The study explored women’s purposes, experiences, and motivation for using herbal medicine during pregnancy, childbirth, and postpartum and experiences associated with the use.

Two specific questions motivated this study:

1) What are the perceived benefits and adverse impacts associated with herbal medicine use in pregnancy, labour, and the postpartum stages of maternal health?

2) What motivated women to utilise herbal uterotonics during pregnancy, childbirth, and the postpartum?

First, data was obtained from a search in four databases: CINAHL, Medline, Web of Science, and EMBASE from January 2000 to December 2018. These databases were chosen for their comprehensiveness and relevance to the review objective. Maternal health and herbal medicine use discourses received more considerable attention within the search period, especially in less advanced countries. The references of included studies were also tracked for additional papers. Search words and terms were combined with the Boolean operators AND or OR, which narrowed and widened the search, respectively. Some were shortened to capture various relevant suffixes of a term for maximum coverage. Speech marks were used if it was necessary to keep multiple words together as a single search term to further ensure relevance. The search used the terms, “Herbal Medicine,” OR “traditional medicine” OR “herbal uterotonics” OR “Complementary and Alternative Medicine” OR “herbal medicine” OR “experiences” OR “experience” OR “motivation” OR “adverse outcomes” OR “reasons” OR “benefits”. At the second stage, we searched for “pregnancy,” OR “childbirth,” OR “delivery” OR Pregnancy Complications*, AND “Maternal Health Outcome*”. Overall, searches were conducted using both free texts and medical subject headings. All database search was conducted from September to December 2019.

Studies were screened through a two-stage process. First, the imported publications from the searched databases were assessed against; 1) primary research papers of either qualitative, quantitative and mixed methods; 2) must be explicitly on “herbal medicine”, “Complementary and Alternative Medicine” and for “pre/pregnancy”, “labour or birth or delivery”, “postpartum”; 3) written in English, 4) published in peer-reviewed journals’; 5) be written in English; and 6) have full text. Secondly, articles that met the first set of criteria were screened for quality (Table 2).

Studies were included if they reported findings in preparation for pregnancy, promoting fertility, treating pregnancy-related problems, used to induce or assist labour, to terminate a pregnancy (abortion), to maintain general wellbeing during pregnancy or postnatal wellbeing. Studies were also included if they described the views, attitudes, or beliefs of women towards TM. The search strategy included primary research (quantitative, qualitative, randomised control studies, and mixed methods studies). Studies that reported combined use of TM and pharmaceuticals were included. We excluded grey literature, unpublished reports, commentary, and perspectives. Studies were excluded if they focused on CAM, HM, or general use of HM without recourse to maternal health. All abstracts were reviewed to identify those articles that addressed HM use and maternal health or women’s health as a significant concept, and references of each article were hand-searched for additional eligible studies. Opinion pieces, reports, editorials, seminal works, and systematic reviews were excluded in this review. Articles examining HM use in pre-pregnancy, pregnancy, labour, and the postnatal seeking to improve maternal health outcomes but not peer-reviewed were also excluded [Figure 1 & Table 1].

For example, studies that reported TM use for general maternal health complaints and complications such as postmenopausal symptoms, breast cancer, herbal treatments for electroconvulsive shock (ECS) -induced memory deficits [17], Herbal Medicines for Gastrointestinal Disorders in Children and Adolescents [18], and related research articles [19] [20] were excluded. The screening procedure is shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart [Table 1].

All references were pooled to Endnote reference management software for screening. Quality appraisal of eligible studies was assessed the study design, study aim,

sampling procedure of all included studies, role of confounding factors for potential bias, and potential generalizability of findings. This process was conducted using the Mixed Method Appraisal Tool (MMAT) [21], for all eligible qualitative, quantitative, and mixed methods studies [22]. The MMAT was used to assess the quality of the identified papers. This quality assessment tool was found to have a moderate to perfect inter-rater reliability score [23].

The tool was designed to assess the quality of articles that were conducted with qualitative, quantitative, and mixed methods designs [21]. There are four quality assessment criteria for quantitative studies and three criteria for qualitative, and the quality of each study was determined by counting the asterisks (*) assigned, according to the set criteria. For mixed methods studies, the premise was that the overall quality of a combination would not exceed the quality of its weakest component [22]. Two reviewers completed this process, and where there were discrepancies, a team of reviewers intervened to resolve it. To optimise objectivity in the quality appraisal process, review articles of eligible studies were not included in the assessment. Using the MMAT appraisal approach, the overall quality score for mixed-methods designs was the lowest score of the study components [22] [23]. The findings of the quality appraisal of eligible studies were reported in Table 2.

A narrative synthesis approach was employed to present the findings [21]. In keeping with this framework (Figure 1 & Table 1), data were reported with an emphasis on highlighting the key and unique factors influencing women’s utilisation of herbal medicines during pregnancy, labour and the postpartum stages of maternal health.

Themes were generated using inductive coding procedures concerning the study questions. Deductive codes were based on the research questions [24] [25]. Individual articles were thoroughly read, to identify common patterns and themes based on the predefined and emergent topics. Points of variations and convergence in the eligible studies were highlighted to derive key ideas using a constant comparison approach. Duplicate extraction was completed for 60% of the included articles, with differences checked by all authors.

To understand the different findings, we adopted the narrative synthesis approach for primary qualitative, quantitative, and mixed methods research (Table 3).

A narrative evidence synthesis of studies was undertaken using thematic analysis. During the analysis, a data extraction form was created in Word document using tables. Data extraction was conducted on all 21 articles by authors, using a qualitative approach. Line by line coding and search for related concepts on HM use in pregnancy, childbirth, and the postpartum was conducted for each data set and comparisons made. Any inconsistencies in the data were discussed, and their management agreed upon. We adapted Gibbs framework for data analysis in the process. This began with familiarisation, code building, theme development, and data consolidation and interpretation [39]. Data was analysed independently

and coded by four researchers. The process involved prolonged engagement with the data with regular checks. The codes and concepts were harmonised while unrelated concepts/codes that did not translate to the dominant factors identified, synthesis was then undertaken as an interpretive, inductive process.

Several factors influenced women’s decisions for using HM. While herbal medicine use among mothers was not significantly associated with their sociodemographic characteristics in some countries, both obstetric histories and fundamental demographic factors influenced women’s decision-making and the action they took. For example, herbal product users, mostly among Hispanic mothers in the United States, were mostly among younger mothers than non-users [27] [32].

Culturally, native-born mothers were less receptive to over-the-counter medication than foreign-born Hispanic women in the United States [27]. In the same study, over-the-counter medications intake among mothers was more common among educated women than less educated ones [27]. In other research in the US, Hispanic women reported more HM use, compared to Caucasian women, and the inclusion of a point to the confidence level did not suggest the use of herbal medicine and other natural products could increase over time [30]. The use of HM among pregnant women was found to increase as they grow older in a multistate study in the US [30]. In the same study, women who took decaffeinated coffee or tea were also slightly more likely to use herbal or other natural products in pregnancy and post-delivery [30].

In another study in the US [27], mothers’ demographic and obstetric characteristics such as place of birth, education, timely care, history of medical problems, age, and parity (in univariate statistical analysis) found that prescription medication of herbal medicine was more than twice higher among women with a history of medical problems as opposed to those without such problems (aOR = 2.59, 95% CI: 1.59 - 4.25, p = 0.0001) [33]. In terms of age, older women of about 30 years or more were associated with HM use in Uganda [33].

However, these findings were contrary to those from Australia [13], where research showed that demographic characteristics such as education, employment status, income levels, or marital status were not significant determinants of HM use among women [13]. It was also found that women who sought Medical Specialist care during obstetric abnormality or complications, including fertility problems, were less likely to utilise HM than other women [13]. There was also no difference in maternal outcomes for users and non-users in the same study [13].

Most women used herbal medicine/remedies based on the given health condition/diagnosis and accompanying treatment plans [7] [8] [14] [15] [35] [37], and the desire to get over the pain, the complication or if infertility persisted over time [27] [28]. Women felt that using HM to treat the condition would have a substantial impact on their quality of life and birth outcomes, even when noticeable potential side-effects of the medicine were known [10] [11] [12] [29]. For example, women who reported diabetes, weight increase, gastrointestinal complications, bleeding, and urinary tract infections (UTIs) perceived using HM as a better alternative to prescription medication or allopathic medicine [27] [32]. Specifically, HM was a preferred choice and was common among pregnant women who perceived their health status as “average” or “unhealthy”. The evidence shows that most pregnant women across the studies use HM to enhance their health status, strengthen their uterus and improve body immunity in the early stages of the pregnancy to avoid complications and reduced labour [30] [32] [33].

Conversely, from the findings from a randomized controlled trial in Malawi reported, HM use in pregnancy, labour, and the postpartum, showed substantial adverse implications on maternal outcomes. For example, mothers who used particular herbs, locally known as Mwanamphepo, a group of herbal medicines commonly used to induce or facilitate labour, had a significant association with increased occurrence of maternal morbidity and neonatal mortality than non-users [15]. The chances that neonatal morbidities and mortalities could occur among users of the labour enhancing herbs were approximately 22% higher than mothers who did not [15]. Another study that solicited women’s views on maternal illnesses and medications used from two months through to the end of pregnancy found that HM use was positively associated with increased maternal age [30].

The choice of treatment for maternal illness was influenced partly by the source and quality of information on HM women received. However, all of those sources that were not duly authorised to vend and supply and circulate HM products and relevant information left significantly adverse implications on overall health outcomes of users [4] [33]. This means that women who utilised some HM products were most likely influenced by the source they originated and the quality of the information about the products. For studies that indicated the source and quality of information, first, some women decided in-person to use HM in pregnancy, labour, or postpartum [37] [38]. Second, some had initially witnessed others use it or received recommendations from friends, family, healthcare workers (physicians and nurses), internet pharmacies, direct herbs from the bush, or traditional herbalists [29], gave the recommendation to mothers before the decisions to use particular HM. Third, HM was readily available and accessible in HM shops, illegal dealers, herbal shops and clinics [8], and some women capitalised on that to remedy painful health diagnosis [13] [26] [31] [35]. For example, in Nigeria, more than two-thirds of pregnant women reportedly used herbal medicines that were self-prepared or already packaged [29]. Meanwhile, the majority obtained HM from the open markets, road hawkers, herbal shops, pharmacies, direct herbs from the bush, or recommendations from herbalists [29], physicians, and nurses [26] [35]. Similar influence on women’s decisions to use HM was reported in a study in Egypt [38]. For instance, a study involving 400 early postpartum women in an urban community in Norway, 39% (n = 156) who used herbs complained of varied harmful outcomes; the most significant determinant for use was as a result of limited information about the herbs used [36]. Additionally, it was found that a higher proportion of women may have used harmful drugs in the first trimester (20.5% of 83 women) than the second trimester (15.4% of 90) and 12.6% of women in the third trimester [36].

However, in some geographical locations, women obtained expert information on HM products, and their appropriate use before the acquisition. For example, women who used HM in Norway and Nigeria (Enugu area), in pregnancy had high knowledge or were familiar with other people who had tremendous knowledge about the herbal products before deciding on the choices made [9] [37]. Overall, women’s exposure to the information on HM was found as a significant, influential factor in HM uptake. It must be noted that the influence of location on HM use was, however, widespread among women in both rural and urban settings. In the Middle East, women in urban areas with high education and had ready access to maternal healthcare were reported using HM at substantial levels than even rural areas in other countries [8] [34].

Some HM users documented in the study realised that they were at risks of developing worsening health complications and associated side-effects from using HM [8] [27] [32]. In some studies, it was observed that although some pregnant women had no intentions to use HM, nurses, and midwives recommended known HM products to them to help treat multiple obstetric complaints and discomforts including nausea and vomiting, labour stimulation, perineal discomfort, lactation disorders, postpartum depression, preterm labour, postpartum haemorrhage, labour analgesia, and malpresentation [26], cold, nausea, sleeping problems, constipation, treat chronic illness, to prepare for childbirth labour [4], and to solve bladder problems [30].

However, users prioritised using HM in the midst of the risks of obstetric complications associated with the use as more relevant [3] [8]. Four groups of women were observed: first, women who were seeking fertility treatment preferred to endure possible risks of HM than to endure the shame of childlessness from community members and spouse families [33]. Second, women who experienced common discomforts such as nausea and vomiting during pregnancy were prone to use alternative medicines, regardless of the effects. Third, those who sought HM, to augment on-going labour, or with postdate pregnancies and seeking to induce delivery, were likely to accept HM recommendations [14] [26].

The findings have shown that most women were bent on using HM to address multiple obstetric problems, yet, some treatment modalities and the herbal products used, were not adequately investigated for their safety in pregnancy in many countries [4] [14] [26] [30] - [35]. An example was reported in Bolivia, where government regulations disallowed the use of some HM products. However, women persisted in using them [28].

HM products were concurrently used with allopathic or orthodox medicines. The concurrent use was found to have dire consequences on the health of pregnant women and the unborn. Countries where HM use was integrated in the mainstream health system such as the US, women had few limitations consulting their physicians on the best possible HM to use [4] [29]. Therefore, women in places like Nigeria, Uganda, and Kenya perceived the non-integration of HM product utilisation as a barrier to seeking education on the different kinds of HM available and receiving adequate information on the treatment modalities and correct dosages [12] [28] [29]. That aside, countries with weak enforcement of the regulatory frameworks on HM posed threats and barriers to the utilisation, because of limited knowledge on the toxicity and plant constituents as well as the potential adverse effects on the use [28] [31]. Previous research in Ohio, the US, had some concerns about the non-publication of herbs and herbal medicines via influential national dailies and magazines, although HM was integrated into their health system [12]. These had implications on consumers’ knowledge about the adverse effects of the medicines. For instance, limited exposure to herbal drugs was the cause of a lack of knowledge and non-use among pregnant women in Taiwan [7].

However, in some places, HM was the most affordable choice, given the widespread health financing challenges women faced. For instance, in most low- and middle-income countries (LMICs), herbal medicines may not be only relatively cheap, dependent on “how much the client has” and sometimes payable in kind [29]. HM was readily available and accessible than conventional medicines. However, a significant barrier was the claims on decisions made. Nevertheless, in the case of Bolivia, social norms were against the intake of contraception, although their increased knowledge of the different methods, which motivated women’s use of alternative medical remedies [28]. Disgrace women could potentially experience from community members for wanting family planning pills, coupled with the disapproval of spouses/husbands, were important reasons for using HM.

According to the World Health Organisation (WHO), the increased use of HM and herbal products is was found to have some correlation with the culture and historical norms within which such products first evolved [6]. The literature demonstrates that most herbal medicines that claim to provide effective cures for various diseases lack sufficient evidence for safety, efficacy, and quality requirements. This problem is compounded by the lack of information about appropriate usage provided at the point of supply. This compromises the safe use of HM [6].

In this evaluation, women’s confidence in the potency of HM to treat pains, misery, and trauma was an essential determinant in their choices. For instance, in one study, Fakeye and colleagues reported women (22.4%) believed HM had more significant potential to cure their health problems than conventional medicine. In contrast, 21.1% perceived HM to be harmful in pregnancy [29]. A few of the women used HM as part of their culture, while a significant number (19.7%) utilised HM when conventional medicines failed [29]. In many locations, mothers perceived that HM had the potential to treat multiple illnesses compared to conventional medicines [8] [31] [38]. In rural Uganda, addressing infertility in marriage was the primary motivation for using herbal medicine, and this occurred without sufficient knowledge on the safety and perceived efficacy of the particular HM product [33].

In the US, a study involving 485 Hispanic women found that one in five pregnant women (20%) believed herbs were safer and better at treating ill-health conditions [27]. In the same study, herbs were used to improve general health and to increase energy. A few women (12%) used herbs for anaemia, allergies, hypertension, and gastrointestinal symptoms [27]. However, in Kenya, mothers used it to treat back pain, toothache, indigestion, and infectious diseases such as respiratory tract infections and malaria [34]. In places like Russia, Europe, and Australia, nausea and cold-related complaints in pregnancy were crucial drivers for the use of herbal medicine in a multi-country study [4]. Similar results to those of Kennedy et al. [4] were obtained in North Carolina [26]. They wished “to do everything they can” to decrease the potentially adverse maternal outcomes.

Relatedly, only about 29% of women in the survey in Bolivia reported that HM was easy to access to help with abortion care than prescription drugs [28]. Other women chose HM over modern medicines for abortion care due to a general mistrust of the safety, fear of the adverse effects, and substantial doubts of the effectiveness of modern drugs [28]. Such findings were not reported only in Bolivia but in countries like Norway [37], Malawi [15], Taiwan [7], and Nigeria [9]. Also, in a study that explored herbal medicine use among pregnant women attending family health centers in Alexandria, Egypt, found that more than half of the women (about 65%) reported HM was more effective at relieving problems in pregnancy [38].

The studies considered in this report have shown that the final decision about using HM to address specific health problems was influenced by the advice of over-counter-drug dealers, herbalists, physicians, and supportive others. However, the time is taken in deciding to use HM differed considerably depending on women’s health needs, information available, and preference. First, the potential risks and benefits of the particular HM used were considered [4] [12] [13] [28] [29]. However, some studies discovered women’s personal preferences motivated the choices and decisions made. For example, a study in Australia demonstrated that improving overall maternal outcomes, weight loss before pregnancy were the crucial determinants for using HM [13]. Relatedly, women who used HM in pregnancy and pre/pregnancy were more likely to use the same during labour and after delivery. For example, in Quebec area in Canada; Mousally and colleagues reported that herbal product intake in the third trimester was motivated by prior experience using it in pre-pregnancy and pregnancy [35].

Second, the varied complications women suffer were determinants in the decision-making process. Among 4866 mothers of nonmalformed infants from 1997 to 2005, 282 (5.8%) of those mothers to these infants reported the use of herbal or natural treatments in that research conducted in North America (Canada and US) [30].

Moreover, some women made decisions based on their health condition, and the information received about the effectiveness of the medicines [12] [28] [29] [31] [33].

A particularly concerning aspect of HM use among women was about the combined use of conventional medicine and HM, and often failed to inform or obtain expert views about the medicine [32]. Such attitudes were reported in Norway, Nigeria, and the Middle East [8] [14] [29] [32], meanwhile, women in a US study disclosed the combined use to their physician [13]. While guidelines for the use of most HM in pregnancy recommends that women obtain counsel from physicians and caregivers before using HM in the advanced countries [13] [14] [27] [36], and non-compliance was shown in some studies [5] [6] [10]. For example, a study in Norway has revealed that about one-third of the women failed to comply with physician counsel on the grounds of lack of trust in their competence [37].

In Norway, the use of HM and conventional or modern medicines, concurrently, were reported among 600 pregnant women [14]. However, there were adverse implications on the combined use. For example, among these mothers [14], there was a significant association between women who used iron-rich herbs during pregnancy and high birth weights on the one hand and use of raspberry leaves and caesarean delivery (23.5% vs. 9.1%) on the other, among women who used both forms of medicines in that study [14] after controlling for gestational length and maternal age [14].

Some respondents were more concerned about the side effects/contraindications of Western medicine than HM [34]. About 30.4% of respondents in Nigeria thought that the side effects of some HM could be dangerous [29]. Meanwhile, among the 405 respondents in the same study who had used herbs before and during pregnancy, 18.0% had experienced some reactions including, dizziness, malaise, headache, and rashes, post-administration of HM [29]. Evidence showed decreased use of HM during pregnancy in Taiwan was partly associated with adverse concerns about previous exposure to HM [7].

Given that primiparous women, younger mothers, and less educated mothers were the most users of HM in pregnancy and labour, the regulatory frameworks and law enforcement agencies need to intensify the monitoring of manufacturers of herbal products as well as traditional healers and traditional birth attendants, especially in LMICs. It was observed that specific Chinese HM was increasingly used by women. However, their perceived safety was not confirmed, and these resulted in avoidable maternal and neonatal morbidities and mortalities [11]. Also, the study has found that about 70% of pregnant women in a study in the United States, were given over-the-counter herbal medication during admission to treat diabetes and urinary tract infection, meanwhile, later interrogations on the said products revealed that there was insufficient evidence on the safety of those medicines before the sale [27]. Therefore, further research is needed to understand the safety of HM used pregnant women.

Stakeholders on maternal and neonatal health service delivery systems need to intensify public education and enforce regulations on the use of HM among pregnant women. Given that early mothers were less exposed to the adverse effects of HM use on in pregnancy and birth outcomes, ANC education could be re-tailored to eradicate inaccurate perceptions about the potency of HM in solving their pregnancy and birth complications. This study suggests the healthy integration of the HM clinics with the maternity/ANC departments in the health facilities in LMICs to help regulate mothers’ intake of toxic plant products. This is particularly required in LMICs.

This article must be read against the following limitations. The paper was written using references extracted from four central databases conducted in the English Language, which may not be representative of the overall content on HM product use in pre/pregnancy, delivery, and postpartum. Nevertheless, an additional search through the reference list of included studies [Figure 1], potentially minimised the potential for non-inclusion of relevant articles and thereby reduced biases in the dataset. The review captured a diverse group of articles that used different study methodologies, which made it challenging to conduct meta-analysis or check for publication bias of those studies.

Further, the qualitative content analysis approach was adapted to extract the data as contained in the results. This may be criticized due to its potential to bias the analysis and thus, the study findings. However, this was addressed by ensuring a non-biased approach to coding, identification, and categorisation of all instances and dimensions of women’s decision-making process on HM use. However, we are confident that the inductive coding process complemented to avoid potential biases.