Background: This study aimed to determine the effectiveness of aroma hand treatment in alleviating fatigue and promoting relaxation of mothers in their early postpartum period. Methods: This is a quasi-experimental study with a two-group pretest - post-test design which used purposive sampling and non-random assignment of 242 consenting Japanese early postpartum mothers who were patients from a hospital maternity unit in Tokyo, Japan. The intervention involved a 20-minute aroma hand treatment using an effleurage method. The participants selected from 5 essential oils: pure lavender, ylang-ylang, citron, rosewood, and sweet orange. Relaxation promotion and fatigue alleviation as the main outcomes were measured using self-administered valid and reliable questionnaires. Statistical analysis was performed using the two-sample t-test, two-way factorial ANOVA, and simple main effect test. SPSS ver. 23.0 (SPSS, Chicago, IL, USA) was used for data analysis at a 5% significance level. Results: Of 242 participants (intervention group, n = 122; comparison group, n = 120), 229 participants (intervention group, n = 115; comparison group, n = 114) were analyzed per protocol. The intervention group showed a significant improvement in relaxation (t = 6.43 , p < 0.001). A significant difference in the simple main effect test of relaxation (F = 37.58, p < 0.001) was found. However, there was no significant reduction in fatigue. The majority (88.4%) of the participants indicated high satisfaction with the aroma hand treatment, and 90.5% evaluated the length of intervention time as appropriate. Conclusions: The aroma hand treatment effectively promoted relaxation of early postpartum mothers, but was less effective in alleviating their fatigue. Based on their high satisfaction rate, aroma hand treatment using essential oils may be considered effective in promoting relaxation of early postpartum mothers.
Postpartum mothers face difficult periods after giving birth and have unmet needs for support in those periods, particularly support from other new mothers [
Approximately 60% of postpartum mothers have moderate fatigue, which is significantly associated with maternal health [
The essential oils used in aromatherapy treatments promote relaxation when their fragrant component stimulates the hypothalamus and activates the parasympathetic nervous system [
In terms of the effects of using aromatherapy in the medical field, blood pressure and anxiety were reduced [
We previously developed a short aroma hand treatment method for early postpartum mothers as a pilot study in preparation for the present study. The results of our previous pilot study indicated fatigue reduction and relaxation promotion of the mothers post intervention. The process evaluation in terms of mothers’ satisfaction level and impression of providers’ thoughtfulness confirmed the usefulness of aroma hand treatment [
In the present study, we established a comparison group together with an optimum sample size to clarify the effects of using the method developed for the mothers in the intervention group. This study aimed to specifically examine the effects of a short aroma hand treatment for early postpartum mothers in terms of relaxation promotion and fatigue reduction, and the satisfaction level of the mothers undergoing the aromatherapy. The authors predicted a favorable outcome from the aroma hand treatment intervention with a high satisfaction.
This study used a quasi-experimental design consisting of a convenience sample and a nonequivalent control group with non-random group assignment.
The participants were mothers in their early postpartum period (days 1 - 7) and who had been admitted before delivery to a large-scale general hospital with a 52-bed maternity unit in Tokyo, Japan. The hospital had perinatal and life-saving transport support systems. The hospitalized mothers were in their early 30s as average age. The ratio of cesarean sections was 27.7%. Consistent with maternity care in Japan, the length of hospital stay was typically 4 - 5 days for a normal delivery and 8 days for a cesarean section [
The approximate number of participants necessary for the study to have an adequate effect size was calculated using the estimation method developed by Cohen (1992) [
The intervention treatment included applying 1 of 5 types of essential aroma oil (i.e., pure lavender, ylang-ylang, citron, rosewood, and sweet orange) by massaging to the mother’s hands and forearms. The intervention treatment was provided by 10 research assistants. During their year-long preparation, they attended various training sessions and seminars provided by the Certified Nurses of Japanese Society of Aromatherapy and they gained experience through volunteer-related activities. In addition, the research assistants passed a technical qualifying examination for independent professional skills and completed a lecture on puerperium care. The aroma treatments used a blend of sweet almond oil as the carrier oil and the applied essential oil. The concentration of the essential oil was diluted to within 2% in consideration of the women who were in their early postpartum period [
Prior to the intervention treatment, the research assistants provided verbal and written explanations to the participants regarding the efficacy of the various aromas of the oils. The participants were then able to smell each oil, after which they selected the oil for their treatment. To ensure safety, the participants received a patch test before starting the intervention treatment to determine any allergic reaction to the aromatherapy ingredients.
The research assistants applied the essential oil using the massage method described by Hashemi et al. (2015) [
The authors recruited participants during their postpartum hospital stay using purposive sampling with the assistance of the hospital nurse manager. The authors and nurse manager confirmed whether the postpartum mothers met the inclusion criteria.
The authors informed the mothers verbally and in writing about the purpose of the study, as well as about the confidentiality, anonymity, and safety of personal data. If the mothers agreed to participate in the study, the authors obtained their written consent. The authors provided an explanation of their right to withdraw from the study without penalty, and a withdrawal form. The participants could also mail the withdrawal form if necessary. Data were collected from August 2016 to December 2016. We used an anonymous self-filled questionnaire and attempted to obtain reliable data by the following methods: 1) in the pilot study, the deficiencies in the methods were confirmed and the questionnaire was corrected; 2) the participants received a detailed explanation on how to fill out the questionnaire; 3) data with missing values and inadequacies were excluded.
The self-report questionnaires were administered during the mothers’ hospital stay. Completed questionnaires were placed in a secure box on the unit, providing convenience and anonymity. Collection of the outcome evaluation data was carried out for the pre-test and post-test. The pre-test was requested the day before the intervention, whereas the post-test was requested for the current day after about 24 hours of the pre-test. The timing of the post-test immediately after the intervention was in accordance with the studies of Nakakita and Takenoue (2009) [
This study was conducted after obtaining approval from the Ethics Committee for Epidemiological Studies of Tokyo Healthcare University, Tokyo, Japan (approval no. 27-27) on December 28, 2015. A written explanation was provided to the participants regarding the study objectives, methods, protection of anonymity, and voluntary basis of participation following the Declaration of Helsinki. It was also explained that the collected data would be used solely for this study. A signed informed consent was obtained from each participant.
The demographics and outcome measures included fatigue and relaxation scales and author-developed outcome evaluation. The outcome measures provided both quantitative and qualitative data.
Fatigue was assessed using the “subjective symptoms” 13-item subscale of the Self-Diagnosis Check List for Assessment of Worker’s Accumulated Fatigue [
Relaxation was evaluated using a revised version of the rating scale of emotion using the items referring to relaxation. Nedate and Kamisato (1984) developed this scale for measuring the subjective sense of relaxation [
For the process evaluation, the participants completed the 5-item survey developed by the authors which includes 1) treatment satisfaction, 2) meeting of expectations, 3) adequacy of intervention time, 4) satisfaction in receiving essential oils, and 5) provider’s communication skills. A five-point Likert scale was used for scoring each item, with higher scores indicating a more positive acceptance of the intervention. The participants also responded to an open-ended question seeking their opinion about the intervention.
SPSS ver. 23.0 (SPSS, Chicago, IL, USA) was used for data analyses with the significance level set at 5%. Unpaired Student’s t-test and χ2-test were used to compare the following basic characteristics: each scale score of the participants and each variable before the program between the 2 groups. Per-protocol analysis, two-way factorial analysis of variance (ANOVA), and simple main effect test were used to analyze and test the differences between the intervention and control groups to verify the effectiveness of the intervention. If significant differences were found in the two-way factorial ANOVA, a simple main effect test was used in the next stage. A frequency distribution table was created from the 5 items in the process evaluation. The open-ended remarks were analyzed using constant comparative analysis as described by Lyn (2015) [
Regarding the flow of participants who met the study inclusion criteria (
Among these mothers, there were 122 mothers in the intervention group and 120 mothers in the comparison group who agreed to participate in the study. The study was completed by 115 mothers (94.3%) in the intervention group and 114 mothers (95.0%) in the comparison group.
Finally, the per-protocol analysis included 115 participants in the intervention group and 114 participants in the comparison group; dropouts such as those who lacked data, canceled, or did not return their responses were excluded.
There were no significant differences in the characteristics or pretest scale scores between the intervention and control groups (
It was anticipated that there would be an interaction effect between intervention and time and a difference in the pattern of changes between the 2 groups. First, to examine a two-factor interaction, two-way factorial ANOVA was conducted for each scale. For the ANOVA, the dependent variable was each scale score, the between-subjects factor was the presence or absence of intervention, and the within-subjects factor was time. There were significant interaction effects between intervention and time in the Relaxation scale (F = 39.68, p < 0.001). However, there was no significant interaction effects between intervention and time in the Fatigue scale (F = 3.71, p = 0.055) (
To verify the differences between groups, a simple main effect test for each scale with a significant interaction effect was performed. A significant difference between the intervention group and the comparison group was shown by the simple main effect test of Relaxation (F = 37.58, p < 0.001) (
Intervention group | Comparison group | ||||||
---|---|---|---|---|---|---|---|
(n = 115) | (n = 114) | ||||||
Demographic variable | M | SD | M | SD | t-value | df | p-value |
Age (years) | 33.4 | 4.03 | 33.3 | 4.44 | 0.095 | 218 | 0.924 |
Postpartum days | 3.1 | 1.29 | 2.8 | 1.36 | 1.548 | 227 | 0.123 |
Attribute | n | % | n | % | total | χ2 | p-value |
Delivery methods | |||||||
normal vaginal | 72 | 62.6 | 79 | 69.3 | 151 | 1.141 | 0.286 |
caesarean section | 43 | 37.4 | 35 | 30.7 | 78 | ||
Birth experience | |||||||
primipara | 76 | 66.1 | 64 | 56.1 | 140 | 2.415 | 0.491 |
multipara (2 times) | 31 | 27.0 | 40 | 35.1 | 71 | ||
multipara (3 times) | 7 | 6.1 | 9 | 7.9 | 16 | ||
multipara (4 times) | 1 | 0.9 | 1 | 0.9 | 2 | ||
Previous disease | |||||||
yes | 7 | 6.1 | 10 | 8.8 | 17 | 0.601 | 0.438 |
no | 108 | 93.9 | 104 | 91.2 | 212 | ||
Pregnancy complication | |||||||
yes | 39 | 33.9 | 29 | 25.4 | 68 | 1.969 | 0.161 |
no | 76 | 66.1 | 85 | 74.6 | 161 | ||
Selected essential oil | |||||||
sweet orange | 43 | 37.4 | |||||
citron | 23 | 20.0 | |||||
ylang-ylang | 20 | 17.4 | |||||
pure lavender | 19 | 16.5 | |||||
rosewood | 10 | 8.7 | |||||
Each scale and subscale | M | SD | M | SD | t-value | df | p-value |
Fatigue | 8.7 | 6.6 | 8.6 | 7.5 | 0.096 | 227 | 0.924 |
Relaxation | 22.7 | 8.4 | 22.9 | 9.0 | −0.105 | 227 | 0.917 |
Scale | SS | df | MS | F | p-value | ||
---|---|---|---|---|---|---|---|
Fatigue | time | 60.97 | 1 | 60.97 | 1.65 | 0.200 | |
intervention | 115.76 | 1 | 115.76 | 1.17 | 0.280 | ||
time × intervention | 137.19 | 1 | 137.19 | 3.71 | 0.055 | ||
Relaxation | time | 306.41 | 1 | 306.41 | 5.53 | <0.05 | * |
intervention | 2078.75 | 1 | 2078.75 | 16.81 | <0.001 | *** | |
time × intervention | 2198.08 | 1 | 2198.08 | 39.68 | <0.001 | *** |
*p < 0.05, ***p < 0.001.
Fatigue. Therefore, the aroma hand treatment caused a significant increase in relaxation but it did not significantly alleviate fatigue.
In the process evaluation, 84.4% of the participants were satisfied with the treatment methods and 90.5% felt that the intervention time was appropriate. The majority (66.1%) of the participants indicated a high match between their expectations and the intervention, and 91.3% highly evaluated the provider’s communication skills (
This was a quasi-experimental study wherein data were collected from 2 groups at different times. To verify whether a simple aroma hand treatment is effective in relieving fatigue and promoting relaxation of postpartum mothers, pilot studies were conducted to thoroughly examine this methodology. The relaxation scale scores showed a significant increase in the intervention group compared with the comparison group, but the fatigue scale scores showed no significant decrease. These results suggest that aroma hand treatment using essential oils is effective for promoting relaxation and is highly satisfying for early postpartum mothers.
Most mothers experience poor sleep and fatigue during the early postpartum period [
As mothers in the early postpartum period require care for fatigue reduction and relaxation, it would be beneficial to disseminate aromatherapy treatment as
Category | Code |
---|---|
Increased relaxation | It felt good |
I became sleepy | |
I felt healed | |
Improvement in physical condition | Improvement of edema |
Shoulder tensions abated | |
Improvement of rough hand | |
High satisfaction | I was happy |
I was able to select the scent | |
Experienced at the hospital | |
Just a good time | |
Need improvement of techniques | Lack of pressure |
Lack of rhythm | |
Need to maintain an effective amount of essential oil | Lack of good scent |
Hope the essential oil is appropriate for the symptoms |
an integrated component of nursing care [
The process evaluation largely received high satisfaction ratings from the participants. However, the participants opined that technical improvements are needed because of the insufficient treatment pressure and rhythm shortage. Further points for improvement included the proper use of essential oils to avoid aroma shortage and the correct choice of the essential oil to relieve particular symptoms.
Additional studies on how to promote the use of hand aroma treatment as an intervention treatment is recommended because of the ease and rapidity of its application (i.e., 20 minutes) in hospitalized puerperal mothers. Once nurses master the aroma treatment techniques, the process becomes more convenient and easier. Appropriate training and experience of nurses in aromatherapy massage is crucial in achieving positive results [
There are some limitations of this study. First, the internal validity for the intervention effect was deemed weaker because the research study design was a nonequivalent control group design instead of a randomized controlled trial. Second, limited generalizability and potential bias cannot be completely controlled because data were collected only from a single hospital. Third, it was not possible to measure the duration of the intervention effect because the post-test was conducted only once. Future prospects include training nurses in other maternity hospitals on how to implement aromatherapy treatment. Notably, the nonreduction of fatigue deserves clarification. Moreover, the effectiveness of aroma hand treatment needs to be further analyzed in a larger population before clinical application.
This study, which clarified the effectiveness of aromatherapy treatment in alleviating fatigue and promoting relaxation of mothers during the early postpartum period, obtained the following important findings:
1) The post intervention fatigue scale scores of the intervention group were not significantly higher than those of the comparison group.
2) The post intervention relaxation scale scores of the intervention group were significantly higher than those of the comparison group.
3) The majority of the participants indicated a high satisfaction with the aroma hand treatment and evaluated the intervention duration as appropriate.
4) Five categories of opinions were extracted from the participants: a) increased relaxation, b) improved physical condition, c) high satisfaction, d) need improvement of techniques, and e) need to maintain an effective amount of the essential oil.
The authors would like to thank all the participants, as well as the facility staff and research assistants for their valuable contributions in this study. The authors also thank Dr. Edward Barroga (http://orcid.org/0000-0002-8920-2607), Advisor of the Academic Writing Desk of St. Luke’s International University, Japan, and Associate Professor and Senior Medical Editor of Tokyo Medical University, Japan for reviewing and editing the manuscript.
The results of this study were presented at the 37th Annual Conference of the Japan Academy of Nursing Science in 2017.
The authors declare that there they have no conflicts of interest associated with this study.
All procedures were performed in accordance with the ethical standards of the responsible committees for human experimentation (institutional and national) and the 1964 Helsinki Declaration and later amendments. Informed consent was obtained from all patients.
Animal StudiesAnimal studies were not performed in this study.
Approval by Ethics CommitteeThe protocol of this research project was approved by the Ethics Committee for Epidemiological Studies of Tokyo Healthcare University, Tokyo, Japan (approval no. 27-27) on December 28, 2015.
Asazawa, K., Kato, Y., Koinuma, R., Takemoto, N. and Tsutsui, S. (2018) Effectiveness of Aromatherapy Treatment in Alleviating Fatigue and Promoting Relaxation of Mothers during the Early Postpartum Period. Open Journal of Nursing, 8, 196-209. https://doi.org/10.4236/ojn.2018.83017