The World Health Organisation(WHO)  defines “traditional medicine (TM)” as  a comprehensive term referring to  both TM systems(such as traditional Chinese medicine, Indian ayurveda and Arabic unani medicine) and various forms of indigenous medicines.It  includes medication therapies( which involves use of herbal medicines,animal parts and/or minerals) and nonmedication therapies( carried out primarily without the use of medication, as in the case of acupuncture, manual therapies and spiritual therapies).TM is further used to refer to“complementary”, “alternative” or “non-conventional” medicine[1].

The history,evolution and use  of herbal medicines is anectodal.Besides the crude interventions such as amputations and other surgeries done without anaesthesia, most medical treatments were ineffective until the twentieth century.It is claimed that humans following affliction by various ailements learnt to find remedies from plant,animal and mineral extracts [2]. Where the gap did exist in the orthodox medical practice,herbal medicines  dictated medical practice as far as the times of  ancient Hindu and Chines cultures.Additionally ,these remedies are documented to have been practiced by the Greek scholar Theophrastus(371-287BC) and by the Pedanius Dioscorides(AD 40-90),a surgeon in the Roman army,whose De Materia was for centuries,the bible of herbal remedies[3].

However the drawback of HM has been  the reliance by the practisioners  on self-beliefs and attitudes without scientific backing.Subsequently, reports indicate that influential figures such as Paracelsus and other reformers had rejected the traditional medical authority and advanced the idea of use of the Doctrine of signanture.This doctrine presumed that form,taste or smell of a plant indicated its application in treatment[4].Therefore,whereas most HM were and are still useless,and some even toxic,they have  remained popular then and now[3, 5]

The World Health Organization (WHO) estimates that 80% of the population in Africa and 40% in China use traditional medicine (TM) of whom herbal medicine (HM) is a cornerstone [6, 7]. Preganacy, a dynamic state associated with   physiological, anatomical,biochemical and psychological changes [8, 9] and altered form of immunity[9], causes symptoms and signs that may cause anxiety amongst the gravid women and quite often drive them to seek medical care or even self-prescribe herbal medicines[10].The choice they are likely to take, is influenced by the theories of planned behaviour (TPB) [11] and that of the health belief model(HBM)[12].

Therefore the prevalence of HMiP varies depending on the geographical region, ethnicity, cultural traditions, and social status.It is as low as 12% in Nairobi, Kenya[13], 20% in Northern Uganda[14],25.7% in Malawi[15],34.4%in Australia [10],48.6% in Ethiopia[16],57.8% in the United Kingdom and as high as 82.3%[17] in the middle east.

HMiP continues to gain momentum due to availability, affordability, perceived efficacy and safety, and cultural acceptance of herbs across different ethnic backgrounds [7, 10, 14, 18-20] and insufficient allopathic health care services [18]. It is employed to manage pregnancy-related illnesses [10, 13, 15, 16, 20], facilitation of labour[14],management of anaemia [21] and promoting fetal development [21-23] among others.

Moreover HMiP is associated with side effects including but not limited to maternal organ damage, abortions, rupture of the uterus et cetera.These lead to increased maternal and perinatal morbidity and mortality [15, 19, 20, 24]. Unfortunately, the majority of the public is unaware of the potential toxicities caused by these herbs that lack of sufficient information such as standard dosages [15, 22]. Additionaly no active pharmacovigillance system that would help track adverse effects associated with HMiP.Therefore majority go unreported [15, 23].

Several factors are reported to   influence the use of herbal medicines. Studies conducted in Kenya, Ethiopia, central Uganda and Bangladesh have reported increased odds of use with aging [13], being married, low economic status and low level of education [13, 16, 25], rural residence [16], unemployment [20] and perceived safety [14, 22].  Furthermore, Kennedy et al [26] reported that primigravida and students who were not in a health-related course were more likely to use herbal medicines during pregnancy [26].

Although the government of Uganda has put efforts to increase access to health services for pregnant women to reduce maternal ad perinatal morbidity and mortality, and passed a traditional and complementary medicines bill on 2nd February 2019, anectodotal information reveals less impact as far as MHiP is concerned. According to the bill, no herbal medicine should be on sale, offered for sale, or distributed unless authorized by the council (MOH, 2019). We therefore undertook this study to ascertain the prevalence of HMiP and factors that contribute to herbal medicine use among pregnant women in Eastern Uganda.

Study Design

A descriptive cross-sectional study design with mixed methods that employed qualitative and quantitative data collection was used.

Study Area

This study was conducted at the Young Child Clinic (YCC) of Mbale Regional Referral and Teaching Hospital (MRRTH). MRRTH is 400 beds tertiary university teaching hospital located in Mbale city, Eastern Uganda. It serves as the main referral hospital for more than 15 neighboring districts with an estimated population of about 4.5 million people. MRRTH is comprised of different departments. The Obstetrics and `Gynaecology department offers Antenatal, intra-natal, postnatal ad gynecological services. The postnatal clinic offers postnatal care to mothers,immunization, child growth and development monitoring services  to about  600 clients per month. Importantly about 30-50 mothers per day attend the YCC clinic on a regular basis as they seek both postnatal care and child health promotion services [27].

Study Population

The study population for the quantitative study included postnatal mothers who had come to attend YCC clinic with an infant at most 6months.The mothers provided informed consent for inclusion in this study.Postnatal mothers unwilling to take part in the study were excluded but continued getting uninterrupted postnatal services.

A formula for cross-sectional studies by Kish and Leslie was used to estimate the sample size,

Where; N = Estimated sample, Z= Z-score for 95% confidence interval=1.96

p= Estimated prevalence of herbal medicine in pregnancy which was estimated to be 21% considering that there is no reference data in the area (Richard et al., 2016)

d= Acceptable margin of error, 5%.

For the qualitative part,we included mothers that had not taken part in the quantitative study.A conducive environment away from the stresses of the clinic was chosen.We did choose mothers that had been served since these were likely to be more relaxed.

Sampling Procedure

A simple random sampling method was applied for the quantitative part of the study.Postnatal mothers registered at the post-natal clinic were randomly selected with a target of 7mothers per day.This was guided by the duration of the study,which was two months. For the qualitative part,purposive  selection technique was used until we the point of  saturation.

Quantitative Data

Pretested interviewer-administered questionnaires with closed-ended questions were used to collect data on prevalence, and factors associated with HMiP.After collection, data was entered into Microsoft excel spread sheet and exported to STATA 14 version for analysis. Descriptive analysis was performed, and results presented by way of tables, graphs and charts. Categorical variables were analyzed as frequencies and percentages.Chi-square test was performed to check for association between factors and outcome variables before performing logistic regression.

 Univariable analysis was run to identify variability of factors for multivariate analysis.Strength of association was measured using odds ratios, and 95% confidence interval. A p - value < 0.05 was considered statistically significant. The statistical goodness of fit for the model was checked.

Qualitative Data

In-depth interviews using interview guides were conducted to collect data about the knowledge mothers had about HMiP.Interview guides were developed based on both the Theory of Planned Behaviour (TPB) and the health belief model (HBM).

Theory of Planned Behaviour(TPB) presumes that individual behaviour represents conscious reasoned choice and is influenced or shaped by cognitive thinking and social pressures.It further asserts that behaviours are based on ones’ intention regarding that behaviour,which in turn is a function of one’s attitude(herein definbed as overall positive or negative feelings about performing behaviour in question,which may be assessed as a summation of one’s beliefs regarding the the different consequences of that behaviour,weighted by the desirability of those consequences) towards the behaviour,subjective norm regarding the behaviour, and perceptions of control over that behaviour [11]

On the other hand the HBM developed in the 1950s by Hichbaum,Rosenstock and others[12],   is a theoretical model that is used to predict individual changes in health behaviour geared at promoting health and preventing disease.It supposes that health behaviour is  influenced by perceived susceptibility,perceived severity,perceived benefits,cue to action and self-efficacy .

To analyse qualitative data,we employed deductive analysis.We based it  on an iterative reading of data and preliminary analysis.The steps of analysis included, data familiarization, coding and identification of a thematic framework, quote sorting, thematic categorization of quotes and interpretation of outcomes.

We used audio recorded information,transcribed it to English verbatim and coded it to generate meaningful themes using NVIVO 11 plus (QSR International, Burlington, Massachusetts).The nodes developed were used to code the transcripts inductively following a process of constant comparison between the emerging themes/codes and pre-existing codes. Any emergent code was added as a free node or attached to a tree node according to its place in the initial thematic framework. Salient quotes were noted.

 Coding density was used to identify recurrent themes. The themes with the highest coding density were categorized as major themes and the others as minor themes. Based on this, a final thematic model was developed. The results were summarized and presented as thematic codes. The researcher initially familiarized herself with the data by reading and re-reading the transcripts.

Quality control

Before the commencement of the study, the data collection tools were piloted to ensure that all the questions were written appropriately and could be understood. For those mothers who did not understand English, the questions were translated into the local languages using a research assistant who was fluent in English and the local language. 

At the end of each day, the questionnaires were cross checked thoroughly for completeness and appropriateness. The questionnaires were kept under lock and key.Data was double entered and stored in password protected computers. 

Ethical Consideration

 The ethical clearance was obtained from the Institutional Review Board of MRRTH under number MRRH-REC OUT 011/2020.  Informed consent was obtained from all participants in the study before collecting data. The participants were informed of voluntary nature of participation and ability to withdraw from the study at any time without undue explanations and that this would never jeopardize ability to seek services from any department of MRRTH.

Socio-demographic characteristics of the 281 participants.

A total of 281 women were invited to take part in this study and all agreed to participate- generating a response rate of 100%. The mean age of the participants was 25.83 years (standard deviation (SD) of ±0.4). Most 63% (177/281) of the participants were Christians, with the majority 90.8% (255/281) being married (being in a union and staying with a male partner). Close to half, 48 % (135/281) of the mothers attained either no formal education or had had primary education and 59.4% (167/281) were unemployed.Furthermore, 74%  of the mothers resided in rural settings. Moreover, whereas 35.2 % (99/281) were primiparous, only 21.7% (61/281) were grand multiparous (Table 1).

Prevalence of herbal medicine use in Pregnancy

The prevalence of herbal medicine use in pregnancy (HMiP) was 85% (239/281) (Table 1).

Table 1: Socio-demographic characteristics of the 281 study participants.

Factors Associated with Herbal Medicine Use During Pregnancy

Several factors emerged in relation to HMiP.These included previous use, parity, religion, awareness of the indication of herbal medicine for induction and enhancing labour, and willingness to disclose herbal medicine to health workers. The odds of herbal medicine use during pregnancy were 10.0 times higher among participants who had used herbal medicines in a previous pregnancy compared to one that had not. (Tables 2- 4).

Table 2: Relationship between socio-demographic characteristics of the study population and HMiP.

Table 3: Obstetric factors associated with herbal medicine use during pregnancy.

95% confidence interval and 0.05 level of significance, n represents Frequency.

Table 4: Multivariate analysis of factors associated with herbal medicine use in Pregnancy.

(R2 = 0.3043, Prob > chi2 = 0.0000) (**P – less than 0.001, *P less than 0.05).

Relationship between attitude and HMiP.

HMiP was very likely if one had done so during the antecedent pregnancy.In this study,77.3% (145/188) had used HMiP in the antecedent pregnancy. Furthermore, the majority 77.9% (219/281) were not willing to discuss with health care practitioners about herbal medicines use while only 59.8% were willing to disclose use to the health care providers. Moreover, the majority 64.3% (153/239) were satisfied with the outcome of HMiP and only 18.8% (45/239) of the users reported a history of experiencing undesirable effects attributable to herbs (Table 5).

Table 5: Prevalence and attitude towards herbal medicine use during pregnancy.

Indications for herbal medicines use during pregnancy

The major obstetric indications for HMiP were; to enhance labour at 76.7%, need to alleviate pregnancy-associated fatigue at 29.74% and need to keep the baby healthy at 28.45%. Other medical indications included management of concurrent infections such as sexually transmitted illnesses (STIs) at 48.15%, yellow fever 25.93% and urinary tract infection (UTI) at 18.52%. Socio-culturally, 50.21%, and 25.94% believed they were effective and safe respectively (Table 6).

Table 6: Indications for herbal medicines use during pregnancy.

Reasons for not using herbal medicine in pregnancy

The major two reasons advanced by the 15% of those that never used HMiP were ignorance about which ones to use and safety concerns (Table 7). 

Table 7: Reasons for not using herbal medicine.

Source of information regarding HMiP

Family members and relatives emerged as the top sources of information (68.62%).

Table 8: Source of information for mothers that had used herbal medicine during most recent pregnancy.

Qualitative Results

In-depth interviews involving 20 mothers were carried out.

Half of them were young mothers (≤ 24years),55% were Christians and lagely unemployed,765%. Significantly only 20% were grandmultiparous. (Table 9).

Table 9: Socio-demographic characteristics of the 20 mothers that participated in the qualitative study.

During thjese in-depth interviews,several themes emerged.

The majority (12/20) of them believed that herbal medicines were very vital for a successful pregnancy outcome and had no adverse effects.

Awareness

All mothers had the knowledge and different understanding of HMiP.

“I know herbal medicines are natural medicines from plants that are prepared by herbalists and given to pregnant women for helping them to deliver their babies safely…” MRRH 12, 27-year-old mother of 2.

“My grandparents prepare herbal remedies and encourage me to take them every time I am pregnant…. but I also know of herbalists who sell them to pregnant mothers….” MRRH 7, 24 years old multiparous.

Effective

The majority of the mothers,55% (11/20) believed that herbal medicines were as effective as conventional medicines.

“My friend used to produce babies with wounds and blisters but after taking the herbal medicines she started producing healthy babies”, confessed MRRH 4, 25-year-old mother of 1

Other mothers attributed the use of herbal medicine to the failure of hospital medicines to cure their ailments. However, others considered herbal medicines to be as effective as allopathic medicines.

“…. Earlier I had gone to the hospital and got capsules but I did not get any improvement. But when they bought cooked herbal medicines, cough and itching stopped”, said MRRH 6, 24-year-old mother of 2

Another mother reported;

“They are like hospital drugs because they also work”, narrated MRRH 11, 20-year-old mother of 2

Since mothers believed herbal medicines were effective, they would encourage other mothers to use them during pregnancy as stated by 21yr old;

 “I would encourage other pregnant women to use herbal medicines because they work”, MRRH 10, 21-year-old prime gravida

One mother gave hospital medicines priority but failed to get the desired effect and opted for herbal medicines.

“…Even me the first time I was given I just poured it away but the second time I was worse off after the hospital medicines had failed to work for me so I decided to try.”, MRRH 7, 24 -year-old mother of 2.

Safety

45% (9/20) of the  mothers believed herbal medicines were safe during pregnancy depending on personal experiences.They reported no untoward event attributable to HMiP.

“Yes, because I did not get any problem”, said  MRRH 9,30-year-old mother of 6

Some mothers were not sure about the safety of the herbal medicines during pregnancy as per this verbatim;

“I don’t know whether it’s safe or not but all I know is that herbs work and they are medicines”, confessed MRRH 11, 20-year-old mother of 2

And for some mothers believed it is try and error.

“Those who prepare it say it’s safe, so it’s try and error”, said MRRH 3, 30-year-old mother of 5

Previous Herbal Medicines Use During Pregnancy

Mothers who had used herbal medicines before were more likely to use herbal medicines in the current pregnancy, especially after a positive experience.

“They work because I have been using it on every child”, MRRH 9, 28-year-old mother of 6

Accessibilty

Herbal medicines are readily available within the community and can be used anytime in case of need. Some herbs are both nutritional and medicinal and are planted in the garden.All mothers 100% agreed on this.

“These are natural local medicines which we can get any time we want”, MRRH 12, 27-year-old mother of 2

“… My grandmother showed me the plants so I would go and pick every day and use”, said MRRH 16, an 18-year-old mother of 1

Cheap

Many mothers freely acquired herbal medicines from the garden

“These are medicines we get by ourselves at home”, MRRH 14, 23-year-old mother of 1

Undesirable effects of herbal medicine 

On the other hand, a few mothers 3/20(15%) reported side effects associated with HMiP. They reported this as a deterent to use of herbal medicine in pregnancy.

“On my second child, I had labour for a long time and I was advised to take some herbal medicine by an herbalist to quicken the labour. It is the toughest delivery I have gone through because I bled almost to death ……’’, narrated MRRH 19, 28-year-old mother of 6

“…when I was in labour, I had severe contractions and the midwife asked me if I had taken some herbal medicines.  And I told her I was taking herbal medicines for cough and syphilis”, MRRH 6, 24-year-old mother of 2

“For sitting they weaken the pelvic muscles, and for drinking is worse they contain … (pause)...substance that can rupture the uterus”. She added “my sister got a ruptured uterus because of drinking herbal medicines during labour”, MRRH 7, 24-year-old mother of 1

“. A friend bought herbal medicines for STI but after taking them, she got an abortion”, MRRH 2, 37-year-old mother of 4

Indications For Use

Several sub themes emerged out of this theme.

Concurrent Illnesses

During the pregnancy, other mothers experienced illnesses like STIs, Respiratory infections, and also prevent infecting the fetus which prompted them to use herbal medicines.

 “On this baby, I took some herbal medicines when I had cough and syphilis. Earlier I had gone to the hospital and got capsules but I did not get any improvement. But when they bought cooked herbal medicines, cough and itching stopped”. MRRH7 24, -year-old mother prime gravida

 “They sell some liquid which you take for STIs and also prevent infecting the baby”, MRRH 2, 37-year-old mother 4

Fear Of Caesarean Section

Culturally, women are considered failures or not women enough when they undergo a caesarean section.There was strongly belief that  herbal medicines prevented caesarean section.This sentiment was echoed by 8/20(40%) of the mothers.

“We use herbal medicines because we fear operations and we don’t want to fail while delivering”, MRRH 1, 29-year-old mother of 4

Enlarging Pelvic Bones

Most mothers strongly believed that herbal medicines enlarged pelvic bones during pregnancy which is not the case with conventional medicines.

“These traditional medicines help in opening the birth canal”, MRRH 18, 28-year-old mother of 3

“Herbal medicines enlarge pelvic bones so that you deliver easily”, MRRH 9,30-year-old mother of 8

Enhancing Labour

Herbal medicines were believed to increase contractions and were largely used during labour or in preparation for labour.

“When you have labour pains, you chew the roots of lisaga (local name), also called Jjobyo, to increase the frequency of uterine contractions”, explained 11 27-year-old mother of 2

“I took hot water, with a lot of tea leaves to increase contractions”, said MRRH 12, 27-year-old mother of 2

Similarly, another mother reported that,

“Nderema makes the baby slippery during labour”, MRRH 10, 21-year-old prime gravida

Fatigue

Several mothers become weak during pregnancy and some use herbs to get energy in order to continue with their daily activities normally. 

“On my first born, I tried out and I got the energy to do my work and everything because of herbal medicines”, MMRH 5, 20-year-old mother of 2

“I used the one for bathing to get the energy to do my work”, 20-year-old prime gravida

Chase Away Evil Spirits

 “To prevent postpartum psychosis and removes also evil spirits”, MRRH 1, 29-year-old mother of 4.

The current study aimed at determining the prevalence and factors associated with herbal medicine use during pregnancy (HMiP) among postnatal mothers in eastern Uganda.

According to the current study, 85% of pregnant women used herbal medicines during the most recent pregnancy.Such a high rate of use is in agreement with studies elsewhere such as Luwero district in Uganda that reported 100% prevalence[25], 90.3% in Ivory Coast[28], Bangladesh (in the Middle East) and  Russia that reported 82.3%[17], 80% reported in a meta-analysis involving studies on African women during maternal and reproductive health issues[29],  70%  [20] and 69% [26] respectively. 

Furthermore, this high prevalence of HMiP is in contrast to studies in Africa that reported rates as low as 20% in Northern Uganda [14],12% in Nairobi Kenya [13], 25.7% in Malawi [15] and 48.6% in Ethiopia [16]. Additionally, other studies  outside Africa have reported lower rates such as  34.4% -57.8% in Australia  and the United Kingdom [10, 30],40-48% in Norway and Italy [31, 32],48.4% in Iran[22], and 6-9% in the United states of America and Canada [33, 34].It  generally seems that the more advanced the country’s economy is,the less likelihood of HMiP.This may be attributable to  a more available, functional  and advanced practice of allopathic medicine compared to low income countries mostly in Africa[35].

The finding of the study continues to highlight the intra-country and inter-continental differences in knowledge, attitude, and practices of herbal medicine. For example, whereas Nyeko et al in Northern Uganda reported a prevalence rate of 20%, we report a fourfold increase in the same country but in a different region. Similarly, a study by Deborah A Kennedy et al reported widespread differences in the prevalence of HM use in pregnancy(HMiP) among different regions of the same continent and even among different countries of the same region[26]. Moreover , in the case of Malawi reported by Zamawe et el ,the authors investigated use of a particular group of herbs called Mwanamphepo that induce labour in contrast to us that looked at use for any reason. These differences could largely be attributed to different socio-cultural differences and beliefs, disparities in income and standards of living that may affect accessibility and affordability to modern health care services.Furthermore, laws governing the marketing and accessibility of these herbal medicines plays a part in accessibility.

As earlier alluded to,the theory of planned behaviour (TPB) influences attitudes and  perception mothers to herbal medicines.In Uganda, most traditions and culture  encourage the use of herbal medicines[25].Not surprising,most of the participants had positive attitude and perceptions about HMiP.Notwithstanding, Nyeko et al reported a lower prevalence of HMiP in  northern  Uganda while in Luwero[25] 100% was reported.Uganda’s population distribution is in such a way that the people in the North are largely of Nilotic ethnic group in contrast to the East,west and central where the Bantu predominate and are of different cultures and traditions compared to the north.

Significant to note is that thje majority of the mothers 77.94% were not willing to discuss with the health workers about HMiP while 59.79% expressed willingness to disclose to the health workers about it. This was in agreement with a study done in Ethiopia that reported that 89.8.% of pregnant using herbal medicine had not discussed the issue with health workers [16]. This emphasises the need for the attending physcians to always take history of not only allopathic medicines use but also herbs since both categories can have adverse effects on preganacy outcomes especially if used in the first trimester [36-42]. However, it is urged she should be treated with respect and dignity irrespective of her choices [43, 44]. More communication between the mother and her family (if applicable) and the attending physcian is warranted.

In this study, it emerged that HMiP largely took place during the third trimester, 47.3%. This is consistent with findings in Ethiopia [16] but contradicting those reported by study in Luwero, Uganda [25] and a review in the middle east where most was used during the first trimester [17]. The difference in timing of herbal medicines use during pregnancy depends on the desired effects and may be culturally influenced. For example, whereas mothers in this study reported the need to prepare their bodies both psychologically and physically for delivery-a finding consistent with a previous study in Northern Uganda [14]- herbs for enhancing and inducing labour were used during the third trimester to avoid abortions and preterm labour. And only 7.72% of the mothers completed the WHO recommended eight antenatal contacts, this may suggest that during this time,mothers may be utilizing other remedies other than the modern health care system and allopathic medicines.

As the findings indicate, herbal medicine used during pregnancy was not only used to treat pregnancy-related conditions, but also other common illnesses and for social and cultural reasons. In this study, sexually transmitted infections (STI) were the most common concurrent infection. Others included yellow fever, urinary tract infections (UTI) and respiratory infections. The management of these illnesses during pregnancy using herbs has been highlighted in a previous study in Northern Uganda [14].  These herbal medicines may delay prompt diagnosis and effective treatment of these conditions with resultant adverse consequences to both the mother and fetus, including pregnancy wastage, a concern also previously highlighted [45].

The major pregnancy-related reason for herbal medicine use was enhancing labour at 76.72%. This is in contrast to studies in Uganda, Ethiopia, and Kenya that revealed management of anaemia at 21.7% [21], common cold,66% [16], and toothache [13] as the commonest indications respectively. Furthermore, a study in Iran reported that the top three indications for herbal medicine use were to promote feotal health and intelligence (28.3%), to boost women’s health status (27.4%), and to relieve common discomfort during pregnancy (25.5%) [22]. Other indications included fatigue (29.74%), keeping the baby healthy (28.45%), preventing postpartum psychosis (3.88%), and anaemia (3.02%). Furthermore, studies carried out elsewhere have identified similar indications [13, 16, 26, 46] except for the prevention of postpartum psychosis.

In the current study, 64.02% of herbal medicine users were satisfied with the results. Women  perceive these herbal medicines to be safe and superior in some cases to the orthodox medications.During the in-depth interviews,mothers made a mention of how they were able to cure ‘in-utero related blisters  and wounds’ that had failed to be managed in preceeding pregnancies by the modern medicines.The perceived safety is reported in other studies in Luwero in Uganda[25] ,Nigeria[47, 48].Social culturally, most mothers believed herbal medicines are effective and safe during pregnancy which is in line with other previous studies [13-16, 20, 29]

HMiP may further be influenced by the practice of attending phsicians and midwives.In some settings such as in Russia, a study reported support of the practice by the physicians[26]. Studies in  Africa reported  that  the majority of the pharmacists  dispensing these herbal medicines are unaware of their pharmacokinetics and even the active ingradients in these drugs [49, 50].Thus if the physicians are unaware of the adverse effects,one can only imagine the extent to which the consumers will be blind-folded in terms of the adverse effects of these herbs.It has been reported in earlier studies that although most mothers perceived HM to be safe, they were  associated with adverse effects.

In the current study, 18.83% of herbal medicine users experienced side effects attributable to the use of herbal medicines. A study done in Ethiopia reported a lower rate of side effects at 8.8% [16]. During in-depth interviews, mothers revealed how their relatives and or friends had suffered uterine rupture or abortion following HM consumption.Other side effects such as nausea and vomiting have been reported in the literature[20]. When taken in large amounts, some herbs such as Aloe vera were associated with abortions. These findings have been reported by a study in Malawi [15], the Middle East [17], and the United States [51]. This possibility of adverse effects is fostered by the fact that even among approved therapeutics, the risk in pregnancy is unknown for 91.2% [42].

The odds of herbal medicine use during pregnancy were 10.0 times higher among mothers that had history of use. These results are consistent with other studies elsewhere [14, 26]. This may be because of the belief that herbal medicines worked in solving their other problems, perceived minimal or no side effects, and the longstanding integration of HM into the culture and positive attitude premised on ownership of this indigenous medicine. This positive attitude and belief in traditional medicine and herbs has been reported in studies elsewhere [29, 52]. Similar findings have been reported in other studies that low level of education and use of hernbs in the index pregnancy significantly influenced herbal medicine use in pregnancy [13, 16].

Additionally,the primegravidas were more  likely to use HMiP compared to the multiparous ( odds of  1 versus  0.3 ,though  not statistically significant at multivariate).This is agreement to other studies elsewhere that have reported more likely use of  herbs by the primiparous in comparison to their multiparous counterparts[16, 17, 25, 26].This may be explained by probebele anxiety and uncertainity about the pregnancy for the primiparous comoared to the multiparpous ones.

The majority of the mothers during in-depth interviews cited cost and accessibility as the common factors influencing HMiP. The herbal medicines were reportedly cheaper and readily accessible since some mothers would easily get them from their gardens and bush. This is exarbated by long queues and almost unending drug stockouts in modern health facilities. These issues of underfunding coupled with low ratios of human resources for health threaten attainment of sustainable development goals (SDGS) 3,4,5 and 8[53]. With the belief that herbs have the same efficacy as hospital drugs, mothers may opt to go for herbal medicines which are readily available at any time of need. These findings are echoed in previous studies that have reported preference of Traditional medicine (TM) due to factors like availability,accessibility and affordability of these herbs[13, 29]

Furthermore, mothers expressed reservations of the ability of allopathic medicines to tackle some of the health problems such as contracted pelvis. As they narrated, they resort to seeking answers using herbal medicine. For example, whereas the answer to the contracted pelvis is caesarean delivery as advised by the health workers, they thought that herbal medicine would widen the pelvis and enable vaginal delivery. Wanial et al reported that in Eastern Uganda, most cultures considered women that underwent caesarean section as weak and inferior to those that had vaginal births and at times led to family breakdown [54]. This finding underpins the issues of gender and the expectations of society of a pregnant woman. Therefore, not surprisingly, women reported the use of herbal medicine to enlarge their pelvises,’ smoothen’ labour, and avoid caesarean section.

Laws regulating the manufacture,approval,sales and distribution of herbal medicines are not as restrictive as it is with modern medicines[20, 41, 44, 55].No wonder research has also  reported that in patients who had used herbal medicine with reported desirable therapeutic outcomes, the benefits reported were actually due to presence of undisclosed orthodox medicines that herbs had been  adulterated with[56, 57].

Among the 15 non-users, the majority (26.19%) did not use HM because of they lacked knowledge about them. Despite the mothers' urge to use the herbs, most non-users could not identify the herbs. This was followed by a lack of belief in the herbs and the unavailability of the herbs (14.29%). Some mothers who lived in town did not have access to herbal medicines.

One cannot be blind to the fact that most gravid mothers got information about HMiP from   family members and other relatives,68.62%. In a study in central Uganda,100% of respondents used HMiP on recommendation of friends and family members,which collaborates our findings[25]. In a study done in Bangladesh, mothers did not use herbs because they were either refused by family members or health workers [20]. The shift from use of herbal medicine to modern medicines may be driven by the rural urban migrartion that results into disintergration of the traditional family fabric. In contrast though,Malan et al in Ivory Coast reported that most women practise was self-initiated[28].Nevertheless this calls for interventions that target  family and community  in addressing the issue of HMiP.

HMiP is very prevalent in this community and is largely influenced by previous history of use and information from mothers and friends.Significant to note is that amongst the indications for use is to widen the pelvis and caesarean section mode of delivery.

Furthermore,more investment in health resources to reduce waiting times,curtail drug stock-outs and improved health education are needed to prevail over HMiP

Because of potential toxicity and safety concerns regarding HMiP,there is need to establish a pharmacovigilance system that is intergrated within the communities and health facilities so that data pertaining to  composition,preparation ,storage ,indications,dosage and duration , and adverse effects can be collected.

• Which are the most common herbal medicines used amongst pregnant women in eastern Uganda?
• What are the commonest indications for which herbal medicines are used in Pregnacy?
• What are the active ingradients in such herbs used during pregnancy?

Consent for publication: Not required.

Availability of data and materials: All the relevant data is herein. In case one needs raw data, the corresponding author can be contacted on Jntezi@gmail.com

Competing interests: The authors declare no competing interests.

This research was supported by the Forgarty International Center of the National Institute of Health, US Department of state Office of the U. S, Global AIDS Coordinator and Health Diplomacy(S/GAC), and President’s Emergency Plan for AIDS Relief (PEPFAR) under award number 1R25TW011213.However, this content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH).

Acknowledgements:We are grately indebted to our mothers who agreed to take part in this study,the staff of the departments of Obstetrics and Gynaecology of bothe Mbale Regionsal referral and teaching hospital and Busitema University Faculty of  Health sciences.

Lastly, we acknowledge the support of NIH towards the data collection.

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