Herbal medicine use by pregnant women in Bangladesh: a cross-sectional study

This study was a descriptive cross-sectional in design, conducted at two public hospitals – Dhaka Mohanagar Hospital and Nazirabazar Maternity Hospital – in Dhaka, Bangladesh. Postpartum women before discharge from the hospitals were eligible to take part in the survey. Exclusion criteria were women who were in intensive care unit, in high dependency unit or were being managed for a severe condition. Women unable to speak or mentally unstable were also excluded. This study was part of a multinational research for which ethical approval was obtained from the Institutional Review Board on Human Subjects Research and Ethics Committees, Hanyang University, Seoul, Korea (HYI-17-067-2). Written informed consent was obtained from all participants.

After reviewing the literature [5, 20], the survey questionnaire was developed in English and then translated into Bengali language to suit the target population. The Bengali questionnaire was back translated into English to confirm the validity. Face validity of the questionnaire was done by two physicians in the target hospitals and a traditional medicine healthcare practitioner. The questionnaire was then pilot tested on a sample of 20 participants and based on the results, a few items were revised. Final version of the questionnaire comprised 30 items, with multiple choice, and open-ended questions (See Additional file 1: Survey questionnaire). It was divided into five sections. First section included general questions such as health status, mode of delivery, gravidity, exposure to secondary smoking, and antenatal care services. A question on maternal smoking was included in the questionnaire for pilot study, which showed no smoker out of 20 participants. Physicians in the target hospitals suggested to omit the question on the grounds that social norms and traditional values do not favor smoking by young girls or women in South Asian countries including Bangladesh [22]. Therefore, it was suggested that if such a question was included, there was a risk not to get any response or to get false positive or false negative answer. The question was, therefore, excluded, and question on secondary smoking was included. Multiple studies have found association between maternal exposure to passive smoking and low birth weight [23‐25]. It is reported that pregnant women are consistently exposed to home smoking in many countries, especially in the developing countries where legislations on active and passive smoking are rather weak. High number of pregnant women exposed to home smoking is also reported from Asian countries including Bangladesh [26].

Second section comprised questions on morbidities during pregnancy (polyhydramnios, oligohydramnios, convulsions, fainting, high grade fever, severe anemia, premature rupture of water bag, severe headache, placenta previa, placental abruption gestational diabetes, hypertension, urinary tract infections, hyperemesis), complications during labor and maternal complications after childbirth (fetal distress, prolonged labor, abnormal presentation, profuse bleeding, urinary and fecal incontinence, severe anemia, smelly vaginal discharge, severe headache, high grade fever, convulsions, postpartum haemorrhage, postpartum depression, haemorrhoids). Third section included questions regarding herbal medicines use such as, modalities of herbal medicines and their indications, side effects if any, frequency of use, source of recommendation on herbal medicines use in pregnancy, disclosure of use with doctor or midwife, reason of use and non-use. To ensure that respondents only report HM used for medicinal purposes, the question was asked, “Did you use any herb or herbal preparation (syrup, paste, powder) for medicinal purposes or to improve your health during your last pregnancy?” Fourth section of the questionnaire included characteristics of the newborn baby such as birth weight, any birth defect and neonatal symptoms (neonatal jaundice, breathing problems, cardiac symptoms, tender or tense abdomen, convulsions, unconsciousness, bowel problems, lethargy or no activity). The fifth and final section asked questions related to sociodemographic characteristics of the participants. Monthly household income was categorized into three groups: low income (< $200), middle income ($201 - $400), and high income (> $400).

One supervisor (MAH) and four data collectors were trained and participated in the process of data collection. They were in regular contact with the main researcher (MA). Experienced female data collectors were recruited to make sure accurate data were collected. Experienced and female interviewers are more likely to be friendly and generate a good response rate [27]. A total of 300 women were invited to participate in the study when they were shifted to maternity wards after the childbirth. The participation was entirely voluntary and a complete anonymity was ensured. Information related to complications during labor, after birth, and newborn characteristics was collected with the help of hospital staff. Whereas, other questions were asked from the participants themselves. The survey was conducted from July 4 to August 12, 2017.

A total of 300 women were invited to the study and only 243 agreed to participate in the survey, generating a response rate of 81%. Data of 243 postpartum women were included in the final analysis. Sociodemographic characteristics of the study participants are presented in Table 1. Mean age of the respondents was 26.22 ± 5.54 years. Fifty-eight per cent aged 21 to 30 years, 88.1% belonged to urban areas, 63% had up to elementary school, 12.8% were employed, 65.4% were from middle income group, and 63.4% of the participants reported that it took less than 30 min to get to the nearest health facility.

Tables 2 and 3 presents medical characteristics of the study participants. Overall, 63.8% of the childbirths were conducted via normal delivery (includes forceps delivery), 77% of the childbirths were full term, 56.4% of women had one to 3 antenatal visits, 67.1% of the women were exposed to secondary smoking, 65.4% were multigravida, 45.3% women had experienced their first pregnancy between 20 to 24 years of age, 55.6% used HM prior to last pregnancy, and 40.7% experienced at least one morbidity during pregnancy.

Characteristics of neonates are presented in Table 3. In terms of birth weight, 63.4% were between 2.5 to 3 kg, followed by more than 3 kg (33.7%). Neonatal symptoms were reported in 52.7% of the cases. There were seven (2.9%) cases of birth problems that included one case of cardiac anomaly and six cases of congenital nasolacrimal duct obstruction (not shown in tables). Out of 243 childbirths, 50.2% were baby boys and 49.8% were baby girls (not shown in tables).

Out of 243 respondents (Tables 1 and 2), 70% used at least one modality of HM in their last pregnancy. HM were more commonly used among women who aged 21 to 30 years (57.6%), lived in urban areas (90%), had completed education up to elementary school (65.9%), unemployed (92.9%), belonged to middle income group (68.2%), and could access the nearest health facility in less than 30 min (64.1%). Chi square analysis showed that use of HM during pregnancy was significantly associated with women who were unemployed (X² = 16.510; p value = 0.000).

Regarding medical characteristics, 60% of HM users had used HM prior to last pregnancy, had one to three antenatal care visits (58.2%), were exposed to passive smoking at home (67.1%), were multigravida (66.5%), and experienced first pregnancy between 20 to 24 years (47.1%). Chi square analysis showed that prior use of HM (X² = 4.527; p value = 0.033) was significantly associated with its use during pregnancy.

Use of HM in terms of pregnancy outcome is presented in Table 3. No significant association was found between use of HM and pregnancy outcome.

Self-reported indications according to each modality of HM are presented in Table 4. The most frequently used HM – ginger – was used for nausea/vomiting (76.5%), cold/flu (30.4%), and cough (2.9%). Black seed was used for nausea/vomiting (60.3%), as galactagogue (39.7%), and for allergies (3.2%). Lemon tea was used for cough (59.2%) and nausea/vomiting (46.9%).

The most frequently reported side effects after its use during pregnancy were dry mouth (6), nausea/vomiting (3), drowsiness (3), diarrhea (2), and palpitation (1).

As presented in Table 5, the main recommending source for HM is the members of their family, friends or neighbor (71.1%), followed by herbalist (28.2%), Islamic/religious text (24.7%), and midwife/health worker (20%).

Among 170 users of herbal medicine (Table 5), 54.1% reported using it occasionally, daily (37.6%), weekly (4.1%), twice or more a week (2.9%), and only once (1.2%).

Among 170 users (Table 5), only 25.3% disclosed it to their doctor or midwife. The most frequently reported reasons for non-disclosure were forgot to inform (52%), followed by doctor did not ask (31.2%), afraid of doctor’s response (9.6%), and it was not important to disclose (7.2%).

Reasons for using HM during pregnancy are presented in Table 5. Among 169 users, the most frequently reported reasons for using HM were it was cheap and accessible (94.1%), followed by belief that it was safe (68.6%), belief that it was effective (13%), family tradition/culture (5.9%), and unsatisfied with modern medicine (2.4%). Among 73 non-users, the most frequently reported reasons for not using HM during pregnancy were family did not let them use (61.6%), followed by doctor or midwife did not let them use (53.4%), belief that it was not effective (20.5%), and satisfied with modern medicine (13.7%).