JRSSEM 2022, Vol. 01, No. 9, 1280 – 1292

E-ISSN: 2807 - 6311, P-ISSN: 2807 - 6494

DOI : 10.36418/jrssem.v1i9.118 https://jrssem.publikasiindonesia.id/index.php/jrssem/index

EFFECT OF RELAXATION THERAPY ON ANXIETY LEVEL

AND BREAST MILK PRODUCTION IN PREGNANT AND

POSTPARTUM MOTHERS: Systematic Literature

Review

Mutiara Ayu Muthiatulsalimah

Rr Sri Endang Pujiastuti

Aris Santjaka

Runjati

1,2,3,4

Master of Applied Midwifery Health Polytechnic, Ministry of Health, Semarang

e-mail: mutiattul@gmail.com

, rarastut[email protected]

, arissantjaka@gmail.com

runjati@yahoo.com

*Correspondence: mutiattul@gmail.com

Submitted: 28 March 2022, Revised: 04 April 2022, Accepted: 15 April 2022

Abstract. Anxiety in pregnant and postpartum women can affect the condition of the mother and

baby. Psychological stress can influence the hypothalamus and pituitary gland to secrete

Adrenocorticotropic Hormone to produce cortisol. The amount of cortisol is high, resulting in

inhibited milk production. Relaxation therapy is able to stimulate the milk ejection reflex more

efficiently than standard practice in health care facilities which only focus on optimizing body

functions, without involving the mind and soul. This review conducted a systematic review to

evaluate the effect of interventions using Relaxation Therapy in increasing breast milk production.

A literature search was conducted using the PRISMA guidelines including studies of relaxation

therapy interventions during the pregnancy and postpartum period. Using a literature keyword

search strategy, 718 studies related to relaxation therapy in pregnant and postpartum women were

found and 25 studies were eligible for inclusion in the analysis. A total of 10 studies on anxiety in

pregnant women, 5 studies on anxiety in postpartum mothers, 3 studies on cortisol hormone levels,

5 studies on breast milk production and 2 studies on prolactin hormone levels. These studies were

conducted in Malaysia, France, England, Greece, Korea, Turkey, America, Taiwan, Iran, Indonesia,

Spain, Denmark and India. The samples analyzed were 1,608 pregnant women and 1227

postpartum women. Based on the results of a review, Relaxation Therapy in the form of

Hypnobreastfeeding and Music Therapy is effective in stimulating the production of breast milk

and prolactin hormones in postpartum mothers. Hypnosis, Music Therapy and Benson's relaxation

technique were associated with a significant reduction in anxiety levels as indicated by an increase

in PSS scores and a decrease in salivary cortisol.

Keywords: anxiety; cortisol hormone; milk production; prolactin hormone; relaxation therapy.

Mutiara Ayu Muthiatulsalimah, Rr Sri Endang Pujiastuti, Aris Santjaka, Runjati
 
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DOI : 10.36418/jrssem.v1i9.118      https://jrssem.publikasiindonesia.id/index.php/jrssem/index 
INTRODUCTION 
 
Pregnancy is the most important period 
in the human life cycle. During pregnancy, 
there is often a decrease in well-being, an 
increase  in  anxiety  and  stress.  During 
pregnancy, mothers experience significant 
changes  in  their  physiological  and 
psychological  functions.  The  process  of 
adjusting to this new situation then causes 
anxiety.  Anxiety  in  pregnancy  is  an 
emotional reaction that occurs in pregnant 
women related to the mother's concern for 
the  welfare  of  herself  and  her  fetus  (Li, 
Newell-Price,  Jones,  Ledger,  &  Li,  2012); 
(Kestler-Peleg,  Shamir-Dardikman, 
Hermoni,  &  Ginzburg,  2015);  (Duijts, 
Jaddoe, Hofman, & Moll, 2010). 
Research on  factors related  to  anxiety 
levels before delivery, from 64 respondents 
obtained  10.9%  experienced mild anxiety, 
70.3% moderate anxiety, and 18.8% severe 
anxiety.  This  is  caused  by  hormonal 
changes  that  also  cause  the  mother's 
emotions to become unstable (LetiniĿ et al., 
2016);  (Loke  &  Chan,  2013).  Excessive 
anxiety causes levels of stress hormones to 
increase  (beta-endorphin, 
Adrenocorticotropic Hormone, cortisol and 
epinephrine)  (Cai,  Wardlaw,  &  Brown, 
2012); (General, 2017). When the amount of 
stress hormone increases, the blood vessels 
in  the  body  will  constrict.  This  reduces 
blood flow and oxygen supply to the fetus 
and disrupts its growth and  development 
(Ho,  2013).  Pregnant  women  with  high 
levels  of  anxiety  are  strong  predictors  of 
postpartum  depression,  these  conditions 
affect the breastfeeding process so that it 
can affect milk production (Ali et al., 2020). 
Research  in  the  city  of  Palembang 
showed  that  32%  of  mothers  stopped 
breastfeeding because they complained of 
insufficient  milk  (Lazard,  Scheinfeld, 
Bernhardt, Wilcox, & Suran, 2015). Another 
study in Australia showed that 556 mothers 
gave  birth,  29%  stopped  breastfeeding 
their  babies  in  the  second  week  on  the 
grounds  that  their  breast  milk  was 
insufficient  (Fotiou,  Siahanidou, 
Vlastarakos,  Tavoulari,  &  Chrousos,  2018). 
The rate of desire to breastfeed in various 
countries is now far higher than the rate of 
starting  breastfeeding.  Reports  in  Canada 
stated that during pregnancy about 80% of 
mothers who intend to breastfeed there are 
only  30%  who  breastfeed  for  at  least  6 
months.  Feeling  tired  after  giving  birth 
causes  mothers  to  be  lazy  to  breastfeed 
their babies, besides that milk production is 
not  smooth  causing  mothers  not  to  give 
breast milk  to their babies, this is  what is 
called  lactation  failure  (Meedya,  Fahy,  & 
Kable, 2010); (Legrand et al., 2017). 
The  psychological  condition  of  the 
mother  affects  the  success  of  lactation. 
Mothers  who  have  symptoms  of 
depression  tend  to  have  low  self-
confidence  in  breastfeeding  and  have 
difficulty regarding the position of the baby 
while  breastfeeding  (Tragea,  Chrousos, 
Alexopoulos, & Darviri, 2014); (Downe et al., 
2015).  Some  studies  have  reported  that 
emotional stress on the mother inhibits the 
let-down reflex which causes disruption of 
milk flow which results in a decrease in milk 
volume  so  that  it  affect  the  duration  of 
breastfeeding.  Psychological,  social  and 
spiritual stress can affect the hypothalamus 
and  pituitary  gland  to  excrete 
Adrenocorticotropic  Hormone  (AC-TH). 
This can affect the hormone adrenaline (a 

1282 | Effect of Relaxation Therapy on Anxiety Level and Breast Milk Production in Pregnant

and Postpartum Mothers: Systematic Literature Review

hormone that affects stress) and produce

cortisol. When the amount of cortisol is

high, then milk production will be inhibited.

Therefore, a relaxation therapy is needed as

an effort to reduce the hormone cortisol

and reflect let-down in the mother (Shin &

Kim, 2011); (Bauer, Victorson, Rosenbloom,

Barocas, & Silver, 2010); (Newby, Lang,

Werner-Seidler, Holmes, & Moulds, 2014).

The intervention that has been

developed by many researchers to reduce

anxiety and increase milk production is by

using relaxation therapy. Relaxation

techniques are natural healing techniques

and are part of a holistic self-care strategy

to deal with complaints such as fatigue,

pain, sleep disturbances, stress and anxiety.

Physiologically, relaxation will stimulate the

parasympathetic nervous system so as to

increase the production of endorphins,

reduce heart rate, increase lung expansion

so that it can develop optimally and

muscles become relaxed. Relaxation

therapy is able to stimulate the milk

ejection reflex which is more efficient than

standard practice in health care facilities

such as breastcare which only focuses on

optimizing body functions, without

involving the mind and soul which also

affects milk production and breastfeeding

success. The application of holistic health

sciences must pay attention to the

psychoneuro-endocrino-immuno (PNE-I)

aspect because the imbalance between the

mind and the soul causes disturbances in

the balance between the nervous,

hormonal and immune systems. Therefore,

the application of relaxation therapy that

involves the soul and mind to increase milk

production and breastfeeding success is

very much needed.

The results showed that relaxation

exercises were effective in reducing the

anxiety of primigravida pregnant women

undergoing IVF. The results of other studies

also showed that relaxation during

breastfeeding affects the mother's

psychological condition and increases milk

production. The results of a systematic

review of 5 studies that examined

relaxation therapy on breast milk

production it was found that Relaxation

therapy has been shown to increase milk

production in mothers with babies

premature.

Based on the description above, a

review will be conducted on the effect of

Relaxation Therapy on anxiety levels and

milk production in pregnant and

postpartum women.

METHODS

The research design used the

Systematic Literature Review method by

collecting and analyzing 25 journals from

various database sources such as; PubMed,

Science Direct, and Google Scholar. This

literature search was determined within the

last ten years, from 2010 to 2020.

RESULTS AND DISCUSSION

A. Study Quality and Risk of Bias

Based on the overall study that is

summarized, it shows the results of data

analysis and significant testing

regarding the given intervention. A

total of 7 studies were rated as low risk

of bias, the studies applied the same

eligibility criteria to select all study

subjects, all potential subjects

Mutiara Ayu Muthiatulsalimah, Rr Sri Endang Pujiastuti, Aris Santjaka, Runjati

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underwent the same diagnostic

procedures and had the same chance of

detecting and reporting cases,

exposure history, including the time

and reason for the change in exposure

status diagnosed. without the influence

of knowledge of exposure status

(blind).

Assessment of study bias set out in

a systematic review is at risk of selection

bias because most of the determinants

of the large sample are non-probability

techniques, so there is a lack of random

selection procedures on research

samples. Studies using a pre-

experimental design are also at risk for

bias, because the study was conducted

in only one group and the results were

observed before and after the

intervention. The high risk of bias can

also be caused by several other factors

that contribute to the psychology of

each individual that triggers anxiety

that causes milk production to be not

smooth.

B. Analysis of Relaxation Therapy

Results on Anxiety Levels for

Pregnant Women

The results of the analysis of the

level of anxiety in pregnant women are

presented based on parameters,

namely seen through the State-Trait

Anxiety Inventory (STAI) score,

Depression Anxiety and Stress Scale

(DASS),Pregnancy Stress Rating Scale

(PSRS), Spielberger's Anxiety Scale,

Wijma Delivery Expectancy / Experience

Questionnaire B (W-DEQ).

Six studies used STAI to measure

anxiety levels in pregnant women. All

studies show a significant reduction in

anxiety levels. Studies that provide

hypnosis interventions show a decrease

in Anxiety to its minimum value of 20

(mild anxiety), right in the middle of a

hypnotic cycle. With p value = 0.05.

Studies that provide Relaxation

Breathing and Progressive Muscle

Relaxation interventions show the

results of the A-state median value of

the Intervention group 38.0 (mild

anxiety), the control group 40.0

(moderate anxiety), the median A-trait

value of the intervention group 37.0

(mild anxiety) control group 36.0 (mild

anxiety). Studies that provided self-

hypnosis showed results. The

intervention group's level of fear and

anxiety was lower than the control

group P = 0.001. The mean value of the

intervention group was 10.1 (normal),

the control group was 10, 5 (normal).

Two studies that provided Music

Therapy intervention showed results.

The intervention group showed a

significant reduction in anxiety

compared to the control group. The

pretest score of the intervention group

was 43.72 (moderate anxiety), posttest

42.79 (moderate anxiety), pretest

control group 43.23 (moderate anxiety),

posttest 43.87 (moderate anxiety).The

anxiety score of the music therapy

group, decreased by 5 points from 39.6

(moderate anxiety) to 34.1 (mild

anxiety) p = 0.01. And the recreational

therapy group score also decreased 5

points from 36.5 (mild anxiety) to 31.4

(mild anxiety) p = 0.04 The control

group decreased by 2 points from 35.6

(mild anxiety) to 33.2 (mild anxiety),

statistically (p > 0.05). The study that

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and Postpartum Mothers: Systematic Literature Review

provided Benson's relaxation technique

showed that the intervention group's

State Anxiety Score was 21,9 (mild

anxiety), control group 25 (mild

anxiety), Trait score 19.5 (normal),

control group 25.9 (mild anxiety).

Relaxation training is effective in

reducing anxiety in pregnant women

P=0.001.

One study using Depression Anxiety

and Stress Scale (DASS) to measure

anxiety levels. Studies that administered

hypnosis showed that the mean scores

of stress and anxiety were found to

remain within normal parameters

during the hypnosis session. Before the

intervention the average score of

anxiety was 2 (normal), the first

intervention average score remained 2

(normal), the second and third

interventions the average score

increased to 8 (normal). Although the

patients' stress scores improved slightly

during the second and third hypnosis

sessions they remained within normal

parameters.

Two studies used the Wijma

Delivery Expectancy/Experience

Questionnaire A (W-DEQ) to measure

levels of fear. The study that provided

the intervention in the form of

hypnobirthing showed the

experimental group's mean score of

16.47 (normal) was significantly lower

than the control group's 95.47 (severe

fear). Hypnobirthing was able to reduce

the fear of pregnant women during

delivery P = 0.000. Studies that

provided intervention in the form of EFT

In the EFT group the Wijma Delivery

Expectancy / Experience Questionnaire

score (version B) had a significant

difference from the control group (p <

0.001). EFT has the effect of reducing

maternal fear before delivery.

One study using Pregnancy Stress

Rating Scale (PSRS) to measure the level

of anxiety. Studies that provide music

therapy have a difference between pre-

test and post-test PSRS scores,

respectively, for the experimental group

Pre=53.7 (mild anxiety) Post=54.02

(mild anxiety) and the control group

Pre=49, 92 (mild anxiety) Post=54.94

(mild anxiety), p = 0.02.

C. Analysis of Relaxation Therapy

Results on Anxiety Levels in

Postpartum Mothers

The results of the analysis of the

level of anxiety in postpartum mothers

are presented based on parameters,

namely the State-Trait Anxiety

Inventory (STAI) score, Depression

Anxiety and Stress Scale (DASS),

Hamilton Rating Scale for Anxiety (HRS-

A), cortisol hormone levels.

Anxiety scores measured using STAI

showed that the study that provided

the hypnobreastfeeding intervention

had a significant and significant

difference in anxiety between the group

that was given the intervention and the

group that was not given the

intervention P=0.002. The mean score

of the intervention group was 27.9 (mild

anxiety), the control group was 34.07

(mild anxiety).

Three studies used the DASS to

measure anxiety levels in pregnant

women. All studies show a significant

reduction in anxiety levels. The study

that gave the hypnobreastfeeding

Mutiara Ayu Muthiatulsalimah, Rr Sri Endang Pujiastuti, Aris Santjaka, Runjati

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intervention showed that the

respondents' anxiety before the

intervention of the experimental group

was 14.22 (moderate anxiety),

decreased to 7.67 (normal) after the

intervention. The control group, the

anxiety score was 13.83 (moderate

anxiety), decreased to 9.39 (mild

anxiety). P value 0.001. Study on

hypnosis intervention showed results

The intervention group had lower

postpartum anxiety than the control

group (postpartum care), the

intervention group score = 2.88

(normal), control = 38.36 (very severe),

p = 023. Studies that provided the

intervention Mindfulness Based Stress

(MBSR), Mindfulness-Based Cognitive

Therapy (MBCT), Mindful Self-

compassion (MSC) showed results The

intervention group showed a greater

reduction in anxiety than the control

group. Intervention group score

Pretest=7.08 (mild anxiety), Posttest

2.46 (normal), Control group score

Pretest=7.5 (mild anxiety), posttest 7.25

(mild anxiety) P=0.012.

Anxiety scores were measured using

HRS-A showing the results that there

was a significant difference between the

results of the pretest posttest. Pretest

the average intervention group was

20.63 (mild anxiety) and the posttest

score was 10.50 (normal), with

significance level value= 0.001

Three studies used cortisol levels to

measure anxiety levels in pregnant

women. All studies showed a significant

reduction in anxiety levels with a

decrease in cortisol levels as a

determining parameter. Studies that

provide an intervention in the form of

listening to audiorecording containing

relaxation show the results In the

intervention group the average cortisol

hormone level in the 2nd week before

the intervention was 0.048, after 0.039,

the control group was 0.041, the 6th

week before the intervention was 0.044,

after 0.036, the control group was

0.044. Studies that giving hypnosis

showed the results that Cortisol levels

(hypnosis and relaxation p = 0.02 and

0.03, hypnosis and usual care p = 0.08

and 0.05). group cortisol levels 30

minutes after delivery (hypnosis versus

relaxation p = 0.08, hypnosis versus

usual care 0, 10) and 6 weeks

postpartum (hypnosis versus relaxation:

p = 0.85, 0.51, and 0.68, hypnosis versus

usual care: p = 0.85, 0.93, and 0.96).

One

study displays the results of measuring

6th month salivary cortisol levels of 0.36

mg / dl at 8 am and an increase of 0.41

mg / dl at 8:30 in women who are

mostly breastfeeding, and 0.27-0.30 mg

/ dl in women who are mostly bottle-

feeding. Women who mostly breastfed

their babies had higher salivary cortisol

levels at 8 a.m. (p = 0.05) and 8:30 a.m.

(p = 0.02) than those who were bottle-

fed for 6 months. This effect remained

significant after controlling for feeding

differences (p = 0.01, p = 0.015,

respectively).

D. Analysis of Relaxation Therapy

Results on Milk Production in

Postpartum Mothers

The results of the analysis of breast

milk production in postpartum mothers

are presented based on parameters,

namely seen through measuring cups

1286 | Effect of Relaxation Therapy on Anxiety Level and Breast Milk Production in Pregnant

and Postpartum Mothers: Systematic Literature Review

and prolactin hormone levels.

Five articles used measuring cups

and breast pumps to measure milk

production in postpartum mothers. All

studies showed an increase in breast

milk production after the intervention.

Studies that provide

hypnobreadtfeeding show that there is

an effect of hypnobreastfeeding on

productionbreast milk in nursing

mothers who work, the average value

of production breast milk before

treatment 210 ml/day and after

treatment 255 ml/day. The study that

gave hypnobreastfeeding combined

with oxytocin massage showed that

the amount of milk production

between the intervention group

(median = 10.00; SD = 10.36) and the

control group (median = 4.50; SD =

4.21) was statistically significant ( p <

0.001). Studies that also provided

hypnobreasfeeding combined with

oxytocin massage in the

hypnobreastfeedin group and

massage oxytocin productionbreast

milk 79.10 ml/2 pumps/day, the

hypnobreastfeeding group only (60.51

ml/2 pumps/day), oxytocin massage

only (53.32 ml/2 pumps/day), and the

control breast care group 41, 18 ml/2

pumps/day. Studies providing music

therapy The volume of breast milk in

the music therapy group increased

significantly during the four days of the

intervention. Day 1 with MT was 7.04

ml (SD ± 1.49) and NMT was 6.56ml

(SD ± 1.49) v/s day 4 with MT 7.86 ml

(SD ± 1.32) and NMT was 7.34 ml (SD

± 1.31) & statistically significant (p-

value: 0.024). The study that gave

music therapy to the experimental

group produced significantly more

breast milk (P < 0.0012). The mothers

in this group also produced milk with a

significantly higher fat content during

the first 6 days of the study.

Two articles used prolactin hormone

levels to measure milk production in

postpartum mothers. Values (p < 0.05)

for both treatment groups. The

intervention group produced 200

grams of breast milk and the hormone

prolactin 250 ng/ml, in the acupressure

group the production of breast milk

was 90 grams and the hormone

prolactin was 100 ng/ml. In another

study, the intervention group had

higher prolactin levels (273.53 ng/ml)

than the control group (209.37 ng/ml).

In another study, prolactin levels were

found to be higher in postpartum

mothers with normal glucose levels

than in postpartum mothers with

prediabetes/diabetes (mean 98.2 vs

80.2 ng/mL, P = 0.0003).

DISCUSSION

E. Effect of Relaxation Therapy on the

anxiety of pregnant women

Anxiety and worry in pregnant

women if not handled seriously will

have an impact and influence on the

physical and psychological well-being

of the mother and the fetus. Anxiety in

pregnant women will increase when the

delivery schedule is getting closer,

namely entering the third trimester, the

mother begins to think about the birth

process and the condition of the baby

to be born. Mothers who suffer from

Mutiara Ayu Muthiatulsalimah, Rr Sri Endang Pujiastuti, Aris Santjaka, Runjati

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stress and anxiety during the third

trimester of pregnancy will experience

an increase in the release of stress

hormones, causing disruption of blood

flow in the uterus and resulting in weak

uterine muscle contractions. This

incident causes the length of the labor

process (long parturition), the risk of

sectio caesaria, and delivery with tools.

The risk for the baby can cause

congenital abnormalities in the form of

failure to close the cleft palate,

premature birth, giving birth to babies

with low birth weight (LBW), emergency

(fetal distress) and in the long term

related to behavioral and emotional

disorders in children. Hypnosis has

been used for a long time in clinical

practice to treat health problems

including stress and anxiety

experienced by pregnant women.

Based on the results of the review, 2

studies that provided music therapy

showed a decrease in anxiety scores

after the intervention. Both studies took

the same research sample for anxiety

scores, namely pregnant women who

experienced moderate anxiety, but

differences appeared in anxiety scores

after the intervention. One study

decreased the score from 43.72 to

42.79, but the score category was still

classified as moderate anxiety.

Meanwhile, anxiety scores in other

studies decreased from 39.6 (moderate

anxiety) to 34.1 (mild anxiety).

The difference in anxiety categories

in the two studies was due to

differences in the duration of the

intervention. There are many factors

outside of pregnancy that cause

maternal anxiety levels to increase, this

is why giving an intervention for 14

days does not have a significant effect

in reducing anxiety scores compared to

studies that provide intervention at 48-

72 hours postpartum. Statistically, both

studies showed a p value <0.005,

meaning that the provision of

relaxation therapy intervention in the

form of music therapy had an effect in

reducing anxiety levels in pregnant

women.

Another study that shows the

results of a significant reduction in

anxiety levels is the provision of an

intervention in the form of

hypnobirthing. Studies that provided an

intervention in the form of

hypnobirthing showed the

experimental group's mean score of

16.47 (normal) was significantly lower

than the control group's 95.47 (severe

fear). Past meta-analysis results provide

evidence that relaxation therapy

reduces symptoms anxiety, depression,

phobia or worry in anxiety disorder

patients. The results of this review

support that relaxation technique

training is a non-pharmacological

intervention that can improve well-

being during pregnancy.

F. Effect of Relaxation Therapy on

postpartum maternal anxiety

Postpartum mothers will experience

physiological, psychological and social

adaptations. However, not all

postpartum mothers can pass the

postpartum adaptation smoothly.

Postpartum mothers may experience

psychological disorders during the

postpartum period, one of which is

1288 | Effect of Relaxation Therapy on Anxiety Level and Breast Milk Production in Pregnant

and Postpartum Mothers: Systematic Literature Review

anxiety. Sudden changes in postpartum

mothers are the main causes of

emotional disappointment, pain in the

early puerperium, fatigue due to lack of

sleep during labor and anxiety about

her ability to care for her baby, fear of

not being attractive to her husband,

especially emotions during the first

week of being unstable and changes

His mood in the first 3-4 days, this

period is very varied and influenced by

so many factors, the main emphasis is

on the nursing approach by providing

help, sympathy and encouragement.

The results of the previous review

presented the results that hypnosis was

able to reduce postpartum anxiety.

Based on the results of the review, 2

studies that gave hypnosis showed a

decrease in anxiety scores after the

intervention. Both studies showed a

decrease in anxiety with the normal

category. Studies that provide hypnosis

in the form of hypnobreastfeeding

combined with giving acupressure have

shown that anxiety decreases from

moderate anxiety (score 14.22) to

normal (score 7.67). Another study did

not present an anxiety score before the

intervention, the measurement of

anxiety scores was carried out 4 times

at 16, 20, 28 gestational ages and at 36

weeks of gestation, there was a

comparison of scores between the

intervention group (normal score 2.88)

and the control group (score 38.36

severe anxiety).

According to a study that examined

the effects of hypnobreastfeeding on

anxiety, the results showed that

hypnobreastfeeding was able to

function as an effective non-

pharmacological therapy to reduce

anxiety and pain without any adverse

side effects. Another study presented

data that from 60 postpartum mothers

there were significant differences. and

significant effect on anxiety between

the groups given the

hypnobreastfeeding intervention and

those who were not given the

hypnobreastfeeding intervention.

Hypnobreastfeeding relaxation can be

done since the third trimester during

pregnancy. It can be used as a means to

communicate with the baby and

prepare for labor and can reduce pain

during labor. Mothers who have relaxed

since pregnancy can go through the

labor process in a relaxed, comfortable

manner and are more prepared to

become mothers when the baby is

born. In addition, it can reduce the risk

of postpartum depression.

Another study presents data that

hypnosis is able to reduce cortiol

hormone levels in third trimester

pregnant women, if carried out

continuously during breastfeeding it

can reduce cortisol levels so as to create

a sense of comfort during

breastfeeding and increase milk

production.

One of the factors that have

the potential to contribute to increased

cortisol levels in postpartum mother is

the effect of the mother's sleep hours.

Fatigue and sleep disturbances from

breastfeeding at night or early in the

morning can be stressors and alter the

stress response. In addition, women

who breastfeed their babies directly

may wake up more than once during

Mutiara Ayu Muthiatulsalimah, Rr Sri Endang Pujiastuti, Aris Santjaka, Runjati

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the night to nurse their babies. And

after waking up in the morning the

mother immediately started daily

activities, so the rhythm of cortisol

secretion began to increase at that

time, and resulted in higher cortisol

levels.

G. Effect of Relaxation Therapy on

postpartum mother's milk

production

Breast milk is the main choice of

food for infants, because at birth the

baby produces only a small amount of

salivary or pancreatic amylase, thus the

baby is not ready to digest complex

carbohydrates obtained from solid

foods. In addition, breastfeeding

provides many benefits, including the

fulfillment of nutritional,

immunological and psychological

needs. Meanwhile, the benefit for the

mother is that the reproductive organs

of the mother will return to their pre-

pregnancy state more quickly and will

increase closer contact between

mother and baby. As a method that is

able to create persuasive situations in

one's subconscious,

hypnobreastfeeding is able to increase

the motivation and confidence of

mothers to produce and give breast

milk to babies, create a sense of

comfort, reduce anxiety experienced by

mothers during breastfeeding.

The

results of a previous review showed that

relaxation therapy has been shown to

increase milk production in mothers of

premature babies. Body and mind

stress-releasing techniques have a

positive effect on breastfeeding

duration.

Based on the results of the review, 2

studies that provided

hypnobreastfeeding showed an

increase in breast milk volume after the

intervention. The duration of the

intervention was 7 and 4 days,

respectively. In studies that provide

intervention for 7 days have more

breast milk volume. Average

volumebreast milkbefore treatment

210 ml/2 pumps/day and after

treatment 255 ml/2 pumps/day on day

7 after the intervention. Another study

in the hypnobreastfeeding group, the

volume of breast milk was 60.51 ml/2

pumps/day on day 4 after the

intervention.Differences in volume are

affected by the end point of data

collection. According to theoryon the

days the first time the baby is born, if

the baby is breastfeeding well, the

breasts will empty quickly and produce

more milk, the milk production will

gradually be produced 10-100 ml / day

on days 1-9 after giving birth, and will

be optimally 700-800 ml at 10-14 days.

The results show that hypnotherapy

is more effective in triggering the

hormone prolactin which then triggers

an increase in breast milk production,

because hypnobreastfeeding can affect

the mother's belief, even though it is

temporary, in the form of focus of

attention.

CONCLUSIONS

Based on the previous discussion, the

authors conclude that Relaxation Therapy is

in the form of:

1. Hypnosis, Music Therapy, and Benson's

1290 | Effect of Relaxation Therapy on Anxiety Level and Breast Milk Production in Pregnant 
and Postpartum Mothers: Systematic Literature Review 
 
relaxation  technique  are  able  to 
overcome  anxiety  in  postpartum 
mothers,  and  a  decrease  in  cortisol 
hormone  levels  which  is  one  of  the 
parameters for assessing anxiety levels 
in postpartum mothers. 
2.  Hypnobreastfeeding  and  Music 
Therapy  is  able  to  overcome  the 
problem of insufficient milk production 
in  postpartum  mothers  and  increase 
the  hormone  prolactin  which  is  the 
hormone  that  determines  breast  milk 
production. 
 
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