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Table 3 Thematic analysis: women’s use of CMPs in pregnancy and lactation and perceived benefits

From: Complementary medicine products used in pregnancy and lactation and an examination of the information sources accessed pertaining to maternal health literacy: a systematic review of qualitative studies

Use of CMPs during pregnancy
Major themes Subthemes Over-arching motive ‘Protective or preventative action’ OR ‘Facilitation of a normal process’ Selected examples (full thematic analysis can be seen in Additional file 3) (in italics – participant direct quotes; in Roman (non-italicised) - text quotes (the papers did not always include quotes)
Women’s use of CMPs – perceived physical benefits
  For the benefit of the pregnancy • Prevention of vaginal bleeding and miscarriage in early pregnancy • Protect against vaginal leaking and bleeding in both early and late pregnancy Protective or preventative action “At the initial stages of my pregnancy I was bleeding and I came to the hospital for drugs but it was persistent. So I went for herbal medicine and it helped me” (Focus group participant, ANC client, Madina)” (Dako-Gyeke et al. 2013, p211) [62]
• Ensure a safe pregnancy Facilitation of a normal process “I have been advised to drink boiled herbs (Mbita) for the preservation and protection of my unborn baby, so that I may have a safe pregnancy and labour.” (Ngomane & Mulaudzi, 2012, p34) [57]
  For the benefit of the baby • Promotion of the developing baby’s physical health - assist the baby’s intrauterine growth and support their well-being, health and vitality • Monitor the baby’s health and growth Facilitation of a normal process “I think both [iron pills and herbal medicine] are important, aren’t they? I take the herbals regularly and I feel that my baby is healthy that was also what I did in my first pregnancy. I regularly took the herbals and nothing’s wrong with my baby. In fact, he was very vigorous. (Woman 6)” (Wulandari & Whelan, 2011, p868–9) [53]
• No perceived benefit for the use of CMPs in pregnancy – taking vitamins was incompatible with Japanese cultural beliefs around taking medications in pregnancy Neither “I have been eating Japanese food in the United States just like I did in Japan when I had my first child. I never took a vitamin with my first child. .. and it did not have any bad effects on my child. .. then American doctors told me that it’s better to take vitamins. .. I don’t mind taking it, but I don’t know why I need to take it, as nothing bad happened with my first child in Japan.” (Yeo et al., 2000, p194) [49]
  For the benefit of the mother • Prevention or treatment of common illnesses associated with pregnancy like thrush and urinary tract infections • Prevention or treatment of non-pregnancy related illnesses • First line treatment of maternal danger signs in pregnancy • Protection against the development of pregnancy complications Protective or preventative action “The participants identified ‘aseje’, (a special concoction, mainly herbs) as one of the attractions of seeking care from TBAs. It is believed that the ‘aseje’ prevents development of any complications during pregnancy and labour and keeps pregnant women healthy” (Okafor et al. 2014, p46) [8]
• Safe support for mother’s own physical health • Treatment of maternal anaemia; provision of nourishment • Safe form of treatment for nausea and vomiting of pregnancy • Treatment of abdominal pain in pregnancy Facilitation of a normal process “Tonic herbs can be thought of as lying somewhere in between food and drugs; they are used therapeutically, to treat sub-clinical conditions or to prevent health degeneration. They are used to strengthen, nourish and support the body, to prevent rather than cure disease […] The most popular herb was raspberry leaf (Rubus idaeus) - a uterine tonic - used by 22 women.” (Westfall 2003 – herbal healing, pp26–27) [40].
  For the benefit of the labour and birthing processes • Prevention of vaginal tearing during birth and reducing risk of caesarean section • Prevention of foetal distress Protective or preventative action “A typical example is what is locally known as amalagala, a product of crushed sweet-potato leaves mixed with water. This mixture is administered to pregnant women, who bathe in it or sit on it to lessen the risk of requiring a Caesarean section or of vaginal tearing during delivery. The women did not discuss trial and error for this concoction but unanimously reported confidence in its efficacy” (Rutakumwa & Krogman, 2007) [59]
• Use of herbal tonics to tone the uterus and strengthen it in preparation for labour • Prepare for an easy birth • Enhance or induce labour • Relieve labour pains • Induce expulsion of retained placenta • Relieve afterbirth pains Facilitation of a normal process “Consumption of traditional herbal medicine was also mentioned as a way of preparing for an easy birth. The traditional herbal medicine was referred to as ya tom. A woman must consume ya tom three times per day for three consecutive days. Women can purchase dried herbal medicine and boil it until it reduces to small cup quantity and drink it as tea. This is believed to make the baby strong, hence facilitating an easy birth.” (Liamputtong et al. 2005, p146) [4]
Women’s use of CMPs in pregnancy to protect against spiritual threats to themselves and their unborn babies – perceived benefits involving spiritual protection
  For the benefit of both mother and baby • Protect the baby from spiritual threats that could cause physical harm including death of the foetus or preterm labour Protective or preventative action “All the women in this study stated that both the mother and baby might fall ill because of kuhabula. To prevent illness therefore, the women expressed belief in the power of traditional doctors and medicine, or divine prayer if the women or family was religious”. .. [traditional medicines are taken] to make sure that the baby is protected on all fronts; protected from kuhabula [acquisition of illnesses from bad spirits in the environment] through the use of traditional medicine” (Thwala et al., 2011, p95) [47]
II. Use of CMPs during breastfeeding
Women’s use of CMPs – perceived physical benefits
  For the benefit of the breastfeeding process • Increased breastmilk production – perceived and diagnosed milk insufficiency • Use of galactagogues ‘just in case’ breastmilk supply needs support • Use of galactagogues to build supply as part of a cultural tradition (note, no mention of perceived insufficiency) Facilitation of a normal process “I think it’s [fenugreek] worth trying. And as for me, I certainly find that useful and reassuring that I have found something effective to increase my milk supply. As a new mum, you just never know, you never know what is coming, what problems you will encounter and I certainly did not anticipate that milk supply will be an issue. I have always thought that breastfeeding is easy and will come naturally because everyone else does it, and I wasn’t told about it being an issue”. (BW 12). (Sim et al., 2014, p216) [55]
  For the benefit of the breastfeeding process and the mother’s physical health • Use of galactagogues supports post-birth recovery and also builds breastmilk supply Facilitation of a normal process “During the early postpartum period as women recovered, family members again provided certain foods that were believed to have ‘hot effects’ and bring the body into balance. These types of food are seen as essential for healing and recovery from the birthing process (arising from Ayurveda traditions), including relieving back pain, promoting menstrual flow to cleanse the body, building the mother’s milk supply, and preventing weakness and illness in later life. ‘Hot foods’ included … chai (fennel seed tea with ginger) … and other special foods … made from ‘heat-producing’ ingredients such as ginger powder, fennel seeds … and special herbs.” (Grewal, 2008, p294) [43]
Protective or preventative action
  For the benefit of the mother’s physical health • Expulsion of lochia through ‘uterine cleansing’ and control of postpartum bleeding • Assists in recovery after childbirth • Restoration of physical balance through heat Facilitation of a normal process “You eat them [chicken herbal medicine] so that your body will settle back to normal quicker and if you don’t use them then it will take you a long time to get back to normal. The bleeding will go on for a long time and that will make you very thin. That is not good.. . If you bleed too long the body won’t get back to normal again and this can make you pale and skinny. If you have the chicken herbs to eat then your blood will be good and you will feel strong quickly.. . You eat them to give you strength and also to wash out your blood quickly too” (Rice, 2000, p29) [44]
• Treatment of a prolapsed uterus • Protection of the mother’s future health Protective or preventative action “Considered the most important Chinese cultural practice is ‘doing (or sitting) the month’ (zuoyuezi). … ‘Doing the month’ includes activity restrictions, avoiding ‘wind chill’ ... and eating raw ginger soup with Chinese herbs to ‘rid the body of cold’ … If such practices as described are not followed, the new mother is at risk for ‘the month disease,’ which is thought to have deleterious effects on their health for the rest of their lives (Callister et al., 2011, pp390–1) [61]
  For the benefit of the breastfeeding baby • Protection of the breastfeeding baby through the mother’s use of CMPs • Purification of mother’s breasts in preparation for breastfeeding and to ensure breastmilk is sweet Protective or 2preventative action “The ingestion of local herbs is used as a means of warding off any harmful effects to the baby […] To protect the baby from health problems … the newly delivered mother, her mother, and her mother-in-law - should take local drugs [herbal medicines] before the grandmother sees the baby for the first time” (Juntunen et al., 2011, p177) [7]
• Promotion of the baby’s health through enabling the mother to continue to breastfeed Facilitation of a normal process “All participants seemed to have adopted the ‘breast is best’ philosophy. These women acknowledged and appreciated the health, physical and psychological benefits of breastfeeding to both mothers and infants. […] Recognition of the importance and significance of breastfeeding was identified as the main facilitator to develop perseverance and a determined attitude to breastfeed: “I mean honestly, if drinking snake oil would make me have more breast milk I would have done it, anything that helps!” (Sim et al., 2014, p216) [55]
Women’s use of CMPs during breastfeeding – perceived mental-emotional benefits
  For the benefit of the mother • Increased self-confidence, self-empowerment and reassurance • Increases my ability for self-care Facilitation of a normal process “Many participants also mentioned the feeling of reassurance through the use of herbal supplements during breastfeeding, which was especially important for first-time mothers. Hence, the use of herbal galactagogue was described as a method of reassurance in the context of their own perceptions. The positive emotional impact contributed to the success of breastfeeding practices amongst the participants.” (Sim et al., 2014, p216) [55]
• Restoration of mind-body balance Protective or preventative action “The herbs in hot bath, such as leaves of Nat, release aromatic oils, which are believed to relieve mind–heart, emotional, and psychological stress. LD said ‘the water for a hot bath is boiled with leaves of an herb named Nat. The leaves will prevent her from feeling dizzy or being intoxicated.’ Leaves of Nat … can be used for treating fatigue, exhaustion, psychological and emotional imbalances, and postpartum depression [and also] to ward off a malevolent spirit and to make holy water. The women in this study used both the medicinal and supernatural properties of Nat leaves to treat the mind–heart essence” (Elter et al., 2016, p253) [58].
Women’s use of CMPs during breastfeeding – perceived benefits involving spiritual protection
  For the benefit of the mother • Spiritual protection in the postpartum period Protective or preventative action In Thailand, Nat leaves are also used to ward off a malevolent spirit and to make holy water. The women in this study used both the medicinal and supernatural properties of Nat leaves to treat the mind–heart essence” (Elter et al., 2016, p253) [58]
Women’s use of CMPs during breastfeeding – perceived cultural benefits
  For the benefit of the mother • Cultural cleansing rituals after childbirth Facilitation of a normal process “Also first-time mothers are expected to go through a cultural cleansing known as sooru in Kasem and kosoto in Nankani, regardless of the bitterness of their breastmilk. The process involves the pouring of warm herbal water over the mother for a period of 3 days if the child is a male and for 4 days if the child is female” (Aborigo et al. 2012, p76) [60]
III. Additional themes relating to perceived benefits of women’s use of CMPs throughout the childbearing continuum
 Perceptions of safety regarding CMP use in pregnancy and lactation • Complementary medicines are safer than pharmaceutical medications • Receiving reassurance that herbal medicines are safe during pregnancy and breastfeeding Protective or preventative action ‘I am certainly not opposed to the idea of using herbs during breastfeeding, as long as I know and have checked with my child health nurses and doctors or even ringing up a pharmacist’ (BW 12)” (Sim et al., 2014, p216) [55]
 Using both CMPs and concurrently accessing biomedical care promotes best care for both mother and baby • Better management of maternity complications in pregnancy and birth • Protection of the baby from diseases understood to arise from spiritual causes as well as from diseases treatable with biomedical medicines Protective or preventative action “I use traditional medicines during the pregnancy … I also go to the hospital every month to have check-ups. They give me pills which I take home to drink together with the traditional medicines [...I use both traditional medicines and hospital medicines] to make sure that the baby is protected on all fronts; protected from kuhabula [acquisition of illnesses from bad spirits in the environment] through the use of traditional medicine as well as protected from the hospital diseases by using their modern medicine.” (Thwala et al., 2012, p95) [69]