN,

Hadisaputro S, Anies, Soejoenoes A. Effect of
Massage and Aromatherapy on Stress and
Prolactin Level among Primiparous Puerperal
Mothers In Semarang, Central Java, Indonesia.
Belitung Nursing Journal 2016;2(4):48-57

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