SCIENTIFIC PAPER

The Safety of Anastatica hierochuntica as an Agent to Assist Birth Delivery

Sebelas Maret University
Ratna Bintari, Apta Devi Nurul Nafisa, Nur Irfani Agita Suwarna
Introduction
The usage of herbal medicine in a developing country are very popular, including the one that
is believed can facilitate labor. The most common herbal medicine used during pregnancy is
Anastatica hierochuntica (in Indonesia we call it Rumput Fatimah or Grass of Fatimah). It is very
popular both in public and among the primary health care providers, but it does not get much attention
although the safety and efficacy towards pregnancy has not been proven yet. There is still limited
studies about this dessert plant which is leaving so many unanswered questions. The practice of herbal
medicine usage has been developed and handed down from generation to generation based on the
theory, beliefs, experience, and testimony.
Apart from that, any forms of medical intervention related to childbirth also needs evaluation.
The health care providers, especially obstetricians and midwives, have the important role connected to
this issue. The pregnant women itself should understand about pregnancy and childbirth for the sake
of herself and the babies.
Material and Methods
We conducted a comprehensive search of some systematic reviews, article, and experimental
studies published in NCBI using the combination of these following terms: Anastatica hierochuntica,
oxytocin, herbal, labor, and pregnancy. The search covered the period from 2009 until 2017. Titles
and abstracts were reviewed for possible inclusion and exclusion. We also read the full article of the
selected titles and abstracts then checked the reference list for more information sources.
Results
From a cross-sectional, descriptive study conducted in Malaysia by Sooi and Keng, [1] the
herbal usage during pregnancy is common in developing countries. The respondents include Malay
pregnant women in the last trimester and women within two-days after childbirth. The study is focus
on statistical analysis to determine the prevalence and use of herbal medicines during pregnancy and
elemental studies towards the most common herbal products used. The result of statistical analysis
from 460 respondents are grouped according to specific variable: sociodemographic (age, occupation,
education, income), trimester of pregnancy, dose of herbal medicines, information sources, reasons,
sources of herbal medicines, and the type of herbal medicines.
The correlation between sociodemographic and herbs consumption found out to be
significant in particular aspects only: age and income (Table 1).
Table 1
Relationship between sociodemographic characteristics and herbal medicines use during pregnancy
Characteristic Herbal users n (%) Herbal non-users n (%) X2 stat (df) P value
Age
<30 48 (10.4) 180 (39.1)
>30 110 (23.9) 122 (26.6) 19.20 <0.001*
Occupation
Unemployed 97 (21.1) 181 (39.4)
Employed 61 (13.2) 121 (26.6) 4.89 0.087
Education
Primary 107 (23.3) 190 (41.3)
Secondary 14 (3.0) 44 (9.6)
Tertiary 37 (8.0) 68 (14.8) 3.09 0.213
Income
<RM1000 91 (19.8) 207 (45.0)
RM1000-RM3000 52 (11.3) 78 (17.0)
>RM3000 15 (3.2) 17 (3.7) 22.44 <0.001*
Gravidity
Primid 24 (5.2) 78 (17.0)
2-5 91 (19.8) 172 (37.4)
6 and above 43 (9.3) 52 (11.3) 10.32 0.006*
*P < 0.05
Data about administration during pregnancy (Table 2) showed that most of the respondents
were using the herbs during labor (73.4%), minute number in first semester (7.6%), and none of them
administered the herbs in second trimester.
Table 2
Use of herbal medicines according to the trimester of pregnancy
Gestation period N % of total respondents
During 1st trimester 12 7.6
During 2nd trimester 0 0
During 3rd trimester 28 17.7
During entire pregnancy 2 1.3
During labor 116 73.4

The study turned out that some of the respondents were unsure about the dose of herbs they
consumed daily (Figure 1).

Figure 1 Amount of herbal medicines consumed daily

The interesting part is the source of information about herbal medicines (Table 3). Majority of
respondents know it from their parents (60.8%), followed by traditional midwives (10.1%), friends
(10.1%), relatives (9.5%), parents-in-law (5.1%), mass media (1.9%), company (1.9%), and
healthcare provider (0.6%).
Table 3
Information source of herbal medicines
Information Source N %
Parents 96 60.8
Traditional midwives 16 10.1
Friends 16 10.1
Relative 15 9.5
Parents in-law 8 5.1
Mass media 3 1.9
Company 3 1.9
Healthcare providers 1 0.6

The main reason why they choose to consume herbal products during their pregnancy is to
facilitate labor. This is followed by a promotion of health status, traditional practice and to relieve
common discomfort during pregnancy, to keep warm, to keep sexual pleasure, to restore youth, to
prevent whitish discharge, and to promote fetal physical health and intelligence. The percentage are
shown in the table below (Table 4).
Table 4
Common reasons for herbal medicinal usage during pregnancy (n = 158)
Reasons Yes n (%) No n (%)
Facilitate labor 141 (89.2) 17 (10.8)
Promote health status 49 (31.0) 109 (69.0)
Traditional practice 36 (22.8) 122 (77.2)
Relieve common discomfort during 17 (10.8) 141 (89.2)
pregnancy
Keep warm 17 (10.8) 141 (89.2)
Sexual pleasure 11 (7.0) 147 (93.0)
Restore youth 11 (7.0) 147 (93.0)
Prevent whitish discharge 10 (6.3) 148 (93.7)
Promote fetal physical health and intelligence 9 (5.7) 149 (94.3)

From the questionnaire, it is known that pregnant women can easily get herbal medicines by
buying it directly from traditional midwives, store and self-preparations, also from herbal shops
(Figure 2).
Figure 2 Sources of herbal medicines

The statistical data also reported that Anastatica hierochuntica is the most popular herbs
commonly used during pregnancy (60.1%) based on the result of the survey (Table 5).
Table 5
Most common herbal medicines use during the pregnancy period
Types of herb N %
S. Fatimah (Anastatica hierochuntica L.) 101 63.9
Minyak Selusuh ( Coconut Oil) 53 33.5
Unidentified Herbs 10 6.3
Halia (Zingiber officinale) 5 3.2
Bawang Merah (Allium ascalonicum) 5 3.2
Bawang Putih (Allium sativum) 4 2.5
Serai (Cymbopogon citratus) 4 2.5
Kunyit (Curruma longa) 2 1.2
Manjakani (Croton caudatus) 2 1.2
Inai (Lawsonia inermis) 2 1.2
Sirih (Piper betle L.) 2 1.2
Jarum Mas (Striga asiatica) 2 1.2
Pegaga (Centella asiatica L.) 1 0.6
Sepang (Caesalpinia sappan) 1 0.6
Homeopathy 18 11.4

Build up on the statistical data, an elemental analysis then be held to dried branches, flowers,
and grounded forms of Anastatica hierochuntica. As a preparation, the Anastatica hierochuntica were
cyclically dehydrated by washing it using variation of ethanol concentration (75%, 95%, and 100%)
for 15 minutes each. Following the process, anastatica hierochuntica were removed from ethanol and
dried by hexamethyl-disilazane evaporative technique for 10 minutes and then redried in specimen
plate for about half an hour. A coating within the sputter will be the last step preparations of
specimens.
The digital stereomicroscope images were taken using Energy Dispersive X-ray (EDX). This
examination showed that Anastatica hierochuntica had useful minerals such as calcium (Ca),
magnesium (Mg), aluminum (Al), potassium (K), zinc (Zn), and iron (Fe), apart from the major
number of carbon (C), oxygen (O), and silica (Si). The distribution are different in every part of
Anastatica hierochuntica (Table 6). It would be the key to decide what part of Anastatica
hierochuntica that will be utilized.
Table 6
EDX weight and atomic percentage of the various elements detected in Anastatica hierochuntica L.
Branch 1 Stigma Stem
Element Weight Atomic Element Weight Atomic Element Weight Atomic
% % % % % %
CK 38.78 48.13 CK 35.19 46.77 CK 16.98 24.81
OK 49.31 45.95 OK 42.73 42.63 OK 52.42 57.50
Al K 2.18 1.21 Mg K 0.85 0.56 Mg K 1.25 0.90
Si K 6.89 3.66 Al K 3.61 2.13 Al K 5.09 3.31
Ca K 2.84 1.05 Si K 7.19 4.09 Si K 18.51 11.57
KK 1.19 0.49 KK 1.33 0.59
Ca K 6.11 2.43 Ca K 0.78 0.34
Fe K 3.14 0.90 Zn K 3.64 0.98
Totals 100.00 Totals 100.00 Totals 100.00

Branch 2 Flower Powder

Element Weight Atomic Element Weight Atomic Element Weight Atomic
% % % % % %
CK 39.52 50.12 CK 17.96 26.59 CK 42.10 50.31
OK 46.73 44.49 OK 46.35 51.52 OK 53.72 48.20
Si K 1.01 0.55 Mg K 0.39 0.29 Ca K 4.18 1.50
Ca K 12.74 4.84 Al K 1.67 1.10
Si K 31.10 19.70
Fe K 2.53 0.80
Totals 100.00 Totals 100.00 Totals 100.00

The minerals found in Anastatica hierochuntica play important role to maintenance human
health and also beneficial for pregnancy. Additionally, according to Lothian, [2] the pain of labor is
what most women worry about. Calcium itself plays critical role in nerve and muscle regulation, so it
will work along with magnesium to regulate uterus contraction and expected to reduce pain. This
could explain why pregnant women are consuming the herbal medicine that is believed can encourage
healthy pregnancies.
The Anastatica hierochuntica is widely consumed as a tea beverage. It is powdered and then
mixed with honey as a remedy for difficult childbirth and uterine hemorrhage. In addition, it is also
beneficial in treating asthma, gastrointestinal disorders, depression, high blood pressure, indigestion,
headache, cold, fever, malaria, epilepsy, fatigue, diabetes, heart disease, and infertility. [3] The
continuous used of Anastatica hierochuntica as traditional medicine is caused by the cultural belief
that it is highly recommended for antepartum care, eases childbirth, reduces uterine hemorrhage, and
facilitates expulsion of a dead fetus. The testimony stated that it has anti-oxidant, [4] anti-microbial,
and hypoglycemic properties too. [5,6]
 Some healthcare professional have hypothesis that the action of Anastatica hierochuntica is
agonist to oxytocin, based on the same effect that can be produced: the uterine contracting or oxytocin
effect and the blood pressure lowering effect which is controlled by calcium [1,7].
But if the administration of this herbs is in wrong dose and timing, it might be fatal. Some
obstetricians noticed that majority of hemorrhage case in postpartum women have history of
Anastatica hierochuntica consumption. This may happen because the uterine hyper-stimulation and
over induction of labor that cause rupture of the uterus. But once again, there is still lack of evidence
about the mechanism of this herb so it must be assessed later.
The high prevalence of utilization of Anastatica hierochuntica in the majority of pregnant
women cannot be separated from the traditional beliefs that herbal products do not contain harmful
chemicals like the common pharmaceutical drugs because the herbs are coming directly from nature.
Supported also by the practical experiences and observations that showed no significant adverse
effects and has been going on for many generations. Even some studies stated that 4% to 62% of
pregnant women continued to consume herbal medicines during her pregnancy despite the fact that
they are lack of knowledge about the good and bad side of it. [1]
Data obtained from the study reveals that only a few women were aware of the possibility of
the herbs being contaminated. Moreover, most of women know the adverse effects for the fetus that
may follow: abortion, fetal growth retardation, premature delivery, malformation, and fetal death. But
ironically, there is still some who believed that the practice is effective in increasing the well-being of
the mother and fetus.
A high maternal mortality nowadays also caused by the medical intervention given (Figure 3).
The data shows that the most common maternal mortality is severe bleeding caused by the oxytocin
and manual compression. [8] This is why evaluation of the current maternal care is needed.

Figure 3 Evidence-based interventions for major causes of maternal mortality. Other direct causes
include ectopic pregnancy, embolism, and anesthesia-related complications. Indirect causes include
anemia, malaria, and heart disease. Reproduced from USAID From the American People. Maternal
and Child Health Web site.
Discussion
The usage of Anastatica hierochuntica has been widely known in developing countries for
years. It will be impossible to stop the usage because the practice has been passed down generation to
generation and sill continues. Not to mention that the products are easily found too. It leads to the
urge of conducting more studies to assess the safety and efficacy of Anastatica hierochuntica towards
maternal health. Evaluation on medical intervention also needed, regarding the fact that most of
women trust the herbal medicine more than pharmaceutical drugs.
It is also stated before, that main reason of consuming herbal products is to facilitate labor. It
has the strong association with the factors that determine how safe the pregnancy was. Birth is
intended to happen simply without worry or trouble and medical intervention without clear indication
will disrupt the physiologic process of birth. According to the World Health Organization (WHO) and
Lamaze International, there are six key, known as Healthy Birth Practice, which promote, support,
and protect normal birth. [9]
The first one is let labor begins on its own without any intervention, because it will be
healthier and safer for both mother and baby. For this reason, avoid Anastatica hierochuntica
consumption will be better. Then walking, moving around, and changing positions throughout labor
will help labor progress, coping the pain, enhance comfort, and decrease the risk of complication.
Bringing relatives for support is also essential. But remember, that as much as possible the relatives
should understand which one is potentially benefit or harmful for the labor too, considering the survey
that tell us about the majority of parents act as the main information source of herbal products
administration.
Healthcare providers play a role in the safe birth by minimizing interventions that are not
medically necessary, for an instance intravenous lines and electronic fetal monitoring restrict
women’s ability to walk, change positions, and find comfort during contractions. The intravenous
lines are not really needed when the women are able to eat and drink so she has enough energy to
persevere during labor. The electronic fetal monitoring also can be replaced by intermittent
auscultation. The routine use of this technology will increase the risk of cesarean surgery instead,
which has a long-term risks for the mother. Epidurals interfere that aimed to relief pain during labor
also has negative effect. If there is no pain, the brain dos not get any signal to keep releasing oxytocin.
Consequently synthetic oxytocin, called Pitocin, is needed. The administration of this synthetic
oxytocin will affect molecular pathways and downstream that need to be assessed further. As well as
the consumption of Anastatica hierochuntica that is also believed to have the same effect as oxytocin
in inducing labor. [10,11] For every healthcare providers, it is important to note that any interventions
with no clear medical indications set a cascade for other interventions which can interrupt the normal
childbirth and expose the women and unborn babies to unnecessary risks.
Laboring mother also recommended to avoid giving birth on the back, but better to follow the
body’s urges to push rather than pushing in a directed way because it is mentioned before that manual
compression may cause a severe bleeding. As the birth delivery succeeded, keep mother and baby
together. It is best for mother, baby, and breastfeeding when the baby is placed skin-to-skin with his
mother. It will make the early hours and days after birth safer for mothers and babies.
The other challenge concerning this maternal issue is the unreported use of herbal medication,
more specifically Anastatica hierochuntica. Majority of women did not report their use of herbal
medication to their doctor. In most cases they came to the doctor when severity occurs. They only tell
their doctor about the history of herbal medications when being asked. Thus, healthcare providers
must be aware if a pregnant women came and reported some problems. They need to ask about
whether she consume herbal medications or not, especially the common herbal used in the country. If
the healthcare providers knew the exact herbal product consumed, they can give appropriate
educational intervention according to the bioactivity, mechanism, and other properties of the herb.
More research should be conducted because there still massive usage of herbal medications even in
this very modern era. Lack of evidence about the effect of herbs upon the pregnancy will make the
assessment of maternal morbidity and mortality difficult. The study of the herb itself would be very
beneficial to know the elemental content since many minerals play significant roles in the molecular
pathways.
 Referring to the maternal mortality trends, the major causes are hemorrhage (27.1%) with
more than 72.6% of it were classified as postpartum hemorrhage, hypertension (14%), sepsis (10.7%),
abortive outcomes (7.9%), and embolism or other direct causes (12.8%). [12] It may lead to the ideas
that Anastatica hierochuntica, which has an oxytocin effect, blood pressure lowering effect, and anti-
microbial properties as stated before, are very potential to be used as an agent assisting childbirth and
decrease maternal mortality ratio (MMR), especially a maternal mortality that caused by postpartum
hemorrhage, hypertension, and sepsis. Those three are the most common cause of maternal mortality
that may be handled because the presence of the oxytocin effect, blood pressure lowering effect, and
antimicrobial properties consecutively. But the most important thing of utilization is about doses and
timing of administration. The current challenge is to know more about these two crucial things that
have not been widely studied.
The mortality ratio also depends on the presence of trained health personnel. The data below
reveals that the presence of healthcare providers is inversely proportional to the maternal mortality
ratio (Figure 4). [8] For this reason, a promotion of healthcare professional service is absolute.

Figure 4 Relationship between maternal mortality ratio and proportion of births attended by trained
personnel in the Southeast Asian region, by country, 1995. Reproduced from World Health
Organization Regional Office for South-East Asia. Health & Evidence Information Web site.
Conclusion
Any interventions of labor and birth, including the uses of herbal medicine and medical
intervention without a clear indication, have some adverse effects for the mother and babies. As a
medical students, we need to conduct further researches and studies about the Anastatica
hierochuntica together with the medical professionals. In accordance to the effects of Anastatica
hierochuntica that are potential to reduce the maternal mortality rate (MMR), many deep-related
studies are needed for an optimal usage. Evaluation of standard maternity care is an obligation for the
government. Childbirth education for any pregnant women will be essential to improve the quality of
labor and birth delivery. It will convince every mother that they can give birth without any
intervention or fear. They also will be helped to understand more about how maternity care influence
the health and safety of both mother and the baby.
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