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 [7, 16, 19, 32, 35]. This study indicated that the rate of CAM use increased to 71.5% during pregnancy and had a higher prevalence than previously reported. Various factors such as differences in culture and ethnicity, sociodemographic factors, the use of health services and the difference in CAM treatments in a local area, lack of or inconsistent CAM definition and study design were reported to be responsible for these differences in the prevalence of CAM use [7, 32, 35, 36]. 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 [3, 7, 9, 16]. This study determined that phytotherapy, spiritual meditation and therapeutic touch were the most commonly used methods. These results were quite similar to the findings of Swan and Strouss et al. [37, 38]. Other studies conducted among the general population in our country report that herbal products and religious rituals are the most widely used CAM [39, 40]. This is a very important finding because it shows that the approach towards culturally widely used CAM applications continues during pregnancy as well. However, this should be interpreted with caution because of the potential impact of culture and ethnicity. These require further studies to examine and explore previous CAM use as well as cultural practice and belief and health outcomes of pregnant women.
The mean score of pregnant women on the whole CACMAS was 108.37 ± 7.71; the scores on the sub-scales of the intellectual view to complementary medicine, dissatisfaction with modern medicine and holistic view of health were found to be 33.46 ± 2.95, 33.04 ± 4.49 and 41.85 ± 4.75, respectively. Pregnant women were found to have positive attitudes towards CAM methods in general. Socioeconomic status, health insurance coverage, religion, education, income, parity, place of residence, the use of herbal medicines for other conditions, old age, employment status, marital status, personal attitudes towards both CAM and birth, CAM use before pregnancy, chronic disease/medication, cultural norms and health beliefs were reported to influence women with respect to CAM use [3, 8, 36, 41]. In our study, pregnant women particularly those who lived in villages, were single, had a high school level of education, and had no concerns about triggering problems due to using CAM had a positive association between the CACMAS score.
And also, significant differences were observed in this study between the women’s scores on the CACMAS with respect to symptoms experienced during pregnancy. Thus, this study’s result can be interpreted as pregnant women who have pregnancy complaints have positive attitudes towards CAM methods and this could be the reason for increased CAM use. The concern and uncertainty of the risk of preterm birth can cause negative attitudes towards CAM.
Some studies reported that between 7% and 82% of pregnant women use herbal remedies or other natural health products. Different herbal medicines are used by different ethnic groups because diverse cultural backgrounds and traditional beliefs [2, 11, 36, 41]. The most used herbs during pregnancy are chamomile, ginger, blueberry, mint, cranberry, valerian, raspberry, echinacea, black cumin, lemon tea, anise, cinnamon, castor oil, prune and mustard oil and raspberry leaves [32, 35, 37, 41, 42]. Ginger, honey, lime, mint-lemon and raisins were most commonly used by the participants in this study. Thus, this reveals that herbs differ among different cultures and countries . Women appear to be interested in herbal remedies because of their preference to use a natural substance. Women believe that ‘natural’ implies ‘safe’ and have the perception that these products are safer than other drugs and are associated with no risk [9, 19, 32, 38, 41]. Many women are unaware of their side effects and generally self-prescribe herbal medicines because of the belief that they are harmless during pregnancy [19, 32]. Although some herbal medicines are reported to be useful and have low side effects, there is no sufficient evidence to prove their safety and efficacy during pregnancy [19, 41]. Thus, providers should inquire about the routine CAM use specific for their trimester and complaints faced by the pregnant women.
The following are the most frequently reported reasons for CAM use: its affordability, accessibility, effectiveness, safety and naturality; familial and cultural traditions; dissatisfaction with modern medicine; its ability to improve health conditions during pregnancy; prevention of general diseases and complications; protection of foetus health; its ability to enhance immunity and relaxation as well as maintain well-being and preparing the uterus for birth [7, 9, 32, 35]. Similar results were observed in this study: CAM methods were used for relaxation, maintenance of the health of the foetus as well as pregnant woman and alleviation of symptoms. Although the reason for CAM use to prepare for childbirth and to facilitate it is common [32, 41], this reason was not specified in this study. These results are also reflected in the CAM use during birth, with only 13% who applied back massage during labour. CAM use during birth helps women to perceive birth as a natural event, decreases their fear and anxiety levels, increases their ability to cope with labour pains, increases their self-confidence and provides them a more positive birth experience . Pregnant women do not benefit enough from the application of CAM therapies to facilitate the birth because health professionals use or offer limited CAM practices in a community/birth centre. In this context, the crucial role played by the providers with respect to CAM practices and consultation at labour and pregnancy is worth mentioning.
There is little evidence to support CAM use during pregnancy, which raises questions of its potential risks and possible benefits [16, 41]. Most pregnant women in this study reported that they perceived benefits of CAM use, did not experience any harm and recommended CAM to others. However, majority of them were also worried that CAM use might lead to preterm birth. In a study conducted in Iran, 83.7% of the pregnant women were satisfied with CAM use . 8% of the pregnant women in a study conducted in Bangladesh experienced side effects . In a study conducted in Palestine, 91.7% of the women found these treatments beneficial, and 99.2% of them did not report side effects . These results are quite similar with our study findings. Although high use and high utility rates have been reported, still nearly three-quarters of pregnant women fear that CAM methods may cause preterm birth. This paradoxical situation indicates that most users were not aware of the safety, efficacy or potential drug interactions [36, 41]. It was observed that women mostly do not inform their midwives or obstetricians about their CAM use; health professionals do not question the use of CAM; they use CAM methods on their own [7, 16, 19, 42]. Approximately 56% of the women in this study reported that they used CAM on their own without consulting. Therefore, the concerns about CAM use by pregnant women without the knowledge or contribution of healthcare professionals should be underlined. Thus, health professionals play a key role in maternity care that requires closer attention. They should increase their knowledge to allow women who use CAM and those providing care to women during pregnancy and birth to be fully informed [7, 16, 19, 23, 38]. Moreover, the results of this study provide a basis for CAM use in pregnancy as well as provide an understanding of positive attitude toward CAM use by pregnant women in Turkey where traditional practice and usage is common. These outcomes indicate the risk for pregnant women that are more likely to use methods and show the importance of counselling about CAM use to prevent its side effects. Thus, pregnant women should be counselled comprehensively on CAM which can eventually lead to the use of methods that do not compromise maternal and fetal health.
This study has some limitations. First, it was conducted in a single hospital with random sampling. Therefore, the results are likely to be valid only for the local population. Further studies must be conducted over a wide area, including population groups that represent the regional diversity in Turkey. But the study was carried out in a city with a developed education and economic level in Turkey. These rates reflect a certain part of the society, but even if the results of the study are carried out in a certain region, the results of the study show that the use of CAM is significantly higher due to the low level of education and living in the village due to high migration ratein this region. Therefore, the widespread use of CAM during pregnancy in one of the most developed cities of the country predicts that the study will be widely used throughout the country and may even be used at a higher rate in underdeveloped regions.
A major limitation of this study was the use of postnatal data collection to assess CAM use throughout the pregnancy. The study did not question CAM use for symptoms specific to the trimester. Questioning regarding this in future prospective studies that follow up on a weekly or monthly basis could provide more reliable and valid data. In the study, another limitation might be that complications in the mother and baby were excluded from the study. Given the association of CAMS with complications, these results may be important. However, due to the nature of the clinical survey, in case of complications in the mother and baby, reliable and effective answers to the questions of the survey cannot be obtained.