Accepted Manuscript

Massage as adjuvant therapy in the management of post-cesarean pain and anxiety:

A randomized clinical trial

Sussan Saatsaz, Rozita Rezaei, Abbas Alipour, Zahra Beheshti

PII: S1744-3881(16)30045-7
DOI: 10.1016/j.ctcp.2016.05.014
Reference: CTCP 661

To appear in: Complementary Therapies in Clinical Practice

Received Date: 11 November 2015

Revised Date: 24 May 2016
Accepted Date: 24 May 2016

Please cite this article as: Saatsaz S, Rezaei R, Alipour A, Beheshti Z, Massage as adjuvant therapy
in the management of post-cesarean pain and anxiety: A randomized clinical trial, Complementary
Therapies in Clinical Practice (2016), doi: 10.1016/j.ctcp.2016.05.014.

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 ACCEPTED MANUSCRIPT

Massage as Adjuvant Therapy in the Management of Postcesarian Pain

and anxiety : A Randomised Clinical Trial

Sussan Saatsaz 1 ,Rozita Rezaei 2.Abbas Alipour‫٭‬3, Zahra Beheshti4

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1- Faculty of Nursing and Midwifery department of Amol, Mazandaran University of Medical
Sciences, Sari, Iran: s.saatsaz@mazums.ac.ir

2- Faculty of Nursing and Midwifery department of Amol, Mazandaran University of Medical

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Sciences, Sari, Iran r.rezaei@mazums.ac.ir

3- Phd .Faculty of Community Medicine department of Mazandaran University of Medical Sciences,

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Sari, Iran (corresponding author) Tel:+989111521952

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4- Faculty of Nursing and Midwifery department of Amol, Mazandaran University of Medical
Sciences, Sari, Iran: z.beheshti@mazums.ac.ir
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Massage as adjuvant therapy in the management of Post-

cesarean Pain and Anxiety: A randomized Clinical Trial
Abstract

Objective: The present study was conducted to determine the effect of massage on post-cesarean
pain and anxiety.
Methods: The present single-blind clinical trial was conducted on 156 primiparous women undergone
elective cesarean section. The participants were randomly divided into three groups, including a hand

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and foot massage group, a foot massage group and a control group (n=52 per group). the patients’
intensity of pain, vital signs and anxiety level were measured before, immediately after and 90
minutes after the massage.
Results: A significant reduction was observed in the intensity of pain immediately and 90 minutes

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after massage (P<0.001). Moreover, changes in some of the physiological parameters, including blood
pressure and respiration rate, were significant after massage (P<0.001); however, this change was not
significant for pulse rate. A significant reduction was also observed in the level of anxiety (P<0.001)

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and a significant increase in the frequency of breastfeeding (P<0.001) after massage.
Conclusion: As an effective nursing intervention presenting no side-effects, hand and foot massage
can be helpful in the management of postoperative pain and stress.
Keywords

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Massage, pain, cesarean section, anxiety
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Introduction
Childbirth through cesarean section is among the most common surgical procedures
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in the world, and comprised 60% of childbirths(1). In Iran, cesarean section is also
highly prevalent, and research shows that 47.9% of childbirths are performed in this
way(2). Cesarean birth imposes physiological stresses of anesthesia, surgical
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procedure, physical recovery, and postoperative complications(3) such as pain and

stress(4). Many other researchers reported an increased anxiety in women who
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undergo cesarean section for childbirth. Hospitalization, undergoing surgical

operation, an incomplete pain relief, fear of abdominal wound infection and the
administration of analgesics and other drugs affect the patient’s breast milk and are
commonly experienced as situations that cause anxiety (3, 6, 7).
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Through a neuroendocrine reflex and an increased sympathetic tone, postoperative

pain can lead to such complications as compromising the immune system, reactive
hypoglycemia (delaying wound healing), increased myocardial oxygen consumption ,
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paralytic ileus and reduced respiratory function (8) . Postoperative pain relief is a
highly important issue in midwifery, because pain-induced endocrine changes can
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lead to anxiety. Moreover, the pain caused by the abdominal scar interferes with the
mother’s proper positioning for breastfeeding and an effective breastfeeding as a
result(9). The management of postoperative anxiety and pain reduces the patient's
discomfort, enables early walking, reduces hospital stay and hospital costs and
increases patient satisfaction (10). In addition, an adequate and rapid pain control
scheme following cesarean section contributes to an earlier beginning of
breastfeeding, which itself aids the postpartum uterine contraction (11). A wide
range of postoperative pain management methods are available, including the use of
opioid analgesics, which are considered the most common pain relief intervention
(9). Opioid pain relief causes complications such as nausea and vomiting, overdose,
mood disorders and delayed return to normal life after discharge from the hospital,
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which then increase the financial costs incurred by the patient (12, 13). the use of
opioid reduces the mother's level of consciousness and subsequently her attention
to the newborn and prevents the development of an effective mother-child bond
(14). The inadequacy of analgesics in and by themselves for pain relief (15) , the
patients’ tendency to economize on medication use and many other contributing
factors have drawn the nursing system to focus on adjuvant therapies and non-
medical pain relief methods (16). The majority of these interventions are inexpensive
and have little or no side-effects (17) , increase the patients' activity levels and
coping abilities, increase the family’s share in care for their patient and reduce the

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patient’s anxiety, medical costs and hospital bed occupancy. These methods are now
being used independently or in combination with other therapies (18). Other
therapies such as massage therapy, music therapy, relaxation techniques, hypnosis,

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medicinal herbs and therapeutic touch have become common methods of pain
management (19). Further studies are undoubtedly required for examining the

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benefits of these interventions.
The review of literature has shown some evidence on the benefits of hand and foot
massage for postoperative pain relief (20). Massage seeks to affect the motor,
nervous and cardiovascular systems, thus leading to a full body rest and total body

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relaxation, deep breathing and drowsiness (21). The pain sensory receptors are
mainly located under the skin and in the deep tissues and are concentrated in the
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hands and feet (22). Massage aids the venous return and the lymphatic flow,
stimulates cutaneous and subcutaneous sensory receptors and helps reduce the
feeling of pain. Massage also helps with the removal of lactic acid from between the
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muscle fibers and reduces fatigue and anxiety. It is therefore reasonable to expect
good outcomes from hand and foot massage (23). Various studies have examined
the efficacy of massage in reducing postoperative anxiety and pain and have yielded
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contradictory results. Some studies have shown hand and foot massage to have no
significant effects on the postoperative intensity of pain and anxiety (24, 25). some
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others, however, have shown it to be effective (6, 13, 26, 27) In a review of studies
conducted between 1999 and 2007, massage was found to reduce pain. The
researchers, however, noted that the type of surgery performed, the subjects
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examined and the duration and method of performing the massage have not been
homogeneous in the reviewed studies, and as these factors affect the results of the
interventions, more in-depth studies are recommended to be conducted on this
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subject(19).
The uncertainties in the medical community about the effectiveness of adjuvant
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medicine are one of the major challenges for the inclusion of these measures in
routine care procedures, further necessitating a rich research-based evidence for the
faster inclusion of these measures in routine care interventions.
The present study was conducted to determine the effect of massage on post-
cesarean pain and anxiety as well as on the patients’ vital signs and breastfeeding
frequency.
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Methodology and Design
Design
The present single-blind clinical trial was conducted to determine the effect of
massage on post-cesarean pain and stress in a statistical population comprising of all
the pregnant women presenting to the hospital for elective cesarean section.

Data Collection
This study was conducted over a period of 11 months from July 2014 to June 2015 at

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Imam Ali teaching hospital of Amol, affiliated with Mazandaran University of Medical
Sciences.

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Subjects
Study participants included 156 primiparous women undergoing elective cesarean
section at the above hospital, who were selected by convenience sampling method.

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The study inclusion criteria consisted of being aged 20-35, being primiparous, giving
birth to a living and healthy child, being conscious and having junior high school or
higher degree of education to comprehend the numerical pain scale. Subjects with
cardiovascular diseases, respiratory diseases and psychological disorders such as

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depression and fear, those sensitive to touch, those who had wounds on their hands
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or feet that could interfere with the massage, those with phlebitis or traumatic
arthritis in the massage area and those who had received local anesthetics or had
longitudinal abdominal incisions during their cesarean section were excluded from
the study. Written consents were obtained from eligible participants, who were then
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randomly divided into a foot massage group, a hand and foot massage group and a
control group. The card drawing technique was used to randomize the assignment of
subjects to the groups. A total of 156 identical cards were first prepared, and 52
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were labeled “foot massage”, 52 “hand and foot massage” and 52 “no
interventions”. A card was randomly drawn for each participant who entered the
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study by an independent assistant researcher (engaged only in the randomization

process) and the type of intervention written on the card was announced by another
researcher (in charge of the hand and foot massage).
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Data Collection Tools

Data were collected using a demographic information form (age, degree of
education, occupation, place of residence, type of insurance, history of surgery,
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underlying diseases, etc.), a form enquiring about analgesic use (quantity and
frequency), a checklist for controlling the vital signs (pulse rate, respiration rate and
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blood pressure), the Visual Analog Scale (VAS) to assess the intensity of pain and
Spielberger's State Anxiety Inventory to assess anxiety.
The VAS is a measurement instrument for assessing the intensity of pain on a 10 cm
line with one end marked “no pain” and the other marked “the worst imaginable
pain”. The patient marks his intensity of pain on this line. The reliability and validity
of this pain measuring instrument has been previously confirmed (28-30). A score of
1-3 indicates mild pain, 4-7 moderate pain and 8-10 severe pain.
Spielberger's anxiety inventory comprises 20 items scored from 1 to 4 based on a 4-
point scale of “not at all”, “somewhat”, “moderately so” and “very much so”,
counting for a maximum score of 80 and a minimum of 20, with higher scores
suggesting greater levels of anxiety. Scores from 20 to 31 suggest mild anxiety, 32 to
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42 moderate to low anxiety, 43 to 53 moderate to high anxiety, 54 to 64 relatively
severe anxieties, 65 to 75 severe anxiety and 76 and higher very severe anxiety. This
questionnaire has been standardized for use in Iran with reliability of 0.91 and
concurrent validity of 99% (31).
Procedures
After the surgery ended, the precise timing of the patient's admission to the surgical
ward was recorded. In the afternoon of the day of surgery and four hours after the
administration of the last dose of the analgesic commonly prescribed in the ward,
i.e. Diclofenac suppository, the mean intensity of pain was measured by an assistant

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researcher who was blinded to the group allocation procedures and was not
involved in performing the massages. In the intervention groups, in addition to the
routine care provided in the ward, hand and foot massage was performed by the

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assistant researcher without any special implements. The massage therapy included:
Petrissage: Applying a direct , slow and rhythmic pressure with the finger tips.

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Kneading: Similar to wringing and twisting and turning performed consecutively and
in alternate directions.
Friction: Circular rubbing of the target area with the anterior surface of the last
phalanx or the palm depending on its size (32).

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To assess the reliability of the data, massaging was performed for all the
participants by the same skilled massage therapist. The patients were first advised to
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assume a comfortable position and to avoid talking during the massage session
unless necessary. The patient’s hands and feet were first cleaned with a disposable
wet wipe; the masseuse then applied Vaseline to her own hands and massaged each
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of the patient’s limbs for five minutes, the hands being first and the feet next. Each
foot was raised and supported during the massage by a pillow placed underneath it,
which was later removed. The intensity of pain and the level of anxiety were
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measured and recorded in each group by another independent assistant researcher

blinded to the groupings. The intensity of pain was re-measured 90 minutes after the
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intervention to determine the massage’s duration of effectiveness. The control

group received only the routine ward care. Over the 90-minute duration of the
assessment, none of the groups received any analgesics.
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Ethical Standards
This study was approved by the Ethics Committee of Mazandaran University of
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Medical Sciences. All the participants submitted their informed written consents and
were informed of their right to withdraw from the study at any time.
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Statistical Analysis:

The Shapiro-Wilk test was used to examine the normal distribution of the data. The
descriptive baseline characteristics of the three groups (the control group, the foot
massage group and the hand and foot massage group) were tabulated as mean±SD, as
median (interquartile range) or as percentage. The categorical data of the three groups
were compared and statistically analyzed using the Chi- square test or Fisher ’s
Exact test . Continuous data were statistically analyzed using the ANOVA and the
Kruskal-Wallis H test. The Kruskal Wallis test with post hoc multiple comparisons
and the Mann-Whitney U test were used for comparing the values between the
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groups. The primary efficacy data on the VAS pain score, stress levels and
hemodynamic (RR, PR and systolic and diastolic blood pressures) were examined
using the intention-to-treat analysis. The General Linear Model (GLM) was used to
compare the VAS score, the stress level and the hemodynamics between the three
groups through the repeated measures ANOVA. The time point of evaluation was
considered a within-subjects factor while the intervention state (the control group, the
foot massage group and the hand and foot massage group) was considered a between-
subjects factor. The time groups (interaction term) was considered as group
differences (between control group, foot massage group and foot and hand massage

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group) in their response over time. Mauchly’s Sphericity test was used to examine
the compound symmetry assumption. A P-value of 0.05 or less was considered
statistically significant according to the Bonferroni method of adjusting the P-value

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for multiple comparisons. Data were analyzed using IBM SPSS statistics version 22
and stata version 12.

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Results:

Participants

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In this study 156 primiparous women in three group of foot massage (N=52), hand
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and foot massage (N=52) and control (N=52) were studied.

Basic demographic and clinical characteristics of patients in three groups are

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presented in Table 1. As shown in table 1, no significant difference was detected in

average age ( P= 0.27), newborn weight, BMI, educational level, job state, residency
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state, intended pregnancy state, past medical history of chronic disease or surgery
and analgesic consumption in inpatient time between groups.
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Outcomes

Pain score
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Figure 1 and table 2 shows the mean values of the pre-and post-intervention VAS
parameters of each group. As shown in table. 2, there was a statistically main effect
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for time [F (2,306) = 191.26, P<0.001], indicating that when the three groups were
combined, the average pain score at baseline was higher than the average at after
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massage time and 90 minutes after massage. Table 2 shows there was also a
statistically significant main effect for group assignment [F (2,153) = 145.94,
P<0.001], indicating that the trials and control group differed in their average scores
across time. Pain scores in massage groups was better than control group (p<0.001)
but the difference between foot massage group and foot and hand massage group
was not statistically significant (P=0.98). In the graph we see that the groups have
non-parallel lines that decrease over time and are getting progressively away from
each other over time (group time interaction or interaction effect) [F(4,306) =
131.93, P<0.001].
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anxiety level

Figure 1 and table 2 shows that there is a statistically significant time trend (within-
subject differences or time effect) for anxiety levels [F (2,306) = 104.1, P<0.001] and
massage groups are initially getting less depressed over time and then rising slightly.
anxiety levels in massage groups were better than control group but there is no
statistically significant differences between groups (between-subject differences or
group effect) [F (2,153), p=0.47]. In the graph we see that the groups have non-

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parallel lines that the reduction slope of foot and hand massage group was greater
than foot massage group (interaction effect) [F(4,306)=34.18, P<0.001].

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Hemodynamic indicators levels

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Figure 1 and table 2 shows that there is not a statistically significant time trend
(within-subject differences or time effect) for PR levels [F(2,306)=1.82, P=0.17]. Pulse

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rate levels in massage groups were letter than control group but there is no
statistically significant differences between groups (between-subject differences or
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group effect) [F(2,153)=2.99, p=0.06]. The reduction slope of massage groups were
greater than control group but this difference were not statistically significant (no
interaction effect) [F(4,306)=0.41, P=0.77].
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For other hemodynamic indicators (RR, systolic blood pressure, and diastolic blood
pressure) level, there is a statistically significant time trend (within-subject
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differences or time effect) (P<0.001). The levels in massage groups were letter than
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control group but there is no statistically significant differences between groups

(between-subject differences or group effect) (p>0.05). In the figure 1 we see that
the groups have non-parallel lines that the reduction slope of foot and hand massage
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groups was greater than foot massage group (interaction effect) (P<0.001).

Breastfeeding frequency
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The median (inter-quartile range) of breastfeeding frequency in control, foot

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massage, and foot and hang massage groups were 1 (1-2), 2 (1-2), and 2 (1-3)
respectively. ). Mann Whitney tests with Bonferroni correction (effects reported at a
0.025 level of significance) were used to follow up this finding. The increased in
frequency values was significantly different between the massage groups and control
group (P<0.001) and between two massage groups was not statistically significant
(P=0.058).
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Table 1. Basic demographic and clinical characteristics in the three groups

Group P
value
Control Foot massage Hand and foot
massage
(n=52) (n=52) (n=52)

Age 27.75±3.22 27.04±2.77 26.73±3.81 0.27

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Newborn weight 3113.85±382.91 3091.73±417.19 3166.35±420.05 0.63

Educational Low 3 (5.8) 4 (7.7) 5 (9.6) 0.94

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level
Medium 31 (59.6) 31 (59.6) 32 (61.5)

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High 18 (34.6) 17 (32.7) 15 (28.8)

Job House 42 (80.8) 48 (92.3) 48 (92.3) 0.104

keeper

Employed 10 (19.2)
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Residency Village 20 (38.5) 17 (32.7) 18 (34.6) 0.82

City 32 (61.5) 35 (67.3) 34 (65.4)

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BMI <19.8 6 (11.5) 7 (13.5) 4 (7.7) 0.95

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19.8-26 20 (38.5) 18 (34.6) 22 (42.3)

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26-29 21 (40.4) 20 (38.5) 20 (38.5)

>29 5 (9.6) 7 (13.5) 6 (11.5)

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Pregnancy intended 41 (78.8) 40 (76.9) 39 (75) 0.9

Chronic disease 5 (9.6) 4 (7.7) 3 (5.8) 0.76

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Premium surgery 4 (7.7) 5 (9.6) 7 (13.5) 0.61

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Analgesic Rare 36 (69.2) 33 (63.5) 34 (65.4) 0.49

consumption
Average 13 (25) 14 (26.9) 17 (32.7)

High 3 (5.8) 5 (9.6) 1 (1.9)

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Table 2. Pain score, stress level and hemodynamic indicators before, after and 90 minutes
after massage in the three groups

Time

Before After 90 minutes

massage massage after
massage

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Pain score Control 5.29±0.89 5.73±0.69 6.17±0.58

Foot massage 4.96±0.87 3.31±0.64 3.62±0.69

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Foot and hand 5.09±0.89 3.15±0.64 3.56±0.57
massage

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Stress Control 30.17±6.98 30.38±6.93 30.6±6.95
score
Foot massage 31.52±9.93 28.23±8.88 30.04±9.24

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Foot and hand 31.04±8.48 26.42±7.15 28.21±6.97
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massage

Systolic Control 113.46±13.74 114.57±10.2 115.7±10.71

blood
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pressure Foot massage 117.21±12.81 112.12±10.4 114.7±8.88

Foot and hand 115.67±14.45 108.4±6.7 110.2±6.71

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massage
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Diastolic Control 68.65±10.25 69.28±9.69 69.9±9.31

blood
pressure Foot massage 70.48±10.54 66.92±8.35 69.71±5.64
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Foot and hand 69.13±9.74 65.29±6.89 67.02±5.71

massage

Respiratory
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Control 20.1±1.25 20.13±0.82 20.19±1.24

rate
Foot massage 20.46±0.93 19.54±1.59 20±1.39
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Foot and hand 21.15±1.18 18.96±1.52 19.75±1.61

massage

Pulse rate Control 82.77±7.79 82.63±6.4 82.48±8.13

Foot massage 80.56±9.39 79.37±7.17 79.17±8.44

Foot and hand 83.06±8.47 80.9±8.31 81.48±7.4

massage
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Fig 2. The trend of changes in the pain score, stress level and hemodynamic indicators
before (time:1), after (time:2) and 90 minutes after (time:3) post-delivery massage in the
three groups
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Discussion and conclusion

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The results of the present study showed a significant reduction in the intensity
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of pain following massage. A similar study conducted in Turkey examined post-

cesarean intensity of pain in three groups, including a hand and foot massage
group, a foot massage group and a control group and found a significant
reduction in the intensity of pain following massage (32). The results of a study
by Abbaspour et al. also showed a significant reduction in post-cesarean pain
after 20 minutes of hand and foot massage (4). Many other researchers have
achieved similar results about the effect of massage (14, 20, 33-35). In their
review study, Chanif et al. also concluded that, as a nursing intervention,
massage can help reduce postoperative pain (19) , which is consistent with the
results of the present study . However, in studies by Hulme et al. and Albert et
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al., massage had no effects on the intensity of pain, which was attributed to the
short duration of the massage therapy and the patients' lack of familiarity with
this form of therapy (24, 36). The main mechanism by which massage reduces
pain can be explained by the gate control theory. This theory holds that the local
pain sensation has systemic effects on the pain receptors and the nerve
impulses transmitted through the nerve fibers A-Delta and C to the central
nervous system possessing the gate control system. T-cells are then activated
and the gate is opened as a result. The pain message thus reaches the brain.

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Postoperative pain is recognized and interpreted in a similar way. Foot massage
stimulates the nerve fibers (the A-beta fibers) on the foot and the dermatome
containing tactile and pressure receptors. The receptors then transmit the nerve

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impulse to the central nervous system. The gate control system is activated
through the inhibitory inter neuron while the excitatory interneuron is inhibited,

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resulting in the inhibition of the T-cells and the subsequent closing of the gate.
The pain message is not transmitted to the central nervous system(18, 19).
Massage also reduces the sensation of pain by increasing endorphin levels (37).

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The placebo effect is another potential mechanism helping reduce the sensation
of pain through the patient’s anticipation of a reduction in his pain with massage
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(38, 39), which can be a confounding factor.
Although the intensity of pain was lower in the hand and foot massage group
compared to the foot massage group , the difference between the groups was not
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statistically significant. A study conducted by Degirmen et al. produced similar

results (32) ; however, Latifi et al. found a significant pain reduction in the hand
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and foot massage group compared to the foot massage group and attributed this
difference to the longer duration of massage in the hand and foot group (20
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minutes vs. 10 minutes);(23). Considering that even short massage sessions

were found to be effective in many studies (28, 40) and given the main
mechanism of massage (the gate control theory), and as each foot has 7000
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nerve endings and thus the highest innervation density (19) , foot massage can
be said to have a greater effect on the reduction of pain, which was performed in
both of the intervention groups in the present study. However, the effect of the
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duration of massage is another contributing factor that needs to be investigated

in future studies.
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In the present study, the intensity of pain increased consistently in the control
group until minute 90; in the intervention groups, however, it increased
gradually after a significant reduction witnessed immediately after the massage.
Nevertheless, it was still lower than before receiving the massage and lower than
at minute 90 in the control group. Many other studies have achieved similar
results, implying a limited duration of effectiveness for massage interventions (4,
32, 39). Since none of the groups received analgesics during the 90 minutes, the
increase in the intensity of pain was expected. The lower increase in the intensity
of pain in the intervention groups compared to in the control group can be
explained by the gate control mechanism, which has an immediate effect that
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may last for different durations of time, or by the chemical control of pain due to
increased endorphin levels lasting 1.5 hours(6).
The results of the present study suggest a statistically significant trend of
changes in the physiological parameters examined (respiration rate and systolic
and diastolic blood pressures), as they gradually increased in the control group,
and initially decreased and then increased in the intervention groups; the
difference in the trend of changes was significant across the groups (except for
pulse rate). However, when comparing the groups in terms of these parameters

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irrespective of the time of the measurement, they were lower in the intervention
groups than in the control group, although the difference was not significant,
which may be attributed to the small sample size used for assessing the

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parameters. Different studies found conflicting results in relation to these
parameters. In some studies, all these parameters reduced significantly after

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massage (6, 23). In a study by Abdelaziz, massage reduced the pulse rate and the
systolic and diastolic pressures, but had no effects on the respiration rate (41). In
a study by Wang et al , no significant differences were observed in the systolic

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and diastolic blood pressures (20). Albert found no significant difference in any
of the vital signs(24). Since patient's pain affects vital signs, especially pulse rate,
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and systolic and diastolic blood pressures(41), the pain-reducing effect of
massage and the potential stimulation of the parasympathetic system and the
subsequent relaxation (19) can cause changes in the patient's vital signs. More
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in-depth studies are required for obtaining more accurate results.

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The results of the present study showed a reduced level of anxiety after massage,
which is consistent with the results obtained in studies by Nazari et al.,
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Buyukyilmazet al., Mitchinson et al., and Cutshall(6, 40, 42, 43). Postoperative
pain causes anxiety, and anxiety activates the hypothalamic-pituitary-adrenal
axis, leading to increased cortisol levels (44). Massage reduces pain, increases
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the blood flow and improves sleep, ultimately leading to a potential reduction in
anxiety as well (37). Another possible hypothesis is that massage increases the
activity of the parasympathetic system and reduces cortisol levels from the
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baseline (31% on average) while increasing the release of active

neurotransmitters such as serotonin (28% on average) and dopamine (31% on
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average), thereby reducing the level of anxiety(44).

The frequency of breastfeeding increased significantly after massage. Abbaspour
et al.(4). obtained similar results. As breastfeeding is largely influenced by
intervening factors such as pain, an effective post-cesarean pain relief leads to
the patient’s earlier walking, a better mother-child bonding and a successful
beginning and continuation of breastfeeding, which can affect the mothers'
desire to breastfeed.
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Study strengths and limitations

The strengths of the present study included the matching of the groups in terms of
parity, the newborn’s gender, the type of surgery, the type of abdominal incision,
the type, method and timing of analgesic administration, the randomized allocation
of the patients into the intervention and control groups and the blinding of the
assistant researcher to the patients’ groupings for an unbiased assessment of the
intensity of pain.

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The limitations of the study included the patients’ receiving of only one session
massage. It is not clear whether more frequent massage sessions during the
patient’s hospitalization would have affected the outcomes or not, as the stress felt
by the patient on the first session of massage may turn into relaxation during later

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sessions, thereby producing different outcomes. There was a lack of sufficient data
on the appropriate timing for starting the massage and its advised duration for

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achieving better long and short term outcomes, which may have affected the results
of the study. Given the small sample size and the single gender of the subjects
assessed, the results of the study cannot be easily generalized to other patients with
different genders and undergoing different surgeries.

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Recommendations
Future studies are recommended to be conducted with larger sample sizes for a
more accurate assessment of massage outcomes. Further studies are required to
examine the most effective duration for each massage session, the most appropriate
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timing for starting the postoperative massage, the right frequency of massage and
the most efficient sites for its performance.
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Conclusion
According to the results obtained, massage reduces post-cesarean pain and anxiety.
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Given its simplicity, effectiveness, safety, cost-effectiveness and lack of side-effects,

massage therapy is recommended to be performed on patients as a pain and anxiety
reducing intervention.
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Conflicts of Interest statement

The authors have no conflicts of interest to declare.
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Acknowledgment
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The authors would like to express their gratitude to all the patients who participated in
this research. This article is based on the results of a grant research project funded by
Mazandaran University of Medical Sciences, Sari, Iran (Contract Number: 999).
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