Effects of Cinnamon

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www.jcimjournal.com/jim

July 2014, Vol.12, No.4 360 Journal of Integrative Medicine

1 Introduction

Episiotomy is the most common obstetric interventionin the world. Its prevalence has been reported to be 43%

to 100% in primiparous women in Asia[1] and up to 100%in some hospitals of major cities in Iran[2].

Prevalence of perineal pain in people with episiotomyis about fourfold compared to those with no episiotomy[3].Perineal pain adversely affects different aspects of women’slife including lactation, child care and daily chores[4].Postpartum is a sensitive time when mothers must juggletheir own recovery while dealing with the needs of theirnewborns. Effective pain relief is a major aspect of postpartumcare that can positively affect women’s life[5-7].

There are several common methods used for reducing pain and accelerating the episiotomy-healing process[3].

Nonsteroidal anti-inammatory drugs are among the typicalmedications used to reduce episiotomy pain[4], though theymay cause some side effects such as peptic ulcers[8]. Betadine(Iodine) is also commonly used to prevent infection andhelp with healing of the episiotomy wound. However,various studies show that it has no significant effect onmicroorganism-reduction[9]. Many women nd the currentavailable methods unsatisfactory and are looking for othereffective and safe options.

Only a few studies have been conducted on the care ofthis very common wound[10]. Some studies have examinedthe effects of herbal remedies such as lavender [11], oliveoil [12], or curcumin[13] on episiotomy pain and healing.However, definitive effects of these methods have not

been verified through clinical trials, and more extensivestudies are still required in this area[3].

Cinnamon is a widely used spice worldwide[14]. It has beenfound to have numerous properties including anti-inflamma-tory, antioxidant, and antimicrobial[15]. Analgesic[16,17] andwound-healing[18] effects of its ethanol extract have beenshown in laboratory rats. Also, no signicant adverse ef -fects of cinnamon have been found in human studies[19].

Considering the above-mentioned evidence on the possibleefcacy and safety of cinnamon extract, plus the lack of

any human studies on its analgesic and healing effects, this

study was conducted to determine the effects of a 10-dayapplication of 2% cinnamon extract ointment on episiotomywound. The primary outcomes involved reducing perineal

pain and accelerating healing of the episiotomy wound;secondary outcomes measured consumption of other analgesics,as compared to the placebo group.

2 Materials and methods

2.1 Study design, participants and setting

This study was a randomized, double-blind, placebo-

controlled trial. Women aged 18 to 40 years with parity1-3 who had vaginal birth with episiotomy were includedin the study. Exclusion criteria were: being illiterate; havingno access to a phone line (for follow-up); use of drugs or

psychotropic substances; gestational age of less than 37 or

more than 42 weeks; history of chronic physical or mentaldiseases that may interfere with healing; following a specialdiet; long-term (over 18 h) rupture of amniotic sac; severeanemia (haemoglobin less than 70 g/L at admission); historyof hypersensitivity to certain drugs; extension of episiotomy(tears of grade 3 or 4); and operative delivery.

Recruitment was done at two hospitals affiliated to theTabriz University of Medical Sciences (Alzahra, Taleghani,Iran), and one hospital affiliated to the Social SecurityOrganization (29 Bahman). The hospitals are the only

public maternity facilities in Tabriz and have the highestnumber of clients for vaginal delivery services among all

centers in Tabriz, Iran.In these hospitals, episiotomy is usually performed inmore than 90% of the first vaginal deliveries, and 70%of the second and third deliveries. Episiotomy incision andrepair is often done by midwifery students, obstetricsassistants, and senior medical students, and in some cases

by employed midwives. Cephalexin (500 mg, oral) is routinelyadministered four times a day for 6 d after delivery. In allthe three medical centers, non-continuous stitches are used torepair episiotomy.2.2 Allocation and intervention

Allocation sequence was determined by block randomizationwith block sizes of 4 and 6, and allocation ratio of 1:1 usinga computer-generated randomization schedule with strat-ication for center (three centers) and parity (two strata:

rst and second or third). Sequentially numbered, opaque,

sealed envelopes of the same shape and size containingcinnamon or placebo ointment were used to conceal theallocation and to maintain blinding. Every package containedone 40 g cinnamon or placebo tube with no label on it.

The packages and allocation sequence were prepared by a person who was not involved in the recruitment, datacollection and data analysis. Therefore, the investigatorsand participants were unaware of the type of ointmentgiven to every participant (double blinding).

After obtaining written informed consent from eligiblewomen at the rst stage of delivery, the investigator (rst

author, AM) attended at bedside of every participant torecord details of delivery and episiotomy procedure in achecklist. The person in charge of delivery was requestedto use no disinfectant on the perineal area. The rst part

of the questionnaire (socio-demographic and reproductivecharacteristics) was completed based on the le documenta-tion and interview with the participants. The investigatormeasured episiotomy incision length using a sterile tooland transferring it onto a ruler. After baseline assessment


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of less than 0.05 were considered statistically signicant.

2.6 Ethical approval

This research project was approved scientifically by theResearch Committee of the Tabriz University of MedicalSciences and ethically by the ethic committee of the university

(Ethic code: 91157). Also, it was registered in the Iranianregistration system with IRCT201211303706N18 on 13December 2012 before starting participant recruitment.

3 Results

3.1 Recruitment and follow-up

Participant recruitment was carried out from 20 February to31 October, 2013 and follow-up ended on 11 November, 2013.A total of 233 patients were initially screened, but 86 wereexcluded because of ineligibility. Three patients refused to

participate due to high work load and inability to use the

ointment regularly. Thus, 72 participants were allocatedinto each group. Follow-up rate was 100% up through the8-hour mark, and at 10-11 d after delivery was 86% in thecinnamon group and 85% in the placebo group (Figure 1).3.2 Participant characteristics

More than half (60%) in each group were primiparous.The groups were similar in terms of socio-demographic

and reproductive characteristics. Mean age of the par-ticipants was (26.4 ± 4.9) years. About one third (35%)reported that their income did not sufce their expenses.

A majority of the participants were Azari (89%), housewives(94%), and lived in the city (88%). Mean duration of episioto-

my incision repair was (31.1 ± 16.7) min in the cinnamongroup and (35.6 ± 18.0) min in the placebo group. Meaninterval between episiotomy incision and start of repairwas (15.3 ± 6.6) min in the cinnamon group and (17.4 ±7.2) min in the placebo group (Table 1). Most of participantsin both cinnamon (90%) and placebo (80%) groups hadused toilet at squatting position.3.3 Primary outcomes

Mean pain intensity at baseline was 5.0 ± 1.8 in thecinnamon group and 4.6 ± 2.0 in the placebo group. At allthree follow-up assessments, intensity of pain in the cinnamongroup was significantly lower than that in the placebo

group. Adjusted pain score difference (MD) was -0.6 (95%confidence interval (CI): -1.0 to -0.2) at (4±1) h, -0.9(95% CI: -1.4 to -0.3) at (8±1) h, and -1.4 (95% CI: -2.0 to-0.7) at 10-11 d postpartum (Table 2). Compared to baseline,

pain intensity reduction at (4±1) h, (8±1) h, and (10-11) d postpartum was 16%, 26%, and 76% in the cinnamon groupand 2%, 4%, and 43% in the placebo group, respectively.

Figure 1 Flowchart of the study


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July 2014, Vol.12, No.4363Journal of Integrative Medicine


Mean baseline REEDA score was 3.4 ± 1.6 in the cinnamongroup and 3.2 ± 1.5 in the placebo group. The score of thecinnamon group was signicantly lower than that of the

placebo group at both of the follow-up assessments: -0.2(95% CI: -0.4 to -0.04) at (8±1) h and -1.6 (95% CI: -2.0 to-1.1) on 10-11 d postpartum (Table 2). Compared to baseline,REEDA score reduction was 53% in the cinnamon groupand 6% in the placebo group at 10-11 d postpartum.

In the repeated measurement test, both overall painintensity score (-0.9 (95% CI: -1.36 to -0.53)), and overall

healing score (-0.9 (95% CI: -0.6 to -1.16)) after interventionwere signicantly lower in the cinnamon group as compared

to the placebo group ( P 0.05) betweenthe groups at baseline and the (8±1) h in terms of REE-DA components except wound approximation ( P =0.02).During 10 d postpartum, in the intervention group vs the

placebo group, there was no redness (39% vs 15%), noedema (71% vs 34%), no ecchymosis (95% vs 82%), no

Table 1 Socio-demographic and reproductive characteristics of the participants

Characteristics Cinnamon group (n=72) Placebo group (n=72)

Age (years) 27.3±5.1 25.7±4.5

Education (years) 9.9±3.8 9.4±3.7

Body mass index (kg/m2) 25.0±3.2 24.6±3.7Duration of second stage of labor (min) 39.1±23.3 39.5±26.5

Duration of third stage of labor (min) 8.2±3.5 9.2±5.1

Interval between episiotomy incision and start of repair (min) 15.3±6.6 17.4±7.2

External length of episiotomy (cm) 3.4±0.7 3.4±0.8

Length of episiotomy repair (min) 31.1±16.7 35.6±18.0

Weight of newborn (g) 3 164±503 3 294±507

Neonatal head circumference (cm) 34.6±1.3 34.8±1.3

Urban resident 62 (86.1%) 64 (88.9%)

Job (employed) 6 (8.4%) 3 (4.2%)

Economy statusIncome upper than spent 2 (2.8%) 6 (8.3%)

Income equal spent 45 (62.5%) 40 (55.6%)

Income lower than spent 25 (34.7%) 26 (36.1%)

Placenta exit (spontaneous) 69 (95.8%) 67 (93.1%)

Data indicate mean ± standard deviation or number (%).

Table 2 Comparison of pain and healing status between the study groups at different time points

Group

Pain (VAS, 0-10) Healing status (REEDA scale, 0-15)

Baseline(4±1) h afterintervention

(8±1) h afterintervention

10-11 d afterdelivery

Baseline(8±1) h afterintervention

10-11 d afterdelivery

Cinnamon 5.0±1.8 4.2±1.6 3.7±1.8 1.2±1.6 3.4±1.6 3.5±1.4 1.6±1.3

Placebo 4.6±2.0 4.5±1.7 4.4±1.7 2.6±2.1 3.2±1.5 3.5±1.4 3.0±1.6

Mean difference (95% CI) 0.5 (-0.1to 1.1)

-0.6 (-1.0to -0.2)

-0.9 (-1.4to -0.3)

-1.4 (-2.0to -0.7)

0.2 (-0.2to 0.7)

-0.2 (-0.4to -0.04)

-1.6 (-2.0to -1.1)

P value 0.12 0.003 0.002


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discharge (13% vs 23%) and complete closure (65% vs 39%). Wound-healing scores in the cinnamon group wassignicantly less than those in the placebo group in 4 of

5 components ( P


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July 2014, Vol.12, No.4365Journal of Integrative Medicine


and anti-inammatory effects work via reducing nitric oxide

and activating analgesic paths of cholinergic and glutamatergiccompounds[25,26]. Cinnamon extract can also reduce in-ammation by its polyphenol compounds

[27].A 2012 study showed that lavender essence has similar

effects on postpartum perineal pain, probably due to the presence of linalool and trephine compounds in lavender,similar to cinnamon compounds[11]. In a study, the positiveeffect of turmeric ointment was attributed to its curcumincompound[28]. It is believed that this substance asserts itseffect through inhibition of cyclooxygenase and reductionof nitric oxide[29], which is similar to linalool’s function incinnamon.

In the present study, the cinnamon group’s decreases inredness and presence of seroanguinous or purulent secretionon the 10th day were probably due to cinnamon’s anti-in-ammatory

[27] and antimicrobial[14] properties.

Wound dehiscence in the present study (1 case in thecinnamon group and 5 cases in the placebo group) wasslightly more common than what is expected based oninternational references, i.e., 0.1% to 2.1%[30]. However, itwas slightly less than what is found in the study conductedin Arak-Iran, in which the wound dehiscence was 3% inthe group using a sitz bath of lavender oil and 8% in thegroup using betadine[31]. A possible reason for this slightlyhigher dehiscence might be related to insufcient skills of

the students who performed most episiotomy proceduresin the hospitals. In the present study, repair duration wasrelatively long (35 min) which is probably accompaniedwith more manipulation of the incision, and may adverselyaffect wound healing.

We have no possibility to biopsy for follow-up of thewound due to nancial limitations. Although in this study

loss to follow-up at the 10th day was relatively high (15%),given that both groups had similar numbers and reasons ofwithdrawals (even higher frequency of withdrawals in thecinnamon group due to expressing improvement), the lossto follow-up probably has not affected the results in anysignicant way. Considering lack of previous studies on

human wounds, a low dose of cinnamon (2%) was used inthe present study.

This is the rst human study on the analgesic and healing

effects of cinnamon. Similar results have been shownin previous studies on non-human research subjects[18].More human studies carried out in other settings would bevaluable to conrm these effects on episiotomy and other

wounds. This study does not have enough statistical powerto identify safety of the intervention, which should beassessed in other trials on higher numbers of participantsor in meta-analysis of primary studies. Also, because no

particular side effects were reported in this and in otherstudies with higher doses (3%) on laboratory rats[18,22],future studies should be conducted with various doses of

cinnamon to identify the most effective dose.

5 Conclusion

Results of this study indicate that application of 2%

cinnamon ointment on episiotomy incisions has a signicanteffect in decreasing perineal pain and accelerating healingof the incision.

6 Competing interests

The authors declare that they have no competing interests.

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