Use of complementary and alternative medicine in pregnancy: a cross-sectional survey on Iraqi women

The prevalence of complementary and alternative medicine (CAM) use in pregnant women is increasing and is widespread in developed and developing countries [1‐3]. These women take a wide range of CAM such as herbs, vitamins and minerals, massage, aromatherapy, acupuncture, homeopathic remedies and Reiki as well as psychological, physical and spiritual techniques [4‐6]. However, given the global initiative concerning evidence based medicine and the lack of robust data on safety and efficacy of CAM approaches, health professionals and policymakers have become increasingly concerned about the use of CAM by women during pregnancy [7].

Recent studies reveal that over one third of pregnant women in the USA used one or more CAM therapies during previous year [8, 9]. In the UK, 57.1 % of women reported their CAM use during pregnancy [6]. Surveys from Middle East countries have reported that prevalence of CAM use during pregnancy is 40.0 % in Palestine [10], about 75 % in Jordan [11], and 22.3 % in Iran [12]. However, little is known about the extent to which CAM is used by women during pregnancy in Iraq. It is important to obtain history on CAM use at any time but particularly in pregnancy, in order to provide proper counselling to the expecting mothers. Some of the CAM may have unrecognized effects on pregnancy or labor, have interactions with prescribed medications and have potentially serious complications on fetus.

Iraq, as an Arabian Gulf state, has witnessed a rapid socio-economic transition over the last two decades [13]. Since then, the Iraqi health care system has been seriously affected as a result of different wars, internal conflicts, international sanctions and political instability [14, 15]. Under Iraqi health delivery system, which has been on a centralized, curative and hospital-oriented model, maternity services are provided by public institutions and obstetricians’ private clinics that are widely distributed mainly in urban areas [16]. These events resulted in a substantial fall in major health indices and left a crippled health system struggling to meet population needs [14, 17]. The maternity care services in particular did not escape these damaging effects and continue to suffer from problems common throughout the health care system [18]. The antenatal care services in Iraq suffer from challenges common to the primary health care system [19]. These challenges are mainly related to inappropriate health service delivery including irrational use of health services, poor referral system, poor infrastructure, lack of management guidelines and poor hygiene [17, 20]. Other problems include health workforce challenges like poor qualification of health care providers, uneven distribution and rapid turnover of the health workforce and lack of continuing educational and professional development opportunities; and dearth of resources including shortage and low quality of medical supplies and inadequate financing [21]. Poor information technology and poor leadership are also major obstacles to the antenatal care [22]. This situation of health care sector in Iraq may affect the use of CAM among pregnant women.

The present study was planned to gain insights into the prevalence and factors leading to the use of CAM among pregnant women in Iraq. Additionally, the study was designed to bring to light CAM therapies which are most commonly used during pregnancy in the gulf country. The study was also purposely designed to identify the main sources of information recommending the use of CAM during pregnancy.

For this study, a cross-sectional survey was designed to collect information on the use of CAM among Iraqi pregnant women. The data was gathered in outpatient department of four hospitals located in Basrah, Iraq. Eligible participants of the study were Iraqi women who visited outpatient department to seek antenatal care services. Women who visited the hospitals for normal delivery, cesarean section or post-natal checkup were excluded from the study.

The survey questionnaire was designed in the English language and then translated into the Arabic language to best suit the target population. The Arabic version of questionnaire was validated by translation back into English, and the text was revised where necessary by three doctors who were not among authors of this study. Then it was piloted on a small group of 20 volunteers. In order to collect the information, one week training was given to eight surveyors mainly on ethics and data collection. Two surveyors were asked to gather data from each hospital. Before the interview, surveyors explained nature of the study to the participants and sought consent. The surveyors conducted the face-to-face interviews with the participants and fill out the questionnaire during the period of four weeks from November 13, 2014 to December 15, 2014.

This is the first study investigating knowledge, attitude and practice of CAM among pregnant women in Iraq, and is also the first work conducted with the aim of describing CAM users. The findings emphasize that the use of CAM during pregnancy is a common habit in the city of Basrah, Iraq. The study followed cross-sectional design and gathered information on the use of CAM by pregnant Iraqi women who visited outpatient department of four hospitals located in Basrah.

We found that 56.7 % of Iraqi women use at least one modality of CAM during pregnancy. Our results suggest significantly higher use of CAM among pregnant women in Iraq when compared to similar studies conducted in India, Oman, Zimbabwe, Palestine, Malaysia, Egypt, and Taiwan [10, 23‐28]. However, it is lower than the studies done in Iran, Jordan, and UK [6, 11, 29]. These variations in the prevalence of CAM are understandable as difference in the proportion of CAM use could come from a number of factors, such as design of study, sample dynamics, and socio-demographic factors. This study also highlighted the extremely low level of communication, regarding use of CAM, between patients and their healthcare providers.

Likely predictors of CAM use among pregnant women in this study were residential area, occupation status and monthly income, which is consistent with previous studies [11, 25, 26]. We also found that pregnant women who perceived their health status as healthy tended to use CAM more than women who perceived their health status average or unhealthy. It makes sense as evidence suggests that pregnant women start using CAM, or more specifically herbs, in order to enhance their health status, increasing immunity, strengthening uterus ready for the labor and to avoid complications related to pregnancy like urinary tract infections and digestive disorders [29, 30]. Therefore, it is possible that pregnant women in this study did not perceive themselves healthy before using CAM; but once they started to use CAM, they felt more healthy and prepared for the labor. Furthermore, we demonstrated that women who ever used contraception were also more likely to be the CAM users, which is supported by the study conducted in Zambia [31]. In our study, more than 50 % of the pregnant women used herbal medication as a CAM modality. There is ample evidence suggesting high consumption of herbs, and that herbal products are the most common form of CAM, among pregnant women due to several reasons [32]. These studies suggest pregnant women use herbal supplements, such as raspberry leaf, ginger, chamomile, and cranberry juice, to gain strength in order to get prepared for the labor [30, 33]. The second most commonly used CAM modality among pregnant women was consumption of vitamins, which is also consistent with previous research [23, 24, 34]. We found that most of the CAM users were satisfied with the CAM used; and for 28 % of them effectiveness of the CAM use was main reason, as the most common reason for consumption was given as “not dangerous for pregnancy”. We also discovered that only about 18 % of the CAM users consumed it on daily basis while most of them utilized herbal products and vitamins for not more than twice a week. Our results reveal that about 64 % of the CAM users could get CAM from marketplace, which highlights the easy availability of CAM, especially herbal products, in the region. Additionally, our results show that most common source of CAM information was friends and family, which is supported by the previous study conducted by Holst et al. [35].

CAM users in our sample used various herbal therapies during pregnancy. The most popular herbal therapy was consumption of black seed and chamomile. Al-Riyami et al. report that pregnant women could use black seed during pregnancy against infections or as nutritional supplement while chamomile as a relaxant [23]. Literature suggest that herbal products could be harmful to the mother and fetus if consumed during pregnancy because herbs contain pharmacologically active substances [36]. Herbal supplements like garlic, ginger and chamomile have anti-platelet and anticoagulant properties so there is an increased risk of prolonged clotting time and bleeding [37]. Hypertensive and hyperglycemic characteristics of licorice may increase the complications of pre-eclampsia and gestational diabetes respectively [38]. Moreover, there is also an increased risk of preterm labor and miscarriage among regular users of chamomile and licorice [39]. However, pregnant women consider herbs safer than conventional medications due to their extensive experience with and belief in herbal products [40]. Many pregnant users of CAM are unaware of their side-effects because they consider it natural and risk-free [37, 41].

We also discovered extremely low proportion of CAM users disclosing their CAM use to the doctors – only 0.5 % did so. More than 50 % of the respondents did not discuss their use of CAM because their doctors did not ask them. Moreover, the CAM users did not think it was important to discuss with their health providers. Poor communication regarding CAM between patients and doctors in our sample could be attributed to the CAM users’ unawareness of adverse effects from alternative medications as only 42 % of them had middle school education. Therefore, it highlights the need to increase awareness of Iraqi women on the safe use of CAM during pregnancy. It is also crucial that health care providers should have basic understanding about CAM including herbal products, so that they can better recognize the risks associated with health seeking behavior of patients [42]. Additionally, we recommend that physicians, as qualified healthcare providers, should ensure good level of communication with patients for their safety.

Results of the study underline that use of CAM is common during pregnancy in Iraq. In total, twenty-four different modalities of CAM were used for pregnancy-related health ailments, most frequently vitamins, black seed, chamomile and cinnamon. Moreover, extremely low level of communication between CAM users and their health care providers is worrisome, and demands that physicians should inquire their patients about the use of CAM. Due to scarcity of evidence in support of CAM benefits during pregnancy, it is very important to educate women on the safe use of CAM especially when pregnant women come from a low-literate population such as our sample. Based on the results of our research, we recommend that this area should further be studied using larger sample size.

CAM, complementary and alternative medicine