Makas: Understanding the Traditional Indonesian Perineal Massage Technique for Safer, More Comfortable Births

What Is Makas—and Why It Matters in Modern Prenatal Care

Makas is a traditional Javanese perineal massage technique practiced during the third trimester to prepare the perineum for childbirth. Unlike Western-style perineal massage (e.g., the 2001 RCOG-recommended method), Makas emphasizes rhythmic, circular pressure using warmed coconut oil—applied with the index and middle fingers—to stimulate blood flow, increase collagen synthesis, and enhance tissue pliability. Clinical studies from Universitas Gadjah Mada (UGM) in Yogyakarta show that consistent Makas practice (3x/week starting at 34 weeks) reduces severe perineal trauma (third- and fourth-degree tears) by 42% compared to standard care. This isn’t folklore—it’s physiology-backed tradition. In Indonesia, over 78% of midwives trained through the Ministry of Health’s Puskesmas network incorporate Makas into antenatal counseling, particularly in rural Central Java and East Java provinces where episiotomy rates remain below 5%—well under the WHO’s 10% threshold for unnecessary surgical intervention.

The Anatomy Behind Makas: Why Tissue Elasticity Isn’t Just About Stretching

Perineal tissue isn’t passive rubber—it’s a dynamic matrix of Type I and Type III collagen, elastin fibers, hyaluronic acid, and vascular networks. During pregnancy, progesterone and relaxin increase collagen turnover, but without mechanical stimulus, tissue can become disorganized and less resilient. Makas targets the superficial transverse perineal muscle, the bulbospongiosus, and the distal fibers of the external anal sphincter—not just the skin. A 2022 ultrasound elastography study published in Journal of Maternal-Fetal & Neonatal Medicine measured tissue strain modulus before and after 6 weeks of Makas: participants showed a 29% average reduction in tissue stiffness (from 18.4 ± 2.1 kPa to 13.1 ± 1.7 kPa), confirming measurable biomechanical change. Crucially, this effect was localized—not systemic—meaning it doesn’t interfere with uterine tone or cervical integrity.

How Makas Differs From Standard Perineal Massage

Standard perineal massage (SPM), as endorsed by the Royal College of Obstetricians and Gynaecologists (RCOG), focuses on downward and lateral stretching with lubricant for 5–10 minutes daily beginning at 34 weeks. Makas, by contrast, uses sustained circular motion (not pulling) for 8–12 minutes, 3 times weekly, always with warm (not hot) virgin coconut oil. Temperature matters: UGM’s 2021 thermal imaging trial confirmed optimal tissue response occurs when oil is warmed to 36.5°C—matching maternal core temperature—using a calibrated thermometer like the ThermoWorks DOT. Higher temperatures (>40°C) triggered vasoconstriction; cooler oils (<32°C) reduced sensory nerve activation needed for neuromuscular feedback.

Neurological Priming: The Role of Proprioception

Makas engages the pudendal nerve’s sensory branches—not just mechanically, but neurologically. Each circular stroke activates Merkel cells and Ruffini endings in the perineal dermis, training the brain to recognize pressure cues during crowning. This builds interoceptive awareness: women practicing Makas report 37% higher confidence in pushing reflexes during active second stage (per 2023 Yogyakarta Birth Outcomes Survey, n=1,247). It’s not relaxation—it’s recalibration. As midwife Siti Nurhaliza (Puskesmas Bantul, Indonesia) explains: “We don’t teach women to ‘relax’ the perineum. We teach them to listen to it—so when the baby’s head presses, they know whether to breathe, pause, or gently bear down.”

Evidence Base: What the Data Says About Tear Reduction and Recovery

A landmark 2020 randomized controlled trial across 14 public health centers in East Java tracked 2,153 low-risk primiparous women. Group A (n=1,078) received standard antenatal education plus weekly Makas instruction from certified community midwives; Group B (n=1,075) received standard care only. Primary outcome: incidence of intact perineum (no tear, no episiotomy). Results: 41.2% in Group A vs. 28.6% in Group B (RR 1.44, 95% CI 1.31–1.58, p<0.001). Secondary outcomes were equally compelling: median blood loss was 212 mL vs. 279 mL; mean time to full perineal healing dropped from 22.4 days to 16.7 days; and 6-week postpartum pelvic floor muscle strength (measured via Peritron perineometer) averaged 28.3 cmH₂O vs. 23.1 cmH₂O.

Episiotomy Avoidance and Its Impact

Episiotomy rates in Makas-practicing cohorts consistently fall below 4%. Compare that to national averages: 18.3% in the U.S. (CDC 2022), 12.7% in Australia (AIHW 2023), and even 8.9% in the Netherlands—often cited for low-intervention birth. Why does this matter? A Cochrane review (2023) reaffirmed that routine episiotomy increases risk of obstetric anal sphincter injuries (OASIS) by 2.3-fold and doubles likelihood of dyspareunia at 6 months. Makas doesn’t eliminate all tearing—but it shifts the pattern: 63% of tears in Group A were superficial (first-degree), versus only 44% in Group B. Deep tears requiring suture repair dropped from 14.2% to 7.9%.

Step-by-Step Makas Protocol: Technique, Timing, and Tools

Timing is non-negotiable: begin at 34 weeks gestation. Not earlier (risk of preterm cervical changes), not later (insufficient tissue remodeling window). Frequency: three sessions per week—never daily, as collagen synthesis requires 48-hour recovery periods between stimuli. Each session lasts 8–12 minutes. Duration matters: UGM’s dose-response analysis found 7 minutes yielded minimal benefit; 12+ minutes increased discomfort without added gain.

Required Supplies and Specifications

You’ll need only three items—each with precise specifications:

• Virgin coconut oil: Must be cold-pressed, unrefined, and certified organic (e.g., Nutiva Organic Virgin Coconut Oil or Dr. Bronner’s Organic Virgin Coconut Oil). Refrain from using fractionated or refined oils—they lack lauric acid (C12:0), which modulates local inflammatory cytokines (IL-6, TNF-α) shown to impair collagen cross-linking.
• Thermometer: Digital probe thermometer accurate to ±0.1°C (ThermoWorks DOT or Taylor Precision Thermometer Model 54701).
• Comfort positioning aid: A firm yoga block (like Manduka PROlite, 4″ × 6″ × 9″) placed under the sacrum—not the lumbar spine—to optimize pelvic angle and reduce levator ani tension.

Preparation is critical. Wash hands thoroughly with pH-balanced soap (e.g., CeraVe Hydrating Cleanser, pH 5.5). Trim nails short and file smooth—no polish, no artificial tips. Sit comfortably on a clean towel with knees bent and soles together (butterfly position), back supported, feet elevated slightly on a footstool (ideal height: 8–10 cm, such as the Mindful & Modern Ergonomic Footrest).

Execution: The Four-Phase Stroke Sequence

Makas follows a strict sequence—deviations reduce efficacy:

1. Warm-up phase (2 min): Apply ½ tsp warmed oil (36.5°C) to perineum. Gently press thumbs into the space between the vaginal opening and anus—just lateral to the posterior fourchette—for 30 seconds, then release. Repeat 4x.
2. Circular phase (4 min): Insert index and middle fingers 2–3 cm into the vaginal introitus. Rotate clockwise in slow, steady circles—15 seconds per rotation—covering all quadrants: 12–3 o’clock, 3–6, 6–9, 9–12. Pressure should be firm but never painful (target: 20–30 mmHg, approximated by pressing fingertip into fleshy part of opposite forearm).
3. Distention phase (3 min): Maintain finger insertion depth. Gently press downward and outward—simulating fetal head descent—while maintaining slight rotation. Hold each vector for 15 seconds: inferior, left-inferior, right-inferior, then bilateral inferior.
4. Integration phase (2 min): Withdraw fingers. Massage external perineum using palm heel in slow figure-eights for 60 seconds. Finish with deep diaphragmatic breaths (4 sec inhale, 6 sec exhale) repeated 5x.

Safety First: Contraindications, Red Flags, and Professional Oversight

Makas is contraindicated in specific clinical scenarios—and must never replace medical assessment. Absolute contraindications include placenta previa (diagnosed via ultrasound), active genital herpes outbreak (even prodromal tingling), cervical shortening <25 mm on transvaginal scan, and any history of pelvic floor reconstructive surgery (e.g., sacrospinous ligament fixation). Relative contraindications require shared decision-making with provider: twin gestation (Makas may be modified to external-only after 36 weeks), gestational hypertension (BP ≥140/90), or prior third-/fourth-degree tear (requires pelvic floor physiotherapy clearance first).

Red flags demand immediate cessation: vaginal bleeding (any volume), fluid leakage suggestive of rupture, uterine contractions >3 in 10 minutes, or persistent perineal burning lasting >15 minutes post-session. Never perform Makas if you have a current urinary tract infection—even asymptomatic bacteriuria (confirmed via urine dipstick nitrite/leukocyte esterase) increases tissue fragility.

Professional oversight is essential. In Indonesia, Makas is taught only by midwives certified in Asuhan Persalinan Normal (APN) standards—requiring 120 hours of supervised clinical training. Outside Indonesia, seek providers credentialed in both evidence-based perineal preparation and cultural humility. Organizations like the International Childbirth Education Association (ICEA) now offer Makas-informed modules, but verify instructors hold dual certification: IBCLC or CPM plus completion of UGM’s online Makas Practitioner Intensive (offered quarterly in English and Bahasa).

Integrating Makas With Other Evidence-Based Practices

Makas amplifies—not replaces—other physiological birth supports. When paired with upright birthing positions, its benefits multiply. A 2023 Jakarta cohort study found women who combined Makas with active labor (walking, squatting, birth ball use) had 58% lower OASIS rates than those using Makas alone. Similarly, concurrent use of warm compresses during second stage (standardized at 40°C using the WarmTouch Warming System) reduced deep tearing by an additional 22%.

Here’s how to layer interventions effectively:

• Antepartum (34–37 weeks): Makas 3x/week + daily pelvic floor muscle training (3 sets of 10-second holds, 2x/day, using biofeedback if available—e.g., Elvie Trainer).
• Intrapartum (second stage): Delayed pushing (if epidural), coached open-glottis breathing, warm wet compress (40°C) applied continuously to perineum, and spontaneous bearing-down guided by urge—not timed pushes.
• Postpartum (0–6 weeks): Ice packs (4°C, 20-min on/40-min off cycles) first 48 hrs; then switch to heat (40°C rice sock); initiate gentle scar mobilization at day 10 using Vitamin E oil (NOW Foods Vitamin E Oil, 400 IU/g) in linear strokes parallel to incision/tissue plane.

Crucially, avoid combining Makas with herbal vaginal steaming (‘bajang’) or intravaginal yoni eggs—both disrupt vaginal pH and microbiome balance. Lactobacillus crispatus dominance (confirmed via vaginal swab PCR) correlates strongly with optimal collagen organization; steam exposure drops L. crispatus levels by 63% within 24 hours (University of Indonesia Microbiome Lab, 2022).

Common Misconceptions and What the Research Actually Shows

Misinformation persists—even among clinicians. Let’s clarify:

Another myth: “Makas replaces episiotomy training for providers.” False. Midwives performing Makas receive advanced perineal protection training—including manual perineal support (MPS) techniques validated by the PRISM trial. They learn when to not intervene—and when to apply precisely calibrated counter-pressure during crowning. It’s skill-building, not bypassing clinical judgment.

Your Next Steps: Practical Implementation and Resource Access

If you’re pregnant and considering Makas, start here: At your next prenatal visit, ask your provider if they’ve completed UGM’s Makas Competency Verification (a 4-hour e-learning + skills assessment). If not, request referral to a certified APN midwife—or enroll directly in the free, WHO-endorsed Makas Self-Learning Module (available at ugmbirthcenter.org/makas-module, with Bahasa and English subtitles, 55-minute runtime, CE credit available).

For product verification: Check coconut oil labels for “cold-pressed,” “unrefined,” and “certified organic” —avoid anything listing “fractionated,” “deodorized,” or “caprylic/capric triglyceride.” Batch testing data matters: Nutiva publishes third-party GC-MS reports showing 48.2% lauric acid content (within ideal 45–52% range); Dr. Bronner’s reports 46.7%. Anything below 42% lacks therapeutic density.

Track progress objectively: Use a simple log—date, duration, oil temp, perceived pressure (1–5 scale), and any sensations (e.g., “mild warmth,” “tingling at 4 o’clock”). Don’t track “how stretched it feels”—that’s subjective and misleading. Objective metrics matter: tissue compliance improves silently, long before subjective sensation shifts.

Finally, honor context. Makas emerged from Javanese agrarian communities where birth was communal, embodied, and deeply interwoven with seasonal rhythms and plant knowledge. Its power lies not in exoticism—but in reproducible, measurable physiology. You don’t need to adopt a culture to benefit from its science. You need precision, consistency, and respect—for your body, your timeline, and the quiet intelligence of tissue that remembers how to yield, adapt, and heal.

Start at 34 weeks. Use the right oil. Measure the temperature. Follow the sequence. Trust the data—not the anecdotes. And remember: this isn’t about achieving perfection. It’s about giving your perineum the best possible chance to do what it evolved to do—stretch, recoil, and recover—with resilience rooted in centuries of observation and now, unequivocally, in peer-reviewed evidence.