1. Introduction

The postpartum period initiates right after delivery and continues until the end of 6 weeks after delivery. During this time, the mother experiences numerous biopsychological changes [2]. Fatigue and decreased energy level are among the most frequent symptoms reported by women in postpartum. Studies investigating the energy level in the postpartum period are scarce [5]. Furthermore, there is a direct relationship between fatigue and energy levels in the 6 first weeks of postpartum with gestational age and labor duration [7]. The responsibility of caring for the baby could cause fatigue and decrease energy in the mothers during the postpartum period, i.e. a predictor of postpartum depression [10]. 

Reflexology is a branch of complementary medicine and a cheap and non-invasive method [15]. The mental effects of reflexology include increased energy, wellbeing, strengthening a positive attitude, and receiving electromagnetic energy from the ground by the foot [17]. In recent years, reflexology has been popular in the promotion of health, quality of life, as well as healthcare, especially in the field of maternal and child health. This is due to the increasing interest in complementary and alternative therapies [18]. The management role and the impact of midwives in employing complementary medicine provide a positive attitude and reduce medical interventions in maternity care services [20].

2. Materials and Methods

This quasi-experimental study was performed in two groups of reflexology and control. The inclusion criteria of the study included the following: primiparous; natural childbirth; delivering a full-term and healthy baby; breastfeeding exclusively; The lack of any diagnosed acute and chronic physical and mental illnesses (diabetes, hypertension, depression, etc.); achieving a score of ≥25 (medium, low energy level) from the energy items of the Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F); referral between 10 and 15 days after delivery; the lack of using sedatives; as well as no varicose veins, pain, or injury in the lower leg. The study exclusion criteria included discontinuing participation in the study; failure to follow the massage program by the mothers for any reason for one session; as well as the occurrence of any adverse effects during the intervention, including sensitivity to the desired oil and sensitivity to touch.

The sample size was considered at a 95% confidence level and 80% test power, assuming that the effect of foot reflexology on fatigue in nulliparous women be reduced by 7 units as statistically significant. There were 32 individuals per group, i.e. estimated to be 35 subjects in each group (N=70), considering the sample dropout. A researcher-made demographic-midwifery questionnaire and the VAS-F were implemented to collect the required information. The midwifery demographic questionnaire consisted of 11 items, i.e. completed through an interview before initiating the intervention. 

The obtained data were analyzed in SPSS at P<0.05 by Independent Samples t-test, Chi-squared test, Fisher’s Exact test, and repeated-measures Analysis of Variance (ANOVA).

3. Results

According to the present research results, the reflexology and control groups were homogeneous in terms of all demographic characteristics and revealed no statistically significant difference in this regard.

Furthermore, the pairwise comparison of Bonferroni test data indicated that the mean energy level of the study participants at one week after the intervention was significantly higher than immediately after (P<0.001) and before the intervention (P=0.02); thus, the effect of the group was not significant, but the effect of time was significant in this area.

4. Discussion

The current study explored the effects of foot reflexology on the energy level of primiparous mothers experiencing natural delivery. According to the collected findings, there was no significant difference in energy score between the intervention and control groups (P>0.05). Therefore, it seems that providing a massage or touching non-reflective areas could be as effective as the results of this study (even to a small extent), and indoctrination may be influential in this regard. Accordingly, the increase in energy levels in the control group may have been due to the inductive effect of mothers with cesarean section experience, who finally participated in an intervention to enhance their energy levels.

Touch plays an essential role in individuals and stimulating skin receptors could present a soothing and positive effect on the individuals [26]. However, in the explored intervention group, increasing energy levels could reflect the effectiveness of reflexology on the energy levels of mothers with a cesarean section experience. Despite the same number of massage sessions in both studies (3 consecutive sessions) and energy assessment with the VAS-F, the results of their study were inconsistent with our achieved data [1].

5. Conclusion

The provided massage intervention was not as effective as a non-invasive, low-cost method to improve the postpartum energy level in the study participants.

Ethical Considerations

Compliance with ethical guidelines

This article ethically approved by the Vice-Chancellor for Research, School of Nursing and Midwifery, Tehran University of Medical Sciences (Code: IR.TUMS.FNM.REC.1396.4070). It was also registered in the Iranian clinical trial database (Code:IRCT20110425006284N13).

Funding

This article was extracted from the first author's Master’s degree thesis conducted in the Department of Midwifery, Faculty of Nursing and Midwifery, University of Tehran. The School of Nursing and Midwifery of Tehran University of Medical Sciences is sincerely appreciated for financially supporting this research.

Authors' contributions

Conceptualization: Shokoofeh Maleki, Maryam Modarres; Research methods and sampling: Maryam Modarres, Shokoofeh Maleki; Data analysis: Shima Haqqani, Shokoofeh Maleki; drafting and review: All authors.

Conflicts of interest

The authors declared no conflict of interest

Acknowledgements

The officials of the health centers in the south of Tehran and all the mothers participating in this study are appreciated for their sincere cooperation.

 

References

1.Bastani F, Rouhi Rahim Begloo E, Haghani H. [Effectiveness of foot reflexology on maternal post C-section fatigue: A non-randomized clinical trial (Persian)]. Evidence Based Care. 2015; 5(3):51-62. [DOI:10.22038/EBCJ.2015.4949]

2.Mardasi F, Tadayon M, Najar Sh, Haghighizadeh MH. [The effect of foot massage on sleep disorders among mothers in postpartum period (Persian)]. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2013; 16(73):19-28. [DOI:10.22038/IJOGI.2013.1950]

3.Shahid A, Shen J, Shapiro CM. Measurements of sleepiness and fatigue. Journal of Psychosomatic Research. 2010; 69(1):81-9. [DOI:10.1016/j.jpsychores.2010.04.001] [PMID]

4.Taylor J, Johnson M. How women manage fatigue after childbirth. Midwifery. 2010; 26(3):367-75. [DOI:10.1016/j.midw.2008.07.004] [PMID] [PMCID]

5.Malta LA, McDonald SW, Hegadoren KM, Weller CA, Tough SC. Influence of interpersonal violence on maternal anxiety, depression, stress and parenting morale in the early postpartum: A community based pregnancy cohort study. BMC Pregnancy and Childbirth. 2012; 12:153. [DOI:10.1186/1471-2393-12-153] [PMID] [PMCID]

6.Grant A, Ashurst H, Sleep J, McIntosh J. Ultrasound and pulsed electromagnetic energy treatment for perineal trauma. A randomized placebo‐controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology. 1989; 96(4):434-9. [DOI:10.1111/j.1471-0528.1989.tb02419.x] [PMID]

7.Troy NW, Dalgas-Pelish P. The natural evolution of postpartum fatigue among a group of primiparous women. Clinical Nursing Research. 1997; 6(2):126-39. [DOI:10.1177/105477389700600202] [PMID]

8.Parsa K. [Postpartum depression (Persian)]. Journal of Holistic Nursing and Midwifery. 1991; 1(2):10-5. http://hnmj.gums.ac.ir/article-1-1340-en.html

9.Niwayama R, Nishitani Sh, Takamura T, Shinohara K, Honda S, Miyamura T, et al. Oxytocin mediates a calming effect on postpartum mood in primiparous mothers. Breastfeeding Medicine. 2017; 12(2):103-9. [DOI:10.1089/bfm.2016.0052] [PMID]

10.Cheng CY, Pickler RH. Perinatal stress, fatigue, depressive symptoms, and immune modulation in late pregnancy and one month postpartum. The Scientific World Journal. 2014; 2014:652630. [DOI:10.1155/2014/652630] [PMID] [PMCID]

11.Field T, Diego M, Hernandez-Reif M. Prenatal depression effects on the fetus and newborn: A review. Infant Behavior and Development. 2006; 29(3):445-55. [DOI:10.1016/j.infbeh.2006.03.003] [PMID]

12.Lee KA, Zaffke ME. Longitudinal changes in fatigue and energy during pregnancy and the postpartum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 1999; 28(2):183-91. [DOI:10.1111/j.1552-6909.1999.tb01983.x] [PMID]

13.Warren C, Mwangi A, Oweya E, Kamunya R, Koskei N. Safeguarding maternal and newborn health: Improving the quality of postnatal care in Kenya. International Journal for Quality in Health Care. 2010; 22(1):24-30. [DOI:10.1093/intqhc/mzp050] [PMID]

14.Conrad P, Adams C. The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman - a pilot study. Complementary Therapies in Clinical Practice. 2012; 18(3):164-8. [DOI:10.1016/j.ctcp.2012.05.002] [PMID]

15.Abdollahi Fard S, Dolatian M, Heshmat R, Alavi Majd H. [Effect of foot reflexology on physical and psychological symptoms of premenstrual syndrome (Persian)]. Pajoohandeh. 2013; 18(1):8-15. http://pajoohande.sbmu.ac.ir/article-1-1490-en.html

16.Cressy S. Reflexology. Oxford: Heinemann; 2003. https://books.google.com/books?id=-qjBakp1BBUC&dq

17.Burns E, Zobbi V, Panzeri D, Oskrochi R, Regalia A. Aromatherapy in childbirth: A pilot randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology. 2007; 114(7):838-44. [DOI:10.1111/j.1471-0528.2007.01381.x] [PMID]

18.Lee J, Han M, Chung Y, Kim J, Choi J. Effects of foot reflexology on fatigue, sleep and pain: A systematic review and meta-analysis. Journal of Korean Academy of Nursing. 2011; 41(6):821-33. [DOI:10.4040/jkan.2011.41.6.821] [PMID]

19.Mollart L. Women, midwives and reflexology: Making a difference. Women and Birth. 2015; 28(Suppl 1):S50. [DOI:10.1016/j.wombi.2015.07.159]

20.Hall HG, McKenna LG, Griffiths DL. Midwives’ support for complementary and alternative medicine: A literature review. Women and Birth. 2012; 25(1):4-12. [DOI:10.1016/j.wombi.2010.12.005] [PMID]

21.Talebi F. [Investigating comparising of pain, fatigue and satisfaction in physiological birth and normal vaginal delivery in Shahid Akbarabady Educational Hospital 2011 (Persian)] [MSc. thesis]. Tehran: Tehran University of Medical Sciences; 2011. http://fnm.tums.ac.ir/userfiles/Dessertation/Fa/Talebi.pdf

22.Troy NW, Dalgas-Pelish P. The effectiveness of a self-care intervention for the management of postpartum fatigue. Applied Nursing Research. 2003; 16(1):38-45. [DOI:10.1053/apnr.2003.50001] [PMID]

23.Elaheh R. Effect of reflexology on the severity of fatigue and anxiety of cesarean section mothers with vulnerable infants. Tehran: Medical University Tehran; 2013.

24.Oh SY, Lim NY. The effects of self-administered hand reflexology on fatigue in student nurses in clinical practice. Journal of Korean Academy of Fundamentals of Nursing. 2004; 11(3):256-64. https://j.kafn.or.kr/journal/view.php?year=2004&vol=11&spage=256

25.Monzillo E, Gronowicz G. New insights on therapeutic touch: a discussion of experimental methodology and design that resulted in significant effects on normal human cells and osteosarcoma. Explore. 2011; 7(1):44-51. [DOI:10.1016/j.explore.2010.10.001] [PMID]

26.Gallace A, Spence C. The science of interpersonal touch: An overview. Neuroscience & Biobehavioral Reviews. 2010; 34(2):246-59. [DOI:10.1016/j.neubiorev.2008.10.004] [PMID]