Hartanti et al.

/ Effectiveness of Infant Massage on Strengthening Bonding and

Effectiveness of Infant Massage on Strengthening Bonding and
Improving Sleep Quality
Ainurrizma Tri Hartanti1), Harsono Salimo2), Vitri Widyaningsih3)
1) Masters Program in Public Health, Universitas Sebelas Maret 2)Department of Pediatrics, Dr.

Moewardi Hospital, Surakarta 3)Faculty of Medicine, Universitas Sebelas Maret

ABSTRACT
Background: Baby massage is the oldest and most popular touch therapy known to mankind,
which is also the art of health care and treatment that has been practiced for centuries. This
study aims to determine the effect of infant massage on bonding attachments between mother
and baby and the quality of infant sleep. Subjects and Method: This was experimental study
with Randomized Controlled Trial (RCT) design conducted in five health centers in Ponorogo
Regency, East Java in March to April 2019. The total sample was 120 mothers and infants aged
3 to 6 months divided between massage groups (treatment) and not massage (control) based
on The dependent variable of this study was bonding attachment and sleep quality. The
independent variable in this study was infant massage. Data collection was using
questionnaires and checklists. This study used the Mann-Whitney test Result: Infant massage
effectively increased bonding attachment (effect size = 6.19; p <0.001), increased infant sleep
duration (effect size= 2.79, p <0.001), decreases the number of baby awakened (effect size =
-2.78; p <0.001), decreased duration awakened (effect size= -0.80; p= 0.001), Conclusion:
Baby massage effectively increased bonding attachment and sleep duration, and effectively
decreased the number of awakenings and the duration of awakening.
Keywords: baby massage, bonding attachment, sleep quality
Correspondence: Ainurrizma Tri Hartanti, Public Health Postgraduate Program, Universitas
Sebelas Maret. Jl. Ir. Sutami 36 A, Surakarta 57126, Central Java. Email:

[email protected]. Mobile: 085784939555 BACKGROUND Sleep is a top priority for

babies, because at this time, neuro-brain repair occurs and ap- proximately 75% of growth
hormone is pro- duced. When sleeping, the baby's brain will develop and reach its peak
because the bo- dy will produce more growth hormone than when the baby is awake. In
addition, in the first year the baby's brain will grow 3 times from the state of birth or about
80% of the adult brain (Ifalahma and Sulistiyanti, 2016). Therefore, babies who sleep longer
will achieve optimal growth and develop- ment and allow the body to repair and re- new all
cells in the body (Kusumastuti et al.,
e-ISSN: 2549-0265 165 2016). Baby sleep quality not only affects physical development, but
also its attitude the next day (Dewi et al., 2014). Sleep also has a great effect on the body's
mental, emotional, physical and immune systems (Ifalahma and Sulistiyanti, 2016).
A lot of babies have sleep problems in Indonesia, which is around 44.2%. How- ever,
almost or even more than 72% of pa- rents do not consider sleep disorders in in- fants as a
problem. Although it was consi- dered a problem, they only considered it as a small
problem. In fact, sleep problems can disrupt a baby's growth, cause vulnera- ble immune
functions, and disrupt the re-
Indonesian Journal of Medicine (2019), 4(2): 165-175
https://doi.org/10.26911/theijmed.2019.04.02.10

gulation of the endocrine system (Permata, 2017). A study by Martini (2014) stated that
51.3% of babies experiences sleep disturb- ances, 42% sleep times less than 9 hours a
night, wake up more than three times a night and wake up at night more than one hour.

Besides sleeping problems, babies also still need an adaptation process to the extrauterine
environment. One way to strengthen the adaptation process of new- born babies is to
strengthen bonding at- tachments. Bonding attachment through maternal love is a unique
connection that develops between mother and baby and be- comes permanent over time.
Attachments between mother and baby can start from the time of pregnancy, childbirth, and
post- partum period. The loving attachment of mother to baby is one of the most impor- tant
factors in the development and growth of healthy children (Çinar and Öztürk, 2014).

Mothers should get sufficient know- ledge about the importance of bonding at- tachments
between mothers and babies so that the needs of these bonding attach- ments are fulfilled
for infant growth and de- velopment (Ethicasari, 2012).
The achievement of optimal growth and development results required stimu- lation and
development of child develop- ment in a comprehensive and quality man- ner carried out
during the critical period, which was since the womb until the age of 2 years old. This
stimulation activity was car- ried out as early as possible from the womb until the age of 2
years old as proclaimed by the Government of Indonesia through the "First Thousand Days
of Life" program (Ministry of Health, 2017).
Currently, various therapies have been developed, both pharmacological and
non-pharmacological therapies. One of the
166 e-ISSN: 2549-0265 non-pharmacological therapies to overcome the problem of infant
sleep is baby massage (Hikmah, 2010). One form of stimulation that can be given is
massage stimulation. Baby massage is one of the efforts made by parents as part of
fulfilling children's basic needs. By doing massage stimulation it is hoped that it can improve
the quality of life so that optimal child growth is achieved and can strengthen the bonding
between parents and children as an expression of love through touch. Parents are
expected to be able to carry out massage activities for children at home so that they can
support the program of Healthy Indonesia efforts by promoting promotive and preventive
efforts with community empowerment (Ministry of Health, 2017).
Baby massage was a useful tool to improve maternal skills in interacting with infants
(Gnazzo et al., 2015). The definition of massage intervention is a manual ap- plication
mainly by the mother's hands of certain techniques in structures located within the soft
tissues of the skin, fascia, muscles, ligaments, blood vessels, and ten- dons (Zhang and
Wang, 2019). Baby mas- sage is a relatively easy intervention that has a positive effect on
babies and their pa- rents. Neonatal nurses who get baby mas- sage training can teach
parents the techni- que of doing baby massage as a way to build bonds between parents
and their babies and parents can participate in their baby's care (Pados and
McGlothen-Bell, 2019).
Soft touch on the baby is a beautiful means of bonding between the baby and parents
(Roesli, 2016). Many experts who have proven that baby massage done by parents
(especially mothers) can provide many benefits such as weight and length, sleep better,
elimination and reduction in colic, better physiological and behavioral responses (Dalili et
al., 2016; Wahyuni et al., 2018).
Hartanti et al./ Effectiveness of Infant Massage on Strengthening Bonding and
Massage has a positive effect on mo- ther-baby interactions, improves the quality of baby's
sleep, reduces baby's crying, lo- wers bilirubin levels, increases the frequ- ency of
defecation in the neonate, encou- rages interactions between mother and baby, decreases
their crying, and increases mother-baby interaction(Gürol and Polat, 2012; Serrano et al.,
2010;Chen et al., 2011; Lin et al., 2015).
Baby massage can also increase the development of high-risk postnatal babies, such as
premature newborns or children who are exposed to HIV, increasing physi- cal growth and
digestive function in prema- ture babies. Baby massage can also increase the production of
breast milk, can develop communication, and understand baby cues (Sari et al., 2013;
Porreca et al., 2017; Choi et al., 2015).
SUBJECTS AND METHOD 1. Study Design This was an experimental study with a Ran-
domized Controlled Trial (RCT) design con- ducted in five health centers in Ponorogo
Regency, East Java in March to April 2019. 2. Population and Sample The populations of
this study were all mo- thers and infants aged 3 to 6 months in five health centers in
Ponorogo District, East Java. The Puskesmas were North Ponorogo, South Ponorogo,
Babadan, Sukorejo, and Kunti Health Center. A sample of 120 mothers and infants divided
into 2 groups, namely 60 infants in the control group and 60 infants in the treatment group
was selected by simple random sampling. 3. Study Variables The independent variable in
this study was infant massage. The dependent variables were bonding attachment and
quality of infant sleep.
e-ISSN: 2549-0265 167 4. Operational Definition of Variables Baby massage was a
massage performed by mothers who have been given baby massage training twice for 15
minutes every day, mentoring by enumerators for the first 5-7 days, which is then carried
out indepen- dently by the mother for 30 days.
Bonding attachment was a relation- ship of affection and attachment between parents and
their babies.
The quality of a baby's sleep was a certain physiological condition that is ob- tained during
a baby's sleep to restore body processes that occur when the baby wakes up. Rated for 30
consecutive days.. 5. Study instrument Bonding attachment was collected by Ma- ternal
Attachment Inventory (MAI) check- list. The quality of a baby's sleep was collec- ted by
Brief Infant Sleep Questionnaire (BISQ) questionnaire. Other data was col- lected using a
set of questionnaire. 6. Data Analysis Univariate analysis to describe the charac- teristics
of each variable based on the re- sults of the study. Bivariate analyses to determine the
differrences before and after the baby massage treatment using the Mann-Whitney test. 7.
Research Ethics Research ethics in this study include approval sheets, anonymity,
confidentiality, and ethical feasibility. Ethical feasibility in this study came from the Health
Research Ethics Committee of Dr. Hospital. Moe- wardi Surakarta with the number: 318/ III
/ HREC / 2019.
RESULTS 1. Univariate Analysis The results of univariate analysis in this study were
conducted to determine the cha- racteristics of each study variable which in- cluded the age
of the baby, age of the mo- ther, bonding attachment, infant sleep du-
Indonesian Journal of Medicine (2019), 4(2): 165-175
https://doi.org/10.26911/theijmed.2019.04.02.10
ration, number of awakenings, and dura- tion of waking between massage groups and
168 e-ISSN: 2549-0265 non massage group, before and after treatment.
Table 1. The characteristics of sample (continuous data)
Variables n Mean SD Min Max Age of Infants (months old) 120 4.30 1.15 3 6 Maternal Age (years
old) 120 31.75 5.02 20 45 Bonding attachment Before treatment Massage 60 88.15 2.20 84 95
Non massage 60 88.20 2.23 84 95 After treatment Massage 60 99.60 1.15 96 102 Non massage 60
88.80 2.18 86 94 Sleep duration Before treatment Massage 60 8.42 0.56 7 10 Non massage 60
8.38 0.48 8 10 After treatment Massage 60 9.21 0.15 9 9.6 Non massage 60 8.83 0.12 8.6 9.1
Number of awakenings Before treatment Massage 60 3.58 0.85 2 6 Non massage 60 3.52 0.81 2
5 After treatment Massage 60 2.13 0.34 2 3 Non massage 60 3.32 0.50 2 4 Duration of
awakenings Before treatment Massage 60 41.08 19.42 10 90 Non massage 60 41.17 21.71 20 120
After treatment Massage 60 22.17 9.22 10 50 Non massage 60 34.33 19.53 15 90
2. Bivariate Analysis Table 2. The Mann-Whitney test of the difference in bonding
attachment scores in the massage group and non massage group, before and after
treatment
Group N Mean Median SD p Before treatment Non massage 60 88.20 88.00 2.20 0.876 Massage
60 88.15 88.00 2.23 After treatment Non massage 60 88.80 88.00 2.18 <0.001 Massage 60 99.60
100.00 1.15 Effect Size = 3.56 Based on Table 2, the Mann-Whitney test results showed a
significant difference in the attachment bonding score in the mas- sage group and non
massage between
before and after the baby massage treat- ment. Baby massage effectively increased
bonding attachments between mother and baby (p<0.001; d= 3.56).
Hartanti et al./ Effectiveness of Infant Massage on Strengthening Bonding and
Table 3. The Mann-Whitney test of the difference in the duration of a baby's night
sleep in the massage group and non massage, before and after treatment
Group N Mean Median SD p Before treatment Non massage 60 8.38 8.00 0.48 0.509 Massage
60 8.42 8.25 0.56 After treatment Non massage 60 8.83 8.82 0.12 <0.001 Massage 60 9.21 9.17
0.15 Effect Size = 2.79 Based on Table 3, the Mann-Whitney test results showed that there
were significant differences in the duration of the baby's night sleep in the massage group
and non
e-ISSN: 2549-0265 169 massage between before and after the baby massage treatment.
Baby massage effective- ly increased the duration of baby's sleep (p<0.001; d= 2.79).
Table 4. The Mann-Whitney test of the difference in the number of awakenings in
groups of massage and non massage, before and after treatment
Group N Mean Median SD p Before treatment Non massage 60 3.52 4.00 0.81 0.910 Massage
60 3.58 4.00 0.85 After treatment Non massage 60 3.32 3.00 0.50 <0.001 Massage 60 2.13 2.00
0.34 Effect Size = -2.78 Based on Table 4, the Mann-Whitney test results showed that there
were significant differences in the number of babies waking up in the massage group and
non massage
between before and after the treatment of infant massage. Baby massage was effective in
reducing the number of baby awakenings (p <0.001; d= 2.78).
Table 5. The Mann-Whitney test of the different duration of awakening in the massage
group and non massage, before and after treatment
Group N Mean Median SD p Before treatment Non massage 60 41.17 40.00 21.71 0.678
Massage 60 41.08 40.00 19.42 After treatment Non massage 60 34.33 30.00 19.53 0.001
Massage 60 22.17 20.00 9.22 Effect Size = -0.80
Based on Table 5, the Mann-Whitney test results showed significant differences in the
duration of awakening in the massage group and non massage between before and after
the baby massage treatment. Baby massage effectively decreased the duration of baby
awakenings (p= 0.001; d= -0.80).
DISCUSSION 1. The Effect of Baby Massage on
Bonding Attachment The results of this study showed that there were significant
differences in bonding at- tachment scores in the massage group and non massage group
between before and af- ter the baby massage treatment and showed that infant massage
was effective to in-
Indonesian Journal of Medicine (2019), 4(2): 165-175
https://doi.org/10.26911/theijmed.2019.04.02.10
crease bonding attachments between mo- thers and infants (d= 3.56; p<0.001).
Engagement was a close and intimate relationship with people such as mothers, fathers,
siblings, spouses, children and clo- se friends. Parental attachment was defined as a series
of inner behaviors that would make babies develop intimate relationships with their primary

caregivers (Salehi et al., 2019). Interaction between mother and baby was the first
intrapersonal interaction of the baby and plays an important role in building trust. This has a
major influence on infant language development, emotional regulation, and cognitive
development. Me- anwhile, children whose mothers regularly engage in quality interactions
with them tend to show a high index of mental deve- lopment at 2 years of age (Chung et
al., 2018). The quality of the initial dyadic inte- raction between the primary caregiver and
the baby was very important for the social and emotional, cognitive, language and bra- in
development of the child (Parfitt et al., 2013). A responsive attitude on the part of mothers
played an important role in deve- loping strong and effective attachments bet- ween mother
and baby (Lai et al., 2016).
Quality interaction behavior between mother and baby can facilitate the baby's
social-emotional, behavioral and cognitive development which then occurred and was even
related to the child's physical health. Babies need reciprocal interaction with pa- rents to
become interested in social interac- tion and develop secure attachment rela- tionships in
older age. Based on the quality of interactions between parents and babies, they would
form an attachment style during the first year of life. The baby attachment model directed
children's behavior in social relations in the future (Korja et al., 2012)
Prasetyono (2013) stated thattouch is the first form of communication parents
170 e-ISSN: 2549-0265 have with babies. Touch on baby means talking. Baby massage
combined aspects of closeness, namely eye contact, smiling, and other facial expressions.
Regular baby mas- sage twice a day can help parents to un- derstand the baby's wishes
through the sign language provided. Baby massage was one approach that made an
important contri- bution to the psychological and phsiological welfare of infants and mothers
and helped to form harmonious relationships (Vicente et al., 2017).
This study was in accordance with the study of Lindensmith (2018) which showed the
results that infant massage was effective in improving the relationship between mo- ther
and baby in mothers who experience post-partum anesthesia. Baby massage can increase
attachment through a baby's to- uch. Maternal attitude to the baby, mater- nal sensitivity,
and infant's response to the mother showed an increased score after a baby massage
intervention. Oxytocin is a hormone that plays a key role in maternal behavior, which can
therefore have an impact on mother-baby interacttions. Mas- sages given to the neonate by
the mother every day can increase and maintain the emotional bond between mother and
baby (Shoghi et al., 2018).
Mothers who did baby massage repor- ted that they were able to adapt better and have a
greater level of confidence in caring for their babies (Vicente et al., 2017). Other studies
have found that mothers who mas- sage their babies have a faster decline in symptoms of
depression and lower stress (Holditch-Davis et al., 2013).
Another study conducted in Turkey by Gürol and Polat (2012) stated that baby massage
increased the attachment between mother and baby. Massage can increase maternal care
for babies, which in turn can increase positive interactions between mo- ther and baby.
Baby massage made inter-
Hartanti et al./ Effectiveness of Infant Massage on Strengthening Bonding and
action between mother and baby more active so that it can build emotional bonds between
mother and baby (Lee, 2017). Mas- sage the baby positively influenced the mo- ther's
mood. It showed that baby massage can increase the interaction between mo- ther and
baby for mothers with postpartum depression (Cooke, 2015). 2. The Effect of Baby
Massage on
Quality of Sleep In this study, there were significant differ- rences in the duration of sleep
of infants in the massage group and non massage bet- ween before and after treatment (d
= 2.79; p <0.001).
The results of this study showed a significant difference in the number of infants in the
massage and non-massage groups between before and after the baby massage treatment
(d = -2.78, p <0.001)
The results of this study showed a sig- nificant difference in the duration of wa- king in the
massage group and non-mas- sage group between before and after the baby massage

treatment (d= -0.80; p= 0.001). This study was in line with the study of Kusumastuti et al.,
(2016) based on Mann Whitney Test different tests on sleep quality showed that p <0.001, it
showed that babies who got massage have better sleep quality than babies who did not get
massage.
Sleep disorders was one of the most difficult problems for parents and babies during the
first months of life. Study from Israel documented an increase in sleep and
e-ISSN: 2549-0265 171 melatonin levels after 2 weeks of massage. Melatonin levels have an
inverse relation- ship with eye movements. This showed that babies who were massaged

would experien- ce more restful/restorative sleep (Field, 2018). Baby massage also

enhanced the adj- ustment of the circadian rhythm in infant sleep to the nocturnal period of
term in- fants (Field, 2017). Baby massage can redu- ce baby crying (Serrano et al., 2010)
Study of Bennett (2013) mentioned that babies did not wake up significantly in the massage
group rather than the non- massage group after intervention. The du- ration of infant night
awakening was far less in the massage group compared to the non-massage group. The
non-massage group had an average duration of waking at night by 16 minutes longer after
the inter- vention than the massage group.
Kulkarni et al. (2010) reported that infants born with gestational age less than 36 weeks
with birth weight <2.5 kg received massage until the age of 8 months old experienced
improvement in sleep quality and a reduced number of awakenings. Ba- bies were more
active during the day and make babies sleep faster. Baby massage done for two weeks
showed that sleep time became easier and babies experienced fe- wer waking nights
(Mindell et al., 2018). Study done by Field (2017) reported that infants in the massage
group had more regular sleep cycles than infants in the non massage group.
AUTHOR CONTRIBUTION Ainurrizma Tri Hartanti, the main author, has role in collecting
and processing the data. Harsono Salimo examined the frame- work of study concepts and
methodologies. Vitri Widyaningsih reviewed study manus- cript.
FUNDING AND SPONSORSHIP This study used the authors’ own fund.
CONFLICT OF INTEREST The authors do not have any conflict of interest.
Indonesian Journal of Medicine (2019), 4(2): 165-175
https://doi.org/10.26911/theijmed.2019.04.02.10
ACKNOWLEDGEMENT
British journal of midwifery. 23(3): The authors would like to thank the Health
166–170. https://doi.org/10.12968/b- Center for assisting the authors and also
jom.2015.23.3.166 study participants.
Dalili H, Sheikhi S, Shariat M, Haghnaza-
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