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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) MastersProgram in Public Health, Universitas Sebelas Maret
2)Department of Pediatrics, Dr. Moewardi Hospital, Surakarta
3)Faculty of Medicine, Universitas Sebelas Maret


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=
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

Ainurrizma Tri Hartanti, Public Health Postgraduate Program, Universitas Sebelas Maret. Jl. Ir.
Sutami 36 A, Surakarta 57126, Central Java. Email: Mobile:

BACKGROUND 2016). Baby sleep quality not only affects

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

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gulation of the endocrine system (Permata, non-pharmacological therapies to overcome

2017). the problem of infant sleep is baby massage
A study by Martini (2014) stated that (Hikmah, 2010). One form of stimulation
51.3% of babies experiences sleep disturb- that can be given is massage stimulation.
ances, 42% sleep times less than 9 hours a Baby massage is one of the efforts made by
night, wake up more than three times a parents as part of fulfilling children's basic
night and wake up at night more than one needs. By doing massage stimulation it is
hour. hoped that it can improve the quality of life
Besides sleeping problems, babies so that optimal child growth is achieved
also still need an adaptation process to the and can strengthen the bonding between
extrauterine environment. One way to parents and children as an expression of
strengthen the adaptation process of new- love through touch. Parents are expected to
born babies is to strengthen bonding at- be able to carry out massage activities for
tachments. Bonding attachment through children at home so that they can support
maternal love is a unique connection that the program of Healthy Indonesia efforts by
develops between mother and baby and be- promoting promotive and preventive efforts
comes permanent over time. Attachments with community empowerment (Ministry of
between mother and baby can start from Health, 2017).
the time of pregnancy, childbirth, and post- Baby massage was a useful tool to
partum period. The loving attachment of improve maternal skills in interacting with
mother to baby is one of the most impor- infants (Gnazzo et al., 2015). The definition
tant factors in the development and growth of massage intervention is a manual ap-
of healthy children (Çinar and Öztürk, plication mainly by the mother's hands of
2014). certain techniques in structures located
Mothers should get sufficient know- within the soft tissues of the skin, fascia,
ledge about the importance of bonding at- muscles, ligaments, blood vessels, and ten-
tachments between mothers and babies so dons (Zhang and Wang, 2019). Baby mas-
that the needs of these bonding attach- sage is a relatively easy intervention that
ments are fulfilled for infant growth and de- has a positive effect on babies and their pa-
velopment (Ethicasari, 2012). rents. Neonatal nurses who get baby mas-
The achievement of optimal growth sage training can teach parents the techni-
and development results required stimu- que of doing baby massage as a way to build
lation and development of child develop- bonds between parents and their babies
ment in a comprehensive and quality man- and parents can participate in their baby's
ner carried out during the critical period, care (Pados and McGlothen-Bell, 2019).
which was since the womb until the age of 2 Soft touch on the baby is a beautiful
years old. This stimulation activity was car- means of bonding between the baby and
ried out as early as possible from the womb parents (Roesli, 2016). Many experts who
until the age of 2 years old as proclaimed by have proven that baby massage done by
the Government of Indonesia through the parents (especially mothers) can provide
"First Thousand Days of Life" program many benefits such as weight and length,
(Ministry of Health, 2017). sleep better, elimination and reduction in
Currently, various therapies have colic, better physiological and behavioral
been developed, both pharmacological and responses (Dalili et al., 2016; Wahyuni et
non-pharmacological therapies. One of the al., 2018).

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Hartanti et al./ Effectiveness of Infant Massage on Strengthening Bonding and

Massage has a positive effect on mo- 4. Operational Definition of Variables

ther-baby interactions, improves the quality Baby massage was a massage performed by
of baby's sleep, reduces baby's crying, lo- mothers who have been given baby massage
wers bilirubin levels, increases the frequ- training twice for 15 minutes every day,
ency of defecation in the neonate, encou- mentoring by enumerators for the first 5-7
rages interactions between mother and days, which is then carried out indepen-
baby, decreases their crying, and increases dently by the mother for 30 days.
mother-baby interaction(Gürol and Polat, Bonding attachment was a relation-
2012; Serrano et al., 2010;Chen et al., 2011; ship of affection and attachment between
Lin et al., 2015). parents and their babies.
Baby massage can also increase the The quality of a baby's sleep was a
development of high-risk postnatal babies, certain physiological condition that is ob-
such as premature newborns or children tained during a baby's sleep to restore body
who are exposed to HIV, increasing physi- processes that occur when the baby wakes
cal growth and digestive function in prema- up. Rated for 30 consecutive days..
ture babies. Baby massage can also increase 5. Study instrument
the production of breast milk, can develop Bonding attachment was collected by Ma-
communication, and understand baby cues ternal Attachment Inventory (MAI) check-
(Sari et al., 2013; Porreca et al., 2017; Choi list. The quality of a baby's sleep was collec-
et al., 2015). ted by Brief Infant Sleep Questionnaire
(BISQ) questionnaire. Other data was col-
SUBJECTS AND METHOD lected using a set of questionnaire.
1. Study Design 6. Data Analysis
This was an experimental study with a Ran- Univariate analysis to describe the charac-
domized Controlled Trial (RCT) design con- teristics of each variable based on the re-
ducted in five health centers in Ponorogo sults of the study. Bivariate analyses to
Regency, East Java in March to April 2019. determine the differrences before and after
2. Population and Sample the baby massage treatment using the
The populations of this study were all mo- Mann-Whitney test.
thers and infants aged 3 to 6 months in five 7. Research Ethics
health centers in Ponorogo District, East Research ethics in this study include
Java. The Puskesmas were North Ponorogo, approval sheets, anonymity, confidentiality,
South Ponorogo, Babadan, Sukorejo, and and ethical feasibility. Ethical feasibility in
Kunti Health Center. A sample of 120 this study came from the Health Research
mothers and infants divided into 2 groups, Ethics Committee of Dr. Hospital. Moe-
namely 60 infants in the control group and wardi Surakarta with the number: 318/ III
60 infants in the treatment group was / HREC / 2019.
selected by simple random sampling.
3. Study Variables RESULTS
The independent variable in this study was 1. Univariate Analysis
infant massage. The dependent variables The results of univariate analysis in this
were bonding attachment and quality of study were conducted to determine the cha-
infant sleep. racteristics of each study variable which in-
cluded the age of the baby, age of the mo-
ther, bonding attachment, infant sleep du-

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ration, number of awakenings, and dura- non massage group, before and after
tion of waking between massage groups and 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 before and after the baby massage treat-
results showed a significant difference in ment. Baby massage effectively increased
the attachment bonding score in the mas- bonding attachments between mother and
sage group and non massage between baby (p<0.001; d= 3.56).

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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 massage between before and after the baby
results showed that there were significant massage treatment. Baby massage effective-
differences in the duration of the baby's ly increased the duration of baby's sleep
night sleep in the massage group and non (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 between before and after the treatment of
results showed that there were significant infant massage. Baby massage was effective
differences in the number of babies waking in reducing the number of baby awakenings
up in the massage group and non massage (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 DISCUSSION

results showed significant differences in the 1. The Effect of Baby Massage on
duration of awakening in the massage Bonding Attachment
group and non massage between before and The results of this study showed that there
after the baby massage treatment. Baby were significant differences in bonding at-
massage effectively decreased the duration tachment scores in the massage group and
of baby awakenings (p= 0.001; d= -0.80). non massage group between before and af-
ter the baby massage treatment and showed
that infant massage was effective to in-

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crease bonding attachments between mo- have with babies. Touch on baby means
thers and infants (d= 3.56; p<0.001). talking. Baby massage combined aspects of
Engagement was a close and intimate closeness, namely eye contact, smiling, and
relationship with people such as mothers, other facial expressions. Regular baby mas-
fathers, siblings, spouses, children and clo- sage twice a day can help parents to un-
se friends. Parental attachment was defined derstand the baby's wishes through the sign
as a series of inner behaviors that would language provided. Baby massage was one
make babies develop intimate relationships approach that made an important contri-
with their primary caregivers (Salehi et al., bution to the psychological and phsiological
2019). welfare of infants and mothers and helped
Interaction between mother and baby to form harmonious relationships (Vicente
was the first intrapersonal interaction of et al., 2017).
the baby and plays an important role in This study was in accordance with the
building trust. This has a major influence study of Lindensmith (2018) which showed
on infant language development, emotional the results that infant massage was effective
regulation, and cognitive development. Me- in improving the relationship between mo-
anwhile, children whose mothers regularly ther and baby in mothers who experience
engage in quality interactions with them post-partum anesthesia. Baby massage can
tend to show a high index of mental deve- increase attachment through a baby's to-
lopment at 2 years of age (Chung et al., uch. Maternal attitude to the baby, mater-
2018). The quality of the initial dyadic inte- nal sensitivity, and infant's response to the
raction between the primary caregiver and mother showed an increased score after a
the baby was very important for the social baby massage intervention. Oxytocin is a
and emotional, cognitive, language and bra- hormone that plays a key role in maternal
in development of the child (Parfitt et al., behavior, which can therefore have an
2013). A responsive attitude on the part of impact on mother-baby interacttions. Mas-
mothers played an important role in deve- sages given to the neonate by the mother
loping strong and effective attachments bet- every day can increase and maintain the
ween mother and baby (Lai et al., 2016). emotional bond between mother and baby
Quality interaction behavior between (Shoghi et al., 2018).
mother and baby can facilitate the baby's Mothers who did baby massage repor-
social-emotional, behavioral and cognitive ted that they were able to adapt better and
development which then occurred and was have a greater level of confidence in caring
even related to the child's physical health. for their babies (Vicente et al., 2017). Other
Babies need reciprocal interaction with pa- studies have found that mothers who mas-
rents to become interested in social interac- sage their babies have a faster decline in
tion and develop secure attachment rela- symptoms of depression and lower stress
tionships in older age. Based on the quality (Holditch-Davis et al., 2013).
of interactions between parents and babies, Another study conducted in Turkey by
they would form an attachment style during Gürol and Polat (2012) stated that baby
the first year of life. The baby attachment massage increased the attachment between
model directed children's behavior in social mother and baby. Massage can increase
relations in the future (Korja et al., 2012) maternal care for babies, which in turn can
Prasetyono (2013) stated thattouch is increase positive interactions between mo-
the first form of communication parents ther and baby. Baby massage made inter-

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Hartanti et al./ Effectiveness of Infant Massage on Strengthening Bonding and

action between mother and baby more melatonin levels after 2 weeks of massage.
active so that it can build emotional bonds Melatonin levels have an inverse relation-
between mother and baby (Lee, 2017). Mas- ship with eye movements. This showed that
sage the baby positively influenced the mo- babies who were massaged would experien-
ther's mood. It showed that baby massage ce more restful/restorative sleep (Field,
can increase the interaction between mo- 2018).
ther and baby for mothers with postpartum Baby massage also enhanced the adj-
depression (Cooke, 2015). ustment of the circadian rhythm in infant
2. The Effect of Baby Massage on sleep to the nocturnal period of term in-
Quality of Sleep fants (Field, 2017). Baby massage can redu-
In this study, there were significant differ- ce baby crying (Serrano et al., 2010)
rences in the duration of sleep of infants in Study of Bennett (2013) mentioned
the massage group and non massage bet- that babies did not wake up significantly in
ween before and after treatment (d = 2.79; the massage group rather than the non-
p <0.001). massage group after intervention. The du-
The results of this study showed a ration of infant night awakening was far
significant difference in the number of less in the massage group compared to the
infants in the massage and non-massage non-massage group. The non-massage
groups between before and after the baby group had an average duration of waking at
massage treatment (d = -2.78, p <0.001) night by 16 minutes longer after the inter-
The results of this study showed a sig- vention than the massage group.
nificant difference in the duration of wa- Kulkarni et al. (2010) reported that
king in the massage group and non-mas- infants born with gestational age less than
sage group between before and after the 36 weeks with birth weight <2.5 kg received
baby massage treatment (d= -0.80; p= massage until the age of 8 months old
0.001). experienced improvement in sleep quality
This study was in line with the study and a reduced number of awakenings. Ba-
of Kusumastuti et al., (2016) based on bies were more active during the day and
Mann Whitney Test different tests on sleep make babies sleep faster. Baby massage
quality showed that p <0.001, it showed done for two weeks showed that sleep time
that babies who got massage have better became easier and babies experienced fe-
sleep quality than babies who did not get wer waking nights (Mindell et al., 2018).
massage. Study done by Field (2017) reported that
Sleep disorders was one of the most infants in the massage group had more
difficult problems for parents and babies regular sleep cycles than infants in the non
during the first months of life. Study from massage group.
Israel documented an increase in sleep and
AUTHOR CONTRIBUTION This study used the authors’ own fund.
Ainurrizma Tri Hartanti, the main author,
has role in collecting and processing the CONFLICT OF INTEREST
data. Harsono Salimo examined the frame- The authors do not have any conflict of
work of study concepts and methodologies. interest.
Vitri Widyaningsih reviewed study manus-

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Indonesian Journal of Medicine (2019), 4(2): 165-175

ACKNOWLEDGEMENT British journal of midwifery. 23(3):

The authors would like to thank the Health 166–170.
Center for assisting the authors and also jom.2015.23.3.166
study participants. Dalili H, Sheikhi S, Shariat M, Haghnaza-
rian E (2016). Effects of baby massage
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