The Efficacy of Honey for the Treatment of Perineal Wounds Following Vaginal Birth: A Narrative Review

TL;DR

This review explores whether honey can help heal wounds in the perineal area after vaginal childbirth, suggesting it may be effective but more research is needed.

Contribution

The paper evaluates the potential of medical grade honey as a treatment for perineal wounds post-vaginal birth, highlighting its antimicrobial and healing properties.

Findings

Six out of seven controlled studies showed honey improved wound healing and reduced pain medication use.

Non-controlled studies also reported improved healing and reduced pain and prickling sensations.

Variability in honey formulations suggests the need for standardized medical grade honey for consistent results.

Abstract

Background/Objectives: During vaginal delivery, the perineum can be damaged either by episiotomy or by a spontaneous perineal tear, leading to several complications. The wound healing process should proceed as quickly and properly as possible without an infection. Medical grade honey (MGH) may be a potent treatment option due to its antimicrobial and pro-healing activities. This literature study investigated the role of honey in the treatment of vaginal wounds after delivery. Methods: Studies published before 17 July 2024 in the PubMed, Web of Science, Embase, Scopus, EBSCO host/CINAHL, Cochrane Library, and Google Scholar databases about honey, episiotomy wounds, and perineal tears, as well as those investigating wound healing and/or pain, were assessed. Results: Ten studies were included (six RCTs, of which three were double-blind, one was quasi-experimental with a posttest only, and three were observational studies without a control group), with 723 participants in total. Six of the seven controlled studies showed honey significantly improved various outcome measures, such as improved wound healing, and reduced need for pain medication. The three non-controlled studies also had a positive outcome, improving wound healing and decreasing pain intensity and prickling sensation. However, the overall quality of available evidence is limited. Different types of honey concentrations, origins, and additives were used in the included studies. Using a standardized MGH formulation may help to maintain consistent and potent effects. Therefore, additional research is needed to determine the efficacy of MGH in perineal trauma and to establish guidelines for clinical use. Conclusions: Honey potentially has a great effect on wound healing of perineal trauma; however, more research is necessary to substantiate the findings in the current literature.

Figures

Tables

Table 3. Summary of key outcomes per study. S = significant effect in favor of honey; NS = no significant difference; + = positive effect reported without significance mentioned (no control group).

Study	Wound Healing	Pain Intensity	Pain Relief Drugs Used	Pricking Sensation
Dompas, R. [35]	+
Gerosa, D. [32]		NS	S	NS
Ghaderbasti, S. [36]	S
Jaiswal, N. [37]	+	+		+
Lavaf, M. [38]	S	NS	NS
Manjula, P. [39]	S
Mulyaningsih, S. [40]	S
Nikpour, M. [41]	NS	NS
Pal, S. [42]	+	+
Torkashvand, S. [43]	S

Full text

1. Introduction

During vaginal delivery, the perineum can be damaged either by episiotomy or by a spontaneous perineal tear. At least 85% of women undergoing vaginal delivery suffer from perineal trauma of varying degrees [1,2]. In the UK, only 8.6% of the nulliparous women who give birth in the hospital have an intact perineum, and 28.5% of the multiparous women [3]. The episiotomy rate in vaginal deliveries varies worldwide, from 91% in Thailand to 4% in Denmark [4]. In the Netherlands, 16% of women who gave birth received an episiotomy in 2020 [5].

An episiotomy is a surgical procedure in which an incision is made in the perineum in the final stage of labor to dilate the vaginal orifice [6,7]. Various types of incisions are performed. In Europe, the mediolateral incision is the most common, and in the United States, the midline episiotomy is [6,7]. Indications for an episiotomy are fetal distress and shoulder dystocia [7,8]. Perineal tears can be divided into four grades: Grade 1 is a laceration limited to the vaginal mucosa or perineal skin; grade 2 involves the perineal muscles; grade 3 also includes the anal sphincter muscles; and grade 4 extends through the rectal mucosa [9,10]. In the literature, it remains unclear whether episiotomies could be used to prevent third- and fourth-degree tears, as the studies supporting this claim are observational and may be affected by confounding [9,11]. Routine use of episiotomies is not recommended by the World Health Organization [12] and the American College of Obstetrics and Gynecologists [13].

Perineal trauma is associated with both short- and long-term complications, such as pain and increased infection rates, which can lead to wound dehiscence [2,13,14,15,16,17]. Up to 80% of the dehiscence of episiotomy wounds are due to infection [18]. The incidence of infection after perineal trauma varies from 0.1% to 23.6% and wound dehiscence occurs between 0.21% to 24.6% [19]. Some studies show that severe perineal trauma is associated with anal incontinence, dyspareunia, and delays in resuming sexual activity [16,17,20,21,22]. Additionally, there might be an association between postpartum physical symptoms, such as pain and infection, and postnatal depression, anxiety, or posttraumatic stress symptoms [2]. Proper treatment is crucial to prevent an infection and accelerate recovery.

Honey may be a potent treatment to accelerate healing and has been used as therapy for wounds and local infections for thousands of years. It is an easily accessible, affordable option with good healing properties [23,24]. Honey is a thick, viscous substance composed of water, sugars, proteins, amino acids, enzymes (e.g., glucose oxidase), beeswax, minerals, pigments, and pollen [25]. Medical-grade honey (MGH) differs from regular honey because it is carefully assessed to ensure the quality of the honey, its safety, and efficacy. MGH is free of pollutants like pesticides, herbicides, heavy metals, and antibiotics [26].

MGH has antimicrobial and pro-healing properties. MGH promotes wound healing by multiple mechanisms, often related to its physicochemical composition. Its physical viscous state creates a moist wound environment, ensuring faster healing than dry or wet wounds. Autolytic debridement is stimulated by the low pH, the activation of proteases, and the lymphatic outflow generated by the osmotic activity. Granulation tissue formation, angiogenesis, and epithelialization are enhanced by the high sugar content serving as a nutrient source for the proliferation and migration of skin cells. Edema is reduced by honey’s anti-inflammatory properties and osmotic activities attracting lymph fluid from beneath the wound bed [23,24,27].

Honey’s antimicrobial mechanisms are also mediated by a multitude of mechanisms. Honey has a strong osmotic effect due to the high amount of sugar in honey, causing bacterial dehydration and inhibiting bacterial growth and cell division [23]. Glucose oxidase gradually converts glucose into gluconic acid and hydrogen peroxide. Gluconic acid causes the acidity of honey to reach a pH between 3.5 and 4.0, creating an environment inhospitable for bacterial growth [23]. Hydrogen peroxide aids in eliminating bacteria and sterilizes the wound site [24,25,27]. Phytomolecules in honey, such as flavonoids and polyphenols (e.g., methylglyoxal, B-defensin, chrysin), can have direct antimicrobial activity against planktonic bacteria and those existing in biofilms [23], or against viruses, fungi, and protozoa [27]. No resistance to honey has been reported to date because of the multitude of antimicrobial mechanisms [28]. Moreover, MGH possesses an immunomodulatory activity, having a dual role in controlling inflammation and infection [29]. In the inflammatory phase, honey can stimulate pro-inflammatory cytokines such as TNF-α, IL-1β, and IL-6, and activate B-, T-lymphocytes, and neutrophils that subsequently help to resolve infections. Contiguously, honey can downregulate NF-κβ and MAPK pathways and exert anti-inflammatory and antioxidant effects, stimulating wound healing and reducing scar formation [23,24,27,29]. MGH is considered safe in wound care, with minimal adverse effects. Honey allergy is very rare, with an estimated incidence of 1:100,000 people consuming honey [30]. Topical application of honey may be even less harmful than consuming it; however, it is not advised to use honey in people with a known allergy. Another side effect of honey may be experiencing a stinging or burning sensation upon application to injured tissue. This pain is thought to be caused by a strong osmotic effect, especially when high concentrations of honey are used. However, honey has also been reported to decrease pain levels during wound evolution [31]. Therefore, MGH may be a good therapy option for perineal wounds.

This study aims to conduct a literature search to investigate the clinical efficacy and the effects on experienced pain and wound healing of honey on episiotomy wounds or perineal tears.

2. Results

2.1. Study Selection

A systematic literature search was performed in databases PubMed, Embase, Cochrane, EBSCO host/CINAHL, Web of Science, and Scopus, followed by a free-text search on Google Scholar. More details on the search strategy, study selection, and data extraction can be found in the methods section. A total of 55 studies were identified from different databases, as demonstrated in the flowchart (Figure 1). The duplicates (n = 26) were removed before screening, and 29 articles remained. These remaining articles were screened, and 17 were excluded based on title and abstract when it was clear that the topic of the publication was unrelated. The full text of twelve reports was sought, of which two could not be retrieved (no full text available). In the end, 10 studies were included in this article.

2.2. Study Characteristics

The ten studies have a total of 723 participants who received an episiotomy or had a perineal tear. The number of participants per study ranged from 20 to 120. In three studies it remains unclear whether participants had perineal tears or episiotomies (n = 86). In the other studies, a total of 579 participants received an episiotomy and 50 participants had perineal tears. Due to the loss of follow-up in one of these studies [32], the perineal trauma status for eight participants remains unknown. Different outcome measures were examined; the majority of studies had episiotomy wound healing as the primary outcome measure, assessed through the REEDA-score (see Table 1). This scale can be used to evaluate the wound healing process by describing the following five parameters: redness, edema, ecchymosis, discharge, and approximation of perineal tissue [33,34]. A lower total score indicates better wound healing.

Five studies investigated the effect of honey on perineal pain intensity, assessed through the Visual Analogue Scale (VAS) for instance. Other outcome measures were pricking or burning sensation and tenderness (VAS), the number and dosage of pain relief drugs used, and the size of the wound (cm). Six study designs are randomized controlled trials (RCTs). Also, two comparative clinical study designs are used, a quasi-experimental posttest-only control group design and a one-group pretest–posttest design. Of all the studies, four took place in Iran, three in India, two in Indonesia, and one in Switzerland.

A clear overview of the included studies is provided in Table 2. Here, more detailed study characteristics such as the year of publication, country, study design, number of participants, inclusion and exclusion criteria, intervention and treatment details, control group, outcomes, and main conclusions are presented.

2.3. Data Synthesis

A meta-analysis could not be conducted due to the heterogeneity of studies. There are large variations in study design and intervention, e.g., honey formulation, dosing, application route, frequency of administration, and treatment duration, and differences in other study parameters, such as the use and composition of the control group, assessed outcome parameters, and evaluated time points (see Table 2). Due to the extensivity and diversity of the included studies, we created a new table to provide a quick overview of the results and enable a direct visual comparison of the studies (Table 3). The results can be divided into four key outcomes: wound healing, pain intensity, use of drugs to relieve pain, and pricking sensation. The significance level was included in the table depending on the study type having a control group.

The effect of honey on wound healing was investigated in nine of the ten included studies. Eight studies reported beneficial effects of honey, five of these studies were with a control group [35,36,37,38,39,40,42,43]. Torkashvand et al. [43] demonstrated a significantly lower mean REEDA score in the Olea ointment group (honey) compared to the control group at four intervals. The same applies to the honey group in the RCT by Lavaf et al. [38] on the 7th day postpartum. The RCT by Manjula et al. [39] showed a significantly faster healing pace with honey compared to betadine, and the RCT of Ghaderbasti et al. [36] proved that there was a significantly greater reduction in REEDA score in the honey group compared to the olive oil group. Mulyaningsih et al. [40] conducted a quasi-experimental, posttest-only control group study, in which the consumption of pineapple juice and honey had a significant effect on the acceleration of perineal wound healing. Nikpour et al. did not find a significant difference in wound healing when comparing the mean REEDA scores of the different treatment groups (honey, curcumin, and placebo) [41]. Jaiswal et al. and Pal et al. performed comparative clinical studies in which the outcome after treatment was compared to baseline levels [37,42]. Jaiswal found significant improvements in redness and edema, while Pal found significant improvements in redness, edema, and ecchymosis, both supporting a positive effect in wound healing. The one-group pretest–posttest study by Dompas et al. [35] referred to ‘an effect’. In this study, honey was consumed, combined with boiled water and betel leaves. This study did not examine whether the results were significant.

Regarding the intensity of pain, no significant differences were found in the RCTs of Gerosa et al., Nikpour et al., and Lavaf et al. [32,38,41]. However, 93% of the women in the study of Gerosa et al. were (very) satisfied with the use of honey. They found a significant decreases in the use of ibuprofen on day 4 in favor of the honey group despite the effects on pricking sensation being statistically non-significant. Lavaf did not find differences in the intake of pain relief drugs. However, Jaiswal et al. found significantly lower mean pain scores and less tenderness in the honey group after treatment when compared to before treatment [37]. In line with these findings, Pal et al. also demonstrated significantly reduced perineal pain, and less tenderness by honey [42].

3. Discussion

Many studies support the effectiveness of honey in wound management, for instance, in burns, diabetic foot ulcers, and chronic wounds [31,44,45]. Some studies indicate that honey can help reduce pain after tonsillectomy and in cold sores [46,47]. In this review, 10 studies were included, with a total of n = 723 participants who received an episiotomy or had a perineal tear. These studies have provided insight into the efficacy of honey on perineal trauma. Nine of the ten included studies found a positive effect of honey in at least one of the outcome measures. Wound healing was improved in eight out of nine studies, pain intensity was improved in two out of five studies, and pricking sensation and use of pain relief drugs improved in one out of two studies. Thus, it is found to accelerate recovery and improve the patient’s quality of life. In line with the conclusions of most of the included studies, the use of honey for the treatment of perineal wounds can be recommended.

Despite the consistent findings in wound healing and sometimes positive outcomes in other parameters, it is hard to draw an overarching conclusion, and the results should be interpreted with caution. There are many variables in the study setup, intervention, control groups, evaluated time points, and outcome parameters. Two studies investigated the effect of consuming honey [35,40], while the other studies investigated the effect of local application. Not only does the application of honey vary, but the composition of honey does as well. For example, pure honey [39], a mixture of honey with olive oil and sesame oil [43], 80% Manuka honey with 20% wax [32], 30–35% honey [38,41], honey in combination with boiled betel leaves [35], and pineapple juice with honey [40] were used in the studies considered. A higher percentage of honey does not necessarily lead to a more significant improvement in wound healing. Even with lower concentrations of honey, such as 30%, significant improvements in wound healing are observed. Honey is a natural product and, due to differences in composition and quality, the biological activity of honey varies. In addition, there might have been some interaction between honey and other supplements; however, these comprehensive medical preparations can have an additive effect. More research into the chemical composition and identification of the bioactive compounds of honey or other supplements and their molecular targets may further improve the therapeutic action on vaginal trauma in the future. In contrast to regular honey, (supplemented) MGH is, at least, standardized and carefully checked to ensure its quality, safety, and efficacy, and it is considered more consistent in its activity [26,48]. Therefore, it is recommended that MGH be used in future studies.

Moreover, the overall quality of available evidence is limited. Many studies lack transparency in their presentation of the results and methods. For instance, in the results section of the study by Jaiswal et al. [37], several tables are presented without captions or clear explanations, which complicates the interpretation of the results. Some studies are less reliable due to the lack of clearly formulated inclusion and exclusion criteria, for instance in the studies of Mulyaningsih et al. [40] and Dompas et al. [35] In addition, only three RCTs were double-blinded [36,38,41]. The other studies were (probably) not blinded, or single-blind, because no information was given about blinding. Also, unreliable study designs are included, such as the one-group pretest–posttest design [35], and the quasi-experimental design [40]. Quasi-experimental designs are susceptible to confounding variables as there is a lack of randomization, which can lead to bias. The findings of these study designs have a higher chance of being influenced by external factors.

Also, multiple studies lacked a proper control group. For example, when comparing the findings after treatment to the baseline level (before treatment) [35,37,42]. For wound healing, pain, and other outcomes, maturation effects are probable, because of expected improvement over time. In addition, the control group of the included studies varied from no intervention to placebo, standard hospital care, or another non-conventional treatment. Standard care can differ between hospitals. Because there is no consistent control group across all studies, no overarching conclusions can be drawn. The studies conducted by Nikpour et al., Lavaf et al., and Ghaderbasti et al. compared honey with a placebo [36,38,41]. However, it is very challenging to create a placebo for honey, due to its distinctive texture and scent. This raises questions about the integrity of the blinding process, potentially introducing bias. In addition, a placebo can also have some activity, e.g., by creating a moist wound environment. This might be a possible explanation as to why no significant differences were found in the study by Nikpour et al.

In most studies where honey was applied topically, it was used twice daily for a duration of 3 to 14 days, mostly for 10 days. Only in the study of Torkashvand et al. [43] was it used every 8 h, and in the study of Lavaf et al. [38] honey is applied once daily. It cannot be concluded that applying honey more frequently leads to a greater significant improvement. Only two studies reported the dosing (5 mL and one knuckle of cream). The use of clear application protocols and standardized honey formulations should help to ensure consistent results in future studies.

Some studies used a small sample size of 20 or 30 participants [35,37,42]. Small sample sizes can lead to less precise, less powerful, and more biased results. The ten studies were conducted in only four countries: Iran, Switzerland, Indonesia, and India. Four of these studies were performed in Iran, and three in India. This can negatively impact the reliability of the findings because of potential cultural and socioeconomic biases.

Many of the included studies did not distinguish between perineal tears versus episiotomies. Therefore, it is not possible to draw reliable conclusions about the differential effects of honey on the type of perineal trauma. It is important to draw this distinction, because there may be a difference in healing between perineal tears and episiotomy wounds.

The strength of this review is that it offers a comprehensive overview of the current literature concerning the use of honey for episiotomy wounds and perineal tears regarding wound healing and perineal pain. This patient group is considered homogeneous, as all individuals are postpartum women within a similar age range. This review includes a wide range of recent studies, with different study designs. Due to the systematic approach of our search, the extensivity of the search terms, and the search being performed in six different databases (and using additional sources), we expect that all relevant papers were found and included in this review.

To our knowledge, no previous literature review has specifically focused on perineal trauma and honey. However, Barbosa et al. conducted a systematic review recently (2024) investigating the effects of honey on wound healing and pain relief in obstetric wounds, including cesarean sections, episiotomies, and perineal tears, based exclusively on randomized controlled trials [49]. Surprisingly, they included only two RCTs with perineal wounds. Our review included six RCTs and other study designs. In addition, this review focused on perineal trauma, as cesarean sections and perineal injuries are not comparable, particularly due to differences in location, structure, and the microbiome. Barbosa et al. [49] concluded that honey has no significant improvement in wound healing, but that it is effective in reducing pain and decreasing the use of pain control medication.

This study is a good foundation for further research. Future studies are recommended to use MGH in (double)blinded randomized controlled trials. A power calculation is required to determine the sample size. Also, more research about adverse events, patient satisfaction, and overall experiences with honey treatment is warranted. Other outcome measures that should be examined include the effect of honey on scar formation, dyspareunia, infection and dehiscence, psychological well-being, and healthcare costs. MGH has been found effective in preventing infections previously in other studies, e.g., for the treatment of lacerations and C-sections [50,51,52]. It would be interesting to investigate the prophylactic activity of MGH for perineal wounds in the future.

4. Materials and Methods

4.1. Search Strategy

A literature search was performed on 17 July 2024 in databases PubMed, Embase, Cochrane, EBSCO host/CINAHL, Web of Science, and Scopus. Additionally, a search was performed on Google Scholar, and the reference lists of all the included studies were reviewed manually for studies that were eligible for inclusion (“snowballing”). The literature search included all studies investigating the effect of honey on episiotomy wounds or perineal tears. MeSH-terms and free-text terms that were used are, for example, (episiotomy) [MeSH] OR (episiotomy*) OR (perineotom*) OR (“perineal tear*”) OR (“perineal laceration*”) OR (“vaginal tear*”) AND (honey) [MeSH]. The full searches conducted in the different databases can be seen in ‘Appendix A’. Filters were not added regarding language or date of publication.

4.2. Study Selection

After obtaining all references, duplicates were removed. The first selection was based on the title and abstract. Next, the full texts were retrieved and assessed to see if they met the inclusion and exclusion criteria. The inclusion criteria were as follows: (1). studies with postpartum women who had a vaginal delivery and received an episiotomy, or had a perineal tear; (2). treatment with honey, compared to (no) control group or placebo; (3). the outcome measure being pain or wound healing. Exclusion criteria were as follows: (1). no episiotomy or perineal tear; (2). no intervention with honey; (3). there is no possibility of extracting data. The search included studies and articles published in any language. Whenever necessary, studies not written in English were translated with ‘Google Translate’. All articles were reviewed by one reviewer.

4.3. Data Extraction

The following data are extracted from the included studies: author, year of publication, research country, trial design, sample size, the inclusion-and-exclusion criteria, intervention and type of honey that was used, control group, dosage and frequency of treatment, outcome measures, results, and conclusion. Standardization of the study characteristics is difficult due to the diversity of research aims, study setup, and differences in reported outcome measures. However, we have unbiased and concisely presented as much relevant information as possible.

5. Conclusions

The findings of this review suggest that honey potentially has a great effect on wound healing and pain intensity of perineal trauma, as several studies show promising outcomes. However, the overall quality of available evidence is limited. Therefore, additional research, preferably in well-described large RCTs using MGH, is needed to determine the efficacy of honey in perineal trauma and to establish guidelines for clinical use. Performing cost-efficacy studies and investigating the prophylactic activity of MGH would be of additional interest.