2nd International Conference on Applied Science and Health

Research for Better Society: Developing Science and Technology to Improve

Health and Well-being

ICASH-A051

THE EFFECT OF COMBINED MARMET AND OXYTOCIN MASSAGE

TO COLOSTRUM PRODUCTION AMONG SECTION CAESAREAN
MOTHER
Barirah1*, Eti Mulyati2, Norma Yunita2

1) Postgraduate Applied Science Program in Midwifery, Poltekes Kemenkes

Semarang, Semarang, Indonesia
2) Stikes Insan Unggul Surabaya, Surabaya, Indonesia

*Corresponding author’s E-mail : barirahmst563@gmail.com

ABSTRACT

Background: Barriers to breastfeeding occurred on postpartum mother after section caesarean due to
postoperative pain can inhibit nerve posterior pituitary gland that produces the hormone oxytocin that
plays a role in the process of lactation. Marmet technique is one safe way that can be done to stimulate
the breast to produce more milk, whilst oxytocin massage is conducted along the vertebrae to costae
fifth, sixth and an attempt to stimulate the hormones prolactin and oxytocin after delivery.
Aims: The objective of this study was to analyze the effect of marmet and oxytocin massage
combination in improving colostrum production.
Methods: The population in this study was a postpartum mother after 2 hours delivery. A total of 18
postpartum mothers were involved, divided into 9 treatments and 9 controls. Observations included
viewing data on time measurements and the amount of colostrum secreted through the breast of the
post-partum mother (instrument = syringe and spoon) and for measuring the oxytocin massage of the
researcher using the oxytocin massage guide.
Result: The average time of postpartum mothers in the intervention groups to produce colostrum after
Marmet and massage techniques combined oxytocin (treatment group) was of 5.86 hours whilst mothers
who do not receive any treatment able to produce after 5.89 hours. Statistical test results in getting P
value = 0939, p value ie p> α (0.05), indicating there is no effect of the combination of massage
techniques Marmet and oxytocin on colostrum production among post section caesarea mothers.
Conclusions: Providing education for mothers and families is needed in order to support the production
of colostrum sooner after birth.

Keywords: Technical Marmet, Massage Oxytocin, Colostrum, Sectio Caesarean mother

INTRODUCTION
Mother's breast milk is the most ideal for babies as it contains all the nutrients needed in a number and
proper consideration. Mother's milk is ideal for growth and development of children, improving health,
preventing diseases, and reducing healthcare and meal costs [1]. Colostrum is a liquid with a strong
yellowish color that comes out of the breasts in the first few hours of life which contains rich secretory
immunoglobulin A [2], which contains antibodies to protect infants from a variety of infectious
diseases, especially diarrhea [3]. Sectio caesarea is an act committed with intention to deliver the baby
through an incision in the wall of the uterus to preserve the lives of mothers and babies in case of
abnormal delivery. Delivery this way may possesses breastfeeding problem to mother and baby.

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

Mothers who undergo Sectio caesarea surgery may not produce their own breast milk within the first
24 hours - sometimes it can take up to 48 hours – postpartum. However, it is recommended that the
baby is attached to the mother's breast to help stimulate the discharge of first milk. Physiological delay
in colostrum expenditure in the mother Sectio caesarea due to the onset of postpartum pain can inhibit
the instrumental oxytocin hormone production in the process [4].
Infant Mortality Rate (IMR) is an important indicator to determine the adequacy of the provision of
colostrum in the newborn. In Indonesia, government support for exclusive breastfeeding has made
various efforts such as the National Movement for Increase Use of Mother's Milk (GNPP-ASI),
Mother's Milk Concerned Citizens Movement and Government’s Decree on Mother's Milk (PP-ASI).
However, in reality only 4% of babies are breastfed in the first hour of birth and 8% of infants receiving
exclusive breastfeeding. This is well below the government’s 80% target on exclusive breastfeeding
since the year 2000.
IDHS in 2007 reported that IMR in Indonesia is 34 per 1,000 live births. Despite the continued decline,
IMR in Indonesia is still far higher than other ASEAN member countries. For comparison, the IMR in
Singapore is 3 per 1,000 live births, in Brunei is 8 per 1,000, in Malaysia is 10 per 1,000, in Vietnam is
18 per 1,000, and in Thailand is 20 per 1,00010. With 42%, the proportion of mortality in infants aged
0-11 months is the highest because of diarrhea10. According to UNICEF, the average exclusive coverage
of the world is 38%. Based on demographic and health survey of Indonesia in 1997 and 2003, it is
known that the rate of exclusive breastfeeding dropped from 49% to 39%, while the use of infant
formula increased threefold.
Impediment in colostrum production among mothers who gave birth with sectio caesarea occur for
several reasons. In addition to the levels of the prolactin and oxytocin hormones, the pain that arises
after the withdrawal of pain-reliever drugs effect used during the sectio caesarea can cause the mother
to postpone for breastfeeding and cause delays in colostrum production. The post-operative pain that
interferes with the working mother can inhibit the posterior pituitary gland that produces the oxytocin
hormone that plays a role in the process of lactation.
RISKESDAS report in 2010 showed an increase in exclusive breastfeeding for infants aged <6 months.
The analysis showed the total number of infants aged 0-6 months who received exclusive breastfeeding
as much as 1,348,532, while as many as 1,134,952 babies were not exclusively breastfed. In East Java
province, 102,960 babies are not breastfed exclusively. WHO estimates that the number of labor by
sectio caesarea is approximately 10% to 15% of all births in the developing world, including 20% for
United Kingdom, and up to 21% for United States and Canada in 2003. Based on a preliminary study
of initial data obtained from Islamic Navy Hospital Surabaya, occurrence of sectio caesarea is as many
as 275 cases in 2014 and in the last 3 months of 2015, there were 58 cases of maternal childbirth by
sectio caesarea [5].
Interventions that can be done to help increasing production of maternal colostrum among sectio
caesarea mothers is with Marmet and oxytocin massage techniques. Marmet technique is performed
manually and helps breastfeeding milk ejection reflex. Oxytocin massaging action is conducted along
the vertebrae to fifth and sixth costae, in an attempt to stimulate the prolactin and oxytocin post-delivery.
The success of this technique depends on a combination of massage and the mother’s own breastmilk
production. This technique is effective and low-risk. The workings of oxytocin massage in influencing
expenditure of colostrum is to provide stimulus to the vertebra to costae 5-6, thereby increasing the
posterior pituitary stimulation to release the oxytocin. Subsequently, the oxytocin stimulates
contractions in myoepithelial cells for spraying breastmilk [6, 7].
This impulse is then proceed to the hypothalamus through the spinal cord. So, the hypothalamus will
reduce cost factor that inhibits the secretion of prolactin and otherwise stimulate spending factors that
trigger the secretion of prolactin. The prolactin will further stimulate the anterior pituitary and the cells
of the alveoli which function is to produce milk. Colostrum excretion on maternal sectio caesarea will
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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

be faster, so that the mother is able to give colostrum as soon as possible in the newborn. From that
sense, the researchers chose to give a combination of Marmet and massage techniques to better assess
the effectiveness of oxytocin timing and amount on maternal colostrum excretion postpartum sectio
caesarea [8].

METHODS
The research is a quasi-experimental research design with post-test only approach. This study is looking
at the variable results at the same time, with both the treatment group and the control group after
treatment is given only in the treatment group [9]. Also, this study observed the timing and amount of
excretion on maternal colostrum after the respondents were treated (posttest) with Marmet and massage
techniques oxytocin.
The variable independent in this study is Marmet and oxytocin massage techniques while the dependent
variable is the timing and amount of colostrum excretion on maternal postpartum sectio caesarea. The
population in this study were 22 postpartum women in their first 12 hours pre-production of colostrum
who underwent sectio caesarea at Islamic Hospital Surabaya in April-May 2015. Sample selection
method used in this research is consecutive sampling. The sampling inclusion criteria were postpartum
sectio caesarea mothers who have neither received the marmet techniques nor oxytocin massage
therapy; whereas the exclusion criteria is the postpartum sectio caesarea mother who already produced
colostrum, mother who underwent examination using radioactive substances, and HIV-positive mother
who has not received antiretroviral therapy. The total sample of 18 respondents were chosen based on
the inclusion and exclusion criteria. During the 47-day study, the researchers obtained a sample of nine
treatments and nine control, with the total sample size was 18 primigravida and 42 multigravida. The
sample criteria are as follows:
A. The case / treatment group, i.e. postpartum primigravida mother who was provided oxytocin massage
B. The control group, i.e. the postpartum primigravida mother who was not treated with oxytocin
massage
Data is collected using observation sheets, checklist, and Marmet and oxytocin massage guidance list.
The observed objectives include the timing and amount of colostrum excreted through the breast post-
sectio caesarea (instrument = syringe and spoon) and combination of manual Marmet and oxytocin
massage techniques. The data analysis used data normality test by using Kolmogorov-Smirnov test.
Because the data is normally distributed, the data analysis used independent t-test. If the p-value from
independent t-test is p <α (0.05), H0 will be rejected, which means that there is the effect of Marmet and
oxytocin massage combination to the time and amount of colostrum secretion in postpartum sectio
caesarea mother.

RESULTS
The results of this study are presented in the form of univariate and bivariate analysis can be seen in the
following table:

Univariate Analysis
Table 1. Frequency Distribution Spending time maternal colostrum postpartum sectio caesarea in the
treatment group and the control group
Marmet And Oxytocin massage Total
Long time Combination
expenditure
Colostrum Treatment Control
N % N % N %
4 hours 1 11.1 0 0 1 1.6
4.05 hours 0 0 1 11.1 1 1.5

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Health and Well-being

Marmet And Oxytocin massage Total

Long time Combination
expenditure
Colostrum Treatment Control
N % N % N %
5h 1 11.1 1 11,1 2 11.1
6 hours 5 55.6 2 22.2 7 38.9
6.05 hours 0 0 1 11.1 1 5.6
6.15 hours 0 0 2 22 2 2 11.1
6.35 hours 0 0 1 11.1 1 5.6
6.45 hours 1 11.1 0 0 1 5.6
7.30 hours 1 11.1 1 11,1 2 11.1
Total 9 100 9 100 18 100
Table 1 shows that the majority of the time spending on maternal colostrum postpartum sectio caesarea
(for both the treatment and control group is 6 hours with 7 (38.9%) of the total sample.
Table 2. Frequency Distribution of total expenditures maternal colostrum postpartum section
caesarean in the treatment group and the control group
Marmet And Oxytocin Total
Total
massage Combination
Colostrum
Treatment Control
issued
N % N % N %
0 cc 1 11.1 4 44.4 5 27.8
0.01cc 0 0 1 11.1 1 5, 6
0.05 cc 0 0 3 33.3 3 16.7
0.10 cc 0 0 1 11.1 1 5.6
1 cc 1 11.1 0 0 1 5.6
2cc 2 22.2 0 0 2 11.1
5 cc 2 22.2 0 0 2 11.1
10 cc 2 22.2 0 0 2 11.1
13 cc 1 11.1 0 0 1 5.6
Total 9 100 9 100 18 100
The table 2 shows that most postpartum sectio caesarea mothers who received a combination of Marmet
and oxytocin massage techniques produced the colostrum as much as 2 cc, 5 cc and 10 cc.

Table 3. Distribution effect of combination technical Marmet and oxytocin massage of time colostrum
expenditures in postpartum sectio caesarea mothers
Time required Mean SD SE P Value N
for expenditure of colostrum
Treatment 5.8611 0.91644 0.30548 9
0.939
Controls 5.899 0.90569 0.30190 9

Table 3 showed that the average time taken by the treatment group to secrete colostrum after provision
of combined Marmet and oxytocin massage techniques is 5.86 hours with a standard deviation of 0.92.
Meanwhile, the average time taken for those did not receive the combined Marmet and oxytocin
massage techniques (the control group) is 5.89 hours with a standard deviation of 0.91. Statistical test
results in p value = 0.939. As the p value is > α (0.05), the number indicates that there is no effect of
the between the combination Marmet and oxytocin massage techniques and colostrum secretion time
in postpartum sectio caesarea mothers.

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

Table 4. Distribution Effect of combination of Marmet and oxytocin massage technique and total
colostrum secreted by postpartum sectio caesarea mothers
Amount of colostrum Mean SD SE P N
Secreted by Value
postpartum sectio caesarea
Treatment 5.3333 4.63681 1.5456 9
0.009
Control 0.0289 0.03551 0.01184 9

Result showed that the mean amount of colostrum produced by the mothers who received the
combination of Marmet and oxytocin massage techniques (treatment group) is 5,333cc with a standard
deviation of 4.6368. On the other hand, the mean of those who did not receive the combined massage
techniques (the control group) is 0,0289cc with standard deviation of 0.03551. Statistical test results
obtained p value = 0.009. As p value <α (0.05), therefore H0 is rejected, indicating that there is an effect
of the combination of massage techniques to total production of colostrum in postpartum sectio
caesarea mothers.

DISCUSSION
Effect of combination techniques of Marmet and oxytocin massage and production time of colostrum in
postpartum sectio caesarea mothers
From the results of the study it was found that the average time required by the postpartum mother to
release colostrum by combining the Marmet and oxytocin massage technique (Treatment) is 5.86 hours
with the standard deviation value of 0.92; in contrast to the average length of time by those who did not
perform the combination technique (Control) of 5.89 hours with a standard deviation of 0.91. Statistical
test obtained p-value = 0.939, which means that there is no effect of combining the massage techniques
and the colostrum secretion time on postpartum sectio caesarea mothers in Islamic Hospital
Surabaya[10].
Delivery with sectio caesarea will inhibit the formation of milk production. General anesthesia
performed during sectio caesarea surgery paralyzes the central nervous system as a whole. Therefore,
women who undergo anesthetic procedures are experiencing difficulties in breastfeeding because the
nervous system will not stimulate the posterior pituitary which delays the production of prolactin
hormone. [4, 14, 15]. However, breastfeeding as often as possible after the sectio caesarean procedures
will minimize these problems.
Effect of combination techniques of Marmet and oxytocin massage and total production of colostrum
in postpartum sectio caesarea mothers
From the results, the average amount of colostrum produced by the postpartum mothers who received
the combination of Marmet and oxytocin massage techniques (treatment) is 5,333 cc with a standard
deviation value of 4.6368. On the contrary, the average amount of colostrum produced by those who
did not receive the combination techniques (control) is 0.0289 cc with a standard deviation value of
0.03551. Statistical test results obtained p value = 0.009, means that at alpha 5% there is an effect of
combining the Marmet and oxytocin massage techniques to the postpartum sectio caesarea mothers’
total production of colostrum.
Marmet technique can help lock breastmilk production reflex (let down reflex), which is effective in the
first few days of breastfeeding because of thick colostrum consistency and mature milk is produced.
Marmet technique developed a method of massage to stimulate breastfeeding reflexes. The success of
Mamet technique is attributed to the combination of massage and hormone secretion method.
Meanwhile, oxytocin massage is a way to help speed up production of breastmilk or colostrum through
massage stimulation on both sides of the spine - from the neck towards the shoulder blade bone
continued to costae under both the breast postpartum [18, 19].

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

The combined techniques of Marmet and oxytocin massage will provide stimulation to the spinal cord,
medulla oblongata neurotransmitter that send messages to the hypothalamus. Thereby, the posterior
pituitary will secrete oxytocin hormone which causes the breasts to produce milk. Massaging around
the spine area will also relieve stress and tension and facilitate the oxytocin hormone to produce milk.
Furthermore, nipple suction by the baby immediately after birth will also assist breastmilk production
[20, 21].
The production of breastmilk and breastfeeding process smoothness require stimulation on the breast
muscles to the breast glands for necessary contraction in the process of lactation. Stimulation to the
breast muscles can be done with the provision of Marmet and oxytocin massage techniques [22]. Based
on this study, it was found that all respondents produced sufficient quantity of colostrum. To increase
breastmilk production, stimulation exerts on the breast muscles by providing a combination of Marmet
and massage techniques can stimulate oxytocin reflex drainage or let down reflex [8, 23].

CONCLUSIONS
There is an effect of combining the Marmet and oxytocin massage techniques to the total colostrum
production in postpartum sectio caesarea mothers. It is therefore suggested that every health worker or
midwife who encounter cases such as lack of colostrum production should provide counseling to the
mothers on the massage techniques combination and on early provision of breastmilk to the baby.

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