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Special Report

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Pregnancy and labor massage


Expert Rev. Obstet. Gynecol. 5(2), 177–181 (2010)
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Tiffany Field Massage therapy has been demonstrated to be effective during pregnancy. Women who
Touch Research Institute, received massage therapy reported decreased depression, anxiety, and leg and back pain.
University of Miami School of Cortisol levels decreased and, in turn, excessive fetal activity decreased, and the rate of
Medicine, Department of prematurity was lower in the massage group. In a study of labor pain, women who received
Pediatrics (D-820), massage therapy experienced significantly less pain, and their labors were on average 3 h shorter
PO Box 016820, Miami, with less need for medication. An underlying mechanism we have been exploring is that these
FL 33101, USA effects are mediated by increased vagal activity. This likely occurs by the stimulation of pressure
Tel.: +1 305 243 6781
receptors that are innervated by vagal afferent fibers, which ultimately project to the limbic
Fax: +1 305 243 6488
tfield@med.miami.edu
system, including hypothalamic structures involved in autonomic nervous system regulation and
cortisol secretion.

Keywords : alternative therapy • labor pain • postpartum depression • pregnancy massage • prematurity

Complementary and alternative therapies have that has been noted in fetuses of depressed
For personal use only.

become increasingly popular for pregnant women  (Figure 1) . The most important finding
women and women in labor. In one survey, was the lower incidence of prematurity (0 vs 11%
the majority of pregnant women who partici- in the control group).
pated (62%) and 61% of providers of prenatal In the third study, pregnant women diagnosed
healthcare reported that they used comple- with major depression were given 12 weeks of
mentary and alternative therapies during twice weekly massage therapy by their sig-
pregnancy [1] . The most common alternative nificant other, or only standard treatment as a
therapies recommended during pregnancy were control group [3] . The massage therapy group
massage therapy (61%), acupuncture (45%), women versus the control group women not only
­relaxation (43%), yoga (41%) and chiropractic had reduced depression by the end of the therapy
therapies (37%). period, but they also had reduced depression and
cortisol levels during the postpartum period.
Pregnancy massage Their newborns were also less likely to be born
Massage therapy has been demonstrated to be prematurely (4 vs 16%) and with low birth-
effective during pregnancy in three studies by weight (2 vs 10%), and they had lower cortisol
our group [2–4] . In the first study, therapists levels and performed better on the Brazelton
provided massage therapy for 20 min per week Neonatal Behavioral Assessment habituation,
for 5 weeks  [4] . The women reported decreased orientation and motor scales.
depression, anxiety and leg and back pain. Cortisol The higher-than-national-average prematu-
levels decreased and, in turn, excessive fetal activ- rity and low birthweight rates for the depressed
ity decreased, and the rate of ­prematurity was mothers in this sample were not surprising given
lower in the massage group. previous reports on a greater incidence of prema-
In the second study, depressed pregnant turity in depressed women [5,6] . The decreased
women were massaged by their significant others depression and low back pain in the massaged
over a 16‑week period using the same protocol women and their fewer prenatal complications,
(20‑min massages twice weekly) [2] . As in the including a 75% lower prematurity rate and
first study, significant decreases were noted in an 80% lower incidence of low birthweight in
depression and anxiety, as well as cortisol levels. the massaged depressed women, were also not
In addition, like the results of the first study, surprising given our previous finding of a lower
pregnancy outcomes were improved, includ- prematurity rate in depressed women given
ing a reduction in excessive fetal movement ­pregnancy massage [2] .

www.expert-reviews.com 10.1586/EOG.10.12 © 2010 Expert Reviews Ltd ISSN 1747-4108 177


Special Report Field

significantly less pain, and their labors were


45
on average 3 h shorter with less need for
medication (Figure 2) .
First day
40
Second-to-last day Potential underlying mechanisms
for massage therapy effects
35
Some suggest that massage effects can be
explained by the ‘gate theory’ [10] . This is a
30 kind of metaphor for the pain message trav-
eling more slowly than the pressure mes-
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25 sage from massage (i.e., the stimulation of


Score

pressure receptors). Pressure messages travel


20 more rapidly than pain messages, reaching
the brain faster and closing the gate to the
15 pain message. A more biological explana-
tion of the gate theory is that cells in the
10 dorsal horn of the spinal cord act like a
switch between the nerve impulses from the
5 different fibers. Pain is carried more slowly
by the less insulated (unmyelinated) C neu-
0 rons, whereas massage signals are carried
more rapidly by the A neurons (myelinated)
CES-D Fetal movement
that close the gate to the C impulses and
allow the A signals through. In this way,
For personal use only.

Figure 1. Mean Center for Epidemiological Studies Depression scores and fetal the massage stimulation (A fibers) closes the
movement scores on first day (black) and second to last day (gray) of pregnancy gate to the pain stimulus (C fibers).
massage study. An alternative underlying mechanism
CES-D: Center for Epidemiological Studies Depression Score.
we have been exploring is that these
Data from [2] .
effects are mediated by increased vagal
activity. Vagal activity increases immedi-
These findings were unique in that post­partum depression ately after massage therapy sessions and across repeated sessions
and cortisol levels were decreased in the massaged women. The of massage therapy [11] . In these studies, significant increases in
decrease in depression by week 32 of gestation in the massaged vagal activity occurred following massage therapy. This likely
women persisted through the duration of pregnancy and the post- happens by the stimulation of pressure receptors that are inner-
partum period. To have mothers less depressed during the neona- vated by vagal afferent fibers, which ultimately project to the
tal period would likely enhance their bonding with their infants. limbic system, including hypothalamic structures involved in
Having more mature and more interactive newborns would also autonomic nervous system regulation and cortisol secretion.
certainly enhance that process [7] . The fact that the newborns These pathways are supported by several lines of evidence. First,
of the massaged mothers also had lower cortisol ­levels than the anatomical studies indicate that baroreceptors, and to a lesser
newborns of the control mothers may relate to the mothers’ lower extent, mechanoreceptors under the skin (i.e., Pacinian corpus-
cortisol levels and their decreasing depression across pregnancy. cles) are innervated by vagal afferent fibers projecting to the vagal
nucleus of the solitary tract, the predominant source of afferent
Labor massage inputs to the efferent neurons of the nucleus ambiguous and the
It is interesting that while labor is an anxiety-provoking experi- dorsal motor nucleus of the vagus [12] . Second, functional studies
ence, and while massage therapy has been noted to reduce anxiety indicate that electrical vagal stimulation results in reduced cortisol
in many studies, the focus of massage therapy labor studies has responses in depressed patients [13] . Third, as already noted, we have
been almost exclusively on the alleviation of pain. In one study, recently shown that moderate pressure massage (but not light pres-
massage was noted to lessen the pain intensity during phase 1 sure massage) elicits a significant increase in vagal activity in both
and 2 dilation, but there were no significant differences between infants and adults [14] . Fourth, data collected across several studies
the massage and control groups at phase 3 dilation [8] . by our group and others indicate that massage therapy decreases
In a study we conducted on labor pain, the pregnant women’s heart rate [15–17] , lowers blood pressure [17–19] and reduces cortisol
partners massaged them during the first 15 min of every hour levels  [20,21] . Last, a functional MRI study revealed that massage
of labor [9] . The partners were given instructions on massaging therapy increased cerebral blood flow across several brain regions
the back and the legs (the areas of greatest pain) of the preg- involved in depression and stress regulation, including the amyg-
nant women from a side-lying position. The women experienced dala and the hypothalamus [22] , suggesting that massage therapy

178 Expert Rev. Obstet. Gynecol. 5(2), (2010)


Pregnancy & labor massage Special Report

involves hypothalamic regulation of auto-


nomic nervous system activity, cortisol
secretion and limbic activity associated with 11.3
emotion regulation.
Inverse relationships between vagal
activity and cortisol levels have also been 8.5
reported  [23] . In addition, psychological
stressors that reduce vagal activity have

Hours
been noted to increase cortisol levels [24] .
Increased vagal activity results in a slow-
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ing of physiology (decreased heart rate


and blood pressure) and downregulation
of cortisol [25] . Others have interpreted
this relationship as vagal activity playing
an inhibitory role in the regulation of allo-
static systems [23] . As Thayer and Sternberg
noted, the prefrontal cortex and amygdala
are important CNS structures linked to the Control Massage
regulation of emotion and allostatic systems,
including hypothalamic–pituitary–adrenal Figure 2. Mean number hours of labor in control and massage groups.
axis ­function [23] . Data from [9] .

Expert commentary magnetic resonance imaging study, massage therapy increased cere-
Previous reports have found that depressed women have a bral flow in different brain regions involved in depression and stress
For personal use only.

greater incidence of prematurity and low birthweight rates [5,6] . regulation, including the amygdala and hypothalamus [22] . This
In our studies, massage therapy has been effective during implies that massage therapy engages hypothalamic regulation of
pregnancy [2–4] . Depressed women given massage therapy had autonomic nervous system activity, cortisol secretion and limbic
fewer prenatal complications, including a 75% lower prema- activity related with emotional regulation. Psychological stressors
turity rate and an 80% lower incidence of low birthweight [2] . that reduce vagal activity increase cortisol levels [24] , but increased
They also reported decreased depression, anxiety and back vagal activity decreases heart rate and blood pressure, as well as
pain. Surprisingly, postpartum depression and cortisol levels cortisol [25] .
decreased in the massaged women. Their newborns also had
lower cortisol levels than the newborns of the control mothers, Five-year view
which may relate to their mothers’ lower cortisol levels and their Like China, the USA may eventually have touch rooms in their
decreasing depression across pregnancy. In addition, the new- hospitals where couples will learn the massage for both the pregnant
borns performed better on the Brazelton Neonatal Behavioral women and the newborn. In time, the USA may come to have
Assessment habituation, orientation and motor scales. With the low 1% rate of prematurity of China instead of the 14% rate it
mothers less depressed during the neonatal period along with currently has. Additional research on underlying mechanisms for
more mature and interactive newborns, the bonding process the massage effects will help to advance this field.
between them is enhanced [7] .
In many studies massage therapy has been known for reducing Acknowledgements
anxiety. In the study we conducted on labor pain, the pregnant Tiffany Field would like to thank her collaborators and Lissette Medina for
women’s partners massaged their back and legs from a side-lying assisting with this research, and the pregnant women who participated in
position during the first 15 min of every hour of labor [9] . The her studies.
women experienced less pain, and their labors were on average
3 h shorter with less need for medication. Financial & competing interests disclosure
Some credit the massage therapy effects with the gate the- The studies discussed in this article were supported by NIH Senior Research
ory  [10] . This suggests that pressure messages travel more rap- Scientist Awards (MH 00331 and AT 01585) and an NIH Merit award
idly than pain messages, therefore reaching the brain faster (M 46586), NIH grants (AT1003 and HD 056036), and a March of Dimes
and closing the gate to the pain message. Another underlying grant (12-FY03–48) to Tiffany Field and funding from the Johnson & Johnson
mechanism we have been exploring is that these massage therapy Pediatric Institute. The author has no other relevant affiliations or financial
effects occur because vagal activity increases following massage involvement with any organization or entity with a financial interest in or
therapy. In our previous studies, we have demonstrated that financial conflict with the subject matter or materials discussed in the
moderate-pressure massage and not light-pressure massage elicits ­manuscript apart from those disclosed.
a significant increase in vagal activity. According to a functional No writing assistance was utilized in the production of this manuscript.

www.expert-reviews.com 179
Special Report Field

Key issues
• Massage therapy is the most common alternative therapy recommended during pregnancy.
• Massage therapy has been demonstrated to be effective during pregnancy. The women reported decreased depression, anxiety, and
leg and back pain.
• Depressed pregnant women given the pregnancy massage experienced fewer prenatal complications.
• In our study on labor pain, the women receiving massage therapy experienced significantly less pain, and their labors were on average
3 h shorter with less need for medication.
• The most important finding was the lower incidence of prematurity and low birthweight in the massaged depressed women.
• Postpartum depression and cortisol levels were decreased in the massaged women. The newborns of the massaged mothers also had
Expert Review of Obstetrics & Gynecology Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14

lower cortisol levels than the newborns of the control mothers, and performed better on the Brazelton Neonatal Behavioral Assessment
habituation, orientation and motor scales. An underlying mechanism we have been exploring is that these effects are mediated by
increased vagal activity.

References •• Showed decreased anxiety and stress medication. In addition, the massaged
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Pregnancy & labor massage Special Report

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25–32 (2000). Refract. Surg. 27, 884–890 (2001). Affiliation
18 Ahles TA, Tope DM, Pinkson B et al. 22 Ouchi Y, Kanno T, Okada H et al. • Tiffany Field
Massage therapy for patients undergoing Changes in cerebral blood flow under the Touch Research Institute, University of
autologous bone marrow transplantation. prone condition with and without massage. Miami School of Medicine, Department of
J. Pain Symptom Manage. 18, 157–163 Neurosci. Lett. 407, 131–135 (2006). Pediatrics (D‑820), PO Box 016820,
(1999). Miami, FL 33101, USA
23 Thayer JF, Sternberg E. Beyond heart rate
Hernandez-Reif M, Field T, Krasnegor J, Tel.: +1 305 243 6781
19 variability: vagal regulation of allostatic
Theakston H, Hossain Z, Burman I. Fax: +1 305 243 6488
systems. Ann. NY Acad. Sci. 1088, 361–372
High blood pressure and associated tfield@med.miami.edu
(2006).
For personal use only.

www.expert-reviews.com 181

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