complementary medicine products used in pregnancy and ......larisa ariadne justine barnes1,2*,...

RESEARCH ARTICLE Open Access

Complementary medicine products used inpregnancy and lactation and anexamination of the information sourcesaccessed pertaining to maternal healthliteracy: a systematic review of qualitativestudiesLarisa Ariadne Justine Barnes1,2* , Lesley Barclay2,3, Kirsten McCaffery4 and Parisa Aslani5

Abstract

Background: The prevalence of complementary medicine use in pregnancy and lactation has been increasinglynoted internationally. This systematic review aimed to determine the complementary medicine products (CMPs)used in pregnancy and/or lactation for the benefit of the mother, the pregnancy, child and/or the breastfeedingprocess. Additionally, it aimed to explore the resources women used, and to examine the role of maternal healthliteracy in this process.

Methods: Seven databases were comprehensively searched to identify studies published in peer-reviewed journals(1995–2017). Relevant data were extracted and thematic analysis undertaken to identify key themes related to thereview objectives.

Results: A total of 4574 articles were identified; 28 qualitative studies met the inclusion criteria. Quantitative studieswere removed for a separate, concurrent review. Herbal medicines were the main CMPs identified (n = 21 papers) inthe qualitative studies, with a smaller number examining vitamin and mineral supplements together with herbalmedicines (n = 3), and micronutrient supplements (n = 3). Shared cultural knowledge and traditions, followed bywomen elders and health care professionals were the information sources most accessed by women when choosingto use CMPs. Women used CMPs for perceived physical, mental-emotional, spiritual and cultural benefits for theirpregnancies, their own health, the health of their unborn or breastfeeding babies, and/or the breastfeeding process.Two over-arching motives were identified: 1) to protect themselves or their babies from adverse events; 2) to facilitatethe normal physiological processes of pregnancy, birth and lactation. Decisions to use CMPs were made within thecontext of their own cultures, reflected in the locus of control regarding decision-making in pregnancy and lactation,and in the health literacy environment. Medical pluralism was very common and women navigated through andbetween different health care services and systems throughout their pregnancies and breastfeeding journeys.

(Continued on next page)

* Correspondence: [email protected] of Pharmacy, The University of Sydney, Camperdown, NSW 2006,Australia2University Centre for Rural Health, The University of Sydney, PO Box 3074,Lismore, NSW 2480, AustraliaFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Barnes et al. BMC Complementary and Alternative Medicine (2018) 18:229 https://doi.org/10.1186/s12906-018-2283-9

http://crossmark.crossref.org/dialog/?doi=10.1186/s12906-018-2283-9&domain=pdfhttp://orcid.org/0000-0002-9847-775Xmailto:[email protected]://creativecommons.org/licenses/by/4.0/http://creativecommons.org/publicdomain/zero/1.0/

(Continued from previous page)

Conclusions: Pregnant and breastfeeding women use herbal medicines and micronutrient supplements for a varietyof perceived benefits to their babies’ and their own holistic health. Women access a range of CMP-related informationsources with shared cultural knowledge and women elders the most frequently accessed sources, followed by HCPs.Culture influences maternal health literacy and thus women’s health care choices including CMP use.

Keywords: Pregnancy, Lactation, Breastfeeding, Complementary medicine products, Health literacy, Culture, Medicalpluralism, Health care choices,

BackgroundMedical pluralism, or the co-existence of different medicalor therapeutic systems and traditions in one local settinghas been recognised in most societies around the world[1]. Studies in both low and high income countries showthat women routinely seek pre and postnatal health carefrom both traditional and allopathic providers, even whenaccess to care from biomedically trained midwives anddoctors is available [2–6]. In some places this is due to dif-ferent cultural understandings of health and illness regard-ing specific needs for care during the reproductive phasesof a woman’s life [7, 8], but can also be to receive specificservices from the different forms of care sought, or for spe-cific pregnancy or breastfeeding related concerns [9–11].Internationally and across economic strata, the desire forholistic care has also been associated with women’s choicesto use traditional or complementary medicines in preg-nancy, birth and lactation [12–16]. Holism can be seensimply as the recognition and care for both the physicalbody and the mind and emotions [17], or be a more multi-faceted concept that incorporates the health of body, mindand spirit [18]. First Nations’ concepts of holism alsoencompass social and cultural connections to Land, Elders,and Nation, and views political, cultural and social deter-minants of health as interconnected [19–21].The prevalence of complementary medicine use in preg-

nancy and lactation has been increasingly noted globally.One multinational study found that of 23 countries, ratesof herbal medicine use in pregnancy were the highest inRussia (69.0%), Australia (43.8%) and Poland (49.8%) [22].A cross-sectional survey of Hispanic women in Indianapo-lis USA found that 14.2 and 13.0% of women surveyedbegan using herbal remedies in pregnancy and breastfeed-ing, respectively [23]. A UK study investigating variousforms of complementary and alternative medicine (CAM)used in pregnancy found that 5.1% of women surveyedused dietary supplements, 34.9% used vitamins and 5.4%used herbal medicines, and that 35% of women who usedCAM also visited a trained CAM practitioner [24]. Com-plementary medicine use in lower income countries hasalso been documented. For example 12% of Kenyanwomen living in Nairobi, and 52.4% of Malaysian womenin the Tumpat district used herbal medicine in their re-cent pregnancies [25, 26]. Concerns with complementary

medicine use in pregnancy and lactation are frequentlyraised for the health of the mothers, in pregnancy due tounknown effects of complementary medicine products(CMPs) on the baby in utero. Lactation is also a concernas little is known about risks associated with CMP expos-ure through breastmilk [27–29].Health literacy refers to an individual’s ability to search

for, understand, and apply health information when mak-ing decisions about their health [30], and influences thehealth care decisions women make during pregnancy andlactation. Maternal health literacy can be defined as “thecognitive and social skills that determine the motivationand ability of women to gain access to, understand anduse information in ways that promote and maintain theirhealth and that of their children” ([31], p381). In short,the knowledge, skills and confidence a woman has will in-fluence the health care choices she makes whilst pregnantand breastfeeding. The World Health Organisation identi-fies four overarching factors in health literacy: (i) thehealth care team and system, (ii) the condition or illness,(iii) therapy (medications, lifestyle modifications, exerciseprescriptions, etc.), and (iv) patient-related factors such asprior knowledge of health and health care, literacy, nu-meracy and communication skills and cultural back-ground [32]. Access to appropriate information sources,as well as the ability to appraise the information obtainedin order to make safe and pertinent decisions, are also keycomponents of health literacy [33, 34].The objectives of this systematic review were to deter-

mine what sources of information on complementaryand alternative medicine products (CMPs) have been de-scribed in the literature from a range of countries, andare used in pregnancy and lactation for the benefit ofthe mother, the pregnancy, child and/or the breastfeed-ing process. The role of maternal health literacy in thesepractices was also examined. This paper focuses on theresults from the qualitative studies included in this sys-tematic review. It complements a concurrent synthesisof the quantitative papers looking at the same question.

MethodsProtocol and registration numberDetails of the protocol for this systematic reviewwere registered on PROSPERO and can be accessed

Barnes et al. BMC Complementary and Alternative Medicine (2018) 18:229 Page 2 of 27

at: https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016052283.

Literature search strategy and criteriaAn electronic search of seven databases was undertaken:AMED Allied and Complementary Medicine (via Ovid SP),CINAHL (via Ebsco), Cochrane Database of Systematic Re-views (via Ovid SP), EMBASE (via Ovid SP), Maternity andInfant Care (via Ovid SP), Medline (via Ovid SP), andPubMed. The date range was set between 1995 and 2015to reflect developments in the field of health literacy overthis time, as well as increases in the documentation ofcomplementary medicine use in pregnancy world-wide andin complementary medicine research [35]. A second searchof the seven databases was also performed to check forsubsequent publications published from 2015-Jun 2017 be-fore completing this review. A variety of terms were usedto cover the four central themes of the review: pregnancy,lactation, complementary and alternative medicine prod-ucts (CMPs) and health literacy. CMPs were operationallydefined as ingested herbal medicines given for specifictherapeutic purposes in foods, tea, decoction, tablet, cap-sule or ethanolic extract forms, topical herbal preparationssuch as herbal washes, creams or ointments, and aroma-therapy oils for inhalation, as well as dietary vitamin andmineral supplements and pre and probiotic supplements.Terms within each concept (pregnancy, lactation, comple-mentary medicine and health literacy) were combined withOR, and results from each concept combined with AND(Additional file 1). Reference lists from relevant studies andreview papers were also hand searched. An initial system-atic literature search was conducted and papers’ titles werescreened for inclusion or exclusion based on set criteria(Table 1). This was followed by a screening of all remainingpapers’ abstracts and then full text versions of papersagainst the same criteria. The lead author (LAJB) screenedall papers by title, abstract and full text. PA participated inthe screening of titles and full text papers. Differencesregarding study selection were resolved by discussionbetween LAJB and PA. Although the transition fromnon-pregnant woman through conception, pregnancy,labour, birth, and the postpartum period is a continuumexperienced by each childbearing woman, these differentstages are described differently within the literature. Forthe purposes of this systematic review, the use of comple-mentary therapies across the childbearing continuum ofpregnancy, labour and birth, and breastfeeding in the post-partum period (defined as up to 24 months) [36] have beenexamined.

Critical appraisal of reporting qualityEach paper was assessed according to the 32 item check-list Consolidated Criteria for Reporting Qualitative Re-search (COREQ) [37]. The COREQ checklist aims to

assess how comprehensively and explicitly qualitativestudies are reported and covers three main domains: 1) re-search team and reflexivity, 2) study design and 3) analysisand findings [37]. Use of the COREQ checklist guided theassessment of the rigour and methodological coherence ofthe included papers and contributed to the synthesisrequired as part of the systematic review process.

Data extractionAll papers included were analysed comprehensively inorder to extract applicable data including: author and year,country study was performed in, number of participants,data collection and analysis methods, major factorsexplored, CMP type discussed, childbearing stage ofrelevance to the CMP use, and CMP-related informationsources accessed. Following this, major and minor themeswere identified and data from each study was summarisedwithin these themes with illustrating participant quotes,where relevant.

Table 1 Inclusion and exclusion criteria

Inclusion criteria

1. Use of qualitative methods for data collection including focusgroup discussions or in-depth interviews

2. Focus on the use of complementary medicine products as definedoperationally above

3. Described CMP use in pregnancy and/or lactation

4. CMPs were used by the woman for the benefit of her own healthin pregnancy, the pregnancy itself, the baby and/or the breastfeedingprocess

5. Information sources the woman accessed with regards to theCMPs used are reported

6. Health literacy, or related concepts, were discussed

Exclusion criteria

• Pre-conceptual folic acid supplementation only

• Trials of CMPs in pregnancy or lactation (trial would have been theinformation source on the CMP studied)

• Information sources not clearly identifiable

• Potential information sources identified by the authors, but notclearly identified by participants

• Data not collected from pregnant and breastfeeding womenthemselves

• Data only collected from health care practitioners

• Study protocols or social marketing campaigns

• Overview or commentary papers on CAM modalities, philosophiesor practices regarding women’s health

• Overview or commentary papers on biomedical maternity carephilosophies

• Commentary papers on CMP use or the lack of uptake ofrecommended nutritional supplements in pregnancy, including iron,folic acid and iodine.

• Studies where CMPs were given directly to infants, and not thebreastfeeding mothers

• Studies focussing on CAM use to treat infertility


https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016052283https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016052283

Thematic analysisFindings across the studies were aggregated following themethods set out by Thomas and Harden [38] and Braunand Clarke [39]. Firstly descriptive themes were developedto describe the use of CMPs by pregnant and breastfeedingwomen for the benefit of their own health whilst pregnant,the pregnancy, baby or breastfeeding process, and todescribe the information sources women accessed whenchoosing to use CMPs in pregnancy and lactation. Follow-ing this, analytical themes were developed in order to delvedeeper into the concept of CMP use in pregnancy andlactation and women’s access to information sources – thereasons for CMP use, the perceived and actual benefits ofCMP use and what influences women to use CMPs inpregnancy and lactation.During the coding process, it was necessary to delin-

eate between perceived benefits of taking CMPs for themother, the pregnancy, the growing baby, and thebreastfeeding process. For clarity these perceived bene-fits are divided into these different themes, but it shouldalso be recognised that there is overlap. For example, itis of benefit to the mother’s health to avoid miscarriage,but also obviously of benefit to the pregnancy. Paperswere also analysed for specific results on health literacy.

ResultsStudy selectionThe search strategy generated 4574 citations after dupli-cates were eliminated (Fig. 1). After reviewing titles andabstracts 683 papers were examined by full text. After stud-ies focussing only on folic acid supplementation were re-moved, 22 qualitative studies were identified for inclusion.The reference lists of these 22 qualitative studies wereexamined by title, abstract and full text, and a further twostudies were found that fulfilled the inclusion criteria. Thesecond search of the seven databases yielded an additional506 citations. After screening, a further four papers wereidentified, making a total of 28 papers covering 26 studiesfor inclusion in this qualitative synthesis. The three publica-tions by Westfall [10, 40, 41] report on different aspects ofone large study. Therefore, although the 28 included publi-cations present the findings of 26 investigations, for clarity,the total number of studies will be referred to as 28hereafter.

COREQ appraisal resultsThe studies included varied in how comprehensively theyfulfilled the criteria for each domain of the COREQ check-list (Additional file 2). Critical appraisal of the papers identi-fied a number of gaps in the reporting of the papers overall.For the first domain Research team and reflexivity, overall

the papers reported well on who conducted the interviewsand focus groups (19/28), researchers’ credentials (19/28),but less than half (13/28) reported on gender of the

researchers. Interviewer characteristics, occupation, experi-ence and whether a relationship was established betweenresearchers and participants prior to the start of a study,and whether participants knew the researchers’ goals andreasons for doing the research were not well reported.For domain two Study design, only 20/28 papers identi-

fied the methodological orientation of the researchreported. Sampling method was reported clearly in 25/28papers as was the number of participants (26/28), and to alesser extent, place of data collection (21/28) and descrip-tion of the sample (23/28). However, gaps across the stud-ies can be seen in reporting the method of approachingparticipants (13/28 reported this), non-participation rates(9/28) and whether any other people were present duringdata collection besides researchers and participants (6/28).Data saturation was only discussed in 7/28 papers andtranscripts were returned for participant comment in only7/28 papers.For Domain 3 Analysis and findings, the coding tree was

only provided in 7/28 papers and in 10/28 studies partici-pants provided feedback on the findings. Additionally, 11/28 papers reported on the number of coders. The presenta-tion of the analysis and findings were clearly reportedacross most of the papers with major themes being clearlypresented in the results sections of all 28 papers, and 24/28papers also included descriptions of diverse cases or minorthemes.

Pertinent features of included studiesTable 2 describes significant features of the studies in-cluded in this synthesis.

Geographical and economic classificationsCountries from all World Bank economic classifications[42] are represented in the sample, although the majorityof studies come from countries with Low-IncomeEconomies (LICs) or Lower-Middle-Income Economies(LMICs) classifications, and two of the studies fromHigh-Income Economies (HICs) included actually focuson the experiences of women from poorer countries: im-migrants to Canada from India, a LMIC [43]; and Hmongrefugees from Thailand, an Upper-Middle-IncomeEconomy (UPIC) living in Australia (HIC) with very loweducation and income levels [44]. Additionally, three ofthe included studies from Canada (HIC) [10, 40, 41] werefrom the same study, so the number of women involvedfrom HIC backgrounds in the overall synthesis is only 143out of more than 1075 total participants across all studies(for Waiswa et al. [45] exact numbers in the 10 FGDs werenot given). Thirteen studies were from African nations: 12from the Sub-Saharan region and one from North Africaand eight studies focussed on East or South Asianwomen’s experiences.


Theoretical frameworks for the data analysis methodsThe theoretical frameworks for the studies varied: sevenused an ethnographical basis [7, 44, 46–50], one combinedethnography with content analysis [51], four others usedsome form of content analysis [45, 52–54], and four re-ported using thematic analysis [10, 40, 41, 55]. Ethno-botanical research [56], narrative analysis [57], andnaturalistic qualitative descriptive processes [43] providedthe theoretical framework for one paper each. Phenomen-ology was used in two papers [4, 58]. The final five papersdid not state the theoretical framework used [8, 59–62].

Data collection methodsEleven studies utilised in-depth interviews only [4, 10, 40,41, 43, 49, 53, 55, 57, 61, 63] and two studies used focusgroup discussions only [8, 52] to collect data. Five studies

combined focus group discussions and in-depth inter-views [45, 51, 54, 60, 62], four studies combined in-depthinterviews with participant observation [44, 46, 48, 58],and one study combined informal conversations, in-depthinterviews, focus group discussions and participant obser-vation [50]. Data was collected using open-ended inter-views and participatory observation [7], group interviewsand individual interviews [56], unstructured one-on-oneinterviews [64], semi-structured interviews [59] andunstructured interviews [47] in the final five studies.

Number of participants across and within studiesThe total number of participants that can be countedacross all studies was 1075 but would actually be higher asexact numbers of participants were not reported in onestudy [45] and additional quotes from HCPs are given in

Fig. 1 PRISMA flowchart showing review process and final number of papers in the review


Table

2Pertinen

tfeatures

ofinclud

edstud

ies

Autho

r(date)

Cou

ntry

(econo

mic

classification

a )Num

berof

participants

Datacollection

metho

dDataanalysis

metho

dStud

yaims

CMPs

repo

rted

onin

thepape

rsb

Stagein

thecontinuu

mof

childbe

aringrepo

rting

useof

theCMPas

interpretedby

theauthor

c

Inform

ationsources

wom

enaccess

for

CMPs

Abo

rigoet

al.

(2012)

[60]

Ghana

(LMIC)

253(includ

ing35

wom

enwith

newbo

rninfants;8tradition

albirth

attend

antsandlocal

healers;16

commun

ityleaders;4FocusGroup

Discussions

[FGDs]with

8–10

grandm

othe

rseach;and

12compo

und

heads)

In-dep

thinterviews

[IDIs]andFocus

grou

pdiscussion

s[FGDs]

Not

stated

Toexplore

breastfeed

ing

initiationand

supp

lemen

tatio

n;cultu

ralp

ractices

arou

ndbreastfeed

ing

initiation;

and

implications

forthe

improvem

entof

infant

health

Herbalm

edicines

Breastfeed

ing

Tradition

alBirth

Atten

dants(TBA

s);

herbalists;o

ther

local

healers;wom

en’s

mothe

rs-in

-law

and

grandm

othe

rs;h

eads

ofho

useh

olds

Callisteret

al.

(2011)

[61]

Threecoun

tries:

ThePeop

le’s

Repu

blicof

China

(UPIC),Taiwain

(HIC)andUSA

(HIC)

34Chine

sewom

en(10

livingin

Guang

zhou

,China,12livingTaiwan,

and12

who

had

immigratedto

western

UnitedStates.)

In-dep

thinterviews

Not

stated

Com

parison

ofchildbirthexpe

riences

ofChine

sewom

enin

theircoun

triesof

origin

with

thosewho

hadim

migratedto

the

USA

before

giving

birth;

provideinsigh

tson

Chine

sewom

en’s

cultu

ralp

ractices

and

beliefsassociated

with

giving

birthfornu

rses

andmidwives

inthe

USA

.

Herbalm

edicines

Preg

nancyand

postnatalm

onth

Shared

cultu

ral

tradition

s;wom

en’s

mothe

rsand

mothe

rs-in

-law

Dako-Gyeke

etal.(2013)

[62]

Ghana

(LMIC)

55(includ

ing17

preg

nant

and15

postnatalw

omen

;10

nurse-midwives;2

med

icaldo

ctors;3

commun

itymem

bers;

3spiritualists;1

tradition

albirth

attend

ant;1he

rbalist)

In-dep

thinterviews

andFocusgrou

pdiscussion

s

Not

stated

Describethebe

liefs,

perspe

ctives

and

know

ledg

eof

preg

nancyandbirth

ofpe

ri-Urban

Ghanaianwom

enandho

wthese

influen

cethehe

alth

care

seeking

behaviou

rthese

wom

en.

Herbalm

edicines

Preg

nancy,labo

urandbirth

Herbalists,TBA

sand

somespiritualists

Dam

anik

(2009)

[51]

Indo

nesia(LMIC)

64(includ

ing24

curren

tmothe

rs;

36grandm

othe

rs)

In-dep

thinterviews

andFocusgrou

pdiscussion

s

Con

tent

analysis

andEthn

ograph

yTo

gather

inform

ation

abou

tcultu

ralb

eliefs

andpractices

arou

ndtheuseof

theplant

Torbangu

n(Coleus

amboinicus

Lour)as

agalactagog

ueby

Indo

nesian

wom

enpo

stnatally.

Herbalm

edicines

Breastfeed

ingand

thepo

stpartum

mon

th

Shared

cultu

ral

tradition

s;mothe

rs,

mothe

rs-in

-law,and

husbands

ofthene

wmothe

r

Ejidokun

(2000)

[54]

Nigeria(LMIC)

25(23preg

nant

wom

en;2

health

care

providers

who

werealso

local

grandm

othe

rsand

midwives)

Focusgrou

pdiscussion

s(23preg

nant

wom

en)and

inde

pth

interviews(2

health

Them

atic

conten

tanalysis

Assesstheknow

ledg

e,attitud

esandpractices

relatedto

maternal

anaemiaam

ong

preg

nant

wom

en,

health

workersland

thecommun

ityin

Ironandfolic

acid

tablets

Preg

nancy

Med

ia:radio

&printed

advertisem

entson

buses;he

alth

clinic

workers;information

givenin

places

ofworship

likemosqu

es.


Table

2Pertinen

tfeatures

ofinclud

edstud

ies(Con

tinued)

Autho

r(date)

Cou

ntry

(econo

mic

classification

a )Num

berof

participants

Datacollection

metho

dDataanalysis

metho

dStud

yaims

CMPs

repo

rted

onin

thepape

rsb

Stagein

thecontinuu

mof

childbe

aringrepo

rting

useof

theCMPas

interpretedby

theauthor

c

Inform

ationsources

wom

enaccess

for

CMPs

profession

als)

twoNigeriansites;to

iden

tifybarriersand

enablersto

theuseof

folic

acid

andiro

ntabletsby

preg

nant

wom

en;assessfamily

mem

bers’and

maternalh

ealth

care

providers’aw

aren

ess

ofmaternalanaem

ia,

andho

wmuch

impo

rtance

they

attach

toit.

Elteret

al.

(2016)

[58]

Thailand

(UPIC)

16(allpreg

nant

wom

en)

In-dep

thinterviews,

participant

observations,

anda

demog

raph

icrecord

Interpretive

phen

omen

olog

yTo

explorefirst-tim

eThaimothe

rs’

expe

riences

ofpo

stpartum

family

practices,p

articularly

theirexpe

riences

and

unde

rstand

ings

ofspiritualhe

aling.

Herbalm

edicines

Early

postnatal

perio

dinclud

ing

breastfeed

ing

Shared

cultu

ral

know

ledg

e;family

elde

rs

Grewalet

al.

(2008)

[43]

Canada(HIC)

15(postnatalwom

enwith

babies

less

than

3mon

ths)[N.B.5

health

care

profession

alsand

commun

ityleadersalso

provided

recommen

datio

nsbased

onthestud

yfinding

s]

In-dep

thinterviews

Naturalistic

qualitative

descrip

tive

design

Describeknow

ledg

eandcultu

raltraditio

nsof

newlyim

migrated

Punjabiw

omen

’spreg

nancy,birthand

postnatalexperiences

inCanada;theroleof

family

andcommun

ityin

theseexpe

riences

andho

wwom

enincorporatethese

beliefsandpractices

into

theCanadian

health

care

system

;andwom

en’s

interactions

with

the

Canadianhe

alth

care

system

Herbalm

edicines

Labo

urandbirth,

early

postnatal

perio

dand

breastfeed

ing

Shared

cultu

ral

know

ledg

e;elde

rsespe

cially

femalefamily

mem

bersinclud

ing

mothe

rs,m

othe

rs-

in-law,and

sisters-in-

law

andhu

sbands

(ifno

extend

edfamily

arou

nd)prep

ared

the

herbsin

food

sand

teas

forthewom

en

Holstet

al.

(2009)

[52]

UnitedKing

dom

(HIC)

6preg

nant

wom

en(allwom

enwererecruited

from

anantenatalclinic

andhadused

herbsin

preg

nancy)

One

FocusGroup

Discussion

Con

tent

analysis

Toincrease

unde

rstand

ing

ofwom

en’sreason

sfor

usinghe

rbalprod

ucts

durin

gpreg

nancy

Herbalm

edicines

Preg

nancy

Family

andfrien

ds;

internet;C

AM

and

biom

edicalHCPs

Juntun

enet

al.(2000)

[7]

Tanzania(LIC)

49(includ

ing28

wom

en;

21men

;informantalso

includ

edapastor;traditio

nal

healer;farmers;teache

rs;village

health

workers;traditio

nalb

irth

attend

ant;andtraine

dho

spital

staff)

Ope

n-en

ded

interviewsand

participatory

observation

Ethn

ograph

yTo

iden

tifycultu

ralcare

practices

andbe

liefs

arou

ndhe

alth

protectio

ntheBena

peop

leuse

throug

hout

theirlifetim

e

Herbalm

edicines

Preg

nancy,labo

urandbirth,

early

postnatalp

eriod

Localtraditio

nal

Africanhe

alers;

olde

rwom

enin

thecommun

ity


Table

2Pertinen

tfeatures

ofinclud

edstud

ies(Con

tinued)

Autho

r(date)

Cou

ntry

(econo

mic

classification

a )Num

berof

participants

Datacollection

metho

dDataanalysis

metho

dStud

yaims

CMPs

repo

rted

onin

thepape

rsb

Stagein

thecontinuu

mof

childbe

aringrepo

rting

useof

theCMPas

interpretedby

theauthor

c

Inform

ationsources

wom

enaccess

for

CMPs

Lamxayet

al.

(2011)

[56]

LaoPeop

le’s

Dem

ocratic

Repu

blic(LMIC)

30(23wom

en;7

men

)Group

interviews

andindividu

alinterviews

Ethn

obotanical

research

Tostud

ytheactivities

and

diet

followed

bytheKry

ethn

icgrou

pin

LaoPeop

le’s

Dem

ocratic

Repu

blicdu

ring

preg

nancy,childbirthand

postpartum

confinem

ent

perio

d,andiden

tifymed

icinal

plantsused

durin

gthesetim

es.

Herbalm

edicines

Preg

nancy,labo

urand

birth,

postpartum

perio

dandbreastfeed

ing

Husband

sandothe

rrelatives,o

ther

mothe

rswho

had

givenbirthseveral

times

andactedas

assistantsto

the

birthing

wom

an

Liam

putton

get

al.(2005)

[4]

Thailand

(UPIC)

30(allwom

en-mosthad

recentlygivenbirth;afew

werecurren

tlypreg

nant)

In-dep

thinterviews

Phen

omen

olog

yTo

unde

rstand

wom

en’s

tradition

albe

liefsandpractices

regardingpreg

nancyand

childbirtham

ongwom

enin

NorthernThailand

,including

theroleof

atradition

almidwife.

Herbalm

edicines

Preg

nancy,labo

urand

birth

Mothe

rsor

wom

enandmen

ofolde

rge

neratio

ns;m

ormon

,amagical

healer

orolde

rman

who

has

know

ledg

eabou

tmagicalcuresand

healing

Mog

awane

etal.(2015)

[64]

SouthAfrica

(UPIC)

15(allcurren

tlypreg

nant

wom

en)

Unstructured

one-on

-one

interviews

Qualitative,

explorative,

descrip

tive,

andcontextual

research

design

InvestigatetheIndige

nous

[med

ical]practices

ofpreg

nant

wom

enattend

ingtheDilokong

hospital,Limpo

poProvince,

SouthAfrica

Herbalm

edicines

Preg

nancy,labo

urand

birth

Tradition

alAfrican

Healers,TBA

s,also

commun

ityelde

rsandchurch

leaders

Ngo

mane&

Mulaudzi

(2012)

[57]

SouthAfrica

(UPIC)

12(allcurren

tlypreg

nant

wom

en)

Unstructured

in-dep

thinterviews

Narrativeanalysis

Toexploreandde

scrib

ethe

Indige

nous

beliefsand

practices

that

influen

celate

antenatalclinicattend

ance

bypreg

nant

wom

en

Herbalm

edicines

Preg

nancy,labo

urand

birth

TBAsandfamily

mem

bers

Obe

rmeyer

(2000)

[46]

Morocco

(LMIC)

151(includ

ing126po

stnatal

wom

en;20mod

ern

(biomed

ical)he

alth

care

providers;5tradition

albirth

attend

ants)

Semi-structured

in-dep

thinterviews

andob

servationin

homes

andclinics

Ethn

ograph

yMod

eltheethn

ophysiolog

yandsymbo

lism

ofpreg

nancy

andbirthin

Morocco

andwhat

thisim

pliesforwom

en’s

maternalh

ealth

;und

erstand

wom

en’she

alth

care

and

decision

-makingactio

nsregardingbirth

Herbalm

edicines

andvitamin

supp

lemen

ts

Preg

nancy,labo

urand

birth

Tradition

almidwives

andtradition

alhe

alers

Okaforet

al.

(2014)

[8]

Nigeria(LMIC)

25(allwom

enwho

had

delivered

ababy

inthe

previous

2years)

Focusgrou

pdiscussion

sNotheo

rystated

except

Fram

ework

Metho

dused

toanalysedata

Discoverruralw

omen

’spreferredchoice

ofhe

alth

care

provider

forpreg

nancyand

deliveryservices

inLago

s,Nigeria;inform

maternalh

ealth

care

services

forruralN

igerian

wom

en

Herbalm

edicines

Preg

nancy,labo

urand

birth

TBAs

Rice

(2000)

[44]

Australia(HIC)

33(includ

ing27

wom

en;

threesham

ans;tw

omed

icinewom

en;o

nemagiche

aler)

In-dep

thinterviews

andparticipant

observation

Ethn

ograph

yTo

exam

inecultu

ralb

eliefsand

practices

relatedto

the30

day

confinem

entpe

riodafterbirth

inHmon

gsocietyforHmon

gwom

enno

wresiding

inAustralia.A

lsoto

discuss

tradition

alandchanging

patterns

ofchildbe

aringfor

Herbalm

edicines

Breastfeed

ingandthe

postpartum

mon

thShared

cultu

ral

know

ledg

e;Med

icine

Wom

en,Shamans,

Tradition

alHmon

ghe

alers.


Table

2Pertinen

tfeatures

ofinclud

edstud

ies(Con

tinued)

Autho

r(date)

Cou

ntry

(econo

mic

classification

a )Num

berof

participants

Datacollection

metho

dDataanalysis

metho

dStud

yaims

CMPs

repo

rted

onin

thepape

rsb

Stagein

thecontinuu

mof

childbe

aringrepo

rting

useof

theCMPas

interpretedby

theauthor

c

Inform

ationsources

wom

enaccess

for

CMPs

thesewom

enin

theirne

wsocialen

vironm

ent.

Rutakumwa

&Krog

man

(2007)

[59]

Ugand

a(LIC)

63(allruralw

omen

living

inUgand

a)Semi-structured

interviews

Not

stated

,except

constant

comparative

metho

dof

analysisto

develop

descrip

tive

catego

ries

Iden

tifyruralU

gand

anwom

en’spe

rspe

ctives

ontheirow

nhe

alth

prob

lems,theirsolutio

nsandcoping

strategies,

andtheirrecommen

datio

nsforim

provingservices

tosuittheirhe

alth

need

s.

Herbalm

edicines

Preg

nancy

Shared

cultu

ral

know

ledg

e,olde

rfemalefamily

mem

bers,TBA

s.

Sim

etal.(2014)[55]

Australia(HIC)

20(wom

enallcurrently

breastfeed

ing,

orwho

had

breastfedin

previous

12mon

ths;allh

adused

herbalgalactagog

ues)

In-dep

th,

semi-structured

interviews

Them

atic

analysis-

transcrip

tswere

analysed

using

descrip

tiveand

qualitative

approaches

Und

erstandwom

en’s

perspe

ctives

andattitud

estowards

usinghe

rbal

galactagog

uesdu

ring

breastfeed

ing;

unde

rstand

wom

en’schoicesin

using

alternativemed

icineto

prom

otebreastfeed

ing;

iden

tifyfactorsthat

influen

cetheirde

cision

-making.

Herbalm

edicines

Breastfeed

ing

Internet

and

social-m

edia

basedmothe

rs’

grou

ps,fam

ilyandfrien

ds,trusted

HCPS

[biomed

ical

HCPs,and

CAM

HCPs,and

Lactation

Con

sultants]

Thwalaet

al.(2011)

[47]

Swaziland

(LMIC)

15(allwom

enwith

atleast1child,the

youn

gest

less

than

2yearsold)

Unstructured

interviews

Ethn

ograph

yDescribethevalues,b

eliefs

andchildbirthpractices

ofruralSwaziw

omen

inpreg

nancy,labo

urandthe

postpartum

perio

d.

Herbalm

edicines

Preg

nancy

Shared

cultu

ral

tradition

s,Tradition

alAfricanHealers,

mothe

rs-in

-law.

Waisw

aet

al.(2008)

[45]

Ugand

a(LIC)

10focusgrou

pdiscussion

swith

mothe

rsun

der30

yearsof

age,olde

rmothe

rsinclud

inggrandm

othe

rs,

fathersandchildminde

rs[but

noexactnu

mbe

rgiven

foreach

FGD];6keyinform

ant

interviewswith

6he

alth

workersand4TBAs

Focusgrou

pdiscussion

sand

inde

pthkey

inform

ant

interviews

Latent

them

atic

conten

tanalysis

Assesstheacceptability

ofMillen

nium

Develop

men

tGoalsto

redu

ceinfant

and

maternalm

ortalityin

rural

Ugand

ancommun

ities;

iden

tifyacceptable

factors

andbarriersandto

ante

andpo

stnatalcare.

Herbalm

edicines

Preg

nancy

Shared

cultu

ral

tradition

sand

practices;TBA

s.

Warrin

eret

al.(2014)

[63]

UnitedKing

dom

(HIC)

10(allcurren

tlypreg

nant

wom

en)

In-dep

thinterviews

Not

stated

just

them

aticanalysis

used

inanalysis

oftranscrip

ts

Toinvestigateover

the

coun

ter[OTC

]useof

complem

entary

med

icines

andph

armaceutical

med

ications

inpreg

nancy,

theroleof

othe

rsin

influen

cing

wom

en’s

choice

touseCMPs,and

how

issues

ofchoice

and

controlinfluen

cewom

en’s

useof

OTC

CMPs

and

pharmaceuticalsin

preg

nancy.

Vitamin

and

mineral

supp

lemen

ts,

homoe

opathic

remed

iesand

herbalmed

icines

availableover

the

coun

ter

Preg

nancy

Hom

oeop

aths,

doctorsandmidwives,

othe

rpreg

nant

wom

en.


Table

2Pertinen

tfeatures

ofinclud

edstud

ies(Con

tinued)

Autho

r(date)

Cou

ntry

(econo

mic

classification

a )Num

berof

participants

Datacollection

metho

dDataanalysis

metho

dStud

yaims

CMPs

repo

rted

onin

thepape

rsb

Stagein

thecontinuu

mof

childbe

aringrepo

rting

useof

theCMPas

interpretedby

theauthor

c

Inform

ationsources

wom

enaccess

for

CMPs

Westfall(2003a)

[40]

Herbalh

ealing

Canada(HIC)

33(27curren

tlypreg

nant

wom

en,ofwho

m26

used

herbalmed

icines

inpreg

nancy;

6men

torsinclud

inghe

rbalists,

authorsandmidwives)

In-dep

thinterviews

Them

atic

analysis

Togive

voiceto

wom

en’s

self-prescriptio

nof

herbal

med

icines

inpreg

nancy;

unde

rstand

wom

en’s

percep

tions

oftheroles

andsafety

ofhe

rbal

med

icineusein

preg

nancy,

andthechoice

tousehe

rbal

med

icinein

preg

nancy.

Herbalm

edicines

Preg

nancy

Ownknow

ledg

e,ow

nintuition

,and

trusted

sourcesinclud

ing

books,frien

ds,fam

ilymem

bers,b

iomed

ical

HCPmaternity

care

providers,CAM

HCPs

(herbalists),he

rbal

shop

s,andthe

internet.Sixmen

tors

werelistedby

participants–these

weremidwives

and

childbirthed

ucators

andhe

rbalists

Westfall

(2003b

)[10]

Galactagogue

herbs

Canada(HIC)

23(wom

en,allcurren

tlybreastfeed

ing;

14had

used

herbalgalactagog

ues)

In-dep

thinterviews

Them

atic

analysis

Todiscussthepo

tentialvalue

offivegalactagog

uehe

rbs

used

bybreastfeed

ingwom

en,

includ

ingthewom

en’sow

nob

servations,h

istoricaluse,

safety

andefficacy;inform

future

research.

Herbalm

edicines

Breastfeed

ing

Midwives,friend

s,mothe

rs,p

ublic

health

nurse,do

ula.

Westfall

(2004)

[41]

Anti-em

etic

herbsin

pregna

ncy

Canada(HIC)

27(allcurren

tlypreg

nant;20

hadnausea

andvomiting

ofpreg

nancy,andof

these10

hadused

herbalmed

icines

totreat)

In-dep

thinterviews

Them

atic

analysis

Discuss

thede

tails

ofthehe

rbal

med

icines

used

bywom

ento

treatpreg

nancy-indu

cednausea

andvomiting

.

Herbalm

edicines

Preg

nancy

Herbalists

Wilkinson&

Callister

(2010)

[48]

Ghana

(LMIC)

24(allpreg

nant

wom

en;

someHCPqu

otes

also

includ

ed)

In-dep

thinterviews

andparticipant

observation

Ethn

ograph

ywith

theHealth

BeliefMod

el

Describethepe

rcep

tions

ofchildbirthhe

ldby

Ghanaian

wom

en;inform

health

policy

makersandhe

alth

care

providersto

insure

wom

enreceiveclinicallysafe

and

cultu

rally

sensitive

care.

Herbalm

edicines

andvitamins

Preg

nancy

Herbalists,b

iomed

ical

midwives

Wulandari&

Whe

lan

(2011)

[53]

Indo

nesia(Bali)

(LMIC)

18(allcurren

tlypreg

nant

wom

en)

In-dep

thinterviews

Con

tent

analysis

Explorethebe

liefs,attitu

des

andbe

haviou

rsof

preg

nant

wom

enin

Bali,Indo

nesia

Herbalm

edicines

andiro

ntablets

Preg

nancy

Shared

cultu

ral

know

ledg

e,family

mem

bers

Yeoet

al.

(2000)

[49]

USA

(HIC)

22(11coup

les-11

wom

enandtheir11

husbands

inwereinterviewed

inpreg

nancyandthen

postnatally)

In-dep

thinterviews

Ethn

ograph

yExam

ineJapane

secoup

le’s

percep

tions

andexpe

riences

ofpren

atalcare

andchildbirth

inMichigan,

USA

;explore

implications

forproviding

cultu

rally

compe

tent

care.

Preandpo

stnatal

vitamins

Preg

nancyand

breastfeed

ing

Shared

cultu

ral

know

ledg

e,do

ctors,family

and

frien

ds.

Youn

g&Ali

(2005)

[50]

Tanzania(Zanzibar)

(LIC)

52(includ

ing25

mothe

rs;27

health

care

workersinclud

ing

Inform

alconversatio

ns,

Ethn

ograph

yUsing

ethn

ograph

yas

the

basis,to

describ

etradition

alTradition

aliro

nremed

iesandiro

nPreg

nancyandthe

postpartum

mon

thIro

ntablets–ho

spital

andnu

rses;Traditio

nal


Table

2Pertinen

tfeatures

ofinclud

edstud

ies(Con

tinued)

Autho

r(date)

Cou

ntry

(econo

mic

classification

a )Num

berof

participants

Datacollection

metho

dDataanalysis

metho

dStud

yaims

CMPs

repo

rted

onin

thepape

rsb

Stagein

thecontinuu

mof

childbe

aringrepo

rting

useof

theCMPas

interpretedby

theauthor

c

Inform

ationsources

wom

enaccess

for

CMPs

4go

vernmen

the

alth

officials;

3biom

edicaldo

ctors;2

maternity

wardnu

rses;4

health

aide

s;2ph

armacists;3

three

TBAs;1divine

r/he

aler;3

tradition

almed

icinemakers;5

employeesat

private

pharmacies)

in-dep

thinterviews,focus

grou

pdiscussion

sandparticipant

observation

(non

-biomed

ical)treatm

ents

formaternalironde

ficiency

anaemiain

Zanzibar;d

escribe

wom

en’schoicesin

choo

sing

treatm

ents;inform

health

planne

rsof

thesechoicesso

that

andcultu

rally

approp

riate

care

canbe

provided

,with

the

aim

toredu

cematernal

anaemia.

tablets

remed

ies–tradition

alhe

alers

TBAsTrad

ition

alBirthAssistantsor

Atten

dants,Biom

edical

HCP

sbiom

edically

traine

dhe

alth

care

practitione

rs-nu

rses,m

idwives,d

octors

andob

stetricians;C

AM

HCP

sWestern

complem

entary

med

icinehe

alth

care

practitione

rsinclud

ingna

turopa

thsan

dhe

rbalists

traine

din

Western

Herba

lMed

icine

a LIC

low

incomeecon

omy,LM

IClower

middleincomeecon

omy,UPICup

permiddleincomeecon

omy,HIC

high

incomeecon

omyaccordingto

TheWorld

Bank

Classificatio

ns[33],b

ased

on20

15grossna

tiona

lincom

epe

rcapita

bCom

plem

entary

med

icinetype

discussedin

thepa

per,as

iden

tifiedby

thefirst

author

(LAJB)

cFo

rthepu

rposes

ofthisreview

andan

alysisof

theiden

tifiedstud

ies,thefirst

author

(LAJB)concep

tualised

thecontinuu

mof

child

bearingfrom

preg

nancy,birth,

theearly

postpa

rtum

perio

d,long

erpo

stpa

rtum

perio

dan

dbreastfeed

ingas

sepa

rate

butrelatedstag

es


another [48] without information on how many HCPs par-ticipated. Additionally, some studies [7, 45, 56, 59]included discussions with pregnant or lactating women aswell as other community members, family members andhealth care practitioners without reporting numbers ofeach type of participant. Hence the total number of preg-nant and/or breastfeeding women across all studies thatcan actually be counted is 566, but will have been larger.For those studies where the number of pregnant andlactating women is clearly stated, sample sizes rangedbetween six and one hundred and twenty-six, andaveraged 31. Overall, there was a wide variety in thenumber of participants, with the smallest being a UK studywith just one focus group of six women [52] and the lar-gest including 126 semi-structured interviews with womenwho had recently given birth in Morocco [46]. Most stud-ies had between 15 and 35 participants.

Types of CMP discussedHerbal medicine use was the main CMP discussed, with21/28 focussing on herbal medicines exclusively, 3/28 dis-cussing herbal medicines and vitamin supplements [46, 48,53], and 3/25 discussing iron and folic acid [54], pre andpostnatal vitamins [49], and traditional iron remedies andiron supplements [50] respectively. In addition to vitaminand mineral supplements and herbal medicines, homoeo-pathic remedies were also included in one paper [63].

Focus on pregnancy and/or breastfeedingAlthough the continuum of childbearing can be conceptua-lised from pre-conception through pregnancy, birth, thepostpartum period and breastfeeding, there was great

variety in the foci of the papers included (Fig. 2). Only ninepapers discussed CMP use during breastfeeding [10, 43, 44,49, 51, 55, 56, 58, 60]. The remaining 19 papers discussedCMP use in pregnancy and other childbearing stages with-out reference to breastfeeding.

Information sources accessed by women around theworldThe information sources accessed by women when choos-ing to use CMPs in pregnancy and lactation are illustratedin Fig. 3 (and by country groups, see Additional file 3).Shared cultural knowledge and traditions (14 papers)followed by women elders (women’s own mothers,mothers-in-law and grandmothers, other older experiencedfemale family members) (11 papers) were informationsources identified most commonly. Following this, womenaccessed their health care providers for information – forwomen from LMIC and LIC countries and backgroundsthis included Traditional Birth Assistants, traditional(non-Western) herbalists or healers, medicine women,magical healers or shamans [4, 7, 8, 44–47, 59, 60, 62, 64]but also included biomedical health care practitioners insome studies [48, 50, 54]. Similarly, women from HICbackgrounds often sought information from biomedicalhealth care providers as well as Western herbalists ornaturopathic practitioners [40, 52, 55, 63]. One significantdifference between women in high income countries andlow to middle income countries, was that women in HICsreported accessing CMP information via the Internet,whereas women from low and low-middle income coun-tries did not. The studies involving immigrant women fromlower income countries into HICs (Punjabi women to

Fig. 2 Distribution of studies focussing on CMP use during different stages of the childbearing continuum (n = 28) as identified by the firstauthor (LAJB)


Canada, Hmong women to Australia) showed that thewomen brought their cultural traditions and knowledgewith them to their new countries and that traditionalknowledge and practices remained important. Similarly,Yeo, Fetters [49] found that the strong cultural beliefs heldby Japanese women living in the USA influenced their will-ingness to take prenatal vitamin supplements. Thenear-universality of family and friends being reported as in-formation sources is evident when combining the groupreporting women elders and other female family members,husbands and family and friends together.

Discussion of health literacy in the papersFor the included studies, the role of health literacy inwomen’s use of CMPs during pregnancy and lactation wascomplex. The reasons why mothers make decisions abouttheir own and their children’s health care are influencedby women’s individual skills and abilities to access andevaluate health information, as well as individual skillsand knowledge [65, 66]. None of the included studies dir-ectly measured the health literacy levels of participantsand nor did any discuss findings explicitly in relation tohealth literacy as an over-arching concept. However, par-ticipants’ knowledge, attitudes and practices, all of whichare concepts related to health literacy, were discussed.

Knowledge, attitudes and practicesAll studies discussed participants’ knowledge, attitudesand practices. ‘Health beliefs and practices’ was the mostcommonly discussed aspect of health (18/28 papers)followed by ‘health knowledge, attitudes and practices’(12/28), ‘health care seeking behaviours’ (12/28) and

‘health behaviours’ (11/28). Health beliefs and practiceswere the greatest influence on women’s use of CMPsacross the papers – women took CMPs because of per-ceived health benefits to themselves and/or their babies(discussed further below). The cultural importanceregarding use of CMPs was also evident, especially forwomen from LICs and LMICs [45–47, 50, 51, 53, 54, 59,60], but also for women in UPICs and HICs whodescribed the importance of specific cultural practicesduring pregnancy, childbirth and the postpartum period[4, 43, 44, 49, 58, 61]. For many, the information regard-ing the cultural importance of CMP use during thechildbearing continuum was passed on to them throughwomen elders in their communities [7, 43, 44, 47, 51, 53,57–61, 64] (also see Fig. 3).Women’s health beliefs, practices, and health behaviours

were influenced by their health knowledge and attitudes.For women in developing countries, knowledge of the bio-medical model of pregnancy and birthing care was oftenpoor. Women did not understand how regular antenatalcare could help reduce their own and their babies’ risks ofmorbidity and mortality [45, 57, 62]. Women’s culturalknowledge regarding needs for traditional medical carealong with their needs for psychosocial support led themto seek traditional care, and their albeit limited under-standing of the biomedical model motivated them to ac-cess biomedical care [8, 45–48, 59, 62, 64]. In morewealthy economies, women’s engagement in medical plur-alism was also discussed in relation to health beliefs andpractices. Women’s perceptions of CMPs as being saferthan pharmaceutical medications was explored [10, 40, 41,52, 55, 63], as was their use of CMPs as part of efforts to

Fig. 3 Information sources accessed by women regarding using CMPs in pregnancy and lactation across the synthesis


increase autonomy, and self-responsibility for their ownand their infants’ health [40, 55, 63]. Knowledge regardingthe safety profiles of herbal medicine especially was alsoconsidered low in several of the studies across incomestreams [52, 53, 63], although this was usually discussedfrom the perspective of a biomedical outsider, with requis-ite concerns regarding lack of scientific testing of theCMPs being the basis of authors’ concerns.The focus of almost half the discussions (13/28) was

on how to improve patient outcomes through culturallycompetent care [4, 43–45, 47, 49, 50, 53, 54, 56, 57, 61,64]. Women’s health knowledge, attitudes, beliefs, andpractices were all discussed in relation to their healthcare seeking behaviours and especially in the poorercountries where maternal morbidity and mortality arehigh, in relation to their health outcomes. For thesepoorer communities, whole of community approaches toimproving the health literacy through education and in-formation dissemination were commonly proposed [45,50, 53, 54, 57, 60], as often pregnant or breastfeedingwomen experienced significant barriers to accessing bio-medical health care. These barriers included geograph-ical isolation and/or gender inequities [47, 59, 60], aswell as cultural norms that advocated familydecision-making over individual decision-making andwhere family based care during pregnancy and the post-partum period was the norm [45, 47, 53, 58, 60]. Forwomen in wealthier economies where culturally compe-tent care was also discussed, the focus was more onwhat biomedical HCPs could do to improveprovider-patient communication and understand theculturally based needs of pregnant and breastfeedingwomen [43, 44, 49, 61].

Women’s use of CMPs in pregnancy and lactation andtheir perceived benefitsThematic analysis revealed that women’s use of CMPs inpregnancy and lactation could be separated into severalthemes with associated subthemes. Additionally,women’s use of CMPs in pregnancy and lactation can beseparated into two main over-arching motives, ‘Protect-ive or preventative actions’ or ‘Facilitation of a normalprocess’ (Table 3). These themes and subthemes are fur-ther elaborated in Additional file 4.

DiscussionAll mothers want what is best for themselves and theirunborn and breastfeeding babies and this review hasidentified that mothers from a range of economicallyadvantaged countries use CMPs to help facilitate this.Underpinning this desire and the decision-making asso-ciated with it are several factors: a woman’s individualhealth literacy, the health literacy environments shemoves in, her own culture and the cultures at play in the

health literacy environment, considerations of safety andwhere the locus of control regarding decision making inpregnancy and lactation sits.

Culture, health literacy and holistic healthThis review’s identification of shared cultural knowledgeas a major information source for women choosing touse CMPs in pregnancy and lactation warrants furtherdiscussion of culture, health literacy and holistic health.The United Nations Educational, Scientific and Cul-

tural Organization defines culture as “the set of distinct-ive spiritual, material, intellectual and emotional featuresof society or a social group, and that it encompasses, inaddition to art and literature, lifestyles, ways of living to-gether, value systems, traditions and beliefs” [67]. Thisdefinition has been accepted by the World Health Orga-nisation’s expert group on the cultural contexts of healthand wellbeing [68]. Culture is a way of life, and can in-clude religious, social or ethnic characteristics, but isalso dynamic as values and practices can change overtime. It is also important to acknowledge that all kindsof knowledge are cultural, including the practices oftraditional health care systems, Western complementaryhealth care systems, and scientific and biomedical prac-tices [68]. A mother’s own culture influences both herindividual health literacy skills and abilities, and how sheaccesses, evaluates and uses health care information andservices in her health literacy environment when makingdecisions about her own and her children’s health. Add-itionally she may also encounter different cultural know-ledge bases within both the health system infrastructureand in the people and relationships within the health lit-eracy environment including other care-givers, thehealth care team and systems accessed, each with theirown personal and medical cultural knowledge bases [31,32, 65]. Thus it can be argued that women make the de-cisions to use CMPs in pregnancy and lactation bothwithin the context of their own cultures and the culturesof the health literacy environment. This is illustrated inFig. 4 which builds on Parker’s [66] model, used by theAustralian Commission on Safety and Quality in HealthCare in their working definition of health literacy [65].The cultural components of health literacy and the waysthey impact on individual health literacy and the healthliteracy environments are depicted in the orange boxesadded to the original model (in green and white). In thisway, the original model is expanded to include both (i)an individual mother’s culture, and how her culture in-fluences the ways she uses her skills and abilities to ac-cess and interpret health information; and (ii) thedifferent cultural knowledge bases extant in the healthliteracy environment in which she moves.‘Protection and prevention’ and ‘Facilitation of normal

physiological processes’.


Table 3 Thematic analysis: women’s use of CMPs in pregnancy and lactation and perceived benefits

Use of CMPs during pregnancy

Major themes Subthemes Over-arching motive‘Protective or preventativeaction’ OR ‘Facilitation ofa normal process’

Selected examples (full thematic analysiscan be seen in Additional file 3)(in italics – participant direct quotes; inRoman (non-italicised) - text quotes(the papers did not always includequotes)

Women’s use of CMPs – perceived physical benefits

For the benefit of thepregnancy

• Prevention of vaginal bleedingand miscarriage in early pregnancy

• Protect against vaginal leakingand bleeding in both early andlate pregnancy

Protective orpreventative action

“At the initial stages of my pregnancy I wasbleeding and I came to the hospital for drugsbut it was persistent. So I went for herbalmedicine and it helped me” (Focus groupparticipant, ANC client, Madina)” (Dako-Gyekeet al. 2013, p211) [62]

• Ensure a safe pregnancy Facilitation of anormal process

“I have been advised to drink boiled herbs(Mbita) for the preservation and protectionof my unborn baby, so that I may have asafe pregnancy and labour.” (Ngomane &Mulaudzi, 2012, p34) [57]

For the benefit of thebaby

• Promotion of the developing baby’sphysical health - assist the baby’sintrauterine growth and support theirwell-being, health and vitality

• Monitor the baby’s health and growth

Facilitation of a normalprocess

“I think both [iron pills and herbal medicine]are important, aren’t they? I take the herbalsregularly and I feel that my baby is healthythat was also what I did in my firstpregnancy. I regularly took the herbals andnothing’s wrong with my baby. In fact, hewas very vigorous. (Woman 6)” (Wulandari &Whelan, 2011, p868–9) [53]

• No perceived benefit for the use ofCMPs in pregnancy – taking vitaminswas incompatible with Japanesecultural beliefs around takingmedications in pregnancy

Neither “I have been eating Japanese food in theUnited States just like I did in Japan when Ihad my first child. I never took a vitamin withmy first child. .. and it did not have any badeffects on my child. .. then American doctorstold me that it’s better to take vitamins. .. Idon’t mind taking it, but I don’t know why Ineed to take it, as nothing bad happenedwith my first child in Japan.” (Yeo et al., 2000,p194) [49]

For the benefit of themother

• Prevention or treatment of commonillnesses associated with pregnancylike thrush and urinary tract infections

• Prevention or treatment ofnon-pregnancy related illnesses

• First line treatment of maternal dangersigns in pregnancy

• Protection against the developmentof pregnancy complications


“The participants identified ‘aseje’, (a specialconcoction, mainly herbs) as one of theattractions of seeking care from TBAs. It isbelieved that the ‘aseje’ preventsdevelopment of any complications duringpregnancy and labour and keeps pregnantwomen healthy” (Okafor et al. 2014, p46) [8]

• Safe support for mother’s own physicalhealth

• Treatment of maternal anaemia; provisionof nourishment

• Safe form of treatment for nausea andvomiting of pregnancy

• Treatment of abdominal pain in pregnancy


“Tonic herbs can be thought of as lyingsomewhere in between food and drugs;they are used therapeutically, to treatsub-clinical conditions or to prevent healthdegeneration. They are used to strengthen,nourish and support the body, to preventrather than cure disease […] The most popularherb was raspberry leaf (Rubus idaeus) - auterine tonic - used by 22 women.” (Westfall2003 – herbal healing, pp26–27) [40].

For the benefit of thelabour and birthingprocesses

• Prevention of vaginal tearing duringbirth and reducing risk of caesareansection

• Prevention of foetal distress


“A typical example is what is locally known asamalagala, a product of crushed sweet-potatoleaves mixed with water. This mixture isadministered to pregnant women, who bathein it or sit on it to lessen the risk of requiring aCaesarean section or of vaginal tearing duringdelivery. The women did not discuss trial anderror for this concoction but unanimouslyreported confidence in its efficacy”


Table 3 Thematic analysis: women’s use of CMPs in pregnancy and lactation and perceived benefits (Continued)

(Rutakumwa & Krogman, 2007) [59]

• Use of herbal tonics to tone the uterusand strengthen it in preparation forlabour

• Prepare for an easy birth• Enhance or induce labour• Relieve labour pains• Induce expulsion of retained placenta• Relieve afterbirth pains


“Consumption of traditional herbal medicinewas also mentioned as a way of preparing foran easy birth. The traditional herbal medicinewas referred to as ya tom. A woman mustconsume ya tom three times per day for threeconsecutive days. Women can purchase driedherbal medicine and boil it until it reduces tosmall cup quantity and drink it as tea. This isbelieved to make the baby strong, hencefacilitating an easy birth.” (Liamputtong et al.2005, p146) [4]

Women’s use of CMPs in pregnancy to protect against spiritual threats to themselves and their unborn babies – perceived benefits involving spiritualprotection

For the benefit of bothmother and baby

• Protect the baby from spiritual threatsthat could cause physical harm includingdeath of the foetus or preterm labour


“All the women in this study stated that boththe mother and baby might fall ill because ofkuhabula. To prevent illness therefore, thewomen expressed belief in the power oftraditional doctors and medicine, or divineprayer if the women or family was religious”. ..[traditional medicines are taken] to make surethat the baby is protected on all fronts;protected from kuhabula [acquisition of illnessesfrom bad spirits in the environment] through theuse of traditional medicine” (Thwala et al., 2011,p95) [47]

II. Use of CMPs during breastfeeding

Women’s use of CMPs – perceived physical benefits

For the benefit of thebreastfeeding process

• Increased breastmilk production –perceived and diagnosed milkinsufficiency

• Use of galactagogues ‘just in case’breastmilk supply needs support

• Use of galactagogues to build supply aspart of a cultural tradition (note, nomention of perceived insufficiency)


“I think it’s [fenugreek] worth trying. And as forme, I certainly find that useful and reassuringthat I have found something effective toincrease my milk supply. As a new mum, youjust never know, you never know what iscoming, what problems you will encounter and Icertainly did not anticipate that milk supply willbe an issue. I have always thought thatbreastfeeding is easy and will come naturallybecause everyone else does it, and I wasn’t toldabout it being an issue”. (BW 12). (Sim et al.,2014, p216) [55]

For the benefit of thebreastfeeding processand the mother’sphysical health

• Use of galactagogues supports post-birthrecovery and also builds breastmilk supply


“During the early postpartum period aswomen recovered, family members againprovided certain foods that were believed tohave ‘hot effects’ and bring the body intobalance. These types of food are seen asessential for healing and recovery from thebirthing process (arising from Ayurvedatraditions), including relieving back pain,promoting menstrual flow to cleanse thebody, building the mother’s milk supply, andpreventing weakness and illness in later life.‘Hot foods’ included … chai (fennel seed teawith ginger) … and other special foods …made from ‘heat-producing’ ingredients suchas ginger powder, fennel seeds … and specialherbs.” (Grewal, 2008, p294) [43]


For the benefit of themother’s physicalhealth

• Expulsion of lochia through ‘uterinecleansing’ and control of postpartumbleeding

• Assists in recovery after childbirth• Restoration of physical balance throughheat


“You eat them [chicken herbal medicine] so thatyour body will settle back to normal quicker andif you don’t use them then it will take you along time to get back to normal. The bleedingwill go on for a long time and that will makeyou very thin. That is not good.. . If you bleedtoo long the body won’t get back to normalagain and this can make you pale and skinny.If you have the chicken herbs to eat then your



blood will be good and you will feel strongquickly.. . You eat them to give you strengthand also to wash out your blood quickly too”(Rice, 2000, p29) [44]

• Treatment of a prolapsed uterus• Protection of the mother’s futurehealth


“Considered the most important Chinesecultural practice is ‘doing (or sitting) themonth’ (zuoyuezi). … ‘Doing the month’includes activity restrictions, avoiding ‘windchill’ ... and eating raw ginger soup withChinese herbs to ‘rid the body of cold’ … Ifsuch practices as described are not followed,the new mother is at risk for ‘the monthdisease,’ which is thought to have deleteriouseffects on their health for the rest of their lives(Callister et al., 2011, pp390–1) [61]

For the benefit of thebreastfeeding baby

• Protection of the breastfeeding babythrough the mother’s use of CMPs

• Purification of mother’s breasts inpreparation for breastfeeding andto ensure breastmilk is sweet

Protective or2preventative action

“The ingestion of local herbs is used as ameans of warding off any harmful effects tothe baby […] To protect the baby from healthproblems … the newly delivered mother, hermother, and her mother-in-law - should takelocal drugs [herbal medicines] before thegrandmother sees the baby for the first time”(Juntunen et al., 2011, p177) [7]

• Promotion of the baby’s health throughenabling the mother to continue tobreastfeed


“All participants seemed to have adopted the‘breast is best’ philosophy. These womenacknowledged and appreciated the health,physical and psychological benefits ofbreastfeeding to both mothers and infants.[…] Recognition of the importance andsignificance of breastfeeding was identified asthe main facilitator to develop perseveranceand a determined attitude to breastfeed: “Imean honestly, if drinking snake oil would makeme have more breast milk I would have done it,anything that helps!” (Sim et al., 2014, p216)[55]

Women’s use of CMPs during breastfeeding – perceived mental-emotional benefits


• Increased self-confidence,self-empowerment and reassurance

• Increases my ability for self-care


“Many participants also mentioned the feelingof reassurance through the use of herbalsupplements during breastfeeding, which wasespecially important for first-time mothers.Hence, the use of herbal galactagogue wasdescribed as a method of reassurance in thecontext of their own perceptions. The positiveemotional impact contributed to the successof breastfeeding practices amongst theparticipants.” (Sim et al., 2014, p216) [55]

• Restoration of mind-body balance Protective orpreventative action

“The herbs in hot bath, such as leaves of Nat,release aromatic oils, which are believed torelieve mind–heart, emotional, andpsychological stress. LD said ‘the water for ahot bath is boiled with leaves of an herb namedNat. The leaves will prevent her from feelingdizzy or being intoxicated.’ Leaves of Nat …can be used for treating fatigue, exhaustion,psychological and emotional imbalances, andpostpartum depression [and also] to ward offa malevolent spirit and to make holy water.The women in this study used both themedicinal and supernatural properties of Natleaves to treat the mind–heart essence” (Elteret al., 2016, p253) [58].

Women’s use of CMPs during breastfeeding – perceived benefits involving spiritual protection


• Spiritual protection in the postpartumperiod


In Thailand, Nat leaves are also used to wardoff a malevolent spirit and to make holy water.


Fig. 4 Impact of culture on health literacy, modified from Parker [66] and the Australian Commission on Safety and Quality in Health Care’sworking definition of health literacy [65]


The women in this study used both themedicinal and supernatural properties of Natleaves to treat the mind–heart essence” (Elteret al., 2016, p253) [58]

Women’s use of CMPs during breastfeeding – perceived cultural benefits


• Cultural cleansing rituals after childbirth Facilitation of a normalprocess

“Also first-time mothers are expected to gothrough a cultural cleansing known as sooruin Kasem and kosoto in Nankani, regardless ofthe bitterness of their breastmilk. The processinvolves the pouring of warm herbal waterover the mother for a period of 3 days if thechild is a male and for 4 days if the child isfemale” (Aborigo et al. 2012, p76) [60]

III. Additional themes relating to perceived benefits of women’s use of CMPs throughout the childbearing continuum

Perceptions of safetyregarding CMP use inpregnancy and lactation

• Complementary medicines are safer thanpharmaceutical medications

• Receiving reassurance that herbalmedicines are safe during pregnancyand breastfeeding


‘I am certainly not opposed to the idea of usingherbs during breastfeeding, as long as I knowand have checked with my child health nursesand doctors or even ringing up a pharmacist’(BW 12)” (Sim et al., 2014, p216) [55]

Using both CMPs andconcurrently accessingbiomedical carepromotes best care forboth mother and baby

• Better management of maternitycomplications in pregnancy and birth

• Protection of the baby from diseasesunderstood to arise from spiritual causesas well as from diseases treatable withbiomedical medicines


“I use traditional medicines during thepregnancy … I also go to the hospital everymonth to have check-ups. They give me pillswhich I take home to drink together with thetraditional medicines [...I use both traditionalmedicines and hospital medicines] to make surethat the baby is protected on all fronts;protected from kuhabula [acquisition of illnessesfrom bad spirits in the environment] through theuse of traditional medicine as well as protectedfrom the hospital diseases by using their modernmedicine.” (Thwala et al., 2012, p95) [69]


Pregnant and lactating women in the countries sam-pled choose to use complementary medicine productsbased on two over-arching themes identified in this syn-thesis, ‘Protective or preventative action’ and/or ‘Facilita-tion of a normal process’. Women’s motivation to useCMPs is based on the desire to both protect themselvesand their babies from adverse events, and to facilitatethe normal physiological processes of pregnancy, birthand breastfeeding. Women attempted to prevent adverseoutcomes in pregnancy including miscarriage or malfor-mation of the baby, ill health of the mother during preg-nancy, and to prevent foetal distress and vaginal tearingin labour and birth. Additionally, CMPs were used toprevent future health problems for both mother andbaby through the restoration of the mother’s health inthe postnatal period and the establishment of breastfeed-ing. Whilst this synthesis predominantly identified per-ceived physical benefits relating to CMP use inpregnancy and lactation, perceived mental-emotional,cultural and spiritual benefits were also found. Again,the impact of culture cannot be underestimated whenexamining women’s health care choices in pregnancyand lactation. Whilst pregnancy, labour, birth andbreastfeeding are physiologically comparable for allwomen, there is great variety in the social and culturalcontexts within which these events occur, as well as inthe individual customs, beliefs, morals and valueswomen will bring to their individual experiences [7, 47,69]. A woman’s cultural heritage and her cultural envir-onment will influence her health care decisions in preg-nancy and lactation [61, 70]. Finlayson & Downe’s [71]systematic review found that cultural beliefs regardingthe need to protect a pregnancy from supernaturalthreats, combined with women’s preferences for trad-itional medicines, contributed to the low use of biomed-ical antenatal services in LICs and LMICs. Alsocontributing to this low utilisation was the commonlyheld cultural view of pregnancy as a normal physio-logical state, as opposed to a biomedical perception ofpregnancy as a risky situation [71]. These results supportthe current review’s identification of the two overarchingmotivating themes ‘protection and prevention’ and ‘fa-cilitation of normal physiological processes’ as strongmotivators for women’s use of CMPs during pregnancyand breastfeeding for women in developing economies.Studies from LIC and LMIC countries included in thepresent review also identified that traditional and cul-tural beliefs contribute to CMP use in pregnancy andlactation, and that women view herbal and traditionalmedicines as being safer, more effective, affordable andmore easily accessed than pharmaceutical medications,[47, 57, 62, 72]. Regarding women in HICs, motivationsfor their CMP use during pregnancy have been exam-ined in four systematic reviews. Pallivalappila et al. [73]

were unable to make definitive conclusions regardingpregnant women’s motivations regarding use of comple-mentary medicine, or their perceptions of the effective-ness and safety of CMPs, due to substantial flaws instudy design and reporting. However, three other re-views of CMP use by pregnant women in HICs [12–14]did find links between CMP use and women’s prefer-ences for holistic approaches to health, along withwomen’s perceptions that use of complementary medi-cine facilitated better health, wellbeing and quality of lifein pregnancy, and could help them prepare for a normallabour and birth. In line with the theme ‘facilitation ofnormal physiological processes’, women’s desire for au-tonomy and control over individual pregnancy healthwere also identified as motivating factors for women’suse of CMPs [12–14]. Consistent with the theme ‘pro-tection and prevention’ Adams et al.’s [12] review alsoidentified that women perceived their CMPs to be saferthan pharmaceutical prescriptions when using CMPs torelieve pregnancy-related complaints.

Locus of control, culture and CMP use in pregnancy andlactationStudies examining the health locus of control aim to de-scribe what health beliefs influence people’s health be-haviours [74]. For pregnancy this could includemeasuring perceived responsibility pregnant womenhold (internal locus of control) and the extent externalforces like chance and health professionals (termed‘powerful others’) will affect the health outcomes of theirbabies [75, 76]. For pregnant and breastfeeding womenfrom LIC, LMIC and UPIC countries, powerful othersalso included their mothers and mothers-in-law andother extended family members who often providedboth antenatal and postpartum care within a context ofculturally prescribed practices. In contrast, for womenfrom HICs, the use of CMPs was associated with in-creasing autonomy and taking self-responsibility fortheir own, and their babies’ health [10, 55, 63]. This find-ing has also been documented in other qualitative andquantitative CAM research [77–79]. Locus of controlcan be seen as part of the wider cultural context and dif-fers between cultures and for women living in countriesof low versus high economic backgrounds.Figure 5 illustrates how the two over-arching motiva-

tors for CMP use, ‘Protective or preventative action’ or‘Facilitation of a normal process’, and considerations oflocus of control sit within the context of culture and itsinfluence on health literacy. Pregnant and lactatingwomen use CMPs for their perceived benefits for themother, the pregnancy, the child and/or the breastfeed-ing process. Overlaying but also integral to this is theinteractive model of health literacy [65, 66] which illus-trates how each individual woman is influenced by her


individual health literacy and her health literacy environ-ment. Culture is integral to both these components: itinfluences a woman’s individual health literacy, and dif-ferent cultural influences come into play at differentlevels of the model, including within different elementsof the health literacy environment.

Medical pluralism and considerations of culturalinfluences on health care decision-making in pregnancyand lactationThe concurrent use of CAM and biomedicine has beenwell d

complementary medicine products used in pregnancy and ......larisa ariadne justine barnes1,2*,...

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