BMC Pregnancy Childbirth. 2016; 16: 296.
Published online 2016 Oct 6. doi: 10.1186/s12884-016-1095-5
PMCID: PMC5053208
1Department of Paediatrics and Child Health, St. Mary’s Hospital Lacor, P.O Box 180, Gulu District, Uganda
2Department
of Epidemiology and Biostatistics, Makerere University School of Public
Health, Makerere University College of Health Sciences, P.O. Box 7072,
Kampala, Uganda
3Department
of Disease Control and Environmental Health, Makerere University School
of Public Health, Makerere University College of Health Sciences, P.O.
Box 7072, Kampala, Uganda
Richard Nyeko, Phone: +256-782 893564, Email: moc.oohay@okeyn_drahcir.
Corresponding author.Abstract
Background
According
to World Health Organization (WHO) estimates, 80 % of the population
living in rural areas in developing countries depends on traditional
medicine for their health needs, including use during pregnancy. Despite
the fact that knowledge of potential side effects of many herbal
medicines in pregnancy is limited and that some herbal products may be
teratogenic, data on the extent of use of herbal medicines by women
during pregnancy in the study setting is largely unknown. We determined
the prevalence and factors associated with herbal medicine use during
pregnancy among women attending postnatal clinics in Gulu district,
Northern Uganda.
Methods
This
was a descriptive cross-sectional study which involved 383 women
attending postnatal care across four sites in Gulu district using
quantitative and qualitative methods of data collection. A structured
questionnaire was used to collect quantitative data while qualitative
data were obtained using focus group discussions and key informant
interviews. The selection of the study participants was by systematic
sampling and the main outcome variable was the proportion of mothers who
used herbal medicine. Quantitative data was coded and entered into a
computerized database using Epidata 3.1. Analysis was done using
Statistical Package for Social Scientists version 13, while thematic
analysis was used for qualitative data.
Results
The
prevalence of herbal medicines use during the current pregnancy was
20 % (78/383), and was commonly used in the second 23 % (18/78) and
third 21 % (16/78) trimesters. The factors significantly associated with
use of herbal medicines during pregnancy were perception (OR 2.18, CI
1.02-4.66), and having ever used herbal medicines during previous
pregnancy (OR 2.51, CI 1.21-5.19) and for other reasons (OR 3.87, CI
1.46-10.25).
Conclusions
The
use of herbal medicines during pregnancy among women in Gulu district
is common, which may be an indicator for poor access to conventional
western healthcare. Perception that herbal medicines are effective and
having ever used herbal medicines during previous pregnancy were
associated with use of herbal medicines during current pregnancy. This
therefore calls for community sensitization drives on the dangers of
indiscriminate use of herbal medicine in pregnancy, as well as
integration of trained traditional herbalists and all those community
persons who influence the process in addressing the varied health needs
of pregnant women.
Keywords: Herbal medicines, Pregnancy, Maternal health services, Maternal mortality
Background
The
use of herbal medicines is believed to be increasing in many developing
and industrialized countries, yet little is known about their use and
safety especially during pregnancy [1].
Herbal medicines in this case are defined as plant-derived material and
preparations perceived to have therapeutic benefits, containing raw or
processed ingredients from one or more plants [2],
and include herbs, herbal materials, herbal preparations, and finished
herbal products that contain parts of plants or other plant materials as
actual ingredients [3].
It is estimated that 80 % of the population living in rural areas in
developing countries depends on traditional medicine for their health
needs [4, 5],
including use during pregnancy. While use of herbal medicines in
pregnancy vary considerably between countries, many of the same herbs
are used [6].
Evidence from the African continent suggests wide variability in use of
herbal medicines during pregnancy, from a high of about 68 % as
reported in one Nigerian study [7] to a low of 12 % in another study [8]. In Lusaka, Zambia, 21 % of pregnant women seeking care in public health system used traditional medicines during pregnancy [9].
In
Uganda, it is estimated that over 60 % of the population seek medical
attention from traditional healers, a pattern which cuts across all
social classes and education levels [4],
where traditional herbal medicine is widely used for prevention,
diagnosis and treatment of social, mental and physical illnesses [10].
Majority of patients in Gulu district, including pregnant women are
suspected to use traditional herbal medicines for a number of ailments,
but the actual burden of use of herbal medicines by women during
pregnancy is still unknown. In the same breath, use of herbal medicine
is believed to be a contributing factor to poor access to, and use of,
maternal healthcare services, including antenatal care (ANC) services
and health facility delivery that are aimed at reduction of maternal
death, currently at 438 per 100,000 live births [11],
indicating that Uganda is unlikely to meet the millennium development
goal (MDG) 5. For instance, whereas over 90 % of pregnant women attend
at least one ANC visit, only about 47 % attend the World Health
Organization (WHO)-recommended four or more ANC visits during their
pregnancy [12], and only 57 % give birth in a health facility [11],
suggesting possibility of resorting to alternative methods of health
care, including use of herbal medicines. According to a report by
Lamorde et al. (2008) in a study of medicinal plants used for HIV/AIDS
related conditions in Gulu and other selected Ugandan disctrics, the
most frequently used herbal medicine plant species include Aloe sp,
Erythrina abyssinica DC, Sarcocephalus latifolius, Psorospermum
febrifugum spach, Mangifera indica L, and Warburgia salutaris [13].
Like modern pharmaceutical drugs, herbal medicines, however, have the potential to cause adverse effects [14].
The causes of such adverse reactions are diverse, including the use of
inherently toxic herbal medicines or an overdose of herbs, conventional
drug-herbal medicine interactions, and idiosyncratic reactions such as
allergies [15].
Therefore, relying on herbal medicines during pregnancy instead of
scientifically proven treatment can have serious consequences, suggested
to include fetal distress and premature deliveries [16], intrauterine growth restriction and decreased fetal survival [17], and congenital malformations [18],
among others. Also among the variety of biological properties of herbal
medicines is the ability to contract the uterus thereby posing the risk
of abortion [19].
Furthermore, concomitant use of herbal products with the pharmaceutical
medications leads to drug interactions with resultant undesirable
effects of increased toxicity and decreased efficacy.
Despite the fact that knowledge of potential side effects of many herbal medicines in pregnancy is limited [1, 20–22], and that some herbal products may be teratogenic [23–25], exposure to herbal products is frequent in pregnancy [26], often on a self-treatment basis [27].
Similarly, while pregnant women recognize the potential risks of drug
usage during pregnancy, they do not realize that herbal products could
also be toxic, premised on the implicit belief that herbal products,
being natural, are necessarily safe [28].
The use of herbal medicines in general, and in pregnancy in particular
has been contributed to by a number of factors, including the belief
that herbal products are safe and general ease of access [29], lack of access to public health system [5]
and high cost of modern healthcare, perceived low costs of herbal
products, socio-demographic characteristics, and social and cultural
influences, among others [30, 31].
On the other hand, women who seek abortion may deliberately use the
frequently unsafe traditional herbal products to induce fetal loss [2].
For instance, in one study of unsafe abortion in rural Tanzania, almost
half of the women who experienced an unsafe abortion had resorted to
traditional providers and plant species were in these cases often used
as abortion remedies [32].
This study therefore seeks to determine the prevalence and factors
associated with use of herbal medicines during pregnancy among women
attending postnatal clinics in Gulu district, northern Uganda.
Methods
Study setting
The
study was conducted in four (4) selected health facilities in Gulu
district, northern Uganda, with a population of 479,496 inhabitants [33].
The main economic activity in the district is subsistence agriculture,
in which over 90 % of the population is engaged. The district has one
government regional referral hospital, two private hospitals, two health
centre IVs and thirteen health centre IIIs which provide maternal
health services including postnatal care services. However, access to
health services still remains a challenge in the district as a whole.
Over 37 % of the population moves a distance of more than 5 km to reach
health services. High levels of poverty and illiteracy, especially among
women, is exacerbated by high prevalence of preventable diseases.
Study design and sample size
This
was a descriptive cross-sectional study, using both quantitative and
qualitative methods, and involving 383 postnatal mothers attending
postnatal clinics (PNC) within the study period. The sample size was
calculated using the Kish Leslie formula [34], using the formula, n = z2pq/d2, where n = required sample size, z = standard normal value corresponding to 95 % confidence interval (1.96), p = estimated proportion of herbal medicine use among pregnant women, which in this case is 21 % [9],
q = p-1, and d = absolute errors between estimated and true value
(5 %). This was multiplied by a design effect of 1.5, giving a total
sample size of 383. The study population consisted of women attending
postnatal clinic in the facilities in Gulu district during the study
period. Women who were critically sick at the time of the visit (5
respondents) and those who were not able to understand the questions
because of language barrier (2 respondents) were excluded.
Sampling technique
Multistage
sampling technique was used to select first, the health facilities for
the study, and later, the respondents from each facility selected. The
health facilities were first grouped into three strata comprising
hospitals, health center IVs and health center IIIs. The only public
hospital together with the two private hospitals were all grouped as one
stratum of ‘hospitals’. Simple random sampling was then used to select
the desired number of facility from each stratum where two hospitals and
one health center each from the health center IV and III strata were
selected as sites for the study. The determination of the number of
health facilities chosen from each stratum was purposive in order to
keep the research within the scope. The selection of the study
participants from each of the sampled health facility was done by
systematic sampling until the required sample size was realized.
According to a preliminary survey of records from the health facility
postnatal registers, it was estimated that about 20 mothers attend the
PNC daily in hospitals and health center IVs (HCIVs), while about 10
attend in health center IIIs (HCIIIs). We therefore recruited 6
participants each day from the hospitals and HCIVs, and 3 from health
center III. Therefore, every third mother (20/6 and 10/3 for
hospitals/HCIV and HCIII respectively) was selected for the study, with
the first participant being picked at random from assigned numbers. The
selected mothers were then introduced to the study in more details,
including the working definition of herbal medicine, and informed
consent obtained for participation in the study before enrollement.
Study procedure and data collection
A
pre-coded and pre-tested structured questionnaire to capture
respondents’ demographic characteristics, obstetrics characteristics,
herbal medicine use during pregnancy and associated factors, and
characteristics of herbal medicine use was used to collect quantitative
data, while qualitative data were collected from focus group discussions
(FGD) and key informant interviews (KII) using FGD and KII guides
respectively. The questionnaires and interview guides were written in
English as well as translated and administered in the local language
understood by the participants.
For
qualitative data, three focus group discussions (FGDs) were conducted in
the community involving women who had not been part of the quantitative
study in order to get a local perspective of the subject matter. Eight
mothers were included in each of the FGDs. The groups involved mothers
in the age group 20–38 years excluding grandmothers and mothers-in-law
who usually have great influence in this community, in order to allow
free expression of views. The discussions were moderated by the
researcher and recorded on tape as well as notes taken by a rapporteur.
Four key informants comprising one village health team (VHT), one local
council one and two midwives were selectively interviewed to get a
broader perspective of the aspects of herbal medicine use during
pregnancy.
Statistical analysis
Quantitative data
Data
were coded and entered into a computerized database using Epidata 3.1.
Data were cleaned and analysis was done at three levels using
Statistical Package for Social Scientists (SPSS) version 13 software
package. In univariate analysis, categorical variables were
summarized as proportions, while continuous variables as means, median
and standard deviations (SD). Prevalence was calculated as the
proportion of study participants who used herbal medicines, the
denominator being all postnatal mothers enrolled in the study. In the
bi-variate analysis, the chi-square test (for categorical variables) and
student t-test (for continuous variables) were used to test if
the factors among mothers who used herbal medicines during pregnancy
were different from those among mothers who did not use herbal
medicines. Odds ratios, with 95 % confidence interval (CI) was used to
measure the strength of association between use of herbal medicines
during pregnancy and individual, socio-cultural, obstetrics/maternal,
and health systems factors.
Multivariable
analysis using logistic regression, backward stepwise procedure was
used to select variables to be included in the final model to determine
the factors that were independently associated with use of herbal
medicine during pregnancy. Included in the model at multivariable
analysis were factors that were significant at bivariate analysis and
those with scientific plausibility though were not significant. P-value <0.05 was considered for statistical significance. Results were summarized in bar graphs, tables, and texts.
Qualitative data
Qualitative
information generated from the FGDs and Key informant interviews were
analyzed manually using thematic analysis according to emerging themes.
Transcribed data were coded and main emerging themes were identified and
presented as text quotes.
Results
Socio-demographic characteristics
Three hundred and eighty three respondents were enrolled in the study (Fig. 1).
Majority, 41 % (156/383) of the respondents were between 20 and
24 years of age and at least 15 % (56/383) were teen mothers (15–19 year
old), 70 % (39/56) of whom were in the legally recognized marriage age
of 18–19 years. More than three-quarter of the respondents, 76 %
(290/383) attained either no formal education or just primary level of
education and majority 74 % (282/383) were residing in rural settings.
The rest of the socio-demographic characteristics of the respondents are
as summarized in Table 1.
While all except two of the respondents attended antenatal care (ANC),
only about half 49 % (186/383) had the recommended ≥4 goal-oriented ANC
attendances. The other obstetrics characteristics of the respondents are
summarized in Table 2.
Study profile
Baseline socio-demographic characteristics of the study population
Obstetrics and other characteristics of the study population
Qualitative findings
The
single most common theme that emerged from the qualitative data was
facilitators of herbal medicine use, in addition to disclosure of herbal
medicine use which also emerged as an issue to the respondents. The
facilitator theme describes the factors that encouraged the use of
herbal medicines and included belief that herbal medicines are effective
in treating many ailments, previous experience with herbal medicines,
cost of modern healthcare, and dissatisfaction with the healthcare
system, among others. The disclosure theme mainly describes the
respondents’ reasons for not volunteering information about use of
herbal medicine to their healthcare providers and included fear of the
health workers reaction, and being denied care. The two themes are
described verbatim in quotes in triangulation with the quantitative data
in the sections below.
Prevalence of herbal medicine use
The
prevalence of herbal medicine use during the current pregnancy was 21 %
(78/383), while use of herbal medicines in general is common in the
study setting (Fig. 2).
Ingestion was the major method of use of herbal medicines 69 % (54/78)
and majority 90 % (70/78) of the users of herbal medicines did not
disclose the use of these local herbs to their attending healthcare
workers at ANC and delivery (Table 3). Views during the FGDs did not differ much from the above finding, as reported by one of the mothers:
“For me I think it is not possible to tell the health workers that you took local herbs because they can become rude to you since they say people should come to hospital when they are sick but not to use local medicines. They can also refuse to give you treatment from the hospital if you say you have taken local medicines when you are also receiving care from the hospital.” FGD, 20 year old mother.
Prevalence of herbal medicine use by respondents
Characteristics of herbal medicine use during pregnancy
Similarly, one of the key informants also observed that:
“We sometimes get to know about these mothers using local herbal medicines during labour from the colour of their liquor or traces of the herbs in the genital parts, otherwise they will not tell you that they have used local herbs…” KII, midwife.
Majority of users of herbal medicines
during pregnancy had multiple reasons for use of these medicines, with
the most common indications being abdominal/waist pain (43 %), febrile
illness (45 %), inducing/enhancing labour (28 %), skin problems (24 %),
nausea and vomiting (22 %), and difficult access to health facility
(41.3 %), amomg others, as summarized in Table 4.
The wide use of herbal medicines for various indications was also
exemplified in one of the FGDs where one respondent asserted thus:
“…local herbs work as well as other medicines. It works in waist pain, perianal wounds in children and “twor rubanga” (TB spine). I had a painful period and when I tried the hospital the medicines did not work but when somebody gave me local herbs, it subsided.” FGD, 28 year old mother of four.
Reasons for using herbal medicine during pregnancy
Factors associated with herbal medicine use
At
bivariate analysis, mothers who believed in herbal medicines were ten
times more likely to use herbal products during pregnancy than those
believing otherwise and this was statistically significant (OR 10.02;
95 % CI 5.67-17.73). This finding was supported by results from the FGDs
where one of the respondents reported:
“I was told that the local herbs are the ones made into modern medicines, so they should work the same way. I have used local herbs for all my ailments, including during my previous pregnancies and I have not experienced any problems. It is true people take local herbs for many illnesses and they get cured, sometimes even if you are taken to the hospital, the doctor can even say go back for local herbs because they cannot manage that condition.” FGD, 35 year old mother.
Similarly, ever having used herbal medicines for
other reasons was significantly associated with use of herbal medicines
during the current pregnancy. The other individual and socio-cultural
factors associated with use of herbal medicines among the respondents
are as summarized in Table 5.
Individual and socio-cultural factors associated with use of herbal medicines
Parity
showed a statistically significant negative association with use of
herbal medicines during pregnancy (OR 0.50; 95 % CI 0.25-0.98), implying
women who are first time mothers were less likely to use herbal
medicines during pregnancy. Women who used herbal medicines in their
previous pregnancies were eight times more likely to use herbal
medicines in their current pregnancies and this was statistically
significant (OR 7.98; 95 % CI 4.45-14.30). Similarly, residing more than
5kms from the nearest health facility was more likely to be associated
with use of herbal medicine during pregnancy and this was statistically
significant (OR 2.43; 95 % CI 1.46-4.05) (Table 6).
This finding was supported by results from the FGDs as typified by one
respondent who, in expressing her concern, observed thus:
“You can waste your little money and time going to the health facilities for problems like pain, cough, fever and the only thing they tell you is that there is no medicine, sometimes you only come back with aspirin or panadol, or you can even come back without any medicine and yet you travel from long distance which is expensive. So it is better to first get help from home and maybe only go to the health facility when you have failed to improve.” FGD, a mother of five.
Obstetric/maternal and health systems factors associated with use of herbal medicine during pregnancy
Simlilarly, one of the key informants from one of the health facilities reported:
“…some of our mothers come from far distances to receive healthcare services and sometimes they are not able to afford transport money, so they prefer to use local herbs and only come to hospitals at the end…” KII, midwife.
At multivariable logistic
regression analysis, belief that herbal medicines are effective/safe, as
well as previous use of herbal medicines during pregnancy or for other
reasons were the only significant independent predictors of use of
herbal medicines during pregnancy in this study. The factors that
remained in the model even though were not statistically significant
were age, distance from nearest health facility, self-medication and
parity (Table 7).
Multivariable logistic regression model for use of herbal medicines
Discussion
The
present study determined the prevalence and factors associated with use
of herbal medicines during pregnancy among 383 women attending
postnatal clinics in Gulu district, Uganda. Our main findings show that
use of herbal medicines during pregnancy in the study setting is common.
Prevalence of herbal medicine use
The
prevalence of herbal medicines use during pregnancy among the
postpartum women in the current study is comparable to one reported by
Yolan et al. (2007) in Lusaka, Zambia [9].
The current finding, however, contrasts with results from a similar
study in Nigeria where a much higher proportion of women used herbal
medicines during pregnancy [7].
The finding from the present study also shows a lower prevalence of use
of herbal medicines during pregnancy in comparison with other similar
studies [14, 35, 36]; but higher than the prevalence reported by Mothupi (2014) in Kenya [30] and by Gharoro and Igbafe (2000) in another Nigerian study [8].
This could be attributed to the differences in the populations studied,
as well as differences in socio-cultural contexts, and health care
systems (availability of services, access, and trust) in the different
study settings. Furthermore, while Titilayo and colleagues (2009) looked
broadly at use of herbal medicines in recent years among pregnant women
[7],
our study focused on current use, which renders plausible explanation
to the likely higher percentage of use reported in their study as
compared to that in the present study. Similarly, though Gharoro and
Igbafe (2000) studied use of herbs among postnatal women [8],
they only considered use of few specific herbs which is likely to
explain the relatively lower prevalence of use. Similarly, the
relatively lower prevalence of herbal medicine use during pregnancy
found in the present study as compared to that from other studies could
also be partly attributed to possible non-disclosure. This is supported
by the fact that a significant number of respondents in the present
study admitted that they would not disclose use of herbal medicine to
the healthcare providers if they sought care from herbalists, a finding
similar to that previously reported by Yolan et al. (2007) in Zambia [9].
Factors associated with use of herbal medicines
Majority
of the mothers who used herbal medicines during pregnancy perceived and
believed that herbal medicines are effective and safe during pregnancy,
a finding comparable to that by Azriani et al. (2008) in Malaysia [37].
This finding is also consistent wth previous findings by Mothupi (2014)
in Nairobi, Kenya, were respondents used herbal medicine during
pregnancy becasue of perception that western medicine was ‘not working’
and that herbal medicine was better or more effectice for their illness [30]. Similar findings have been reported by other authors [7, 31, 38],
and could be explained by the fact that perception on the effectiveness
of herbal medicines in solving problems will tend to influence whether
mothers might use them again in the next pregnancy. More still, the
above findings could also be related to cultural beliefs on causation of
ill-health and belief that herbal medicines are inherently safe and
cure many illnesses. Therefore, given that majority of the women do
interface with the healthcare system at least once during their
pregnancy, the healthcare providers should use this as an opportunity to
sensitize them on the various limitations and potential adverse effects
of herbal medicines, especially with regards to pregnancy.
Women
who used herbal medicines during their previous pregnancies, as well as
those who had ever used herbal medicines for other reasons were more
likely to have used herbal medicines in their current pregnancies. This
finding is consistent with that reported by Mothupi (2014) among
postpartum women accessing public healthcare in Nairobi, Kenya [30],
and suggests that the use of herbal medicines in previous pregnancy
(cies) will likely predict their use in future pregnancies. The
relatively common background use of herbal medicines in this setting as
found in the present study was evidenced in one of the FGDs where six of
the eight participants reported to have ever used herbal medicines for
various other reasons. The above findings might be explained by the
women’s previous experiences with, and belief that herbal medicines
worked in solving their other problems, as well as to its longstanding
integration into the culture and its perception as their own indigenous
medicine.
There was a tendency to
higher use of herbal medicines during pregnancy among women from rural
areas (23 %) compared to their urban counterparts (14 %). Relatedly,
women living farther away (more than 5kms) from any nearest health
facility were twice more likely to use herbal medicines during pregnancy
than those living less than 5kms from the nearest health facility, and
this was statistically significant on bivariate analysis (p = 0.001),
though did not independently predict use of herbal medicines. This could
be attributed to challenges of accessibility of health services, and
supports a previous report by Mothupi (2014) in Nairobi, Kenya [30], and Mbwanji (2012) in Tanzania [39]
that long distance to the nearest health facility was a significant
factor associated with use of herbal medicine during pregnancy. This
finding may not be surprising since long distance from health facility
hinders access to modern healthcare by increasing costs of
transportation, as well as time to access health services. Herbal
products, being readily available, cheap and provided by members who are
well known in the community, therefore becomes an easier alternative.
This implies that addressing challenges of availability and
accessibility of healthcare services should be an important
consideration in addressing the prevalent use of herbal medicines during
pregnancy in this population.
Indications and characteristics of herbal medicine use
Herbal
medicines in the present study were used for multiple reasons including
to relief symptoms such as fever, abdominal and waist pain, respiratory
illnesses, and skin problems, as well as nausea and vomiting among
others, a finding that resonates with that from several authors [7, 40, 41].
This finding has important implications given the fact that these are
common symptoms which may indicate underlying serious complications
during pregnancy such as severe malaria, or severe bacterial infections
(urinary tract infections, pelvic inflammatory disease, septicaemia, or
chorioamnionitis). This therefore calls for concerted health educations
and community sensitizations as the use of herbal remedies may delay
prompt diagnosis and effective treatment of these conditions with
resultant adverse consequences to both the mother and fetus, including
pregnancy wastage, a concern also previously highlighted by Kennedy et
al. (2013) in a multinational study of herbal medicine use during
pregnancy [6].
This scenario may also be important as a proxy indicator of lack of
access to reliable healthcare services to the population, thereby
calling for a thorough assessment of healthcare in the region.
Ingestion
was the single most common method of using herbal medicine during
pregnancy among the women in the study setting, with the other methods
being smearing on the abdomen and insertion in the vagina, a finding
similar to that by Kamatenesi and Oryem (2007) in a study in western
Uganda [42].
These methods of usage, as found in the current and previous studies,
may be attributed to the perceived actions and effects of the particular
herbal products used, but with potential implications for interactions
and interference with the routine orally ingested ANC medications.
Similarly, the practice of particularly inserting herbal products in the
vagina places these women at high risk of infections (genital tract
infections), accidental rupture of membranes and pregnancy wastage. This
finding therefore calls for concerted efforts in community
sensitization in changing some of these potentially dangerious
practices.
Herbal medicines in the study setting were
mainly used during the second (23 %) and third (21 %) trimesters. Using
herbal medicines during different trimesters of pregnancy may be
associated with different effects, and shows great variation from one
setting to another. For instance, in their study of herbal medicines use
during pregnancy in western Uganda, Kamatenesi and Oryem (2007) found
that herbal medicines were more commonly taken during labour (91 %) and
in the third trimester (40 %), with very low use during the first
trimester (7 %) [42].
In a Malaysian study, majority of the mothers took herbal medicines
during the third trimester only (80 %), mainly to facilitate labour [37], a finding also reported by Rolanda and Sally (2006) in South Africa [43].
The variability in the timing of use of the herbal medicines could
possibly be explained by the differences in the perceived desired
effects and the reasons for use at a particular time; socio-cultural
variability and belief, as well as differences in the types of herbs
used by the different population groups. The use of herbal medicines
during the first trimester as also found in the current study however
raises concerns since this is the critical period of organogenesis, with
potential risks for adverse effects like congenital anomalies.
A
significant number of the users of herbal medicines during pregnancy in
the current study used the herbal products concomitantly with the
conventional medicines given during the antenatal care, a finding much
higher than reported by Tabatabace (2011) in Iran [14].
In addition, more than half of the herbal medicine users during
pregnancy reported to have not adhered to the conventional medicines
dispensed during antenatal visits. This finding has an important policy
implication as it presents a serious concern to components of the
goal-oriented ANC interventions, especially prevention of maternal
anaemia and malaria, as well as elimination of mother-to-child
transmission when HIV positive expectant mothers do not adhere to
antiretroviral drugs as a result of using herbal products. Furthermore,
as suggested by Oshikoya et al. (2007) [44] and Chen et al. (2011) [45],
concurrent use of herbal products with the conventional medicines as
depicted in this study may result in interactions which may alter the
pharmacokinetics of the drugs leading to an increase or decrease in
plasma concentrations, thus altering the therapeutic outcomes.
Limitations of the study
The
study was conducted among postnatal mothers attending postnatal clinics
which may have affected its generalizability since only a small
proportion of mothers attend postnatal care. Similarly, the exclusion of
emancipated minors who were not accompanied by adults is also likely to
have affected the generalizability of the study findings. This study
also included only two lower health facilities which may not be
representative of the many health facilities at that level. However,
attempt was made to overcome these shortcomings by triangulating the
quantitative method with qualitative information collected within the
local communities outside the health facilities. Information bias was
also a likely problem since use of herbal medicines is very often
perceived negatively by health workers, and hence some women may have
feared admitting to use of herbal medicines.
Conclusions
The
use of herbal medicines during pregnancy among women in Gulu district
is common, which may be an indicator for poor access to conventional
western healthcare. The factors associated with use of herbal medicines
during pregnancy include believe that herbal medicines are effective and
safe, and having ever used herbal medicines during previous pregnancies
and for other reasons. Many users have confidence in the efficacy of
herbal medicines as an alternative treatment, with oral ingestion being
the major method of use.
This
therefore calls for community sensitization drives on the dangers of
indiscriminate use of herbal medicine in pregnancy, as well as
integration of trained traditional herbalists and all those community
persons who influence the process in addressing the varied health needs
of pregnant women.
Acknowledgements
In
a special way, I would like to thank the management and staff of Gulu
district health office and the health facilities in which this study was
done for making it possible to undertake this study in their
facilities. A special tribute goes to the respondents who participated
in this study.
Funding
This study was not funded by any external body.
Availability of data and materials
The dataset supporting the conclusions of this article is available on request to the corresponding author.
Authors’ contributions
RN
was the initiator of the study and contributed to the study design,
data collection, and interpretation of results. NMT and AAH contributed
to the study design, interpretation of results and drafting of the
manuscript. All authors have read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Consent
to publish this manuscript from the participants was deemed not
applicable since the manuscript does not contain any individual person
data.
Ethics approval and consent to participate
Approval
to carry out the study was sought from Makerere University School of
Public Health Higher Degrees, Research and Ethics Committee and the
Uganda National Council for Science and Technology. Institutional
consent to carry out the research were sought and obtained from the
district leadership and the individual health facility management.
Voluntary informed consent was obtained from the participants before
participating in the study after explanation in the language they
understood best, the nature and purpose of the study, the potential
benefits and risks if any. Young mothers below 18 years of age were
enrolled in the study if they were accompanied by another adult who gave
informed consent allowing participation in the study. Confidentiality
was observed throughout the study and participants’ identifiers were
used instead of names. Withdrawal from the study at any time was an
option for those who wished to do so and this did not carry any penalty.
Abbreviations
| ANC | Antenatal care |
| FGD | Focus group discussion |
| HC | Health center |
| KII | Key informant interview |
| SD | Standard deviation |
| UBOS | Uganda Bureau of Statistics |
| VHT | Village health team |
| WHO | World Health Organization |
Contributor Information
Richard Nyeko, Phone: +256-782 893564, Email: moc.oohay@okeyn_drahcir.Nazarius Mbona Tumwesigye, Email: gu.ca.hpsum@zan.
Abdullah Ali Halage, Email: gu.ca.hpsum@egalaha.
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