CHAPTER ONE

INTRODUCTION

Background to the study:

Complementary and Alternative Medicine (CAM) use in Nigeria is becoming more popular, (Onyiapat, Okoronkwo & Ogbonnaya, 2011; Ezeome & Anarado, 2007; Amira, & Okubadejo, 2007), as in many other countries of the world. Globally, the prevalence of CAM use range from 30% to 75% (World Health Organization [WHO], 2002). CAM includes various approaches/techniques outside the western conventional medicine that are used to prevent and/or treat illnesses/diseases as well as promote health. CAM has been defined by the National Center for Complementary and Alternative Medicine [NCCAM], (2009), as a group of various medical and health care systems, practices and products that are not currently part of conventional medicine. When unconventional approach and/or product are used together with conventional medicine, it is said to be complementary; but when it is used in place of conventional medicine, it becomes an alternative medicine. Therefore CAM is an umbrella term used for both complementary and alternative health care practices.

The role played by CAM during pregnancy, can no longer be dismissed as a faddish whim accessed by poorer people. The trend is increasing globally and lack of robust evidence of safety, particularly when used in a vulnerable population such as pregnant women is not a deterrent to CAM use (Fraser & Cooper, 2009). Pregnancy is a vulnerable period especially the first trimester. This is the period of organogenesis when rapid cell division and migration takes place. Any alteration during the process of mitosis and meiosis could result to serious pregnancy complications that may affect both mother and baby adversely. This adverse effect could be temporal or permanent and could be in the form of foetal malformation. The pregnancy complications may consequently result to maternal and perinatal morbidity and

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mortality. Pregnancy being a vulnerable period may be compounded in a rural community like Udi LGA where there is lack of functional conventional medical services.

Recently, just before this study was carried out, the researcher conducted a focus group discussion (FGD) on CAM use among pregnant women in Ezeagu LGA. Ezeagu LGA is a neighbouring LGA to Udi LGA. It was formerly in Udi LGA. The focus group discussion involved six pregnant women who were engaged in discussions of what women use during pregnancy, how and why pregnant women use such practices among others. The focus group discussion revealed that pregnant women use a plethora of products, services and practices under the umbrella of CAM. However, this present study will concentrate on three main categories of CAM including biological products, alternative medical systems and mind body interventions (spiritual therapy) selected from the NCCAM classification of CAM.

There is some evidence regarding the safety of CAM as well as evidence of its harm. Although CAM is believed to be natural, but natural does not imply safety and efficacy. While some CAM may have undetected benefits, others may contain substances that can cause miscarriages, premature birth, uterine contractions, feotal malformations, decreased clotting factors in the blood etc. Some CAM practitioners fail to appreciate the risks associated with the use of some of these therapies during pregnancy, (Tiran, 2007), and focus only on the benefits. The growing popularity of CAM use may increase the deliberate or inadvertent use of CAM during pregnancy, thus raising the possibility of adverse maternal and foetal effects. Even when therapy is considered safe for normal use, there is no evidence that it is effective in handling the condition that necessitated its use and that it is safe for the growing foetus. The implication is that the condition may get worse if effective treatment is not instituted. Therefore it is inappropriate to use some brands of CAM in place of therapies scientifically proven to be effective.

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Compared to conventional medicine, scientific research on the efficacy and safety of CAM is limited, (Anderson, & Johnson, 2005; Warriner, 2007). Even when conventional maternity care providers discourage use of CAM especially during pregnancy, some women are likely to continue to use CAM despite professional advice and perceived lack of evidence, (Tiran, 2007). Many pregnant women self medicate and some do not disclose use to their orthodox maternity care provider, (Furlow, Patel, Sen & Lui, 2008; Holst, Wright, Haavik & Nordeng, 2009; LowDog, 2009). On the other hand, maternity care providers fail to assess pregnant women for use of CAM. The trend of non assessment and non disclosure of expectant mothers’ use of CAM can lead to unintentional and unanticipated CAM-drug interactions when combined with conventional medicine (NCCAM, 2009). Maternity care providers’ lack of assessment of their clients for use of CAM may be as a result of lack or poor knowledge about CAM practices. Therefore, midwives’ understanding of CAM, its benefits and potential dangers is very important as they have to screen their clients for use of CAM, record and evaluate the outcome, to ensure best care and safety.

There have been explosion of various types of CAM in use. To create a kind of order, these types of CAM have been classified by some established committees. Two of such committees are the NCCAM and House of Lord Select Committee on Science and Technology. The NCCAM classified CAM into, alternative medical systems, for example, homeopathy and naturopathy; mind-body interventions, such as meditation, and prayer; biological products, examples: herbs and food; manipulative therapies, such as, chiropractics and massage; and energy therapies, examples: magnetic fields, therapeutic touch, (Fan, 2005). The House of Lords Select Committee on Science and Technology classification grouped CAM into three and is mainly based on therapies that have been professionally organized, eg, acupuncture, herbal medicine; therapies considered complementary to other

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forms of health care, eg, nutrition, aromatherapy; and traditional systems, eg, Chinese medicine and other alternative medicines (Fraser & Cooper, 2009).

CAM is built on the philosophical orientation of holism and the recognition that optimum interaction between the body, mind and spirit establishes harmony. Unlike the reductionist approach of conventional medicine which treat human beings in part, CAM holds that the whole body is greater and more than the sum of its parts and recognizes the impact of the total life experiences on the health of the individual.

In developed countries, more females than males use CAM in the general adult population (Barnes & Bloom, 2008; Adams, Lui & Sibbritt, 2009; Maclennan, Myers & Taylor, 2006) and what is being used under the umbrella of CAM varies in form, number and ailment in different parts of the world. Prior to pregnancy, women may have used CAM and may continue to use or initiate using CAM during pregnancy and for parturition, regardless of the lack of scientific evidence concerning its safety (Fraser & Cooper, 2009) and efficacy. The use of CAM by pregnant mothers is very popular in developed countries and relatively common in developing countries (Forster, Denning, Wills, Bolger & McCarthy, 2006; Tabatabaee, 2011). Globally, the use of CAM among pregnant women ranges from 7% to 55%, (Tiran, 2003) and up to 96% (Forster, Denning, Wills, Bolger & McCarthy, 2006).

A significant use of CAM has been recorded among: English pregnant women, (57.8%) including herbs and spiritual therapy (Holst, et al., 2009); Australian Women, (36% to 73%), and the most prevalent being herbs such as castor oil and ginger (Skouteris, Werthein, Rallis, Paxton, Kelly, & Milgrom, 2008; Forster, et al, 2006); Canadian women, (9%) with evening primrose and ginger being the most popular, (Moussally, Oraichi, & Berard, 2009); Iranian women, (30.8%), including ammi, saatar and sweet basil (Tabatabaee, 2011), and Zambian women, (21% to 30%), (Banda, et al., 2007).

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There exist distinct ethnic differences in the use of CAM among pregnant women in developed countries. Gibson et al, (2001), in their survey of CAM use among women in USA, recorded greater use among the white women than non white women. Forster et al, (2006), also stated that Australian women whose native (first), language was English were more likely than non-English natives to use CAM during pregnancy.

Expectant mothers turn to CAM for various reasons which may be pregnancy-related. This may include attempts to relieve morning sickness, (Forster et al, 2006; Tabatabaee, 2011), and concerns about the safety of the unborn child, (Dugoua, 2010). Pregnant women are also likely to use CAM because, they believe it provides additional strategies for managing disorders of pregnancy which may be seen as minor physiological discomforts of pregnancy by the conventional maternity care providers, and therefore may not be managed with conventional medicine, (Fraser et al, 2009).

Maternity care providers especially midwives have an increasing obligation to be conversant of various models of health care used during pregnancy including CAM. This is because midwives are usually consulted for professional opinion and advice during pregnancy. Conventional Midwives who are unaware of existing CAM may lose an important opportunity to make use of the positive features (cheap, safe, effective and accessible), of CAM as well as advice their clients accordingly on associated usage risks. Nigerian nurses/midwives may fail to live up to the above obligation. This is because most nursing and midwifery education in Nigeria is under the umbrella of Western Conventional Medical practices. There may be lack of general information or even misinformation/misconceptions about CAM used by women during pregnancy.

The use of CAM among Nigerian women during pregnancy is unknown. Studies carried out in Nigeria on CAM use were among: the general adult population, (Onyiapat et al, 2011);

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cancer clients, (Ezeome et al, 2007); children with chronic health conditions, (Oshikoya, Sebanjo, Njokanma & Sopie, 2008); hypertensive clients, (Amira, & Okubadejo, 2007); and diabetic clients, (Ogbera, Dada, Adeyeye & Jewo, 2010). The present study was conceived based on the scarcity of empirical literature on CAM use particularly among women in Udi LGA of Enugu State and South East Nigerian women in general during pregnancy. Unfortunately, Studies carried out in Nigeria were limited to herbal medicine (an example of a class of CAM), use during pregnancy and were mainly hospital based. This has created a gap in knowledge which the researcher intends to fill. This present study is community-based and will reveal the types of CAM used by women during pregnancy under the three selected categories. This study will provide some fundamental information on the most common CAM practices during pregnancy in Udi LGA.

Statement of problem:

Globally, maternal mortality is the leading cause of death among women of childbearing age (United Nations Report, 2009). WHO (2008), estimates that out of more than 133 million babies born yearly worldwide, more than 3 million are stillborn. Ninety percent of these births are from developing and underdeveloped countries (WHO, 2008), including Nigeria. The causes of these deaths were mainly due to pregnancy and labour complications, (WHO, 2008), which advance in medical sciences and technology is expected to manage effectively.

Delay in decision making concerning the choice of health care, delay in accessing conventional health care institutions and adequate reproductive health care services and cultural practices could indirectly contribute to increase in maternal mortality. The persistent increase in maternal mortality is an indicator that most women (especially those in the rural area), do not access and utilize adequate reproductive health care services (WHO, 2012) especially during pregnancy.

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Bearing in mind the issue of thalidomide effect in the 1960s (MIMS, 2009), as well as the influence of physiological changes of pregnancy on pharmacological action and pharmacokinetics of conventional medicine (Freyer, 2008; Gibbon, 2008; Erdejic, Francetic, Makar-Ausperger, Likic & Radacic-Aumiler, 2010), conventional maternity care providers and pregnant women may hesitate to prescribe and take conventional medicine respectively, as there may be perceived risks to mother, feotus, or both.

In Nigeria, people while being ignorant of the composi