**4. Discussion**

The current randomized controlled study was aimed at evaluating the effectiveness of neroli essential oil aromatherapy in relieving anxiety and perceived pain in women in labor. Results showed that neroli oil aromatherapy significantly and positively impacts women's experience of perceived pain and anxiety during labor, representing a further confirmation of the effectiveness of non-pharmacological methods in making the childbirth a less stressful experience.

Specifically, our findings showed that neroli oil reduced women's perception of pain and anxiety, which appeared less intense than in the women that did not receive aromatherapy treatment. Specifically, as the labor progressed, pain and anxiety increased in all participants, but the increase was milder in the experimental group when compared to the control group. Furthermore, since the average anxiety and perceived pain scores measured before labor did not differ between the experimental and control groups, while differed significantly after childbirth, we can conclude that neroli oil aromatherapy had a positive effect on anxiety and perceived pain. These findings confirm the results obtained in previous studies using other essential oils [16,28,38,39]. For instance, the use of essential oils in aromatherapy, thanks to their validated analgesic, anti-inflammatory, calming, and relaxing effects, has been proven to alleviate physical and emotional disorders in cancer patients [40]. This makes it reasonable to infer that aromatherapy represents a helpful alternative method for anxiety and pain control [41–43].

A second finding showed that the mean anxiety scores were higher in the multiparas than in the primiparas in all stages of labor. This might be explained by taking into account the role that previous experience might play in pregnant women's experience [44]. Provided that childbirth is a physically painful experience, we might hypothesize that having already gone through labor can be a predisposing factor for greater expectations of perceived pain, therefore explaining the differences in perceived anxiety in the two groups (i.e., primiparas vs. multiparas). However, this is a speculative and hypothetical explanation, as other studies have shown that primiparas experience more anxiety than multiparas during labor [44–47]. Thus, future studies should collect data about the quality of previous childbirth experiences in multiparas and assess whether negative experiences can affect anxiety during labor.

Findings should be read in light of some limitations. First, this study assessed only one mode of aromatherapy and one essential oil, and did not compare different techniques of aromatherapy administration or other essential oils. Future research should replicate this study assessing whether other techniques of aromatherapy and other essential oils are more or less effective than that used in this study. Second, the stressful condition under which participants had to answer the questionnaires may have confounded their responses to the pain and anxiety assessment. However, we tried to overcome this intrinsic limitation by administering not stressful and easy to use questionnaires (i.e., VAS and VAS-A). Third, we did not collect information about previous childbirth experiences or any other experience (e.g., previous negative medical experiences) that could have affected anxiety.

Despite these limitations, the findings obtained in the current study point to the fact that available non-pharmacological remedies such as aromatherapy are effective in relieving pain and anxiety in women during the most difficult phase of pregnancy, that is, labor and childbirth [48]. They also represent a viable alternative to a strict medicalization of labor [49], providing midwifes and Ob/Gyns with natural methods that can be easily used [10]. The relevance of our results also consists in the fact that when pain and anxiety are less severe, labor progresses more easily and with less difficulties. Therefore, neroli oil can and should be used as an alternative tool to relieve anxiety and perceived pain in women during all stages of labor.
