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:
Complementary and Alternative Medicine (CAM) use in Nigeria is becoming more popular,
(Onyiapat, Okoronkwo & Ogbonnaya, 2011; Ezeome & Anarado, 2007; Amira, &
Okubadejo, 2007), as in many other countries of the world. Globally, the prevalence of CAM
use range from 30% to 75% (World Health Organization [WHO], 2002). CAM includes
various approaches/techniques outside the western conventional medicine that are used to
prevent and/or treat illnesses/diseases as well as promote health. CAM has been defined by
the National Center for Complementary and Alternative Medicine [NCCAM], (2009), 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 trend is increasing globally and lack of robust evidence of
safety, particularly when used in a vulnerable population such as pregnant women is not a
deterrent to CAM use (Fraser & Cooper, 2009). 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. Some CAM practitioners fail to appreciate the risks
associated with the use of some of these therapies during pregnancy, (Tiran, 2007), and focus
only on the benefits. 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.
Compared to conventional medicine, scientific research on the efficacy and safety of CAM is
limited, (Anderson, & Johnson, 2005; Warriner, 2007). Even when conventional maternity
care providers discourage use of CAM especially during pregnancy, some women are likely
to continue to use CAM despite professional advice and perceived lack of evidence, (Tiran,
2007). Many pregnant women self medicate and some do not disclose use to their orthodox
maternity care provider, (Furlow, Patel, Sen & Lui, 2008; Holst, Wright, Haavik & Nordeng,
2009; LowDog, 2009). On the other hand, maternity care providers fail to assess pregnant
women for use of CAM. The trend of non assessment and non disclosure of expectant
mothers’ use of CAM can lead to unintentional and unanticipated CAM-drug interactions
when combined with conventional medicine (NCCAM, 2009). 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. The NCCAM classified CAM into, alternative medical systems, for example,
homeopathy and naturopathy; mind-body interventions, such as meditation, and prayer;
biological products, examples: herbs and food; manipulative therapies, such as, chiropractics
and massage; and energy therapies, examples: magnetic fields, therapeutic touch, (Fan,
2005). The House of Lords Select Committee on Science and Technology classification
grouped CAM into three and is mainly based on therapies that have been professionally
organized, eg, acupuncture, herbal medicine; therapies considered complementary to other
forms of health care, eg, nutrition, aromatherapy; and traditional systems, eg, Chinese
medicine and other alternative medicines (Fraser & Cooper, 2009).
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.
In developed countries, more females than males use CAM in the general adult population
(Barnes & Bloom, 2008; Adams, Lui & Sibbritt, 2009; Maclennan, Myers & Taylor, 2006)
and what is being used under the umbrella of CAM varies in form, number and ailment in
different parts of the world. Prior to pregnancy, women may have used CAM and may
continue to use or initiate using CAM during pregnancy and for parturition, regardless of the
lack of scientific evidence concerning its safety (Fraser & Cooper, 2009) and efficacy. The
use of CAM by pregnant mothers is very popular in developed countries and relatively
common in developing countries (Forster, Denning, Wills, Bolger & McCarthy, 2006;
Tabatabaee, 2011). Globally, the use of CAM among pregnant women ranges from 7% to
55%, (Tiran, 2003) and up to 96% (Forster, Denning, Wills, Bolger & McCarthy, 2006).
A significant use of CAM has been recorded among: English pregnant women, (57.8%)
including herbs and spiritual therapy (Holst, et al., 2009); Australian Women, (36% to 73%),
and the most prevalent being herbs such as castor oil and ginger (Skouteris, Werthein, Rallis,
Paxton, Kelly, & Milgrom, 2008; Forster, et al, 2006); Canadian women, (9%) with evening
primrose and ginger being the most popular, (Moussally, Oraichi, & Berard, 2009); Iranian
women, (30.8%), including ammi, saatar and sweet basil (Tabatabaee, 2011), and Zambian
women, (21% to 30%), (Banda, et al., 2007).
There exist distinct ethnic differences in the use of CAM among pregnant women in
developed countries. Gibson et al, (2001), in their survey of CAM use among women in
USA, recorded greater use among the white women than non white women. Forster et al,
(2006), also stated that Australian women whose native (first), language was English were
more likely than non-English natives to use CAM during pregnancy.
Expectant mothers turn to CAM for various reasons which may be pregnancy-related. This
may include attempts to relieve morning sickness, (Forster et al, 2006; Tabatabaee, 2011),
and concerns about the safety of the unborn child, (Dugoua, 2010). Pregnant women are also
likely to use CAM because, they believe it provides additional strategies for managing
disorders of pregnancy which may be seen as minor physiological discomforts of pregnancy
by the conventional maternity care providers, and therefore may not be managed with
conventional medicine, (Fraser et al, 2009).
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.
The use of CAM among Nigerian women during pregnancy is unknown. Studies carried out
in Nigeria on CAM use were among: the general adult population, (Onyiapat et al, 2011);
cancer clients, (Ezeome et al, 2007); children with chronic health conditions, (Oshikoya,
Sebanjo, Njokanma & Sopie, 2008); hypertensive clients, (Amira, & Okubadejo, 2007); and
diabetic clients, (Ogbera, Dada, Adeyeye & Jewo, 2010). 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, 2009). WHO (2008), 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, 2008), including Nigeria.
The causes of these deaths were mainly due to pregnancy and labour complications, (WHO,
2008), 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, 2012)
especially during pregnancy.
Bearing in mind the issue of thalidomide effect in the 1960s (MIMS, 2009), as well as the
influence of physiological changes of pregnancy on pharmacological action and
pharmacokinetics of conventional medicine (Freyer, 2008; Gibbon, 2008; Erdejic, Francetic,
Makar-Ausperger, Likic & Radacic-Aumiler, 2010), 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 (Obi, Akunyili, Ekpo & Orisakwe, 2006; Orisakwe &
Atuboyedia, 2012).
If pregnant women do not access and utilize conventional health care services as has been
reported in literature (WHO, 2012), 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:
1. Determine the prevalence of CAM use among pregnant women in Udi LGA.
2. Ascertain the various types of CAM women in Udi LGA use during pregnancy.
3. Identify patterns of CAM use among pregnant women in Udi LGA.
4. Elicit the reasons for CAM use among pregnant women in Udi LGA.
5. Determine benefits of CAM use as perceived by pregnant women in Udi LGA.
6. Ascertain adverse effects associated with use of CAM as perceived by pregnant
women in Udi LGA.
7. Elicit the association between the demographic characteristics of pregnant women in
Udi LGA and use of CAM.
Research questions:
1. What is the prevalence of CAM use among pregnant women in Udi LGA?
2. What are the various types of CAM used by women in Udi LGA during pregnancy?
3. What are the patterns of CAM use among pregnant women in Udi LGA?
4. What are the reasons for CAM use among pregnant women in Udi LGA?
5. What are the benefits of using CAM as perceived by pregnant women in Udi LGA?
6. What are the adverse effects associated with use of CAM as perceived by pregnant
women in Udi LGA?
7. 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.
Operational definition of terms:
1. CAM: Complementary and Alternative Medicine implies therapies and approaches
that are not orthodox, which are being used during pregnancy in Udi LGA. Within the
context of this study, they include alternative medical systems such as engaging the
services of TBAs, spiritual interventions such as prayer and biologically-based
therapies such as herbs.
2. Prevalence of CAM use: This is the percentage of pregnant women in Udi LGA who
used and/or is using CAM during the time of study (previous, current and/or both
users).
3. Categories of CAM: It is the various types or classes of CAM women in Udi LGA
use during pregnancy. They include the following:
· Alternative medical systems: Examples are natural remedies, folk remedies,
Traditional African medicine such as use of traditional birth attendant, traditional
external cephalic version.
· Mind-body interventions (Spiritual therapies): Examples, meditation, prayer,
vision, pregnancy ritual/ cleansing/deliverance, divination, incantations,
consultations with deities or spiritualists, music.
· Biologically-based therapies: These make use of substances found in nature to
alleviate discomforts or disorders of pregnancy, examples herbal mixtures, herbal
tea, edible clay, dietary restrictions such as forbidden to eat snail or grass cutter
meat, dietary supplements.
4. Patterns of CAM use in this study refer to the route of administration, time of CAM
use during pregnancy, use of CAM and conventional medicine.
5. Reasons for CAM use: These include factors responsible for use of CAM among
pregnant women in Udi LGA. It could be related to pregnancy, unborn baby, culture
and access.
6. Benefit of CAM use in this study refers to positive expectations and satisfaction
derived from using CAM as perceived by pregnant women in Udi LGA.
7. Unwanted effect of CAM: perceived adverse effects associated with use of CAM
during pregnancy such as miscarriages, bleeding, low birth weight, feotal
malformation etc.
8. Demographic profile of pregnant women: This includes age, parity, occupation,
habits, marital status and educational level of pregnant women in Udi LGA who use
CAM.
9. Use of CAM: This includes procurement, consumption and application of CAM. It
also means patronizing (visits, consultations, engaging the services) CAM
practitioners, consultation with deities, and self medication with CAM anytime during
pregnancy.
10. Pregnant women: Females who habour a child in the uterus, from conception to the
period of delivery, with no existing medical or surgical conditions. And pregnancy
would have been confirmed through positive signs of pregnancy such as foetal heart
heard, foetal movements seen, palpation of foetal parts and