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The use of traditional medicine in maternity care among African women in Africa and the diaspora: a systematic review

"Natisha Wirth" (2019-11-28)

The use of traditional medicine in maternity care among African women in Africa and the diaspora: a systematic review
There is a paucity of literature describing traditional health practices and beliefs of African women. The purpose of this study was to undertake a systematic review of the use of traditional medicine (TM) to address maternal and reproductive health complaints and wellbeing by African women in Africa and the diaspora.

A literature search of published articles, grey literature and unpublished studies was conducted using eight medical and social science databases (CINAHL, EMBASE, Infomit, Ovid Medline, ProQuest, PsychINFO, PubMed and SCOPUS) from the inception of each database until 31 December 2016. Critical appraisal was conducted using a quality assessment tool (QAT).

A total of 20 studies conducted in 12 African countries representing 11,858 women were included. No literature was found on African women in the diaspora related to maternal use of TM or complementary and alternative medicine (CAM). The prevalence of TM use among the African women was as high as 80%. The most common TM used was herbal medicine for reasons related to treatment of pregnancy related symptoms. Frequent TM users were pregnant women with no formal education, low income, and living far from public health facilities. Lack of access to the mainstream maternity care was the major determining factor for use of TM.
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TM is widely used by African women for maternal and reproductive health issues due to lack of access to the mainstream maternity care. Further research is required to examine the various types of traditional and cultural health practices (other than herbal medicine), the beliefs towards TM, and the health seeking behaviors of African women in Africa and the diaspora.

Open Peer Review reports
Depending on the cultural or ethnic groups engaging with traditional health practices, the term traditional medicine (TM) or complementary and alternative medicine (CAM) are used, albeit interchangeably. The label CAM is commonly used in studies from Western countries whereas TM is used for developing regions (such as Africa) in which Western medicine is not the predominant health care system.

The World Medicines Situation 2011 report estimates that between 70 and 95% of the population in developing countries use TM [1]. In Africa, more than 80% of the population use TM [2]. For the majority, TM is the only accessible primary health care option particularly for the rural African communities [3], and continued use of TM in Africa is likely due to limited accessibility, availability and affordability of modern medicine. In addition, given that TM has a significantly longer history than Western medicine in Africa, there is a deep rooted cultural trust towards TM and traditional medicine practitioners among many Africans [4, 5]. For example, rural African women usually prefer traditional health practitioners such as traditional birth attendants to biomedical health care professionals [6,7,8].
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Use of traditional and complementary medicines for maternity related health complaints is common [9,10,11]. Although international estimates vary considerably, there appears to be increasing CAM use in maternity with research from many regions showing that up to 87% of women are using some form of traditional and complementary therapies, with more conservative estimates ranging between 20 and 60% [10, 12,13,14]. Women in Western Societies use CAM for various conditions including (but not limited to) the treatment of premenstrual tension [15], pregnancy related problems [16], back pain [17], infertility [18], postmenopausal symptoms [19], for induction of labor [20].

In most parts of Africa, cultural and traditional health practices play a significant role in maternal health care [7]. In rural Africa, communities tend to adhere to the traditional belief that pregnancy and delivery is the province of traditional birth attendants [21]. Hence, African women perceive traditional healers as primary health care workers [6]. Currently there is a paucity of literature describing the traditional health practices of African women to enhance fertility, promote healthy pregnancy, ensure a normal birth, and promote and maintain health during the postnatal period.

The purpose of this article was to undertake a systematic review describing patterns of TM use for various maternal and reproductive health complaints among women in Africa and the diaspora. More specifically, the review aimed at describing the prevalence of TM use in relation to maternal and reproductive health care, reasons and/or motivators for TM use, common types of maternal and reproductive health complaints treated by TM, types of TMs used, views/perceptions and characteristics of TM users.

In this review, TM refers to "the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health, as well as in the prevention, diagnosis, improvement or treatment of physical and mental illnesses" as defined by the World Health Organization (WHO) [22].
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Search strategy
The search included the following eight databases: CINAHL, EMBASE, Infomit, Ovid Medline, ProQuest, PsychINFO, PubMed and SCOPUS and was conducted from the inception of each database until 31 December 2016. The search terms employed were the same for all databases. A detailed search strategy was developed by author (ZS) with input from authors (TD) and (CS). The search strategy combined terms for: (i) women or females, (ii) African or African-born migrants, (iii) traditional medicine, and (iv) maternal health conditions. All possible synonyms of these terms were listed and combined using Boolean operators (see Additional file 1 for more details). The reference lists of all included articles were also checked for other relevant studies.

Inclusion and exclusion criteria
Studies were included if they reported use of TM by African women or African-born migrant women for reasons related to the preparation for pregnancy, promoting fertility, treating pregnancy related symptoms, maintenance of general wellbeing during pregnancy, inducing or assisting labour, terminating pregnancy (abortion), and enhancing milk secretion or postnatal wellbeing. Studies were also included if describing the views, attitudes or beliefs of women towards TM. The search strategy included primary research (quantitative, qualitative and mixed methods), grey literature and unpublished reports.

Studies were excluded if they focused on women’s use of TM for general purposes and other conditions which were not directly related to maternal health care (e.g. postmenopausal symptoms, breast cancer and prevention of mother to child transmission of HIV). Studies that reported combined use of TM and pharmaceuticals were excluded if the data on TM could not be separated. Ethno-botanical surveys were also excluded.

Study selection and data extraction
Author ZS conducted the search from November to December 2016. A step-by-step review strategy was implemented to identify all relevant studies. Studies retrieved by the search were assessed first by title and then by abstracts by author ZS. This was followed by reading full texts to identify the final studies for inclusion. Data was extracted according to a predefined reference by all authors (ZS, TD and CS) with disagreement resolved through discussion. The data extracted covered the country of studies, participants’ demographics, prevalence of TM use, details of TMs used, characteristics of TM users, maternal conditions treated by TM, reasons of use, source of information, disclosure of TM use to health professionals, and the method of data collection. All search results were imported into Endnote, a bibliographic management software system and analysed.
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Quality assessment
There is no agreed set of methods for assessing the quality of observational studies describing CAM use [23,24,25]. Bishop and colleagues recently developed a Quality Assessment Tool (QAT) for a systematic review of the prevalence of complementary medicine use in pediatric cancer [23]. The QAT has also been modified by Grant and colleagues for a systematic review on use of CAM by people with cardiovascular diseases [25]. We have used the modified version of the QAT to undertake quality appraisal of the 18 quantitative studies (two qualitative studies were excluded from appraisal as QAT is not designed to assess quality of such studies). We were also unable to carry out a separate quality analysis for these articles because the number of studies was too small to allow us to draw firm conclusions. Author ZS and CS assessed the quality of studies with disagreements resolved by discussion.

Reporting and data analysis
A narrative synthesis of studies was undertaken. Data such as prevalence rates were analysed and grouped together for comparison between studies and/or countries. Quality assessment scores were calculated.

Study selection and characteristics
The database search identified 1949 potential references, from which 488 duplicates were removed. A total of 92 references were reviewed by abstract and 59 were not directly related to the aim of the review. The remaining 33 articles were examined by full text and a total of 20 articles were included [7, 8, 26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43]. Thirteen articles which examined an ethno-botanical survey of herbs used in pregnancy, focused on use of both TM and pharmaceuticals, reported the use of TM for treatment of HIV and cancer were excluded (Fig. 1).
Of the 20 studies included, four were conducted in Nigeria [28, 30, 40, 41], three in South Africa [8, 33, 43], and two each in Ethiopia [27, 32], Uganda [31, 37] and Tanzania [39, 42]. The remaining seven studies were conducted in Zimbabwe [35], Zambia [26], Mali [36], Lesotho [34], Kenya [7], Morocco [29], and Egypt [38]. No study was found related to maternal use of TM or CAM among African women of the diaspora.

Studies were published between 1985 and 2016, from which 13 (65%) were published between 2014 and 2016. Of the selected articles, 17 studies were quantitative while two were qualitative. One study utilised a mixed research method which included a structured questionnaire survey with pregnant women and focus group discussions involving TM providers. From this study, the data that concerned only the women was extracted in keeping with the aim of this review.
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Sample and study setting
Twenty studies investigated the use and/or the perception of TM for various maternal health conditions among 11, 858 African women. The sample size of the quantitative studies ranged from 72 to 5686 participants. Five studies included a sample of 500 or more participants [26, 30, 33, 40, 41]. Thirteen (72.2%) studies included pregnant women who were currently attending health facilities [26,27,28, 30, 32,33,34,35,36,37,38, 41, 42]. Five studies focused on surveying women who were mothers or had been pregnant in the past 2–5 years [7, 8, 29, 40, 43] preceding their data collection. Other studies sampled nursing mothers [28], women attending a fertility clinic [31], and women who underwent unsafe abortion [39]. Most studies reported on women of childbearing age (18–45 years).

Study quality
As shown in Table 1, the modified QAT included four major assessment criteria: i) study methodology, ii) sampling, iii) participant characteristics, and iv) TM use. A total of 15 specific quality assessment criteria were weighted according to their relative importance as described by Bishop and colleagues [23]. Three items scored a maximum of 2 points, 8 items scored 1 point, and 4 items scored 0.5 points. The maximum score was 16.
Study quality varied significantly between studies with QAT percentage scores ranging from 25% to 59.4%. Fifteen studies attained less than 50% of the maximum score [7, 26,27,28,29, 32,33,34, 36,37,38,39,40,41,42] (Table 2). All quantitative studies used retrospective data collection methods in which there was a potential for risk of recall bias. Only five studies used a retrospective data collection within the 12 months to minimise the risk of recall bias [7, 26,27,28, 31]. Eleven studies (61.1%) collected data with a piloted questionnaire, while five (27.8%) studies adjusted for potential confounders in their analysis. Seven studies reported a response rate which ranged between 74% and 100%. Only three studies recruited a multicenter sample in an attempt to achieve a representative sample of participants to the larger population from which they were drawn. Fifteen studies collected socio-economic data and 16 studies reported the age of participants. Only five studies reported the ethnicity of the study participants, most studies were from regions or countries of homogenous populations.