Original Research
Use of Complementary and Alternative
Medicines During the Third Trimester
Abdul Rouf Pallivalapila, Msc, Derek Stewart, PhD,
Rajvir Singh, PhD, and James S. McLay, PhD
OBJECTIVE: To estimate the prevalence, indications, and
associated factors for complementary and alternative
medicine use during the last trimester of pregnancy.
METHODS: A questionnaire survey was conducted of
women with a live birth (N5700) admitted to the post-
natal unit at the Royal Aberdeen Maternity Hospital,
northeast Scotland. Outcome measures included: com-
plementary and alternative medicine used; vitamins
and minerals used; reasons for complementary and alter-
native medicine use; independent associated factors for
use; views; and experiences. Descriptive and inferential
statistical analysis was performed.
RESULTS: The response rate was 79.6% of eligible
women. Two thirds of respondents (61.4%) reported
using complementary and alternative medicine, exclud-
ing vitamins and minerals, during the third trimester.
Respondents reported using a total of 30 different
complementary and alternative medicine modalities, of
which oral herbal products were the most common (38%
of respondents, 40 different products). The independent
associated factors for complementary and alternative
medicine use identified were: complementary and alter-
native medicine use before pregnancy (odds ratio [OR]
4.36, 95% confidence interval [CI] 2.39–7.95, P,.001);
a university education (OR 2.41, 95% CI 1.46–4.0,
P5.001), and complementary and alternative medicine
use by family or friends (OR 2.36, 95% CI 1.61–3.47,
P,.001). There was no association with health care
From the Institute of Medical Sciences, The University of Aberdeen, Pharmacy
Practice, School of Pharmacy and Life Sciences, Robert Gordon University, and
Royal Aberdeen Maternity Hospital, Aberdeen, and Ninewells Hospital and
Medical School, Dundee, United Kingdom; and Biostatistics, Medical Research
Center, Hamad Medical Corporation, Doha, Qatar.
Funded by The University of Aberdeen.
Corresponding author: James S. McLay, PhD, Institute of Medical Sciences, The
University of Aberdeen, Aberdeen, U.K.; e-mail: j.mclay@abdn.ac.uk.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2014 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/15
204 VOL. 125, NO. 1, JANUARY 2015
Ashalatha Shetty, MBChB, Binita Pande, MBChB,
professional recommendations. Users were significantly
more likely than nonusers to agree that complementary
and alternative medicines were safer than prescribed
medicines (P5.006), less likely to be associated with side
effects (P#.001), and could interfere with conventional
medicines (P#.001).
CONCLUSION: Despite the majority of respondents,
and notably users, being uncertain about their safety
and effectiveness, complementary and alternative med-
icine modalities and complementary and alternative
medicine products are widely used during the third
trimester of pregnancy in this study population. Although
prior use was the most significant independent associ-
ated factor, the role of family and friends, rather than
health professionals, in the decision to use complemen-
tary and alternative medicine may be of concern.
(Obstet Gynecol 2015;125:204–11)
DOI: 10.1097/AOG.0000000000000596
LEVEL OF EVIDENCE: III
T
he most widely accepted definitions of comple-
mentary and alternative medicines originate from
the World Health Organization and the National Cen-
ter for Complementary and Alternative Medicines in
the United States.1,2 The National Center for Comple-
mentary and Alternative Medicines definition of com-
plementary and alternative medicine as “a group of
diverse medical and health care systems, practices,
and products that are not presently considered to be
part of conventional medicine,”2 implies that national,
cultural, and ethnic differences, together with the
extensive and expanding list of complementary and
alternative medicines, make interpretation of what
constitutes complementary and alternative medicine
complex.3–8
Despite a lack of efficacy and safety data, 50–90%
of women irrespective of age and health status report
complementary and alternative medicine use.9–12
There is increasing evidence for potential com-
plementary and alternative medicine-related maternal
OBSTETRICS & GYNECOLOGY
and fetal harm both during the first13–18 and last tri-
mesters.19–24 This issue was reinforced in a recommen-
dation from the U.K. National Institute for Clinical
Excellence stating that “pregnant women should be
informed that few complementary therapies have
been established as being safe and effective during
pregnancy. Women should not assume that such ther-
apies are safe and they should be used as little as
possible during pregnancy.”25 We recently reported
that two thirds of U.K. women use complementary
and alternative medicine during early pregnancy26;
however, there is a lack of robust data describing
complementary and alternative medicine use during
late pregnancy.27
The aim of this study was to estimate the preva-
lence of complementary and alternative medicine use
and reasons for use together with independent associ-
ated factors for use in pregnant women during the last
trimester.
MATERIALS AND METHODS
The participants were all women with a live birth
admitted to the postnatal unit at the Royal Aberdeen
Maternity Hospital, northeast Scotland over a 3-month
study period during 2012.
A pilot questionnaire was developed from the
published literature reporting complementary and
alternative medicine use by pregnant women.26,27
Complementary and alternative medicine in our
study was defined as: referring to the diagnosis, treat-
ment, and prevention of illness by various practi-
tioners using therapies such as herbals medicines,
homeopathic medicines, acupuncture, aromatherapy,
chiropractic, vitamins and minerals, and certain food
products. As an aid, the questionnaire contained an
extensive list of specific complementary and alterna-
tive medicine modalities and products. The question-
naire content and structure were reviewed for face and
content validity by four individuals with experience in
the care of pregnant women, and associated research,
followed by piloting in a random sample of 20 post-
partum women who were excluded from full study
analysis. Minor modifications were made to the ques-
tionnaire postpiloting.
The final questionnaire contained four sections:
demographics (five items); health during pregnancy
and obstetric history (eight items); personal use
complementary and alternative medicine therapies
during the last trimester of pregnancy (nine items,
extensive checklist of complementary and alternative
medicine modalities and products); and attitudes
toward complementary and alternative medicine use
during pregnancy (six items). Questions were a mix of
VOL. 125, NO. 1, JANUARY 2015
closed and Likert-type statements. The questionnaire
together with a study invitation letter and information
leaflet was distributed by a researcher based in the
postnatal unit. The invitation letter, information
leaflet, questionnaire, and researcher all stressed that
the study focused on complementary and alternative
medicine use only during the preceding 3 months. No
incentives were offered to participants to take part and
because the questionnaire was anonymous, no re-
minders were issued.
With an expected response rate of 50%, 700
questionnaires were distributed over a 3-month period
during 2012 to achieve a minimum of 350 responses,
calculated to be a sample of sufficient size to estimate
proportions within a 95% confidence interval (CI)
of 65%.
Data were coded and entered into an SPSS 22.0
database and analyzed using descriptive statistics to
profile respondents. x2 was used to test association
between variables (eg, age, level of education, ethnic
origin, and so on) and complementary and alternative
medicine use in pregnancy. Variables identified as
significant in univariate analysis were entered into
binary logistic regression. P#.05 was considered sta-
tistically significant.
This research was approved by National Health
Service North of Scotland Research Ethics Committee
and National Health Service Grampian Research and
Development Committee on June 27, 2011 (REC 11/
AL/0094).
RESULTS
Of the 700 questionnaires distributed, 557 were
returned, giving a response rate of 79.6% of eligible
women. Respondent characteristics are reported in
Table 1. The majority were white (80.4%) and aged
older than 25 years (84.1%), with more than half
(57.6%) of respondents in their first pregnancy. One
fourth (25.1%) had a preexisting medical condition.
Of the respondents, 61.4% reported using com-
plementary and alternative medicine (excluding vita-
mins and minerals) and 38% herbals during the last
trimester of pregnancy. Vitamins and minerals were
also used by 45.5% of respondents. Approximately
one sixth of respondents (15.7%) reported using
complementary and alternative medicine before
becoming pregnant, of whom 46.0% stopped when
becoming pregnant.
The complementary and alternative medicine
modalities used, who recommended use (eg, health
professional, family, friend), and the medical indica-
tions for use are reported in Table 2. More than 30
complementary and alternative medicine modalities
Pallivalapila et al CAM Use During Late Pregnancy 205
Table 1. Respondent Demographics (n5557) raspberry tea or capsules (49.6% of herbal users) for
induction of labor, ripening of the cervix, and uterine
Characteristic % (n) toning; cranberry (19.3%) for urinary tract infection
Age (y)
and thrush; ginger beyond cooking (16.4%) for upset
15–24 16.0 (89) stomach and nausea; chamomile (11.9%) for relaxa-
25–34 61.8 (344) tion; and eucalyptus (9.8%) for cold symptoms.
35 or older 22.3 (124) The recommendations to use complementary and
Living circumstances alternative medicine modalities and products during
With spouse, partner 86.5 (482)
Other 13.5 (75)
the last trimester of pregnancy were principally made
Education* by family and friends and midwives. Midwives were
University (degree-level qualification) 49.7 (28) more frequently cited by respondents as recommend-
College (non–degree-level qualification) 28.1 (157) ing approaches such as massage, aromatherapy,
Secondary school 22.2 (124) acupressure, and meditation, whereas family and
Ethnic origin
White British 80.4 (448)
friends were more frequently cited for recommending
Other 19.6 (109) herbal products, homeopathy, acupuncture, reflexol-
1st pregnancy 57.6 (321) ogy, and spiritual healing.
No. of neonates delivered* Comparison of pregnant complementary and
1 87.8 (489) alternative medicine users with nonusers is reported
2 or more 12.2 (68)
Delivery week*
in Table 4. In univariate analysis, complementary and
Less than 34 3.4 (19) alternative medicine users were significantly more
34–37 12.3 (69) likely to have used complementary and alternative
Later than 37 84.3 (470) medicine before becoming pregnant (P,.001), have
Mode of delivery* family and friends who use complementary and alter-
Normal vaginal 41.0 (228)
Other 59.0 (329)
native medicine (P,.001), to have a university educa-
Weight of neonate(s) (g)* tion (P,.001), to be older (P5.01), to be in their first
Less than 2,500 8.1 (45) pregnancy (P5.005), to have a preexisting medical
2,500–3,500 51.8 (289) condition (P5.008), and to be non-white British
More than 3,500 40.1 (223) (P5.049). However, in binary logistic regression, the
Mother’s medical problem(s) during and after
birth*
only variables retained were: complementary and
Yes 30.9 (172) alternative medicine use before pregnancy (odds ratio
Mother’s existing medical condition(s) 25.1 (140) [OR] 4.36, 95% CI 2.39–7.95, P,.001); a university
Asthma 10.1 (56) education (OR 2.41, 95% CI 1.46–4.0, P5.001), and
Hypertension 4.7 (26) complementary and alternative medicine use by fam-
Depression 2.3 (13)
Diabetes 2.2 (12)
ily or friends (OR 2.36, 95% CI 1.61–3.47, P,.001).
Epilepsy 0.9 (5) Comparison of complementary and alternative
Others 7.0 (40) medicine users with nonusers is reported in Table 5.
Concurrent prescribed medication 46.0 (256) The majority of users (91.5%) and nonusers (92%)
Neonate’s medical problem(s)* were uncertain or disagreed that complementary
Yes 32.2 (179)
and alternative medicine use during pregnancy was
* Missing values. more effective than conventional medicines pre-
scribed by their doctor. However, despite this, users
were reportedly used during the last 3 months of preg- were significantly more likely than nonusers to agree
nancy, of which the most frequently reported were: that complementary and alternative medicines were
herbals (62.0% of complementary and alternative safer than prescribed medicines (P5.006), less likely
medicine users); massage (45.3%) for back and muscle to be associated with side effects (P,.001), and could
pain and relaxation; yoga (20.8%) for general well- interfere with conventional medicines (P,.001). Two
being, pain relief, and preparation for labor; nutra- thirds of respondents (68.6%) agreed that comple-
ceuticals (15.5%) for well-being and constipation; mentary and alternative medicine use should be
and aromatherapy (8.5%) for relaxation and pain reported to their health professionals with comple-
control. mentary and alternative medicine users more likely
The specific herbal products, recommenders, and to agree (P,.001). More than half of respondents
indications for use are reported in Table 3. The five (53.7%) agreed that complementary and alternative
most commonly reported herbal products were: medicines should be available through the National

206 Pallivalapila et al CAM Use During Late Pregnancy OBSTETRICS & GYNECOLOGY
Table 2. Complementary and Alternative Medicine Modalities Used, Referrals, and Indications (n5342)

Recommended By*
Patients
Using Family,
CAM CAM Doctor Midwife Pharmacist Friend Internet Magazine Other Indications

Herbal 62.0 (212) See Table 3

products

Massage 45.3 (155) 5.8 (9) 23.9 (37) 1.3 (2) 21.3 (33) 5.2 (8) 2.6 (4) 18.7 (29) Back and muscle
aches and pains,
relaxation
Yoga 20.8 (71) 4.2 (3) 16.9 (12) 1.4 (1) 29.6 (21) 5.6 (4) 1.4 (1) 28.2 (20) General well-being,
pain, breathing,
preparation for
labor
Nutraceuticals 15.5 (53) 7.5 (4) 11.3 (6) 1.9 (1) 9.4 (5) 0 18.9 (10) 15.1 (8) General well-being,
constipation,
indigestion
Reflexology 9.1 (31) 6.5 (2) 16.1 (5) 0 32.3 (10) 6.5 (2) 0 22.6 (7) Induce labor, back
pain, relaxation
Aromatherapy 8.5 (29) 10.3 (3) 20.7 (6) 0.0 10.3 (3) 6.9 (2) 6.9 (2) 27.6 (8) Pain relief,
relaxation, sleep
Spiritual 8.2 (28) 3.6 (1) 0 3.6 (1) 25.0 (7) 0 0 28.6 (8) Faith and personal
healing belief, calming,
neonate well-
being
Homeopathy 7.3 (25) 12.0 (3) 12.0 (3) 0.0 36.0 (9) 0.0 0.0 36.0 (9) Aid healing,
bruising and
bleeding after
delivery
Meditation 7.0 (24) 0.0 16.7 (4) 0.0 12.5 (3) 4.2 (1) 4.2 (1) 41.7 (10) Relaxation
Hypnosis 6.5 (22) 9.1 (2) 27.3 (6) 0.0 4.5 (1) 4.5 (1) 9.1 (2) 31.2 (7) Birth preparation,
relaxation
Acupuncture 5.0 (17) 11.8 (2) 11.8 (2) 0.0 41.2 (7) 5.9 (1) 5.9 (1) 11.8 (2) Bring on labor,
nausea and
vomiting
Acupressure 4.1 (14) 7.1 (1) 28.6 (4) 7.1 (1) 7.1 (1) 14.2 (2) 7.1 (1) 14.2 (2) Bring on labor
Osteopathy 4.1 (14) 14.3 (2) 14.3 (2) 0.0 28.6 (4) 0.0 0.0 28.6 (4) Back and pelvic
pain
Reiki 3.2 (11) 0.0 9.1 (1) 0.0 72.7 (7) 0.0 0.0 0.0 Back pain, stress
relief
Chiropractic 1.5 (5) 40.0 (2) 0.0 0.0 20.0 (1) 0.0 0.0 20.0 (1) Back and hip pain
Shiatsu 1.5 (5) 20.0 (1) 40.0 (2) 20.0 (1) 0.0 0.0 0.0 20.0 (1) Back pain,
relaxation
Alexander 0.9 (3) 0.0 33.0 (1) 0.0 0.0 0.0 0.0 0.0 Back pain, stress
technique relief
Autogenic 0.9 (3) 0.0 0.0 0.0 0.0 0.0 33.3 (1) 33.3 (1) Relaxation
training
Chinese 0.9 (3) 33.3 (1) 0.0 0.0 0.0 0.0 33.3 (1) 33.3 (1) General well-being
medicine
Ayurveda 0.3 (1) 0.0 0.0 0.0 100.0 (1) 0.0 0.0 0.0 Help feel positive
Cranial 0.3 (1) 0.0 0.0 0.0 0.0 0.0 0.0 100.0 (1) Back and hip pain
osteopathy
Others 5.6 (19) Pain, stress relief,
healing, induce
labor
CAM, complementary and alternative medicine.
Data are % (n).
* Do not total 100% owing to missing data.

VOL. 125, NO. 1, JANUARY 2015 Pallivalapila et al CAM Use During Late Pregnancy 207
Table 3. Herbal Products Used, Referrals, and Indications (n5212)

Recommended by
Patients
Herbal Using Family,
Product Product Doctor Midwife Pharmacist Friend Internet Magazine Other Indications

Raspberry 57.1 (121) 2.5 (3) 19.8 (24) 0.8 (1) 29.8 (36) 21.5 (26) 7.4 (9) 5.0 (6) Induce labor,
tea or ripen cervix,
capsules uterine toning
Cranberry 22.2 (47) 10.6 (5) 17.0 (8) 4.3 (2) 10.6 (5) 2.1 (1) 6.4 (3) 23.4 (11) UTI and thrush
Ginger 18.9 (40) 0 17.5 (7) 0 40.0 (16) 0 12.5 (5) 12.5 (5) Upset stomach,
(beyond nausea
cooking)
Chamomile 13.7 (29) 0 13.8 (4) 0 34.5 (10) 0 3.4 (1) 13.8 (4) Sleep, relaxation,
sickness
Eucalyptus 11.3 (24) 0 8.3 (2) 0 25.0 (6) 4.2 (1) 4.2 (1) 8.4 (2) Cold treatment,
blocked nose
Peppermint 9.5 (21) 0 14.3 (3) 0 28.6 (6) 14.3 (3) 0 9.5 (2) Indigestion, settle
stomach
Aloe 7.5 (16) 6.3 (1) 25.0 (4) 6.3 (1) 25.0 (4) 18.8 (3) 0 6.3 (1) Skin
Grapefruit 6.6 (14) 7.1 (1) 0 0 35.7 (5) 0 0 14.3 (2) Settle stomach,
vitamin C
supplement
Echinacea 3.8 (8) 0 12.5 (1) 12.5 (1) 25.0 (2) 0 0 25.0 (2) General well-
being
Evening 3.8 (8) 12.5 (1) 12.5 (1) 0 12.5 (1) 50.0 (4) 0 0 Induce labor,
primrose soften cervix
Senna 3.8 (8) 25.0 (2) 25.0 (2) 0 0 0 0 12.5 (1) Constipation
Rosemary 3.3 (7) 0 14.3 (1) 14.3 (1) 14.3 (1) 0 0 28.6 (2) Relax muscles
Garlic 2.8 (6) 33.3 (2) 0 0 33.3 (2) 16.7 (1) 0 0 General well-
(beyond being, nausea
cooking)
Clove oil 2.8 (6) 16.7 (1) 50.0 (3) 0 16.7 (1) 0 16.7 (1) 0 Toothache
Ginseng 2.4 (5) 0 20.0 (1) 0 0 0 0 20.0 (1) Energy
Clary 2.4 (5) 0 40.0 (2) 0 40.0 (2) 20.0 (1) 0 0 Relaxation, induce
labor
Jasmine 1.4 (3) 0 0 0 33.3 (1) 0 33.3 (1) 33.3 (1) Back pain, bring
on labor,
relaxation
Barberry 0.9 (2) 0 0 0 50.0 (1) 0 0 0 Headache
St. John’s 0.9 (2) 0 0 0 50.0 (1) 0 0 0 Stress relief
Wort
Black 0.9 (2) 0 50.0 (1) 0 50.0 (1) 0 0 0 Birth preparation,
cohosh knee pain
Blue 0.9 (2) 0 50.0 (1) 0 0 0 0 50.0 (1) Birth preparation,
cohosh knee pain
Aconite 0.9 (2) 0 0 0 0 0 0 100.0 (2) Anxiety
Kelp 0.5 (1) 0 100.0 (1) 0 0 0 0 0 Birth preparation
Cat’s claw 0.5 (1) 0 0 0 100.0 (1) 0 0 0 Knee pain
Comfrey 0.5 (1) 0 100.0 (1) 0 0 0 0 0 Birth preparation
Ginkgo 0.5 (1) 0 0 0 0 0 100.0 (1) 0 None given
Bee pollen 0.5 (1) 0 0 0 0 0 0 0 Hay fever
Milk thistle 0.5 (1) 100.0 0 0 0 0 0 0 Healthy diet
(1)
Others 9.4 (20) Pain, healing,
induce labor
UTI, urinary tract infection.
Data are % (n).

208 Pallivalapila et al CAM Use During Late Pregnancy OBSTETRICS & GYNECOLOGY
Table 4. Comparison of Complementary and Alternative Medicine Users and Nonusers (n5557)

Characteristic Users (n5342) Nonusers (n5215) P (x2)

Age (y)
15–24 13.2 (45) 20.5 (44)
25–34 61.1 (209) 62.8 (135) ,.01
35 or older 25.7 (88) 16.7 (36)
Education
University 57.0 (195) 38.0 (81)
College 28.1 (96) 28.2 (60) ,.001
Secondary school 14.9 (51) 33.8 (72)
Ethnic origin
White British 77.8 (266) 84.7 (182) .046
Others 22.2 (76) 15.3 (33)
First pregnancy 62.3 (213) 107 (50.0) .004
Medical condition 35.1 (120) 24.3 (52) .007
CAM use before pregnancy 22.0 (75) 5.7 (12) ,.001
CAM use by family, friends 49.7 (170) 22.8 (49) ,.001
CAM, complementary and alternative medicine.
Data are % (n).

Health Service, with users being significantly more
likely to agree (P5.025).
DISCUSSION
This study reports the prevalence of all complemen-
tary and alternative medicine modalities used and the
associated factors for use during the last trimester of
pregnancy. Almost two thirds of respondents reported
using complementary and alternative medicine, total-
ing 30 different modalities. Herbal products were the
most frequently cited with one or more of 40 different
products being used by almost half of respondents.
The indications for use varied with complementary
and alternative medicine modality and product,
largely being used for symptom control, general
well-being, and induction of or preparation for labor.
The principal associated factors for complementary
and alternative medicine use were: use before preg-
nancy, university education, and use by family and
friends.

Table 5. Responses of Users and Nonusers to Attitudinal Statements Regarding Complementary and
Alternative Medicine Use (n5557)

Strongly Agree or Strongly Disagree or

Agree Uncertain Disagree
P*
Statement Users Nonusers Users Nonusers Users Nonusers (x2)

CAMs are more effective than conventional 8.5 (29) 7.0 (15) 61.1 (209) 67.0 (144) 30.4 (104) 25.1 (54) .302
medicines prescribed by my doctors during
pregnancy
During pregnancy CAMs are safer than 19.0 (65) 9.8 (21) 57.0 (195) 67.9 (146) 24.0 (82) 21.4 (46) .006
conventional medicines prescribed by my
doctor
Complementary and alternative therapies can 36.3 (124) 21.9 (47) 51.2 (175) 68.4 (147) 12.6 (43) 8.8 (19) ,.001
cause side effects
CAMs can interfere with conventional medicines 29.2 (100) 19.5 (42) 50.9 (174) 67.0 (144) 19.9 (68) 12.6 (27) ,.001
prescribed by my doctors
Health care professionals should be informed by 75.7 (259) 57.2 (123) 22.8 (78) 40.5 (87) 1.5 (5) 1.4 (3) ,.001
patients about the use of any CAM during
pregnancy
CAMs should be available through the National 60.2 (206) 43.3 (93) 33.9 (166) 46.0 (99) 5.8 (20) 9.8 (21) .025
Health Service
CAM, complementary and alternative medicine.
Data are % (n).
* P is the comparison between proportions of users and nonusers.

VOL. 125, NO. 1, JANUARY 2015 Pallivalapila et al CAM Use During Late Pregnancy 209
 Unlike previous reports,27 our study included
a definition of complementary and alternative medi-
cine together with detailed checklists for both comple-
mentary and alternative medicine modalities and
specific complementary and alternative medicine
products. A further strength is the nature of data col-
lection emphasizing complementary and alternative
medicine use during the 3 months before delivery,
thus minimizing recall bias. Limitations, however,
are the use of self-reported data, sampling from one
center, and the lack of data from nonrespondents,
possibly limiting generalizability. However, the age
and ethnicity of respondents are similar to those
recently reported for the total pregnant population
of England and Wales.28
As identified in a recent systematic review, there is
a lack of robust data describing complementary and
alternative medicine use during late pregnancy.27 Four
previous studies from Iran, Malaysia, Italy, and the
United States have reported on herbal use in relation
to the stage of pregnancy; however, none assessed the
full spectrum of complementary and alternative medi-
cine modalities. The findings reported by these studies
were inconsistent with two reporting higher use of herb-
als in the first trimester29,30 and two higher use in the
third trimester.31,32 More recently two further studies
reporting complementary and alternative medicine
use during pregnancy have been published; however,
neither linked complementary and alternative medicine
use to stage of pregnancy.33,34 Only one other U.K.
study has assessed complementary and alternative med-
icine use linked to stage of pregnancy.35 Bishop et al
reported an increase in complementary and alternative
medicine use from 6% in the first trimester to 26.3% in
the third trimester of pregnancy, a level less than half
that observed in our study population. However, a key
limitation of the Bishop study is the 20-year gap
between data collection and publication and the rapid
expansion in availability and use of complementary and
alternative medicine in recent years may explain differ-
ences observed. Although we have not performed a lon-
gitudinal study of complementary and alternative
medicine use throughout pregnancy, we have recently
reported the results of a survey of complementary and
alternative medicine use during early pregnancy in the
same study center and population.26 Although the prev-
alence of complementary and alternative medicine use
during the early and late stages of pregnancy is similar,
the number and range of complementary and alterna-
tive medicine modalities and herbal products used
increased during the last trimester. Notably the use of
raspberry tea or capsules, for induction of labor, ripen-
ing of the cervix, and uterine toning, was reported by
210 Pallivalapila et al CAM Use During Late Pregnancy
almost 60% of complementary and alternative medicine
users (40% of respondents). Such prevalence may be of
concern given that there is no evidence of benefit36 and
there is some evidence of potential harm as a result of
CYP450 enzyme inhibition,37 estrogenic activity,38 and,
in animal studies, the development of precocious
puberty and growth restriction in offspring.39
In our study the only significant independent
associated factor for complementary and alternative
medicine use were: university education; use before
pregnancy; and use by family and friends. Although the
first two have been previously reported,26 the impor-
tance of use by family and friends is novel. Considering
the lack of robust evidence supporting complementary
and alternative medicine use in pregnancy the lack of
professional input may be of concern. However, health
care professionals do not always apply an evidence-
based approach, as highlighted in a recent U.K. study
of midwives and obstetricians, which identified that
health care professionals personally using complemen-
tary and alternative medicine were eight times more
likely than nonusers to professionally recommend com-
plementary and alternative medicine to their patients.40
Given the lack of safety and efficacy data, a qualitative
research approach to better understand the drivers and
motivators for complementary and alternative medicine
use during pregnancy is required. In addition, there is
a need to derive robust data on the effectiveness and
safety of the most commonly used complementary and
alternative medicine modalities and products.
The use of complementary and alternative med-
icine during the third trimester of pregnancy is
common with key associated factors being: use before
pregnancy, university education, and use by family
and friends. Given the absence for safety or efficacy
and some evidence for potential harm, the high use of
raspberry tea and capsules for the induction of labor
and uterine toning may be of concern.
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