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The Use and the User of Herbal Remedies During Pregnancy

Article  in  Journal of alternative and complementary medicine (New York, N.Y.) · July 2009
DOI: 10.1089/acm.2008.0467 · Source: PubMed

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THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 15, Number 7, 2009, pp. 787–792
ª Mary Ann Liebert, Inc.
DOI: 10.1089=acm.2008.0467

The Use and the User of Herbal

Remedies During Pregnancy

Lone Holst, M.Sc.Pharm.,1 David Wright, Ph.D.,2 Svein Haavik, Ph.D.,3 and Hedvig Nordeng, Ph.D.4

Abstract

Background: The physiologic changes that occur during pregnancy can lead to a variety of conditions that can
usually be self-treated. There are no licensed medicines for conditions such as morning sickness or insomnia in
pregnancy, and evidence from Western countries suggests that patients often resort to using herbal medicines.
Research on the health behaviors of pregnant women in the United Kingdom with respect to herbal remedies has
not been undertaken.
Objective: The objective of this study is to describe the use and the user of herbal remedies during pregnancy
and to study the sources of information about herbs used.
Design: The study design was a survey among expectant mothers more than 20 weeks pregnant presenting at an
antenatal clinic.
Setting: The setting was an antenatal clinic and antenatal ultrasound department at Norfolk and Norwich
University Hospital. One thousand and thirty-seven (1037) questionnaires were handed out between November
2007 and February 2008.
Results: Five hundred and seventy-eight (578) questionnaires were returned (55.7%). Three hundred and thirty-
four (334) of the 578 respondents (57.8%) reported using herbal remedies during pregnancy with a mean of 1.2
remedies per woman (median: 1, range: 0–10). The most commonly used remedies were ginger, cranberry, and
raspberry leaf. The most probable user had been pregnant before and had a university degree. ‘‘Family and friends’’
were the most frequently cited source of information about herbal remedies during pregnancy, and more than 75%
of the users reportedly did not tell their doctor or midwife about the use.
Conclusions: A large percentage of the women in the study used herbal remedies during pregnancy—many of
them without informing their doctor or midwife. Doctors or midwives should ask pregnant women if they use
herbal remedies during pregnancy. Health care personnel should be open to discuss the use of herbal remedies
during pregnancy and be able to give balanced information as the use is so widespread.

Introduction seeking perceived safer alternatives such as herbal reme-

dies.8–14 Although authors regularly make this assertion, the

T he numerous physiologic changes that occur during

pregnancy commonly result in a variety of conditions
including morning sickness (70%1), insomnia (66%–94%2),
heartburn (30–50%3), constipation (11%–38%4), ankle edema
(12%5), anemia (14%–52% in third trimester6), and urinary
tract infection (1%–13%7), among others. Licensed over-
the-counter medicines are only available for a limited number
of conditions associated with pregnancy, and this may be one
factor that leads women to choose alternative remedies. It is
suggested that concerns by women regarding use of phar-
maceuticals in pregnancy can make people more interested in
relationship between negative attitudes to conventional med-
icines in pregnancy and use of alternative therapies has not
been quantified.9,10,13
The lack of license status for conventional medicines in
pregnancy, however, is frequently not due to safety reasons
but rather to unwillingness to test products in this patient
group. Therefore, there are conventional medicines that have
been widely used and monitored in pregnancy with no ev-
idence of adverse effects (e.g., prochlorperazine15), and these
are prescribed when the prescriber perceives that the benefits
outweigh the risks. Interestingly, however, evidence seems

1
Department of Chemistry=Centre for Pharmacy, University of Bergen, Bergen, Norway.
2
School of Chemical Sciences and Pharmacy, University of East Anglia, England.
3
Centre for Pharmacy, University of Bergen, Norway.
4
School of Pharmacy, University of Oslo, Norway.

787
788
to suggest that pregnant women frequently seek and utilize
herbal remedies8 in preference to Western medicines, which
are monitored when used for unlicensed purposes, such as
pregnancy.
In the United States, use of herbal remedies in pregnancy is
believed to range from 4% to 45%,9,13,16–18 in Australia it is
between 12% and 62%,12,19–21 and in Canada between 61 and
96%.8,14 One (1) Norwegian study found that 36% of pregnant
women reported using herbal remedies.10 Certain character-
istics are more predictive of herbal remedy use and these in-
clude older, tertiary educated, English-speaking, nonsmokers,
and primiparous.19 Gibson (United States)16 reported that
trends were seen toward greater use among white women
and women with at least college education but no association
to age or income level. Hepner (United States) reported that
the use of herbal remedies was most frequent in the age group
41–50 years, but that the difference was not significant.9 Maats
(Australia) reported that women using herbs were more likely
to be primiparous, married, and to have a tertiary level of
education.21 Nordeng (Norway) reported that women be-
tween 26 and 35 years of age, with a prior history of use and
with higher knowledge about herbs, were more prone to use
herbs during pregnancy.22 Refuerzo (United States) found
significantly higher use of herbal treatments among older
women of higher socioeconomic class and with higher edu-
cation.18 There is no complete agreement among the authors,
but age and education seem to be the most important factors.
No similar studies are found about the use of herbs during
pregnancy in the United Kingdom. Also, no research in the
United Kingdom has been undertaken to determine the actual
and preferred sources of information on herbal drugs.
The aims of the study were to describe the use and the
user of herbal remedies during pregnancy and to explore the
health-seeking behavior of users and nonusers of herbal rem-
edies during pregnancy.
Materials and Methods
The questionnaire
The survey was based on a questionnaire developed
by Nordeng10 at the University of Oslo, Norway. To clarify
what kind of remedies the study was concerned about, the
following definition of an ‘‘herbal preparation or medicine’’
was given in the questionnaire: ‘‘any kind of product, such
as a tablet, a mixture, an ointment or herbal teas which are
produced from plants and used to acquire better health.’’
The following sociodemographic and lifestyle data were
collected: Year of birth, number of pregnancies prior to this
one, marital status, smoking during pregnancy, medicines
taken regularly, education level, and payment for prescrip-
tion medicines (as a proxy for social status).
Prior use of herbal remedies was ascertained and specific
questions regarding nine different herbal remedies were in-
cluded (Table 1).
For each remedy, participants were asked if they were
aware of it and if so, whether they had used it during
pregnancy and if so, what condition they had used it for. An
open question about other herbal remedies used was also
included.
Participants who had used herbal remedies were asked
about who recommended it to them and if they had told
their doctor about the use.
HOLST ET AL.
Table 1. The Nine Different Herbs for Which
Specific Questions were Asked
Common name Latin (binomial) name
Echinacea, coneflower Echinacea purpurea (L.) Monech,
Echinacea angustifolia DC,
Echinacea pallida (Nutt.)
Floradix
Mixture of iron-rich herbs
Ginger Zingiber officinale Roscoe
Chamomile Matricaria recutita L.
Valerian Valeriana officinalis L.
Cranberry Vaccinium macrocarpon Aiton
Horsetail Equisetum arvense L.
Raspberry leaf Rubus idaeus L.
St. John’s wort Hypericum perforatum L.
Study population and data collection
Expectant mothers more than 20 weeks pregnant presen-
ting at the antenatal clinics held within Norfolk and Norwich
University Hospital (NNUH) teaching hospital between
November 26, 2007 and February 15, 2008 were given a pa-
tient information leaflet, a questionnaire, and a stamped
addressed envelope. The envelope was handed out by the re-
searcher in the waiting room while the women were waiting
to go to their appointment. The researcher explained the aim
of the study for each potential participant.
Statistics
Chi-square tests were used to analyse univariate associa-
tions between variables.
Logistic regression was used to study associations be-
tween sociodemographic and lifestyle variables and use of
herbal remedies during pregnancy. Forward logistic regres-
sion analysis was used to generate models. Variables related
to use of herbal remedies with significance level of 0.05 or
greater were included in the model. Interaction factors were
included in addition to single variables where appropriate.
The statistical analyses were performed using Statistical
Packages for Social Sciences (SPSS) version 15.
Ethics
The study was approved by the Essex 1 Research Ethics
Committee, Harlow, Essex, UK.
Results
The user and the use of herbal remedies
during pregnancy
Altogether, 1037 questionnaires were given to women more
than 20 weeks pregnant presenting at the antenatal clinics
held within NNUH teaching hospital. Of those, 578 were re-
turned (55.7%). Three hundred and thirty-four (334) of the 578
women (57.8%) had used herbal remedies during pregnancy
with a mean of 1.2 remedies per woman (median: 1, range: 0–10).
Characteristics of the participants are given in Table 2.
Most of the women (363 corresponding to 62.8%) had been
pregnant before. Almost all women were married or co-
habitant (514 corresponding to 88.9%). Approximately equal
amounts had General Certificate of Secondary Education
(GCSE)=Ordinary-level (O-level) (32.2%) and university
USE OF HERBAL REMEDIES IN PREGNANCY 789

Table 2. Characteristics of the 578 Women in the Study According to Use

of Herbal Remedies During Pregnancy

Users of herbs during Nonusers of herbs

Characteristics pregnancy during pregnancy

Total (%) 578 (100.0) 334 (57.8) 244 (42.2)

Used herbs before
No 182 (31.5) 53 (15.9) 129 (52.9)
Uncertain 30 (5.2) 12 (3.6) 18 (7.4)
Yes 357 (61.8) 262a (79.4) 95 (38.9)
Age (years)

30 249 (43.1) 112 (33.5) 118 (48.4)
>30 310 (53.6) 198a (59.3) 131 (46.3)
Prior pregnancies
None 197 (34.1) 101 (30.2) 96 (39.3)
1 or more 362 (62.6) 225a (67.4) 137 (56.1)
Smoking during pregnancy
Not at all 478 (82.7) 277 (82.9) 201 (82.3)
Now and then 55 (9.5) 35 (10.5) 20 (8.2)
Daily 29 (5.0) 17 (5.1) 12 (4.9)
Marital status
Married=cohabitant 514 (88.9) 304 (91.0) 210 (86.1)
Single 39 (6.7) 22 (6.6) 17 (7.0)
Other 11 (1.9) 4 (1.2) 7 (2.9)
Highest completed education
GCSE=O-level 186 (32.2) 98 (29.3) 88 (36.1)
A-level or other lower education 179 (31.0) 97 (29.0) 82 (33.6)
University degree 183 (31.7) 127a (38.0) 56 (23.0)
Medicines taken regularly
No 447 (77.3) 255 (76.3) 192 (78.7)
Yes 109 (18.9) 71 (21.3) 38 (15.6)
Pay for prescriptionsb
No 267 (46.2) 150 (44.9) 117 (48.0)
Yes 291 (50.3) 178a (53.3) 113 (46.3)

Sums do not always add up due to missing information.

GCSE, General Certificate of Secondary Education, O-level, Ordinary level.
a
Statistically significant difference.
b
Might not give a completely correct picture as pregnant women do not pay for prescription medicines.

education (31.7%). Significantly ( p < 0.05) more women who
had used herbs in the past also used them during pregnancy.
The variables tested in the logistic regression were: age, edu-
cation, ‘‘number of prior pregnancies,’’ and ‘‘pay for prescrip-
tions’’ and all interaction factors among those. The only significant
factor was the interaction between ‘‘number of prior pregnancies’’
and education, Exp (B) ¼ 3.245 (1.992; 5.288), Wald ¼ 22.337
( p < 0.05). The Hosmer-Lemeshow goodness-of-fit test showed a
p ¼ 1.0, which supports the model. The most probable user had
a university degree and had been pregnant before.
The most commonly used herbs in pregnancy are pre-
sented in Table 3.
It is seen that the six most commonly used were among
the ones asked specifically about. The remaining three of
those had hardly any users (valerian: 4, St. John’s wort: 2,
and horsetail: 1). Another 28 remedies were mentioned by
users but none of them had more than 5 users. In addition, 15
participants reported use of homeopathic remedies, but they
are not included in the analysis.
Information-seeking behavior of users and nonusers
of herbal remedies during pregnancy
The sources of information about herbs used during
pregnancy are given in Table 4.
‘‘Family and friends’’ were reported to be the most used
source of information about herbs taken during pregnancy.
Information from health care personnel (doctor, midwife,
nurse, pharmacist) was received by 71 (21.3%) of the users.
Only 5.8% of the users got their information from an alter-
native practitioner. Of the 262 women who answered the
question about informing their doctor about use of herbal
remedies, 200 (76.3%) did not, 18 (6.9%) were uncertain, and
44 (16.8%) did.
Preferred sources of information for future questions
about herbs are given in Table 5.
For future information, the ‘‘health food store’’ is seen to
be the preferred source for nonusers as well as for users.
Nurse or midwife comes in second place in both groups but
after that, users seem to rely on family and friends instead
of other health care personnel, while nonusers prefer health
care personnel.
Discussion
The use and the user of herbal remedies
during pregnancy
Herbal remedies were found to be used by 57.8% of the
participants. This is quite a high percentage compared to most
790 HOLST ET AL.

Table 3. The Most Commonly Used Herbs in Pregnancy Among 578 Women
at the Norfolk and Norwich University Hospital Antenatal Clinic

% of the 334 % of all 578

Herb Number of users users participants Most common indication

Ginger 157 47.0 27.2 Nausea=sickness

Cranberry 144 43.1 24.9 Urinary tract infection
(prevention or treatment)
Raspberry leaf 137 41.0 23.7 Prepare uterus=cervix for labor
Chamomile 76 22.8 13.1 Relax=help sleep
Floradix
(iron-rich herbs) 44 13.2 7.6 Iron supplement
Echinacea 25 7.5 4.3 Prevent=treat cold
Peppermint 21 6.3 3.6 Indigestion
Lavender 11 3.3 1.9 Help sleep
Fennel 8 2.4 1.4 Indigestion
Nettle 7 2.1 1.2 Detoxification

other studies of similar size. Australian studies performed from the market in February 2008 due to inadequate scientific
in antenatal clinics found 12%12 and 36%,19 respectively. An documentation of its safety.24 The Danish Veterinary and
American study from a rural obstetric clinic17 found 45.2% Food Administration stated that it is not dangerous to con-
and another American study from a postnatal ward18 looked sume food containing ginger, but that the amount in different
at complementary and alternative treatment in general and herbal products is too high.24
found 4.1% only. The Norwegian study (performed as inter- The intention was to study various characteristics for the
views no more than 3 days after delivery), which this study participants to be able to describe ‘‘the most typical user of
was based on, found 36% users of herbal remedies.10 herbal remedies in pregnancy.’’ The developed model showed
Ginger was used by almost half of the users in this study, that mothers with a university degree and being in their sec-
which is high compared to other surveys and may be ex- ond or higher-order pregnancy were three times more likely
plained by the very common use of ginger in biscuits and beer to self-treat with herbal medicines. This finding is in line with
in the United Kingdom. Cranberry was also used by a much other studies.9,18,19
higher percentage in this study than in any other: 43.1% ver- Of perhaps greatest concern was the finding that 76% of
sus 28.7%,17 8.3%,10 and 24.1%.19 Conversely, peppermint the pregnant women reported not informing their doctor that
was used by only 6.3% of the users here compared to 39.8% in they were utilizing herbal medicines, and reasons for this
an American study17 and echinacea by 7.5% compared to require elucidation. Frequencies of informing the doctor
22.9% in Norway.10 ranging from 33% to 52% are reported in other countries.25,26
A review of four studies on the effect of ginger against Self-report should be improved to enable prescribers to as-
nausea and vomiting during pregnancy concludes that 1 g of certain the patient’s symptoms, seek advice on the safety of
ginger daily is more effective than placebo and that no ad- the herbal medicines on the patient’s behalf, and prevent
verse outcomes or side-effects were detected for the 3 weeks any interactions with any prescribed medicine. In Sweden, a
duration of the study.23 Interestingly, however, GraviFrisk
question regarding herbal remedies use is included in the
(which translates to something like ‘‘PregnaWell’’ and equates standard questions all pregnant women are asked when
to a daily dose of 6 g of dried ground ginger), which was ad- attending their antenatal clinic. The information is then
vertised for pregnant women in Denmark, was withdrawn
Table 5. Sources Preferred for Future Information
About Herbs
Table 4. Sources of Information for Products
Actually Used During Pregnancy Source Number of women (%)a
Source Number of women (%)a Nonusers Users
2) n ¼ 501 n ¼ 194 n ¼ 307 All
1) n ¼ 259
Family or friends 160 (61.8) Family or friends 72 (37.1) 150 (48.9) 222 (44.3)
My own idea 83 (32.0) Newspaper or 35 (18.0) 81 (26.4) 116 (23.2)
Newspaper or magazine 47 (18.1) magazine
Health food store 20 (7.7) Health food store 115 (59.3) 186 (60.6) 301 (60.1)
Doctor 20 (7.7) Doctor 104 (53.6) 107 (34.9) 211 (42.1)
Alternative therapist 15 (5.8) Alternative therapist 54 (27.8) 92 (30.0) 146 (29.1)
Pharmacist 5 (1.9) Pharmacist 87 (44.8) 105 (34.2) 192 (38.3)
Nurse or midwife 58 (22.4) Nurse or midwife 104 (53.6) 151 (49.2) 255 (50.1)
Other 18 (6.9) Other 27 (13.9) 66 (21.5) 93 (18.6)
Internet 3 (1.2) Internet 22 (11.3) 48 (15.6) 70 (14.0)
Books 9 (3.5) Books 0 15 (4.9) 15 (3.0)
a a
Please note that the percentages add up to more than 100 as more Please note that the percentages add up to more than 100 as more
than one source could be given. than one source could be given.
USE OF HERBAL REMEDIES IN PREGNANCY
collated and available from a database at the Swedish Medical
Birth Register.27
Health-seeking behavior of users and nonusers
of herbal remedies during pregnancy
The most important source of information about herbal
remedies was found to be ‘‘family and friends,’’ which is
similar to other findings8,10,19 and is of some concern as there
is no reason to believe that these persons are competent to
give advice on herbs to pregnant women.
The sources of information that women would seek in the
future differ from those they actually used in pregnancy. The
reason for this discrepancy could be an easier access or a lower
threshold to discuss use of herbal remedies with family and
friends compared to health care personnel. The preferred fu-
ture source was health food shops. This is similar to the
finding in the Norwegian study.10 This is also of some concern
as the competence of the personnel in health food shops is
unclear. A small study performed by the Norwegian Con-
sumer Council in 200228 concluding that only 2 of 12 em-
ployees in randomly selected health food shops in Norway
could give correct answers to four basic questions regarding
herbal remedies and an American study on customers to one
separate herbal shop29 concluded that the employees had no
particular training in pharmacology, physiology, or herbal-
ism. No such research has been undertaken in the United
Kingdom, although similar findings would be expected as
herbal remedy shops are unregulated and there is no require-
ment for staff training.
Only one third of users reported that they had been ad-
vised by health care professionals to use herbal remedies.
Research in other countries has found that Western-trained
medical practitioners generally have little knowledge of
herbal remedies, their safety, or potential interactions,30,31
and this may provide one reason for only one third recom-
mending this course of action.
The results do, however, require consideration with re-
spect to the study’s limitations. The results may not be gen-
eralizable with a 56% response rate, and women who were
more interested in herbal drugs may have been more eager
to fill out and return the questionnaire. Consequently, this
could have overestimated the prevalence of herbal drug use.
Conversely, the identified prevalence may be under-
estimated, with the survey being undertaken in the middle of
pregnancy, and use later than the 20th week will not be
identified. For ethical reasons, the researcher was only al-
lowed to approach patients who had given verbal consent
to the clinic receptionist, and therefore consent to partici-
pate was not sought from all attendees. Finally, the research
was also only carried out in one hospital in one region in
the United Kingdom; consequently, the respondents may
not be representative of pregnant women in the United
Kingdom.
Conclusions
More than half of women attending one antenatal clinic in
the East of England reported using herbal remedies during
pregnancy: mostly ginger, cranberry, raspberry leaves, and
chamomile. Although the clinic provided care for patients
from both deprived and affluent areas, the behavior may not
791
be generalizable for the rest of the United Kingdom. A na-
tionwide survey is probably warranted to obtain a complete
picture.
Doctors or midwives were rarely informed about use of
herbal remedies during pregnancy. One possible reason could
be that health care personnel are not expected to be open to
discuss such use or have adequate knowledge about herbal
remedies. It would, however, seem appropriate for all health
care professionals to be educated and aware of herbal rem-
edy use during pregnancy. Certain patient groups are more
likely to use herbal remedies during pregnancy; however,
this should not prevent all patients from being questioned
regarding herbal medicine use.
With few exceptions, there is still a lack of well-conducted
studies on the safety of herbs during pregnancy. As use
of herbal remedies is so widespread during pregnancy, this
should be a prioritized area of future research.
Acknowledgments
The authors want to thank everyone working in the an-
tenatal clinic and antenatal ultrasound department at the
Norfolk and Norwich University Hospital. A special thanks
to the receptionists, without whom the study would not have
been possible.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Lone Holst, M.Sc.Pharm
Department of Chemistry=Centre for Pharmacy
University of Bergen
Allégaten 41
N-5007 Bergen
Norway
E-mail: lone.holst@farm.uib.no