How to Access PDR For Herbal Medicines in PDF Format

High prevalence of herbal medicines used in pregnancy and the lack of information on their safety is a public concern. Despite this, no significant research has been done regarding potential adverse effects of using herbal medicines during pregnancy, especially among developing Asian countries.

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Cross-sectional studies were searched up to year 2016 on PubMed/Medline and EMBASE, the data were extracted and quality of studies was assessed using the quality appraisal tool. The findings are reported in accordance to the PRISMA checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Classification on safety of identified herbal medicines was done based on current scientific literature.

This study included eight cross-sectional studies (2729 participants) from seven different Asian countries, of which 1283 (47.01%) women used one or more herbal medicines during pregnancy. Peppermint (22.8%), aniseed (14.7%), olibanum (12.9%), flixweed seed (12.2%) and ginger (11.5%) were the most frequently used herbal medicines. Out of the 33 identified herbal medicines, 13 were classified as safe to use, five as use with caution, eight were potentially harmful to use in pregnancy and information on seven herbal medicines was not available in the current literature.

Several herbal medicines identified in this review were classified to be potentially harmful or the information regarding safety in pregnancy was missing. It is recommended that contraindicated herbal medicines should be avoided and other herbals should be taken under supervision of a qualified health care practitioner. The classification regarding safety of herbal medicines in pregnancy can be utilized to create awareness on prevention of adverse effects.

Asian countries have a long history of using traditional herbal medicines to manage various medical conditions [1]. A multiethnic study reported that 50% of the Asians consumed one or more herbal products to manage their health [2]. In Asian countries, medicinal plants and their preparations can be easily purchased from condimental shops and homeopathic stores for self-treatment or can be obtained by visiting traditional healers [3]. Herbs can also be obtained as unregulated food products which usually do not go through standard regulatory process [4]. Consequently there is always a risk of contamination with heavy metals or undeclared pharmacological agents [5].

Despite such risks, herbal medicines are popular among pregnant women [4]. Its prevalence up to 60% in the developed countries [6] is mainly because of the belief that herbs are natural and free of any adverse effects compared to conventional medicine [7]. Local traditions and social pressure could also be the reason behind this practice [8].

These socio-cultural factors may affect the outcome of pregnancy [9,10,11]. For instance, one study showed that women using herbal medicines during pregnancy had higher incidence of threatening miscarriage, and newborns of herbal users were smaller for their gestational age [12]. The authors hypothesized that such association could be result of the regular intake of chamomile and licorice throughout the course of pregnancy. Other studies have also evaluated possible adverse effects of using various herbal medicines during pregnancy [13, 14]. Amid these safety concerns, few studies have classified the commonly used herbal medicines in pregnancy according to their safety status.

Nordeng et al. reported that 39% of pregnant women used herbal medicines that were potentially harmful or for which sufficient information on safety was unavailable [15]. More recently, Kennedy et al. classified the safety of most commonly used herbal medicines during pregnancy in American, Australian and European populations [16]. However, the herbal medicines used in Asian population should be different from those used in western countries due to difference in culture and traditions [17]. Several studies from Asian region have indicated use of herbal medicines during pregnancy [18, 19] but no attempt has been made to classify the safety of herbal medicines used in pregnancy among developing Asian countries. This study has two aims. The first is to identify the most commonly used herbal medicines in pregnancy among developing Asian countries through a systematic review. The second is to classify the identified herbal medicines according to their safety status.

To identify commonly used herbal medicines among target population, the population-based cross-sectional studies were reviewed. Cross-sectional studies were selected because such studies typically report a large variety of herbal medicines [21,22,23]. It was hypothesized that such studies would allow authors to identify and subsequently classify as many herbal medicines as possible. Moreover, cross-sectional studies are frequently conducted to study health behaviour among pregnant women. The rationale to restrict selection to cross-sectional studies was to make the findings of the reviewed studies comparable.

If any of the identified herbal medicines was not listed in the reference sources, PubMed/MEDLINE and EMBASE (Ovid) were searched using the search strategy presented in Additional file 2 as Table S2. The search was performed from inception to August 2017. While classifying the safety of herbal medicines, evidence from human studies was considered first, followed by animal studies. If an herbal medicine was composed of two or more herbs, each herb was individually evaluated and classified. Based on a recent study [16], the identified herbal medicines were classified into four groups. Description of how these classifications were defined is presented in Table 1.

Flowchart of the studies included in this systematic review is illustrated in Fig. 1. The initial search of the databases yielded 598 records, of which eight records were duplicate and 572 others were excluded as ineligible after reading their titles or abstracts. Full texts of the remaining 18 records were downloaded and screened or in some cases, the full texts were screened online. After screening through eligibility criteria, 10 studies were considered ineligible. Therefore, eight studies were found eligible and were included in the systematic review.

In total, 1283 out of 2729 (47.01%) women used at least one herbal medicine any time during their last pregnancy. A long list of herbal medicines was identified from the reviewed articles. In this review, we only report those modalities that were used by 10 or more subjects. As a result, 31 different herbal medicines (individual herb or mixture as preparation) were determined, which are presented in Table 4. Most frequently used herbal medicines included peppermint (292), aniseed (188), olibanum (166) and flixweed seed (156). Nearly all of the herbal medicines were administered via oral route, whereas only two were used topically, one as an inhalation and one through vaginal route.

Details on safety classification of most frequently used herbal medicines during pregnancy are given in Table 5. Out of 33 individual herbs, only 13 were classified as safe to use in pregnancy. For seven herbal medicines that included flixweed seed, black seed, chicory and others, there was insufficient information in current literature. Frequency of the herbal medicines that were classified according to each safety category is presented in Fig. 2. In total, eight herbal medicines were classified as potentially harmful to use in pregnancy. These included pennyroyal, licorice, sage, ammi and others. Out of these eight herbal medicines, human studies reporting harmful effects were available for only two herbs; the rest were categorized based on animal studies or their potential to cause harm to mother and/or fetus.

Frequency of herbal medicines used in pregnancy according to their safety classification. a Herbal medicines in this section are classified as safe to use in pregnancy. b Herbal medicines in this section should not be used without consulting a qualified health care practitioner. c Information on safety for herbal medicines in this section is not available in current literature. d Herbal medicines in this section can be harmful to mother or fetus. Note: Number of herbal medicine users for each type is given in percentage out of total number of users

Systematic reviews usually focus on discovering the effectiveness of interventions [34]. To the best of our understanding, this is the first systematic review to identify the most commonly used herbal medicines in pregnancy in the Asian countries and classify them according to their safety status based on reference sources. The review comprised of eight cross-sectional studies that included data on 2729 women. The findings suggest that use of herbal medicines during pregnancy can have a number of adverse effects to mother and/or fetus.

Pennyroyal and licorice were also among the most frequently used herbal medicines and were classified as potentially harmful in pregnancy. These were consumed by pregnant women to manage breathing and digestion related problems respectively. In literature, use of pennyroyal is contraindicated during pregnancy [16] as cases of death have been reported following the misuse of its volatile oil to induce abortion [28]. Similarly, other studies have shown that ingestion of licorice during pregnancy can alter hormone levels and can lead to preterm delivery [39]. There is no scientific report to support the effectiveness of these herbal medicines especially among pregnant women.

This systematic review has some limitations. The quality assessment tool which was used to appraise the quality of studies included, has been used in systematic reviews of observational studies previously [31, 32]. The tool is a modified version of Newcastle-Ottawa Scale for cross-sectional studies. The Newcastle-Ottawa Scale in its original form only determines basic quality indicators of the reviewed studies [40]. Whereas the modified version was considered more suitable to the purpose of this study, especially given the discrete nature of studies on herbal medicines. Moreover, it is an easily applicable and understandable instrument to appraise important methodological aspects of an observational study. However, only five of its items are standard whereas the rest of items are modifiable according to objective of the review. This can affect the scoring system and the scores may not be comparable across different systematic reviews. 2ff7e9595c