THE EFFECTS OF BABY MASSAGE ON ATTACHMENT BETWEEN MOTHER AND THEIR INFANTS

A study was made from June 2008 to February 2010 in Turkey. There were 57 in the experimental group, 60 in the control group. Between the dates of the study, all healthy mothers giving birth for the first time and their healthy babies were included. Data were collected about their demographic characteristics and by using the Maternal Attachment Inventory (MAI). All mothers were assessed on the first and the last days of the 38-day study period. In the experimental group, the babies received a 15-minute massage therapy session everyday during the 38 days.

The MAI was developed to measure maternal affectionate attachment. This is the unique, affectionate relationship that develops between a woman and her infant. It persists over time, and is a key element of maternal adaptation (Muller, 1994). The MAI consists of 26 items representing maternal activities and feelings that indicate affection. Before development of the MAI, maternal affectionate attachment had been most frequently determined by observing the rate or pattern of maternal attachment behaviors (Muller). Observational measures, however, are time-consuming and generally difficult to apply in a clinical setting. In addition, there is little agreement that one behavior or group of behaviors constitutes evidence of maternal attachment. By direct measurement of mothers’ feelings through the MAI, these validity concerns in relation to interpreting mothers’ behaviors can be avoided. Although mothers’ feelings about their infants are not sufficient to define the complexity of mother–infant attachment, they are thought to be indicators of the probable presence of attachment.

For the study, massage techniques were a combination of effleurage and petrissage to the baby’s face, neck, shoulders, arms, chest, back, waist and legs. The effleurage consisted of smooth, long, rhythmic strokes up either side of the spine and out across the shoulders, with both hands working simultaneously, while the petrissage consisted of gentle kneading. Additionally, slow steady pressure was applied intermittently to the shoulders, neck, face, and lower back. All massages were demonstrated by the same trained person and mothers were advised to choose a moment when both she and her child are relaxed and calm; a half hour after the baby had eaten was recommended.

Baby massage education was given twice at the first home visit and the second home visit (15th day). The mother’s application of baby massage was observed at the second home visit and evaluated for correct technique. These babies received 15-minute massage sessions every day of the week for 38 days; the number of massage sessions are a minimum of 30 and a maximum of 38. The researcher followed a detailed visit-by-visit protocol to help women improve their health-related behaviors, the care of their baby, and observed the status of baby massage application. On the last day of the study, the MAI was filled out on the last home visit in the experimental group.

There was no significant difference found in the pretest mean value baseline of the MAI score in both groups. The posttest mean values of the MAI of the experimental group mothers were significantly higher than those of control group. There was a significant difference between groups. The results of the study have shown that baby massage is effective in increasing the mother–infant attachment.

When maternal attachment levels of experimental group mothers applying massage to their babies and control group mothers not applying massage to their babies were compared in posttest measurements, it was found that the maternal attachment of the group applying massage significantly higher. Maternal attachment of the control group also increased in the posttest measurement; however, this increase was very low when compared to the experimental group.

The relative youth of the mothers and the fact that they were undertaking the primary care of their first baby increased compliance with the study and attachment. This may explain the minor increase in maternal attachment behavior of mothers in the control group.

In Turkish culture, children are very precious and important. Women want to have a child as soon as they get married. If a woman does not have a baby, she is exposed to negative reactions from her husband and his family. Being a mother is very important, in particular, to have a male baby is extremely important. For this reason, it is expected that maternal attachment level naturally increases. The aim of this study was to determine how baby massage affects this increase. This result confirms the hypothesis of the study—baby massage strengthens the attachment between mother and baby. Most of the mothers in both groups were 26–35 years of age group, who are graduates of secondary school and not working. Traditionally, these women’s common goal is to get married and give birth to a child in the eastern part of Turkey. However, educated women have more roles than being a partner or a mother.

The first year of life is extremely important in terms of the baby’s psychological development. It is during this period, that the sense of basic trust is formed. The relationship between the mother and the baby has been the subject of several research studies (Muller-Nix et al., 2004; Zeanah, Borris, & Larrieu, 1997). Attachment is an emotional and expected condition between the mother and the baby that begins in the first days of life.

Attachment theory is an assessment of the response to the baby’s physical and emotional needs (Mills-Koonce et al., 2007). According to Mercer, maternal attachment begins during pregnancy and continues with delivery. Maternal attachment is a unique, tender loving relationship that develops between the mother and the baby; its consistency leads to the development of feelings of trust in the infant as a result. Postpartum attachment and care between the mother and the baby is important for the baby to lead a physical, spiritual, and emotional health in life.

Mothers have an important role as the primary caregiver. If the relationship between mother and baby is inadequate, the baby may have severe developmental and psychological problems (Brandt, Andrews, & Kvale, 1998). Attachment is therefore accepted as one of the fundamental processes in order to improve psychological development and to establish the baby’s relationship to the outside world (Wilson et al., 2000).

A healthy attachment is also of great importance in the determination of the baby’s character and habits. The first touches greatly strengthen attachment behavior (Kavlak & Şirin, 2007). The sense of touch is very important in the newborn period and infanthood for perceiving the environment. Proper stimulation of the baby’s sense of touch affects psychosocial development positively.

Massage is one of the easiest and most natural ways of establishing a sense of touch and eye contact which improves attachment between mothers and babies. The early contact between mother and her newborn gives confidence to the mother’s breastfeeding, in addition to developing the mother’s attachment behavior (Matthiesen, Ransjö-Arvidson, Nissen, & Uvnäs-Moberg, 2001).

Ferber et al. (2005) determined that mothers who applied massage to their premature infants achieved an easier interaction. Lee (2006) also reported that baby massage encourages the interaction between mother and baby. Moore and Anderson (2007) found that skin-to-skin contact between mother and infant affects the infants’ health, decreases their crying, and increases the mother–infant interaction. Onozawa, Glover, Adams, Modi, and Kumar (2001) reported that the mother–infant interaction was increased among those mothers who had performed massage on their infants.

In 2009, Kavlak and Şirin studied healthy babies and mothers to evaluate and determine validity and reliability of the Maternal Attachment Inventory (MAI) scale for the Turkish population. Moreover, Bal Yilmaz and Conk (2009) studied mothers who had 15-day-old healthy babies to investigate the effect of four months of massage application on sleep duration, growth and development of babies, and mothers’ anxiety levels. Bal Yılmaz and Conk reported that infants’ sleep duration was increased when their mothers spent more time with them and massaged them. In a study conducted with mothers who recently delivered healthy babies, İnal and Yıldız (2005) investigated the effect of massage applied for 6 months on the babies’ growth and mental-motor development. Inal and Yildiz found statistically significant results that infants who received massage gained more weight and increased their mental–motor development. In a study conducted with premature and low birthweight babies and their mothers, Sarıkaya Karabudak and Öztürk (2008) reported that regularly applied baby massage positively affected weight gain and the mental–motor development of babies.

Massage is one of the oldest forms of treatment in the world, having first been described in China during the second century B.C. and soon after in India and Egypt. Maternal attachment depends on two important factors; (a) interaction between mother and her baby and (b) sensual contact between them. Baby massage is the simplest and easiest way of communication, that makes contact between mother and her baby. In eastern Anatolia, Turkey, the families have many children. The mothers who live in this region generally avoid touching their babies. The main reasons are cold weather conditions, socioeconomic conditions, and swaddling. In addition, there is no work regarding the effects of massage on mother-infant attachment in Turkey up to now. For this reason, this work has been carried out to determine the applicability of baby massage in Turkish families and its effects on the level of maternal attachment. It is of note that the Turkish edition of Infant Massage, a Handbook for Loving Parents (Vimala McClure, Bantam/Random House, NY) has been in production in 2018.

Infant massage for primary caregivers and high-risk babies is now used more often. It is reported that massage regulates the baby’s sleep, respiration and urinary requirements; decreases colic and stress; and affects mother–infant interaction in a positive way. Studies have determined that mothers giving massage to premature babies have more interaction with their babies. In their studies, Moore and Anderson (2007) found that skin-to-skin contact between the mother and the baby in the early period affected the health status of baby, decreased crying and increased mother–infant interaction.

Infant massage is a simple, cheap and effective technique supporting infant development. It is accepted as a new practice that is gradually gaining popularity by being applicable to both the babies and their mothers; it can be performed independently. However, many mothers do not know that they can communicate with their babies by touch as they think that they may easily hurt their babies. Those mothers should be instructed by using various interactive methods such as tactile, visual, auditory contact. For those families who cannot have direct early contact with their baby for various reasons, nurses should advise them that this situation would not directly cause a problem. Their concerns should be alleviated because although early contact is a factor that strengthens attachment development, it is not an essential prerequisite.

The effects of massage in terms of mother–infant attachment and other general benefits for baby health should be considered; all medical personnel, especially nurses, should encourage mothers to apply massage to their babies. Encouraging the use of massage provides an important contribution to healthy babies. In the literature, the effects of baby massage on the maternal attachment levels in mothers with healthy infants and weight gain of preterm infants have been investigated. Mothers with babies who were born prematurely or had some defects or illness, have more risk of attachment deprivation. Accordingly, it might be suggested that nurses include baby massage among the routines of mother and baby care in both healthy and ill babies, and that facilitating baby massage and mother–infant attachment should be included in the internal training given to neonatal nurses as well as providing counseling to the mothers in this regard.

THE EFFECTS OF BABY MASSAGE ON ATTACHMENT BETWEEN MOTHER AND THEIR INFANTS

A study was made from June 2008 to February 2010 in Turkey. There were 57 in the experimental group, 60 in the control group. Between the dates of the study, all healthy mothers giving birth for the first time and their healthy babies were included. Data were collected about their demographic characteristics and by using the Maternal Attachment Inventory (MAI). All mothers were assessed on the first and the last days of the 38-day study period. In the experimental group, the babies received a 15-minute massage therapy session everyday during the 38 days.

The MAI was developed to measure maternal affectionate attachment. This is the unique, affectionate relationship that develops between a woman and her infant. It persists over time, and is a key element of maternal adaptation (Muller, 1994). The MAI consists of 26 items representing maternal activities and feelings that indicate affection. Before development of the MAI, maternal affectionate attachment had been most frequently determined by observing the rate or pattern of maternal attachment behaviors (Muller). Observational measures, however, are time-consuming and generally difficult to apply in a clinical setting. In addition, there is little agreement that one behavior or group of behaviors constitutes evidence of maternal attachment. By direct measurement of mothers’ feelings through the MAI, these validity concerns in relation to interpreting mothers’ behaviors can be avoided. Although mothers’ feelings about their infants are not sufficient to define the complexity of mother–infant attachment, they are thought to be indicators of the probable presence of attachment.

For the study, massage techniques were a combination of effleurage and petrissage to the baby’s face, neck, shoulders, arms, chest, back, waist and legs. The effleurage consisted of smooth, long, rhythmic strokes up either side of the spine and out across the shoulders, with both hands working simultaneously, while the petrissage consisted of gentle kneading. Additionally, slow steady pressure was applied intermittently to the shoulders, neck, face, and lower back. All massages were demonstrated by the same trained person and mothers were advised to choose a moment when both she and her child are relaxed and calm; a half hour after the baby had eaten was recommended.

Baby massage education was given twice at the first home visit and the second home visit (15th day). The mother’s application of baby massage was observed at the second home visit and evaluated for correct technique. These babies received 15-minute massage sessions every day of the week for 38 days; the number of massage sessions are a minimum of 30 and a maximum of 38. The researcher followed a detailed visit-by-visit protocol to help women improve their health-related behaviors, the care of their baby, and observed the status of baby massage application. On the last day of the study, the MAI was filled out on the last home visit in the experimental group.

There was no significant difference found in the pretest mean value baseline of the MAI score in both groups. The posttest mean values of the MAI of the experimental group mothers were significantly higher than those of control group. There was a significant difference between groups. The results of the study have shown that baby massage is effective in increasing the mother–infant attachment.

When maternal attachment levels of experimental group mothers applying massage to their babies and control group mothers not applying massage to their babies were compared in posttest measurements, it was found that the maternal attachment of the group applying massage significantly higher. Maternal attachment of the control group also increased in the posttest measurement; however, this increase was very low when compared to the experimental group.

The relative youth of the mothers and the fact that they were undertaking the primary care of their first baby increased compliance with the study and attachment. This may explain the minor increase in maternal attachment behavior of mothers in the control group.

In Turkish culture, children are very precious and important. Women want to have a child as soon as they get married. If a woman does not have a baby, she is exposed to negative reactions from her husband and his family. Being a mother is very important, in particular, to have a male baby is extremely important. For this reason, it is expected that maternal attachment level naturally increases. The aim of this study was to determine how baby massage affects this increase. This result confirms the hypothesis of the study—baby massage strengthens the attachment between mother and baby. Most of the mothers in both groups were 26–35 years of age group, who are graduates of secondary school and not working. Traditionally, these women’s common goal is to get married and give birth to a child in the eastern part of Turkey. However, educated women have more roles than being a partner or a mother.

The first year of life is extremely important in terms of the baby’s psychological development. It is during this period, that the sense of basic trust is formed. The relationship between the mother and the baby has been the subject of several research studies (Muller-Nix et al., 2004; Zeanah, Borris, & Larrieu, 1997). Attachment is an emotional and expected condition between the mother and the baby that begins in the first days of life.

Attachment theory is an assessment of the response to the baby’s physical and emotional needs (Mills-Koonce et al., 2007). According to Mercer, maternal attachment begins during pregnancy and continues with delivery. Maternal attachment is a unique, tender loving relationship that develops between the mother and the baby; its consistency leads to the development of feelings of trust in the infant as a result. Postpartum attachment and care between the mother and the baby is important for the baby to lead a physical, spiritual, and emotional health in life.

Mothers have an important role as the primary caregiver. If the relationship between mother and baby is inadequate, the baby may have severe developmental and psychological problems (Brandt, Andrews, & Kvale, 1998). Attachment is therefore accepted as one of the fundamental processes in order to improve psychological development and to establish the baby’s relationship to the outside world (Wilson et al., 2000).

A healthy attachment is also of great importance in the determination of the baby’s character and habits. The first touches greatly strengthen attachment behavior (Kavlak & Şirin, 2007). The sense of touch is very important in the newborn period and infanthood for perceiving the environment. Proper stimulation of the baby’s sense of touch affects psychosocial development positively.

Massage is one of the easiest and most natural ways of establishing a sense of touch and eye contact which improves attachment between mothers and babies. The early contact between mother and her newborn gives confidence to the mother’s breastfeeding, in addition to developing the mother’s attachment behavior (Matthiesen, Ransjö-Arvidson, Nissen, & Uvnäs-Moberg, 2001).

Ferber et al. (2005) determined that mothers who applied massage to their premature infants achieved an easier interaction. Lee (2006) also reported that baby massage encourages the interaction between mother and baby. Moore and Anderson (2007) found that skin-to-skin contact between mother and infant affects the infants’ health, decreases their crying, and increases the mother–infant interaction. Onozawa, Glover, Adams, Modi, and Kumar (2001) reported that the mother–infant interaction was increased among those mothers who had performed massage on their infants.

In 2009, Kavlak and Şirin studied healthy babies and mothers to evaluate and determine validity and reliability of the Maternal Attachment Inventory (MAI) scale for the Turkish population. Moreover, Bal Yilmaz and Conk (2009) studied mothers who had 15-day-old healthy babies to investigate the effect of four months of massage application on sleep duration, growth and development of babies, and mothers’ anxiety levels. Bal Yılmaz and Conk reported that infants’ sleep duration was increased when their mothers spent more time with them and massaged them. In a study conducted with mothers who recently delivered healthy babies, İnal and Yıldız (2005) investigated the effect of massage applied for 6 months on the babies’ growth and mental-motor development. Inal and Yildiz found statistically significant results that infants who received massage gained more weight and increased their mental–motor development. In a study conducted with premature and low birthweight babies and their mothers, Sarıkaya Karabudak and Öztürk (2008) reported that regularly applied baby massage positively affected weight gain and the mental–motor development of babies.

Massage is one of the oldest forms of treatment in the world, having first been described in China during the second century B.C. and soon after in India and Egypt. Maternal attachment depends on two important factors; (a) interaction between mother and her baby and (b) sensual contact between them. Baby massage is the simplest and easiest way of communication, that makes contact between mother and her baby. In eastern Anatolia, Turkey, the families have many children. The mothers who live in this region generally avoid touching their babies. The main reasons are cold weather conditions, socioeconomic conditions, and swaddling. In addition, there is no work regarding the effects of massage on mother-infant attachment in Turkey up to now. For this reason, this work has been carried out to determine the applicability of baby massage in Turkish families and its effects on the level of maternal attachment. It is of note that the Turkish edition of Infant Massage, a Handbook for Loving Parents (Vimala McClure, Bantam/Random House, NY) has been in production in 2018.

Infant massage for primary caregivers and high-risk babies is now used more often. It is reported that massage regulates the baby’s sleep, respiration and urinary requirements; decreases colic and stress; and affects mother–infant interaction in a positive way. Studies have determined that mothers giving massage to premature babies have more interaction with their babies. In their studies, Moore and Anderson (2007) found that skin-to-skin contact between the mother and the baby in the early period affected the health status of baby, decreased crying and increased mother–infant interaction.

Infant massage is a simple, cheap and effective technique supporting infant development. It is accepted as a new practice that is gradually gaining popularity by being applicable to both the babies and their mothers; it can be performed independently. However, many mothers do not know that they can communicate with their babies by touch as they think that they may easily hurt their babies. Those mothers should be instructed by using various interactive methods such as tactile, visual, auditory contact. For those families who cannot have direct early contact with their baby for various reasons, nurses should advise them that this situation would not directly cause a problem. Their concerns should be alleviated because although early contact is a factor that strengthens attachment development, it is not an essential prerequisite.

The effects of massage in terms of mother–infant attachment and other general benefits for baby health should be considered; all medical personnel, especially nurses, should encourage mothers to apply massage to their babies. Encouraging the use of massage provides an important contribution to healthy babies. In the literature, the effects of baby massage on the maternal attachment levels in mothers with healthy infants and weight gain of preterm infants have been investigated. Mothers with babies who were born prematurely or had some defects or illness, have more risk of attachment deprivation. Accordingly, it might be suggested that nurses include baby massage among the routines of mother and baby care in both healthy and ill babies, and that facilitating baby massage and mother–infant attachment should be included in the internal training given to neonatal nurses as well as providing counseling to the mothers in this regard.

THE IMPORTANCE OF SKIN STIMULATION FOR HUMAN BABIES

Mothers who have meaningful skin contact during pregnancy and labor tend to have easier labors and are more responsive to their infants. Touching and handling her baby assists the new mother in milk production by aiding in the secretion of prolactin, the “mothering hormone.” By regularly massaging her baby, the mother not only sets up a cycle of healthy responses which improves her mothering abilities day by day, but also enhances her baby’s well-being, his disposition, and the relationship between the two of them. The process begun at the embryonic stage thus continues, allowing a natural unfolding of the baby’s potential within the safe and loving arms of his mother.

Nurturing stimulation of the skin—handling, cuddling, rocking and massage—increases cardiac functions of the human infant; massage stimulates the respiratory, circulatory, and gastrointestinal systems—benefits especially appreciated by the “colicky” baby and his parents.

A baby’s first experience with the surrounding environment occurs through touch, developing prenatally as early as 16 weeks. Nature begins the massage before the baby is born. As opposed to the extremely short labors of most other animals, it has been suggested that a human mother’s extended labor helps make up for the lack of postpartum licking performed by other mammal mothers. For the human infant, the contractions of labor provide some of the same type of preparation for the functioning of his internal systems as early licking of the newborn does for other mammals.

Touch impacts short-term development during infancy and early childhood, and has long-term effects. Through this contact, newborns are able to learn about their world, bond with their parents, and communicate their needs and wants. Eighty percent of a baby’s communication is expressed through body movement. When parents engage in appropriate touch, young children have an improved chance to successfully develop socially, emotionally, and intellectually.

Infants who experience more physical contact with parents demonstrate increased mental development in the first six months of life compared to young children who receive limited physical interaction. This improved cognitive development has been shown to last even after eight years, illustrating the importance of positive interactions. Infants who receive above-average levels of affection from their parents are shown to be less likely to be hostile, anxious, or emotionally distressed as adults.

Studies with premature babies using techniques similar to those taught in this book have demonstrated that daily massage is of tremendous benefit. Research projects at the University of Miami Medical Center, headed up by the Touch Research Institute’s founder, Dr. Tiffany Field, have shown remarkable results. In one study, twenty premature babies were massaged three times a day for fifteen minutes each. They averaged forty-seven percent greater weight gain per day, were more active and alert, and showed more mature neurological development than infants who did not receive massage. In addition, their hospital stay averaged six days less. After many years of study and observation, the International Association of Infant Massage has established guidelines for using massage and holding techniques with premature babies.

Dallas psychologist Ruth Rice conducted a study with thirty premature babies after they had left the hospital. She divided them into two groups. The mothers in the control group were instructed in usual newborn care, while those in the experimental group were taught a daily massage and rocking regime. At four months of age, the babies who had been massaged were ahead in both neurological development and weight gain.

The natural sensory stimulation of massage speeds myelination of the brain and the nervous system. The myelin sheath is a fatty covering around each nerve, like insulation around electric wire. It protects the nervous system and speeds the transmission of impulses from the brain to the rest of the body. The process of coating the nerves is not complete at birth, but skin stimulation speeds the process, thus enhancing rapid neural-cell firing and improving brain-body communication.

In 1978 transcutaneous oxygen monitoring was developed, which enabled physicians to measure oxygen tension in the body through an electrode on the skin. It was discovered that hospitalized infants experienced tremendous upheavals in oxygen levels when subjected to stress. Touch Relaxation, holding techniques and massage have been found to mitigate these fluctuations, and these methods are being used in hospitals routinely now to help infants maintain a steady state through the stresses of diaper changes, heel sticks, and other intrusions.

New research demonstrates similar results every day, confirming what age-old tradition has told us: infants need loving touch. Lawrence Schachner, M.D., a professor at the department of dermatology and cutaneous surgery at the University of Miami School of Medicine, advises that touch can benefit babies with skin disorders such as eczema. “It may furthermore improve parent-baby interaction,” he says. Dr. Tiffany Field concurs. She notes that loving touch triggers physiological changes that help infants grow and develop, stimulating nerves in the brain that facilitate food absorption and lowering stress hormone levels, resulting in improved immune system functioning. A report by the Families and Work Institutes states that during the first three years of life, the vast majority of connections between brain cells are formed. They conclude that loving interaction such as massage can directly affect a child’s emotional development and ability to handle stress as an adult.

Loving skin contact and massage benefits mothers and fathers as well. Mothers who have meaningful skin contact during pregnancy and labor tend to have easier labors and are more responsive to their infants. In addition, research has shown that mothers whose pregnancies were filled with chronic stress often have babies who cry more and for longer periods than those whose pregnancies were peaceful and supported.

Fathers who make the effort to bond with their infants by giving the mother loving massages, talking and singing to the baby, feeling its movements in his partner’s belly, attending classes with their partner, and reading up on infant development and psychology, and massaging their infants, tend to be more attentive and accomplished fathers. By regularly massaging your baby (and getting some loving massages yourself during pregnancy), you set up a cycle of healthy responses that improve your mothering skills day by day and enhance your baby’s well-being, disposition, and the relationship between all three of you.

Infant Massage, Bonding, Baby-Wearing and Attachment – Part One