Complementary and alternative medicine use during early pregnancy
European Journal of Obstetrics & Gynecology and Reproductive Biology, pages 251 - 255
To determine the prevalence and explore predictors of Complementary and Alternative Medicine (CAM) use during early pregnancy.
A questionnaire survey of pregnant women (500) attending for mid trimester scan at the maternity services in Grampian, North-East Scotland. Outcome measures included; CAM used; vitamins and minerals used; independent predictors of use; views and experiences. Descriptive and inferential statistical analysis.
The response rate was 66%. Two thirds of respondents (63%) reported using CAM, excluding vitamins and minerals, during early pregnancy. Respondents reported using a total of 28 different CAM modalities, of which oral herbal products were the most common (37% of respondents, 25 different products). The independent predictors of CAM use identified were: use by family and friends (OR 4.1, 95% CI 2.3–7.3,p < 0.001); ethnicity (non-white British) (OR 3.4, 95% CI 1.8–6.8,p < 0.001); and use prior to pregnancy (OR 2.4, 95% CI 1.2–4.8,p = 0.014). In comparison to prescribed medicines, most users were uncertain if CAM were safer (63%), more effective (66%), free from possible adverse effects (46%) or drug-CAM interactions (50%).
Despite the majority of respondents being uncertain about their safety and effectiveness, CAM modalities and CAM products are widely used during the early stages of pregnancy in this study population. The role of family and friends rather than health professionals in the decision to use CAM may be of concern and requires further investigation.
Keywords: Antenatal, Complementary therapies, Herbal medicine, Pregnancy, Views and experiences.
The World Health Organisation defines complementary and alternative medicine (CAM) as a ‘broad set of health care practices that are not part of that country's own tradition and are not integrated into the dominant health care system’  . CAM approaches are diverse and include modalities such as herbal and homeopathic therapies, acupuncture, aromatherapy, Reiki, Shiatsu and yoga  . While few CAM approaches are supported by robust efficacy, effectiveness or safety data, , and use is widespread, with women reportedly the major users both in health and disease  . Although CAM modalities have been used for centuries and exponents of CAM cite this as evidence of safety, there is a real lack of scientifically valid safety and efficacy data. These issues may be of a particular concern during the early stages of pregnancy and fetogenesis, a time during which several herbal products have been associated with both maternal and foetal harm, , and . In the UK the precautionary approach to the use of CAM during pregnancy was reinforced in 2008 following guidance from the National Institute for Clinical Excellence (NICE Recommendation ID 195, CG62), which stated “Pregnant women should be informed that few complementary therapies have been established as being safe and effective during pregnancy. Women should not assume that such therapies are safe and they should be used as little as possible during pregnancy”.
Since 2008, over 20 surveys from Europe, the Americas, Asia, Australia and Oceania, and Africa have reported on the prevalence of CAM use by pregnant women, (10–33) as highlighted in a recent systematic review  . Thirteen of these studies reported on more than one CAM modality, a further nine studies focused on herbals only and the remaining two on herbals and vitamins. Reported prevalence rates ranged from 5.8% to 74.2% in two separate studies conducted in the USA and . This wide variation is attributed to many factors including lack of or inconsistent CAM definition, differences in culture and ethnicity, and study design. Although all studies assessed CAM use during pregnancy, only nine reported on CAM usage and stage of pregnancy, , , , , , , , , , and . The link between stage of pregnancy and CAM use remains unclear, with five studies, , , , and reporting highest use during the latter stages, and three highest use during the early stages of pregnancy, , and .
While the majority of studies quantified associations between demographic variables and CAM use during pregnancy,, , , , , , , , , , , , , , , , , and less than half used a multivariate approach to identify independent predictors, , , , , , , , and . Predictors included: use of CAM prior to pregnancy, , , and , higher educational attainment, , , , and , presence of chronic disease/prescribed medication, , and , ethnic background/nationality and , higher income  and age  . A major limitation of the majority published studies is the use of postnatal data collection to assess CAM use throughout the whole of pregnancy. There is a lack of UK data describing CAM use during early pregnancy, and a number of reasons limiting the generalizability of published data to UK populations and practice. These include: inconsistency in CAM definition and scope of CAM, clear cultural influences on CAM use and the dynamic nature of popular CAM use. Therefore the aim of this study was to determine the prevalence and explore predictors of CAM use during early pregnancy in a UK population.
Materials and methods
The subjects were women attending for their mid-trimester (18–21 weeks) scan at the Royal Aberdeen Maternity Hospital, North-East Scotland. With an expected response rate of 40%, 500 questionnaires were distributed over a two month period during 2012 to achieve a minimum of 217 responses, calculated to be the appropriate sample size with a margin of error of 5% and a confidence interval of 95%.
A pilot questionnaire was developed from the published literature reporting the use of CAM by pregnant women, , , , , , , , , , , , , , , , , , , , , , , and . CAM in our study was defined as the diagnosis, treatment and prevention of illness by various practitioners using therapies such as herbal and homeopathic products, acupuncture, aromatherapy, chiropracty, vitamins and minerals and certain food products. Furthermore as a prompt the questionnaire contained an extensive list of specific CAM modalities and products. The questionnaire content and structure was reviewed for face and content validity by four individuals with experience in the care of pregnant women and associated research, followed by piloting in a random sample of 20 pregnant women, who were excluded from the full study. Minor modifications were made to the questionnaire post piloting.
The final questionnaire contained four sections comprising: health and medication use during pregnancy (4 items); personal use of CAM therapies (7 items, extensive checklist of CAM modalities and products); attitudes toward CAM use during pregnancy (6 items); and demographics (5 items). Questions were a mix of closed and Likert statements. The questionnaire, together with a study invitation letter, information leaflet and reply paid envelope, was distributed at the screening clinics. As the questionnaire was anonymous no reminders were issued.
Data were coded and entered into an SPSS database (SPSS Inc., Cary, NC version 21.0) and analysed using descriptive statistics to profile respondents. Chi-square was used to test association between variables (e.g. age, level of education, ethnic origin etc.) and CAM use in pregnancy. Variables identified as significant in univariate analysis were entered into binary logistic regression.pValues <0.05 were considered statistically significant.
This research was approved by NHS North of Scotland Research Ethics Committee and NHS Grampian Research and Development Committee on 27th June 2011(REC 11/AL/0094).
Of the 500 questionnaires distributed, 332 were returned, giving an overall response rate of 66%. Respondent demographics are reported in Table 1 . The majority were Caucasian, aged over 25 years, and reported a university education.
|With spouse, partner||83 (277)|
|Secondary school||19 (63)|
|White British||80 (260)|
|First pregnancy||46 (151)|
|Existing medical conditions||27 (91)|
|Concurrent prescribed medication||45 (150)|
Two thirds of respondents (63%) reported using CAM (excluding vitamins and minerals) during the early stage of pregnancy. Vitamins and minerals were also used by 73% of respondents. Almost one quarter of respondents (23%) reported using CAM prior to becoming pregnant, of whom one third (37%) stopped on becoming pregnant. Respondents reported using a total of 28 different CAM modalities of which herbal products were the most commonly used by over a third of respondents.
The CAM modalities used, the proportion using, recommender (e.g. health professional, family, friend) and the medical indications for use are reported in Table 2 . The specific herbal products, recommenders and medical indications for use are reported in Table 3 . Twenty-five different herbal products were reported, of which the six most frequently used were: ginger (beyond cooking), cranberry, chamomile, raspberry tea/capsules, tea tree oil and senna.
|CAM||% Using||Recommended by (%) *||Reasons for using CAM given by respondents|
|Herbal products||59 (122)||See Table 3|
|Massage||33 (69)||4||39||0||19||7||0||9||Back pain, relaxation|
|Nutraceuticals||19 (39)||5||21||0||0||8||28||18||General health, constipation, stomach|
|Aromatherapy||17 (36)||0||17||0||0||0||0||3||Pain, nausea|
|Yoga||16 (33)||0||12||0||30||6||3.0||36||Back pain, relaxation, general health|
|Alexander technique||1.9 (4)||0||0||0||25||25.0||0||25||Pain, exercise|
|Chinese medicine||0.5 (1)||0||0||0||0||0||0||0||Fertility|
* Do not total 100% due to missing data, percentages rounded up or down to two significant figures.
|Herbal product||% Using||Recommended by (%) *||Reasons given by respondents for using herbal products|
|Ginger (beyond cooking)||42 (51)||0||26||4||31||12||2||8||Nausea|
|Cranberry||26 (32)||3||53||0||9||3||0||6||Urinary symptoms, prevention|
|Chamomile||21 (26)||8||0||8||22||3||14||9||Relaxation, help sleep, digestion|
|Raspberry tea/capsules||13 (16)||19||6||6||0||13||13||19||Labor preparation, alternative to black tea|
|Tea tree oil||11 (13)||8||0||8||23||8||0||14||Skin, antiseptic|
|Echinacea||7.4 (9)||0||0||0||44||22||11||0||Cold symptoms|
|Grapefruit||5.7 (7)||0||0||0||0||0||0||57||Vitamin C|
|Garlic (beyond cooking)||4.9 (6)||0||0||0||17||0||0||0||Nausea|
|Eucalyptus||4.1 (5)||0||0||20||40||0||0||40||Cold symptoms|
|Clove oil||3.3 (4)||0||0||50||0||0||0||50||Dental pain|
|Evening primrose oil||2.5 (3)||33||0||0||0||0||0||67||Skin|
|Nettle root||1.6 (2)||0||0||0||50||0||50||0||Nausea|
|Co-enzyme Q10||1.6 (2)||0||0||0||0||0||0||0|
|Bee pollen||0.8 (1)||0||0||0||0||0||0||100||Chapped lips|
* Do not total 100% due to missing data, percentages rounded up or down to two significant figures.
The recommendations to use CAM modalities and products during the early stage of pregnancy were principally made by family and friends and midwives. Midwives were more frequently cited by respondents as recommending approaches such as massage, reflexology and homeopathy, while family and friends were more frequently cited for herbals, yoga, reiki and hypnosis.
CAM users were significantly more likely to have used CAM prior to becoming pregnant (p < 0.0001), have family and friends who use CAM (p < 0.0001), to have a university education (p < 0.001), and to be non-white British (p < 0.001). However in binary logistic regression the variables retained were: CAM use by family, friends (OR 4.1, 95% CI 2.3–7.3,p < 0.001); ethnicity, non-white British (OR 3.5, 95% CI 1.8–6.8,p < 0.001) and CAM use prior to pregnancy (OR 2.4, 95% CI 1.2–4.8,p = 0.014). Comparison of CAM users with non-users is reported in Table 4 .
|Characteristic||Users (n = 208) % (n)||Non-users (n = 124) % (n)||p-Value|
|15–-24||10 (21)||17.7 (22)||0.124|
|25–34||68 (141)||63.7 (79)|
|≥35||22 (46)||18.5 (23)|
|University||60 (125)||37.9 (47)||<0.001|
|College||25 (51)||37.1 (46)|
|Secondary school||15 (32)||25.0 (31)|
|White British||72 (150)||88.7 (110)||<0.001|
|Other||27 (58)||11.3 (14)|
|First pregnancy||50 (103)||39.0 (48)||0.064|
|Medical condition||28 (58)||26.6 (33)||0.063|
|Prescribed medication||49 (101)||39.8 (49)||0.124|
|CAM use before pregnancy||30 (63)||10.6 (13)||<0.0001|
|CAM use by family, friends||51 (105)||16.3 (20)||<0.0001|
While two thirds of respondents were uncertain whether CAM use was safer than conventional prescribed medicines during pregnancy, users were significantly more likely than non-users, to agree that CAM were safer (p = 0.04). A similar proportion of respondents were uncertain whether CAM were more effective than prescribed medicines (p = 0.551). Just over half of respondents were uncertain whether CAM could interfere with conventional medicines; users were significantly more likely to disagree with this statement (p < 0.0001). Over half of respondents were uncertain if CAM therapies could cause side effects, with users significantly more likely to agree (p < 0.00001). When asked if patients should report CAM use to their health professional three quarters of respondents agreed with this statement, with CAM users being significantly more likely to agree (p < 0.001). Finally when asked whether CAM should be available through the NHS at no cost, just over half of respondents agreed, with users being significantly more likely to agree (p < 0.003). Comparison of the attitudes expressed by CAM users with non-users is reported in Table 5 .
|Statement||% (n) strongly agree/agree||% (n) uncertain||% (n) strongly disagree/disagree||p-Value|
|During pregnancy complementary and alternative medicine are safer than conventional medicines prescribed by my doctor||19 (39)||8.8 (11)||63 (130)||73 (91)||19 (39)||18 (22)||0.040|
|Complementary and alternative medicine are more effective than conventional medicine prescribed by my doctors during pregnancy||6.8 (14)||4.0 (5)||66 (138)||70 (87)||27 (56)||26 (32)||0.551|
|Complementary and alternative medicine can interfere with conventional medicines prescribed by my doctors||36 (74)||27 (34)||50 (103)||70 (87)||15 (31)||2.4 (3)||<0.0001|
|Complementary and alternative medicine can cause side effects||41 (86)||27 (34)||46 (96)||71 (88)||13 (26)||1.6 (2)||<0.00001|
|Health care professionals should be informed by patients about the use of any complementary and alternative medicine during pregnancy||78 (161)||60 (74)||20 (41)||38.7 (48)||2.9 (6)||1.6 (2)||<0.001|
|Complementary and alternative medicine should be available through the NHS||61 (127)||44 (54)||31 (65)||50 (62)||7.7 (16)||6.4 (8)||0.003|
To our knowledge this is the first UK study to report the prevalence of CAM use, and the predictors of use during the early stages of pregnancy. Two thirds of respondents reported using CAM, which included 28 different modalities during the early stages of pregnancy. Herbal products were the most frequently cited, with one or more of 25 different products being used by over a third of all respondents. The significant predictors for CAM use identified in our population were: use by family and friends, use before pregnancy, and being non-white British.
Unlike previous reports, our study included a definition of CAM together with comprehensively detailed checklists for both CAM modalities and specific CAM products. A further strength of our study is the relatively prospective nature of data collection minimising recall bias. Limitations however are the use of convenience sampling, with data being collected from only one centre in North East Scotland, and the lack of data from non-respondents, both of which may limit external validity. However the age and ethnicity of our study population are similar to those recently reported demographic statistics of pregnant women in England and Wales  .
Although a number of studies have previously reported on the prevalence of CAM use with stage of pregnancy, , , , , , , and , the general lack of standardised CAM definition, together with the absence of detailed checklists for research participants, makes direct comparison of study results potentially misleading. The only comparable study performed in a UK population, with data more than 20 years old, reported that 6.0% of women used CAM during their first trimester, increasing to 12.4% during the second and 26.5% during the third  . The level of CAM use observed in our study is similar to that reported for 67.5% of Qatari women during their first trimester  . However this comparison should be interpreted with caution due to the potential impact of culture and ethnicity.
Herbal products were the most frequently reported CAM modality in our study being used by almost half of respondents. This level of use is greater than previously reported from the USA, Australia, Europe and Asia, , , , , , , , , , , , , , , , , , , , and , although similar to the 52.4% reported in a Malaysian population and 59.9% reported by Sim et al. for breast feeding mothers in Australia  . However, as stated earlier direct comparison may again lack validity  .
Given the global drive toward evidence based medicine  and the lack of robust safety and efficacy data for CAM approaches, the use during early pregnancy may be a key issue. Furthermore, in our study over a third of all respondents reported the use of oral herbal products, which in light of the increasing recognition of potential adverse events, , , , and and potential for drug-herb interactions  , may be significant both for maternal and foetal health.
Logistic regression identified the significant predictors of CAM use during pregnancy as: CAM use by family and friends; ethnicity (non-white British); and CAM use prior to pregnancy. While previous studies have identified predictors for CAM use, including CAM use prior to pregnancy, , and , higher educational attainment, , and chronic disease/medication, , and , ethnic background/nationality and , higher income  and age  , ours is the first study to highlight the prominence of CAM use by family and friends as an independent predictor for CAM use in the early stages of pregnancy. The importance of family and friends, who may bring a very personal perspective to the decision to use CAM during pregnancy, rather than trained healthcare professionals, may be of concern. However, a recent survey of UK health professionals involved in the care of pregnant women identified that those who were CAM users themselves were eight times more likely to recommend or advise the use of CAM to pregnant women  .
Despite the high levels of CAM use, most users were uncertain of the safety, effectiveness or the potential for drug interactions with prescribed medicines. Such a paradoxical situation has been previously reported for women using CAM while breast feeding  , in which almost half of respondents believed that herbal medicines were safer than conventional medicines. The explanation for the apparent inconsistency between their stated uncertainty regarding CAM safety and effectiveness, and their decision to use CAM may be complex and involve issues such as control  , empowerment and a belief that CAM, especially herbal medicines, are not chemicals  . Whatever the reasons for these apparently paradoxical belief sets these issues merit further work to explore relationships between specific CAM modalities and possible concerns expressed by users and the drivers for and expectations of CAM use.
CAM modalities and CAM products are widely used during the early stages of pregnancy in this study population. The role of family and friends, rather than health professionals, in the decision to use CAM may be of concern and requires further investigation.
Conflict of interest
The author(s) report no conflict of interest.
This study was funded from internal institutional resources.
CAM therapies especially herbals are extensively used by women during the early stages of pregnancy with a key predictor being use by family and friends.
We acknowledge the support of all the staff at the antenatal clinic, Royal Aberdeen Maternity Hospital, in carrying out this project and also all the women who participated by completing and returning the questionnaire.
-  World Health Organisation. Traditional medicines: definitions. (World Health Organisation, 2014) 〈http://www.who.int/medicines/areas/traditional/definitions/en/index.html〉 (accessed June 2014)
-  E. Ernst, M.H. Pittler, B. Wider. The desktop guide to complementary and alternative medicine. (Mosby Elsevier, Amsterdam, 2006)
-  A. Fugh-Berman, F. Kronenberg. Complementary and alternative medicine (CAM) in reproductive-age women: a review of randomized controlled trials. Reprod Toxicol. 2003;17(2):137-152 Crossref
-  National Center for Complementary and Alternative Medicine. National Center for Complementary and Alternative Medicine. (, 2014) 〈http://nccam.nih.gov/health/whatiscam〉 (accessed June 2014)
-  D.M. Marcus, W. Snodgrass. Do no harm: avoidance of herbal medicines during pregnancy. Obstet Gynecol. 2005;5(1):1119-1122 Crossref
-  K.J. Hunt, H.F. Coelho, B. Wider, et al. Complementary and alternative medicine use in England: results from a National Survey. Int J Clin Pract.. 2010;64(11):1496-1502 Crossref
-  E. Ernst. Herbal medicinal products during pregnancy: are they safe?. BJOG. 2002;109:227-235 Crossref
-  C.H. Chuang, P. Doyle, J.D. Wang, P.J. Chang, J.N. Lai, P.C. Chen. Herbal medicines used during the first trimester and major congenital malformations an analysis of data from a pregnancy cohort study. Drug Saf. 2006;29(6):537-548 Crossref
-  M. Elvin-Lewis. Should we be concerned about herbal remedies. J Ethnopharmacol.. 2001;75(2–3):141-164 Crossref
-  J. Adams, D. Sibbritt, C. Lui. The use of complementary and alternative medicine during pregnancy: a longitudinal study of Australian. Women Birth. 2011;38(3):200-206 Crossref
-  J.L. Bishop, K. Northstone, J.R. Green, E.A. Thompson. The use of complementary and alternative medicine in pregnancy: data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Complement Ther Med. 2011;19(6):303-310 Crossref
-  Al-Riyami, M. Intisar, Q. Intisar, Al-Busaidy, I.S. Al-Zakwani. Medication use during pregnancy in Omani women. Int J Clin Pharm. 2011;33(4):634-641
-  M. Kalder, K. Knoblauch, I. Hrgovic, K. Münstedt. Use of complementary and alternative medicine during pregnancy and delivery. Arch Gynecol Obstet. 2011;283(3):475-482 Crossref
-  R. Khresheh. How women manage nausea and vomiting during pregnancy: a Jordanian study. Midwifery. 2011;27(1):42-45 Crossref
-  H. Nordeng, G. Koren, A. Einarson. Use of herbal drugs during pregnancy among 600 Norwegian women in relation to concurrent use of conventional drugs and pregnancy outcome. Complement Ther Clin Prac. 2011;17(3):147-151 Crossref
-  M. Tabatabaee. Use of herbal medicine among pregnant women referring to Valiasr hospital in Kazeroon. J Med Plants. 2011;10(37):96-108
-  J. Bercaw, B. Maheshwari, H. Sangi-Haghpeykar. The use during pregnancy of prescription, over-the-counter, and alternative medications among Hispanic women. Birth. 2010;37(3):211-218 Crossref
-  C.S. Broussard, C. Louik, M.A. Honein, A.A. Mitchell. National birth defects prevention study, herbal use before and during pregnancy. Am J Obstet Gynecol. 2010;202(5):443.e1-443.e6 Crossref
-  L. Cuzzolin, G. Benoni. Safety issues of phytomedicines in pregnancy and paediatrics. K.G. Ramawat (Ed.) Herbal drugs: ethnomedicine to modern medicine (Springer Berlin Heidelberg, Heidelberg, 2009) 381-396 Crossref
-  K. Kochhar, J.R.M. Saywell, T.W. Zollinger, et al. Herbal remedy use among hispanic women during pregnancy and while breast feeding: are physicians informed?. Hispanic Health Care Int. 2010;8(2):93-106 Crossref
-  F. Lapi, A. Vannacci, M. Moschini, et al. Use, attitudes and knowledge of complementary and alternative drugs (CADs) among pregnant women: a preliminary survey in Tuscany. Evid-Based Comp Alt. 2010;7(4):477-486 Crossref
-  M. Leppee, J. Culig, M. Eric, J. Boskovic, N. Colak. Vitamin, mineral and iron supplementation in pregnancy: cross-sectional study. Biopolym Cell. 2010;26(2):128-135 Crossref
-  C. Louik, P. Gardiner, K. Kelley, A.A. Mitchell. Use of herbal treatments in pregnancy. Am J Obset Gynecol. 2010;202(5):439
-  H. Mohamed, J. Abdin, D. Al Kozaai. Knowledge, attitude and practice of complementary and alternative medicine (CAM) among pregnant women: a preliminary survey in Qatar. Middle East J Fam Med. 2010;7(10):5-14
-  C.H. Chuang, P.J. Chang, W.S. Hsieh, Y.J. Tsai, S.J. Lin, P.J. Chen. Chinese herbal medicine use in Taiwan during pregnancy and the postpartum period: a population-based cohort study. Int J Nurs Stud. 2009;46(6):787-795 Crossref
-  T.O. Fakeye, R. Adisa, I.E. Musa. Attitude and use of herbal medicines among pregnant women in Nigeria. BMC Complement Alt Med. 2009;9:53 Crossref
-  D.A. Forster, G. Wills, A. Denning, M. Bolger. The use of folic acid and other vitamins before and during pregnancy in a group of women in Melbourne, Australia. Midwifery. 2009;25(2):134-146 Crossref
-  L. Holst, D. Wright, H. Nordeng, S. Haavik. Use of herbal preparations during pregnancy: focus group discussion among expectant mothers attending a hospital antenatal clinic in Norwich, UK. Complement Ther Clin Prac. 2009;15(4):225-229 Crossref
-  K. Moussally, D. Oraichi, A. Berard. Herbal products use during pregnancy: prevalence and predictors. Pharmacoepidermiol Durg Saf. 2009;18(6):454-461 Crossref
-  A.A. Rahman, S.A. Sulaiman, Z. Ahmad, H. Salleh, W.N. Daud, A.M. Hamid. Women's attitude and sociodemographic characteristics influencing usage of herbal medicines during pregnancy in Tumpat District, Kelantan. Southeast Asian J Trop Med Pubulic Health. 2009;40(2):330-337
-  H. Skouteris, E.H. Wertheim, S. Rallis, S.J. Paxton, L. Kelly, J. Milgrom. Use of complementary and alternative medicines by a sample of Australian women during pregnancy. Aust NZ J Obstet Gynaecol. 2008;48(4):384-390 Crossref
-  J. Frawley, J. Adams, D. Sibbritt, A. Steel, A. Broom, C. Gallois. Prevalence and determinants of complementary and alternative medicine use during pregnancy: results from a nationally representative sample of Australian pregnant women. Aust NZ J Obstet Gynaecol. 2013;53(Is4):347-352 Crossref
-  H.R. Hall, K. Jolly. Women's use of complementary and alternative medicines during pregnancy: a cross-sectional study. Midwifery. 2013;10.1016/j.midw.2013. 06.001
-  A.R. Pallivalappila, D. Stewart, A. Shetty, B. Pande, J.S. McLay. Complementary and alternative medicines use during pregnancy: a systematic review of pregnant women and healthcare professional views and experiences. Evid-Based Comp Alt. 2013;10.1155/2013/205639
-  J. Henderson, H. Gao, M. Redshaw. Experiencing maternity care: the care received and perceptions of women from different ethnic groups. BMC Pregnancy Childbirth. 2013;13:196 Crossref
-  T.F. Sim, J. Sherriff, H.L. Hattingh, R. Parsons, L.B.G. Tee. The use of herbal medicines during breastfeeding: a population-based survey in Western Australia. BMC Complementary Alt Med. 2013;13:317 Crossref
-  The Cochrane Collaboration. The Cochrane Collaboration. (, 2014) 〈http://www.cochrane.org/〉 (accessed June 2014)
-  D.N. Patel, W.L. Low, L.L. Tan, et al. Adverse events associated with the use of complementary medicine and health supplements: an analysis of reports in the Singapore pharmacovigilance database from 1998 to 2009. Clin Toxicol (Phila). 2012;50(6):481-489 Crossref
-  P. Posadzki, L.K. Watson, E. Ernst. Adverse effects of herbal medicines: an overview of systematic reviews. Clin Med. 2013;13(1):7-12 Crossref
-  P. Posadzki, A. Alotaibi, E. Ernst. Adverse effects of aromatherapy: a systematic review of case reports and case series. Int J Risk Saf Med. 2012;24(3):147-161
-  E. Ernst, P. Posadzki. Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: systematic review. NZ Med J. 2012;125(1353):87-140
-  E. Ernst. Fatalities after CAM: an overview. Brit J Gen Pract. 2011;61(587):404-405 Crossref
-  J.S. McLay, D. Stewart, J. George, C. Rore, S.D. Heys. Complementary and alternative medicines use by Scottish women with breast cancer, what, why and the potential for drug interactions?. Eur J Clin Pharm. 2012;68(5):811-819 Crossref
-  D. Stewart, A.R. Pallivalappila, A. Shetty, B. Pande, J.S. McLay. Healthcare professional views and experiences of complementary and alternative therapies in obstetric practice in North-East Scotland. Br J Obstet Gynaecol. 2014;121:1015-1019
-  M. Mitchell, Risk. pregnancy and complementary and alternative medicine. Complementary Ther Clin Pract. 2010;16(2):109-113 Crossref
-  S. Warriner, K. Bryan, A.M. Brown. Women's attitude towards the use of complementary and alternative medicines (CAM) in pregnancy. Midwifery. 2014;1:138-143
a Institute of Medical Sciences, The University of Aberdeen, Aberdeen AB24 3FX, UK
b School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen AB10 7QJ, UK
c Royal Aberdeen Maternity Hospital, NHS Grampian, Aberdeen AB25 2ZL, UK
d Ninewells Hospital and Medical School, Dundee, UK
e Biostatistics, Medical Research Center, Hamad Medical Corporation, Doha, Qatar
f Institute of Medical Sciences, The University of Aberdeen, Aberdeen AB24 3FX, UK
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