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COMPLEMENTARY AND ALTERNATIVE MEDICINE USE AMONG PREGNANT WOMEN IN UDI LOCAL GOVERNMENT AREA OF ENUGU STATE, NIGERIA
Abstract
This study was designed to obtain information on the use of Complementary and Alternative Medicine (CAM) among pregnant women in Udi LGA of Enugu State. Cross sectional descriptive survey design was used for the study. A sample of 400 pregnant women was systematically drawn from the twenty political wards in Udi Local Government Area (LGA) of Enugu State. Interview administered questionnaire developed by the researcher was the only tool used for data collection. Major findings revealed that majority (81.2%) of pregnant women in Udi LGA use CAM during pregnancy out of which 53.8% were previous users while 87.7% were still using CAM at the time of study. Pregnant women use CAM ranging from one single type to sixteen different types with the most commonly used CAM being biological products eg, herbal tea, herbal mixture; and alternative medicine eg engaging the services of traditional birth attendant. While Most (89.5%) of the CAM used by pregnant women was consumed orally, approximately half use CAM together with conventional medicine. The most striking reasons for CAM use were easy access to CAM (44.6%) and to reduce the weight of the baby (41.5%). Majority of the respondents (79.1%) claimed that the CAM they used was beneficial and without adverse effect(s). In conclusion, the use of CAM by women during pregnancy is highly prevalent in Udi LGA. Therefore, maternity care providers especially midwives need to be conversant with CAM commonly used by women during pregnancy. This will equip the midwives to counsel their clients appropriately for best care and safety.
CHAPTER ONE
INTRODUCTION
Background to the study:
The use of Complementary and Alternative Medicine (CAM) in Nigeria is increasingly popular, as it is in many other parts of the world. as in many other countries of the world. Globally, the prevalence of CAM use ranges from 30% to 75% (World Health Organization [WHO], 2022). Complementary and Alternative Medicine (CAM) has been defined by the National Center for Complementary and Integrative Health (NCCIH) as a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine. This definition has evolved over time to include a variety of approaches categorized by their primary therapeutic input, such as nutritional (e.g., dietary supplements, herbs), psychological (e.g., mindfulness), and physical (e.g., massage, acupuncture) therapies Te Huia(2019) as a group of various medical and health care systems, practices and products that are not currently part of conventional medicine. When unconventional approach and/or product are used together with conventional medicine, it is said to be complementary; but when it is used in place of conventional medicine, it becomes an alternative medicine. Therefore CAM is an umbrella term used for both complementary and alternative health care practices.
The role played by CAM during pregnancy, can no longer be dismissed as a faddish whim accessed by poorer people. The global trend of using Complementary and Alternative Medicine (CAM) is increasing, even among vulnerable populations such as pregnant women, despite the lack of robust evidence supporting its safety (Jazieh 2021). Pregnancy is a vulnerable period especially the first trimester. This is the period of organogenesis when rapid cell division and migration takes place. Any alteration during the process of mitosis and meiosis could result to serious pregnancy complications that may affect both mother and baby adversely. This adverse effect could be temporal or permanent and could be in the form of foetal malformation. The pregnancy complications may consequently result to maternal and perinatal morbidity and mortality. Pregnancy being a vulnerable period may be compounded in a rural community like Udi LGA where there is lack of functional conventional medical services.
Recently, just before this study was carried out, the researcher conducted a focus group discussion (FGD) on CAM use among pregnant women in Ezeagu LGA. Ezeagu LGA is a neighbouring LGA to Udi LGA. It was formerly in Udi LGA. The focus group discussion involved six pregnant women who were engaged in discussions of what women use during pregnancy, how and why pregnant women use such practices among others. The focus group discussion revealed that pregnant women use a plethora of products, services and practices under the umbrella of CAM. However, this present study will concentrate on three main categories of CAM including biological products, alternative medical systems and mind body interventions (spiritual therapy) selected from the NCCAM classification of CAM.
There is some evidence regarding the safety of CAM as well as evidence of its harm.
Although CAM is believed to be natural, but natural does not imply safety and efficacy. While some CAM may have undetected benefits, others may contain substances that can cause miscarriages, premature birth, uterine contractions, feotal malformations, decreased clotting factors in the blood etc. practitioners often overlook the risks associated with certain therapies during pregnancy, focusing primarily on the benefits. Despite the potential hazards, such as the risk of fetal abnormalities and pregnancy complications, CAM practitioners might not fully appreciate these risks. This gap in understanding underscores the need for comprehensive education and guidelines to ensure the safe use of CAM during pregnancy. (Dathe, 2022). The growing popularity of CAM use may increase the deliberate or inadvertent use of CAM during pregnancy, thus raising the possibility of adverse maternal and foetal effects. Even when therapy is considered safe for normal use, there is no evidence that it is effective in handling the condition that necessitated its use and that it is safe for the growing foetus. The implication is that the condition may get worse if effective treatment is not instituted. Therefore it is inappropriate to use some brands of CAM in place of therapies scientifically proven to be effective.
Recent studies indicate that compared to conventional medicine, the scientific research on the efficacy and safety of Complementary and Alternative Medicine (CAM) remains limited. This is due to several challenges, including difficulties in standardizing treatments, designing placebo controls, and securing funding for high-quality research. Despite these obstacles, some CAM therapies, such as acupuncture and homeopathy, have been studied extensively and shown mixed results regarding their effectiveness. Moreover, many CAM therapies lack rigorous evidence from well-designed studies, making it hard to substantiate their safety and efficacy on par with conventional treatments. (Jongbloed, 2022). Even when conventional maternity care providers discourage the use of CAM during pregnancy, some women continue to use it despite professional advice and perceived lack of evidence. A recent study found that even with healthcare providers advising against CAM, many pregnant women in Iraq continued its use, often without disclosing this to their doctors. The reasons for continued use included perceived effectiveness and cultural influences (Hwang, 2022). many pregnant women self-medicate and often do not disclose this practice to their conventional maternity care providers. For instance, research conducted in Ethiopia found that 44.6% of pregnant women reported self-medicating during their current pregnancy. The common reasons included ease of access to medications and the perception that their ailments were not serious enough to warrant professional consultation. Additionally, a significant portion of these women used antibiotics and analgesics without medical supervision. (Fekadu, 2020). On the other hand, maternity care providers fail to assess pregnant women for use of CAM. The trend of not assessing and disclosing expectant mothers’ use of CAM (Complementary and Alternative Medicine) poses significant risks, including potential CAM-drug interactions when combined with conventional medicine. This lack of communication can lead to unintentional and harmful interactions, as highlighted by recent studies. Research indicates that many pregnant women use CAM therapies such as herbal medicines and may not disclose this usage to their healthcare providers, increasing the risk of adverse effects when combined with prescribed medications (Holst, 2023). Maternity care providers’ lack of assessment of their clients for use of CAM may be as a result of lack or poor knowledge about CAM practices. Therefore, midwives’ understanding of CAM, its benefits and potential dangers is very important as they have to screen their clients for use of CAM, record and evaluate the outcome, to ensure best care and safety.
There have been explosion of various types of CAM in use. To create a kind of order, these types of CAM have been classified by some established committees. Two of such committees are the NCCAM and House of Lord Select Committee on Science and Technology. Recent definitions from the National Center for Complementary and Integrative Health (NCCIH) classify Complementary and Alternative Medicine (CAM) into five categories: alternative medical systems, mind-body interventions, biologically based treatments, manipulative and body-based methods, and energy therapies. These classifications cover a range of practices including homeopathy, meditation, herbal products, chiropractic care, and therapies involving magnetic fields or therapeutic touch.(HON, 2021). The House of Lords Select Committee on Science and Technology (2023) groups Complementary and Alternative Medicine (CAM) into three categories: professionally organized therapies like acupuncture and herbal medicine; complementary therapies such as nutrition and aromatherapy; and traditional systems including Chinese medicine. This classification highlights varying levels of professional organization and evidence supporting these therapies (Publications Parliament 2023) . CAM is built on the philosophical orientation of holism and the recognition that optimum interaction between the body, mind and spirit establishes harmony. Unlike the reductionist approach of conventional medicine which treat human beings in part, CAM holds that the whole body is greater and more than the sum of its parts and recognizes the impact of the total life experiences on the health of the individual.
The use of complementary and alternative medicine (CAM) remains more prevalent among females than males in developed countries. A 2021 survey showed that women continue to be the primary users of CAM, utilizing various therapies for a range of health conditions. The types of CAM used and the health issues they address differ significantly worldwide, reflecting cultural and regional variations in CAM practices (HealthyPlace, 2023; Education and Information Technologies, 2023). Many pregnant women may use complementary and alternative medicine (CAM) despite the lack of scientific evidence concerning its safety. For instance, a study conducted in Palestine found that a significant number of women continue using CAM during pregnancy, even without robust evidence of its safety or efficacy (Quzmar, 2021).
Inadequate communication between pregnant women and physicians on HM use highlights a deficiency in the quality of care that may be associated with unfavourable maternal outcomes. Thus, physician engagement in effective and unbiased communication about HM during antenatal care, along with evidence-based guidance on HM use, can help mitigate the potential risks associated with inappropriate HM use. (Hwang, 2024). CAM use is reported to be common worldwide during pregnancy. It was revealed in a recent survey that 69% of women in the United States, 57% of women in England, 51% of women in Germany, 52% of women in Australia and 70% of women in Bangladesh use CAM methods (Frawley, 2022)
When compared with the international literature, some differences regarding the various CAM use methods of pregnant women were found as well. Popular CAM methods during pregnancy include nutritional supplements, herbal medicines, vitamins, yoga and meditation, massage, relaxation methods, acupuncture and homoeopathy. (Bowman, 2022).
Expectant mothers often turn to Complementary and Alternative Medicine (CAM) for various pregnancy-related reasons, such as to alleviate morning sickness and manage stress. During the COVID-19 pandemic, expectant mothers faced increased psychological stress, leading many to explore CAM options for relief and support. This review highlighted the importance of social support in managing stress and the significant role CAM played during this period. ( Taylor,2021)
Maternity care providers especially midwives have an increasing obligation to be conversant of various models of health care used during pregnancy including CAM. This is because midwives are usually consulted for professional opinion and advice during pregnancy. Conventional Midwives who are unaware of existing CAM may lose an important
opportunity to make use of the positive features (cheap, safe, effective and accessible), of CAM as well as advice their clients accordingly on associated usage risks. Nigerian nurses/midwives may fail to live up to the above obligation. This is because most nursing and midwifery education in Nigeria is under the umbrella of Western Conventional Medical practices. There may be lack of general information or even misinformation/misconceptions about CAM used by women during pregnancy.
Nigeria is a developing country with
more than 70% of the population living in rural areas and half the population survive on less than 1 dollar per day. In addition, with most CAM products easily accessible and affordable, people are more likely to resort to it than the more expensive conventional therapy coupled with the non-existence of national health insurance scheme. Most of the studies on CAM use in developed countries have been carried out on middle and high income group. (Ngozi, 2021). The present study was conceived based on the scarcity of empirical literature on CAM use particularly among women in Udi
LGA of Enugu State and South East Nigerian women in general during pregnancy. Unfortunately, Studies carried out in Nigeria were limited to herbal medicine (an example of a class of CAM), use during pregnancy and were mainly hospital based. This has created a gap in knowledge which the researcher intends to fill. This present study is community-based and will reveal the types of CAM used by women during pregnancy under the three selected categories. This study will provide some fundamental information on the most common CAM practices during pregnancy in Udi LGA.
Statement of problem:
Globally, maternal mortality is the leading cause of death among women of childbearing age (United Nations Report, 2024). WHO (2024), estimates that out of more than 133 million babies born yearly worldwide, more than 3 million are stillborn. Ninety percent of these births are from developing and underdeveloped countries (WHO, 2024), including Nigeria. The causes of these deaths were mainly due to pregnancy and labour complications, (WHO, 2024), which advance in medical sciences and technology is expected to manage effectively.
Delay in decision making concerning the choice of health care, delay in accessing conventional health care institutions and adequate reproductive health care services and cultural practices could indirectly contribute to increase in maternal mortality. The persistent increase in maternal mortality is an indicator that most women (especially those in the rural area), do not access and utilize adequate reproductive health care services (WHO, 2024) especially during pregnancy.
Bearing in mind the issue of thalidomide effect in the 1960s (MIMS, 2023), Women are commonly prescribed a variety of medications during pregnancy. As most organ systems are affected by the substantial anatomical and physiological changes that occur during pregnancy, it is expected that pharmacokinetics (PK) (absorption, distribution, metabolism, and excretion of drugs) would also be affected in ways that may necessitate changes in dosing schedules. Pariente(2020). Conventional maternity care providers and pregnant women may hesitate to prescribe and take conventional medicine respectively, as there may be perceived risks to mother, feotus, or both.
In Nigeria, people while being ignorant of the compositions, use, benefits and side effects of unconventional health care products, take for granted that because these products were approved by National Agency for Food Drug Administration and Control (NAFDAC), they are safe. The presence of NAFDAC number on the packaging of a product does not mean that such product has undergone stringent testing to prove their efficacy and safety. Moreover, ready to use herbal products with NAFDAC number have been found to be contaminated with heavy metals. The fact that these products are approved by NAFDAC and are easily accessible has increased the perception that they are natural and safe. This trend which is neither static nor decreasing is likely to continue if there is no control by the National drug safety monitoring system. There is a need for regulation by the appropriate authority to ensure evidence of safety, efficacy and rational use of CAM. Onyiapat (2021)
If pregnant women do not access and utilize conventional health care services as has been reported in literature (WHO, 2024), what then do they use? What happens during the periods of delays? Do pregnant women fall under the category of people who utilize unconventional health care products simply because they were approved by NAFDAC? These questions prompted the researcher to survey CAM use among pregnant women in Udi LGA.
Purpose of the study
The overall aim of this study is to determine the prevalence of CAM use among pregnant women under the three selected categories of CAM in Udi LGA. Specifically, the objectives of the study include to:
- Determine the prevalence of CAM use among pregnant women in Udi LGA.
- Ascertain the various types of CAM women in Udi LGA use during pregnancy.
- Identify patterns of CAM use among pregnant women in Udi LGA.
- Elicit the reasons for CAM use among pregnant women in Udi LGA.
- Determine benefits of CAM use as perceived by pregnant women in Udi LGA.
- Ascertain adverse effects associated with use of CAM as perceived by pregnant women in Udi LGA.
- Elicit the association between the demographic characteristics of pregnant women in Udi LGA and use of CAM.
Research questions:
- What is the prevalence of CAM use among pregnant women in Udi LGA?
- What are the various types of CAM used by women in Udi LGA during pregnancy?
- What are the patterns of CAM use among pregnant women in Udi LGA?
- What are the reasons for CAM use among pregnant women in Udi LGA?
- What are the benefits of using CAM as perceived by pregnant women in Udi LGA?
- What are the adverse effects associated with use of CAM as perceived by pregnant women in Udi LGA?
- What is the association between demographic characteristics of pregnant women in Udi LGA and use of CAM?
Significance of the study:
Results of the study will reveal the prevalence of CAM use, classes of CAM used, pattern of use, reasons for use, perceived benefits and adverse effects associated with CAM use among pregnant women in Udi LGA. This information will equip health care providers particularly, midwives and obstetricians & gynaecologists, inform them to device appropriate measures in form of detailed CAM history, health education and counseling of pregnant women on the use of CAM.
Findings from demographic profile of women including level of education, income and age will be useful in understanding how these characteristics are related to women use of CAM. Findings from this study also, will be useful to stakeholders/policy makers (maternity care providers, NAFDAC, Safe Motherhood) in women’s health and will offer guidance on the regulation of what is being used during pregnancy, under the umbrella of CAM. This will assist in safeguarding the health and life of mothers as well as decrease maternal mortality. This study will also serve as a source of reference in this area of research for future researchers.
Scope of the study:
The study is delimited to pregnant women in Udi LGA. The study will also be delimited to use of CAM during pregnancy. Variables for the study include CAM used during pregnancy, pattern of CAM use, reasons for use, perceived benefits and adverse effects associated with use. Demographic profile of CAM users is also included as a variable.