the first few days after birth are a critical period for mothers ( 1 ) .
childbirth is a significant life transition event , especially for primiparous women ( 2 ) . in the postpartum period ,
mothers are faced with multiple biological , psychological , and social changes and the need to adapt to new problems and concerns ( 3 ) .
some mothers are very stressed and anxious and experience difficulties adapting to their new lives and responsibilities ( 4 ) .
the postpartum period is a critical time , during which mothers may feel very fatigued , exhausted , and anxious .
anxiety is one of the most common complaints in the postpartum period . in a previous study by denis ,
the prevalence of postpartum anxiety was reported to be 18% in a study in maryland in the u.s .
( 6 ) and 12.7% in a study in south australia ( 2 ) . in vancouver , canada ,
the incidence of postpartum anxiety was reported to be 14.2% in the first week after delivery , 12.1% in the fourth week , and 9.2% in the eighth week ( 5 ) . in a study on the prevalence of anxiety and fear of childbirth in the postpartum period in tehran , iran ,
14.7% of mothers reported mild anxiety , 26% had medium - to - low anxiety , 23% had above average anxiety , 27.3% had relatively severe anxiety , and 12.7% had severe anxiety ( 7 ) . in another study in shiraz , iran ,
severe postpartum anxiety was observed in 85.5% of mothers , with 14% reporting mild anxiety ( 8) . studies in ramsar ( 9 ) , mashhad ( 10 ) , and west azerbaijan , iran ( 11 ) , reported that the prevalence of anxiety was 36.4% , 35.7% , 29% , and 39% , respectively .
these results point to a higher prevalence of anxiety among mothers in iran compared to that in other countries .
anxiety may delay or prevent the release of oxytocin during the breast - feeding period and potentially interfere with the breast milk letdown reflex ( 12 ) .
anxiety may strengthen avoidance behavior of mothers , as well as negatively influence the emotional bond between the mother and infant , putting the mother - infant attachment bond at risk ( 13 ) .
in addition , anxiety is a very strong predictor of postpartum depression ( 15 ) , which is usually observed at the same time ( 2 , 16 ) . as
a diagnosis of postpartum anxiety can help prevent subsequent depression ( 15 ) , interventions need to be designed to reduce this disorder .
various methods have been used to reduce anxiety , with therapeutic touch and massage some of the oldest applications ( 17 ) .
the prevalence of anxiety and the cost of treatment in the u.s . has led half of patients to use supplementary and alternative medicine , including massage , so that massage was the fourth most applied therapy among patients with anxiety ( 5.2% ) ( 18 ) .
massage regulates the autonomic nervous system and therefore decreases the levels of cortisol , adrenaline , and noradrenalin .
it can also adjust neural activity in the amygdale , frontal brain , and the control network .
in addition , massage stimulates the sensory afferent c fibers in the skin , affecting the human body and mind .
intermittent pressure applied during massage increases blood circulation and lymphatic drainage ( 19 ) , which causes changes in the heart rate and blood pressure ( 20 ) .
this type of therapy also causes muscle relaxation , leading to increased comfort , reduced pain , and eventually reduced anxiety ( 17 ) .
relaxation in the postpartum period decreases the activity of the sympathetic nervous system and can prevent postpartum depression , and it can also increase effective mother - infant attachment ( 21 ) .
the use of complementary medicine in maternity care may reduce pharmacological interventions and their effects on infants ( 22 ) .
as noted earlier , there is a high prevalence of postpartum anxiety among iranian mothers , with remarkable negative outcomes , and prevention strategies and interventions can minimize the incidence of mental disorders after childbirth and improve the developmental outcomes of infants in a timely manner .
thus , this study was designed to examine the effects of slow - stroke back massage on postpartum anxiety .
this single - blind randomized controlled clinical trial consisted of 100 primiparous mothers referred to the shahidan mobini hospital ( sabzevar , iran ) between july and september 2015 .
the proposal was approved by the ethics committee of iran university of medical sciences ( ir.iums.rec.1394.26109 94.3.3 ) , and the study was registered with the iranian registry of clinical trials ( irct i d : n15 201506042248 ) .
the inclusion criteria were as follows : being primiparous with a healthy baby , maternal age of 18 - 45 years , ability to read and write , and breastfeeding while in the hospital .
the exclusion criteria included a history of chronic diseases , addiction , known mental health problems , facing a disaster in the last 6 months in their lives or their relatives lives , infertility , use of analgesics or epidural anesthesia during labor or in the postpartum period , and the presence of any ulcer , infection , or any other lesion in an area that would prevent massage .
a dual - block randomization design was used to allocate the mothers to the two groups : massage ( n = 50 ) and control ( n = 50 ) . in the dual - block two in one design , there were two possible sequences of ab and ba .
based on the list , each mother was assigned to the experimental or control group . to prevent the effects of postpartum fatigue and insomnia on the outcome of the study ,
the intervention was performed in the 4 - 18 hours postpartum period ( 23 ) .
the sampling was carried out from july to september 2015 . in this single - blind trial ,
the observer and mothers could not be blinded due to the nature of the study .
based on the inclusion criteria , about 45% of mothers were not eligible to participate in the study due to muliparity .
a total of 105 mothers met the study criteria and were included in the study .
after providing the necessary clarifications in relation to the objectives of the study and obtaining written consent from the mothers , the participants completed a socio - demographic questionnaire .
the mothers were then transferred to a quiet room , with a temperature of 27c , soft light , and free of environmental stimuli .
after the mothers were made comfortable on beds in the room , they completed spielberger s state anxiety inventory ( stai ) . in the experimental group ,
slow - stroke back massage was performed for 20 min , in a sitting position .
vaseline , an odorless ointment , was chosen for the massage because the smell of the mother is an important stimulus for infants ( 24 ) and is necessary for the development of attachment between the mother and infant . using odorless vaseline
the individual who performed the massage received training under the supervision of traditional medicine experts and earned a certificate to perform massage . in the control group ,
after 20 min and again the following morning , the mothers completed the stai . using the following formula ,
the required sample size was estimated as 45 subjects , with a confidence level of 95% , power of 80% , and assuming that the effect of the massage on the level of maternal anxiety on the first postpartum data was significant : considering a probability of incomplete questionnaires of 10% , the sample size was determined as 50 for each group .
the tools used in this study included a socio - demographic questionnaire and the stai .
the socio - demographic information included the mother s and father s ages , ethnicity , infant gender and birth weight , maternal education and occupation , economic and residence status , number of pregnancies and abortions , desirability of the pregnancy , the mother s and father s satisfaction with the infant s gender , and history of drug usage during the pregnancy and postpartum period .
the stai is a standard questionnaire containing 20 items , which are designed to check the status of fear , tension , unrest , and anxiety feelings of individuals in the current situation and the moment .
there are four possible responses to each statement : with 1 denoting never , 2 denoting sometimes , 3 denoting high , and 4 denoting very high .
each statement is assigned a score of between 1 and 4 , with 4 indicating a high level of anxiety . the total score of the scale is between 20 and 80 , with a score of 20 - 31 indicating mild anxiety , 32 - 42 signifying moderate anxiety , and 43 - 53 denoting moderate - to - severe anxiety . scores of 54 - 64 denote relatively severe anxiety , whereas scores of 65 - 75 mean severe anxiety .
the validity and reliability of this questionnaire have been demonstrated previously in research conducted in iran .
furthermore , its scientific reliability was confirmed in 1993 by mahram ( cronbach s alpha in the norm society and in the criterion community were 0.945 and 0.941 , respectively ) ( 26 ) . in studies by kordi et al . ( 27 ) and dareshouri mohammadi ( 28 ) , the reliability of the stai was reported to be r = 0.82 and r = 0.92 , respectively .
slow - stroke back massage was originally described by elizabeth ( 29 ) as a slow rhythmic light touch with the hands . in the present study ,
the procedure of the massage consisted of the following steps : the mother was seated on the edge of the bed .
then , the researcher grasped the top of the mother s shoulders with both hands and placed the thumbs of each hand just below the base of the skull , making tiny circular movements on the upper neck . in the next stage ,
the researcher placed the palm of one hand at the base of the skull and made a long and smooth stroke all the way down the patient s spine to her waist .
the second hand followed the first at the base of the skull and stroked down the spine as the first hand returned to the base of the skull .
next , the researcher placed her hands on either side of the mother s neck under the mother s ears and stroked down and over the mother s collarbones with her thumbs just over the shoulder blades and repeated the motion several times .
then , she placed the thumb of each of her hands beside the spine , beginning with the shoulders , and moved the thumbs down the spine to the waist and repeated this movement several times .
finally , she completed the procedure by placing her palms on each side of the mother s neck and making continuous , long , sweeping strokes down the neck , across each shoulder , and down the back near the spine and repeated the entire process several times ( 30 ) .
spss , version 22 software was used to analyze the data . to compare the demographic variables of the control and experimental groups ,
a repeated measures analysis of variance was used to compare changes in the anxiety levels before and after the intervention . statistical significance in the tests was considered as p < 0.05 .
the tools used in this study included a socio - demographic questionnaire and the stai .
the socio - demographic information included the mother s and father s ages , ethnicity , infant gender and birth weight , maternal education and occupation , economic and residence status , number of pregnancies and abortions , desirability of the pregnancy , the mother s and father s satisfaction with the infant s gender , and history of drug usage during the pregnancy and postpartum period .
the stai is a standard questionnaire containing 20 items , which are designed to check the status of fear , tension , unrest , and anxiety feelings of individuals in the current situation and the moment .
there are four possible responses to each statement : with 1 denoting never , 2 denoting sometimes , 3 denoting high , and 4 denoting very high .
each statement is assigned a score of between 1 and 4 , with 4 indicating a high level of anxiety . the total score of the scale is between 20 and 80 , with a score of 20 - 31 indicating mild anxiety , 32 - 42 signifying moderate anxiety , and 43 - 53 denoting moderate - to - severe anxiety . scores of 54 - 64 denote relatively severe anxiety , whereas scores of 65 - 75 mean severe anxiety . scores of more than 76 are suggestive of very severe anxiety ( 25 ) .
the validity and reliability of this questionnaire have been demonstrated previously in research conducted in iran .
furthermore , its scientific reliability was confirmed in 1993 by mahram ( cronbach s alpha in the norm society and in the criterion community were 0.945 and 0.941 , respectively ) ( 26 ) . in studies by kordi et al .
( 27 ) and dareshouri mohammadi ( 28 ) , the reliability of the stai was reported to be r = 0.82 and r = 0.92 , respectively .
slow - stroke back massage was originally described by elizabeth ( 29 ) as a slow rhythmic light touch with the hands . in the present study ,
the procedure of the massage consisted of the following steps : the mother was seated on the edge of the bed .
then , the researcher grasped the top of the mother s shoulders with both hands and placed the thumbs of each hand just below the base of the skull , making tiny circular movements on the upper neck . in the next stage ,
the researcher placed the palm of one hand at the base of the skull and made a long and smooth stroke all the way down the patient s spine to her waist .
the second hand followed the first at the base of the skull and stroked down the spine as the first hand returned to the base of the skull .
next , the researcher placed her hands on either side of the mother s neck under the mother s ears and stroked down and over the mother s collarbones with her thumbs just over the shoulder blades and repeated the motion several times .
then , she placed the thumb of each of her hands beside the spine , beginning with the shoulders , and moved the thumbs down the spine to the waist and repeated this movement several times .
finally , she completed the procedure by placing her palms on each side of the mother s neck and making continuous , long , sweeping strokes down the neck , across each shoulder , and down the back near the spine and repeated the entire process several times ( 30 ) .
spss , version 22 software was used to analyze the data . to compare the demographic variables of the control and experimental groups ,
a repeated measures analysis of variance was used to compare changes in the anxiety levels before and after the intervention . statistical significance in the tests was considered as p < 0.05 .
this study consisted of 100 primiparous women assigned to a massage therapy group ( n = 50 ) or a control group ( n = 50 ) .
about 46% of the mothers had a secondary education , and 94% were homemakers . in terms of economic status , 81% of the mothers had an adequate family income , and 9% belonged to low - income families .
the ethnicity of the majority of the mothers in both groups was fars , iranian .
there were no missing values , as the number of items that the mothers had to complete was low .
the results indicated that the two groups were matched in terms of socio - demographic characteristics ( table 1 ) .
there was no significant difference between the average anxiety level of the control group at the pretest and post - test stages and the next morning ( p = 0.973 ) . in the experimental group
, there was a significant difference between the average state anxiety before and immediately after the massage and the next morning ( p < 0.001 ) , with the mean anxiety score reduced in this group ( table 2 ) .
there was no significant difference between the average state anxiety of the mothers in the two groups before the massage ( p = 0.268 ) , whereas there was a significant between - group difference after the massage ( p < 0 .
this study is the first to assess the effect of massage on anxiety levels in the postpartum period . the aim of this study was to evaluate the effect of slow - stroke back massages on the anxiety of primiparous women on the first postpartum day .
the results showed that slow - stroke back massage was an effective intervention to reduce anxiety levels on the first postpartum day in primiparous women . in this study , after receiving the massage , the anxiety level of the experimental group was significantly reduced ( p < 0.001 ) , and the difference in the anxiety scores of the two groups was significant ( p < 0.001 ) , with the scores in the intervention group significantly reduced compared to those of the control group .
this represents a higher improvement of the anxiety in the intervention group than the control group after the intervention .
research on mothers on the first day after labor ( 23 ) , third day after labor ( 31 ) and second day after birth ( 32 ) reported similar results .
the results of the present study revealed that the level of anxiety in the control group did not change after the intervention ( p = 0.973 ) .
this result was not consistent with the results of karagozoglu s ( 33 ) and bazrafshan s ( 34 ) studies , who reported increased anxiety .
this may be due to differences in the taking care method of the control group in the two studies . in the present study , the researcher remained with the mother for 20 min in a calm room , which was different from ordinary hospital rooms . in the present study , the average anxiety score in the two groups before the intervention was moderate ( 32 - 42 ) .
in other studies of pregnant women in iran ( 34 ) and india ( 35 ) , the average level of anxiety before the intervention ( 43  53 ) was high . unlike the present study ,
the aforementioned studies were carried out during pregnancy , in which the level of anxiety and depression may be high .
this may explain the differences in the level of anxiety between those studies and the present one .
the results of two studies in iran showed that the maternal psychological state ( 36 ) and well - being index ( 37 ) of mothers improved in the postpartum period ( 36 , 37 ) .
thus far , studies have reported positive effects of massage on anxiety in patients undergoing colorectal surgery ( 38 ) , patients with heart failure ( 39 ) , elderly individuals ( 40 ) , patients prior to labor ( 41 ) , patients undergoing eye surgery ( 42 ) , and patients with generalized anxiety ( 18 ) .
the results of the present study are consistent with the results of the previous studies and indicate that massage can decrease postpartum anxiety .
the findings of this study showed that slow - stroke back massage in the first few days after birth reduced the mother s anxiety level .
therefore , it is recommended that midwives and nurses use massage in the early days after labor to help the mother achieve relaxation . with the current facilities in iran
, it seems that using simple and safe methods , such as massage , is appropriate action to reduce anxiety after labor and its consequences .
although providing these services and psychological support may seem difficult for the midwifery and nursing staff and broaden their duties , taking these actions and supplying sufficient human resources in hospitals seems essential to improve the mental health of mothers and to reduce the problems caused by it .
in addition , a mother s close relative or husband could be taught the procedure and asked to apply it in the hospital and during the first postpartum weeks . in this study ,
however , this screening test only reveals the anxiety of the subjects . to improve the assessment
, we recommend that in the future , study assessment be done by interviews and that maternal satisfaction with the procedure be assessed .
in addition , we recommend that maternal well - being should be evaluated during the 2-month postpartum period in future studies to determine whether the effects of the intervention are prolonged . during the postpartum period , mothers may be very anxious due to insomnia , pain , fatigue , and breast - feeding initiation problems .
although the family is close to the mother , they always care for the baby , and they really do not know how they can help improve maternal well - being .
this study showed that slow - stroke back massage is an effective , simple , inexpensive , and noninvasive intervention to reduce the anxiety level on the first postpartum day in nulliparous women .
as mobini hospital is the only obstetric and gynecologic center in sabzevar city , and all pregnant mothers are referred to this center , the results can be generalized to all sabzevarian mothers .
this study did not evaluate some interfering factors , such as satisfaction with the behavior of the hospital staff , the enjoyment level of the social protection , and other life stressors during the past year .
it is also possible that the random allocation of the mothers to two groups buffered the effects of those variables on the study outcome .
the second weak point of the study is that postpartum fatigue may be a confounder , which we could not assess , as there is no validated instrument for fatigue assessment in the postpartum period in iran .
the first strong point of the study is that the mothers cooperated fully with the study and filled out the stai correctly .
the second one is that the same researcher performed all the massage procedures on all the mothers .
during the postpartum period , mothers may be very anxious due to insomnia , pain , fatigue , and breast - feeding initiation problems .
although the family is close to the mother , they always care for the baby , and they really do not know how they can help improve maternal well - being .
this study showed that slow - stroke back massage is an effective , simple , inexpensive , and noninvasive intervention to reduce the anxiety level on the first postpartum day in nulliparous women .
as mobini hospital is the only obstetric and gynecologic center in sabzevar city , and all pregnant mothers are referred to this center , the results can be generalized to all sabzevarian mothers .
this study did not evaluate some interfering factors , such as satisfaction with the behavior of the hospital staff , the enjoyment level of the social protection , and other life stressors during the past year .
it is also possible that the random allocation of the mothers to two groups buffered the effects of those variables on the study outcome .
the second weak point of the study is that postpartum fatigue may be a confounder , which we could not assess , as there is no validated instrument for fatigue assessment in the postpartum period in iran .
the first strong point of the study is that the mothers cooperated fully with the study and filled out the stai correctly .
the second one is that the same researcher performed all the massage procedures on all the mothers .
 backgroundanxiety disorder is common during the postpartum period . back 
 massage relaxation techniques are one of the most important nonpharmacological interventions to prevent and control postpartum - related anxiety.objectivesto determine the effectiveness of slow - stroke back massage on the anxiety levels of primiparous mothers in the first days after delivery.materials and methodsthis single - blind controlled clinical trial consisted of 100 primiparous mothers with normal deliveries . 
 the mothers were randomly allocated to interventional ( n = 50 ) or control ( n = 50 ) groups using binary blocks . both groups 
 were followed up just before , immediately after , and the morning after the intervention . 
 data were collected using a demographic questionnaire and spielberger s state anxiety inventory ( stai ) questionnaire.resultsthe mean age of the mothers was 22 years . 
 there were no significant between - group differences in age ( p = 0.333 ) , education ( p = 0.427 ) , and medication during labor and the postpartum period ( p = 0.412 ) . 
 there was no statistically significant difference between the mean anxiety scores of the experimental ( 6.66  35.48 ) and control groups ( 9.05  37.42 ) before the intervention ( p = 0.268 ) . 
 immediately after the massage and the next morning , there was a significant between - group difference in the anxiety scores ( p < 0.001).conclusionsthe findings demonstrate that slow - stroke back massage is a simple , inexpensive , noninvasive , and effective method to reduce the anxiety levels of primiparous women during the first postpartum day . 
1. Background
2. Objectives
3. Materials and Methods
3.1. Instruments
3.2. STAI
3.3. Slow-Stroke Back Massage
3.4. Statistical Analysis
4. Results
5. Discussion
5.1. Conclusion
5.2. Limitations and Strengths of the Study