Indigenous herbal medicine use and its associated factors among pregnant women attending antenatal care at public health facilities in Dire Dawa, Ethiopia: a cross-sectional study
Traditional medicine (TM) is characterised by the WHO as ‘health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques, and exercises, applied singly or in combination to treat, diagnose, and prevent illnesses and maintain well-being’. Indigenous herbal medicine (IHM), a branch of TM, refers to the use of locally available herbs for the treatment of illness and enhancement of general health and well-being. These herbal medicines consist of herbs, herbal materials herbal preparations and completed herbal products that have active components that are plant parts like seeds, leaves, stems, flowers and roots. From a historical perspective, the WHO estimated that 80% of the global population used traditional and complementary medicine as primary healthcare. Regarding the current global prevalence, available systematic review data reveal 32.4% medicinal herb use during pregnancy worldwide. However, the prevalence of IHM use by pregnant women varies across countries owing to differences in access, regulations, cultural aspects, historical influence, socioeconomic levels and conventional healthcare system progress. Generally, the prevalence of use is higher in low-income countries where access to conventional healthcare is inadequate, TM is protuberant due to its cultural and historical reputation, and TM is one of the key sources, or sometimes the only available basis of healthcare. In Africa, including Ethiopia, the prevalence of IHMs is high and widely used by pregnant women and the population too. For instance, a systematic review of studies in Africa shows the prevalence rate varying from 12% to 60%. Likewise, a meta-analysis study revealed that the prevalence of herbal medicine use in Ethiopia is 46% (95% CI 37% to 54%). This is because there is a lack of modern healthcare services and medicine in proportion to people, being available only to a limited number of pregnant women because they are either expensive or few are available for too many people. Herbs could be used for a variety of reasons, like infection prevention by increasing immunity through the use of medicinal plants. Studies also have identified some reasons that force pregnant women to use IHM, like physiological symptoms during pregnancy, including nausea, vomiting, heartburn, constipation and so on. Similarly, studies show that pregnant women use IHMs for conditions like exhaustion, respiratory and skin problems, and nutritional problems. Moreover, some studies have identified three key factors that contribute to pregnant women using herbal remedies: availability, perceived better therapeutic value in comparison to conventional medicines and affordability. IHMs benefited from the development of many effective remedies that evolved through many generations. Besides, the majority of contemporary pharmaceuticals and dietary supplements are developed after processing medicinal plants. However, IHMs have associated complications that affect pregnant women and their fetus. For instance, IHM use could result in heartburn, increased blood flow, miscarriage, premature labour and allergic reactions. They also have herb–drug interactions, are associated with induced liver injury , and complicate the care of pregnant women who have pre-existing conditions such as epilepsy or asthma. Moreover, intrauterine death and intrauterine growth restriction, uterine rupture, stillbirth, birth defects of the eye, ear and heart, and other risks have also been linked to the use of IHMs by pregnant women. Due to various reasons, pregnant women in low-resource countries, including Ethiopia, commonly use herbal medicines. Although there are many different types of herbal medicines that come from different cultures, studies are lacking, and the few available are highly variable and inconsistent. Therefore, the purpose of this study was to investigate the prevalence of IHM use and its associated factors among pregnant women attending antenatal care (ANC) at public health facilities in Dire Dawa Administration, eastern Ethiopia, which helps in generating evidence and interventions to lower the risks from over-the-counter (OTC) herbal medicine use by pregnant women.   Study area and period The study was conducted in the Dire Dawa administration, which is located 515 km east of Addis Ababa, the capital city of Ethiopia. According to 2020 population projections, 506 000 people live in the Dire Dawa Administration (68% of whom are estimated to be urban inhabitants), which has 38 rural and 9 urban kebeles (the smallest administrative units). This administration has two public hospitals (1 referral and 1 general), 15 health centres. One public referral hospital (Dilchora RH) and six public health centres (three urban and three rural) were selected purposefully based on their client flow (information taken from the ANC registration book in each health facility), and the sample size was proportionately allocated. The study was conducted from October to November 2022 . Patient and public involvement None. Study design and population A facility-based cross-sectional study design was employed among 628 randomly selected pregnant women attending ANC at public health facilities in the Dire Dawa Administration. All pregnant women in Dire Dawa administration during the study period were the source population, whereas all randomly selected pregnant women on ANC follow-up at selected public health facilities in Dire Dawa administration during the study period were the study population. Inclusion and exclusion criteria Included were all confirmed pregnant women of any gestational age who had been on ANC follow-up at selected public health facilities in the Dire Dawa administration. However, pregnant women who were severely ill and unable to communicate were excluded. Sample size determination and sampling technique The sample size was determined using the single population proportion formula and considering a proportion of IHM use of 48.6%, a standard normal distribution (z=1.96), a 95% CI and a 4% margin of error. After adding a 10% non-response rate, the final sample size was 660. To obtain all 628 study participants, a simple random sampling technique was used. The sample was proportionally allocated to each public health facility to select a representative sample . Data collection method The data were collected via face-to-face interview using a structured questionnaire that was adapted from literature designed for the same study purpose, and then variables were reviewed to suit the local context. The questionnaire was initially prepared in English, then translated by language experts into the local languages of Afaan Oromoo and Amharic, and finally back into English to maintain consistency. The questionnaire contains four main parts: sociodemographic characteristics; obstetrics; IHM awareness and uses during pregnancy; and environmental, past experience and medical factors. A total of eight health extension workers were recruited for data collection, and four MSc midwives supervised the whole process. Operational definition IHM use is the use of locally available plants (any parts like seeds, roots, leaves, bark or flowers for medicinal purposes) by any route (oral, inhalation, topical application) either self-prescribed or recommended by family members, friends or herbalists to treat some abnormalities during the current pregnancy period. Knowledge was measured using seven items prepared to assess it. Study participants were asked the knowledge-related questions, and value 1 was given for correct answers and value 0 was given for incorrect (or I do not know) answers. Then the respondent’s score was dichotomised as sufficient knowledge or insufficient knowledge after the total score was computed by summing up all the items together. Sufficient in knowledge Study participants who answered equal to or greater than the mean values of knowledge-related questions. Insufficient knowledge Study participants who answered less than the mean values of knowledge-related questions. Perception The pregnant woman’s perception towards the effects of IHM usage during pregnancy. Eight questions were prepared to assess it. Each question has a five-point Likert scale (1=strongly disagree, 2=disagree, 3=not sure, 4=agree and 5=strongly agree). Then the respondent’s score was dichotomised as favourable perception or unfavourable perception (strongly disagree, disagree and not sure to ‘unfavourable’ and agree and strongly agree to ‘favourable’). Income The average family’s monthly income of the pregnant women in Ethiopian Birr. Data quality control The questionnaire was developed in English and translated into the local languages by language experts (Afaan Oromoo, Somali and Amharic) and then back to English to maintain its consistency. The research’s objectives, the sampling procedure, interviewing techniques and general approaches to the study participants were all thoroughly covered over a 2-day training session for data collectors and supervisors. We performed a pretest on 5% of the sample size out of the selected health centres at Adisketema Health Centre (urban) and Wahil Health Centre (rural) 2 weeks before the actual data collection. Based on the findings of the pretest, we made minor modifications to the questionnaire. The data collection process was closely supervised, and the completeness and accuracy of each questionnaire were checked by the investigators and supervisors daily. Data were entered into the EPI DATA software as part of data management. During data cleaning, a logical checking technique was used to identify the errors. Questionnaires are secured in a safe place for confidentiality and as a backup for later, in case a check is necessary. Finally, double data entry was done by two data clerks, and the consistency of the entered data was cross-checked. To determine the internal reliability of the data, Cronbach’s α was calculated (α=0.801). Data management and analysis The data were coded, entered into Epi Data (V.3.1) and exported to SPSS (V.22) statistical software for analysis. A univariate analysis was used to describe the frequency distribution variables. We coded the outcome variables as ‘1’ for ‘IHM user’ and ‘0’ for ‘non-user.’ The association between the outcome and independent variables was analysed using a binary logistic regression model. Variables with a p<0.25 at the bivariable binary logistic regression analysis were retained and entered into the multivariable binary logistic regression analysis using a forward stepwise approach. A multicollinearity test was performed to determine the linear correlation among the independent variables using the variance inflation factor (>10) and standard error (>2). The goodness-of-fit test was performed using the Hosmer-Lemeshow test (p>0.05). For an outcome variable, an adjusted OR (AOR) with a 95% CI and a p value of less than 0.05 was considered statistically significant.   The study was conducted in the Dire Dawa administration, which is located 515 km east of Addis Ababa, the capital city of Ethiopia. According to 2020 population projections, 506 000 people live in the Dire Dawa Administration (68% of whom are estimated to be urban inhabitants), which has 38 rural and 9 urban kebeles (the smallest administrative units). This administration has two public hospitals (1 referral and 1 general), 15 health centres. One public referral hospital (Dilchora RH) and six public health centres (three urban and three rural) were selected purposefully based on their client flow (information taken from the ANC registration book in each health facility), and the sample size was proportionately allocated. The study was conducted from October to November 2022 .   None.   A facility-based cross-sectional study design was employed among 628 randomly selected pregnant women attending ANC at public health facilities in the Dire Dawa Administration. All pregnant women in Dire Dawa administration during the study period were the source population, whereas all randomly selected pregnant women on ANC follow-up at selected public health facilities in Dire Dawa administration during the study period were the study population.   Included were all confirmed pregnant women of any gestational age who had been on ANC follow-up at selected public health facilities in the Dire Dawa administration. However, pregnant women who were severely ill and unable to communicate were excluded.   The sample size was determined using the single population proportion formula and considering a proportion of IHM use of 48.6%, a standard normal distribution (z=1.96), a 95% CI and a 4% margin of error. After adding a 10% non-response rate, the final sample size was 660. To obtain all 628 study participants, a simple random sampling technique was used. The sample was proportionally allocated to each public health facility to select a representative sample .   The data were collected via face-to-face interview using a structured questionnaire that was adapted from literature designed for the same study purpose, and then variables were reviewed to suit the local context. The questionnaire was initially prepared in English, then translated by language experts into the local languages of Afaan Oromoo and Amharic, and finally back into English to maintain consistency. The questionnaire contains four main parts: sociodemographic characteristics; obstetrics; IHM awareness and uses during pregnancy; and environmental, past experience and medical factors. A total of eight health extension workers were recruited for data collection, and four MSc midwives supervised the whole process.   IHM use is the use of locally available plants (any parts like seeds, roots, leaves, bark or flowers for medicinal purposes) by any route (oral, inhalation, topical application) either self-prescribed or recommended by family members, friends or herbalists to treat some abnormalities during the current pregnancy period. Knowledge was measured using seven items prepared to assess it. Study participants were asked the knowledge-related questions, and value 1 was given for correct answers and value 0 was given for incorrect (or I do not know) answers. Then the respondent’s score was dichotomised as sufficient knowledge or insufficient knowledge after the total score was computed by summing up all the items together. Sufficient in knowledge Study participants who answered equal to or greater than the mean values of knowledge-related questions. Insufficient knowledge Study participants who answered less than the mean values of knowledge-related questions. Perception The pregnant woman’s perception towards the effects of IHM usage during pregnancy. Eight questions were prepared to assess it. Each question has a five-point Likert scale (1=strongly disagree, 2=disagree, 3=not sure, 4=agree and 5=strongly agree). Then the respondent’s score was dichotomised as favourable perception or unfavourable perception (strongly disagree, disagree and not sure to ‘unfavourable’ and agree and strongly agree to ‘favourable’). Income The average family’s monthly income of the pregnant women in Ethiopian Birr.   Study participants who answered equal to or greater than the mean values of knowledge-related questions.   Study participants who answered less than the mean values of knowledge-related questions.   The pregnant woman’s perception towards the effects of IHM usage during pregnancy. Eight questions were prepared to assess it. Each question has a five-point Likert scale (1=strongly disagree, 2=disagree, 3=not sure, 4=agree and 5=strongly agree). Then the respondent’s score was dichotomised as favourable perception or unfavourable perception (strongly disagree, disagree and not sure to ‘unfavourable’ and agree and strongly agree to ‘favourable’).   The average family’s monthly income of the pregnant women in Ethiopian Birr.   The questionnaire was developed in English and translated into the local languages by language experts (Afaan Oromoo, Somali and Amharic) and then back to English to maintain its consistency. The research’s objectives, the sampling procedure, interviewing techniques and general approaches to the study participants were all thoroughly covered over a 2-day training session for data collectors and supervisors. We performed a pretest on 5% of the sample size out of the selected health centres at Adisketema Health Centre (urban) and Wahil Health Centre (rural) 2 weeks before the actual data collection. Based on the findings of the pretest, we made minor modifications to the questionnaire. The data collection process was closely supervised, and the completeness and accuracy of each questionnaire were checked by the investigators and supervisors daily. Data were entered into the EPI DATA software as part of data management. During data cleaning, a logical checking technique was used to identify the errors. Questionnaires are secured in a safe place for confidentiality and as a backup for later, in case a check is necessary. Finally, double data entry was done by two data clerks, and the consistency of the entered data was cross-checked. To determine the internal reliability of the data, Cronbach’s α was calculated (α=0.801).   The data were coded, entered into Epi Data (V.3.1) and exported to SPSS (V.22) statistical software for analysis. A univariate analysis was used to describe the frequency distribution variables. We coded the outcome variables as ‘1’ for ‘IHM user’ and ‘0’ for ‘non-user.’ The association between the outcome and independent variables was analysed using a binary logistic regression model. Variables with a p<0.25 at the bivariable binary logistic regression analysis were retained and entered into the multivariable binary logistic regression analysis using a forward stepwise approach. A multicollinearity test was performed to determine the linear correlation among the independent variables using the variance inflation factor (>10) and standard error (>2). The goodness-of-fit test was performed using the Hosmer-Lemeshow test (p>0.05). For an outcome variable, an adjusted OR (AOR) with a 95% CI and a p value of less than 0.05 was considered statistically significant.   Sociodemographic characteristics A total of 628 study participants were included, yielding a response rate of 95.15%. The respondents’ ages ranged from 18 to 40 years (mean=27 years, SD=6.5 years). More than half (65%) of the study participants were rural residents and housewives (51.1%) . Obstetric characteristics 50%, 34.7% and 15.5% of study participants had 3–4, 1–2 and more than four parities, respectively. Around 18.8%, 53.2% and 28% were in the first, second, and third trimesters, respectively. Less than half (45.1%) had three or more ANC visits, and more than half (55.9%) were pregnancies that were planned. Awareness of herbal medicine Most respondents had awareness of IHM (89.6%), and their most common sources of information were neighbours and friends (41.3%), family and relatives (34%), traditional healers (14%) and religious fathers (10.7%). Prevalence of IHM use during the current pregnancy Out of the total of 628 respondents, 47.8% (300) (95% CI 43.8% to 51.6%) used IHM during their current pregnancy. From this, 16.3%, 45%, 29.3%, 3.3%, 3.7% and 2.3% used only the first trimester, only the second trimester, only the third trimester, only the first and second trimesters, only the second and third trimesters, and all trimesters, respectively. Herbals used, indications, parts and additives The most commonly used IHMs were garden cress ( Lepidium sativum ) (32%), bitter leaf ( Vernonia amygdalina ) (25.2%), moringa ( Moringa oleifera ) (24. 5 %), flax seed ( Linum usitatissimum) (15.3% ) and eucalyptus tree ( Eucalyptus globulus ) (13.7%) . The most common stated reasons were related to gastrointestinal system problems: intestinal parasites (27%), nausea and vomiting (21.7%), constipation (20%), to increase appetite (17.3%), relief of stomach aches (9.7%), indigestion (7.7%) and abdominal cramps (7%). The others were related to headache (17.7%), malaria (10.7%), high blood sugar (9.7%) and blood pressure (7.7%). The most commonly used parts of the herbs were seeds and leaves, with different additives . More than half of the respondents used the leaves of herbs, followed by the seeds. Moringa, rue and honey were the most commonly used additives . Routes, number and frequency per day The majority (91.3%) of pregnant women took IHM via oral routes; the rest, 5.7% and 3%, were through nasal inhalation and topical form, respectively. Out of 300 respondents, the majority (142) took 2 types of IHM, followed by 3 types (76) and 1 type. 59.7% of pregnant women took IHM two times, 24.6% took it once (early morning in the bare stomach) and 15.7% took it three times per day. There were herbal medicines occasionally used by pregnant women . Side effects, discussions with health professionals and satisfaction Among IHM users, 16.7% stated side effects after IHM intake. The most commonly stated types of these side effects were malaises (42.6%), abdominal pain (12.5%), vomiting (17%), and headaches (14.9%), and only 3.5% had discussions about them with health professionals. The majority (73%) were satisfied, 23% were on average and 4% were dissatisfied with the use of IHM during pregnancy. Source place and influential factors for IHM usage When asked where they got their IHMs, respondents reported traditional healers (60%), religious places (14%), marketplaces (13.7%), a neighbour (3%), self-preparation (2.7%) and more than one source (6.6%). The most commonly stated influential reasons for using IHMs were the perception that ‘IHMs are more therapeutic than modern medicines’ (43.7%) and ‘safe in pregnancy’ (17%) . knowledge and perception of respondents towards IHM More than half (63.5% and 59.4%) of respondents had sufficient knowledge of the effects of IHM use during pregnancy and a favourable perception of IHM, respectively. Environmental, past experience and medical factors (n=628) Access to health facilities: 18.3%, 53.2% and 28.5% had access to health facilities within <5 km, between 5 and 10 km, and >10 km, respectively. The presence of traditional healers in close proximity: 88.7% and 11.3% of respondents reported the presence of traditional healers >5 km and ≤5 km, respectively. Regarding prior IHM use experience (during a past pregnancy), 45.7% reported using it, and only 9.5% had used IHM for other health problems. Reasons for not using IHM among non-users (n=328) Perceiving unsafe during pregnancy (60.4%), forbidden by husbands (20.4%), preference for modern medicines (14.6%), lack of availability (6.7%). Factors associated with IHM use by pregnant women In the multivariable binary logistic regression analysis, level of education: no formal education (AOR 5.47, 95% CI 2.40 to 12.46), primary level (AOR 4.74, 95% CI 2.15 to 10.44), being a housewife (AOR 4.15, 95% CI 1.83 to 9.37), low number of ANC visits (AOR 2.58, 95% CI 1.27 to 5.25), insufficient knowledge on the effect of IHM during (AOR 4.58, 95% CI 3.02 to 6.77) and favourable perception (AOR 2.54, 95% CI 1.71 to 1.77) were significantly associated with IHM use during the current pregnancy .   A total of 628 study participants were included, yielding a response rate of 95.15%. The respondents’ ages ranged from 18 to 40 years (mean=27 years, SD=6.5 years). More than half (65%) of the study participants were rural residents and housewives (51.1%) . Obstetric characteristics 50%, 34.7% and 15.5% of study participants had 3–4, 1–2 and more than four parities, respectively. Around 18.8%, 53.2% and 28% were in the first, second, and third trimesters, respectively. Less than half (45.1%) had three or more ANC visits, and more than half (55.9%) were pregnancies that were planned.   50%, 34.7% and 15.5% of study participants had 3–4, 1–2 and more than four parities, respectively. Around 18.8%, 53.2% and 28% were in the first, second, and third trimesters, respectively. Less than half (45.1%) had three or more ANC visits, and more than half (55.9%) were pregnancies that were planned.   Most respondents had awareness of IHM (89.6%), and their most common sources of information were neighbours and friends (41.3%), family and relatives (34%), traditional healers (14%) and religious fathers (10.7%).   Out of the total of 628 respondents, 47.8% (300) (95% CI 43.8% to 51.6%) used IHM during their current pregnancy. From this, 16.3%, 45%, 29.3%, 3.3%, 3.7% and 2.3% used only the first trimester, only the second trimester, only the third trimester, only the first and second trimesters, only the second and third trimesters, and all trimesters, respectively.   The most commonly used IHMs were garden cress ( Lepidium sativum ) (32%), bitter leaf ( Vernonia amygdalina ) (25.2%), moringa ( Moringa oleifera ) (24. 5 %), flax seed ( Linum usitatissimum) (15.3% ) and eucalyptus tree ( Eucalyptus globulus ) (13.7%) . The most common stated reasons were related to gastrointestinal system problems: intestinal parasites (27%), nausea and vomiting (21.7%), constipation (20%), to increase appetite (17.3%), relief of stomach aches (9.7%), indigestion (7.7%) and abdominal cramps (7%). The others were related to headache (17.7%), malaria (10.7%), high blood sugar (9.7%) and blood pressure (7.7%). The most commonly used parts of the herbs were seeds and leaves, with different additives . More than half of the respondents used the leaves of herbs, followed by the seeds. Moringa, rue and honey were the most commonly used additives .   The majority (91.3%) of pregnant women took IHM via oral routes; the rest, 5.7% and 3%, were through nasal inhalation and topical form, respectively. Out of 300 respondents, the majority (142) took 2 types of IHM, followed by 3 types (76) and 1 type. 59.7% of pregnant women took IHM two times, 24.6% took it once (early morning in the bare stomach) and 15.7% took it three times per day. There were herbal medicines occasionally used by pregnant women .   Among IHM users, 16.7% stated side effects after IHM intake. The most commonly stated types of these side effects were malaises (42.6%), abdominal pain (12.5%), vomiting (17%), and headaches (14.9%), and only 3.5% had discussions about them with health professionals. The majority (73%) were satisfied, 23% were on average and 4% were dissatisfied with the use of IHM during pregnancy.   When asked where they got their IHMs, respondents reported traditional healers (60%), religious places (14%), marketplaces (13.7%), a neighbour (3%), self-preparation (2.7%) and more than one source (6.6%). The most commonly stated influential reasons for using IHMs were the perception that ‘IHMs are more therapeutic than modern medicines’ (43.7%) and ‘safe in pregnancy’ (17%) .   More than half (63.5% and 59.4%) of respondents had sufficient knowledge of the effects of IHM use during pregnancy and a favourable perception of IHM, respectively.   Access to health facilities: 18.3%, 53.2% and 28.5% had access to health facilities within <5 km, between 5 and 10 km, and >10 km, respectively. The presence of traditional healers in close proximity: 88.7% and 11.3% of respondents reported the presence of traditional healers >5 km and ≤5 km, respectively. Regarding prior IHM use experience (during a past pregnancy), 45.7% reported using it, and only 9.5% had used IHM for other health problems. Reasons for not using IHM among non-users (n=328) Perceiving unsafe during pregnancy (60.4%), forbidden by husbands (20.4%), preference for modern medicines (14.6%), lack of availability (6.7%).   Perceiving unsafe during pregnancy (60.4%), forbidden by husbands (20.4%), preference for modern medicines (14.6%), lack of availability (6.7%).   In the multivariable binary logistic regression analysis, level of education: no formal education (AOR 5.47, 95% CI 2.40 to 12.46), primary level (AOR 4.74, 95% CI 2.15 to 10.44), being a housewife (AOR 4.15, 95% CI 1.83 to 9.37), low number of ANC visits (AOR 2.58, 95% CI 1.27 to 5.25), insufficient knowledge on the effect of IHM during (AOR 4.58, 95% CI 3.02 to 6.77) and favourable perception (AOR 2.54, 95% CI 1.71 to 1.77) were significantly associated with IHM use during the current pregnancy .   For a country with a national policy aimed at strengthening the quality of healthcare, such as Ethiopia, it is fundamental to investigate the status of conventional and TMs with their potential influencing factors, such as in pregnant women. This study gives important findings regarding the prevalence and factors significantly associated with the use of IHM during pregnancy. The present study revealed that the prevalence of IHM use during a current pregnancy is high (one in two pregnant women, 47.8%). This finding was in line with a study in Turkey (47.3%). Such consistency might be because of the aggregated similarity of some sociodemographic characteristics of study participants. In the present study, the majority of study participants were in the age range of 20–30 (54.9%), were housewives (51%) and were married (90.9%). Likewise, in the study in Turkey, the study participants’ ages ranged from 21% to 25%; the majority were housewives (87.4%) and 34.2% had completed only primary school or below. The present finding was also in line with three studies in Ethiopia: Nekemte (50.4%), Gonder (48.5%) and Dessie (51.2%). Similarly, the possible reason for consistency might be related to the major compacted variables among study participants. In all three studies, most participants’ ages were below 30 years, their education level was secondary and below, and they were urban residents, unemployed or housewives. Similarly, in the present study, more than half (54.9%) of participants were in the age range of 20–30 years, unemployed or housewives (51.1%), and the majority were urban dwellers (65%), and their education level was secondary or below (78.2%). The present study’s prevalence is higher than studies conducted in Italy (27.8%), two studies in Africa, Nigeria (36.8%), Uganda (20%) and one study in Ethiopia (36.3%). This discrepancy might be due to study methods. For instance, the study in Italy used only two hospitals and 392 samples with a 10-month study period. The study in Nigeria used only a tertiary hospital and 500 samples selected by systematic techniques. Likewise, the study in Uganda used four study sites, a mixed study design with 383 samples for the quantitative part, and participants were interviewed while attending postnatal care about the use of herbal medicines during their pregnancy period; this could have a recall bias that varied the study result. In addition, the study in Northern Ethiopia, Debre Tabor, used a mixed community-based study design with 267, 12 and 6 sample sizes for quantitative, focus group discussion and in-depth interviews, respectively. While the present study used multiple health settings, both urban and rural, with a facility-based study design and 628 samples, pregnant women attended ANC visits. This may be due to the accessibility and affordability of the regulatory systems of IHM and TM usage in different countries. These may make a difference in countries such as Italy and Nigeria, versus in Ethiopia, where traditional healers and TM usage are relatively common. For instance, in the present study, 88.7% and 11.3% of respondents reported the availability of traditional healers at a distance >5 km and ≤5 km, respectively. The present study’s prevalence, however, is lower than studies conducted in Bangladesh (70%), Iran (71.3%), Zimbabwe (69.9%), Mali (79.9%), Sierra Leone (82.7%) and Uganda (76.7%). The discrepancy may be caused by variations in the study setting, sample size, sampling technique, study design, study populations, study duration and participants’ ages. For instance, in a study in Bangladesh, two public hospitals, a study in Iran, 12 health centres, a study in Mali, 3 health centres and a study in Zimbabwe, only 2 rural districts were included as study settings. In the present study, 3 health centres from urban areas, 3 urban public health centres, 3 rural public health centres and 1 public referral hospital were included. Regarding the sample size, 243, 150, 398, 209, 134 and 46 sample sizes were used in studies in Bangladesh, Iran, Zimbabwe, Mali, Serra Leon and Uganda, respectively. But in the present study, a sample size of 628 was used. In the present study, a facility-based cross-sectional study design was used, while a study in Uganda used a community-based survey, which could also result in result variations. In the present study, the study populations were pregnant women on ANC visits while in a study in Bangladesh, postpartum women were interviewed about patterns of herbal medicines used in the previous pregnancy; this can have recall bias and could result in result variations. In addition, the studies in Zimbabwe and Uganda used convenient and snowball sampling techniques, respectively. While the present study used random sampling techniques. The participant’s age may also be a possible reason for variation, as their experience with IHM knowledge and perception might be related to age. All these methodological variations could create discrepancies between the studies. Besides, the discrepancy may be related to sociocultural variables like residence area, education level and awareness status in different countries and their districts. Moreover, the discrepancy may be related to access to community and/or health facility-based population health education programmes that involve TMs. The present study’s prevalence was also lower than one study conducted in southern Ethiopia, Hosana (73.1%). This discrepancy may be caused by variations in the study setting, sample size and sampling technique. The study in southern Ethiopia, Hosana, used public health facilities available only in the town, a sample size of 363 and a systematic sampling technique. While the present study used public health facilities available both in urban and rural sites, a larger sample size (628) and a random selection technique. Besides, the discrepancy may be related to sociocultural variations and the awareness or attitude of populations in different districts of Ethiopia. According to this study, low levels of education, being housewives, lower ANC visits, insufficient knowledge and favourable perceptions were all associated with a higher likelihood of IHM use during a current pregnancy. Pregnant women who had no formal or primary-level education were more than five and four times more likely to use IHM than those who had secondary or higher education. This was supported by research conducted in Turkey, Nigeria and different parts of Ethiopia. The study conducted at Debre Birhan, Dessie, Gonder, Hosana and Debre Tabor revealed the odds of IHM use during pregnancy were 2, 3, 4, 4 and 9 times higher among pregnant women with low-level education, respectively. Pregnant women who had insufficient knowledge regarding the effects of herbal medicine usage during pregnancy were almost four times more likely to use IHM compared with those who had sufficient knowledge. Previous studies conducted in the west and northern parts of Ethiopia did not assess participants’ knowledge on the effects of herbal medicine usage during pregnancy. But two studies, one in north Ethiopia, Debre Birhan and one in southern Ethiopia, Hosana, assessed participants’ knowledge on the effects of herbal medicine usage during pregnancy. The former study (at Debre Birhan) did not show an association between knowledge and herbal medicine usage during pregnancy. While the latter one revealed that knowledge on the effect of herbal medicine use during pregnancy had a significant association with its use, which is in line with the present study. The possible explanation may be the fact that insufficient knowledge regarding the effects of herbal medicine usage during pregnancy may reduce thoughtfulness to the risks that can occur during pregnancy, either to pregnant women or their fetus or to both. In previous studies done in different parts of Ethiopia, only one study assessed perception but did not show a significant association with the use of IHM by pregnant women. In contrast, the present study showed the odds of IHM use during pregnancy were more than two times higher among favourable preceptors. One possible explanation might be that those who had a favourable perception of IHM might perceive herbal medicines as lacking risks that can occur during pregnancy, either to pregnant women or their fetus or to both. Moreover, the present study revealed two variables having a significant association with the use of IHM by pregnant women: being housewives and the number of ANC visits. Pregnant women who were housewives were almost four times more likely to use IHM compared with their counterparts. The possible explanation might be due to the fact that housewives might have a lack of awareness of IHMs compared with their counterparts and a positive perception towards their use. Pregnant women who attended fewer ANC visits were more than two times more likely to use IHM compared with those who attended more ANC visits. The possible reason might be due to the effects of counselling during ANC, like risk and nutritional counselling, and this needs further research. Furthermore, at the binary level, this study also showed the presence of traditional healers in a nearby area has an association with the use of IHM by pregnant women, but this also needs further study. The present study showed commonly used herbal medicines during pregnancy as garden cress ( L. sativum ) (32%), bitter leaf ( V. amygdalina ) (25.2%), moringa ( M. oleifera) (24.5 %), flax seed ( L. usitatissimum) (15.3% ) and eucalyptus tree ( E. globulus) (13.7% ). A little bit related finding was indicated by a study conducted in Nigeria, in which the bitter leaf/iron weed plant ( V. amygdalina ) (54.3%) was the most common herbal medicine used by pregnant women. Studies conducted in Turkey and Ethiopia showed ginger (Zingiber officinale) as the most common herbal medicine used by pregnant women. Unlike previous studies in Ethiopia , ginger was not the most common herb but rather used as an additive in the present study. A study in Italy showed chamomile, licorice, fennel, aloe, valerian, echinacea, almond oil, propolis and cranberry as the common herbal medicines used by pregnant women. A study in Mali revealed chevalieri (55.5%), Combretum micranthum (39.7%), Parkia biglobosa (12.0%) and Vepris heterophylla (8.1%) as the common herbal medicines used by pregnant women. In addition, a study in Serra Leon identified Luffa acutangula ((L.) Roxb the most cited herbal medicine used during pregnancy). The study at Gonder and Dessie, north Ethiopia, showed ginger (Zingiber ofcinale Roscoe) (43.8%) and garlic (Allium sativum L.) as the the most common herbal medicines used by pregnant women. The study at Debre Birhan showed ginger (Zingiber officinale Roscoe), damakesse (Ocimum lamiifolium) and tenadam (Fringed rue) as the the most common herbal medicines used by pregnant women. In the study at Nekemte, west Ethiopia, ginger (44.36%) and tenaadam (9.15%) were found to be the most common herbal medicines used by pregnant women. This indicates that the types and frequency of herbal medicines vary according to different research findings. This might be due to the fact that there are many different types of herbal medicine from different cultures and the variety of sample sizes in different research studies. Such variation could also be due to differences in user-friendliness, openness (lacking a regulatory body) and environmental spreading of the herbs across diverse countries and provinces in the same country. As per the present study, common indications of herbal remedies were related to gastrointestinal system problems: intestinal parasites (27%), nausea and vomiting (21.7%), constipation (20%), to increase appetite (17.3%) and relief of stomach aches (9.7%). The others were related to headache (17.7%), malaria (10.7%), high blood sugar (9.7%) and blood pressure (7.7%). The indications of herbal remedies also vary; for instance, a study in Mali showed: for well-being (36.7%), symptoms of malaria (37.1%) and to reduce oedema (19.2%)). A study at Serra Leon indicated urinary tract infection and pedal oedema. A study at Dessie, north Ethiopia, showed indications for herbal drug use were nausea/vomiting (43.8%), headache (30.8%) and common cold (25.4%). In a study at Gonder, north Ethiopia, common cold (66%) and inflammation (31.6%) were the most common reasons. This suggests that there are a number of therapeutic tasks that herbal remedies are demanded to play during the gestational period, duties that may require scientific explanation. The present study showed that only a few pregnant women are aware of the side effects after taking herbal medicines and only a few have disclosure for discussion with health professionals about the side effects. This suggests that to prevent the possible harm imposed by the use of herbal medicines, healthcare providers should emphasise safety issues to pregnant women and make functional counselling during ANC cares and provide updated evidence-based information regarding herbal medicines. Unlike the previous studies available in Ethiopia so far, the present study identified traditional healers (60%), followed by religious places, as the major source place to obtain herbal medicines by pregnant women. This indicates the need for training for traditional healers and religious leaders about the possible risks for pregnant women and their fetuses, dose proportion of herbs and gestational time of pregnant women. The present study also revealed the most commonly stated influential reasons for using IHM as perception that ‘IHMs are more therapeutic than modern medicines’ and ‘safe in pregnancy’. Moreover, the present study showed reason for not using IHM among non-users as perceiving unsafe during pregnancy (60.4%), forbidden by husbands (20.4%) and preference for modern medicines (14.6%). These indicates the need for community awareness of herbal medicines including husbands, traditional healers and religious leaders at community level. Furthermore, unlike the previous studies available in Ethiopia, the present study showed the additives, number and frequency per day of IHM used. Consequently, moringa, rue, honey and ginger were commonly used as additives. In the present study, the majority of pregnant women took two types of IHM, followed by three types; the majority took IHM two times per day, and a quarter (24.6%) of them took it once (early morning in the bare stomach). This highlights the issue of herbal medicine frequency as well as dose during pregnancy. The findings of the study could have implications for society, research and practice (health professionals and healthcare programmes). Implications for: Social: The study findings suggest the need for continuous awareness for pregnant women considering education level, housewives and the number of ANC visits since IHM use during pregnancy was higher among these women. They might lack awareness of the risks of pregnancy to themselves and their fetus. It also suggests the need for community awareness to clear up misconceptions about IHM during pregnancy and among general women. Research: The need for future research to identify IHM use by pregnant women at the community level. Another recommendation for further research is to conduct research on the effects of the number of ANC visits and the influence of traditional healers and religious leaders on IHM use by pregnant women. Further research on the bioavailability, dose, efficacy and safety of the herbal medicines used by pregnant women should also be done. Implications for practice (health professionals and health care programmes): According to the study’s findings, health facilities require counselling of pregnant women about IHM use during ANC visits and counselling pregnant women to disclose IHM usage and any untoward or side effects if they use it. Since there is a high prevalence and low disclosure rate of herbal medicine use, it should be ensured that obstetricians, midwives and other health professionals establish a good level of communication with pregnant women during ANC visits. Conclusion The prevalence of herbal medicine use is high (one in two pregnant women) and significantly associated with education level, occupation, ANC visits, knowledge and perceptions. The study’s findings are helpful in advancing comprehension of herbal medicines using status, types and enforcing factors. It is essential that health facilities provide herbal counselling during ANC visits, and health regulatory bodies ought to raise awareness and implement interventions to lower the risks from OTC herbal medicine use by pregnant women.   The prevalence of herbal medicine use is high (one in two pregnant women) and significantly associated with education level, occupation, ANC visits, knowledge and perceptions. The study’s findings are helpful in advancing comprehension of herbal medicines using status, types and enforcing factors. It is essential that health facilities provide herbal counselling during ANC visits, and health regulatory bodies ought to raise awareness and implement interventions to lower the risks from OTC herbal medicine use by pregnant women.   Reviewer comments Author's manuscript   