Frequency of nominated herbal medicines by ward and gender
The specific herbal medicines nominated by inpatients on the various specialized wards generally differed, probably guided by local folklore knowledge of their use. Mumbwa, which are clay rods constituted with one or more local herbs, received the highest number of citations on the Gynaecological ward (GYN); however, patients were seldom aware of the specific herbs that were compounded in these clay rods. Nanda (
Commelina africana) was the next most frequently cited herb on GYN and is known to contract the uterus [
7].
Commelina africana is normally administered orally; however, it was inserted vaginally as a stick by one woman admitted on GYN who poked her cervix/uterus to induce abortion. Kamunye (
Hoslundia opposita) was another commonly nominated herb which, according to local obstetricians, is traditionally used post-partum to cleanse the uterus of any blood clots and heal the vaginal lacerations caused by childbirth.
Hoslundia opposita is reported in the literature to have anti-inflammatory (linked to saponin-content) and wound healing (linked to coumarin-content) properties [
30,
31], which is consistent with
Hoslundia opposita’s local use for gynaecological conditions, as mentioned above. Sere (
Bidens pilosa), was used on all four wards and by both males and females. Sere is reported, in folk medicine, to treat various disease conditions, which is attributed to its varied biological activity including antibacterial, antifungal, anti-inflammatory, antipyretic, antimalarial, antihyperglycaemic, antihypertensive, hepatoprotective, antiulcerogenic, and anticancer properties, among others [
14‐
16].
The specific nomination rate of herbal medicines was lowest on the CPN ward when compared with the other wards; however there was no difference in nomination rate by gender. Mumbwa received a noticeable and comparable number of citations on the three medical wards vs. the GYN ward. However, avocado leaves (
Persea americana), aloe vera (
Aloe barbadensis), beet root (
Beta vulgaris), mululuza (
Vernonia amygdalina), and muzukizi (
Dicliptera laxata) were predominantly cited on the medical wards. Avocado leaves and beet root are used for anaemia.
Commelina africana was mentioned with similar frequencies on both the medical and gynaecological wards. In addition to its uterotonic properties,
Commelina africana is reported to have hypoglycaemic effects [
32].
Vernonia amygdalina is used traditionally to treat malaria: and the herb’s antimalarial activity has been validated [
33].
Dicliptera laxata is used by herbalists in Kenya to treat colorectal cancer [
9] and as antidote to poison in Uganda [
10]: however, studies to document the anticancer and poison antidote properties of this herb are scarce.
Dicliptera laxata is reported to have antimicrobial, anti-inflammatory and antinociceptive properties, with its leaves being used to treat rashes and itching [
11,
12]: the herb is also used to treat headache in Ethiopia [
13].
Among the three herbs nominated on the GYN ward but not on the three medical wards, Kiyondo (
Kalanchoe pinnata Lam) in local Ugandan folklore knowledge is used to dry a newborn’s umbilical cord [
34], treat morning sickness in pregnant women and also has aphrodisiac properties.
Kalanchoe pinnata Lam is proven to have anticonvulsant, antidiabetic and wound healing properties [
35‐
37]. Gwalimu [
Maytenus senegalensis (Lam.) Excell] is used locally to treat infections and inflammatory conditions; and has been demonstrated to have antibacterial and anti-inflammatory properties [
38]. Gwalimu is also used traditionally to treat fertility-related problems. Published information and local folklore knowledge on Ekigaranga was scarce.
We focused on the GYN herbals to identify “new” abortifacients but this did not succeed. However, we highlighted known abortifacients. We also compared GYN versus the medical wards nomination rates (and also by gender) to identify herbals with other active principles, which worked insofar as those identified are already known. The methodological approach used, we believe, was sound although we clearly needed more than 762 cases to make “discoveries”. Furthermore, patients ought to specify the herbal remedies they have taken, which they usually consume to complement conventional western medication. Out of fear, though, the patients may deliberately conceal the required information on herbal medicine use [
39]. Thus, the inquiry skills of the clinical assessment teams should improve, especially on the CPN ward, to increase the chances of eliciting, from the patients, specific information on herbal medicine use.
A considerable proportion of women on GYN (56 %, 107/191) presented with abortion-related diagnoses, which is comparable with the proportion of Tanzanian women (67 %, 125/187) with incomplete abortions who conceded having had unsafe abortion prior to their current hospitalization [
6]. Half the Tanzanian women had resorted to traditional providers and, in these cases, plant species were often used as abortion remedies. However, only one in five Ugandan inpatients with abortion-related diagnoses reported having used herbal medicines in the 4-weeks prior to hospital admission. The annual global estimate of unsafe abortions in women of reproductive age (15–44 years) is 14 per 1000 women and is higher in sub-Saharan Africa (31 per 1000) than in Eastern Europe (6 per 1000) [
40]. In addition, the abortion-attributable proportion of maternal mortality is higher in Eastern Africa (18 %) than in Eastern Europe (11 %), probably because abortion is illegal in Eastern Africa [
41].
No serious suspected ADR was linked definitively to herbal medicine use. Three of the four suspected ADRs that implicated herbal medicine use occurred in patients with abortion-related working diagnoses, in two of whom the intention to abort was explicit. However, the one case of acute kidney injury linked to herbal medicine use in the community might not have been deliberate. Unsafe use of herbal medicines to induce abortions can lead to a high burden of overt preventable ADRs: this information may be relatively easier to elicit clinically from patients. However, it is the more subtle preventable ADRs from herbs when used for other therapeutic purposes which, in the absence of appropriate laboratory support and expertise in clinical diagnosis, might be difficult to link to herbal medicine use and could thus go unnoticed but silently continue to harm patients.
Four in five patients who reported use of herbal medicines during the 4-weeks prior to admission nominated at least one specific or vague herbal medicine during routine clinical elicitation of all medicines. Clinical elicitation is therefore a powerful tool for clinicians to obtain, from patients, useful medication history of both herbal and conventional western medicines to better conduct medicines reconciliation and subsequently provide appropriate pharmaceutical care to inpatients. Concurrent use of conventional and herbal medicines, more so in the community where there is little supervision, may promote herb-drug interactions and increase the risk of ADRs [
42]. Overall, four patients (2 %, 4/222), or one in 50, experienced at least one community-acquired suspected ADR linked to pre-admission use of a herbal remedy signalling a relatively frequent occurrence of patient-reported suspected ADRs linked to pre-admission herbal remedies. Excluding abortion-related suspected ADRs, only one patient in 222 (0.5 %) who coded yes for the use of herbal remedies might have experienced an unintentional community-acquired suspected ADR. Further investigation of the latter rate of 5 per 1000 patients requires a much larger, preferably routine PV system with integrated patient-reporting, and/or pharmacoepidemiological studies to track and assess the safety of herbal remedies used by patients. The patient-reported suspected ADR estimates, however, cannot be generalized to the wider community since the herb-linked suspected ADRs themselves and/or failure by the patients to have sought conventional treatment may have provoked admission. However, a herb-linked ADR estimate of ~5 per 1000 inpatients is sufficiently high for ward staff to pay heed to. We did not take from patients specimens of the consumed herbal medicines and, in some instances, not even the herb constituents could be inferred, which is a limitation. Hospital clinicians need routinely to ask about and periodically obtain, for formal testing, samples of herbal remedies taken by the one in 50 patients with a herb-linked suspected ADR, which might increase the ability to identify definite ADRs. Caution is advised as the low occurrence rate of reported unintentional herbal medicine-linked ADRs may be due to non-disclosure by the patients [
39]. That limitation notwithstanding, our systems need to streamline ADR reporting for conventional medicines before the safety monitoring of herbal medicines can become a genuine reality.
Using logistic regression, our team previously constructed risk-scores for developing a suspected hospital-acquired ADR for which one of the key covariates was pre-admission use of herbal medicines. Those who had used herbal medicines during the 4-weeks prior hospital admission rarely specified the herbs they had taken [
43]. A possible explanation for the failure by patients to specify their herbal medicines may be unlabelled herbal formulations with concoctions/mixtures of several different herbs that patients could not themselves identify [
39]. If so, might the multiple herbs per concoction/mixture, when taken by the patient, have led to a higher likelihood of herb-drug interactions in the hospitalized patients? Future surveillance should ensure that specimens of the herbs taken by patients with linked suspected ADRs are obtained and tested.