Use of Traditional Botanical Medicines During Pregnancy in Rural Rwanda

Abstract

Objective

To evaluate the perceptions of healthcare and traditional medicine providers regarding the type, indications, side effects, and prevalence of traditional medicine use amongst pregnant women in a rural Rwandan population.

Methods

Six focus groups with physicians, nurses, and community health workers and four individual in-depth interviews with traditional medicine providers were held. Qualitative data was gathered using a structured questionnaire querying perceptions of the type, indications, side effects, and prevalence of use of traditional medicines in pregnancy.

Results

The healthcare provider groups perceived a high prevalence of traditional botanical medicine use by pregnant women (50-80%). All three groups reported similar indications for use of the medicines and the socioeconomic status of the pregnant women who use them. The traditional medicine providers and the healthcare providers both perceived that the most commonly used medicine is a mixture of many plants, called Inkuri. The most serious side effect reported was abnormally bright green meconium with a poor neonatal respiratory drive. Thirty-five traditional medicines were identified that are used during pregnancy.

Conclusion

Perceptions of high prevalence of use of traditional medicines during pregnancy with possible negative perinatal outcomes exist in areas of rural Rwanda.

Introduction

According to the World Health Organization (WHO) 65%-80% of the world's population use traditional medicine as their primary form of health care [1]. The prevalence of traditional medicine use in pregnancy is estimated at 12-45% in many parts of Africa [2-4] and is as high as 80% in some countries [5].

The WHO defines traditional medicine as the knowledge or practices used in diagnosing, preventing or eliminating a physical, mental or social disease, which may rely exclusively on past experience, or observations handed down by generations [6]. The most common type of traditional medicine is phytomedicine (herbal medicine) [7], which contains plant materials as the active ingredients for both topical and ingested medicines.

Existing data on the safety and side effects of phytomedicine is not scientifically rigorous and many studies point to adverse effects [8]. Despite this, its use continues to grow in both industrialized and developing nations [9]. Many people believe it is effective for curing illnesses, is cheaper than synthetic medicines [10], and is safer to use in pregnancy [11].

Rwanda is a country with a history of using traditional medicine for a variety of medical and non-medical reasons and little is known about its use and impact in pregnancy. This qualitative study aimed to describe the perceptions among physicians, nurses, community health workers, and traditional medicine providers of the prevalence, type, indications and side effects of phytomedicine in pregnancy in a rural community in the Western Province of Rwanda.

Materials and Methods

This study was conducted in Kagano Sector in Nyamasheke District, located along Lake Kivu in the Western Province of Rwanda. Nyamasheke is one of seven districts in this province. It is 1,174 km² and contains approximately 588 villages. This district is served by Bushenge and Kibogora District Hospitals and has eighteen health centers. The nurse to population ratio is 1:1277, and doctor to population is 1:25,000. These are both well below the World Health Organization standards of 1 nurse for every 1000 inhabitants and 1 doctor for every 10,000 inhabitants [12].

Traditional medicine providers in Rwanda are typically older women living in a village and there are on average 0-2 per village. These providers do not take classes or undergo official training. The trade is most often passed down within a family, and typically from mother to daughter. There is no spiritual component to the preparation and training of the provider.

Community health workers (CHWs) are members of a village who are given basic health care training in a defined range of topics. They assume the responsibility for various aspects of the healthcare of their fellow village members. They may or may not be literate and many were traditional birth attendants or traditional medicine providers in the past. A village usually has two to four CHWs, with at least one male and one female worker. The director of the local health center supervises their activities.

In 2010, 5 physicians, 18 nurses, 5 CHWs, and 4 traditional medicine providers were interviewed at three levels of the healthcare infrastructure: a district hospital (staffed by doctors with a maternity ward and operating theaters), two health centers (staffed by nurses with inpatient services, including a maternity ward, but no operating theater), and two health posts (staffed by nurses, ambulatory services only). Verbal informed consent was obtained from each participant and all consents and interviews were conducted in Kinyarwanda, French, and/or English, per participant preference. Local interpreters were used as needed. All focus group sessions were conducted with convenience samples of participants. In total, 4 focus group sessions were held with nurses and midwives, one with physicians, and one with CHWs. In addition, 4 individual in-depth interviews were held with traditional medicine providers. Focus group questions were designed specifically to elicit information on use of phytomedicine in pregnancy suitable for the participants and/or the type and level of healthcare facility. The focus group sessions addressed the following: description of a typical user, common phytomedicines used, estimated prevalence of use by pregnant women, and perceived indications and reasons for use during pregnancy. The data collected included basic demographic characteristics of the focus group participants and the answers to the questions. Questions were read verbally to each focus group in English by the investigator and translated into Kinyarwanda by the translator, who served as the focus group moderator. The participant responses were translated from Kinyarwanda into English verbally by the translator/moderator and then recorded in English into a notebook by the investigator at the time of the interviews. These responses were later transcribed into a secured Microsoft Word document file. The same set of questions were asked of each traditional medicine provider while the remaining focus groups of physicians, nurses, and community health workers were asked a list of standardized questions depending on their work profession. Approvals from Montefiore Medical Center Institutional Review Board and the Rwandan National Ethics Committee were obtained prior to initiating this research.

Results

All participants approached for this study agreed to participate. All lived and worked in Nyamasheke District. There were five physicians, eighteen nurses, five community health workers, and four traditional medicine providers interviewed (Table 1). The majority of nurses, CHWs, and traditional medicine providers were female. All physicians were male.

Table 1.

Baseline Demographic Characteristics

	Physicians (n=5)	Nurses (n=18)	Community Health Workers (n=5)	Traditional Medicine Providers (n=4)
Age* (years)	46 (40-52)	35 (28-39)	49 (46-56)	56 (40-78)
Sex  Male  Female	5 0	4 14	1 4	1 3
Job Experience* (years)	8 (6-10)	7 (5-8)	6	26 (25-40)

^*Mean (range)

All healthcare providers, at all sites, estimated the average utilization rates of phytomedicine during pregnancy to be 50-80%. CHWs, nurses, and physicians perceived the following to be the most common indications for phytomedicine use by pregnant women: prevention of malformations, induction of labor and augmentation of contractions, prevention of a husband’s infidelity while a woman is pregnant, prevention of abdominal pain during pregnancy, and protection against witchcraft. Physicians and nurses more commonly perceived there to be non-medical reasons that women use traditional medicines, such as protection from witchcraft, compared to the more commonly reported medical indications by the CHWs and traditional medicine providers. Aside from protection from infidelity, traditional medicine providers only reported clinical indications for use.

The most common complication of phytomedicine use in pregnancy, as perceived by participants in both the nurse and physician focus groups, was a normal labor and delivery with absent neonatal respiratory drive in the setting of abnormally bright green meconium-stained amniotic fluid. Neonatal death was reported to be the most common outcome of these pregnancies. Other less commonly cited complications, noted by the physicians only, included abnormal fetal heart rate and placental abruption.

Traditional medicine providers reported that they provided phytomedicines in pregnancy for prevention and treatment of nausea and vomiting, abdominal pain, bleeding and/or hemorrhage during pregnancy, prevention of malformations and retained placenta, protection against husband’s infidelity (which is believed to cause illness and harm to both the baby and the postpartum mother), and induction of labor (Table 2).

Table 2.

Providers’ Perceived Indications for Use of Traditional Herbal Medicine during Pregnancy

Provider	Medical Indications	Non-Medical Indications
Traditional Medicine Providers	-Prevention and treatment of nausea and vomiting -Prevention and treatment of abdominal pain -Prevention of hemorrhage during pregnancy. -Prevention of post partum hemorrhagePrevention of malformations -Prevention or treatment of retained placenta -Induction of labor	-Protection against infidelity
Community Health Workers (CHWs)	-Prevention of cleft palate and other malformations -Prevention of skin diseases and rashes -Protection against neonatal systemic infections -Prevention of recurrent spontaneous abortions -Prevention of abdominal pain
Nurses	-Prevention of abdominal pain, nausea, vomiting, and anorexia -Prevention of eclampsia -Prevention of malformations -Treatment for retained placenta -Induction of labor	-Protection against husband’s infidelity -Belief that ancestral medicine is safer than western medicine -Protection for baby and mother against witchcraft
Physicians	-Prevention of cesarean sections -Protection for a healthy delivery and post partum period -Enhancement of contractions	-Protection against satanic forces -Protection against being poisoned from enemies - Protection against infidelity by the husband which can cause illness and harm both to the mother and baby

The traditional medicine providers identified 35 plants used during pregnancy (Table 3). The plants were generally grown by the provider and not purchased in a market. Individuals noted to purchase phytomedicine for use during pregnancy included pregnant women, mothers-in-law, husbands, and grandmothers. The reported number of pregnant women who visited a provider per week ranged from 1-10. The providers reported medicines are dispensed according to diagnosis and/or symptom during all trimesters of pregnancy. The most common indication during the 1^st and 2^nd trimester of pregnancy was abdominal pain and prevention of malformations. During the third trimester, the most commonly cited indication for phytomedicine use was labor induction.

Table 3.

Traditional Medicine Names and Indications for Use

Traditional Medication	Indication
Umunkamba* Idomo* Umukuzanyana Umuhe Umunyegenyege Akanyamapfundo Igishikashike Imbazi Umuzibaziba Umubogora	Abdominal pain Bleeding in pregnancy Malformations
Ikinyamata	Nausea Anorexia Abdominal pain Bleeding in pregnancy Malformation
Umumenamabuye Gangabukari	Infidelity Abdominal pain Bleeding in pregnancy Malformation
Igisura Umusura	Abdominal pain
Umushishiro Ingando	Abdominal pain in post-partum
Umutu Umufumbegeshi	Nausea Anorexia
Ikize	Infidelity
Umuravumba	Induction of labor/ increasing contractions
Umuhurura	Induction during post term pregnancy
Ikirogoro Umuyobora* Igisayura	Past term pregnancy
Umutyipfu	Preventing abortions
Igifashi	Bleeding in pregnancy
Umusengese	Trichomonas
Umuhe* Umuhanga* Umutanoga* Umucasuka* Igihondohondo* Umusange*	Only used as an ingredient in Inkuri

^*Ingredient in Inkuri

Phytomedicines are prepared in a multitude of ways. The most common ways include mixing crushed fresh herbs with water or combining either crushed or whole leaf herbs with hot water to make tea. Depending on the indication, phytomedicine may exist as a single herb while other times it is a mixture of different herbs. According to the traditional medicine providers interviewed, most commonly the traditional medicine provider prepares the medicines for the customer and rarely does the customer prepare the traditional medicine themselves.

The most common type of prepared combination phytomedicine is called Inkuri. It is usually prepared and sold by the traditional medicine provider. According to our participants, Inkuri is used all over the Nyamasheke District and beyond, but its composition varies by village and traditional medicine provider. It consists of 7-15 different plants crushed and mixed together with mud. The mixture is then compressed into the shape of a cone and allowed to dry. Portions of the bottom of the cone are then scraped off and mixed with water. This is consumed by women starting from approximately the fifth month of pregnancy and continued either daily or periodically until the onset of labor. It is used for a variety of indications, including treatment of abdominal pain and/or nausea and vomiting, prevention of malformations and/or hemorrhage, and induction of labor.

Discussion

Traditional medicine use was perceived by the medical community to be highly prevalent during pregnancy and over 35 plants were used either alone or in combination to make these medicines. The most commonly perceived complication of traditional medicine use in this study was the absence of neonatal respiratory drive in the setting of abnormally bright green meconium-stained amniotic fluid in an otherwise normal labor and delivery course.

Previous studies of traditional medicine use have conservatively reported rates between 12% to 45% in Tanzania, Nigeria, and Zimbabwe [2-4], which are slightly less than our findings. A South African hospital-based study compared women reporting use of traditional medicine with those not reporting such use, and found that traditional medicine use in pregnancy was relatively common (55% of delivering women). Furthermore, a higher cesarean section rate was observed in women who used traditional medicine compared to women who did not use traditional medicine (39% vs. 22%) [13]. A higher frequency of meconium-stained fluid in women who used traditional medicine during pregnancy compared to those who did not (56% vs. 15%) was also noted. This is similar to the perceptions of the Rwandan medical providers in our study, who reported that there is a high rate of abnormally bright green meconium staining amongst women who had used phytomedicine during their pregnancy.

In the Bushenyi district of rural Uganda, a health survey study found that nearly all of the 285 women interviewed reported using herbal medicines during pregnancy and/or to induce labor [5]. Health surveys reported seventy-five plants that were used to induce labor, some of which were believed to be oxytocic by the authors of the study. Participants in our traditional medicine provider, physician, and nurse focus groups reported the existence of traditional medicines that are prescribed specifically for induction of labor. It is possible that these medicines have strong uterotonic effects that result in fetal distress, meconium stained fluid, and poor neonatal outcomes.

Limitations of our study include small sample size, convenience sampling of the cohort we interviewed, language barriers and possible translational errors, and utilization of a single geographic location. Future studies would also benefit from interviewing pregnant women in the hospitals or health centers as well. However, despite these limitations, valuable information was gathered in this investigation and will help direct future studies.

The abundance and availability of phytomedicine in villages, the traditional teachings passed down generation-to-generation, and the beliefs that phytomedicines are safer than allopathic medicines likely all contribute to their continued widespread use in Rwanda. Despite an extensive effort by the Rwandan government to educate women about the adverse effects of phytomedicines taken during pregnancy, the healthcare workers we interviewed believe their use remains widespread. Studies of maternal, fetal and neonatal outcomes in pregnant women using phytomedication are urgently needed to determine the type and rate of adverse outcomes. Delineation of safe versus teratogenic or dangerous traditional medicines for use in pregnancy may help reduce maternal and neonatal morbidity and mortality in countries with widespread use of phytomedicines.

Appendix 1.

List of Questions Asked at Focus Group and Traditional Medicine Providers Interviews

Questions Asked During Focus Group Sessions

Do you ask your patients if they take phytomedicine when they come to the clinic or hospital? As a healthcare provider, what makes you suspect a patient has taken phytomedicine? In your professional opinion and experience, what results or side effects of pregnant women taking phytomedications? What are the reasons pregnant women use phytomedicine? What percentage of pregnant women use phytomedicine? What are names of the phytomedicines pregnant women use in Rwanda? Who provides phytomedicine to these women? Why do some women not take phytomedicine? How is phytomedicine prepared (water, tea, paste, etc)? When CHW’s used to be traditional medicine providers, where did they get herbs? Do CHW’s currently provide medicines to pregnant women? Who provides the phytomedicine people? How many traditional medicine providers are there in each village? Prior to becoming a CHW when you were a traditional medicine provider, can you provide a list of the names of the plants you use to make the phytomedicines?

Questions Asked during Traditional Medicine Interviews

Where do you get your herbs? Do you personally plant the herbs? Do you collect the herbs in the wild or buy them in the market? Who comes to you to get the phytomedicine? How many women each week do you provide phytomedicine to? What medical conditions during pregnancy do you treat with herbs? Do you use phytomedicines for satanic curses? Do you give phytomedicine throughout pregnancy or just before/after birth? How do you prepare your phytomedicines (water, tea, paste)? Do you prepare phytomedicine or do the women prepare it who purchase it from you? Do you mix herbs together or is a single herb used at a time? Have you seen any negative effects of the phytomedicine? Can you provide a list of the names of the plants? Do women come to you asking for a specific medicine or do you prescribe a medicine that you think they need for a certain problem? How did you become a traditional phytomedicine provider? Where do you get your training/knowledge on phytomedicine?