SYSTEMATIC REVIEW The Journal of Nursing Research ▪ VOL. 28, NO.

3, JUNE 2020

The Effects of Aromatherapy on Postpartum

Women: A Systematic Review
Shuo-Shin TSAI1 • Hsiu-Hung WANG2* • Fan-Hao CHOU3

ABSTRACT KEY WORDS:

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aromatherapy, essential oils, postnatal, postpartum,

Background: The postpartum period is the most crucial but also systematic review.
the most fragile stage of most pregnancies. The health benefits
of aromatherapy have recently become more widely accepted
among medical experts. Although a number of studies have ex- Introduction
amined these health benefits, no systematic reviews have been
conducted to assess the effects of aromatherapy on the psycho- The postpartum or postnatal period is regarded as the fourth
physiological health of postpartum women. trimester of pregnancy and is defined as the time between giv-
ing birth and the recovery of a woman's reproductive organs
Purpose: This systematic review was conducted to evaluate the
to their prepregnancy state (Romano, Cacciatore, Giordano,
effectiveness of aromatherapy interventions on the psycho-
& La Rosa, 2010; Sun, 2016). This is the most crucial but also
physiological health of postpartum women, to determine the
methods that were used to measure intervention effectiveness, the most fragile stage of pregnancy (World Health Organization,
and to identify the types of interventions that were used. 2014). Women experience various changes in their physio-
psychological state during the postpartum period and find
Methods: We searched for studies that evaluated the effects of it difficult to adapt to these changes, which may affect their
aromatherapy on postpartum women published in the Chinese
role as mothers as well as their health-related quality of life.
or English languages before March 2018. We used online data-
bases such as the Taiwan Journal Index, Centre for European Therefore, postpartum women require timely assistance to
Policy Studies, Cumulative Index for Nursing and Allied Health adapt to postpartum life (Sun, 2016).
Literature, Cochrane Library, PubMed, and Social Sciences Cita- Aromatherapy, a complementary therapy frequently cate-
tion Index. The search keywords used were “women,” AND gorized under phytotherapy or botanical medicine, involves
“postpartum,” OR “postnatal” AND “aromatherapy,” OR “aroma,” using essential oils (EOs) as therapeutic agents (Dunning,
OR “essential oils.” Only randomized controlled trials including 2013; Gnatta, Kurebayashi, Turrini, & Silva, 2016). The use
humans as study participants were included. The methodologi- of EOs for mental, physical, and spiritual purposes traces back
cal quality of the trials was assessed using the modified Jadad thousands of years to ancient Eastern and Western civiliza-
scale. The quality of the full-text studies was assessed by three tions, including the Chinese, Egyptians, Greeks, Indians, and
reviewers. Romans, among others (Buckle, 2011; Chang, 2014). Aroma-
Results: The 15 studies that were included in this systematic re- therapy is a compound noun that was reportedly first used by
view were performed in Iran, England, and the United States and René Maurice Gattefossé in 1937 (as cited in Chang, 2014;
included 2,131 participants in total. The numbers of participants Gattefosse, 1993). The experiments of Gattefossé confirmed
in each study ranged between 35 and 635. The review found that the scientific argument that, because of their excellent perme-
the effective duration of aromatherapy varied according to the es- ability, EOs can enter the body via pathways such as inhala-
sential oils that were selected. The visual analog scale was the
tion (through the olfactory system) and absorption (through
most frequently used measure of postpartum pain. Most of the
the surface of the skin; Buckle, 2011; Chang, 2014). EOs were
studies found that the aromatherapy intervention improved post-
partum physiological and psychological health, with positive effects applied to treat burns, wounds, gangrenosum, and other trauma
shown on anxiety, depression, distress, fatigue, mood, nipple 1
MSN, RN, Doctoral Candidate, College of Nursing, Kaohsiung Medical
fissure pain, physical pain, post-cesarean-delivery pain, post-
University, and Lecturer, Department of Nursing, Chung-Jen Junior
cesarean-delivery nausea, postepisiotomy pain, postepisiotomy College of Nursing, Health Sciences and Management • 2PhD, RN,
recovery, sleep quality, and stress. Most of the studies reported FAAN, Professor, College of Nursing, Kaohsiung Medical University •
3
no serious intervention-related side effects. PhD, RN, Professor, College of Nursing, Kaohsiung Medical University.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health,
Conclusions: This systematic review may serve as a refer- Inc. All rights reserved.
ence for healthcare workers in caring for postpartum women.
This is an open access article distributed under the Creative Commons
Aromatherapy may be applied as a noninvasive complemen- Attribution License 4.0 (CCBY), which permits unrestricted use,
tary intervention to promote physio-psychological comfort in distribution, and reproduction in any medium, provided the original
postpartum women. work is properly cited.

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The Journal of Nursing Research Shuo-Shin TSAI et al.

injuries during World War I and World War II as well as to treat postepisiotomy pain, postepisiotomy recovery, physical pain,
mental disorders in postwar society (Buckle, 2011; Chang, fatigue, post-cesarean-section (CS) delivery pain, post-CS-
2014). Aromatherapy is defined as the science and art of ther- delivery nausea, and sleep quality, and psychological health
apies that are applied intrinsically using smells and practical factors included mood, anxiety, stress, depression, and dis-
EOs (Lis-Balchin, 1999; Robins, 1999). EOs, known as vola- tress; (c) were designed as randomized controlled trials (RCTs);
tile oils, are extracted from the stems, leaves, flowers, and (d) reported results in a full article that was published in either
fruits of certain plants and may be produced using distillation, Chinese or English; and (e) used humans as study participants.
enfleurage, chemical solvents, resin tapping, carbon dioxide Studies that used combined therapies, case reports, case series,
(CO2), and cold pressing (Ali et al., 2015; Buckle, 2011). descriptive studies, letters to editors, or reviews were excluded.
The dozens of popular EOs in current use include rosemary, The target populations were all postpartum women, and the
tea tree, cinnamon, bergamot, sage, ylang-ylang, chamomile, studies were all conducted for a period of 8 weeks or less.
geranium, jasmine, lavender, lemon, and peppermint (Ali
et al., 2015; Chang, 2014). Most EOs should not be applied Information Sources
to the skin undiluted (Dunning, 2013) and are therefore We searched online databases for Chinese- and English-
commonly administered through baths, local application, language studies evaluating the effects of aromatherapy
and inhalation to prevent or treat diseases, improve immune on postpartum women that were published before March
function, and protect human health (Ali et al., 2015; Buckle, 2018. The online databases that were used included the
2011). The health benefits of aromatherapy are becoming Taiwan Journal Index (Index to Taiwan Periodical Litera-
more widely accepted among medical experts, and a number ture System, n = 35), Chinese Electronic Periodicals Service
of studies have been conducted to evaluate these benefits (Ali (n = 37), Cumulative Index for Nursing and Allied Health
et al., 2015). Gnatta et al. (2016) suggested that aromatherapy Literature (n = 25), Cochrane Library (n = 156), PubMed
is practiced as a nursing intervention because it addresses (n = 395), and Social Sciences Citation Index (n = 45).
psycho-physiological health and has been historically and The search keywords that were used included “women,”
widely practiced by nurses and that it is worth discussing aro- AND “postpartum,” OR “postnatal” AND “aromatherapy,”
matherapy within the context of nursing theory. However, no OR “aroma,” OR “essential oils.” As noted, only RCTs that
published articles have yet investigated the effects of aromather- examined humans as study participants were included in this
apy on postpartum health. In addition, no clinical guidelines review. In addition, the literature was carefully searched for
are currently available for the application of aromatherapy on references and citations to articles included in this study to
postpartum women. Using an alternative, noninvasive thera- avoid repetition and to include as many relevant original stud-
peutic approach such as aromatherapy to address psychoso- ies as possible.
matic discomfort during the postpartum period may highlight
the independence of nursing care while increasing comfort
and relaxation and beneficial treatment outcomes among post-
Study Selection
partum women. The objectives of this article are to (a) review Titles and structured summaries were reviewed independently
the evidence from clinical trials that have assessed the benefits by three researchers to identify potentially relevant articles.
and safety of aromatherapy on the psycho-physiological Next, the full texts of these articles were reviewed to confirm
health of postpartum women, (b) determine the methods that the eligibility criteria were met and to extract the requisite
used to measure the effectiveness of aromatherapy, and (c) information, which included study characteristics (author, year,
identify the intervention approaches that were used. The Pre- country, design, participants, and risk of bias), intervention
ferred Reporting Items for Systematic Reviews and Meta- characteristics (type of aromatherapy, aromatherapy dose,
Analyses guidelines (Moher, Liberati, Tetzlaff, Altman, treatment frequency, administration method, duration per
& The PRISMA Group, 2009) were used during the re- session, total number of sessions, and total duration of inter-
view process to ensure a high level of quality and transpar- vention), and main outcomes. Data extraction was performed
ency in data selection and reporting. by three independent researchers, and any differences in opin-
ion were resolved through mutual discussion and agreement.

Methods Data Items

The modified Jadad scale is frequently used to assess the quality
Eligibility Criteria of trial reports that are candidates for inclusion in systematic re-
Aromatherapy studies meeting the following criteria were in- views. This scale has an interrater reliability of .9, indicating that
cluded in this systematic review: (a) described the intervention, it is a useful tool (Oremus et al., 2001). The methodological qual-
its implementation, and the aromatherapy medium (menthol, ity of the included trials was assessed using the modified Jadad
peppermint, lavender, orange peel, and Citrus aurantium); (b) scale (Oremus et al., 2001). It is highly reliable and easily used.
examined physiological and psychological health of post- Thus, it is feasible to appraise the quality of the original studies
partum participants; that is, physiological health factors (Dimitriou, Mavridou, Manataki, & Damigos, 2017; Oremus
included nipple fissures, postepisiotomy perineal discomfort, et al., 2001). The quality of the trials was analyzed using an

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Aromatherapy on Postpartum VOL. 28, NO. 3, June 2020

eight-item scale (randomization, blinding, withdrawals and Afterward, 540 studies were excluded because of their use
dropouts, inclusion and exclusion criteria, adverse effects, of combined therapies, being a review article, not using
and statistical analysis), and “high” quality was determined EOs in the intervention, not including postpartum partici-
by a score of equal to or greater than 4 (Table 1). All of the pants, and not including human participants. After screening
items were assessed by three researchers, and concurrence the titles and abstracts of the remaining articles, 17 remained
among all three was achieved through discussion. for full-text screening. Three studies were excluded in this
stage because of being either a pilot study (2) or a qualitative
Risk of Bias study (1). In addition, one study was subsequently obtained
The validity of the eligible RCTs was ascertained by evaluat- from a reference. Thus, 15 RCTs were included in this re-
ing the frequency and duration of the aromatherapy interven- view. A detailed flowchart for the study selection process is
tions, determining the methods that were used to measure presented in Figure 1. The included studies were conducted
intervention effectiveness, and identifying the intervention ap- in Iran, England, and the United States, with 2,131 partici-
proaches that were used. Three researchers provided validity pants and the number of participants per study ranging from
ratings independently, and the rating scores given by each 35 to 635. The participants in these studies were all postpar-
matched completely. tum women. Two of the included studies evaluated the effec-
tiveness of aromatherapy in alleviating nipple fissure pain,
five evaluated the alleviation of discomfort and pain and
Results the effect on episiotomy recovery outcomes, three evaluated
the alleviation of pain and nausea after CS, two evaluated
Study Selection improvements in sleep quality, and five evaluated the effect
The initial search strategy identified 693 potentially relevant on psychological health.
articles. After removing duplicates, 557 studies remained.
Trial Quality
TABLE 1. Information on the participants, design, intervention, follow-up,
Modified Jadad Scale main outcome, and modified Jadad scale scores for the stud-
ies are presented in Table 2, and the main results of each
Eight Items of the Modified Jadad Scale Score study are compared numerically. All 15 of the RCTs met
stringent standards for quality. The method of randomization
1. Was the study described as randomized? was appropriate in eight of the studies (Study nos. 1, 7–9, and
Yes +1
11–14), seven studies used no blinding (Study nos. 1, 5–7, and
No 0
11–13), single blinding was used in four studies (Study nos. 3,
2. Was the method of randomization appropriate? 4, 14, and 15), and double blinding (Study nos. 2 and 9) and
Yes +1
triple blinding (Study nos. 8 and 10) were used in two studies
No −1
Not described 0
each. An appropriate blinding procedure was used in five
studies (Study nos. 2, 3, 10, 14, and 15). There were descrip-
3. Was the study described as blinded?
tions of withdrawals and dropouts in eight studies (Study nos.
Yes +1
No 0
1–3, 5, 6, 12, 13, and 15). All of the studies presented clear
descriptions of inclusion and exclusion criteria and applied
4. Was the method of blinding appropriate?
appropriate statistical analysis. Six articles described adverse
Yes +1
No −1
effects of the intervention (Study nos. 3, 4, 8, 9, 13, and 14).
Not described 0 All of the studies received scores between 4 and 6.5, indicat-
ing high quality.
5. Was there a description of withdrawals and dropouts?
Yes +1
No 0 Effects of Aromatherapy on Physiological
6. Was there a clear description of the inclusion and ex- Health
clusion criteria?
Yes +1 Effect of aromatherapy on nipple fissures
No 0
Many lactating mothers experienced varying degrees of nipple
7. Was the method used to assess adverse effects trauma and that most followed poor breastfeeding-related
described? practices (Ahmed, Mohamed, & Abu-Talib, 2015). Two
Yes +1
Iranian studies evaluated improvements in nipple fissures
No 0
in breastfeeding women, with one using an aromatherapy
8. Was the method of statistical analysis described? intervention on 110 primiparous lactating women. This in-
Yes +1
tervention applied four drops of menthol essence on the nipple
No 0
and areola after each feeding for 2 weeks. The visual analog

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The Journal of Nursing Research Shuo-Shin TSAI et al.

Figure 1. Flowchart for study selection. CINAHL = Cumulative Index to Nursing and Allied Health Literature; CEPS = Chinese
Electronic Periodicals Service; SSCI = Social Sciences Citation Index.

scale (VAS; 0–10 cm) and Amir Scale (1–10 mm) were used to Effect of aromatherapy after episiotomy
measure intensity of pain and severity of damage, respectively. Episiotomies are performed to expand the diameter of the out-
In addition, the presence of nipple discharge was observed let pelvis during normal spontaneous delivery (Masoumi,
(Study no. 1). Other studies were conducted to assess the Keramat, & Hajiaghaee, 2011). Five of the included articles
effects of peppermint water in alleviating nipple cracks. Pep- examined the effectiveness of aromatherapy in alleviating
permint water was produced by introducing peppermint EO discomfort and pain and in facilitating recovery after episiot-
gradually into 1 liter of distilled water. After every feeding omy. One study that was conducted in England used laven-
from Day 1 to Day 14, the nipples were washed with water der oil aromatherapy. Subjects in this study took a daily,
and then the nipple and areola were covered with peppermint- half-hour bath into which six drops of lavender oil had been
water-saturated cotton. The nipple and areola were washed added. After each bath, they completed a VAS to measure de-
again before the next feeding (Study no. 12). gree of discomfort experienced. Moreover, the condition of
The results of these studies were consistent in their findings the perineum was assessed as part of the midwife's normal
that menthol essence and peppermint water were respec- daily examination of the subjects. There was some consis-
tively effective in preventing and alleviating nipple pain, fissures, tency in the results between the third and fifth days, with a
and damage in primiparous breastfeeding women when the aro- reduction in mean discomfort scores. However, aromather-
matherapy intervention was conducted after each feeding for apy did not reduce perineum daily discomfort (Study no.
2 weeks postpartum. These studies indicate that menthol and 3). In Iran, four studies were conducted to assess the effec-
peppermint aromatherapy may be used in nursing practice tiveness of aromatherapy in reducing discomfort and pain
to alleviate nipple fissures in breastfeeding mothers. and in facilitating recovery after episiotomy. Three of these

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Aromatherapy on Postpartum VOL. 28, NO. 3, June 2020

TABLE 2.
Summary of the 15 RCTs Evaluating Aromatherapy Effects on Postpartum Women
Study Participant Design Intervention Follow-Up Main Outcome Score
1. Akbari, 110 primiparous RCT Four drops of menthol 3, 10, and Nipple fissure pain VAS 5
Alamolhoda, lactating women essence on the nipple and 14 days (p < .001), nipple fissure
Baghban, & Mirabi IG = 55, CG = 55 areola after each feeding damage Amir Scale
(2014) CG = four drops of their own (p < .001), and nipple
Iran milk fissure discharge Amir
Scale (p < .001)
2. Behmanesh et al. 89 episiotomy in RCT/double Ten drops of 2% 2 hours, 5 1. Postepisiotomy pain 6
(2011) primiparous blind lavender-EO-based olive oil and 10 days VAS (p = .030)
Iran women, aged added to 5 L of bathwater, 2. Perineum REEDA
17–34 years twice a day score (p = .001)
IG = 30, G2 = 30, G2 = olive oil, G3 = distilled
G3 = 29 water
3. Dale & Cornwell 635 episiotomy in RCT/single Six drops of pure lavender oil 10 days 1. Daily discomfort VAS: 6.5
(1994) women blind added to bathwater for no significance
England IG = 217, 30 minutes daily 2. Daily mood VAS: no
G2 = 213, G2 = synthetic EO significance
G3 = 205 G3 = inert substance
4. Hadi & Hanid 200 women who RCT/single ▪ Two drops of 2% lavender Half, 8 and Post-CS-delivery pain VAS 4.5
(2011) underwent CS blind essence through oxygen 16 hours (p < .001)
Iran IG = 100, mask for 3 minutes
PG = 100 ▪ Placebo was a similar, clinically
neutral aromatic material
5. Keshavarz Afshar 158 primiparous RCT ▪ A cotton ball containing four 4 and 8 PSQI 4
et al. (2015) women who drops of 10% lavender EO weeks (1) 4 weeks: no
Iran received vaginal and sesame carrier oil placed significance
delivery, aged inside a cylindrical container. (2) 8 weeks (p < .05)
18–35 years They inhaled 10 deep breaths
IG = 79, from a distance of 20 cm,
PG = 79 four times a week.
▪ Placebo was sesame carrier oil.
6. Kianpour, 140 postpartum RCT Three drops of lavender EO on 2 weeks, 1 DASS-21 and the 4
Mansouri, women their palms, rubbed them and 3 months Edinburgh Stress, Anxiety,
Mehrabi, & IG = 70, together. They inhaled it, and Depression Scale
Asghari (2016) SG = 70 three times a day for for stress, anxiety, and
Iran 4 weeks depression: 2 weeks
(p = .012, p = .001, and
p = .003, respectively),
1 M (p = .001), 3 M
(p = .001)
7. Lane et al. (2012) 35 women who RCT ▪ A cotton ball containing spirits 2 and 5 Post-CS-delivery nausea, 4
United States deliver by CS of peppermint placed inside a minutes an ordinal nausea scale:
IG = 22, PG = 8, small ziplock bag. They 2 minutes (p < .001),
SG = 5 inhaled three deep breaths. 5 minutes (p = .005)
▪ Placebo was sterile water
with green food coloring.
8. Mirghafourvand, 96 postpartum RCT/triple ▪ Ten drops of orange peel EO 8 weeks PSQI (p < .05) 6
Charandabi, women blind added to a glass of water.
Hakimi, Khodaie, & IG = 48, They drank it after meals,
Galeshi (2016) PG = 48 three times a day.
Iran ▪ Placebo was water, propylene
glycol, and 1–2 drops of
orange edible EO.
(continues)

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The Journal of Nursing Research Shuo-Shin TSAI et al.

TABLE 2.
Summary of the 15 RCTs Evaluating Aromatherapy Effects on Postpartum Women,
Continued
Study Participant Design Intervention Follow-Up Main Outcome Score
9. Mirghafourvand, 96 postpartum RCT/double ▪ Ten drops of orange peel EO 8 weeks Edinburgh Postnatal 6
Mohammad women blind added to a glass of water. Depression Questionnaire:
Alizadeh IG = 48, They drank it after meals, no significance
Charandabi, PG = 48 three times a day. STAI: no significance
Hakimi, Khodaie, ▪ Placebo was water, propylene
& Galeshi (2017) glycol, and 1–2 drops of
Iran orange edible EO.
10. Olapour et al. 60 women who RCT/triple ▪ Three drops of 10% lavender 4, 8, and 12 Post-CS-delivery pain 5
(2013) deliver by CS blind oil essence were poured on hours VAS: 4 hours (p = .008),
Iran IG = 30, cotton in cast containers. 8 hours (p = .024),
PG = 30 They inhaled it for 5 minutes 12 hours (p = .011)
from a distance of 10 cm.
▪ Placebo was a base of
aromatherapy blend without
lavender essence.
11. Sheikhan et al, 60 episiotomy in RCT Sitz baths (0.25 ml of lavender 4 and 12 Postepisiotomy pain VAS: 4
(2012) primiparous oil essence per 5 L of water) hours, 5 days 4 hours (p = .001),
Iran women for 30 minutes, twice a day 12 hours: no significance,
IG = 30, SG = 30 5 days (p < .001)
Perineum REEDA
score: 5 days (p = .000)
12. Sayyah Melli 196 lactating RCT Peppermint water was poured 14 days 1. Nipple and areola 5
et al. (2007) primiparous on cotton. They put it on cracks Amir Scale
Iran women their nipple and areola after (p < .01)
IG = 98, the nipple was washed with 2. Cracked nipple
CG = 98 water after every feeding. (relative risk = 3.6,
95% CI [2.9, 4.3])
3. Nipple pain rating
scales (odds ratio = 5.6,
95% CI [2.2, 14.6];
p < .005)
13. Sharifipour, 80 women who RCT ▪ Three drops of Citrus 12 hours STAI (p < .001) 6
Bakhteh, & deliver by CS, aurantium essence were
Mirmohammad aged 18–35 years poured on cotton. They
(2015) IG = 40, inhaled it for 5 minutes
Iran PG = 40 from a distance of 10 cm.
▪ Placebo was normal saline.
14. Vakilian, Atarha, 120 episiotomy in RCT/single Sitz baths (five to seven drops 10 days 1. Postepisiotomy pain 6.5
Bekhradi, & primiparous blind of 1.5% lavender EO per 4 L VAS: no significance
Chaman (2011) women of water), twice a day 2. Perineum edema: no
Iran IG = 60, significance
SG = 60 3. Perineum leaved
suture: no significance
4. Perineum redness
(p = .001)
5. Perineum dehiscence:
no significance
(continues)

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Aromatherapy on Postpartum VOL. 28, NO. 3, June 2020

TABLE 2.
Summary of the 15 RCTs Evaluating Aromatherapy Effects on Postpartum Women,
Continued
Study Participant Design Intervention Follow-Up Main Outcome Score
15. Vaziri et al. 56 episiotomy in RCT/single ▪ Five drops of 1% lavender 1 hour and 1. Perineal pain VAS 5.5
(2017) primiparous blind oil essence were poured on tomorrow (p = .004, p < .001)
Iran women, aged cotton. They inhaled it for morning 2. Physical pain VAS
18–35 years 10–15 minutes from a (p < .001)
IG = 29, distance of 20 cm. 3. Fatigue VAS (p = .02,
PG = 27 ▪ Placebo was sesame oil. p < .001)
4. Distress VAS (p < .001)
5. PANAS: positive moods
(p < .001), negative moods
(p = .007, p < .001)

Note. RCTs = randomized controlled trials; IG = intervention group; CG = comparison group; PG = placebo group; SG = standard therapy group; CS = cesarean
section; EO = essential oil; PSQI = Pittsburgh Sleep Quality Index; STAI = State-Trait Anxiety Inventory; VAS = visual analog scale; REEDA = Redness, Edema,
Ecchymosis, Discharge, and Approximation; DASS-21 = 21-item Depression, Anxiety, and Stress Scale; CI = confidence interval; PANAS = Positive and Negative
Affect Schedule.

studies asked the subjects to bathe in lavender oil twice a day purified water, peppermint leaf extract) aromatherapy in-
to reduce pain, dehiscence, the number of sutures, infec- tervention as a useful adjunct treatment for postoperative
tion, and Redness, Edema, Ecchymosis, Discharge, and Ap- nausea after CS delivery (Study no. 7). One of three studies
proximation (REEDA) score (Study nos. 2, 11, and 14). did not find side effects (Study no. 4), whereas the others
Lavender oil baths reduced redness (Study no. 14) and pain did not mention side effects (Study nos. 7 and 10).
and REEDA scores (Study nos. 2 and 11). Furthermore, the On the basis of these findings, lavender (Study nos. 4 and 10)
effectiveness of lavender oil inhalation on perineal pain, and peppermint (Study no. 7) aromatherapies may be used as
physical pain, and fatigue was assessed in one of the included an effective complementary therapy for controlling nausea
studies. The intervention with lavender oil was repeated (Study no. 7) and pain (Study nos. 4 and 10) after CS.
6 hours after the first intervention and at bedtime in three
doses during the first 24 hours after delivery. Lavender Effect of aromatherapy on sleep
oil inhalation was found to be effective in reducing pain Two studies in Iran examined the effectiveness of aromather-
and fatigue (Study no. 15). Two of five studies did not find apy in improving sleep quality in postpartum women. In one
significant side effects (Study nos. 3 and 14), with cases find- of these studies, 158 primiparous women received a cylindri-
ing minor irritation (Study no. 14) and the others reporting cal container in which a cotton ball infused with four drops
no side effects at all (Study nos. 2, 11, and 15). of 10% lavender EO and sesame carrier oil had been placed.
These results suggest that aromatherapy using five to 10 These women were instructed to inhale 10 deep breaths and
drops of lavender oil added to 4–5 liters of bathwater twice then to place the container beside their pillow until morning
a day for 5–10 days (Study nos. 2, 11, and 14) or five drops (Study no. 5). The other Iranian study asked the 96 postpar-
of lavender oil inhalation for 10–15 minutes (Study no. 15) tum women participants to drink one glass of water into
may have beneficial effects on wound care (Study nos. 2, 11, which 10 drops of orange peel EO had been added three
14, and 15) and physical pain and fatigue (Study no. 15) in times a day after each meal for 8 weeks (Study no. 8). One
women after perineal episiotomy. of these two studies found side effects, including dizziness
(6.3%) and increased urination (10.4%; Study no. 8), and
Effect of aromatherapy after cesarean section delivery the other did not mention side effects (Study no. 5).
CS delivery, the most widely performed surgery worldwide, is These results support the positive effects of lavender
continuing to increase in prevalence (Masoumi et al., 2011). (Study no. 5) and orange peel (Study no. 8) aromatherapies
Three studies examined the effectiveness of aromatherapy on the sleep quality of women at 8 weeks postpartum.
in alleviating nausea (Study no. 7) and pain (Study nos. 4 and
10) after CS delivery. In Iran, two studies asked subjects to
inhale lavender essence for 3 and 5 minutes, respectively, to Effect of Aromatherapy on Psychological Health
reduce pain (Study nos. 4 and 10) after CS delivery. Lavender Five studies examined the effectiveness of aromatherapy on
aromatherapy was found to be effective in reducing post- psychological health. The effects of lavender oil bath on daily
cesarean-delivery pain (Study nos. 4 and 10). The results of mood have been assessed in England (Study no. 3), with the
a study conducted in the United States support the use of a results indicating that lavender oil has no effect on daily
spirit of peppermint (82% ethyl alcohol, peppermint oil, mood. However, another study (Study no. 15) reported

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The Journal of Nursing Research Shuo-Shin TSAI et al.

better mood status and distress scores in the lavender oil es- on the psycho-physiological health of the postpartum women
sence inhalation group than in the control group. A clinical subjects are presented in Tables 2 and 3. Lavender was the EO
trial (Study no. 13) investigated the effectiveness of Citrus that had the greatest effect on psycho-physiological health
aurantium essence in improving anxiety in 80 Iranian (n = 9; Study nos. 2–6, 10, 11, 14, and 15).
women. The intervention involved applying three drops of
Citrus aurantium essence and asking the participants to in-
hale for 5 minutes. The results support using this interven- Summary Measures
tion as an effective complementary therapy to help control The primary outcome measurement was relief of pain, includ-
anxiety. This result is in line with another study (Study no. ing nipple fissure pain, physical pain, postepisiotomy pain,
6) that reported significant reductions in stress, anxiety, and post-CS pain, measured using either the VAS or the Pain
and depression in postpartum women who had undergone Rating Scale. Moreover, severity of nipple fissure discharge
an aromatherapy with lavender intervention. However, a and nipple fissure damage were assessed using the Amir Scale;
further study (Study no. 9) reported a nonsignificant reduc- distress was assessed using the distress VAS; fatigue was
tion in depression and anxiety levels during the postpartum assessed using the fatigue VAS; perineal discomfort was assessed
period after aromatherapy with orange EO. using either the daily discomfort VAS or the daily mood VAS;
In summary, three of these five studies indicate that inhala- mood status was assessed using the Positive and Negative
tion aromatherapy, either with lavender oil (Study nos. 6 and Affect Schedule; depression was assessed using either the
15) or Citrus aurantium essence (Study no. 13), improves psy- Edinburgh Postnatal Depression Questionnaire or the 21-item
chological health in postpartum women, whereas the studies Depression, Anxiety, and Stress Scale (DASS-21); anxiety was
that used bath (Study no. 3) and drink (Study no. 9) interven- assessed using the Spielberger State-Trait Anxiety Inventory,
tions found no significant effects. DASS-21, or the Edinburgh Stress, Anxiety, and Depression
Scale; stress was assessed using either DASS-21 or the Edinburgh
Summary of Aromatherapy Outcomes Stress, Anxiety, and Depression Scale; quality of sleep was
The EOs described in the included articles included pure, assessed using the Pittsburgh Sleep Quality Index; post-CS nau-
diluted, and mixtures of multiple EOs. The identified effects sea was assessed using the Ordinal Nausea Scale; and episiotomy

TABLE 3.
Outcomes of Aromatherapy
Outcome No. of Studies Aromatherapy No. of Effects
Physiological health
Nipple fissures 2 Menthol (1) and peppermint (1) 2
After episiotomy 5 Lavender
1. Pain 4 3
2. REEDA
(1) Redness 3 3
(2) Edema 3 2
(3) Ecchymosis 2 2
(4) Discharge 2 2
(5) Approximation 2 2
3. Leaved suture 1 0
4. Dehiscence 1 0
5. Daily discomfort 1 0
After CS delivery 3
1. Pain 2 Lavender 2
2. Nausea 1 Peppermint 1
Sleep 2 Lavender (1) and orange peel (1) 2
Physical pain 1 Lavender 1
Fatigue 1 Lavender 1
Psychological health 5
Mood 2 Lavender 1
Stress 1 Lavender 1
Depression 2 Lavender (1) and orange peel (1) 1 (lavender)
Anxiety 3 Lavender (1), orange peel (1), and Citrus aurantium (1) 2 (lavender and Citrus aurantium)
Distress 1 Lavender 1

Note. CS = caesarean section; REEDA = Redness, Edema, Ecchymosis, Discharge, and Approximation.

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Aromatherapy on Postpartum VOL. 28, NO. 3, June 2020

wound was assessed using the REEDA score. The VAS was that studied human participants were considered. Comple-
the most frequently used measure of postpartum pain. mentary and alternative therapy is integral to the culture of
the Iranian people (Fahimi, Hrgovic, El-Safadi, & Münstedt,
2011), and aromatherapy is one of the most widely used types
Discussion of complementary and alternative therapies (Lis-Balchin,
EOs may be combined with usual care to improve health status, 1999). Moreover, the large majority of studies that were con-
providing a natural and noninvasive option for care (Ali et al., ducted outside Iran were not RCTs. For instance, one study
2015). Twelve of the 15 RCTs evaluated mainly reported on used a nonequivalent control group pretest–posttest design
the effectiveness of aromatherapy in improving physiological to examine the effects of EOs on labor stress, labor anxiety,
health outcomes in postpartum women. Most of the included and postpartum anxiety in Korea (Hur, Cheong, Yun, Lee,
studies found positive effects of the interventions on physiolog- & Song, 2005). Another used a quasi-experimental between-
ical health in postpartum women. Aromatherapy was found to groups design to investigate the effects of aromatherapy mas-
reduce nipple fissure pain, nipple fissure damage severity, nipple sage on psychological health in postpartum women in Japan
fissure discharge, post-CS-delivery pain, post-CS-delivery nau- (Imura, Misao, & Ushijima, 2006).
sea, physical pain, fatigue, postepisiotomy pain, and perineum Because of the nature of aromatherapy intervention, it may
REEDA scores and to improve sleep quality. Although only be difficult to conduct single-, double-, and triple-blinded stud-
five of the included studies examined the effect of aromather- ies. However, eight of the included studies attempted to blind
apy on psychological health outcomes in the postpartum the outcome assessors to minimize potential methodological
period, two of these showed nonsignificant outcomes (Dale bias (Behmanesh et al., 2011; Dale & Cornwell, 1994; Hadi
& Cornwell, 1994; Mirghafourvand, Mohammad-Alizadeh- & Hanid, 2011; Mirghafourvand et al., 2016, 2017; Olapour
Charandabi, Hakimi, Khodaie, & Galeshi, 2017). Although et al., 2013; Vakilian et al., 2011; Vaziri et al., 2017). Moreover,
most of the included studies indicated positive effects of inter- because the other seven included studies were not blinded
ventions in terms of improving postpartum physio-psychological (Akbari et al., 2014; Keshavarz Afshar et al., 2015; Kianpour
health, few of these studies assessed health effects such as nausea, et al., 2016; Lane et al., 2012; Sayyah Melli et al., 2007;
physical pain, fatigue, stress, and distress. Therefore, additional Sharifipour et al., 2015; Sheikhan et al., 2012), bias may have
studies evaluating the effects of aromatherapy on physiological occurred and influenced the study results. To supply further ev-
and psychological health in postpartum women are warranted. idence in support of aromatherapy as a valid therapy in post-
The most common modes of aromatherapy during the post- partum women, studies with rigorous blinding procedures
partum period were the addition of lavender oil to bathwater, should be conducted. Additional systematic review studies eval-
lavender oil inhalation, and menthol oil application to the skin. uating more RCTs should be conducted to better understand
However, lavender oil application caused a skin reaction. Over- the impact of aromatherapy on postpartum women.
all, aromatherapy in these studies was administered using vari- Furthermore, three studies described the adverse effects of
ous methods, including baths, drinking, inhalation, and topical applying aromatherapy interventions that use lavender (Dale
treatment for external use. The methods differed based on the & Cornwell, 1994; Hadi & Hanid, 2011; Vakilian et al., 2011).
health requirements of the postpartum women and the EO that An RCT involving 120 subjects evaluated postepisiotomy
was selected for use. Aromatherapy intervention for 30 minutes healing in a lavender EO treatment group and a povidone–
in baths relieved discomfort and pain and improved recovery iodine sitz bath group, which both received treatment twice
after episiotomy. The effective duration of aromatherapy varied a day for 10 days, and found no significant difference be-
by the EO that was used. tween the two groups in terms of pain intensity, edema,
Although we reviewed all of the RCTs that included humans leaved suture, and dehiscence and a significant difference in
as study participants, this systematic review was affected terms of redness. No side effects were found with the excep-
by methodological limitations. Six electronic databases were tion of slight irritation in two of the studies (Vakilian et al.,
searched, and the review was restricted to published articles 2011). Two studies reported side effects (dizziness and in-
only. However, it was encouraging that the RCTs were avail- creased urination) associated with applying aromatherapy
able for review and that the methodological quality of the in- using orange peel EO. A glass of water with 10 drops of
cluded trials was high. Another limitation is the small number orange peel EO was consumed three times a day for 8 weeks by
of countries in which the included studies were conducted. the experimental group, with significantly lower levels of dizzi-
Most were conducted in Iran. This may be because of two ness and urination reported in the control group, which received
reasons: (a) Aromatherapy is an accessible and convenient routine care (Mirghafourvand et al., 2016, 2017). One study re-
method for improving health in Iran (Akbari et al., 2014; vealed no side effects in the Citrus aurantium essence oil group
Behmanesh et al., 2011; Hadi & Hanid, 2011; Keshavarz (Sharifipour et al., 2015), whereas the other nine studies did
Afshar et al., 2015; Kianpour et al., 2016; Mirghafourvand, not describe adverse effects (Akbari et al., 2014; Behmanesh
Mohammad-Alizadeh-Charandabi, Hakimi, Khodaie, & et al., 2011; Keshavarz Afshar et al., 2015; Kianpour et al.,
Galeshi, 2016, 2017; Olapour et al., 2013; Sayyah Melli 2016; Lane et al., 2012; Olapour et al., 2013; Sayyah Melli
et al., 2007; Sharifipour et al., 2015; Sheikhan et al., 2012; et al., 2007; Sheikhan et al., 2012; Vaziri et al., 2017). According
Vakilian et al., 2011; Vaziri et al., 2017), and (b) only RCTs to the findings of this systematic review regarding side effects,

9
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lavender and Citrus aurantium aromatherapies are likely safe among nursing mothers. World Journal of Nursing Sciences,
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Author Contributions https://doi.org/10.1007/s00404-010-1641-8
Study conception and design: SST Gattefosse, R. M. (1993). Gattefosse's aromatherapy. Essex, England:
Data collection: All authors CW Daniel.
Data analysis and interpretation: All authors Gnatta, J. R., Kurebayashi, L. F. S., Turrini, R. N. T., & Silva, M. J. P.
Drafting of the article: SST (2016). Aromatherapy and nursing: Historical and theoretical
Critical revision of the article: SST, HHW conception. Revista da Escola de Enfermagem da USP, 50(1),
130–136. https://doi.org/10.1590/S0080-623420160000100017
Hadi, N., & Hanid, A. A. (2011). Lavender essence for post-cesarean
Accepted for publication: February 13, 2019 pain. Pakistan Journal of Biological Sciences, 14(11), 664–667.
*Address correspondence to: Hsiu-Hung WANG, No. 100, Shih-Chuan https://doi.org/10.3923/pjbs.2011.664.667
1st Rd., San-Ming District, Kaohsiung City 80708, Taiwan, ROC.
Tel: +886-7-312-1101 ext. 2624; Fax: +886-7-321-8364; Hur, M. H., Cheong, N. Y., Yun, H. S., Lee, M. K., & Song, Y. (2005).
E-mail: hhwang@kmu.edu.tw Effects of delivery nursing care using essential oils on delivery
The authors declare no conflicts of interest. stress response, anxiety during labor, and postpartum status
anxiety. Journal of Korean Academy of Nursing, 35(7), 1277–1284.
Cite this article as: https://doi.org/10.4040/jkan.2005.35.7.1277
Tsai, S. S., Wang, H. H., & Chou, F. H. (2019). The effects of
aromatherapy on postpartum women: A systematic review. The Imura, M., Misao, H., & Ushijima, H. (2006). The psychological effects
Journal of Nursing Research, 28(3), e96. https://doi.org/10.1097/ of aromatherapy-massage in healthy postpartum mothers. Jour-
jnr.0000000000000331 nal of Midwifery and Women’s Health, 51(2), e21–e27. https://doi.
org/10.1016/j.jmwh.2005.08.009
Keshavarz Afshar, M., Behboodi Moghadam, Z., Taghizadeh, Z.,
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