The effect of reflexology on lactation and postpartum comfort in caesarean-delivery primiparous mothers: a randomized controlled study

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O R I G I N A L R E S E A R C H P A P E R

The Effect of Reflexology on Lactation and Postpartum

Comfort in Caesarean-Delivery Primiparous Mothers: A

Randomized Controlled Study

Seyhan Çankaya PhD, Assistant Professor

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Gülay Ratwisch PhD, Professor

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1

Department of Midwifery, Health Sciences Faculty of Selcuk University, Konya, Turkey

2

Department of Gynecologic and Obstetrics Nursing, Florence Nightingale Nursing Faculty of Istanbul University, Istanbul, Turkey Correspondence

Seyhan Çankaya, The Midwifery Department of Health Sciences Faculty, Selcuk University, Konya, Turkey.

Email: seyhane32@gmail.com

Abstract

Aim: This study aimed to investigate the effect of reflexology on lactation and

post-partum comfort in primiparas giving births through caesarean section.

Methods: This randomized controlled trial was conducted in 100 women with first

birth through caesarean section between May 2016 and May 2017. Expectant

mothers were randomly included into an intervention and a control group. The

inter-vention group consisted of mothers in whom reflexology was performed three times

per day at every eight hours for 30 min for 3 days.

Results: The mean scores of the breastfeeding chart system and breastfeeding

satis-faction scores of the mothers in the intervention group were significantly higher than

those of the controls, and the first lactation period of the mothers in the intervention

group was shorter than that of the controls. Mean breast-tension, breast-heat, and

breast-pain scores were similar in both groups on day 1; however, a significant

increase was seen the intervention group on days 2 and 3, compared to those in the

controls. The mean scores of the Postpartum Comfort Questionnaire in the

interven-tion group were significantly better than those of the controls.

Conclusions: Reflexology starts lactation earlier in mothers giving birth via caesarean

section, supports the breastfeeding period, and increases mothers' postpartum

comfort.

K E Y W O R D S

breastfeeding, lactation, nursing, postpartum comfort, reflexology

S U M M A R Y S T A T E M E N T

What is already known about this topic?

• Immediately after caesarean birth, many women suffer from breastfeeding problems due to pain, fatigue, activity intolerance, anaesthesia, and delayed onset of lactation.

• As a result of these avoidable problems, the baby cannot get enough breast milk, and mothers' postpartum comfort decreases.

What this paper adds?

• Evidence in the study indicates that nurses can support effective breastfeeding, especially for caesarean-delivery primiparous mothers, by delivering reflexology, which may start lactation sooner and improve postpartum comfort.

The implications of this paper:

• This randomized controlled trial study provides evidence to sup-port effective breastfeeding, especially for the caesarean-delivery

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primiparous mothers, by delivering reflexology, which may start lactation sooner and improve postpartum comfort.

• This controlled trial study contributes to the knowledge base of healthcare professionals who provide care during childbirth by pro-moting the ability to offer appropriate interventions according to individual needs.

1 |

I N T R O D U C T I O N

The postpartum period is a period in which mothers experience both retrogressive and progressive changes and a series of rapid bio-psy-cho-social changes, and not only the mother but also her family can experience intense stress due to adaptation to these changes during this period. Caesarean (CS) birth brings about some physical and psy-chosocial problems and complications related to surgical interventions and anaesthesia in the postpartum period (Chen et al., 2017; Meloni et al., 2012). In previous studies, it has been reported that the most common physical problems in the early postpartum period after cae-sarean delivery are pain in the incision area, difficulty in taking care of the baby on her own, activity intolerance, fatigue, insomnia, breastfeeding problems (such as no nipple or milk), mastitis, and abdominal tension/gas. Additionally, psychosocial problems encoun-tered most frequently are irritability due to seeing the infant late, anx-iety due to not being able to maintain the maternal role at home, feeling of sadness/guiltiness because of CS delivery, insufficient maternal attachment, and the fear of body image distortion (Duran & Atan, 2011; Pınar, Dogan, Algıer, Kaya, & Çakmak, 2009; Regan, Thompson, & De Franco, 2013). Other studies also report that several factors, such as pain, fatigue, and negative effects of anaesthesia lead to late maternal attachment by affecting breastfeeding and comfort negatively after CS delivery (Capik, Özkan, & Apay, 2014; Karakaplan & Y_{ıldız, 2010).}

Reflexology, which is believed to correspond to specific somatic organs, involves the application of direct topical pressure to specific points on the hands or feet as an alternative and com-plementary therapy used for natural healing (Tabur & Basaran, 2009; Wang, Tsai, Lee, Chang, & Yang, 2008). The roots of reflex-ology date back to ancient China and India more than 5000 years ago (Tabur & Basaran, 2009). In other words, reflexology is an easy, non-pharmacological, and non-invasive procedure performed in any setting without intervening with patients' privacy. The phi-losophy of reflexology is based on the traditional Chinese meridian theory (Tabur & Basaran, 2009; Wang et al., 2008). Although reflexology lacks a comprehensive scientific basis, there are studies reporting that reflexology, as with the other forms of massages, increases relaxation and comfort, and so can rise lactation in pri-miparas (Danasu, 2015; Loganayagi, Sumathi, & Nalini, 2014). In previous studies investigating the association between breastfeeding and reflexology, breastfeeding scores of mothers exposed to reflexology were reported to be higher than those not exposed to reflexology (Danasu, 2015; Loganayagi et al., 2014).

In several studies performed in women within the postpartum period, it was emphasized that reflexology increases sleep quality while decreasing fatigue, stress, and depression, and is one of the interventions used by nurses to decrease the effects of problems in the postpartum period (Choi & Lee, 2015; Li, Chen, Li, Gau, & Huang, 2011).

Many primiparas experience some problems, such as stress, fatigue, anxiety, and difficulty in initiating lactation, due to anaesthesia and pain during the puerperium period or just after the delivery, and thus, infants cannot receive sufficient breast milk due to these pre-ventable problems. With the help of reflexology, nurses can initiate lactation early especially in primiparas with CS delivery, support effec-tive breastfeeding and maternal comfort, reduce the unnecessary use of drugs, and contribute to family budget by decreasing formula feed-ing. Through reflexology, dehydration and infectious diseases occur-ring in infants due to lack of breast milk, and sudden deaths caused by supplementary food can be prevented. It is considered that the pre-sent study contributes to the prepre-sent evidence-based information regarding reflexology and to the nursing literature in terms of protecting and developing both mothers and newborns' health status during the postpartum period.

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M E T H O D S

2.1 |

Aims

This study aimed to investigate the effects of reflexology on lactation, breastfeeding, and maternal comfort in primiparas with CS delivery.

2.2 |

Hypotheses and variables of the study

H1. In women with CS delivery in whom reflexology is performed, the Breastfeeding Charting System (LATCH) scores increase.

H2. Through reflexology, the secretion of colostrum and signs of lacta-tion take place in a shorter time in women with CS.

H3. The Postpartum Comfort Questionnaire (PPCQ) scores also increase in women with CS delivery in whom reflexology is performed.

2.2.1 |

Independent variables

Reflexology treatment given to the mothers constitutes the indepen-dent variable of the present study.

2.2.2 |

Dependent variables

LATCH as a breastfeeding measurement tool, secretion of colostrum, initial signs of lactation, and PPCQ are the dependent variables of the study.

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2.3 |

Study design

This study was designed as a single-blinded, parallel group random-ized controlled trial where the subjects were randomly assigned into intervention (foot reflexology) and control groups. This clinical trial is registered in ClinicalTrials.gov (Ref. no: NCT03686319). Reporting strictly adhered to the CONSORT extension for parallel group randomized trials (Sunay et al., 2013; The CONSORT, 2010b, accessed on 16 February 2016) and the CONSORT 2010 checklist (The CONSORT, 2010a, accessed on 4 March 2016). Those primiparous mothers who met the inclusion criteria, admitted to the clinic for a CS, and accepted to participate in the study were randomly placed into the groups. Reflexology was adminis-tered in mothers in the experimental group by the researcher and the scales were filled in by the researchers through asking the mothers.

2.4 |

Setting and participants

The study was performed among primiparas who were admitted to the maternity department of a university hospital for CS in the province of Konya, Central Anatolia in Turkey. Inclusion criteria included primiparas delivering by CS, at the age of 18 and over, at ≥37 gestational weeks, with single live birth, with stable vital signs, those delivering under general anaesthesia, with the ability of com-munication in Turkish, and those accepting to participate into the study voluntarily. Primiparas with infectious diseases such as shingles, fungus, eczema, warts, and callus in the intervention group, and those with local infections like abscess, open lesion/wound, scar tissue, oedema, hematoma, thrombophlebitis, deep vein thrombosis, coagulopathy, mass, varicosis, deformities on toes, recent fractures or dislocations, tearing of fascia and tendons, those delivering under spinal/epidural anaesthesia, and those with psychiatric disorders such as anxiety and depression were excluded out of the study.

2.5 |

Sample size calculation

Primiparas who met the inclusion criteria and were admitted to the maternity department of a university hospital for CS delivery in the province of Konya constituted the study participants. The sam-ple size, which is a total of 100 mothers - 50 in the intervention and 50 in the control groups, was calculated with a formula by taking the LATCH scores of the two groups (Yenal, Tokat, Ozan, Çeçe, & Abalın, 2013) with the help of G*power 3.1.3 program with 5% margin of error and 85% strength, effect size 0.61 (medium) and with the known mean score of 8.4 (SD = 1.77) in 1 point deviation (Capik et al., 2014; Faul, Erdfelder, Lang, & Buchner, 2007). Because the sample size calculated based on the PPCQ score was low, calculations were performed using the sam-ple size of LATCH score.

2.6 |

Randomisation

Single column groups were created between 1 and 100 by the help of the Random Integer Generator at the Numbers title of the Random.org website (Random.org. Access date: 04.03.2016). Considering the num-bers 1 and 2 in columns, the primiparas were assigned to either of 1 or 2 in order (Random.org. Access date: 04.03.2016). The assignment of the numbers (1 or 2) to the groups (study and control) was made ran-domly by tossing a coin. Number 1 was assigned to the control group and number 2 to the experimental group. Primiparas were blinded and given no information about the other group, while the lead researcher had information about both groups. The analysis of the coded data for groups was conducted only by a statistical expert in order to prevent bias and ensure confidentiality. Rooms at the clinic were for 3 or 4 peo-ple. Therefore, after the caesarean operation, a serious attention was paid to ensure that mothers in the intervention and control group were not placed in the same room in order to prevent any interaction between each other. This study was single-blinded.

2.7 |

Data collection procedures

Data were collected in 2 stages. In the first stage, sociodemographic data were collected by face-to-face pre-operation interviews with the primiparas admitted to a university hospital maternity unit for CS and who met the inclusion criteria and accepted to participate in the study. In addition, the women were assessed for their physical health conditions (foot evaluation and taking medical history) to decide if they met the study criteria. In the second stage of the research (after CS), all the mothers were visited after approximately 3 hours (to allow them to stabilize and recover from the anaesthesia). Reflexology appli-cations in the study group were started at postoperative 3 hours approximately. After CS, in all mothers, the LATCH assessment tool, lactation symptoms (VAS) questionnaire, and the exact time of first colostrum were recorded daily on days 1, 2, and 3. At the end of day 3, the PPCQ was administered.

2.8 |

Interventions

Reflexology is a massage treatment applied by hand and finger tech-niques with pressure onto the reflex points on the soles of the feet. It is an effective and harmless method used to provide free energy flow in the body (Tabur & Basaran, 2009; Wang et al., 2008). Reflexology was performed complying the standard procedures by the first inves-tigator (SC) who had a 250-hour clinical reflexology certificate.

2.8.1 |

Application steps for the intervention

group

Reflexology was performed while the mother was in half-sitting posi-tion, and the researcher holding the mother's foot in sitting position.

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The foot on which reflexology would be performed was kept at an angle of 45by placing a small pillow under the mother's knee to pre-vent tiredness. Reflexology was performed in the interpre-vention group after CS on the right foot for 10 min and left foot for 20 min in con-secutive 30-min seances, three times per day, every eight hours for three days. The procedure was started in about 3 hours after follow-ing CS after the mothers became stable.

2.8.2 |

Preparation of the mothers

A warm chamber where mothers would feel relaxed was prepared, and mothers' relatives/friends were taken out of the room in order to provide mothers' privacy. After ensuring proper foot hygiene and checking that mothers used no cream/lotion, mothers were asked to have bare feet. Reflexology was performed while the mother was in half-sitting position and the researcher was holding the mother's foot in a sitting position. The foot on which reflexology would be per-formed was kept at an angle of 45by placing a small pillow under the mother's knee to prevent fatigue.

2.8.3 |

The procedure time

Reflexology was initiated at least one hour after meals as follows:

1. After the researcher's hands were washed and rubbed to obtain the required temperature, a little Vaseline was applied onto the foot to provide lubrication.

2. First, warm-up and relaxation movements were performed on the right foot for two minutes.

3. Then, after the warm-up, reflexology was, in turn, performed on the reflex points of the brain, pituitary gland, thyroid and parathy-roid glands, diaphragm, lungs, adrenal glands, liver, chest, and upper and lower lymph nodes on the right foot for eight minutes to exterminate the negative effects of anaesthesia and exhaustion (Kunz, 2007).

4. Following the right foot, reflexology was performed on the left foot. In order to increase the mothers' comfort and lactation, which may be negatively affected by the negative effects of anaesthesia, pain, exhaustion, and symptoms of anxiety, reflexol-ogy was performed on the reflexolreflexol-ogy points on the left foot related to the brain and pituitary gland (2 min), thyroid and para-thyroid glands (2 min), lungs (2 min), chest and upper lymph nodes (2 min), lower lymph nodes (2 min), adrenal glands and liver (2 min), large and small intestines (2 min) and solar plexus (1 min), 15 minutes in total. The pressure was applied on the reflex points of the bladder, ovaries, and fallopian tubes for 5 minutes (Kunz, 2007).

While reflexology was performed, mothers were asked to declare the comfort they felt. They were recommended to drink a lot of water in the same day to excrete toxins in the body after reflexology.

2.8.4 |

Application steps for the control group

Participants in the control group did not receive foot reflexology. These two group participants received the same postpartum nursing care except for reflexology therapy. Participants of both groups received the same routine care, which included physical assessment of the women and their babies, neonatal care, and help for breastfeeding.

2.9 |

Measurements

All participants were informed verbally about the design, content, and methods to be used in the study, and the sociodemographic data were obtained via face-to-face interviews. The data were collected between May 2016 and May 2017. In collecting the data related to primiparas and infants, a questionnaire structured by the researchers considering the literature was used in addition to LATCH, VAS, and PPCQ.

2.9.1 |

The structured questionnaire

The questionnaire was developed by the researchers based on the lit-erature and included 50 items (Karakaplan & Yıldız, 2010; Loganayagi et al., 2014; Matias, Nommsen-Rivers, & Dewey, 2011; Regan et al., 2013; Zanardo et al., 2013). In the questionnaire, the first seven ques-tions investigate mothers' sociodemographic features, such as age, marital status, working status, educational level, income level, family type and social security, while other questions evaluate both mothers and infants' characteristics, such as history of pregnancy, gestational weeks, characteristics of newborns, onset of the first colostrum, rea-sons for CS delivery, breastfeeding status, success rate in breastfeeding, anaesthesia-related disorders, and other conditions where mothers need support/assistance.

The Breastfeeding Charting System (LATCH)

Adapted into Turkish by Demirhan (1997) and Yenal and Okumus (2003) based on the original system by Jensen, Wallace, and Kelsay (1995) in accordance with the Apgar scoring system (Demirhan, 1997; Jensen et al., 1995; Yenal & Okumus, 2003), LATCH is a charting system with five subgroups used to assess breastfeeding. As nurses are more likely to use subjective descriptions, such as poor, fair, and well to document and assess breastfeeding, LATCH provides a systematic method to collect information about individ-ual breastfeeding sessions. The system is scored between 0 and 5 to indicate the key components of breastfeeding. Each breastfeeding session is assessed based on the total score. A total score lower than 10 means that mothers are to be supported (Demirhan, 1997; Jensen et al., 1995; Yenal & Okumus, 2003). The letters of the acronym LATCH designate separate areas of assess-ment: “L” for how well infants latch onto the breast, “A” for the amount of audible swallowing,“T” for mothers' nipple type, “C” for

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mothers' level of comfort, and“H” for the amount of support given for infants to hold the breast.

Demirhan (1997), who developed the Turkish version of LATCH, found the following Cronbach Alpha coefficients in women with vagi-nal delivery: 0.70 for the first breastfeeding, 0.68 in the second breastfeeding, and 0.65 in the third breastfeeding. The findings of Yenal and Okumus (2003) reported 0.96 for the first breastfeeding and 0.94 for the second breastfeeding. In the present study, Cronbach Alpha coefficients of LATCH were 0.66 for all days of both groups, 0.69 for all days of the intervention group, and 0.45 for all days of the controls.

2.9.2 |

Visual Analogue Satisfaction Patient Scale

(VASPS) for Breastfeeding Satisfaction

The scale was used to determine the mother's breastfeeding satisfac-tion. The Visual Analog Patient Satisfaction Scale combines the fea-tures of two widely-used scales (Visual Analogue Pain Scale and Wong-Baker Scale) with proven features (K_{ılınçer & Zileli, 2006). The} VASPS is a new scoring system designed to measure the satisfaction degree of the patient or individual who is given medical care. It can be used to measure the degree of satisfaction of the individual with care given in an objective and practical way.

In the scale, there is a flat line with one face at each end, one is at the left end of the line representing complete dissatisfaction and the other at the right end representing the highest level of satisfaction. The mother marks a cross signs on the line corresponding to the degree of medical satisfaction. During scoring, the researcher assigns a score between 0 and 3 (0 = Not at all satisfied, 1_{–2 = A little} satis-fied, 3–4 = Satisfied, 5 = Very satisfied) by specifying this cross sign on a ruler where each 1/5 of the horizontal line is marked (Kılınçer & Zileli, 2006).

The Visual Analogue Scale (VAS) as a Sign of Onset of Lactation

VAS was used to evaluate breast changes during the onset of lactation by mothers' self-reports, as in the study performed by Mauri et al. (2015). Initial signs of lactation were assessed as breast-tension, increase in breast-heat, and breast-pain, and scored from 0 (no signs) to 10 (most powerful signs) (Mauri et al., 2015). VAS is a subjective scale used to evaluate different symptoms (pain, satisfaction, allergic symptoms, anorexia, anxiety, and lactation indications) in many stud-ies without validity and reliability analysis (Berghmans et al., 2017; Blauwhoff-Buskermolen et al., 2016; Klimek et al., 2017; Mauri et al., 2015; Tashjian et al., 2017).

The Postpartum Comfort Questionnaire (PPCQ)

Developed by Kolcaba in 1992, the General Comfort Scale (GCS) was adapted to Turkish by Kuguoglu & Karabacak, 2008. Based on the Turkish version of the GCS, the Postpartum Comfort Questionnaire (PPCQ) was developed by Karakaplan & Yıldız, 2010. Factor analyses were assigned to test the validity and reliability of the GCS. The inter-nal consistency in terms of reliability was tested, and the Cronbach's

alpha was found as 0.78. The PPCQ evaluates the physical, psychospiritual, and sociocultural comfort of mothers after CS or vagi-nal delivery. These comfort areas also constitute the subdimensions of the scale. The scale using a 5-point Likert-type scoring includes 34 items, ranging from 5 (strongly agree) as the highest level of com-fort to 1 (strongly disagree) as the lowest. Reverse coding is applied to the items with negative statements. The minimum and the maximum scores on the scale change between 34 and 170. The scores close to 170 indicate a high level of comfort (Karakaplan & Yıldız, 2010). In the present study, the Cronbach Alpha reliability coefficients for the PPCQ and for physical, psychospiritual, and sociocultural comforts were found as 0.87, 0.85, 0.51, and 0.64, respectively.

2.10 |

Statistical analysis

SPSS 20.0 for Windows (SPSS Inc., Chicago, IL, USA) was used to ana-lyse the data obtained from the study. The appropriateness of the data for normal distribution was tested with the Kolmogorov–Smirnov (K-S) normality test. As descriptive statistical values, numbers, per-centage, mean, standard deviation (SD) and median were used. While the Pearson's chi-square and the Fisher's exact tests were used in the comparison of categorical variables between groups, the Mann– Whitney U test, independent sample t-test, and Kaplan Meier test were used to compare numerical variables in the independent groups. In the comparison of numerical variables according to time, the one-factor variance (the Bonferroni test for an advanced analysis) and the Friedman analyses (the Wilcoxon signed-rank test with Bonferroni correction) tests were used. In addition, in the analysis of the data, modified intention to treat (mITT) and, for verifying purposes, inten-tion to treat (ITT) analyses were carried out. Eleven women (in control groups) who were in the study plan but whose measurement results were not obtained were not included in the ITT analysis because they were not included in any measurement processes other than the initial interview (Abraha & Montedori, 2010; Gravel, Opatrny, & Shapiro, 2007). Missing data of 7 women were completed for ITT analyses. For LATCH, breastfeeding satisfaction, and colostrum indication (first 2 measurements) scores and for the missing scores of the third mea-surement (the Postpartum Comfort Questionnaire), mean values were given for all women (intervention and control groups). ITT results (n: 55/52) and PP (per protocol) analysis results (n: 50/50) showed no statistical difference. Size effect and power analysis were calculated by G-Power 3.1. Cohen's d was calculated, and for all tests, p < 0.05 was the standard for statistical significance.

2.11 |

Ethical consideration

An approval was obtained from both the local ethical board (Registration number: 99950669/53) and the hospital (Registration number: 14567952–900). Potential participants meeting the study criteria were informed about the research purposes and benefits/risks of reflexology, and oral consent was obtained from all participants.

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The subjects were informed about the right of withdrawal from the study at any point with no effects on the care and they were ensured about their confidentiality.

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R E S U L T S

3.1 |

Sample characteristics

One hundred and eighteen women meeting the inclusion criteria were enrolled in the study. Of all the participants, 60 women were random-ized into the intervention group, and 58 into the control group. Ten mothers in the intervention group and eight in the control group were excluded out of the study due to the complication developed in the mothers and/or their infants. As a result, the study was completed with 50 mothers in the intervention group and 50 in the control group. ITT and mITT analyses were carried out in the analysis of the study. Eleven women (from the control group) who were in the study plan but whose measurement results were not obtained were not included in the ITT analysis because they were not included in any measurement processes other than the initial interview (Abraha & Montedori, 2010; Gravel et al., 2007). ITT analyses conducted for 107 mothers showed no differences in findings (Figure 1).

The mean age of the mothers was 24.33 years (SD = 4.13) (min 18-max 41 years). All mothers were married, and their educational sta-tus was primary school and lower (56%, n = 100). Of all the mothers, 97% stated that they had received antenatal care while 85% declared that they had not been informed about CS. Mothers had CS delivery due to the following medical causes: abnormalities in amniotic fluid (33%), delayed progression of birth (25%), breech birth (8%), and IVF conception (7%).

It was found that 62% of the mothers breastfed their infants within the first 30 minutes after CS.

3.2 |

The mean scores of the breastfeeding

charting system and breastfeeding satisfaction scores

of the mothers

Breastfeeding scores of the mothers in the treatment group were found to be significantly higher in the days 1, 2, and 3 in the interven-tion group compared to the control group (p < 0.001) (Table 1). When the changes of LATCH breastfeeding scores of the mothers in both groups during the first three days were assessed in each group sepa-rately, the mean breastfeeding scores on days 1, 2, and 3 were found to increase in both groups (p < 0.001). In the advanced analysis, it was seen that the difference between both groups was significant, and a significant increase was present on day 2 compared to day 1 and also on day 3, compared to days 1 and 2 (p < 0.05) (Table 1). These find-ings support the first hypothesis (H1) of the study.

Breastfeeding satisfaction mean scores of the mothers in the treatment group were found to be higher than the control group in each day (day 1 p < 0.01, days 2 and 3 p < 0.001) (Table 2). In the

Bonferroni test, it was determined that the breastfeeding satisfaction scores of the mothers in both groups increased gradually from day 1 to day 3 (all through days in pairs, there was a significant increase on day 2 compared to day 1, and on day 3 compared to both days 1 and 2). It was found that the mean breastfeeding satisfaction scores of the mothers in the intervention group was higher than those of the controls (t = 3.772, p < 0.001) (Table 2).

3.3 |

The time of onset of the first colostrum and

the symptoms of the first milk in mothers

It was observed that the mean initial breast milk time of the mothers in the intervention group (2.8 hours) was shorter than that in the con-trols (8.8 hours), and the difference between groups was significant based on the Kaplan Meier analysis (Log Rank: Mantel-Cox χ2

= 9.247, p = 0.002) (Figure 2). Based on these findings, the second hypothesis (H2) of the study was verified.

No significant differences were observed between the mean scores of breast-tension, breast-heat, and breast-pain of mothers in both groups on postpartum day 1 after CS (p > 0.05). On days 2 and 3, however, the mean scores of breast-tension, breast-heat, and breast-pain of the mothers in the intervention group were observed to be significantly higher than those of the controls (p < 0.001) (Table 3). When the changes in breast-tension, breast-heat, and breast-pain of the mothers in both groups during the first three days were compared separately in each group, a significant difference was found in both the intervention and control groups on days 1, 2, and 3 (p < 0.001) (Table 3). The signs of lactation were found to increase each day in both groups (day 1 < day 2 < day 3). When we compared days in pairs in advanced analysis, the difference between all pair in both groups was found to be significant (day 1 < day 2 < day 3) (p < 0.05) (Table 3). These findings support the second hypothesis (H2).

3.4 |

The mean scores of the postpartum comfort

questionnaire of mothers

The mothers' mean scores in the total postpartum comfort as well as in its subdomains, namely physical, psychospiritual, and socio-cultural comfort, were found to be significantly higher in the intervention group compared with those in the control group (p < 0.001) (Table 4). Mothers in the intervention group were also observed to be more comfortable and relaxed than those in the control group. These find-ings support the third hypothesis (H3) of the study.

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D I S C U S S I O N

In the present study, the first colostrum and milk secretion time of the mothers in the intervention group were shorter, and their breastfeeding satisfaction scores as well as postpartum comfort levels were higher than those of the controls.

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F I G U R E 1 CONSORT diagram. Selection of participants through each trial stage. *Perform CS operation by spinal or epidural anaesthesia. ** pregnancy below 37 weeks, multiple pregnancies, or insufficient ability to communicate in Turkish

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4.1 |

Mean scores of the breastfeeding charting

system and breastfeeding satisfaction of mothers

There are several studies reporting that, similar to other types of mas-sage, reflexology increases comfort and relaxation, and so may con-tribute to lactation in breastfeeding mothers; however, the number of randomized studies investigating the effects of reflexology on lacta-tion is limited (Danasu, 2015; Loganayagi et al., 2014). In the present study, breastfeeding scores of the mothers in the treatment group were found to be significantly higher in days 1, 2, and 3 in the inter-vention group compared to the control group, and the mothers in the intervention group were found to have higher breastfeed satisfaction scores compared to the controls. In a study investigating the effects of reflexology on breastfeeding with LATCH in 60 primiparous mothers (30 mothers in the intervention and 30 in the control groups) with vaginal delivery, 20-minute reflexology sessions were performed in mothers in the intervention group three times per day for three days, and breastfeeding scores of those who received reflexology were found to be higher and significant than those of the controls (Loganayagi et al., 2014). In another study by Danasu (2015), reflexol-ogy was implemented in 60 primipara and multipara mothers with insufficient lactation (35 with CS and 25 with vaginal delivery) once a T A B L E 2 Comparison of average scores of mothers' breastfeeding satisfaction in both groups according to ITT analysis

Breastfeeding satisfaction *

Intervention Group (_{n = 55)} Control Group (_{n = 52)}

t p

Lowest-Highest (Median) Mean (SD) Lowest-Highest (Median) Mean (SD)

1st_day ₁_{–4 (2)} _{2.5 (0.6)} ₁_{–3 (2)} _{2.1 (0.7)} _3.153 _0.002 2nd_day ₃_{–4 (4)} _{3.6 (0.5)} ₂_{–4 (3)} _{3.0 (0.6)} _5.263 _<0.001 3rd_day ₃_{–5 (4)} _{4.2 (0.6)} ₂_{–5 (3)} _{3.4 (0.6)} _7.136 _<0.001 F F: F: p 146.36 < 0.001 159.48 < 0.001 Significant difference 1 < 2 < 3 1 < 2 < 3 *

Breastfeeding satisfaction was evaluated between 1–5.

t: independent sample t-test, SD: standard deviation (For t SD = df = 105) F: variance analysis in repeated measurements (post hoc Bonferroni test)

F I G U R E 2 Timing of the onset of lactation in mothers in both groups (The Kaplan Meier Graphic)

T A B L E 1 Comparison of mothers' breastfeeding charting system scores in both groups according to ITT analysis

Characteristics of breastfeeding

Intervention Group (_{n = 55)} Control Group (_{n = 52)} Test

Lowest-Highest (Median) Mean (SD) Lowest-Highest (Median) Mean (SD) t p

LATCH 1stday 4.0–10.0 (7) 7.1 (1.5) 5.0–8.0 (6) 6.1 (0.9) t: 4.395 <0.001 LATCH 2ndday 5.0–10.0 (9) 8.6 (1.2) 5.0–10 (7) 7.2 (1.1) t: 6.405 <0.001 LATCH 3rdday 5.0–10.0 (9) 9.1 (0.9) 6.0–10 (8) 8.1 (1.2) t: 4.918 <0.001 F F: 67.87 F: 80.21 p <0.001 <0.001 Significant difference 1 < 2 < 3 1 < 2 < 3

t: independent sample t-test, SD: standard deviation (For t SD = df = 105) F: variance analysis in repeated measurements

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day for five days, and the effects of reflexology on initiating and maintaining lactation were investigated. In the study, it was reported that there was a statistically significant difference between pre-test and post-test scores in the modified breastfeeding scale, and reflexol-ogy was effective on initiating and maintaining lactation. It is thought that reflexology contributes to hormonal balance by decreasing pain and stress and achieving relaxation in postpartum mothers; therefore, it is an effective method in the initiation of lactation. The results of the present study support the hypothesis that reflexology increases the breastfeeding scores in primiparas delivered by CS and received reflexology.

4.2 |

Onset time of the first colostrum and the

symptoms of first milk in mothers

In the present study, it was observed that the mean time of initial breast milk was significantly shorter in mothers in the intervention group (2.8 hours) than that of the controls (8.8 hours). To the best of the researchers' knowledge, there is only one non-randomized study in the literature regarding the effects of reflexology on lactation. In a study involving 200 postpartum mothers (100 in the intervention and 100 in the control group) in which 10–15-min reflexology was applied on the feet in a total of 30–120 hours per person, Li (1996) assessed T A B L E 3 Comparison of signs of lactation seen on mothers' breasts in both groups according to ITT analysis

Lactation status on breasts Intervention Group (_{n = 55)} Control Group (_{n = 52)} Test

Lowest-Highest (Median) Mean (SD) Lowest-Highest Mean (SD) U p

Breast-tension 1stday 0–2 (0.0) 0.1 (0.4) 0–1 (0.0) 0.1 (0.3) 1382.0 0.553 2ndday 0–6 (2.0) 2.5 (1.4) 0–3 (0.0) 0.5 (0.8) 334.0 <0.001 3rdday 0–10 (6.0) 5.3 (2.3) 0–5 (1.0) 1.7 (1.6) 313.0 <0.001 Friedman 102.03 69.76 p <0.001 <0.001 Difference 1 < 2 < 3 1 < 2 < 3 Breast-heat 1st_day ₀_{–3 (0.0)} _{0.2 (0.5)} ₀_{–1 (0.0)} _{0.1 (0.3)} _1358.0 _0.456 2nd_day ₀_{–6 (2.0)} _{2.5 (1.4)} ₀_{–3 (0.0)} _{0.5 (0.8)} _353.5 _<0.001 3rd_day ₀_{–10 (6.0)} _{5.2 (2.3)} ₀_{–5 (1.0)} _{1.7 (1.4)} _283.0 _<0.001 Friedman 101.51 67.95 p <0.001 <0.001 Difference 1 < 2 < 3 1 < 2 < 3 Breast-pain 1stday 0–3 (0.0) 0.2 (0.5) 0–1 (0.0) 0.2 (0.4) 1422.0 0.936 2ndday 0–6 (2.0) 2.5 (1.4) 0–3 (0.5) 0.7 (0.9) 404.0 <0.001 3rdday 0–10 (6.0) 5.2 (2.3) 0–5 (1.0) 1.8 (1.5) 323.5 <0.001 Friedman 102.12 66.97 p <0.001 <0.001 Difference 1 < 2 < 3 1 < 2 < 3

U: Mann Whitney U testi, F: Friedman analizi (the Wilcoxon signed-rank test with Bonferroni correction), SD: standard deviation

T A B L E 4 Comparison of average postpartum comfort questionnaire scores in both groups according to ITT analysis

PPCQ and subdimensions

Intervention Group (n = 55) Control Group (n = 52) Test

Lowest-Highest (Median) Mean (SD) Lowest-Highest (Median) Mean (SD) _t _p

Physical comfort 47_{–70 (62)} 61.9 (4.4) 30_{–66 (47.8)} 47.5 (6.4) 13.400 <0.001

Psychospiritual comfort 46_{–50 (50)} 49.5 (1.1) 41_{–50 (49)} 48.0 (2.3) 4.110 <0.001

Sociocultural comfort 40–50 (45.3) 45.3 (2.4) 28–42 (35.7) 35.7 (3.1) 18.004 <0.001

Total score of PPCQ 139–170 (156.6) 156.6 (5.5) 107–151 (131.1) 131.2 (8.4) 18.426 <0.001 t: independent sample t-test (df = 105), SD: standard deviation

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the first lactation time and found that while lactation was initiated after 43.4 hours in the intervention group, the initial time of lactation was 66.9 hours in the controls; however, the satisfaction status of the mothers related to the rate of lactation was determined to be 98% in the intervention and 67% in the control group. Although our findings related to the first lactation time were similar to those in the study by Li, the first lactation started earlier in the mothers of the present study. In the study by Li, reflexology was performed in mothers only once a day within the first 30 hours after delivery; however, in the present study, reflexology was implemented three times a day and maximum 3 hours after the mothers was awake and aware following anaesthesia. Accordingly, such a difference between the two studies is considered to arise from the fact that reflexology was performed at an earlier time and the number of reflexology sessions applied in a day was higher in the present study.

Among the signs of lactation, the mean levels of breast-tension, breast-heat, and breast-pain of the mothers were determined to be similar in both groups on postpartum day 1; however, the mean scores of breast-tension, breast-heat, and breast-pain of the mothers in the intervention group were found to be higher than those of the controls on days 2 and 3. The signs of lactation were observed to initiate ear-lier in mothers in the intervention group on days 2 and 3, compared to those in the control group. There exist no studies investigating the effects of reflexology on lactation. It is considered that reflexology supports breastfeeding and maternal attachment by increasing the levels of breast-tension, breast-heat, and breast-pain of postpartum mothers and initiating lactation earlier. The present results support the hypothesis that, through reflexology, the secretion of colostrum and signs of lactation take place in a shorter time in primiparas with CS (H2).

4.3 |

Mean scores of the postpartum comfort

questionnaire of mothers

Another objective of the postpartum nursing procedures is to support breastfeeding and increase mothers' comfort by strengthening mater-nal attachment. Many mothers may experience pain, stress, fatigue, and anxiety during the postpartum period, and especially in mothers with CS delivery, such complications are experienced severely at a higher rate and may affect the initiation of maternal attachment nega-tively. In the present study, mothers in the intervention group were determined to be more comfortable/relaxed than those in the con-trols. Although there are various studies in the literature investigating the association between modes of delivery and postpartum comfort, there exist no studies investigating the effects of reflexology on mothers' comfort. In previous studies investigating mothers' comfort, such factors as pain, fatigue, negative effects of anaesthesia, gas spasm, and physical complaints like constipation have been reported to be experienced more by mothers with CS compared to those with vaginal delivery and to influence mothers' comfort negatively at a higher rate (Capik et al., 2014; Pınar et al., 2009). In another study performed by Derya and Pasinlioglu (2015), it was reported that

nursing care given in line with the postpartum comfort theory in mothers with CS increased the level of postpartum comfort. In previ-ous studies, it has been reported that mothers experiencing challenges caused by CS and any postpartum operation have more problems related to newborn care, and in these women maternal attachment may start later (Derya & Pasinlioglu, 2015; Eker & Yurdakul, 2008). The present findings support the hypothesis that postpartum comfort increases in women with CS delivery in whom reflexology is per-formed (H3).

4.4 |

Limitations of the study

The fact that only primiparous and CS mothers took part in the research, the study was conducted only in a Faculty of Medicine, and there was not an active scale to evaluate the time of onset of the first colostrum and the symptoms of the first milk in mothers were regarded as the limitations of this study. Another limitation of this study is that it is a single-blind randomized controlled trial. In other words, only the women included in the study were blinded to the interventions offered. The study was designed as single-blind because the researcher performed the reflexology sessions as well as data collection.

Even though the conditions of the hospital room (temperature, meals, restrooms, and the bath) were similar for all the women and they were asked not to take any herbal supplement to increase lacta-tion, other confounding factors, such as their psychological conditions or family relations (partners and in-laws, etc), were not investigated and they may have affected their comfort levels, which is another limi-tation of the study. The researcher's approached to the mothers in the intervention group early for reflexology application, and helped the mother and the baby to have a skin-to-skin contact, supported the mother for breastfeeding, placed the baby in the breast, and assisted the breastfeeding position, all of which may have caused the earlier discharge of colostrum. Different types and doses of postoper-ative analgesic drugs used in mothers after birth may have different effects on the mother's comfort and pain. In addition, the fact that the LATCH assessment was made by the researcher in both control and intervention groups in the study is another confounding factor. There-fore, all these confounding factors are the limitations of the research. Appropriate statistical tools, mITT, and ITT were conducted in data analysis, and the effect size and power analysis values were calculated.

5 |

C O N C L U S I O N

Consequently, reflexology started lactation and colostrum produc-tion in a shorter time by increasing the number of first milk symp-toms (tension, temperature increase, and pain) in mothers who had CS. In addition, reflexology application provides relief and relaxa-tion in the postpartum period and increases the postpartum com-fort of the mother. It is a simple, innovative, and effective method for the initiation and maintenance of lactation following CS

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delivery, and also for mother's breastfeeding satisfaction and post-partum comfort, all of which are within the scope of the nursing care objectives.

A C K N O W L E D G E M E N T S

This article presents a portion of the findings from Seyhan Çankaya and Gülay Ratwisch's doctoral dissertation. Istanbul University, Health Sciences Institute, Nursing Department of Women Health and Diseases, Thesis of Doctorate, Istanbul.

This study was presented as an oral presentation at 2nd

Interna-tional Congress on Nursing (ICON-2018), _Istanbul, Turkey, April 06-08, 2018.

C O N F L I C T O F I N T E R E S T

The authors declare no conflicts of interest.

A U T H O R S H I P S T A T E M E N T

SC and GR were responsible for the study design; SC were responsi-ble for data collection and analysis; and SC and GR were responsiresponsi-ble for the manuscript writing. The authors confirm that all listed authors meet the authorship criteria and that all authors are in agreement with the content of the manuscript.

F U N D I N G S O U R C E S

No specific grant was received from funding agencies in the public, commercial or non-profit sectors.

O R C I D

Seyhan Çankaya https://orcid.org/0000-0003-0433-2515

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How to cite this article: Çankaya S, Ratwisch G. The Effect of Reflexology on Lactation and Postpartum Comfort in Caesarean-Delivery Primiparous Mothers: A Randomized Controlled Study. Int J Nurs Pract. 2020;26:e12824.https:// doi.org/10.1111/ijn.12824