ORIGINAL RESEARCH: EMPIRICAL RESEARCH –

QUANTITATIVE

Effects of an intervention with drinking chamomile tea on sleep

quality and depression in sleep disturbed postnatal women: a
randomized controlled trial
Shao-Min Chang & Chung-Hey Chen

Accepted for publication 10 September 2015

Correspondence to C.-H. Chen: C H A N G S . - M . & C H E N C . - H . ( 2 0 1 6 ) Effects of an intervention with drinking

e-mail: [email protected] chamomile tea on sleep quality and depression in sleep disturbed postnatal
women: a randomized controlled trial. Journal of Advanced Nursing 72(2), 306–
Shao-Min Chang MS RN
315. doi: 10.1111/jan.12836
Lecturer
Department of Nursing, Fooyin University,
Kaohsiung, Taiwan Abstract
Aim. The purpose of this study was to evaluate the effects of chamomile tea on
Chung-Hey Chen PhD RN sleep quality, fatigue and depression in postpartum women.
Professor Background. Sleep quality is a significant issue for postnatal women. Chamomile
Institute of Allied Health Sciences and is widely used as a folk remedy for its presumed sedative-hypnotic effects.
Department of Nursing, College of
Design. A pretest–post-test randomized controlled trial was used.
Medicine, National Cheng Kung University,
Methods. A total of 80 Taiwanese postnatal women with poor sleep quality
Tainan, Taiwan
(Postpartum Sleep Quality Scale; PSQS score ≧16) were recruited from November
2012-August 2013. They were systematically assigned, with a random start, to
either the experimental group (n = 40) or the control group (n = 40). The
participants in the experimental group were instructed to drink chamomile tea for
a period of 2 weeks. The participants in the control group received regular
postpartum care only. The PSQS, Edinburgh Postnatal Depression Scale, and
Postpartum Fatigue Scale were used to assess outcomes. Two-sample t-tests were
used to examine the mean differences in outcome variables between the two
groups.
Results. Compared with the control group, the experimental group demonstrated
significantly lower scores of physical-symptoms-related sleep inefficiency
(t = 2
482, P = 0
015) and the symptoms of depression (t = 2
372,
P = 0
020). However, the scores for all three instruments were similar for both
groups at 4-week post-test, suggesting that the positive effects of chamomile tea
were limited to the immediate term.
Conclusion. Chamomile tea may be recommended to postpartum women as a
supplementary approach to alleviating depression and sleep quality problems.

Keywords: chamomile tea, clinical trial, complementary therapy, depression, fa-

tigue, nursing, randomized controlled trial, sleep quality, women’s health

306 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Chamomile tea on postnatal depression and sleep quality

ment practices, do not have good night-time sleep quality.

Why is this research needed? Because of the role of the mother in Taiwan as the primary
● Sufficient rest and good-quality sleep is a foundation of caregiver, improving the sleep quality of puerperal women
postpartum health care. is a key health concern. Although the factors that may pre-
● Chamomile is widely used as a folk remedy for its pre- dispose postnatal women to sleep disorders have been pre-
sumed sedative-hypnotic effect and mood stabilizer. viously identified, few studies have been conducted to test
● Knowledge about the effects of chamomile tea on its uses sleep-disorder-related intervention protocols.
in treating insomnia and improving mood for postnatal
women are limited.
Background
What are the key findings?
Sleep disturbances are an important health issue that affects
● Postnatal women drinking German chamomile tea for 2 physical, mental, and emotional health and well-being.
weeks can significantly improve their physical symptoms Sleep quality is a critical factor of influence on quality of
associated with sleep inefficiency and depression symp-
life. Sufficient rest and good-quality sleep is a foundation of
toms.
postpartum health care. Researchers have reported that
● The positive effects of chamomile tea were limited to the
postpartum women experience more sleep disturbance, less
immediate term. The benefits of improving the sleep ineffi-
total sleep time, less sleep efficiency (time asleep vs. time in
ciency and depression symptoms did not continue after
ceasing the tea-drinking therapy. bed), and lower rapid eye movement than either pregnant
women or their non-postpartum peers (Lentz & Killien
How should the findings be used to influence policy/ 1991, Swain et al. 1997, Shinkoda et al. 1999, Lee et al.
practice/research/education? 2000, Gay et al. 2004, Dørheim et al. 2009, Ko et al.
● Chamomile tea may be recommended to postpartum 2010). Most report the highest levels of exhaustion during
women as a supplementary approach to alleviating sleep the first 3 postpartum months, especially for primiparae
quality problems and the symptoms of depression. (Lee et al. 2000, Teng et al. 2007). In a subjective evalua-
● Increase healthcare professionals’ awareness of the correct tion of sleep quality in 325 3-month postnatal women in
and positive use of herbal therapy in postpartum health Finland, Hedman et al. (2002) found that 20
5% reported
care. experiencing restless sleep. Two studies in Taiwan reported
finding higher incidences of restless sleep postnatal women
(67
4%; Ko et al. 2014 and 87
5%; Teng et al. 2007). Sev-
eral studies proposed that parental sleep patterns in the
postpartum period may be associated with the development
Introduction
of their infant’s circadian sleep-wake rhythm and his/her
Women must adjust physically and psychologically after feeding habits (Campbell 1986, Quillin 1997, Gay et al.
giving birth to take care of their newborn. Getting adequate 2004, Yamazaki et al. 2005, McGuire 2013). However,
rest and sleep are critical to the success of this postpartum mode of delivery and parity showed no significant impact
adjustment process. Swain et al. (1997) found that postpar- on maternal night-time sleep (Quillin 1997, Lee et al.
tum women spent 1
12 hours more awake during the night 2000). In addition, research has shown that continuously
than women in general. Hedman et al. (2002) studied 325 disrupted sleep during the postpartum period may nega-
pregnant women in Finland and found that the average tively affect a mother’s daytime functions and lead to fati-
sleep duration for these women at 3-month postpartum was gue and depression, which may hinder the healthy
one hour less than during pregnancy and that 20
5% self- development of the mother-infant relationship (Bei et al.
reported experiencing restless sleep. Huang et al. (2004) 2010, Insana et al. 2011).
found that the average primipara postpartum daily sleep Research has shown that interrupted sleep and increased
time in Taiwan was 4
83  1
63 hours, including about wake time at night may lead to poor sleep efficiency and
two hours of nap time during daylight hours. Teng et al. less the total sleep time in postpartum women (Poitras et al.
(2007) found that Taiwan postpartum women slept an 1973, Campbell 1986, Lentz & Killien 1991, Swain et al.
average of 5
99  1
47 hours. Other research has pointed 1997, Gay et al. 2004). Known causes of sleep disturbance
out that postnatal women need to take naps or daytime include physical discomfort, infant crying, disturbance by
sleep (Swain et al. 1997, Gay et al. 2004). Most Taiwanese bed partners, and perceived stress, among others. Postpar-
postpartum women, while following traditional confine- tum women thus face increased risk of depression

© 2015 John Wiley & Sons Ltd 307

S.-M. Chang and C.-H. Chen

(Eberhard-Gran et al. 2004, Munk-Olsen et al. 2006, Dør- diarrhoea; and to facilitate sleep (Viola et al. 1995, Gyllen-
heim et al. 2009, Bei et al. 2010). Shinkoda et al. (1999) haal et al. 2000, Srivastava et al. 2009).
demonstrated that postpartum women experience increased Chamomile combined valerian is a traditional herbal
irregular wake-cycle sleep and increased wake time at night remedy that has been used since ancient times to treat
during their first 5 postpartum weeks. Lee et al. (2000) insomnia and a wide range of other health complaints
pointed out that even 3~4 week-old babies still significantly (Ying 2002). Chamomile is sold as a tea, an extract, and a
impact the sleep patterns of their mothers. Hedman et al. topical ointment. In Europe today, chamomile is commonly
(2002) found that only 4
7% of 3-week-postpartum women used as an anti-inflammatory agent and mood stabilizer.
do not perceive interrupted nocturnal sleep. Some studies German chamomile is also a natural hypnotic agent because
identified infant awakenings at night as the main cause of it contains the flavonoid apigenin, which has an affinity for
the interrupted nocturnal sleep experienced by mothers benzodiazepine receptors (Cherniack 2006). While studies
(Dharamraj et al. 1981, Yamazaki et al. 2005, Teng et al. have noted the sedative effects of chamomile, there have
2007). been few studies published on its use in treating insomnia.
A variety of herbal teas have long been consumed as The present study is the first study known to the authors to
sleep aids, such as St. John’s wort, passion flower, chamo- explore the effects of chamomile tea on sleep quality, fati-
mile, valerian, and Kava (Beaubrun & Gray 2000). The gue, and depression in postnatal women.
World Health Organization estimates that 80% of the
world’s population relies on herbal medicine (Cass 2004).
The study
The best studied of above herbs as a folk remedy is cha-
momile. Chamomile has been used as a medicine for thou-
Aims
sands of years, with records of use by the ancient
Egyptians, Greeks, and Romans. Chamomile has histori- The purpose of this study was to evaluate the effects of
cally been used as a remedy for colds, sore throats, singe-ingredient chamomile tea on sleep quality, fatigue,
abscesses, gum inflammation (gingivitis), anxiety, insomnia, and depression in postpartum women.
acne, eczema, minor burns, inflammatory bowel disease
(ulcerative colitis), ulcers and childhood ailments such as
Design
chickenpox, diaper rash and colic (Beaubrun & Gray
2000). However, little experimental evidence has been A single-blinded, randomized controlled two-group pretest
published to support the efficacy of this herb. One study and repeated post-tests design was used to investigate the
on mice showed that chamomile has anti-inflammatory immediate (8 weeks postpartum) and long-term (10 weeks
and anti-oxidant effects (Bhaskaran et al. 2010). In the postpartum) effects of the chamomile tea therapy on mater-
United States, Amsterdam et al. (2009) found that oral nal outcomes, namely sleep quality, fatigue and depression.
chamomile extract capsules reduced mild to moderate gen-
eralized anxiety disorder (GAD) symptoms in patients. In
Participants
the United Kingdom, Wang et al. (2005) found that the
benefits to healthy individuals of consuming 5 cups of A convenience sample of 80 women in their sixth postpar-
commercially prepared chamomile tea for 2 weeks lasted tum week was recruited from a teaching hospital in south-
for up to 2 weeks after stopping consumption. ern Taiwan between November 2012–August 2013. The
Chamomile spread to Europe from Egypt German cha- inclusion criteria were: (1) normal childbirth; (2) no postna-
momile and Roman chamomile belong to the chamomile tal complications; (3) Postpartum Sleep Quality Scale ≧16;
family of plants, with German chamomile currently more and (4) informed consent to participate. Postnatal women
widely used in tea. German chamomile tea contains api- who reported having a history of allergy to any herbal tea,
genin, a flavonoid known to have a mild sedative effect. food, or medicine were excluded.
Chamomile flowers contain a large number of therapeuti- The sample size was calculated using power analysis for
cally active compounds that are often categorized according independent t-test. Extrapolating for a medium-high size
to their polarity. The most important bioactive components effect of 0
70, a minimum sample size 64 (32 per group)
are the flavonoids (Tschiggerl & Bucar 2012). The anti- was needed to achieve a power of 0
80 with an alpha of
inflammatory effect of German chamomile is used to 0
05 (Polit & Beck 2011). A dropout rate of 20% was orig-
increase immunity to cancer; to treat gastritis, chronic inally expected for this study, so the eventual sample size
digestive symptoms, anxiety disorders and intestinal was 80 in total, with 40 postnatal women in each group.

308 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Chamomile tea on postnatal depression and sleep quality

(2001) used this Chinese-version EPDS to assess maternal

Intervention
postpartum depression and achieved an internal consistency
At 6 weeks after childbirth, the participants in the experi- Cronbach’s a of 0
87 and concurrent validity with the Beck
mental group were instructed to drink one cup of chamo- Depression Inventory (r = 0
79). The Cronbach’s a for the
mile tea (origin: Germany) per day for weeks. Each cup of EPDS in this study was 0
84.
tea was prepared by steeping one teabag that contained 2 g We used the 12-item Postpartum Fatigue Scale (PFS;
of dried flowers in 300 ml of hot water for 10-15 minutes. Yang 1998) to measure subjective fatigue. Women were
Researchers provided a total of 14 teabags to each experi- asked to score their self-perceived level of fatigue during
mental-group participant. Women in the control group did the previous 1-week period on a 4-point Likert scale
not receive any intervention. (none = 0, mild = 1, moderate = 2, severe = 3). The total
possible scores ranged from 0-36, with a higher score indi-
cating higher postpartum fatigue. According to the work of
Outcome measures
Ko and Lu (2003), the PFS earned an internal consistency
A demographic data form was used to collect information Cronbach’s a of 0
85 and a score for relationship signifi-
on participant demographics (age, education, occupation, cance with the Yoshitake Fatigue Symptom Checklist of
socioeconomic status [SES]) and obstetric variables (type of r = 0
7, which indicates criterion validity. The Cronbach’s
delivery, parity, incidence of prematurity, feeding format, a for the PFS was 0
93 in this study.
neonate gender). We used the index of status position to
determine SES (Lin 1978).
Data collection
We used the 14-item Postpartum Sleep Quality Scale
(PSQS) (Yang et al. 2013) to measure subjective sleep qual- Eighty women who met the inclusion criteria and returned
ity. The PSQS contains two domains: infant night-care- their consent documents were assigned systematically from a
related daytime dysfunction (seven items address how taking random starting point with a week as a unit to either the
care of infants at night affected the postpartum woman’s experimental group (n = 40) or the control group (n = 40).
sleep quality and competency to manage daytime activities) The participants in both groups were asked to complete the
and physical-symptom-related sleep inefficiency (seven items Demographic Data Form, PSQS, EPDS, and PFS question-
address the woman’s physiological interference factors affect- naires at three time periods: before the intervention and at 2
ing sleep and sleep inefficiency symptoms). Women were and 4 weeks postintervention. The latter two sets of question-
asked to score the incidence of sleep problems during the pre- naires were mailed with postage-paid, pre-addressed envelopes
vious 2-week period on a 5-point Likert scale (never = 0, to all of the participants to be filled out and returned. Thirty-
few = 1, sometimes = 2, often = 3, almost always = 4). The five in the experimental and 38 in the control group completed
total possible scores ranged from 0 to 56, with higher scores the 2-week post-test questionnaires (immediate effect); 35 par-
correlating with poorer sleep quality. The PSQS had ade- ticipants in the experimental and 37 in control group com-
quate internal consistency (Cronbach’s a of 0
81), test-retest pleted the 4-week post-test questionnaires (longer term effect).
reliability (r = 0
81), construct validity, and convergent The CONSORT diagram of this study is shown in Figure 1.
validity with the Pittsburgh Sleep Quality Index (Buysse et al.
1989) in Taiwanese postpartum women (Yang et al. 2013).
Validity and reliability
Furthermore, the PSQS was found to have adequate internal
consistency for the participants in the present study (Cron- Validated instruments with good reliability were used to
bach’s a = 0
76). measure the outcomes to enhance the validity and reliability
We used the 10-item Edinburgh Postnatal Depression of the data. Research assistant had prior experience of
Scale (EPDS) (Cox et al. 1987) to measure postpartum intervention implementation and data collection and was
depression. The statements on the EPDS are designed to available for the entire data collection period. Standardized
assess postpartum depressive symptoms during the past instruction and procedure were used under the guidance of
7 days, with answers rated from ‘not at all’ (0) to ‘yes, the lead researcher CHC. All data were inspected carefully
most of the time’ (3). Total possible scores for the EPDS before data were entered and double entry of data was per-
range from 0-30. The Cronbach’s a was 0
87 (Cox et al. formed to eliminate data entry inaccuracies. The baseline
1987). The Chinese version of the EPDS was altered some- data from both the control and experiment group were
what from the original during the process of translation to tested for initial equivalence between the groups to control
reflect the appropriate linguistic and cultural contexts. Heh confounding factors.

© 2015 John Wiley & Sons Ltd 309

S.-M. Chang and C.-H. Chen

Assessed for eligibility (n = 80)

Randomized (n = 80)

Allocation

Allocated to chamomile tea (n = 40) Allocated to routine care (n = 40)

Two-week follow-up

Lost to follow-up (n = 5) Lost to follow-up (n = 2)

Incorrect contact details (n = 1)
Mailing loss (n = 5)
Mailing loss (n = 1)

Analyzed (n = 35) Analyzed (n = 38)

Four-week follow-up

Lost to follow-up (n = 0) Lost to follow-up (n = 1)

Mailing loss (n = 1)

Analyzed (n = 35) Analyzed (n = 37)

Figure 1 Flow diagram of this study.

would not affect their rights in any way. Those who agreed
Ethical considerations
to participate signed a consent form.
This study was approved by the appropriate institutional
review board. On visiting the postnatal clinic for a routine
Data analysis
examination, potential participants were given a written
explanation of the study. We emphasized that participation The SPSS (version 17.0 for Windows) statistical software
in this study was voluntary and that refusing to participate package was used to analyse the data. Demographic char-

310 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Chamomile tea on postnatal depression and sleep quality

acteristics and questionnaire data were summarized using The PSQS, EPDS and PFS scores for these two groups
descriptive statistics, including percentage, mean and stan- prior to the chamomile tea intervention were similar
dard deviation. Two-sample t-tests were used to examine (Table 2). A two-sample t-test was performed to compare
the mean differences in sleep quality, depression and fati- the effectiveness of the intervention. The comparisons of
gue between the two groups. By applying Bonferroni cor- the two groups that were conducted at 2 and 4-week post-
rection for three comparisons, statistically significant test indentified significant differences at the 2-week post-test
differences between the experimental and the control in the PSQS subscale ‘physical-symptoms-related sleep
group for the PSQS, EPDS and PFS at the two different inefficiency’ (t = 2
482, P = 0
015) and in the EPDS
time points were determined by P < 0
025 (Munro 2004). (t = 2
372, P = 0
020). Results identified that the benefits
to postnatal women of drinking German chamomile tea for
2 weeks include significant improvements in the physical
Results
symptoms associated with sleep inefficiency and the symp-
A total of 80 postnatal women were enrolled in this toms of depression. However, there were no significant dif-
study. Valid data were obtained from 35 participants in the ferences between the groups on the 4-week post-test in
experimental group (age range: 24-43 years; mean: 33
20 terms of scores for the three indices.
years) and 38 participants in the control group (age range: The participants reported no side effects from the treat-
25-40 years; mean: 32
68 years). No significant differences ment. In response to the open-ended questions, the experi-
were identified between the groups in terms of demographic mental-group participants reported that drinking German
characteristics (Table 1). chamomile tea effectively promoted sleep quality (40%),

Table 2 Two-sample t-tests for outcome variables, experimental

Table 1 Demographic and obstetric characteristics of the experi- and control groups.
mental and control groups.
Experimental Control
Experimental Control Scales Mean (SD) Mean (SD) t P
Variable (n = 35) (n = 38) v2 P
PSQS Factor 1
Education level Pretest 18
20 (3
612) 18
13 (4
425) 0
072 0
943
High school 4 (11
4%) 2 (5
2%) 5
175 0
075 2-week 15
09 (4
686) 16
47 (5
182) 1
197 0
235
College 20 (57
1%) 31 (81
6%) post-test
Graduate 11 (31
5%) 5 (13
2%) 4-week 13
91 (4
507) 14
27 (5
216) 0
309 0
758
Occupation post-test
Housewife 10 (28
6%) 10 (26
3%) 0
047 0
829 PSQS Factor 2
Employed 25 (71
4%) 28 (73
7%) Pretest 6
29 (4
004) 7
50 (3
391) 1
402 0
165
Social class 2-week 6
11 (2
867) 8
08 (3
787) 2
482 0
015
High 19 (54
3%) 18 (47
4%) 0
910 0
634 post-test
Middle 12 (34
3%) 17 (44
7%) 4-week 6
34 (3
038) 6
95 (3
756) 0
746 0
458
Low 4 (11
4%) 3 (7
9%) post-test
Type of delivery EPDS
Vaginal 23 (65
7%) 25 (65
8%) 0
000 0
955 Pretest 7
86 (4
577) 9
71 (4
274) 1
789 0
078
Caesarean 12 (34
3%) 13 (34
2%) 2-week 7
86 (4
864) 10
47 (4
560) 2
372 0
020
Parity post-test
Primiparous 18 (51
4%) 23 (60
5%) 0
613 0
434 4-week 7
26 (4
361) 9
51 (4
154) 2
248 0
028
Multiparous 17 (48
6%) 15 (39
5%) post-test
Gender of newborn PFS
Male 17 (48
6%) 20 (52
6%) 0
120 0
729 Pretest 13
77 (6
297) 14
74 (7
748) 0
581 0
563
Female 18 (51
4%) 18 (47
4%) 2-week 13
43 (6
473) 15
58 (8
265) 1
230 0
223
Gestational age of newborn post-test
Term 29 (82
9%) 30 (78
9%) 0
180 0
672 4-week 12
11 (5
138) 12
95 (7
524) 0
545 0
588
Preterm 6 (17
1%) 8 (21
1%) post-test
Type of infant feeding
PSQS Factor 1: infant night-care-related daytime dysfunction.
Breast 21 (60
0%) 16 (42
1%) 4
317 0
115
PSQS Factor 2: physical-symptom-related sleep inefficiency.
Bottle 0 (0
0%) 3 (7
9%)
Pretest: at 6 weeks postpartum; 2-week post-test: at 8 weeks post-
Mixed 14 (40
0%) 19 (50
0%)
partum; 4-week post-test: at 10 weeks postpartum.

© 2015 John Wiley & Sons Ltd 311

S.-M. Chang and C.-H. Chen

emotional stability and relaxation (37
1%) and that the tea relieves mood, which helps improve sleep quality. Research
was fragrant (11
4%). has shown that postpartum sleep disturbances significantly
affect the health of new mothers. Taiwanese women have
reported a 90-96% incidence of postpartum fatigue, with
Discussion
their levels of fatigue, encompassing both physical and psy-
We found that postpartum women who drank German cha- chological dimensions, ranging from mild to moderate and
momile tea once each day for weeks realized significant decreasing over time (Ko & Lu 2003). Fatigue negatively has
improvements in their physical-symptoms-related sleep inef- an impact on maternal tasks. The results of the present study
ficiency and postpartum depression (immediate effect). did not confirm that using German chamomile herbal tea
However, these effects were short-lived, with no effects improved postpartum fatigue.
found over the longer term, after the tea-drinking interven- The experimental group in this study considered benefits of
tion had ceased. German chamomile has been previously drinking German chamomile tea to be: facilitating emotional
used to treat sleep disorders. This herb contains apigenin, stability and relaxation and having an aromatic fragrance.
which exerts a slight sedative effect due to its affinity for For postpartum women, drinking German chamomile tea
central benzodiazepine receptors (Viola et al. 1995, Cherni- before bedtime may help calm restlessness, facilitate the post-
ack 2006, Tschiggerl & Bucar 2012). This is the first study natal paternity relationship, and alleviate postpartum fatigue.
to confirm the positive effects of drinking this tea on the Other strategies proposed to improve the sleep quality of
physical-symptoms-related sleep inefficiency of postnatal postpartum women include participation in sports activities,
women. However, we did not identify any effect on infant yoga, and massage. Each has demonstrated varying degrees
night-care-related daytime dysfunctions. The present study of efficacy. In addition to continually caring for her newborn,
also found that, while drinking German chamomile tea for a postpartum mother typically must finish other household
two consecutive weeks had an immediate effect on alleviat- work and may be required to return to her daytime job. All
ing postpartum depression, the effect did not last long after of these tasks exacerbate postpartum tiredness and fatigue.
the intervention ceased. Since the experimental group Therefore, consuming a suitable herbal tea that helps women
demonstrated lower scores of the symptoms of depression relax physically and mentally and contributes to improved
than control group (t = 2
248, P = 0
028), larger sample sleep quality should be considered a feasible and effective
size is needed to examine its longer term effect. Our study intervention.
partially echoes Wang et al. (2005), who found that the This study found that the participants who consumed Ger-
metabolic effects of consuming chamomile persisted during man chamomile tea for two consecutive weeks showed signif-
the 2-week postdosing period. However, the mechanism icant improvement in physical-symptoms-related sleep
behind these effects of chamomile tea on postpartum inefficiency and postpartum depression. However, after stop-
depression remains unclear and merits the further analysis ping the treatment, these positive effects did not last long
of the biological profile of chamomile. A possible interpre- enough to have a detectable effect at the 4-week follow-up
tation may be related to chamomile’s reportedly having a (at 10 weeks postpartum). Multiple daily consumptions or
mechanism of action similar to that of non-steroidal, anti- larger sample size may be recommended to test its lasting
inflammatory drugs (Srivastava et al. 2009). effect in the future. Another possible reason for the lack of a
Teng et al. (2007) found that postpartum depression and longer term effect is that at 8 weeks postpartum (2-week
sleeping with an infant may explain 28% of the variation in post-test) the employed women had completed their 2-month
sleep quality and that postpartum depression is a very impor- maternity leave and returned to their regular jobs. Therefore,
tant factor in predicting sleep quality. Our study results additional measurement points with shorter intervals
found that drinking German chamomile herbal tea effectively between each point may be necessary to confirm the actual
buffers postpartum depression. In the experimental group, duration of the therapeutic effects of chamomile tea.
the value of the PSQS subscale of ‘physical-symptoms-related
sleep inefficiency’ was significantly lower than that of the
Limitations
control group (P < 0
05). Although there were no significant
differences between the two groups in the overall PSQS and One of the limitations of this study is our use of single-
the PSQS subscale ‘Infant night-care-related daytime dys- ingredient chamomile tea that was brewed from dried cha-
function’, the mean post-test scores of the experimental momile flowers; these results may not be generalizable to
group were lower than those of the control group, especially chamomile teas that are blended with other herbs/ingredients.
in the 2-week post-tests. German chamomile calms and Second, because chamomile tea is widely believed to have

312 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Chamomile tea on postnatal depression and sleep quality

sedative-hypnotic effects, future research could use a pla-

Author contributions
cebo tea or compared with other tea to effectively exclude
the placebo effect. Third, the periods from 6 weeks (pret- All authors have agreed on the final version and meet at
ests) after birth to 10 weeks (4-week post-tests) are impor- least one of the following criteria [recommended by the
tant for infants to obtain their circadian rhythm which ICMJE (http://www.icmje.org/recommendations/)]:
influence mothers’ sleep (Nishihara et al. 2002); it is sug-
gested that parameters related to obtaining circadian • substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
rhythm process, e.g. longest sleep period and number of
data;
feeding at night, could be collected in future research.
Finally, the present study only included Taiwanese postna- • drafting the article or revising it critically for important
intellectual content.
tal women; future studies could duplicate it in other coun-
tries to enhance the generalization of chamomile tea
therapy. References
Amsterdam J.D., Li Y., Soeller I., Rockwell K., Mao J.J. & Shults
J. (2009) A randomized, double-blind, placebo-controlled trial of
Conclusion
oral Matricaria recutita (chamomile) extract therapy for
These findings support that drinking single-ingredient cha- generalized anxiety disorder. Journal of Clinical Pharmacology
momile tea once each day for a 2-week period has positive 29(4), 378–382. doi:10.1097/JCP.0b013e3181ac935c.
Beaubrun G. & Gray G.E. (2000) A review of herbal medicines for
and significant effects on the sleep quality and mental
psychiatric disorders. Psychiatric Services 51(9), 1130–1134.
health of postpartum women with poor sleep quality. The Bei B., Milgrom J., Ericksen J. & Trinder J. (2010) Subjective
lack of reported side effects further supports chamomile tea perception of sleep, but not its objective quality, is associated
consumption as an alternative therapy that is safe, simple, with immediate postpartum mood disturbances in healthy
cost-effective, and viable for postnatal women. The numer- women. Sleep 33(4), 531–538.
Bhaskaran N., Shukla S., Srivastava J.K. & Gupta S. (2010)
ous physiological and psychosocial adjustments and changes
Chamomile: an anti-inflammatory agent inhibits inducible nitric
that women experience during the postpartum period make oxide synthase expression by blocking RelA/p65 activity.
their physical and mental health important issues of con- International Journal of Molecular Medicine 26(6), 935–940.
cern to the healthcare community. Chamomile tea may be Buysse D.J., Reynolds C.F., Monk T.H., Berman S.R. & Kupfer
recommended to postpartum women as a supplementary D.J. (1989) The Pittsburgh Sleep Quality Index: a new
approach to alleviating sleep quality problems and the instrument for psychiatric practice and research. Psychiatry
Research 28(2), 193–213.
symptoms of depression. In addition, we hope that health-
Campbell I. (1986) Postpartum sleep patterns of mother-baby
care professionals will reference these findings to increase pairs. Midwifery 2(4), 193–201.
their awareness of the correct and positive use of herbal Cass H. (2004) Herbs for the nervous system: ginkgo, kava,
therapy in postpartum health care. Valerian, Passionflower. Herbal Medicine 2, 82–88.
Cherniack E.P. (2006) The use of alternative medicine for the
treatment of insomnia in the elderly. Psychogeriatrics 6(1),
Acknowledgement 21–30.
Cox J.L., Holden J.M. & Sagovsky R. (1987) Detection of
The National Science Council, Taiwan financially supported postnatal depression. Development of the 10-item Edinburgh
this work. We thank the participants for their help in mak- Postnatal Depression Scale. British Journal of Psychiatry 150,
ing this study possible. 782–786.
Dharamraj C., Sia C.G., Kierney C.M., Parekh A., Harper R.G. &
Weissman B. (1981) Observations on maternal preference for
rooming-in facilities. Pediatrics 67(5), 638–640.
Funding
Dørheim S.K., Bondevik G.T., Eberhard-Gran M. & Bjorvatn B.
This study was funded by Grant NSC 99-2628-B-006-035 (2009) Sleep and depression in postpartum women: a
from the Taiwan National Science Council. population-based study. Sleep 32(7), 847–855.
Eberhard-Gran M., Tambs K., Opjordsmoen S., Skrondal A. &
Eskild A. (2004) Depression during pregnancy and after delivery:
Conflict of interest a repeated measurement study. Journal of Psychosomatic
Obstetrics & Gynecology 25(1), 15–21. doi:10.1080/
No conflict of interest has been declared by the authors. 01674820410001737405.

© 2015 John Wiley & Sons Ltd 313

S.-M. Chang and C.-H. Chen

Gay C.L., Lee K.A. & Lee S.Y. (2004) Sleep patterns and fatigue women before and after delivery. Canadian Psychiatric
in new mothers and fathers. Biological Research for Nursing 5 Association Journal 18(6), 519–526.
(4), 311–318. Polit D.F. & Beck C.T. (2011) Nursing Research: Generating and
Gyllenhaal C., Merritt S.L., Peterson S.D., Block K.I. & Gochenour Assessing Evidence for Nursing Practice, 9th edn. Lippincott
T. (2000) Efficacy and safety of herbal stimulants and sedatives in Williams & Wilkins, Philadelphia.
sleep disorders. Sleep Medicine Reviews 4(3), 229–251. Quillin S.I. (1997) Infant and mother sleep patterns during 4th
Hedman C., Pohjasvaara T., Tolonen U., Suhonen-Malm A.S. & postpartum week. Issues Comprehensive Pediatric Nursing 20(2),
Myllyla V.V. (2002) Effects of pregnancy on mothers’ sleep. 115–123.
Sleep Medicine 3(1), 37–42. Shinkoda H., Matsumoto K. & Park Y.M. (1999) Changes in
Heh S.S. (2001) Validation of the Chinese version of the Edinburgh sleep-wake cycle during the period from late pregnancy to
Postnatal Depression Scale: detecting postnatal depression in puerperium identified through the wrist actigraph and sleep logs.
Taiwanese women. Journal of Nursing Research 9(2), 105–113. Psychiatry and Clinical Neurosciences 53(2), 133–135.
Huang C.M., Carter P.A. & Guo J.L. (2004) A comparison of Srivastava J.K., Pandey M. & Gupta S. (2009) Chamomile, a novel
sleep and daytime sleepiness in depressed and non-depressed and selective COX-2 inhibitor with anti-inflammatory activity.
mothers during the early postpartum period. The Journal of Life Science 85, 663–669.
Nursing Research 12(4), 287–296. Swain A.M., O’Hara M.W., Starr K.R. & Gorman L.L. (1997) A
Insana S.P., Stacom E.E. & Montgomery-Downs H.E. (2011) Actual prospective study of sleep, mood, and cognitive function in
and perceived sleep: association with daytime functioning among postpartum and nonpostpartum women. Obstetrics &
postpartum women. Physiology & Behavior 102(2), 234–238. Gynecology 90(3), 381–386.
Ko Y.L. & Lu C.M. (2003) Psychophysiologic and situational Teng F.L., See L.C., Cheng P.J. & Lee J.T. (2007) The quality of
correlates of postpartum fatigue. Journal of Health Education sleep and its associated factors in the puerperium women. Chang
19, 137–153 (Original work published in Chinese). Gung Nursing 18(4), 499–510 (Original work published in
Ko S.H., Chang S.C. & Chen C.H. (2010) A comparative study of Chinese).
sleep quality between pregnant and non-pregnant Taiwanese Tschiggerl C. & Bucar F. (2012) Guaianolides and volatile
women. Journal of Nursing Scholarship 42(1), 23–30. compounds in chamomile tea. Plant Foods for Human Nutrition
Ko S.H., Chen C.H., Wang H.H. & Su Y.T. (2014) Postpartum 67(2), 129–135.
women’s sleep quality and its predictors in Taiwan. Journal of Viola H., Wasowski C., Levi de Stein M., Wolfman C., Silveira R.,
Nursing Scholarship 46(2), 74–81. Dajas F., Medina J.H. & Paladini A.C. (1995) Apigenin, a
Lee K.A., Zaffke M.E. & McEnany G. (2000) Parity and sleep component of Matricaria recutita flowers, is a central
patterns during and after pregnancy. Obstetrics & Gynecology benzodiazepine receptors-ligand with anxiolytic effects. Planta
95(1), 14–18. Medica 61(3), 213–216.
Lentz M.J. & Killien M.G. (1991) Are you sleeping? Sleep patterns Wang Y., Tang H., Nicholson J.K., Hylands P.J., Sampson J. &
during postpartum hospitalization. The Journal of Perinatal and Holmes E. (2005) A metabonomic strategy for the detection of
Neonatal Nursing 4(4), 30–38. the metabolic effects of chamomile (Matricaria recutita L.)
Lin T. (1978) Psychiatry and Society. Chi-Tsung, Taipei, Taiwan. ingestion. Journal of Agricultural and Food Chemistry 53, 191–
McGuire E. (2013) Maternal and infant sleep postpartum. 196.
Breastfeeding Review 21(2), 38–41. Yamazaki A., Lee K.A., Kennedy H.P. & Weiss S.J. (2005)
Munk-Olsen T., Laursen T.M., Pedersen C.B., Mors O. & Mortensen Sleep-wake cycles, social rhythms, and sleeping arrangement
P.B. (2006) New parents and mental disorders: a population-based during Japanese childbearing family transition. Journal of
register study. The Journal of the American Medical Association Obstetric, Gynecologic, and Neonatal Nursing 34(3), 342–348.
296(21), 2582–2589. doi:10.1001/jama.296.21.2582. Yang Y.O. (1998) The correlation of postpartum fatigue, social
Munro B.H. (2004) Statistical Methods for Health Care Research, support, and maternal confidence. Unpublished Taiwan National
5th edn. Lippincott Williams & Wilkins, New York. Science Council research project report, Taipei, Taiwan.
Nishihara K., Horiuchi S., Eto H. & Uchida S. (2002) The Yang C.L., Yu C.H. & Chen C.H. (2013) Development and
development of infants’ circadian rest-activity rhythm and validation of the Postpartum Sleep Quality Scale. Journal of
mothers’ rhythm. Physiology & Behavior 77, 91–98. Nursing Research 21(2), 148–154.
Poitras R., Thorkildsen A., Gagnon M.A. & Naiman J. (1973) Ying G.J. (2002) Healthful Herbal Tea. Sun-Ching Culture, Taipei,
Auditory discrimination during REM and non-REM sleep in Taiwan.

314 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUANTITATIVE Chamomile tea on postnatal depression and sleep quality

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

© 2015 John Wiley & Sons Ltd 315