Complementary medicine products used in pregnancy and lactation and an examination of the information sources accessed pertaining to maternal health literacy: a systematic review of qualitative studies

Details of the protocol for this systematic review were registered on PROSPERO and can be accessed at: https://​www.​crd.​york.​ac.​uk/​PROSPERO/​display_​record.​asp?​ID=​CRD42016052283.

An electronic search of seven databases was undertaken: AMED Allied and Complementary Medicine (via Ovid SP), CINAHL (via Ebsco), Cochrane Database of Systematic Reviews (via Ovid SP), EMBASE (via Ovid SP), Maternity and Infant Care (via Ovid SP), Medline (via Ovid SP), and PubMed. The date range was set between 1995 and 2015 to reflect developments in the field of health literacy over this time, as well as increases in the documentation of complementary medicine use in pregnancy world-wide and in complementary medicine research [35]. A second search of the seven databases was also performed to check for subsequent publications published from 2015-Jun 2017 before completing this review. A variety of terms were used to cover the four central themes of the review: pregnancy, lactation, complementary and alternative medicine products (CMPs) and health literacy. CMPs were operationally defined as ingested herbal medicines given for specific therapeutic purposes in foods, tea, decoction, tablet, capsule or ethanolic extract forms, topical herbal preparations such as herbal washes, creams or ointments, and aromatherapy oils for inhalation, as well as dietary vitamin and mineral supplements and pre and probiotic supplements. Terms within each concept (pregnancy, lactation, complementary medicine and health literacy) were combined with OR, and results from each concept combined with AND (Additional file 1). Reference lists from relevant studies and review papers were also hand searched. An initial systematic literature search was conducted and papers’ titles were screened for inclusion or exclusion based on set criteria (Table 1). This was followed by a screening of all remaining papers’ abstracts and then full text versions of papers against the same criteria. The lead author (LAJB) screened all papers by title, abstract and full text. PA participated in the screening of titles and full text papers. Differences regarding study selection were resolved by discussion between LAJB and PA. Although the transition from non-pregnant woman through conception, pregnancy, labour, birth, and the postpartum period is a continuum experienced by each childbearing woman, these different stages are described differently within the literature. For the purposes of this systematic review, the use of complementary therapies across the childbearing continuum of pregnancy, labour and birth, and breastfeeding in the postpartum period (defined as up to 24 months) [36] have been examined.

Each paper was assessed according to the 32 item checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) [37]. The COREQ checklist aims to assess how comprehensively and explicitly qualitative studies are reported and covers three main domains: 1) research team and reflexivity, 2) study design and 3) analysis and findings [37]. Use of the COREQ checklist guided the assessment of the rigour and methodological coherence of the included papers and contributed to the synthesis required as part of the systematic review process.

All papers included were analysed comprehensively in order to extract applicable data including: author and year, country study was performed in, number of participants, data collection and analysis methods, major factors explored, CMP type discussed, childbearing stage of relevance to the CMP use, and CMP-related information sources accessed. Following this, major and minor themes were identified and data from each study was summarised within these themes with illustrating participant quotes, where relevant.

Findings across the studies were aggregated following the methods set out by Thomas and Harden [38] and Braun and Clarke [39]. Firstly descriptive themes were developed to describe the use of CMPs by pregnant and breastfeeding women for the benefit of their own health whilst pregnant, the pregnancy, baby or breastfeeding process, and to describe the information sources women accessed when choosing to use CMPs in pregnancy and lactation. Following this, analytical themes were developed in order to delve deeper into the concept of CMP use in pregnancy and lactation and women’s access to information sources – the reasons for CMP use, the perceived and actual benefits of CMP use and what influences women to use CMPs in pregnancy and lactation.

During the coding process, it was necessary to delineate between perceived benefits of taking CMPs for the mother, the pregnancy, the growing baby, and the breastfeeding process. For clarity these perceived benefits are divided into these different themes, but it should also be recognised that there is overlap. For example, it is of benefit to the mother’s health to avoid miscarriage, but also obviously of benefit to the pregnancy. Papers were also analysed for specific results on health literacy.

The search strategy generated 4574 citations after duplicates were eliminated (Fig. 1). After reviewing titles and abstracts 683 papers were examined by full text. After studies focussing only on folic acid supplementation were removed, 22 qualitative studies were identified for inclusion. The reference lists of these 22 qualitative studies were examined by title, abstract and full text, and a further two studies were found that fulfilled the inclusion criteria. The second search of the seven databases yielded an additional 506 citations. After screening, a further four papers were identified, making a total of 28 papers covering 26 studies for inclusion in this qualitative synthesis. The three publications by Westfall [10, 40, 41] report on different aspects of one large study. Therefore, although the 28 included publications present the findings of 26 investigations, for clarity, the total number of studies will be referred to as 28 hereafter.

The studies included varied in how comprehensively they fulfilled the criteria for each domain of the COREQ checklist (Additional file 2). Critical appraisal of the papers identified a number of gaps in the reporting of the papers overall.

Table 2 describes significant features of the studies included in this synthesis.

The information sources accessed by women when choosing to use CMPs in pregnancy and lactation are illustrated in 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 experienced female family members) (11 papers) were information sources identified most commonly. Following this, women accessed their health care providers for information – for women from LMIC and LIC countries and backgrounds this 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 in some studies [48, 50, 54]. Similarly, women from HIC backgrounds often sought information from biomedical health care providers as well as Western herbalists or naturopathic practitioners [40, 52, 55, 63]. One significant difference between women in high income countries and low to middle income countries, was that women in HICs reported accessing CMP information via the Internet, whereas women from low and low-middle income countries did not. The studies involving immigrant women from lower income countries into HICs (Punjabi women to Canada, Hmong women to Australia) showed that the women brought their cultural traditions and knowledge with them to their new countries and that traditional knowledge and practices remained important. Similarly, Yeo, Fetters [49] found that the strong cultural beliefs held by Japanese women living in the USA influenced their willingness to take prenatal vitamin supplements. The near-universality of family and friends being reported as information sources is evident when combining the group reporting women elders and other female family members, husbands and family and friends together.

For the included studies, the role of health literacy in women’s use of CMPs during pregnancy and lactation was complex. The reasons why mothers make decisions about their own and their children’s health care are influenced by women’s individual skills and abilities to access and evaluate health information, as well as individual skills and knowledge [65, 66]. None of the included studies directly measured the health literacy levels of participants and nor did any discuss findings explicitly in relation to health literacy as an over-arching concept. However, participants’ knowledge, attitudes and practices, all of which are concepts related to health literacy, were discussed.

All studies discussed participants’ knowledge, attitudes and practices. ‘Health beliefs and practices’ was the most commonly 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 practices were the greatest influence on women’s use of CMPs across the papers – women took CMPs because of perceived health benefits to themselves and/or their babies (discussed further below). The cultural importance regarding use of CMPs was also evident, especially for women from LICs and LMICs [45‐47, 50, 51, 53, 54, 59, 60], but also for women in UPICs and HICs who described the importance of specific cultural practices during pregnancy, childbirth and the postpartum period [4, 43, 44, 49, 58, 61]. For many, the information regarding the cultural importance of CMP use during the childbearing continuum was passed on to them through women 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 biomedical model of pregnancy and birthing care was often poor. Women did not understand how regular antenatal care could help reduce their own and their babies’ risks of morbidity and mortality [45, 57, 62]. Women’s cultural knowledge regarding needs for traditional medical care along with their needs for psychosocial support led them to seek traditional care, and their albeit limited understanding of the biomedical model motivated them to access biomedical care [8, 45‐48, 59, 62, 64]. In more wealthy economies, women’s engagement in medical pluralism was also discussed in relation to health beliefs and practices. Women’s perceptions of CMPs as being safer than pharmaceutical medications was explored [10, 40, 41, 52, 55, 63], as was their use of CMPs as part of efforts to increase autonomy, and self-responsibility for their own and their infants’ health [40, 55, 63]. Knowledge regarding the safety profiles of herbal medicine especially was also considered low in several of the studies across income streams [52, 53, 63], although this was usually discussed from the perspective of a biomedical outsider, with requisite concerns regarding lack of scientific testing of the CMPs being the basis of authors’ concerns.

The focus of almost half the discussions (13/28) was on how to improve patient outcomes through culturally competent care [4, 43‐45, 47, 49, 50, 53, 54, 56, 57, 61, 64]. Women’s health knowledge, attitudes, beliefs, and practices were all discussed in relation to their health care seeking behaviours and especially in the poorer countries where maternal morbidity and mortality are high, in relation to their health outcomes. For these poorer communities, whole of community approaches to improving the health literacy through education and information dissemination were commonly proposed [45, 50, 53, 54, 57, 60], as often pregnant or breastfeeding women experienced significant barriers to accessing biomedical health care. These barriers included geographical isolation and/or gender inequities [47, 59, 60], as well as cultural norms that advocated family decision-making over individual decision-making and where family based care during pregnancy and the postpartum period was the norm [45, 47, 53, 58, 60]. For women in wealthier economies where culturally competent care was also discussed, the focus was more on what biomedical HCPs could do to improve provider-patient communication and understand the culturally based needs of pregnant and breastfeeding women [43, 44, 49, 61].

Thematic analysis revealed that women’s use of CMPs in pregnancy and lactation could be separated into several themes with associated subthemes. Additionally, women’s use of CMPs in pregnancy and lactation can be separated into two main over-arching motives, ‘Protective or preventative actions’ or ‘Facilitation of a normal process’ (Table 3). These themes and subthemes are further elaborated in Additional file 4.

This review’s identification of shared cultural knowledge as a major information source for women choosing to use CMPs in pregnancy and lactation warrants further discussion of culture, health literacy and holistic health.

The United Nations Educational, Scientific and Cultural Organization defines culture as “the set of distinctive spiritual, material, intellectual and emotional features of society or a social group, and that it encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs” [67]. This definition has been accepted by the World Health Organisation’s expert group on the cultural contexts of health and wellbeing [68]. Culture is a way of life, and can include religious, social or ethnic characteristics, but is also dynamic as values and practices can change over time. It is also important to acknowledge that all kinds of knowledge are cultural, including the practices of traditional health care systems, Western complementary health care systems, and scientific and biomedical practices [68]. A mother’s own culture influences both her individual health literacy skills and abilities, and how she accesses, evaluates and uses health care information and services in her health literacy environment when making decisions about her own and her children’s health. Additionally she may also encounter different cultural knowledge bases within both the health system infrastructure and in the people and relationships within the health literacy environment including other care-givers, the health care team and systems accessed, each with their own personal and medical cultural knowledge bases [31, 32, 65]. Thus it can be argued that women make the decisions to use CMPs in pregnancy and lactation both within the context of their own cultures and the cultures of the health literacy environment. This is illustrated in Fig. 4 which builds on Parker’s [66] model, used by the Australian Commission on Safety and Quality in Health Care in their working definition of health literacy [65]. The cultural components of health literacy and the ways they impact on individual health literacy and the health literacy environments are depicted in the orange boxes added to the original model (in green and white). In this way, the original model is expanded to include both (i) an individual mother’s culture, and how her culture influences the ways she uses her skills and abilities to access and interpret health information; and (ii) the different cultural knowledge bases extant in the health literacy environment in which she moves.

‘Protection and prevention’ and ‘Facilitation of normal physiological processes’.

Pregnant and lactating women in the countries sampled choose to use complementary medicine products based on two over-arching themes identified in this synthesis, ‘Protective or preventative action’ and/or ‘Facilitation of a normal process’. Women’s motivation to use CMPs is based on the desire to both protect themselves and their babies from adverse events, and to facilitate the normal physiological processes of pregnancy, birth and breastfeeding. Women attempted to prevent adverse outcomes in pregnancy including miscarriage or malformation of the baby, ill health of the mother during pregnancy, and to prevent foetal distress and vaginal tearing in labour and birth. Additionally, CMPs were used to prevent future health problems for both mother and baby through the restoration of the mother’s health in the postnatal period and the establishment of breastfeeding. Whilst this synthesis predominantly identified perceived physical benefits relating to CMP use in pregnancy and lactation, perceived mental-emotional, cultural and spiritual benefits were also found. Again, the impact of culture cannot be underestimated when examining women’s health care choices in pregnancy and lactation. Whilst pregnancy, labour, birth and breastfeeding are physiologically comparable for all women, there is great variety in the social and cultural contexts within which these events occur, as well as in the individual customs, beliefs, morals and values women will bring to their individual experiences [7, 47, 69]. A woman’s cultural heritage and her cultural environment will influence her health care decisions in pregnancy and lactation [61, 70]. Finlayson & Downe’s [71] systematic review found that cultural beliefs regarding the need to protect a pregnancy from supernatural threats, combined with women’s preferences for traditional medicines, contributed to the low use of biomedical antenatal services in LICs and LMICs. Also contributing to this low utilisation was the commonly held cultural view of pregnancy as a normal physiological state, as opposed to a biomedical perception of pregnancy as a risky situation [71]. These results support the current review’s identification of the two overarching motivating themes ‘protection and prevention’ and ‘facilitation of normal physiological processes’ as strong motivators for women’s use of CMPs during pregnancy and breastfeeding for women in developing economies. Studies from LIC and LMIC countries included in the present review also identified that traditional and cultural beliefs contribute to CMP use in pregnancy and lactation, and that women view herbal and traditional medicines as being safer, more effective, affordable and more easily accessed than pharmaceutical medications, [47, 57, 62, 72]. Regarding women in HICs, motivations for their CMP use during pregnancy have been examined in four systematic reviews. Pallivalappila et al. [73] were unable to make definitive conclusions regarding pregnant women’s motivations regarding use of complementary medicine, or their perceptions of the effectiveness and safety of CMPs, due to substantial flaws in study design and reporting. However, three other reviews of CMP use by pregnant women in HICs [12‐14] did find links between CMP use and women’s preferences for holistic approaches to health, along with women’s perceptions that use of complementary medicine facilitated better health, wellbeing and quality of life in pregnancy, and could help them prepare for a normal labour and birth. In line with the theme ‘facilitation of normal physiological processes’, women’s desire for autonomy and control over individual pregnancy health were also identified as motivating factors for women’s use of CMPs [12‐14]. Consistent with the theme ‘protection and prevention’ Adams et al.’s [12] review also identified that women perceived their CMPs to be safer than pharmaceutical prescriptions when using CMPs to relieve pregnancy-related complaints.

The concurrent use of CAM and biomedicine has been well documented in many cultures [17, 80] and in pregnancy and lactation around the world [45, 47, 81‐83]. This synthesis also highlights that many women used CMPs within a context of medical pluralism, defined as the co-occurrence of different medical or therapeutic systems and traditions in one local setting [1, 11]. Medical pluralism can also be seen as a patient centred model where individual consumers chose the level of integration between co-occurring health systems, which in turn facilitates a recognition of paradigm differences between biomedicine and complementary or traditional medical systems [84]. Both the autonomy of the individual woman, and the integrity of the different treatment systems she moves through are maintained [84]. Similarly to this current review, medical pluralism was identified as a contributor to women’s choices in Nagata et al.’s [80] systematic review investigating social determinants of iron supplementation in women of reproductive age. Herbal medicines and home remedies were identified as being popular, and often utilised more readily in areas where medical pluralism allowed women to choose between these and biomedical or public health measures. The success of iron supplementation often depended on collaboration or mutual respect between biomedical and traditional medical or complementary medicine systems of healing [80]. Yixi & Rancine’s [85] integrative review of the healthcare experiences of Chinese women immigrants in English-speaking countries also found that women embraced medical pluralism and utilised both Traditional Chinese and the Western biomedical healthcare approaches in a pragmatic way that allowed them to expand their healthcare choices and gave them more comprehensive ways of understanding and managing their health concerns. The current review also showed that women’s engagement with medical pluralism increased their healthcare choices in pregnancy and lactation. Additionally, it was found that women’s health literacy environments also reflect medical pluralism as the important information sources many accessed included biomedical HCPs as well as traditional healers and Western complementary medicine practitioners. As a result, for most of the studies, women navigated through and between different heath care services and systems, seeking and receiving care from both biomedical practitioners and CAM or traditional medical practitioners. However, this does not mean that women asked all their biomedical, traditional or CAM HCPs for information on CMPs. In studies involving women from East or South Asia (Indonesia, Thailand, China, Lao and India), HCPs were not identified as information sources on CMPs, rather shared cultural knowledge, women elders or other family members were the important information sources on herbal medicines [4, 43, 44, 51, 53, 56, 58, 61]. However, except for the study on Kry women from Lao [56], the women in all these studies did engage in medical pluralism as it is evident from the papers that they accessed biomedical care whilst pregnant or breastfeeding. Additionally, their exclusion of HCPs as information sources for CMPs may reflect more the questions asked to investigate the aims of each study, as other studies included in this synthesis showed that biomedical and traditional health care practitioners were important sources of information on CMPs for pregnant and lactating women originating from East Asia (Lao and Japan) [44, 49].

This synthesis revealed that for women from HICs, the use of CMPs throughout the childbearing continuum was associated with the perceptions that CMPs were safer than pharmaceutical medications, and that these women sought reassurance that the herbal medicines they used were safe for pregnancy and breastfeeding. This perception of safety has been found previously in systematic reviews on the use of CAM generally in HIC populations [87, 88] but may not have been explored adequately in developing countries. Although the perception of safety was not a large theme explaining women’s use of CMPs in developing countries, this synthesis did reveal that for women from some LMICs and UPICs, safety for mother and baby was believed to be facilitated by the concurrent use of biomedical care with CMPs, including the prevention of maternity complications in pregnancy and birth, and protection from diseases arising from spiritual forces not treatable with biomedical drugs.

Perceptions of safety may not always be correct. Cultural influences on health care choices cannot always be considered the safest or best outcome options. Some traditional practices may endanger the lives of both mothers and their unborn babies, especially for women in some of the studies from developing nations. As an example, for some countries, one of the perceived benefits of herbal medicine use post-birth was to expel lochia and induce ‘uterine cleansing’ [43, 44, 51]. However, inducing bleeding post-birth can be very dangerous for post-partum women, and the possibility of dying during childbirth is a reality for many of the women in the LICs and LMICs in this review [45, 48].

For the large proportion of studies from economically disadvantaged countries included in this review, policy and practice implications mainly centre on reducing high maternal and infant morbidity and mortality rates. Specific national policies [46, 57], the United Nations Millennium Development Goals [89], or the World Health Organisation’s policies aimed at increasing maternal and neonatal health through education, health checks and micronutrient supplements as part of regular antenatal care [45, 50, 53, 54, 57, 62, 64] or the initiation of exclusive breastfeeding immediately post-birth [60] are discussed. Several factors are implicated in implementing policies in developing countries, including the need to identify and reduce cultural, social, geographical, economic and gender barriers to adequate biomedical antenatal, birthing and postnatal care [45‐47, 59, 71, 90]. Additionally, intervention strategies aimed at promoting heath seeking behaviours to support reductions in child and maternal mortality must consider pregnant and breastfeeding women’s use of CMPs, within the context of their perceptions of health risks, the safe promotion of health and where to go for support with these [90]. This is true for women in developing nations, as well as for women in HICs. Whilst the women participants and their babies in the included studies from USA, Canada, and the UK (all HICs) were at far less risk of pregnancy and birth-related morbidity and mortality than the participants from LIC, LMIC and UPIC countries, the contexts within which these HIC women chose to use CMPs include their own cultural perceptions of how to best support their pregnancies, postnatal health and the health of their babies.

Central to discussions on policy with regard to medical pluralism is an awareness that cultural awareness, including the provision of culturally appropriate care, and consultation and involvement of the whole community is necessary if any policy changes aimed at reducing maternal and infant mortality and increasing maternal and infant survival and health are to succeed [8, 45, 48, 60, 64, 71]. Community-wide consultation is essential to successfully remove barriers to maternal and infant care [45, 57, 62, 64, 71], to identify possible solutions, and educate women’s family-members, including husbands and/or mothers-in-law, who often hold the power to make decisions regarding the health care a woman is able to seek for herself or her baby [45, 59, 60]. Policies that encourage collaboration between biomedical HCPs and TBAs, traditional herbalists and other traditional healers may help improve maternal and child health outcomes [47, 57, 59, 60]. These include policies to enable further training of Traditional Birth Attendants [8, 57, 64] in recognition that TBAs are usually the providers of culturally sensitive, affordable care, are identified as being active participants in helping promote maternal and infant health, and are ideally placed to refer and accompany women at risk to biomedical care in a timely manner when necessary [8, 47, 57, 60]. Additionally, for rural women, TBAs may often be the only HCPs they regularly see [15, 47, 48, 59]. Training of TBAs in minor surgical procedures like suturing, especially in areas where birthing often takes place outside biomedical health care institutions [59] is recommended, but policy changes to encourage more broader collaboration with TBAs and traditional healers and community health workers in education around the importance of antenatal and postnatal care, micronutrient supplementation and other important measures to improve maternal and infant health outcomes is also necessary [47, 54, 57, 59, 60].

For more economically advantaged nations, policy discussions centre on educational needs of biomedical HCPs regarding complementary medicine and CMPs due to policy and practice shifts that emphasise consumers’ rights, choices, and active involvement in health care, and providers’ responsibilities when pregnant or breastfeeding women autonomously choose to incorporate CMPs as part of their health care practices [12, 63]. In HICs policy implications call for biomedical HCPs to be better educated about CMPs, in order to be more able and willing to discuss their use openly and non-judgementally with pregnant or breastfeeding women [3, 23, 24, 52, 55, 63, 91, 92] and to realise the importance of holism to mothers as well as women’s desire for autonomy and control [55, 93, 94]. Regarding breastfeeding specifically, policy implications need to ensure HCPs receive sufficient education in lactation and in helping women to breastfeed successfully in order to be able identify and provide help with breastfeeding difficulties and improve services for breastfeeding women [55, 95‐97].

An important practice implication for biomedical HCPs across all economic strata centres on balancing the provision of evidence-based biomedical care that aims to ensure the safety and health of both mother and baby, and the need to accommodate culturally different health care practices and women’s choices regarding maternal health care. The recognition of the need for culturally appropriate services is linked to the perception that provision of culturally sensitive care has the potential to enhance women’s wellbeing, and in turn the health of their babies and whole communities, provided that other social determinants of health like gender, age, income and personal and ethnic history are also taken into consideration [98‐100]. Cultural understandings shape how women and their caregivers receive information and how they make health care choices [70]. The provision of culturally sensitive care facilitates communication between biomedical and other HCPs, the women they provide care for, and within the whole community. By considering and respecting women’s values and beliefs around pregnancy and childbirth, women’s use of CMPs can be discussed openly. Studies across all economic strata have shown that if a woman perceives her biomedical HCP to have negative or uninterested views on CMPs, she will not candidly discuss her use of them with her HCP [24, 48, 52, 53, 63]. For developing economies, recommendations to provide training of biomedical nurses and midwives in culturally appropriate care aim at reducing cultural barriers to biomedical care and strengthening relationships between biomedical HCPs and the whole community, including traditional practitioners [7, 47, 57]. As mutual respect and communication are facilitated through the provision of culturally appropriate care, it can also help find ways to intervene appropriately if unsafe practices are identified in pregnancy or the postnatal period [47, 58, 60].

Discussions on culturally appropriate care in HICs and UPICs again centre around promoting maternal and infant health, although the focus is less on reducing morbidity and mortality, and more on increasing biomedical HCPs’ understanding and respect for cultural differences when working with women from diverse backgrounds who engage in traditional practices that may not be taught in biomedical education [43, 44, 58, 61]. The need for cultural safety to be taught in universities and health services so that HCPs can develop a critical understanding of social determinants on both their own and others’ health is crucial if culturally sensitive care is to be provided effectively [98, 100]. Recommendations for practice include recognition of the involvement of extended family as influential care-givers in providing pregnancy and postpartum care for many women [43, 58, 61] and recognition of beliefs, experiences and practices that women engage in to promote their holistic health and recovery from childbirth, and prevent future ill-health, especially in the postnatal period [44, 51, 58, 61]. HCPs can help facilitate positive health behaviours through hands-on educational activities, by identifying and working with medical and other influential leaders in the community and women’s partners [49]. Recognising language differences as a potential barrier is also an important aspect of providing culturally competent, good quality maternity care [43, 49, 61]. The use of clear pictorial-based information when communicating with pregnant or breastfeeding women is recommended regardless of a woman’s literacy or education levels, as is the provision of health information in a woman’s own language and the use of translation services [43, 49, 61].

Future research on the inter-professional relationships between biomedical, traditional and/or CAM HCPs providing care to pregnant and breastfeeding women, as well as power dynamics between women and their non-HCP information providers, would be useful in pointing out how to make women’s reproductive journeys whilst engaging in medical pluralism safe and supportive. Additionally, future research needs to encompass explicit measurements of health literacy, and investigation of how different literacy levels impact on women’s understandings and use of CMPs in pregnancy and lactation.