Journal of Ethnopharmacology 150 (2013) 79–84

Contents lists available at ScienceDirect

Journal of Ethnopharmacology
journal homepage: www.elsevier.com/locate/jep

Use of herbal medicines during pregnancy in a group

of Palestinian women
Rowa′ Al-Ramahi n, Nidal Jaradat, Deema Adawi
Department of Pharmacy, Faculty of Medicine and Health Sciences, An-Najah National University, PO Box: 7, Nablus, Palestine

art ic l e i nf o a b s t r a c t

Article history: Ethnopharmacological relevance: The use of herbal medicines during pregnancy is common worldwide
Received 11 February 2013 due to physiological changes that lead to pregnancy related problems.
Received in revised form Objectives: The aims of this study were to measure the prevalence and predictors of herb use among
28 July 2013
a group of Palestinian pregnant women and the possible influence of herbal consumption on pregnancy
Accepted 29 July 2013
Available online 9 August 2013
outcomes.
Methods: This study was a questionnaire-based cross sectional descriptive study. It was conducted in the
Keywords: maternity ward of a governmental hospital between March and May 2012, a random sample of women
Herbal medicines who gave birth during the study period were met and asked to answer a face to face questionnaire.
Pregnancy
Results: Out of 300 women, 120 women (40.0%) used herbs during pregnancy; most women preferred to
Palestine
use herbs because they thought herbs are safer than medications (82.5%), women based in their choices
mainly on advice from family or doctors (36.7%, 33.0%, respectively), 65.8% of them told their doctors that
they used herbs, 91.7% considered these therapies beneficial, and 99.2% reported no side effects. The most
commonly used herbs were anise (Pimpinella anisum) (61.7%), chamomile (Matricaria recutita) (53.3%),
sage (Salvia officinalis) (55%), mixture of herbs (33.3%), and thyme (Thymus vulgaris) (29.2%). Most
women were using herbs on as needed bases. There were no statistically significant differences between
users and non-users of herbs in all socio-demographic variables and pregnancy outcomes.
Conclusions: This study found that the use of herbs during pregnancy is very common among Palestinian
women. Infrequent use of herbs during pregnancy seems to be safe and beneficial. To provide the best
care to pregnant women who use herbal products, clinicians and pharmacist are recommended to stay
up to date with herb use and their safety in pregnancy. Not all women tell their doctors about herbal
products use, so the physicians are recommended to ask pregnant women about this to avoid any
possible negative outcomes on the mother or the fetus.
& 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction surveyed group′s socio-cultural aspect and ethnicity (Dugoua,

2010). The physiological changes will lead to pregnancy-related
The physiological changes that occur in pregnant women lead problems, therefore pregnant women try to treat these problems
them to self treatment. Women try to turn to natural herbal by using over the counter medications (OTC), prescribed medica-
medicines rather than prescription medications, mainly because tions, herbs or life style modifications. The most common reasons
they are concerned about the safety of the fetus (Holst et al., 2009). for herb use are related to pregnancy problems as nausea, vomit-
Herbal medicines are defined as plant—derived or preparations ing, skin problem, constipation, heart burn, and indigestion
perceived to have therapeutic benefits, they include herbs, herbal (Cuzzolin et al., 2010; Holst et al., 2011). Pregnant women like to
materials, and finished herbal products that contain parts of plants use herbal products despite a clear evidence of negative effects in
or other plant materials as active ingredient (World Health some cases and limited data on safety and efficacy (Cuzzolin et al.,
Organization, 2013). Use of herbs during pregnancy is a very 2010). The most commonly used herbs among pregnant women
interesting area. The prevalence of using herbal products during according to other studies included ginger, cranberry, chamomile,
pregnancy varies widely and ranges from 7% to 55%, these peppermint, echinacea, and castor oil (Holst et al., 2009, 2011;
percentages depend on the geographic area surveyed and the Cuzzolin et al., 2010). Pregnant women use Rubus idaeus L.
(raspberry) leaves to relief nausea, increase milk production, and
for labor induction. Mentha piperita L. (peppermint) is used for
n
Corresponding author. Tel.: +972 9 2345113. nausea, vomiting, flatulence, indigestion and heart burn. The uses
E-mail address: rawa_ramahi@najah.edu (R. Al-Ramahi). of Matricaria chamomilla L. (chamomile) include gastrointestinal

0378-8741/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jep.2013.07.041
80 R. Al-Ramahi et al. / Journal of Ethnopharmacology 150 (2013) 79–84

irritation, insomnia, joint pain and relaxation. Vaccinium oxycoccos Chi-squared and Fisher′s exact tests, as applicable. A p-value of
L. (cranberry) is used for urinary tract infections. Prunus amygdalus less than 0.05 was considered to be statistically significant for all
Stokes (almond) oil is used to prevent stretch mark. Zingiber analyses.
officinale Roscoe (ginger) is commonly used for nausea and
vomiting. Caulophyllum thalictroides (L.) Michx (blue cohosh) is
used for labor induction and Ricinus communis L. (castor) oil is
3. Results
used to facilitate labor. Echinacea purpurea (L.) Moench (echinacea)
is thought to be useful for upper respiratory tract infection, cold
Among 330 women approached, 300 accepted to participate in
and flu and to boost immunity. Hypericum perforatum L. (St Johns
the study giving a response rate of 90.1%. Women were mainly
Wort) is used for depression and relaxation while Urtica dioica L.
between 20 and 30 years of age (69.7%), most of them had a high
(nettle) and Taraxacum officinale Webb (dandelion) are used as
school or university degree (37.3% and 39.0%, respectively). Around
nutritional supplements (Pinn and Pallet, 2002; Forster et al.,
two-third of them were multi-para (68.0%) and were from villages
2006; Dugoua, 2010; Holst et al., 2011; Nordeng et al., 2011; ).
(67.3%). Most of them had medical insurance (96.7%), family
Exposure of pregnant women to chemicals such as medications,
monthly income of less than 600 Jordanian dinars (92.7%) and
herbs, and supplements during pregnancy period could affect their
were not working (94.3%). During pregnancy 288 women used
fetuses (Bercaw et al., 2010). Several studies about the prevalence
supplements (96%), 147 women (49.0%) took at least one pre-
of herbal use among pregnant women in other parts of the World
scribed medication and 136 (45.3%) women took at least one over
can be found, but little is known about outcomes of this use on
the counter (OTC) medication.
pregnancy.
Out of 300 women, 120 women (40.0%) used herbs during
There are limited data on the extent of herbal product use
pregnancy, most of the pregnant women used more than one herb
during pregnancy in our country. It is important to know the
prevalence of using herbal products and the herbs used so that
Table 1
proper counselling can be provided. It is important to obtain herb Association between scio-demographic characteristics and the use of herbs during
use history at any time but particularly in pregnancy. Herbs may pregnancy.
have unrecognized effects on pregnancy or labor, have interactions
with prescribed medications and have potentially serious compli- Variable User Non user p-Value
(N¼ 120) (N¼180)
cations on the fetus. The aims of this study were to measure the
(n, %) (n, %)
prevalence of herb use during pregnancy, to identify the most
frequently consumed herbs, to investigate the impact of socio- Age
demographic factors on the use of herbal products and the Less than 20 8 (6.7) 14 (7.8) 0.647
20–30 81 (67.5) 128 (74.1)
possible influence of herbal consumption on pregnancy outcomes
31–40 30 (25.0) 35 (19.4)
among a sample of Palestinian pregnant women. More than 40 1 (0.8) 3 (1.7)

Educational level
Primary and illiterate 8 (6.7) 12 (6.7) 0.335
2. Methods Middle school 15 (12.5) 36 (20.0)
High school 50 (41.7) 62 (34.4)
The study was a questionnaire-based cross sectional study; it Diploma/University 47 (39.2) 70 (38.9)
education
was conducted in the maternity ward of Rafedia Governmental
Hospital between March 2012 and May 2012, after having the Living place
approval from the Institutional Review Board (IRB) at An-Najah City 26 (21.7) 43 (23.9) 0.902
Village 82 (68.3) 119 (66.7)
National University and the required permission from the Pales- Camp 12 (10.0) 18 (9.4)
tinian Ministry of Health. The population of study was all women
Medical insurance
who delivered at the hospital during the study period. The
Yes 115 (95.8) 175 (97.2) 0.511
expected number of women who give birth at the obstetrics and No 5 (4.2) 5 (2.8)
gynecology ward was around 400 women per month based on
Family monthly income
data from hospital, so within the 3 months it was expected to be r 600 JD 115 (95.8) 163 (90.6) 0.086
around 1200 women. Based on this, Raosoft software was used to 4600 JD 5 (4.2) 17 (9.4)
calculate a suitable sample size and it was 292, so we decided to
Work
include 300 pregnant women. According to the registration Yes 7 (5.8) 10 (5.6) 0.919
records during the time of this study; the average number of No 113 (94.2) 170 (94.4)
delivered women was 387.6 per month with a total of 1168 cases, Chronic disease
so this sample size was more than 10% of the population. Yes 2 (1.7) 3 (1.7) 1.0 (fisher)
A random sample of women who gave birth at the hospital were No 118 (98.3) 177 (98.3)
met by a researcher (2 h per day for 3 months) and asked to answer a Parity
face to face questionnaire. Women were interviewed in Arabic after First child 36 (30.0) 60 (33.3) 0.544
getting their verbal consent only once. Women were interviewed More than one 84 (70.0) 120 (66.7)
within 3 days of delivery; each interview lasted approximately 7– OTC medication use
10 min. The questionnaire was anonymous, pretested by a pilot study Yes 60 (50.0) 76 (42.2) 0.185
of 10% of sample for reliability and to check the validity and clarity of No 60 (50.0) 104 (57.8)

the questionnaire. The World Health Organization definition of Prescribed drug use
herbal medicines was used to define herbs. Yes 57 (47.5) 90 (50.0) 0.671
No 63 (52.5) 90 (50.0)
Statistical analyses were performed by using Statistical Package
for Social Sciences (SPSS version 17.0). Mean 7standard deviation Supplement use
were computed for continuous data. Frequencies and percentages Yes 117 (97.5) 171 (95.0) 0.374
(Fisher)
were calculated for categorical variables. Means were compared No 3 (2.5) 9 (5.0)
using Student′s t-test. Categorical variables were compared using
 R. Al-Ramahi et al. / Journal of Ethnopharmacology 150 (2013) 79–84 81

Table 2
The most frequently used herbs and the reported reasons for use (N¼ 120).

Family Scientific name Common name Number (n) Percentage (%) Route of Aim of use
administration

Apiaceae Anise 74 61.7 Oral Flue and cough

Pimpinella anisum L. Abdominal pain
Vomiting
Diuretic
Chest pain
Laxative
Infections
Flatulence
Relaxation
Stomachache
Asteraceae Chamomile 64 53.3 Oral Cough and flue
Matricaria chamomilla L. Abdominal pain
Infections
Diuretic
Flatulence
Relaxation
Pharyngitis
Laxative
Lamiaceae Sage 55 45.8 Oral Vomiting
Salvia officinalis L. Vaginal path Abdominal pain
Mouth wash Infections
heartburn
Teeth pain
Flue
– Mixture of herbs 40 33.3 Oral Cough and flue
Abdominal pain
Relaxant
Laxative
Pharyngitis
Lamiaceae Thyme 35 29.2 Oral Cough and flue
Thymus vulgaris L. Chest pain
Relaxation
Pharyngitis
Arecaceae Dates 34 28.3 Oral Energy
Phoenix dactylifera L. Facilitate delivery
Laxative
Lamiaceae Peppermint 17 14.2 Oral Abdominal pain
Mentha piperita L. Flue
heartburn
Relaxation
Facilitate delivery
Cough
Flatulence
Lauraceae Cinnamomum verum J. Presl Cinnamon 13 10.8 Oral Anemia
Facilitate delivery
Laxative
Abdominal pain
Leguminosae Trigonella foenum-graecum L. Fenugreek 11 9.2 Oral Cough
Infection
Apiaceae Cumin 8 6.7 Oral Facilitate delivery
Cuminum cyminum L. Flatulence
Abdominal pain
Zingiberaceae Ginger 4 3.3 Oral Cold and flue
Zingiber officinale Roscoe Cough
Vomiting
Amaryllidaceae Garlic 3 2.5 Oral Hemorrhoid
Allium sativum L. Vaginal path Urinary tract infections
Ameba
Apiaceae Caraway 3 2.5 Oral Facilitate delivery
Carum carvi L.
Myrtaceae Guava leaves 3 2.5 Oral Cough
Psidium guajava L. Pharyngitis
Apiaceae Fennel 2 1.7 Oral Flue
Foeniculum vulgare Mill. Infections
Relaxation
Rosaceae Almond 2 1.7 Oral Heartburn
Prunus amygdalus Stokes
Apiaceae Parsley 2 1.7 Oral, Vaginal path Urinary tract infections
Petroselinum crispum (Mill.) Nyman ex A.W. Hill
Euphorbiaceae Ricinus communis L. Castor oil 1 0.8 Oral Facilitate delivery
Theaceae Green tea 1 0.8 Oral Laxative
Camellia sinensis (L.) Kuntze
Myrtaceae Clove 1 0.8 Mouth wash Teeth pain
82 R. Al-Ramahi et al. / Journal of Ethnopharmacology 150 (2013) 79–84

Table 2 (continued )

Family Scientific name Common name Number (n) Percentage (%) Route of Aim of use
administration

Syzygium aromaticum (L.) Merr. & L.M. Perry

Rutaceae Lemon 1 0.8 Oral Flue
Citrus limon (L.) Burm. f.
Capparaceae Caper 1 0.8 Oral Abdominal pain
Capparis spinosa L. Flatulence
Ranunculaceae Nigella sativa L. Nigella seeds 1 0.8 Oral Abdominal pain

Table 3 birth (28, 8.2%), (eighteen had respiratory problems, one was
Association between pregnancy and neonatal characteristics and the use of herbs premature, four were premature and had respiratory problem,
during pregnancy. one aspirated meconium fluid, one had closure of ductus arteioses,
one had umbilical injury, one had rash and for one neonate her
Variable User (N¼ 120) Non user (N¼180) p Value
(n, %) (n, %)
mother did not know what was the problem). There were no
statistically significant differences between users and non-users of
Pregnancy at term herbs in any pregnancy or neonatal outcome as shown in Table 3.
Term 102 (85.0) 158 (87.8) 0.488
Preterm 18 (15.0) 22 (12.2)

Parity 4. Discussion
One 36 (30.0) 60 (33.3) 0.544
More than one 84 (70.0) 120 (66.7)
The evaluation of herb consumption among pregnant women
Miscarriage is very important; herbs may have harmful effects on the mother
Yes 8 (6.7) 17 (9.4) 0.394
or the fetus, in addition to possible interactions with medications.
No 112 (93.3) 163 (90.6)
In this study, a large percentage of pregnant women used herbs
Delivery
(40%), this finding is close to a previous study in our country in
Normal 77 (64.2) 109 (60.6) 0.528
Caesarian 43 (35.8) 71 (39.4) 2006 where the percentage was 45.8% (Sawalha, 2007). However it
is higher than many other studies from other parts of the World.
Gestational age
38–42 102 (85.0) 158 (87.8) 0.488
For examples, in Louik et al. (2010) in the United States, they found
Less than 38 18 (15.0) 22 (12.2) that among 4866 mothers between 1997 and 2005, 282 (5.8%)
More than 38 0 (0.0) 0 (0.0) reported use of herbal or natural treatment. In another study, the
Medical problem at birth percentage among Hispanic women in the United States was 19%
Yes 10 (8.3) 18 (10.0) 0.627 (Bercaw et al., 2010). In Norway, in 2001, 36% of women reported
No 110 (91.7) 162 (90.0) herbal use during their pregnancy (Nordeng and Havnen, 2005),
Weight that increased to 39.7% of women in 2011 (Nordeng et al., 2011). In
Less 1.5 0 (0.0) 1 (0.6) 0.375 Australia, it was found that 36% of the consecutive pregnant
Less than 2.5 12 (10.0) 16 (8.9) women who were approached in antenatal clinic at the birth
2.5–4.0 106 (88.3) 155 (86.1)
center at around 36–38 weeks gestation took at least one herbal
More than 4.0 2 (1.7) 8 (4.4)
supplement (Forster et al., 2006), while it was 12% in 2002 (Pinn
and Pallet, 2002). In Canada, the percentage of herb use during
(90.0%), 35.8% used herbs in the third trimester of pregnancy. Most pregnancy was 9.0% (Moussaly et al., 2009). In Italy, 27.8% of
women preferred to use herbs because they thought herbs are safer pregnant women reported taking one or more herbal products
than medications (82.5%), women based in their choices mainly on during pregnancy (Cuzzolin et al., 2010).
advice from family or doctors (36.7%, 33.0%, respectively), 65.8% of On other hand, the rate of herb use in this study is lower than
them told their doctors that they used herbs, 91.7% considered these the rate in other studies. Examples include: Holst et al. (2009)
therapies beneficial, and 99.2% reported no side effects. There were in Norway where the prevalence of using herbs during pregnancy
no statistically significant associations between scio-demographic was 57% with a mean 1.2 remedies per women. In another study
characteristics and the use of herbs as shown in Table 1. by the same author, 57.8% of pregnant women used one or more
The most frequently used herbs were Pimpinella anisum L. herbal remedies during their pregnancy (Holst et al., 2011).
(anise) (61.7%), Matricaria chamomilla L. (chamomile) (53.3%), In United States 45.2% of women from rural outreach clinic and
Salvia officinalis L. (sage) (45.8%), herbal mixture (33.3%), Thymus physician center of West Virginia University used herbs during
vulgaris L. (thyme) (29.2%) and Phoenix dactylifera L. (dates) pregnancy (Glover et al., 2003). Comparison between studies
(28.3%), some women were regular users, in most cases herbs might not be very accurate because different studies might use
were taken as needed. The most common reasons for using herbs different definition of the term “herb”. However, we can say that
were: vomiting, constipation, flue, cough, abdominal pain, urinary herb use during pregnancy seems to be common among Palesti-
tract infection, flatulence, relaxation, heartburn, ulcer, upper and nian women in this study.
lower respiratory tract infection, and to facilitate delivery. Almost In this study, 90% of the herbal product users utilized more
all herbs were taken by the oral route, three cases as vaginal path, than one herb during pregnancy, also the proportion of women
and two cases as mouth wash (Table 2). who used herbs increased throughout pregnancy with the a peak
Two hundred and sixty women delivered at term (86.7%), mean in the third trimester (35.8%) and this may be explained
of gestational age was 39.2 71.762 weeks, 62.0% of deliveries were by concerns about the safety of conventional drug use in the
normal, and the incidence of threatened miscarriage was 8.3%. organogenetic period and it is relation with pregnancy related
Average weight of neonates was 3.2 70.565 kg, two hundred and problem. Majority of herbal product users preferred herbs because
sixty of neonates were within gestational age 38–42 weeks and they considered them safer than medications (82%), this might
forty were less than 38 weeks. Some neonates had problems at be true because 91.7% of them did not report any side effect from
 R. Al-Ramahi et al. / Journal of Ethnopharmacology 150 (2013) 79–84 83

any herb. On the contrary, 99.2% told that they had benefit from bases which reflects infrequent use. This decreases the possibility
using herbs. Most of the women reported informing their doctor of side effects and complications and explains that almost all
that they were utilizing herbal products (65.8%). In other countries, women told that the herbs were useful to them and did not cause
informing doctors ranged from 24% to 52% (Kennedy, 2005; Holst any side effect. Regarding socio-demographic characteristics of the
et al., 2009). This shows high awareness among our women. sample, herb users were similar to non-users in all variables
However, there is a room for improvement in this field because included in the study and there were no statistically significant
all women should tell their doctors if they use herbs. This can be differences between any variable and using herbs. In other studies
improved by encouraging the doctors to ask women about this from other countries in the World statistically significant differ-
because some women may forget to do so. The most important ences were reported in relation to age and place of residence, the
source of information about herbal remedies was found to be family use of herbs was higher among pregnant women living in rural
which is similar to other studies (Hollyer et al., 2002; Nordeng and areas and aged 31–40 years (Forster et al., 2006; Holst et al., 2009;
Havnen, 2004; Forster et al., 2006). This confirms the need of Cuzzolin et al., 2010). Another study found that the youngest and
proper counseling because some traditional uses might not be the oldest women used less frequently herbal drugs compared with
supported by scientific evidence to be used in pregnant women. women in the in between age groups (Nordeng and Havnen, 2005).
The most commonly used herbs in this study included Pimpi- In this study, no statistically significant differences were
nella anisum L. (anise), Matricaria chamomilla L. (chamomile), evident between herb users and non-users in pregnancy and
Salvia officinalis L. (sage), herbals mixture, Thymus vulgaris L. neonatal outcomes, this is similar to another study findings
(thyme) and Phoenix dactylifera L. (dates). In a previous study in (Holst et al., 2008) while in Cuzzolin et al. (2010) study they
our country, sage was the most common one then anise, chamo- reported higher incidence of newborns small gestational age in
mile, thyme, and fenugreek (Sawalha, 2007). In other studies herbal product users.
ginger (Holst et al., 2009, 2011) peppermint (Glover et al., 2003),
raspberry leaves (Forster et al., 2006), floradex (Holst et al., 2008),
and chamomile (Moussaly et al., 2009) were most common ones. 5. Conclusion
This is expected because common herbs differ among different
cultures and countries. Herb use among pregnant women was very common in this
Anise was used by a high percentage of women (61.7%), study. Utilization of herbs among pregnant women was not related
although no studies about its safety and efficacy in pregnancy to any socio-demographic variable. Infrequent use of herbs which
can be found and some books even consider it as not recom- was reported by most women in this study seems to be safe and
mended for therapeutic use during pregnancy. Anise increases the beneficial because no association between utilization of herbs and
action of warfarin, so women on warfarin should be careful pregnancy outcomes was seen, although further studies are
(Skidmore-Roth, 2004). Chamomile was among the herbs widely needed to confirm this. To provide the best care to pregnant
used during pregnancy, although no studies could be found about women who use herbal products, clinicians and pharmacist are
its safety and efficacy also (Holst et al., 2011). Excessive use of recommended to stay up to date with herb use and their safety in
chamomile has to be considered potentially harmful in pregnancy pregnancy. Not all women tell their doctors about herbal products
due to its contraction inducing properties (Newall et al., 1996; use, so the physicians are recommended to ask pregnant women
Johns and Sibeko, 2003). Sage was commonly taken during about this to avoid any possible negative outcomes on the mother
pregnancy by women in this study although sage was reported or the fetus.
to have abortifacient properties so its use in pregnancy is therefore
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