The effect of aromatherapy by essential oil of orange on anxiety during labor: A randomized clinical trial

Abstract

Background:
Labor is a stressful situation that may have an adverse impact. Aromatherapy is a method to control anxiety and stress of women. This study was conducted to investigate the effect of aromatherapy using essential oil of orange on women's anxiety during labor.

Materials and methods:
In this clinical trial study, 100 women during labor were randomly assigned to two groups: intervention group and control group. The women in the intervention group were exposed to orange essential oil, but the women in the control group were exposed to distilled water. The women's anxiety was assessed using the Spielberger inventory. Moreover, physiological parameters such as systolic and diastolic blood pressure, respiration and pulse rates were assessed in all the women before and 20 min after the intervention. The data were analyzed by Chi-square, Wilcoxon, paired t-test, and Mann-Whitney U test. Data were evaluated with the SPSS 16 program. The significance level of P < 0.05 was considered.

Results:
The level of anxiety of women in both intervention (P = 0.03) and control (P = 0.003) groups reduced after the intervention. However, the reduction was more in the intervention group (difference in anxiety scores after the intervention in comparison to before intervention = -3.08) in comparison to the control group (score = -1.14). No significant change was found in the physiological parameters of women in the intervention group after the intervention.

Conclusions:
Aromatherapy is a noninvasive and effective method to help women overcome their anxiety during labor. Orange scent can be useful in childbirth units to help women who are experiencing stress in labor.

Full text

Iranian Journal of Nursing and Midwifery Research | November-December 2015 | Vol. 20 | Issue 6 661
The effect of aromatherapy by essential oil of orange
on anxiety during labor: A randomized clinical trial
Fahimeh Rashidi‑Fakari1, Mahbubeh Tabatabaeichehr1, Hamed Mortazavi2
AbstrAct
Background: Labor is a stressful situation that may have an adverse impact. Aromatherapy is a method to control anxiety and
stress of women. This study was conducted to investigate the effect of aromatherapy using essential oil of orange on women’s
anxiety during labor.
Materials and Methods: In this clinical trial study, 100 women during labor were randomly assigned to two groups: intervention
group and control group. The women in the intervention group were exposed to orange essential oil, but the women in the control
group were exposed to distilled water. The women’s anxiety was assessed using the Spielberger inventory. Moreover, physiological
parameters such as systolic and diastolic blood pressure, respiration and pulse rates were assessed in all the women before and
20 min after the intervention. The data were analyzed by Chi-square, Wilcoxon, paired t-test, and Mann–Whitney U test. Data
were evaluated with the SPSS 16 program. The signicance level of P < 0.05 was considered.
Results: The level of anxiety of women in both intervention (P = 0.03) and control (P = 0.003) groups reduced after the intervention.
However, the reduction was more in the intervention group (difference in anxiety scores after the intervention in comparison to
before intervention = −3.08) in comparison to the control group (score = −1.14). No signicant change was found in the physiological
parameters of women in the intervention group after the intervention.
Conclusions: Aromatherapy is a noninvasive and effective method to help women overcome their anxiety during labor. Orange
scent can be useful in childbirth units to help women who are experiencing stress in labor.
Key words: Anxiety, aromatherapy, labor, orange essential oil
1DepartmentofMidwifery,FacultyofNursingandMidwifery,North
KhorasanUniversityofMedicalSciences,Bojnord,Iran,2Department
ofGeriatricNursing,SchoolofNursing and Midwifery,North
KhorasanUniversityofMedicalSciences,Bojnord,Iran
Address for correspondence:Ms.MahbubehTabatabaeichehr,
DepartmentofMidwifery,FacultyofNursingandMidwifery,
NorthKhorasanUniversityofMedicalSciences,Bojnord,Iran.
E‑mail:Chehr@nkums.ac.ir
Submitted:23‑Jul‑14;Accepted:07‑Jul‑15
been reported to decrease the anxiety of different people such
as nursing students facing their first clinical experience, nurses
during emergency conditions, and hemodialysis patients.[4‑7]
Some studies have shown the impact of aromatherapy
to relieve anxiety during labor,[1,3,8] but Hur et al.[9] have
reported that essential oils might not reduce anxiety.
Orange essential oil (Citrus sinesis), commonly named
as sweet orange, is a member of the Rutaceae family.[10]
Studies have shown that orange scent is a suitable aroma
to decrease anxiety.[4,6,11,12]
Due to lack of studies on the effect of aromatherapy
on anxiety of women during labor, this study aimed to
investigate the effect of aromatherapy using essential oil
of orange on women’s anxiety during labor.
IntroductIon
Labor is considered a stressful condition in pregnant
women which may have negative consequences such
as uteroplacental insufficiency and angina. It may
interfere with uterine muscle contractions and progression
of labor.[1] It has been shown that stress and anxiety increase
the entry of calcium and sodium into the cell that accelerates
heart rate and changes the physiological parameters. In a
pregnant woman, the above‑mentioned conditions lead to
uteroplacental insufficiency and fetal hypoxia.[2]
Various methods are available to handle women’s anxiety
during labor.[3] Aromatherapy is known to be one of the
effective methods to decrease anxiety.[4] Aromatherapy has
Original Article
Access this article online
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Website:
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DOI:
10.4103/1735-9066.170001

Iranian Journal of Nursing and Midwifery Research | November-December 2015 | Vol. 20 | Issue 6 662
Rashidi-Fakari, et al.: Essenal oil of orange on anxiety
Because of limited studies about various aromas in labor
in this population, researchers preferred to use one type of
essential oil and not a mixture.
MAterIAls And Methods
This is a clinical randomized trial. This study’s research
proposal was approved by the research council affiliated
to North Khorasan Medical Science University, Bojnourd,
Iran. Also, the ethics committee of North Khorasan
University of Medical Sciences approved the study’s ethical
considerations. This study has been registered in the IRCT
with the code of 2012111811515N1.
One hundred pregnant women who referred to a teaching
hospital in 2012 and 2013 were chosen. The investigator
referred to the childbirth unit of the chosen hospital and
invited the probable participants to enter the trial.
Participants were randomly assigned to two groups:
Intervention and control.
The sample size was determined based on a pilot study
with 95% confidence interval and a power of 80%, a
society variance of 6 , and a mean difference of 3. Thus,
50 participants were selected in each group. However,
two participants left the intervention group due to
receiving analgesic drugs and losing eagerness to continue
participation in the study [Figure 1].
The inclusion criteria were: Nulliparous women of age
18–35 years with a singleton pregnancy, gestational
age between 37 and 42 weeks, and cervical dilatation
3–5 cm.
The exclusion criteria were: Having the history of
hypertension (BP ≥ 14/9), suffering from headache or
migraine; losing the acuity of smelling sense due to cold
or any allergic disorder; using analgesic or anti‑anxiety
medication during the intervention or 3 h before
intervention; having any psychological disorder, epilepsy,
or asthma; experiencing disturbance in labor process,
induction of labor, and fetal distress.
The women signed the informed consents. Blinding in
the present study was not possible. Randomization was
accomplished by using sealed opaque envelopes that
contained the allocation of participants to one of the
groups. Thus, the allocation was determined after opening
the envelopes.
In order to disperse odor and its effect on the control group
and for reduplication of samples with the last post, sampling
was conducted in one working post in a day. To prevent
the researcher’s bias, data were collected by a researcher
assistant.
For all women, demographic data were collected and
the physiological parameters (systolic and diastolic blood
pressure, pulse, and respiration rate) were measured
before the intervention. The Spielberger inventory was
completed with the researcher’s assistance. The women
in the intervention group were exposed to two drops of
essential oil of orange peel 2% (produced in North Khorasan
Pharmacological Research Center of Medicinal Plants). The
women in the control group were exposed to two drops of
placebo (distilled water). Essential oil and placebo were
placed on non‑absorbable and clean napkins that were
attached to the participants’ clothes at a distance of 20 cm
from their chins. This method of intervention is consistent
with other studies.[1,3] After 20 min of the intervention,
physiological parameters were again measured and
recorded, because insensitivity of the olfactory receptors
occurs after 20 min of inhalation.[13] The Spielberger
inventory was also completed. The physiological parameters
were measured and the inventory was completed between
uterine contractions. After the completion of the intervention
period, the napkins were removed except in cases where
the mother desired that it should remain.
The Spielberger inventory has 20 questions and each
question contents four options. The total score of anxiety
ranges from 20 to 80. The higher score means the higher
state of anxiety.[14,15] The blood pressure was measured
Randomized
Enrollmen
Not eager to continue (n = 1)
Data Analysis (n = 48) Data Analysis (n = 48)
Received aromatherapy (n = 50)
AllocationFollow upAnalysis
Not eager to continue (n = 1)
Leave the study because of treating
Painkillers (n = 1)
Received placebo (n = 49)
Leave the study (n = 1)
Not meeting
Inclusioncriteria
(n = 12)
Assessed for eligibility (n = 112)
Figure 1: Randomization of participants

Iranian Journal of Nursing and Midwifery Research | November-December 2015 | Vol. 20 | Issue 6 663
Rashidi-Fakari, et al.: Essenal oil of orange on anxiety
by a calibrated sphygmomanometer in completely fixed
situations. Respiration and pulse (radial artery) rates were
counted in a complete‑one‑minute.
To determine the normality of the variables,
Kolmogorov–Smirnov test was used. Parametric tests were
applied in normal variables; non‑parametric statistical tests
were used in non‑normal variables.
Non‑normal variables were described as middle, interquartile
range (IQR) and normal variables values were shown as
mean and standard deviation. The data were analyzed using
Chi‑square, Wilcoxon, paired t‑test, and Mann–Whitney U
test via the SPSS 16 program for Windows. The statistical
significance was set at P < 0.05.
results
A total of 96 participants completed this study.
Mann–Whitney U test for age and Chi‑square test for level
of education and occupation status of the participants and
their husbands showed that the experimental and control
groups were homogeneous. The results of the verification of
homogeneity of these two groups are presented in Table 1.
The level of anxiety of women in both intervention (P = 0.03)
and control (P = 0.003) groups reduced after the
intervention. However, the reduction was more in the
intervention group (score = −3.08) in comparison
to the control group (score = −1.14). No significant
change was found in the physiological parameters such as
systolic and diastolic blood pressure and respiration and
pulse rates of women in the intervention group after the
intervention. However, diastolic blood pressure and heart
rate of women in the intervention group were lower. The
physiological indicators of women in the control group
except diastolic blood pressure were not significantly
different [Tables 2 and 3].
dIscussIon
This study showed that aromatherapy by essential oil of
orange reduced the level of anxiety and diastolic blood
pressure and pulse rate.
Mirzaei[1] and Tafazoli[3] showed that essential oil inhalation is
effective in decreasing anxiety during labor. Our results were
similar to those of the above‑mentioned studies, although
we used a different aroma. The reason can be attributed to
cultural similarity, identical tool of measuring anxiety, and
the same delivery phases. Lehrner et al.[12] in a comparative
survey found that orange aroma effectively reduced the
anxiety of the patients who referred to the dentist office.
Holm et al.[16] reported that orange aroma was not effective in
anxiety reduction on accompanies children in urgency part.
Table 1: Demographic and personal characteristics in
experimental and control groups
Variables Study
group
Control
group
P value
Age (years)
M (IQR) 20 (5) 21 (5) 0.8
Level of education n (%)
Illiterate 1 (2.1) 2 (4.2) 0.6
Less than diploma 27 (56.2) 29 (60.4)
Diploma 9 (18.8) 9 (18.8)
Higher than diploma 11 (22.9) 8 (16.7)
Occupation status of women n (%)
Housewife 46 (95.8) 42 (87.5) 0.3
Employed 1 (2.1) 3 (6.2)
Student 1 (2.1) 3 (6.2)
Occupation status of spouses n (%)
Self-employed 26 (54.2) 26 (54.2) 0.5
Workman 15 (31.2) 14 (29.2)
Staff 5 (10.4) 3 (6.2)
Unemployed 1 (2.1) 0 (0)
Farmer 1 (2.1) 4 (8.3)
Student 0 (0) 1 (2.1)
SD: Standard deviation, n: Number, M (IQR): Middle (interquartile range)
Table 2: Comparison of the state anxiety score and
physiological parameters in the experimental group before and
after the intervention
Variables M (IQR) P value
Before
intervention
After
intervention
Anxiety 55 (17) 51 (16) 0.03
Systolic blood pressure (mmHg) 110 (10) 110 (20) 0.2
Diastolic blood pressure (mmHg) 78 (20) 75 (15) 0.2
Pulse rate 92 (15) 89 (17) 0.14
Respiration rate 18 (4) 18 (4) 0.5
M (IQR): Middle (interquartile range)
Table 3: Comparison of the state anxiety score and physiological
parameters in the control group before and after intervention
Variables Before
intervention
After
intervention
P value
Anxiety (mean (SD)) 53.45 (6) 52.31 (6.2) 0.003
Systolic blood pressure
(mmHg) M (IQR)
100 (10) 100 (18) 0.28
Diastolic blood pressure
(mmHg) M (IQR)
65 (10) 60 (20) 0.03
Pulse rate M (IQR) 80 (16) 80 (10) 0.13
Respiration rate M (IQR) 16 (4) 16 (4) 0.79
SD: Standard deviation, M (IQR): Middle (interquartile range)

Iranian Journal of Nursing and Midwifery Research | November-December 2015 | Vol. 20 | Issue 6 664
Rashidi-Fakari, et al.: Essenal oil of orange on anxiety
These results can be attributed to hospital air‑conditioners,
materials, and other intervening factors that were responsible
for such a result, according to their claims.
Kim et al.[4] found the effect of a mixture of orange
essential oil with other essential oil on the anxiety level of
nursing students who were practicing their first intravenous
injections. They found that increase in pulse rate and systolic
blood pressure was lower in the intervention group than
in the control group. Perhaps the reason for this difference
is that in their study, the participants were exposed to the
aroma for a longer time than the participants of the present
study and orange essential oil was used in combination with
other essential oils. But in our study, participants had more
ability for quitting of intervention, because we just used
one aroma and an exclusive procedure for every subject.
The limitation of this study was that blinding of the study
was not possible.
It is recommended to conduct further studies controlling
the confounding factors when orange aroma can be
examined for a longer time to determine its effects more
clearly on the physiological parameters.
conclusIon
Based on the results of the present study, it is concluded
that orange scent may be useful in childbirth units to help
women experiencing this stressful stage of their life (labor)
in decreasing their anxiety and tension.
AcknowledgMents
We thank the Research Assistant of Medical Sciences University of
North Khorasan for providing all the support for the study. We are
also grateful to all the staffs, midwives, and nurses of Bent Al‑Hoda
hospital at Bojnourd, Iran. Research number 349 of your project.
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How to cite: Rashidi-Fakari F, Tabatabaeichehr M, Mortazavi H.
The effect of aromatherapy by essential oil of orange on anxiety
during labor: A randomized clinical trial. Iranian J Nursing Midwifery
Res 2015;20:661-4.
Source of Support: North Khorasan University of Medical Sciences,
Conict of Interest: None declared.