Complementary Therapies in Clinical Practice 42 (2021) 101284

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Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

The effect of postpartum period back massage on serum ghrelin, leptin,

adiponectin and visfatin levels
Asli Goker a, *, Funda Kosova b, Secil Koken Durgun c, Zuhal Demirtas c
a
Manisa Celal Bayar University Faculty of Medicine Department of Obstetrics and Gynecology Manisa, Turkey
b
Manisa Celal Bayar University Vocation School of Health Services, Medical Biochemistry Manisa, Turkey
c
Manisa Celal Bayar University School of Health Department of Midwifery Manisa, Turkey

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

Keywords: In addition to the initiation and continuity of lactation, hormones transferred from mother plasma to milk during
Postpartum massage breastfeeding are also important. The aim of this study was to determine the effect of back massage on maternal
Lactation serum ghrelin, leptin, adiponectin and visfatin levels in women giving birth.
Massage
A total of 60 mothers, participated in this experimental study. Massage was applied in the first 3–4 h after
Ghrelin
Leptin
birth. Blood sample was taken in the postnatal routine.
Adiponectin It was determined that the intervention group did not make a statistically significant difference in ghrelin
Visfatin (1.37 ± 0.7, 1.00 ± 0.2), leptin (0.76 ± 0.5, 0.70 ± 0.1), adiponectin (3.55 ± 0.8, 3.05 ± 0.5) levels compared to
the control group (p > 0.05). However, visfatin (10.53 ± 2.4, 9.97 ± 2.0) levels were statistically higher than the
control group (p < 0.05).
Back massage was found to be beneficial in terms of increased growth factors in breast milk production and
content.

1. Introduction
The development of breast tissue during prenatal, postnatal milk
production and secretion process is defined as lactogenesis. Postnatal
lactation begins with the release of prolactin and oxytocin hormones as a
result of decreased levels of placental estrogen and progesterone hor­
mones [1]. The onset of lactation is affected by many factors. The only
condition for the smooth progression of this period is that the hormones
work in a certain order. However, the physical and psychological factors
that women experience during childbirth cause significant changes in
the hormone cycle in the body. In addition to being tired, the mother has
anxiety about her baby, etc. The process of preventing lactation begins
with condition disorders [2].
There are many methods to initiate and continue lactation in an
effective way. One of these methods is massage. Manuel massage is a
kind of supportive care lasting for 5–30 min and comprising techniques
such as friction and kneading [3]. Massage therapy should be tailored to
the person’s needs and its effect may change with the technique used
and the area applied. It is an important point to whom, when and why
massage is used. Studies show that back massage during the postpartum
period promotes relaxation of the puerperal woman both physically and
psychologically [4] plus it relieved their back pain [5]. Since the
lactational hormone is oxytocin, it is recommended to prefer a massage
that will increase its secretion.
Besides initiating and continuing lactation, hormones from the
mother’s plasma that are transferred to the milk during breastfeeding
play an important role for the baby. Growth factors that promote
development of the offspring are among these hormones. It is known
that these factors and hormones have pivotal impact on growth and
health outcomes of the newborn in his future life [6]. Maternal obesity
for instance is a cause for childhood obesity due to transfer of hormones
[7] A positive correlation between serum leptin levels and BMI in obese
children has been shown by the study of ElSaeed et al. [8]. Ghrelin,
leptin, adipokinin and visfatin are one of the most important growth
factors that affect the future of the newborn.
In addition to the onset and continuity of lactation, the hormones
transferred from the mother’s plasma to milk during lactation are also
important for the baby. These hormones are the growth factors that
ensure the continuity of baby development. The most known of the
growth factors transferred to the baby during lactation are ghrelin,
leptin, adipokinin and visfatin.
Ghrelin is a peptide structure hormone with 28 amino acids, isolated

* Corresponding author.
E-mail address: asli.goker@cbu.edu.tr (A. Goker).

https://doi.org/10.1016/j.ctcp.2020.101284
Received 24 July 2020; Received in revised form 17 November 2020; Accepted 5 December 2020
Available online 11 December 2020
1744-3881/© 2020 Elsevier Ltd. All rights reserved.
A. Goker et al.
as a specific endogenous ligand for the growth hormone releasing re­
ceptor (GHS-R) that stimulates growth hormone (GH) release in-vivo
and in-vitro [9]. Ghrelin is present in both term and premature breast
milk. Although Ghrelin passes from maternal plasma into breast milk, it
is also produced and secreted by breast tissue [10].
One of the most important hormones in milk secretion, leptin, has
been shown to be secreted by the placenta, gastric epithelium, skeletal
muscle, pituitary and mammary gland, mainly in adipose tissue in the
body [11]. A significant relationship between plasma leptin levels and
milk leptin levels has been explained and the transfer of leptin from
mother’s blood to mother’s milk has been shown [12].
Adiponectin in breast milk is 40 times more likely than other major
adipokines in breast milk, such as leptin and ghrelin. Slower weight gain
in the first year of life is associated with high adiponectin exposure in
breast milk, while accelerated weight gain in the second year of life
suggests its role in capturing the growth curve [10].
Visfatin, another cytokine, plays an important role in various meta­
bolic and stress events. Visfatin levels are expected to increase when
stress decreases and breastfeeding increases [13].
2. Method
The research was conducted at State Hospital in the city of Manisa,
Turkey. The study was funded by the scientific research project
department of Manisa Celal Bayar University (project number:
2018–122).
A total of 60 mothers, 30 intervention and 30 control subjects, who
accepted to participate in the research comprised the study group.
Participants who met the inclusion criteria were randomly selected to
the study or control group by simple randomisation. Mothers were aged
between 18 and 35 years, did not have any chronic disease, did not have
any breast problem and started breastfeeding in the first postpartum
hour and continued breastfeeding for at least 2 times in a 4-h period.
Massage was applied by the researcher who had received certificated
back massage training. The procedure was carried out in the patient
room after initial medical care was given and mother and baby settled in
their room, in the first 3–4 h after birth, for 5 min. After minimizing
noise and light, the bed was adjusted to an optimum position, the mother
turned her back to the massager and her hands were raised over her
head, a towel was used to ensure privacy, eflorage, friction, kneading
was applied symmetrically from vertebra towards shoulders.
Mothers in the maternity service are routinely given a hemogram
check postpartum in 4 h. During this check, 2 cc of blood was taken for
our research. All the blood samples were kept at − 80◦ until the time of
analysis. These ghrelin, leptin, adiponectin and visfatin levels were
measured using the ELISA method.
2.1. Ethics of research
The study protocol was approved by the Manisa Celal Bayar Uni­
versity local ethic committee. Legal permits have been obtained from the
Manisa Celal Bayar University Hafsa Sultan Hospital, for the application.
Participation was on a voluntary basis. All the women participating in
the study provided their informed consent. Women were not offered any
incentives for their participation in the study.
2.2. Statistical analyses
The data obtained from the research were analyzed using the sta­
tistical package for social sciences (SPSS) for Windows, version 15.0.
The value of p < 0.05 was deemed statistically significant in compari­
sons. Mean + standard deviation (SD), number percentage distribution,
Student t, Mann-Whitney U and Chi-Square test analyses were per­
formed to evaluate the data collected in accordance with the purpose of
the study.
2
Complementary Therapies in Clinical Practice 42 (2021) 101284
3. Results
Half of the participants (50%) had an educational level of middle
school or higher, 93% were working women and only 6% stated an in­
come more than expenses in the household in the control group, for the
intervention group these values were as follows: 57% primary school
education, 90% working status and 6% more income than expenses,
these data showed no statistical difference. 63% of women in the control
and 66% in the intervention group were experiencing their first preg­
nancy (p > 0,05). There was statistically no difference between groups
with regards to usage of family planning methods and having a planned
pregnancy. In both groups 77% of the women had received an episi­
otomy (p > 0,05). Only 17% in the control and 23% in the intervention
group had followed birth preparation classes during pregnancy (p >
0,05). Numerical data are given in Tables 1 and 2.
Table 2 shows the hormone levels of mothers after back massage. It
was determined that although statistically not significant, ghrelin, leptin
and adiponectin levels were increased in the intervention group. The
level of visfatin was statistically higher than that of the control group.
4. Discussion
Some individual and social initiatives are needed to strengthen
breastfeeding, which has an important role in building the foundation of
a healthy society. In particular, the postnatal period is the time in which
communication between the health worker and the mother is most
active and has an irreplaceable effect in terms of breast milk production
and breastfeeding sustainability [14]. Studies show that breastfeeding is
influenced by stimuli. In the study of Lee et al. (2015) giving back
massages to 60 mothers, it was reported that postpartum pain intensity
decreased [15]. Jahdi et al. (2016) noted that mothers who had post­
natal back massages were relieved and their stress levels decreased [16].
In the study of Kosova et al. (2016), an increase in the level of oxytocin,
prolactin, and noradrenaline, which are effective in breast milk pro­
duction and release, was observed by manipulations during back mas­
sage [17]. In the light of this information, it was deduced that the back
massage performed on mothers would have a positive effect on the
growth factors in the maternal serum. In this study, we aimed to
investigate serum ghrelin, leptin, adiponectin and visfatin levels that
had the effect of back massage on lactation.
Although ghrelin was seen as solely responsible for increasing
growth hormone release in the body during the early years of its dis­
covery, its effects on appetite and regulation of body weight have been
more noticeable in recent years [18]. In the study of Trojnar et al. (2018)
with women in postnatal second day reported a positive association
between weight gain in pregnancy and postpartum first 48 h weight loss
and serum ghrelin level. There is no conclusive evidence that it increases
due to weight gain during pregnancy [19]. According to the study of
Gomez-Diaz et al. (2016), in pregnancy, the placenta plays an important
role in maintaining circulating maternal ghrelin levels [20]. Ghrelin
passes from maternal plasma to breast milk at postnatal, but is also
produced and secreted by breast tissue [10]. In a 2018 study by Zhang
et al. on pregnant goats, ghrelin transcripts and expression of the protein
were reported to be detected in the goat breast gland at all stages of
pregnancy. Intense ghrelin immunoreactivity has been observed in the
Table 1
Characteristics of the women.
Characteristics Control Group Intervention p
Group
Mean age (years) 24,99 ± 4,69 25,66 ± 4,63 0,387
Mean length of marriage 5,99 ± 5,49 6,80 ± 4,89 0,515
(years)
Mean weight (Kg) 70,00 ± 10,74 71,14 ± 12,65 0,685
Mean height (Cm) 160,88 ± 6,05 161,51 ± 5,52 0,652
Mean BMI 27,07 ± 4,10 27,17 ± 4,49 0,920
A. Goker et al.
Table 2
Distribution of hormone levels of mothers in control and intervention group.
Hormone Ghrelin (ng/ Leptin (ng/ Adiponektin Visfatin (ng/
Levels ml) ml) (mg/L) ml)
Control 1.00 ± 0.2 0.70 ± 0.1 3.05 ± 0.5 9.97 ± 2.0
Intervention 1.37 ± 0.7 0.76 ± 0.5 3.55 ± 0.8 10.53 ± 2.4
channels and alveoli of goat mammary glands throughout pregnancy
[21]. Levels of free ghrelin in breast milk are higher than levels of
maternal serum and cord blood ghrelin. As soon as lactation continues,
ghrelin levels rise [10]. One of the biggest contributions to the conti­
nuity of lactation massage application provides. It has been proven in
studies that massage increases the amount of oxytocin in milk release
[22]. In this context, it has been thought that massage increases oxytocin
as well as ghrelin passing from maternal plasma to breast milk. When the
hormone levels of the mothers who agreed to participate in the study
were examined, the serum ghrelin level of the intervention group was
1.37 ± 0.7 and the level of the control group was 1.00 ± 0.2. Although
the level of the intervention group is not statistically significant
compared to the control group, a significant increase is observed. The
results in our study are similar to other literatures. This suggests that
ghrelin may also be increased in breast milk.
Leptin is a hormone in protein structure discovered in 1994, similar
to cytokines and containing 167 amino acids [11]. The concentration of
leptin in breast milk varies between 0.2 and 73.22 ng/mL according to
its fractions and samples used. The presence of a concentration of leptin
higher (2–66 times) in breast milk than in lean samples suggests that
probably part of leptin is associated with milk fat drop or fat-related
proteins. The colostrum’s leptin concentration was higher than in
transition milk and decreased during the first 180 days; indicating
negative association with lactation time. In the study of Dadres et al., in
2019 that followed women for the first 3 months of the end of birth is
evidence of the level of leptin in breast milk dropped [23]. Bouret has
suggested that leptin and ghrelin, the appetite regulator in the baby,
found in breast milk, can permanently affect the system that regulates
appetite by affecting the development of appetite-regulating centers in
the brain, particularly the hypothalamus [10]. Leptin, whose primary
effect is to control the growth of fatty tissue, acts on the hypothalamus,
reducing appetite [24]. Ghrelin antagonizes this anorexigenic effect of
leptin via the hypothalamic neuropeptide Y/Y1 receptor [25]. There­
fore, it has been observed that there is a metabolic antagonism between
ghrelin and leptin in terms of their function in the body [26]. In addi­
tion, a study found that the levels of leptin in the cord blood taken at
birth were parallel to the anthropometric measurements of the baby
[27]. The serum leptin level, which is inversely proportional to gherelin,
is also expected to decrease because of the serum ghrelin level, which is
thought to increase as a result of stimuli that support breastfeeding.
When the hormone levels of the mothers who agreed to participate in the
study were examined, the serum leptin level of the intervention group
was 0.76 ± 0.5 and the level of the control group was 0.70 ± 0.1. There
was no statistically significant difference in intervention group level
compared to control group. In the literature studies, serum leptin levels
were high during lactation [12], although there was no statistical dif­
ference between the control and intervention groups, a significant in­
crease in the study suggests that this was in line with other studies.
Adiponectin which discovered in 1995, is an adipocyte-derived
hormone secreted by adipose tissue [10]. Plasma adiponectin level is
negatively correlated with insulin, leptin level and visceral adipose tis­
sue. It is thought it may be an insulin-sensitizing cytokine [28]. Adipo­
nectin is an endocrine factor secreted in large quantities from adipose
tissue [29]. It can be assumed that high adiponectin production in the
placenta and fetus is associated with fetal growth [30]. While adipo­
nectin levels are low in pregnancy, they increase during the postpartum
period [31]. In a 2018 study by Mohamad et al. to study the relationship
of the presence of adiponectin in maternal serum and breast milk, it was
3
Complementary Therapies in Clinical Practice 42 (2021) 101284
reported that third trimester maternal serum adiponectin level and its
birth weight and weight within the first 12 months of life were related
[32]. In this context, the amount of adiponectin passed from maternal
serum to breast milk is quite important. High levels of adiponectin are
expected to be found as a result of back massage which has an effect on
increasing breast milk. When the hormone levels of the mothers who
agreed to participate in the study were examined, the serum adiponectin
level of the intervention group was 3.55 ± 0.8 and the level of the
control group was 3.05 ± 0.5.
Visfatin is a polypeptide with numerous functions of endocrine,
autocrine, and paracrine [33]. Visfatin, first seen in lymphocytes, was
later found to be a growth factor. In the study of Fukuhara et all, it was
determined that vistafine imitations insulin and binds to insulin re­
ceptors [34]. Maternal serum or plasma visfatin levels have been re­
ported to increase during the second and third trimesters of pregnancy.
There are also studies in the literature in which maternal serum and
plasma visfatin levels are investigated in pregnancy complications such
as preeclampsia. Increased maternal serum and plasma visfatin levels
have been reported in pregnancies complicated by preeclampsia ([35]).
The study by Shaheen et al. (2016), which examined serum visfatin
levels in preeclampsia was reported to have a visfatin concentration of
4.9 ± 3.05 in preeclampsia and 2.2 ± 1.57 in normal pregnancies ([36]).
In contrast, several other studies have reported reduced or unchanged
levels of visfatin in preeclampsia. In the study of Bienertova-vaskü et all
in 2011, it was reported that visfatin concentrations in the maternal
serum showed significant changes after birth, 100 times higher con­
centrations were secreted in breast milk compared to the maternal
serum, and that the concentration of visfatin in the colostrum could be
used to predict weight gain during the first 3 days after birth ([37]). The
role of visfatin, which is thought to be released from the mammary
glands, is quite large during lactation, which creates a metabolic burden
for mothers and causes them to expend a considerable amount of energy
([38]). Studies found that visfatin levels of breastfeeding mothers were
higher than those who did not breastfeed [15]. In this study, maternal
serum was used and when hormone levels were examined after back
massage, the serum visfatin level of the intervention group was 10.53 ±
2.4 and the control group was 9.97 ± 2.0. The level of the intervention
group was significantly higher than that of the control group.
There are a few limitations to this study. Further study groups which
compare primigravid to multigravid women or women who have
attended birth preparation classes to those who have not, blood cortisol
levels measurements in control and study groups for stress level may be
initiated. Another limitation is that the study took place in a western city
of Turkey where breastfeeding may not be considered as natural as in a
village area, thus a more heterogeneous group of women with a back­
ground of village life may be more objective. Another limitation may be
the fact that non breastfeeding women were not included in the study.
5. Conclusion
Although visfatin was statistically increased according to the results
of our study, ghrelin, leptin and adipcytokine levels showed a non-
statistical increase. It may be assumed that ghrelin may be increased
in breast milk due to lactation and ghrelin may be effective in the
development of the baby as it is a cytokine that increases the release of
growth hormone. Leptin and ghrelin act as antagonists of each other.
Visfatin is also associated with visceral adipose tissue and is known to be
a growth factor. The lactation period in particular creates a metabolic
burden for mothers, causing them to expend a significant amount of
energy. It also plays an important role in various metabolic and stress
events. Visfatin levels are expected to increase when stress decreases and
therefore lactation increases. In conclusion, in this study, it appears that
back massage is beneficial in terms of increased growth factors in breast
milk production and content. In the present study, cytokine levels did
not increase statistically after back massage during lactation period, but
the data may indicate that the reason for a significant increase is due to
A. Goker et al.
the duration of back massage. Postnatal period, thanks to the mother’s
back massage, breast milk production will increase and babies will be
fed only with breast milk for the first 6 months. Thus, it appears that the
newborn will benefit from rich growth factors and the risk of developing
chronic disease in later life will be minimized and healthy individuals
will be brought into society.
CRediT authorship contribution statement
Asli Goker: Conceptualization, Methodology, Writing - original
draft. Funda Kosova: Conceptualization, Methodology, Investigation,
Writing - original draft. Secil Koken Durgun: Formal analysis, Writing -
original draft. Zuhal Demirtas: Resources, Formal analysis, Writing -
original draft.
Declaration of competing interest
The authors have no conflict of interest to declare.
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