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The Use of Herbs by California Midwives
JOGNN
RESEARCH
The Use of Herbs by California Midwives Cathi Dennehy, Candy Tsourounis, Lindsey Bui, and Tekoa L. King
Correspondence Cathi Dennehy, PharmD, Department of Clinical Pharmacy, UCSF, 521 Parnassus Ave, Suite C-152, Box 0622, San Francisco, CA 94143. dennehyc@pharmacy. ucsf.edu Keywords herb nurse midwife pregnancy fertility lactation education ginger black cohosh blue cohosh
ABSTRACT Objective: To characterize herbal product use (prevalence, types, indications) among Certified Nurse Midwives/ Certified Midwives (CNMs/CMs) and Licensed Midwives (LMs) practicing in the state of California and to describe formal education related to herbal products received by midwives during midwifery education. Design/Setting/Participants: Cross-sectional survey/California/Practicing midwives. Methods: A list of LMs and CNMs/CMs practicing in California was obtained through the California Medical Board (CMB) and the American College of Nurse Midwives (ACNM), respectively. The survey was mailed to 343 CNMs/CMs (one third of the ACNM mailing list) and 157 LMs (the complete CMB mailing list). Results: Of the 500 surveys mailed, 40 were undeliverable, 146 were returned, and 7 were excluded (30% response rate). Of the 139 completed surveys, 58/102 (57%) of CNMs/CMs and 35/37 (95%) of LMs used herbs, and LMs were more comfortable than CNMs/CMs in recommending herbs to their patients. A majority of LMs had 420 hours of midwifery education on herbs whereas a majority of CNMs/CMs received 0 to 5 hours. Some CNMs/CMs indicated that their practice site limited their ability to use herbs. Common conditions in which LMs and CNMs/CMs used herbs were nausea/vomiting (86% vs. 83%), labor induction (89% vs. 58%), and lactation (86% vs. 65%). Specific herbs for all indications are described. Conclusion: Licensed midwives were more likely than CNMs/CMs to use herbs in clinical practice. This trend was likely a reflection of the amount of education devoted to herbs as well as herbal use limitations that may be encountered in institutional facilities.
JOGNN, 39, 684-693; 2010. DOI: 10.1111/j.1552-6909.2010.01193.x Accepted August 2010
Cathi Dennehy, PharmD, is a health sciences clinical professor in the School of Pharmacy, University of California, San Francisco, CA. Candy Tsourounis, PharmD, is a professor of clinical pharmacy in the School of Pharmacy, University of California, San Francisco, CA. Lindsey Bui, PharmD, BCPS, is an ambulatory care pharmacist at Kaiser Permanente, Stockton, CA.
omplementary and alternative medicine (CAM) is frequently used by individuals living in the United States, especially among women and persons residing in the West (Barnes, Bloom, & Nahin, 2008; Institute of Medicine. Committee on the Use of Complementary and Alternative Medicine by the American Public, 2005). Although CAM encompasses many di¡erent practices, the use of biological products and more speci¢cally nonvitamin, nonmineral natural products is the most prevalent. The 2007 National Health Interview Survey (NHIS) estimated that 18% of adults used such products in the last 12 months (Barnes et al.).
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tagogues as high as 43% (Forster, Denning, Wills, Bolger, & McCarthy, 2006; Holst, Wright, Haavik, & Nordeng, 2009; Nordeng & Havnen, 2004). Studies from the United States described a lower rate of use ranging from 4.1% to 13% (Gibson & Powrie, 2001; Hepner et al., 2002; Refuerzo et al., 2005; Tsui, Dennehy, & Tsourounis, 2001). Reported prevalence can vary substantially depending on the criteria being used. One U.S. study described herbal use during pregnancy to be as high as 45% but included the use of topicals such as aloe, cocoa butter, and witch hazel as well as a beverage containing an herb (Sobe herbal drink) (Glover, Amonkar, Rybeck, & Tracy, 2003).
The authors report no conflict of interest or relevant financial relationships.
Despite the fact that women are frequent users of alternative therapies, there is little known about the use of herbs in pregnancy or how these herbs affect the course of pregnancy or labor. International studies from Australia, Norway, and the United Kingdom describe herb use in pregnancy to be as high as 36% to 58% and the use of herbal galac-
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& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
(Continued)
According to the Dietary Supplement Health and Education Act, the de¢nition of a dietary supplement includes herbal remedies that are taken orally and not applied topically. In addition, food products that contain herbal ingredients like Sobe herbal drink are generally regulated as foods and not as
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RESEARCH
Dennehy, C., Tsourounis, C., Bui, L. and King, T. K.
dietary supplements (United States Food and Drug Administration Center for Food Safety and Applied Nutrition, 1994). Many of these surveys also focus on the use of any herb during pregnancy (e.g., echinacea for cold symptom relief) as opposed to the use of herbs speci¢c to the pregnancy (e.g., nausea/vomiting in pregnancy, labor induction, dysfunctional labor) or the desire to become pregnant (e.g., fertility). Health care providers who care for women during pregnancy, birth, and the postpartum period should ask about herb use, recognize commonly used herbs, and be prepared to discuss their use. In one study, 75% of women did not tell their doctor or midwife about such use, and the most common sources for product information were family and friends (62%), the patient’s own idea (32%), a newspaper or magazine (18%), or a health food store clerk (8%) (Holst et al., 2009). Nurses who spend more time with women during labor and the ¢rst days postpartum may be in an ideal position to elicit information about herb use and thereby help support women in making reasoned choices for self-care. Health care providers and nurses who are more comfortable discussing or recommending herbs during pregnancy may also be more familiar with the types of herbs that are used. In a survey of Canadian physicians and naturopaths only one physician recommended an herbal product to a pregnant patient as compared to 49% of naturopaths (Einarson et al., 2000). A survey of certi¢ed nurse-midwives (CNMs) practicing in North Carolina found that 73% recommended herbal products during pregnancy (Allaire, Moos, & Wells, 2000). A similar national survey reported herb use by CNMs to be 85% (Hastings-Tolsma & Terada, 2009). Midwives frequently care for women during pregnancy. Certi¢ed nurse-midwives educated in nursing and midwifery practice in hospital and out-of-hospital settings in all states in the United States. Certi¢ed midwives (CMs) are educated in midwifery and like nurse-midwives practice in all settings; CNMs/CMs may be in independent practices or they may work within an existing health care system. Certi¢ed professional midwives (CPMs) receive their midwifery education in one of the few freestanding midwifery schools in the United States and or via apprenticeship and self-study. The title CPM refers to certi¢cation by the North American Registry of Midwives, and CPMs may use the title licensed midwives (LM) if they are licensed in the state in which they practice. Certi¢ed professional midwives and
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LMs practice in independent practices that o¡er home birthing services. The population of interest for the current study is CNMs, CMs, and LMs all of whom are licensed to practice midwifery in the state of California. Surveys indicate that midwives commonly recommend herbs in their clinical practice (Allaire et al., 2000; Bayles, 2007; Hastings-Tolsma & Terada, 2009; McFarlin, Gibson, O’Rear, & Harman, 1999). To date there have been four surveys describing herbal preparation use by CNMs (Allaire et al.; Bayles; Hastings-Tolsma & Terada; McFarlin et al.). A national survey evaluated use of herbs speci¢cally for labor stimulation among members of the American College of Nurse-Midwives (ACNM) (McFarlin, et al.). They also surveyed 48 nurse-midwifery educational programs regarding formal curricula related to the use of herbs for cervical ripening, labor induction, and augmentation of labor. Fifty-two percent of respondents reported using herbs to stimulate labor. Black cohosh, red raspberry, castor oil, and evening primrose oil were most commonly recommended for this indication. Interestingly, 69% of CNMs indicated that they learned how to use herbs for labor induction from other CNMs, whereas 64% of the nurse-midwifery professional schools included this topic in their formal curricula. In a more recent national survey, 64% of CNMs reported no CAM content in their basic nurse midwifery educational programs (Hastings-Tolsma & Terada). A majority had learned about CAM through self-study and workshops (HastingsTolsma & Terada). Two additional state-wide surveys documented herb use by CNMs in North Carolina and CAM use by LMs and CNMs in Texas (Allaire et al., 2000; Bayles, 2007). Usage rates ranged from 73% to 90% with respondents frequently using herbs in their practice settings for nausea/vomiting associated with pregnancy, labor stimulation, cervical ripening, perineal discomfort/healing, anemia/iron supplementation, lactation disorders, postpartum depression, preterm labor, postpartum hemorrhage, labor analgesia, and malpresentation. Ginger and peppermint were commonly recommended for nausea and vomiting, whereas evening primrose, black cohosh, blue cohosh, castor oil, and raspberry leaf were used for dysfunctional labor, postterm pregnancy, and labor induction. Despite the information obtained from these surveys, there is still a great deal of information that is unknown regarding the use of herbs by practicing CNMs/CMs and LMs. The purpose of the current
Tekoa L. King, CNM, MPH, is an associate clinical professor in the Department of Obstetrics, Gynecology and Reproductive Health, University of California, San Francisco, CA.
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The frequency and types of herbs used for pregnancy indications by midwives has not been extensively studied.
study was to characterize herbal product use (prevalence, types, indications) among CNMs/CMs and LMs practicing in the state of California. A secondary intent was to describe the professional education related to herbal products received by midwives during midwifery education.
Methods The names and mailing addresses of midwives, including LMs and CNMs/CMs, registered in the State of California were obtained through the California Medical Board (CMB) and the American College of Nurse Midwives (ACNM), respectively.Three hundred and forty-three CNMs/CMs (every third name on the ACNM mailing list totaling one third of the complete list) and 157 LMs (the complete CMB mailing list) were surveyed. The cross-sectional study was approved by the Committee on Human Research at the University of California, San Francisco. The researchers developed the survey tool based on similar surveys previously published in the literature. The survey was administered to three nurses not involved in the study before mailing. Once the survey tool was ¢nalized, the purpose for the survey was provided in a brief cover letter. The cover letter described that participation was voluntary and anonymous (i.e., no personal identi¢ers were used), and the approximate amount of time it would take to complete the survey, 10 minutes. If the individual consented to participate, that individual was asked to return the survey within 2 weeks of receipt. The questionnaire included multiple choice and short answer questions. Respondents were asked to indicate their age and gender as well as their professional education (e.g., degree, certi¢cation, and year obtained). In addition, each respondent was asked to indicate his or her current scope of practice (e.g., practice setting, years in practice, and the average number of deliveries attended per month). Because previous research has documented that herbs were the most common form of CAM used by midwives, we included a series of questions focusing speci¢cally on herbs. The survey asked about the oral use of herbs except for the indication of perineal healing where topical could be listed. Respondents were asked to indicate the estimated amount of time
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(in hours) their educational curricula devoted to herbs, their preferred informational resources about herbs (e.g., other LMs, CNMs/CMs, speci¢c websites, textbooks, or peer-reviewed research publications), and the degree to which the following resources contribute to their knowledge of herbs (Internet, peer-reviewed publications, continuing educational programs, other CNMs/CMs and LMs). Their comfort level in using herbs in their practice was assessed using a 6-point Likert-type scale (0 being uncomfortable and 5 being most comfortable). A separate question asked respondents whether they had experienced any barriers to using herbal products in their practice setting and if so to describe them. The survey also asked respondents to indicate the types of herbs used in clinical practice for a speci¢c pregnancy-related indication within the last year. The list of 11 pregnancyrelated indications was selected based on a review of the literature. Each respondent was asked to provide the name(s) of any herbs used for each indication in decreasing order of preference. A list of all possible herbs was not provided with the survey. For each pregnancy-related indication, respondents were asked to list any variables that would a¡ect their decision to use herbs for that indication. In addition, survey respondents indicated whether they preferred to use a speci¢c manufacturer or supplier. All survey responses were coded and entered into a spreadsheet for analysis. Descriptive statistics were used for the analysis. Means and standard deviations were calculated for continuous variables. Frequencies and percentages were used for categorical variables.
Results Among the 500 surveys mailed, 40 were undeliverable (17 CNM/CMs and 23 LM surveys), Seven surveys were excluded: four from midwives who were no longer in practice and three for being incomplete. After exclusions, our response rate was 102/326 (31%) for CNMs/CMs and 37/134 (28%) for LMs; the overall survey response was 30%. The majority of the CNMs/CMs and LMs were female, with a mean age ranging from 47 to 49, having practiced for 10 years or fewer. CNMs/CMs predominantly worked in a hospital setting whereas LMs predominantly worked in a private setting (Table 1). Professional education related to herbs and recommended herbal references is described inTable 2. Fifty-eight CNMs/CMs (57%) and 35 LMs (95%) reported using herbs in their clinical practice. The mean level of comfort for using herbs in clinical
JOGNN, 39, 684-693; 2010. DOI: 10.1111/j.1552-6909.2010.01193.x
http://jognn.awhonn.org
RESEARCH
Dennehy, C., Tsourounis, C., Bui, L. and King, T. K.
Table 1: Demographic Characteristics of CNM/CM and LM Participants CNMs/CMs
LMs
Demographic Characteristics
n 5 102
n 5 37
Mean age, years (range)
48.5 (28-75)
46.9 (30-62)
Female
101
37
1
ç
45
23
29
4
Male
Various types of midwives receive different formal education on the use herbs for pregnancy indications. (14%), and knowledge (8%). Eleven percent of respondents listed a variety of other reasons for feeling comfortable in using herbs in their practice (e.g., patient preference, provider preference,
Years in practice 10 11-20 420
28
Table 2: Education Related to Herbs
10
CNMs/CMs
LMs
n 5 102
n 5 37
n (%)
n (%)
Time spent in professional curricula related to herbs (hr)
Additional licensure RN
88
ç
0
30 (29)
3 (8)
NP
45
ç
1-5
58 (57)
5 (14)
6-10
9 (9)
7 (19)
Practice settinga Private
38
37
11-20
3 (3)
6 (16)
Hospital
46
1
420
2 (2)
16 (43)
Military
3
ç
Public clinic
29
3
Academic
15
ç
HMO
26
ç
Average number of deliveries per month 0
15
2
1-5
16
29
Herbal references recommended during professional educationa No response
3 (3)
ç
None
65 (64)
6 (16)
Yes
34 (33)
31 (84)
Susun Weed texts
10
24
German Commission E
5
1
1
5
7
40
14
2
Monographs 6-10
41
5
11-15
13
ç
16
22
ç
Other
3b
1c
2
ç
Anne Frye texts Other
b
Did not specify
No response
Note. HMO 5 health maintenance organization. a Respondents were able to indicate more than 1 practice setting. b Respondents indicated ‘‘not applicable.’’ c Respondent indicated ‘‘a few per year.’’
practice was 1.8 for CNMs/CMs and 4.1 for LMs. Seventy-three percent of CNMs/CMs ranked their comfort level in using herbs as 0, 1, or 2, whereas no LMs did. Eighty-four percent of LMs ranked their comfort level in using herbs as 4 or 5, whereas 6% of CNMs/CMs did. The most common rationale stated for feeling comfortable in using herbs (a ranking of 4 or 5) were personal experience (45%), evidence of e⁄cacy (22%), safety and purity
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Information resources used to answer herbal questionsa Other LMs and CNMs
59 (27)
26 (25)
Internet website(s)
41 (19)
16 (16)
Peer-reviewed research
36 (17)
15 (15)
Textbooks c
51 (24)
30 (29)
Other
28 (13)
15 (15)
publication
No response
4 (4)
ç
Note. a Respondents could indicate more than one answer for this section. b A variety of other unique references were cited. c The most common textbooks reported were by Susun Weed, and Anne Frye, Physicians Desk Reference on Herbs and the German Commission E Monographs.
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access to an herbal specialist). The most common rationales stated for feeling uncomfortable in using herbs in clinical practice (a ranking of 0-2) were lack of knowledge (36%), poor evidence of e⁄cacy (23%), lack of personal experience (14%), institutional restrictions (10%), and lack of safety and purity (7%). Ten percent of respondents listed a variety of other reasons for feeling uncomfortable in using herbs in their practice (e.g., patient preference, provider preference, lack of experience and knowledge, and cost).
monly used herbs for each indication are provided in Table 4. Licensed midwives were more likely to recommend herb-based pregnancy teas for overall
Table 4: Most Common Herbs Used by Pregnancy Indication Among Midwives Who Reported Using Herbs in Their Practice
Indication
Fifty-one percent of CNMs/CMs and 26% of LMs reported barriers to using herbs in their practice setting. The most common were institutional restrictions (39%), patient preference (18%), lack of knowledge (14%), poor evidence of e⁄cacy (7%), ¢nancial (5%), lack of availability (5%), and other (11%). The barriers categorized as ‘‘other’’ included misinformation, ignorance and mistrust, not generally well accepted, demand on personal time, safety and purity, and pill burden. Herbal use by pregnancy indication as reported by midwives who were using herbs in their clinical practice is summarized in Table 3. The most com-
CNMs/CMsa
LMs
n/Total (%)
n/Total (%)
0
6/35 (17)
Fertilityb Wild yam Red clover
1/57 (2)
5/35 (14)
Chastetree
2/57 (4)
3/35 (9)
Red raspberry
1/57 (2)
4/35 (11)
41/58 (71)
23/35 (66)
Peppermint
5/58 (9)
10/35 (29)
Chamomile
7/58 (12)
1/35 (3)
Red raspberry
4/58 (7)
9/35 (26)
Yellow dock
8/57 (14)
28/35 (80)
Nettles
5/57 (9)
23/35 (66)
12/57 (21)
8/35 (23)
3/57 (5)
11/35 (31)
Nausea/vomiting Ginger
Anemiab
Table 3: Frequency of Herb Use by Pregnancy Indication Among Midwives Who Reported Using Herbs in Their Practice
Floradix
sc
CNMs/CMsa
LMs
Indication
n/Total (%)
n/Total (%)
Nausea/vomiting
48/58 (83)
30/35 (86)
Lactation/increasing milk supplyb 37/57 (65)
30/35 (86)
False unicorn
ç
Labor inductionb
31/35 (89)
Wild yam
ç
33/57 (58)
Perineal healing/discomfort b
27/57 (47)
35/35 (100)
Anemiab
33/57 (39)
32/35 (91)
Dandelion
Preterm labor/preterm contractions or bleedingd
Malpresentation/breech, labor induction Pulsatilla
10/35 (29) 8/35 (23) b
6/57 (11)
14/35 (40)
b
Malpresentation/breechb
16/57 (28)
19/35 (54)
Labor induction
Dysfunctional Labor/prolonged
11/57 (19)
28/35 (80)
Blue cohosh
15/57 (26)
25/35 (71)
Black cohosh
16/57 (28)
23/35 (66)
10/57 (18)
22/35 (63)
Castor oil
10/57 (18)
8/35 (23)
Labor/anesthesia or analgesiab
8/57 (14)
14/35 (40)
Evening primrose oil
13/57 (23)
1/35 (3)
Preterm labor/preterm
6/57 (11)
22/35 (63)
Cotton root
3/57 (5)
11/57 (19)
4/57 (7)
16/35 (46)
latent phase
b
Postpartum depressionb
contractions or bleedingb Fertility b
Dysfunctional labor/prolonged latent phaseb Blue cohosh
8/57 (14)
21/35 (60)
Black cohosh
8/57 (14)
16/35 (46)
Cotton root
2/57 (4)
6/35 (17)
Note. a CNM/CM responses were combined for those who reported using herbs in their practice (N 5 58). b One CNM/CM provided no answer.
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JOGNN, 39, 684-693; 2010. DOI: 10.1111/j.1552-6909.2010.01193.x
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RESEARCH
Dennehy, C., Tsourounis, C., Bui, L. and King, T. K.
Table 4. Continued Indication
CNMs/CMsa
LMs
n/Total (%)
n/Total (%)
Labor/anesthesia or analgesiab Rescue remedye
2/57 (4)
4/35 (11)
Skull cap
1/57 (2)
4/35 (11)
12/57 (21)
30/35 (86)
Arnica
9/57 (16)
5/35 (14)
Witch hazel
5/57 (9)
8/35 (23)
St. John’s wort
2/57 (4)
7/35 (20)
Motherwort
2/57 (4)
4/35 (11)
2/57 (4)
4/35 (11)
20/57 (35)
16/35 (46)
7/57 (12)
11/35 (31)
Aniseed
7/57 (12)
8/35 (23)
Blessed thistle
5/57 (9)
7/35 (20)
Perineal healing/discomfortb Comfrey
Postpartum depressionb
Skull cap Lactation/increasing milk supply Fenugreek Fennel/mother’s milk tea
f
b
Note. a CNM/CM responses were combined for those who reported using herbs in their practice (N 5 58). b One CNM/CM provided no answer. c Floradix s 5 carrot, nettle worth, spinach, quitch roots, angelica roots, fennel, ocean kelp, African mallow blossom, orange peel, iron, vitamins C, B1, B2, B6, and B12. d Only 6/57 (11%) of CNMs/CMs felt comfortable using herbs for this indication. e Rescue remedy 5 crab apple, Star of Bethlehem, clematis, cherry plum, impatiens, rock rose. f Responses for mother’s milk tea were combined with responses for fennel as mother’s milk tea contains bitter fennel fruit and aniseed fruit.
health and well-being than CNMs/CMs (81% vs. 38%). The most commonly recommended herbs to include in a pregnancy tea were red raspberry (70%) and nettle (42%). Seventy-six percent of CNMs/CMs and 47% of LMs indicated that they had no preference for a particular herbal manufacturer or supplier. Among those that indicated a preferred manufacturer or supplier, the most common were Herb Pharm Inc. (25%), Nature’s Sunshine Products (16%), and The Scarlet Sage Herb Co. (13%). Among the respondents who reported using herbs in their practice, a total of 11 herb-related adverse events (AEs) were reported. The combination of blue and black cohosh was involved in two AEs, one report of uterine hyperstimulation, and the
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other involving fetal tachycardia. The use of blue cohosh by itself was involved in four AEs: meconium stained amniotic £uid, fetal tachycardia, and two unspeci¢ed reactions. Black cohosh was involved in one AE: an allergic reaction. The remaining herbs were involved in one reaction each: ginger associated with icterus, chamomile associated with anaphylaxis, skull cap associated with hypotension, and pennyroyal associated with postpartum hemorrhage.
Discussion The current study is the ¢rst to survey CNMs/CMs and LMs regarding herb use in pregnancy and fertility in the State of California. The study is important because it focuses solely on the use of herbal medicine (as opposed to all CAM modalities) and because the use of herbs in the western United States has been shown to be more prevalent than other parts of the country (Barnes et al., 2008). This survey is also the ¢rst to assess the level of professional education received by both groups in the area of herbal medicine. The only other study that surveyed CNMs and LMs was conducted in Texas and focused on various CAM modalities in pregnancy (Bayles, 2007). Although the current study focused on use of herbs in patients seen by midwives, implications for practice cut across disciplines. All nurses who practice in perinatal care should be familiar with the types of herbal products that women may be using and inquire about herbal product use. The response rate for the current study (30% overall, 31% CNM/CMs and 28% LMs) is comparable to other studies of this kind (Bayles, 2007; McFarlin et al.,1999). Our response rate re£ects the total number of surveys that were evaluated after exclusion criteria were applied. Similarly, the study by McFarlin et al. had a 34% response rate after exclusion criteria were applied. The response rate in the Bayles study did not mention additional exclusion criteria aside from undeliverable surveys and had a slightly lower response rate than the current study (21% overall, 26% CNMs and 13% LMs). CNMs/CMs practiced in a variety of clinical settings with hospital practice being the most common. LMs almost exclusively practiced in private settings. Because hospitals are more likely to have policies in place that limit the widespread use of herbs in clinical practice, this may explain, in part, the higher usage rates reported by LMs. Institutional barriers were also reported by 39% of all respondents. Ten percent of respondents felt uncomfortable in using
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The Use of Herbs by California Midwives
Most herbs used for pregnancy indications lacked evidence-based clinical support and safety data.
herbs in clinical practice because of these institutional barriers whereas a majority (36%) who expressed discomfort cited ‘‘lack of knowledge.’’ As such, even if an institutional barrier did not exist, there are many midwives who still would not choose to use herbs because of their lack of knowledge. Licensed midwives were more comfortable in using herbs in clinical practice than CNMs/CMs. Based on the additional education that LMs reported having received in their professional curricula, this increased level of comfort is not surprising. LMs cited personal experience as the most common reason for their high comfort level whereas CNMs/ CMs cited their lack of knowledge or education as the most common reason for feeling uncomfortable in using herbs. Because LMs spent more time in professional curricula related to herbs, they were also more likely to have been recommended herbal references (84% LMs and 33% CNMs/CMs). The most commonly recommended references, cited by all midwives, were textbooks by Susun Weed (http://www.susun weed.com). It is interesting to note that Susun Weed does not have specialized education in midwifery nor o⁄cial diplomas of any kind. Her knowledge of herbs is mostly self-taught, and her area of focus is folkloric herbalism. In contrast, the other two resources cited by midwives were textbooks by Anne Frye, a certi¢ed professional midwife (CPM), and the German Commission E Monographs, a compendium of herbal monographs containing information on herb use, contraindications, side e¡ects, drug^herb interactions, dose, route of administration, risks, pharmacokinetics, and toxicology (Blumenthal & Busse,1998; Frye & Baker,1998). Although the German Commission E Monographs contain information related to the historical use of herbs, they provide limited safety information in pregnancy. The reference is also outdated and has limited clinical applicability (Blumenthal & Busse). For example, even the most updated version known as the Expanded Commission E Monographs published by the American Botanical Council does not include any information on well-known drug interactions involving St. John’s wort (Blumenthal, Goldberb, & Brinckmann, 2000). This is concerning as St. John’s wort has been found to interact with
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numerous medications that can lead to serious adverse outcomes if overlooked (Borrelli & Izzo, 2009; Zhou, Chan, Pan, Huang, & Lee, 2004). It is also important to note that herb use has been poorly studied in pregnancy with limited animal and in vitro studies and relies heavily on historical evidence of safety. Accessing the primary literature (e.g., individual randomized controlled trials, systematic reviews, and meta-analyses) is the best means of determining how well each individual herb has been studied, the formulation used, and if observational data exists on birth outcomes. Additionally this will provide more timely and up-to-date safety information than textbooks as an herb’s safety pro¢le may change as more research is conducted. Currently, the Food and Drug Administration (FDA) MedWatch program and the American Association of Poison Control Centers collect information on herb-related exposures. Although these surveillance systems collect information on herb-related adverse events, they are not immediately searchable or accessible by nurses and midwives who wish to determine if an adverse event exists involving an herbal product. This leaves to question whether a clearinghouse or database for reporting herbal adverse e¡ects speci¢c to pregnancy is needed. The current study identi¢ed 11 self-reported, herb-related AEs some of which would be considered serious in severity and some of which have been previously reported in the literature. Unless a nurse or midwife is extensively familiar with the literature or is educated by someone who has such knowledge, it is di⁄cult to know which herbs to avoid. The type of informational resources used to answer herbal questions was similar among CNMs/CMs and LMs and most often involved asking a colleague or using a textbook reference as compared to accessing the primary literature. The textbook references used were similar to those recommended during professional education. In another national study, 69% of nurse-midwives reported learning about herbs for cervical ripening from a colleague and only 4% from formal research publications (McFarlin et al., 1999). These data support the need to move toward the use of the primary literature as a means of promoting more evidencebased care. The use of herbs by pregnancy indication demonstrated clear di¡erences between the practices of LMs and CNMs/CMs. Speci¢cally, for every indication, LMs were more likely to use herbs in their practice. The only indication in which usage rates
JOGNN, 39, 684-693; 2010. DOI: 10.1111/j.1552-6909.2010.01193.x
http://jognn.awhonn.org
RESEARCH
Dennehy, C., Tsourounis, C., Bui, L. and King, T. K.
were high and similar in frequency between groups was for nausea and vomiting in pregnancy where 83% to 86% of midwives used herbs. Over 50% of CNMs/CMs also felt comfortable in using herbs for lactation and labor induction. The types of indications with the greatest discrepancy in the use of herbs between CNMs/CMs and LMs were dysfunctional labor/prolonged latent phase (61% di¡erence), perineal healing/discomfort (53% di¡erence), anemia (52% di¡erence), and preterm labor (52% di¡erence). The majority of CNMs/CMs indicated that they had no preference for a particular herbal manufacturer or supplier. The purity and potency of an herb can vary depending on the manufacturer and manufacturing process. Furthermore, intentional and unintentional contaminants, pesticides, bacteria, and heavy metals may have the potential to a¡ect pregnancy outcomes. It is expected that the recently implemented Good Manufacturing Practice Standards issued by the Food and Drug Administration in 2007 will help to minimize introduction of these contaminants (United States FDA, 2007). The types of herbs used for speci¢c pregnancy indications were similar between CNMs/CMs and LMs with ginger being highlighted most frequently for nausea and vomiting in pregnancy. Ginger has favorable support from randomized controlled trials (RCTs) as an e¡ective remedy for this indication (Borrelli, Capasso, Aviello, Pittler, & Izzo, 2005; Chittumma, 2007; Ensiyeh & Sakineh, 2009; Ozgoli, Goli, & Simbar, 2009; Pongrojpaw, 2007). Results from 10 RCTs (5 comparisons to placebo, 4 comparisons to vitamin B6, and 1 comparison to dimenhydrinate) and an observational cohort suggest no negative e¡ect on birth outcomes. Nonetheless, the total population of women studied remains small and could fail to detect an adverse event if it were serious but infrequent. Some practitioners may also have concerns regarding in vitro and animal data which report a mutagenic e¡ect of 6gingerol and early embryonic loss in rats given 15 to 50 g/L of ginger tea (Nakamura & Yamamoto, 1982; Wilkinson, 2000). The other frequently used herbs, black cohosh, blue cohosh, fenugreek, comfrey, yellow dock, and nettle, have not been adequately studied in RCTs for the reported pregnancy indications. Blue cohosh when used as a single herb or in combination with black cohosh has some data that suggests that it should not be used for labor induction due to its vasoconstrictive properties on coronary arteries and associated case reports of seizure, hypoxia, con-
JOGNN 2010; Vol. 39, Issue 6
gestive heart failure, and stroke in infants possibly related to maternal use (Finkel & Zarlengo, 2004; Gunn & Wright, 1996; Jones & Lawson, 1998). The current study also reports two additional AEs involving uterine hyperstimulation and fetal tachycardia with a combination of black and blue cohosh and four adverse events for blue cohosh involving meconium staining, fetal tachycardia, and two unspeci¢ed reactions. As such, the risk of using blue cohosh appears to outweigh any bene¢t. Fenugreek is theorized to stimulate sweat glands, and because the breast is a modi¢ed sweat gland, it has been used to induce lactation (Gabay, 2002). Comfrey has been used historically as a topical wound healing agent, which could explain why midwives use it for perineal healing (Kucera & Kucera, 2007). Importantly, comfrey should never be used internally because it contains hepatotoxic pyrrolizidine alkaloids (Liu et al., 2009). Nettle is also known as common nettle or stinging nettle. It has been used historically for anemia, but there is insu⁄cient reliable information about the e¡ectiveness of nettle for this indication (Jellin, 2010). Similarly, yellow dock has not been studied for anemia (Jellin). The current study had some limitations. The survey was only sent to one third of the CMs/CNMs provided on the ACNM mailing list for the state of California. This was done to limit the scope of the survey to 500 midwives in total but may have excluded CMs/CNMs who were more or less inclined to use herbs in their practice. Although the survey response rate (32%) was similar to other surveys of this kind, having a greater response rate would have provided more complete data. In addition, selection bias may have contributed to the lower response rate with midwives who did not use herbs in their practice being less inclined to respond. Forty-three percent of CNMs/CMs and 5% of LMs reported not using herbs in their clinical practice. As with any survey, our results were also subject to recall bias, particularly with regard to hours devoted to education on herb use, references recommended and herb-related AEs. AEs were self-reported associations and the details of each patient case were not provided, therefore AE causality cannot be con¢rmed. The current study has some implications for practice. Speci¢cally nurses may expect midwives to be more knowledgeable and comfortable in using herbs. This level of comfort however is supported less by empirical evidence and more by historical use. If a patient or a practitioner wishes to use an herb for pregnancy an evidence-based approach
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should be taken. This involves a review of available clinical trial data, adverse reports, and possible drug^herb interactions. Resources that should be searched include, but are not limited to,The Natural Standard, Natural Medicines Comprehensive Database International Bibliographic Information on Dietary Supplements (IBIDS) Database and The Cochrane Collaboration Reviews (Basch & Ulbricht, 2010; Jellin, 2010, http://grande.nal.usda. gov/ibids/, http://www2.cochrane.org/reviews/).
Chittumma, P. (2007). Comparison of the e¡ectiveness of ginger and vitamin B6 for treatment of nausea and vomiting in early pregnancy: A randomized double-blind controlled trial. Journal of the Medical Association of Thailand, 90, 15-20. Cochrane Collaboration. (2010). Cochrane database of systematic reviews [electronic database]. Chichester, U.K.: Wiley. Retrieved from http://www2.cochrane.org/reviews/. Einarson, A., Lawrimore, T., Brand, P., Gallo, M., Rotatone, C., & Koren, G. (2000). Attitudes and practices of physicians and naturopaths toward herbal products, including use during pregnancy and lactation. Canadian Journal of Clinical Pharmacology, 7, 45-49. Ensiyeh, J., & Sakineh, M. A. (2009). Comparing ginger and vitamin B6 for
This survey found that herbs are commonly used and recommended by midwives practicing in California. Important di¡erences appear to exist between CNMs/CMs and LMs with regard to herb use and level of comfort in using and recommending herbs to their clients. In turn, there was a notable di¡erence in the level of education devoted to the use in herbs by CNMs/CMs and LMs. Given the level of herb use in both disciplines, having de¢ned curricula devoted to herbs as part of professional education is important. Ginger was the most commonly used herb for nausea/vomiting and is one of a few herbs to have evidence for this indication. More research is needed to evaluate the safety and e⁄cacy for most of the other herbs used by midwives. More importantly, improved surveillance methods are needed to document the safety of herbs used in pregnancy.
the treatment of nausea and vomiting in pregnancy: A randomized controlled trial. Midwifery, 25, 649-653. Finkel, R. S., & Zarlengo, K. M. (2004). Blue cohosh and perinatal stroke. New England Journal of Medicine, 351, 302-303. Forster, D. A., Denning, A., Wills, G., Bolger, M., & McCarthy, E. (2006). Herbal medicine use during pregnancy in a group of Australian women. BMC Pregnancy Childbirth, 6, 21. Frye, A., & Baker, R. (Eds.). (1998). Holistic midwifery: A comprehensive textbook for midwives in homebirth practice, Vol. 1: Care during pregnancy. Portland, OR: Labrys Press. Gabay, M. P. (2002). Galactogogues: Medications that induce lactation. Journal of Human Lactation, 18, 274-279. Gibson, P., & Powrie, R. (2001). Herbal and alternative medicine use during pregnancy: A cross-sectional survey. Obstetrics and Gynecology, 97, 44s-45s. Glover, D. D., Amonkar, M., Rybeck, B., & Tracy, T. S. (2003). Prescription, over-the-counter, and herbal medicine use in a rural, obstetric population. American Journal of Obstetrics and Gynecology, 188, 1039-1045. Gunn,T. R., & Wright, I. (1996). The use of black and blue cohosh in labour. New Zealand Medical Journal, 109, 410-411. Hastings-Tolsma, M., & Terada, M. (2009). Complementary medicine use by nurse midwives in the United States. Complementary Therapies in Clinical Practice, 15, 212-219.
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(2002). Herbal use in parturients. Anesthesia and Analgesia, 94, 690-693. Holst, L., Wright, D., Haavik, S., & Nordeng, H. (2009). The use and the user of herbal remedies during pregnancy. Journal of Alternative and Complementary Medicine, 15, 787-792. Institute of Medicine. Committee on the Use of Complementary and Alternative Medicine by the American Public. (2005). Complementary and alternative medicine in the United States. Washington, DC: National Academies Press. Jellin, J. M., & Gregory, P. (Eds.). (2010). Pharmacist’s letter/prescriber’s
Bayles, B. P. (2007). Herbal and other complementary medicine use by
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Blumenthal, M., & Busse, W. R. (Eds.). (1998). The complete German com-
Jones, T. K., & Lawson, B. M. (1998). Profound neonatal congestive heart
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Blumenthal, M., Goldberg, A., & Brinckmann, J. (Eds.). (2000). Herbal
Kucera, B. M., & Kucera, H. M. (2007). Wound healing e¡ects of Symphy-
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Liu, F., Wan, S. Y., Jiang, Z., Li, S. F., Ong, E. S., & Osorio, J. C. (2009). Determi-
induced nausea and vomiting. Obstetrics and Gynecology, 105,
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McFarlin, B. L., Gibson, M. H., O’Rear, J., & Harman, P. (1999). A national
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Nakamura, H., & Yamamoto, T. (1982). Mutagen and anti-mutagen in ginger, Zingiber o⁄cinale. Mutation Research, 103, 119-126.
center. American Journal of Obstetrics and Gynecology, 185, 433-437.
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Nordeng, H., & Havnen, G. C. (2004). Use of herbal drugs in pregnancy: A survey among 400 Norwegian women. Pharmacoepidemiology and Drug Safety, 13, 371-380. Ozgoli, G., Goli, M., & Simbar, M. (2009). E¡ects of ginger capsules on
Register, 72, 34751-34958. United States Food and Drug Administration Center for Food Safety and Applied Nutrition. (1994). Dietary supplement health and education act of 1994 (PL 103-417), 103rd Congress. Retrieved from http://
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Pongrojpaw, D. (2007). A randomized comparison of ginger and dimenhydrinate in the treatment of nausea and vomiting in pregnancy. Journal of the Medical Association of Thailand, 90,1703-1709. Refuerzo, J. S., Blackwell, S. C., Sokol, R. J., Lajeunesse, L., Firchau, K., Kruger, M., et al. (2005). Use of over-the-counter medications and herbal remedies in pregnancy. American Journal of Perinatology, 22, 321-324. Tsui, A., Dennehy, C., & Tsourounis, C. (2001). A survey of dietary supplement use during pregnancy at an academic medical
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Act/ucm148003.htm Weed, S. (2010). Herbal medicine and spirit healing the wise woman way. Woodstock, NY: Author. Retrieved from http://www.susunweed. com Wilkinson, J. M. (2000). E¡ect of ginger tea on the fetal development of Sprague-Dawley rats. Reproductive Toxicology, 14, 507-512. Zhou, S., Chan, E., Pan, S. Q., Huang, M., & Lee, E. J. (2004). Pharmacokinetic interactions of drugs with St. John’s wort. Journal of Psychopharmacology, 18, 262-276.
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The Use of Herbs by California Midwives Cathi Dennehy, Candy Tsourounis, Lindsey Bui, and Tekoa L. King
Correspondence Cathi Dennehy, PharmD, Department of Clinical Pharmacy, UCSF, 521 Parnassus Ave, Suite C-152, Box 0622, San Francisco, CA 94143. dennehyc@pharmacy. ucsf.edu Keywords herb nurse midwife pregnancy fertility lactation education ginger black cohosh blue cohosh
ABSTRACT Objective: To characterize herbal product use (prevalence, types, indications) among Certified Nurse Midwives/ Certified Midwives (CNMs/CMs) and Licensed Midwives (LMs) practicing in the state of California and to describe formal education related to herbal products received by midwives during midwifery education. Design/Setting/Participants: Cross-sectional survey/California/Practicing midwives. Methods: A list of LMs and CNMs/CMs practicing in California was obtained through the California Medical Board (CMB) and the American College of Nurse Midwives (ACNM), respectively. The survey was mailed to 343 CNMs/CMs (one third of the ACNM mailing list) and 157 LMs (the complete CMB mailing list). Results: Of the 500 surveys mailed, 40 were undeliverable, 146 were returned, and 7 were excluded (30% response rate). Of the 139 completed surveys, 58/102 (57%) of CNMs/CMs and 35/37 (95%) of LMs used herbs, and LMs were more comfortable than CNMs/CMs in recommending herbs to their patients. A majority of LMs had 420 hours of midwifery education on herbs whereas a majority of CNMs/CMs received 0 to 5 hours. Some CNMs/CMs indicated that their practice site limited their ability to use herbs. Common conditions in which LMs and CNMs/CMs used herbs were nausea/vomiting (86% vs. 83%), labor induction (89% vs. 58%), and lactation (86% vs. 65%). Specific herbs for all indications are described. Conclusion: Licensed midwives were more likely than CNMs/CMs to use herbs in clinical practice. This trend was likely a reflection of the amount of education devoted to herbs as well as herbal use limitations that may be encountered in institutional facilities.
JOGNN, 39, 684-693; 2010. DOI: 10.1111/j.1552-6909.2010.01193.x Accepted August 2010
Cathi Dennehy, PharmD, is a health sciences clinical professor in the School of Pharmacy, University of California, San Francisco, CA. Candy Tsourounis, PharmD, is a professor of clinical pharmacy in the School of Pharmacy, University of California, San Francisco, CA. Lindsey Bui, PharmD, BCPS, is an ambulatory care pharmacist at Kaiser Permanente, Stockton, CA.
omplementary and alternative medicine (CAM) is frequently used by individuals living in the United States, especially among women and persons residing in the West (Barnes, Bloom, & Nahin, 2008; Institute of Medicine. Committee on the Use of Complementary and Alternative Medicine by the American Public, 2005). Although CAM encompasses many di¡erent practices, the use of biological products and more speci¢cally nonvitamin, nonmineral natural products is the most prevalent. The 2007 National Health Interview Survey (NHIS) estimated that 18% of adults used such products in the last 12 months (Barnes et al.).
C
tagogues as high as 43% (Forster, Denning, Wills, Bolger, & McCarthy, 2006; Holst, Wright, Haavik, & Nordeng, 2009; Nordeng & Havnen, 2004). Studies from the United States described a lower rate of use ranging from 4.1% to 13% (Gibson & Powrie, 2001; Hepner et al., 2002; Refuerzo et al., 2005; Tsui, Dennehy, & Tsourounis, 2001). Reported prevalence can vary substantially depending on the criteria being used. One U.S. study described herbal use during pregnancy to be as high as 45% but included the use of topicals such as aloe, cocoa butter, and witch hazel as well as a beverage containing an herb (Sobe herbal drink) (Glover, Amonkar, Rybeck, & Tracy, 2003).
The authors report no conflict of interest or relevant financial relationships.
Despite the fact that women are frequent users of alternative therapies, there is little known about the use of herbs in pregnancy or how these herbs affect the course of pregnancy or labor. International studies from Australia, Norway, and the United Kingdom describe herb use in pregnancy to be as high as 36% to 58% and the use of herbal galac-
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& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
(Continued)
According to the Dietary Supplement Health and Education Act, the de¢nition of a dietary supplement includes herbal remedies that are taken orally and not applied topically. In addition, food products that contain herbal ingredients like Sobe herbal drink are generally regulated as foods and not as
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Dennehy, C., Tsourounis, C., Bui, L. and King, T. K.
dietary supplements (United States Food and Drug Administration Center for Food Safety and Applied Nutrition, 1994). Many of these surveys also focus on the use of any herb during pregnancy (e.g., echinacea for cold symptom relief) as opposed to the use of herbs speci¢c to the pregnancy (e.g., nausea/vomiting in pregnancy, labor induction, dysfunctional labor) or the desire to become pregnant (e.g., fertility). Health care providers who care for women during pregnancy, birth, and the postpartum period should ask about herb use, recognize commonly used herbs, and be prepared to discuss their use. In one study, 75% of women did not tell their doctor or midwife about such use, and the most common sources for product information were family and friends (62%), the patient’s own idea (32%), a newspaper or magazine (18%), or a health food store clerk (8%) (Holst et al., 2009). Nurses who spend more time with women during labor and the ¢rst days postpartum may be in an ideal position to elicit information about herb use and thereby help support women in making reasoned choices for self-care. Health care providers and nurses who are more comfortable discussing or recommending herbs during pregnancy may also be more familiar with the types of herbs that are used. In a survey of Canadian physicians and naturopaths only one physician recommended an herbal product to a pregnant patient as compared to 49% of naturopaths (Einarson et al., 2000). A survey of certi¢ed nurse-midwives (CNMs) practicing in North Carolina found that 73% recommended herbal products during pregnancy (Allaire, Moos, & Wells, 2000). A similar national survey reported herb use by CNMs to be 85% (Hastings-Tolsma & Terada, 2009). Midwives frequently care for women during pregnancy. Certi¢ed nurse-midwives educated in nursing and midwifery practice in hospital and out-of-hospital settings in all states in the United States. Certi¢ed midwives (CMs) are educated in midwifery and like nurse-midwives practice in all settings; CNMs/CMs may be in independent practices or they may work within an existing health care system. Certi¢ed professional midwives (CPMs) receive their midwifery education in one of the few freestanding midwifery schools in the United States and or via apprenticeship and self-study. The title CPM refers to certi¢cation by the North American Registry of Midwives, and CPMs may use the title licensed midwives (LM) if they are licensed in the state in which they practice. Certi¢ed professional midwives and
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LMs practice in independent practices that o¡er home birthing services. The population of interest for the current study is CNMs, CMs, and LMs all of whom are licensed to practice midwifery in the state of California. Surveys indicate that midwives commonly recommend herbs in their clinical practice (Allaire et al., 2000; Bayles, 2007; Hastings-Tolsma & Terada, 2009; McFarlin, Gibson, O’Rear, & Harman, 1999). To date there have been four surveys describing herbal preparation use by CNMs (Allaire et al.; Bayles; Hastings-Tolsma & Terada; McFarlin et al.). A national survey evaluated use of herbs speci¢cally for labor stimulation among members of the American College of Nurse-Midwives (ACNM) (McFarlin, et al.). They also surveyed 48 nurse-midwifery educational programs regarding formal curricula related to the use of herbs for cervical ripening, labor induction, and augmentation of labor. Fifty-two percent of respondents reported using herbs to stimulate labor. Black cohosh, red raspberry, castor oil, and evening primrose oil were most commonly recommended for this indication. Interestingly, 69% of CNMs indicated that they learned how to use herbs for labor induction from other CNMs, whereas 64% of the nurse-midwifery professional schools included this topic in their formal curricula. In a more recent national survey, 64% of CNMs reported no CAM content in their basic nurse midwifery educational programs (Hastings-Tolsma & Terada). A majority had learned about CAM through self-study and workshops (HastingsTolsma & Terada). Two additional state-wide surveys documented herb use by CNMs in North Carolina and CAM use by LMs and CNMs in Texas (Allaire et al., 2000; Bayles, 2007). Usage rates ranged from 73% to 90% with respondents frequently using herbs in their practice settings for nausea/vomiting associated with pregnancy, labor stimulation, cervical ripening, perineal discomfort/healing, anemia/iron supplementation, lactation disorders, postpartum depression, preterm labor, postpartum hemorrhage, labor analgesia, and malpresentation. Ginger and peppermint were commonly recommended for nausea and vomiting, whereas evening primrose, black cohosh, blue cohosh, castor oil, and raspberry leaf were used for dysfunctional labor, postterm pregnancy, and labor induction. Despite the information obtained from these surveys, there is still a great deal of information that is unknown regarding the use of herbs by practicing CNMs/CMs and LMs. The purpose of the current
Tekoa L. King, CNM, MPH, is an associate clinical professor in the Department of Obstetrics, Gynecology and Reproductive Health, University of California, San Francisco, CA.
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The Use of Herbs by California Midwives
The frequency and types of herbs used for pregnancy indications by midwives has not been extensively studied.
study was to characterize herbal product use (prevalence, types, indications) among CNMs/CMs and LMs practicing in the state of California. A secondary intent was to describe the professional education related to herbal products received by midwives during midwifery education.
Methods The names and mailing addresses of midwives, including LMs and CNMs/CMs, registered in the State of California were obtained through the California Medical Board (CMB) and the American College of Nurse Midwives (ACNM), respectively.Three hundred and forty-three CNMs/CMs (every third name on the ACNM mailing list totaling one third of the complete list) and 157 LMs (the complete CMB mailing list) were surveyed. The cross-sectional study was approved by the Committee on Human Research at the University of California, San Francisco. The researchers developed the survey tool based on similar surveys previously published in the literature. The survey was administered to three nurses not involved in the study before mailing. Once the survey tool was ¢nalized, the purpose for the survey was provided in a brief cover letter. The cover letter described that participation was voluntary and anonymous (i.e., no personal identi¢ers were used), and the approximate amount of time it would take to complete the survey, 10 minutes. If the individual consented to participate, that individual was asked to return the survey within 2 weeks of receipt. The questionnaire included multiple choice and short answer questions. Respondents were asked to indicate their age and gender as well as their professional education (e.g., degree, certi¢cation, and year obtained). In addition, each respondent was asked to indicate his or her current scope of practice (e.g., practice setting, years in practice, and the average number of deliveries attended per month). Because previous research has documented that herbs were the most common form of CAM used by midwives, we included a series of questions focusing speci¢cally on herbs. The survey asked about the oral use of herbs except for the indication of perineal healing where topical could be listed. Respondents were asked to indicate the estimated amount of time
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(in hours) their educational curricula devoted to herbs, their preferred informational resources about herbs (e.g., other LMs, CNMs/CMs, speci¢c websites, textbooks, or peer-reviewed research publications), and the degree to which the following resources contribute to their knowledge of herbs (Internet, peer-reviewed publications, continuing educational programs, other CNMs/CMs and LMs). Their comfort level in using herbs in their practice was assessed using a 6-point Likert-type scale (0 being uncomfortable and 5 being most comfortable). A separate question asked respondents whether they had experienced any barriers to using herbal products in their practice setting and if so to describe them. The survey also asked respondents to indicate the types of herbs used in clinical practice for a speci¢c pregnancy-related indication within the last year. The list of 11 pregnancyrelated indications was selected based on a review of the literature. Each respondent was asked to provide the name(s) of any herbs used for each indication in decreasing order of preference. A list of all possible herbs was not provided with the survey. For each pregnancy-related indication, respondents were asked to list any variables that would a¡ect their decision to use herbs for that indication. In addition, survey respondents indicated whether they preferred to use a speci¢c manufacturer or supplier. All survey responses were coded and entered into a spreadsheet for analysis. Descriptive statistics were used for the analysis. Means and standard deviations were calculated for continuous variables. Frequencies and percentages were used for categorical variables.
Results Among the 500 surveys mailed, 40 were undeliverable (17 CNM/CMs and 23 LM surveys), Seven surveys were excluded: four from midwives who were no longer in practice and three for being incomplete. After exclusions, our response rate was 102/326 (31%) for CNMs/CMs and 37/134 (28%) for LMs; the overall survey response was 30%. The majority of the CNMs/CMs and LMs were female, with a mean age ranging from 47 to 49, having practiced for 10 years or fewer. CNMs/CMs predominantly worked in a hospital setting whereas LMs predominantly worked in a private setting (Table 1). Professional education related to herbs and recommended herbal references is described inTable 2. Fifty-eight CNMs/CMs (57%) and 35 LMs (95%) reported using herbs in their clinical practice. The mean level of comfort for using herbs in clinical
JOGNN, 39, 684-693; 2010. DOI: 10.1111/j.1552-6909.2010.01193.x
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RESEARCH
Dennehy, C., Tsourounis, C., Bui, L. and King, T. K.
Table 1: Demographic Characteristics of CNM/CM and LM Participants CNMs/CMs
LMs
Demographic Characteristics
n 5 102
n 5 37
Mean age, years (range)
48.5 (28-75)
46.9 (30-62)
Female
101
37
1
ç
45
23
29
4
Male
Various types of midwives receive different formal education on the use herbs for pregnancy indications. (14%), and knowledge (8%). Eleven percent of respondents listed a variety of other reasons for feeling comfortable in using herbs in their practice (e.g., patient preference, provider preference,
Years in practice 10 11-20 420
28
Table 2: Education Related to Herbs
10
CNMs/CMs
LMs
n 5 102
n 5 37
n (%)
n (%)
Time spent in professional curricula related to herbs (hr)
Additional licensure RN
88
ç
0
30 (29)
3 (8)
NP
45
ç
1-5
58 (57)
5 (14)
6-10
9 (9)
7 (19)
Practice settinga Private
38
37
11-20
3 (3)
6 (16)
Hospital
46
1
420
2 (2)
16 (43)
Military
3
ç
Public clinic
29
3
Academic
15
ç
HMO
26
ç
Average number of deliveries per month 0
15
2
1-5
16
29
Herbal references recommended during professional educationa No response
3 (3)
ç
None
65 (64)
6 (16)
Yes
34 (33)
31 (84)
Susun Weed texts
10
24
German Commission E
5
1
1
5
7
40
14
2
Monographs 6-10
41
5
11-15
13
ç
16
22
ç
Other
3b
1c
2
ç
Anne Frye texts Other
b
Did not specify
No response
Note. HMO 5 health maintenance organization. a Respondents were able to indicate more than 1 practice setting. b Respondents indicated ‘‘not applicable.’’ c Respondent indicated ‘‘a few per year.’’
practice was 1.8 for CNMs/CMs and 4.1 for LMs. Seventy-three percent of CNMs/CMs ranked their comfort level in using herbs as 0, 1, or 2, whereas no LMs did. Eighty-four percent of LMs ranked their comfort level in using herbs as 4 or 5, whereas 6% of CNMs/CMs did. The most common rationale stated for feeling comfortable in using herbs (a ranking of 4 or 5) were personal experience (45%), evidence of e⁄cacy (22%), safety and purity
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Information resources used to answer herbal questionsa Other LMs and CNMs
59 (27)
26 (25)
Internet website(s)
41 (19)
16 (16)
Peer-reviewed research
36 (17)
15 (15)
Textbooks c
51 (24)
30 (29)
Other
28 (13)
15 (15)
publication
No response
4 (4)
ç
Note. a Respondents could indicate more than one answer for this section. b A variety of other unique references were cited. c The most common textbooks reported were by Susun Weed, and Anne Frye, Physicians Desk Reference on Herbs and the German Commission E Monographs.
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access to an herbal specialist). The most common rationales stated for feeling uncomfortable in using herbs in clinical practice (a ranking of 0-2) were lack of knowledge (36%), poor evidence of e⁄cacy (23%), lack of personal experience (14%), institutional restrictions (10%), and lack of safety and purity (7%). Ten percent of respondents listed a variety of other reasons for feeling uncomfortable in using herbs in their practice (e.g., patient preference, provider preference, lack of experience and knowledge, and cost).
monly used herbs for each indication are provided in Table 4. Licensed midwives were more likely to recommend herb-based pregnancy teas for overall
Table 4: Most Common Herbs Used by Pregnancy Indication Among Midwives Who Reported Using Herbs in Their Practice
Indication
Fifty-one percent of CNMs/CMs and 26% of LMs reported barriers to using herbs in their practice setting. The most common were institutional restrictions (39%), patient preference (18%), lack of knowledge (14%), poor evidence of e⁄cacy (7%), ¢nancial (5%), lack of availability (5%), and other (11%). The barriers categorized as ‘‘other’’ included misinformation, ignorance and mistrust, not generally well accepted, demand on personal time, safety and purity, and pill burden. Herbal use by pregnancy indication as reported by midwives who were using herbs in their clinical practice is summarized in Table 3. The most com-
CNMs/CMsa
LMs
n/Total (%)
n/Total (%)
0
6/35 (17)
Fertilityb Wild yam Red clover
1/57 (2)
5/35 (14)
Chastetree
2/57 (4)
3/35 (9)
Red raspberry
1/57 (2)
4/35 (11)
41/58 (71)
23/35 (66)
Peppermint
5/58 (9)
10/35 (29)
Chamomile
7/58 (12)
1/35 (3)
Red raspberry
4/58 (7)
9/35 (26)
Yellow dock
8/57 (14)
28/35 (80)
Nettles
5/57 (9)
23/35 (66)
12/57 (21)
8/35 (23)
3/57 (5)
11/35 (31)
Nausea/vomiting Ginger
Anemiab
Table 3: Frequency of Herb Use by Pregnancy Indication Among Midwives Who Reported Using Herbs in Their Practice
Floradix
sc
CNMs/CMsa
LMs
Indication
n/Total (%)
n/Total (%)
Nausea/vomiting
48/58 (83)
30/35 (86)
Lactation/increasing milk supplyb 37/57 (65)
30/35 (86)
False unicorn
ç
Labor inductionb
31/35 (89)
Wild yam
ç
33/57 (58)
Perineal healing/discomfort b
27/57 (47)
35/35 (100)
Anemiab
33/57 (39)
32/35 (91)
Dandelion
Preterm labor/preterm contractions or bleedingd
Malpresentation/breech, labor induction Pulsatilla
10/35 (29) 8/35 (23) b
6/57 (11)
14/35 (40)
b
Malpresentation/breechb
16/57 (28)
19/35 (54)
Labor induction
Dysfunctional Labor/prolonged
11/57 (19)
28/35 (80)
Blue cohosh
15/57 (26)
25/35 (71)
Black cohosh
16/57 (28)
23/35 (66)
10/57 (18)
22/35 (63)
Castor oil
10/57 (18)
8/35 (23)
Labor/anesthesia or analgesiab
8/57 (14)
14/35 (40)
Evening primrose oil
13/57 (23)
1/35 (3)
Preterm labor/preterm
6/57 (11)
22/35 (63)
Cotton root
3/57 (5)
11/57 (19)
4/57 (7)
16/35 (46)
latent phase
b
Postpartum depressionb
contractions or bleedingb Fertility b
Dysfunctional labor/prolonged latent phaseb Blue cohosh
8/57 (14)
21/35 (60)
Black cohosh
8/57 (14)
16/35 (46)
Cotton root
2/57 (4)
6/35 (17)
Note. a CNM/CM responses were combined for those who reported using herbs in their practice (N 5 58). b One CNM/CM provided no answer.
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Table 4. Continued Indication
CNMs/CMsa
LMs
n/Total (%)
n/Total (%)
Labor/anesthesia or analgesiab Rescue remedye
2/57 (4)
4/35 (11)
Skull cap
1/57 (2)
4/35 (11)
12/57 (21)
30/35 (86)
Arnica
9/57 (16)
5/35 (14)
Witch hazel
5/57 (9)
8/35 (23)
St. John’s wort
2/57 (4)
7/35 (20)
Motherwort
2/57 (4)
4/35 (11)
2/57 (4)
4/35 (11)
20/57 (35)
16/35 (46)
7/57 (12)
11/35 (31)
Aniseed
7/57 (12)
8/35 (23)
Blessed thistle
5/57 (9)
7/35 (20)
Perineal healing/discomfortb Comfrey
Postpartum depressionb
Skull cap Lactation/increasing milk supply Fenugreek Fennel/mother’s milk tea
f
b
Note. a CNM/CM responses were combined for those who reported using herbs in their practice (N 5 58). b One CNM/CM provided no answer. c Floradix s 5 carrot, nettle worth, spinach, quitch roots, angelica roots, fennel, ocean kelp, African mallow blossom, orange peel, iron, vitamins C, B1, B2, B6, and B12. d Only 6/57 (11%) of CNMs/CMs felt comfortable using herbs for this indication. e Rescue remedy 5 crab apple, Star of Bethlehem, clematis, cherry plum, impatiens, rock rose. f Responses for mother’s milk tea were combined with responses for fennel as mother’s milk tea contains bitter fennel fruit and aniseed fruit.
health and well-being than CNMs/CMs (81% vs. 38%). The most commonly recommended herbs to include in a pregnancy tea were red raspberry (70%) and nettle (42%). Seventy-six percent of CNMs/CMs and 47% of LMs indicated that they had no preference for a particular herbal manufacturer or supplier. Among those that indicated a preferred manufacturer or supplier, the most common were Herb Pharm Inc. (25%), Nature’s Sunshine Products (16%), and The Scarlet Sage Herb Co. (13%). Among the respondents who reported using herbs in their practice, a total of 11 herb-related adverse events (AEs) were reported. The combination of blue and black cohosh was involved in two AEs, one report of uterine hyperstimulation, and the
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other involving fetal tachycardia. The use of blue cohosh by itself was involved in four AEs: meconium stained amniotic £uid, fetal tachycardia, and two unspeci¢ed reactions. Black cohosh was involved in one AE: an allergic reaction. The remaining herbs were involved in one reaction each: ginger associated with icterus, chamomile associated with anaphylaxis, skull cap associated with hypotension, and pennyroyal associated with postpartum hemorrhage.
Discussion The current study is the ¢rst to survey CNMs/CMs and LMs regarding herb use in pregnancy and fertility in the State of California. The study is important because it focuses solely on the use of herbal medicine (as opposed to all CAM modalities) and because the use of herbs in the western United States has been shown to be more prevalent than other parts of the country (Barnes et al., 2008). This survey is also the ¢rst to assess the level of professional education received by both groups in the area of herbal medicine. The only other study that surveyed CNMs and LMs was conducted in Texas and focused on various CAM modalities in pregnancy (Bayles, 2007). Although the current study focused on use of herbs in patients seen by midwives, implications for practice cut across disciplines. All nurses who practice in perinatal care should be familiar with the types of herbal products that women may be using and inquire about herbal product use. The response rate for the current study (30% overall, 31% CNM/CMs and 28% LMs) is comparable to other studies of this kind (Bayles, 2007; McFarlin et al.,1999). Our response rate re£ects the total number of surveys that were evaluated after exclusion criteria were applied. Similarly, the study by McFarlin et al. had a 34% response rate after exclusion criteria were applied. The response rate in the Bayles study did not mention additional exclusion criteria aside from undeliverable surveys and had a slightly lower response rate than the current study (21% overall, 26% CNMs and 13% LMs). CNMs/CMs practiced in a variety of clinical settings with hospital practice being the most common. LMs almost exclusively practiced in private settings. Because hospitals are more likely to have policies in place that limit the widespread use of herbs in clinical practice, this may explain, in part, the higher usage rates reported by LMs. Institutional barriers were also reported by 39% of all respondents. Ten percent of respondents felt uncomfortable in using
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Most herbs used for pregnancy indications lacked evidence-based clinical support and safety data.
herbs in clinical practice because of these institutional barriers whereas a majority (36%) who expressed discomfort cited ‘‘lack of knowledge.’’ As such, even if an institutional barrier did not exist, there are many midwives who still would not choose to use herbs because of their lack of knowledge. Licensed midwives were more comfortable in using herbs in clinical practice than CNMs/CMs. Based on the additional education that LMs reported having received in their professional curricula, this increased level of comfort is not surprising. LMs cited personal experience as the most common reason for their high comfort level whereas CNMs/ CMs cited their lack of knowledge or education as the most common reason for feeling uncomfortable in using herbs. Because LMs spent more time in professional curricula related to herbs, they were also more likely to have been recommended herbal references (84% LMs and 33% CNMs/CMs). The most commonly recommended references, cited by all midwives, were textbooks by Susun Weed (http://www.susun weed.com). It is interesting to note that Susun Weed does not have specialized education in midwifery nor o⁄cial diplomas of any kind. Her knowledge of herbs is mostly self-taught, and her area of focus is folkloric herbalism. In contrast, the other two resources cited by midwives were textbooks by Anne Frye, a certi¢ed professional midwife (CPM), and the German Commission E Monographs, a compendium of herbal monographs containing information on herb use, contraindications, side e¡ects, drug^herb interactions, dose, route of administration, risks, pharmacokinetics, and toxicology (Blumenthal & Busse,1998; Frye & Baker,1998). Although the German Commission E Monographs contain information related to the historical use of herbs, they provide limited safety information in pregnancy. The reference is also outdated and has limited clinical applicability (Blumenthal & Busse). For example, even the most updated version known as the Expanded Commission E Monographs published by the American Botanical Council does not include any information on well-known drug interactions involving St. John’s wort (Blumenthal, Goldberb, & Brinckmann, 2000). This is concerning as St. John’s wort has been found to interact with
690
numerous medications that can lead to serious adverse outcomes if overlooked (Borrelli & Izzo, 2009; Zhou, Chan, Pan, Huang, & Lee, 2004). It is also important to note that herb use has been poorly studied in pregnancy with limited animal and in vitro studies and relies heavily on historical evidence of safety. Accessing the primary literature (e.g., individual randomized controlled trials, systematic reviews, and meta-analyses) is the best means of determining how well each individual herb has been studied, the formulation used, and if observational data exists on birth outcomes. Additionally this will provide more timely and up-to-date safety information than textbooks as an herb’s safety pro¢le may change as more research is conducted. Currently, the Food and Drug Administration (FDA) MedWatch program and the American Association of Poison Control Centers collect information on herb-related exposures. Although these surveillance systems collect information on herb-related adverse events, they are not immediately searchable or accessible by nurses and midwives who wish to determine if an adverse event exists involving an herbal product. This leaves to question whether a clearinghouse or database for reporting herbal adverse e¡ects speci¢c to pregnancy is needed. The current study identi¢ed 11 self-reported, herb-related AEs some of which would be considered serious in severity and some of which have been previously reported in the literature. Unless a nurse or midwife is extensively familiar with the literature or is educated by someone who has such knowledge, it is di⁄cult to know which herbs to avoid. The type of informational resources used to answer herbal questions was similar among CNMs/CMs and LMs and most often involved asking a colleague or using a textbook reference as compared to accessing the primary literature. The textbook references used were similar to those recommended during professional education. In another national study, 69% of nurse-midwives reported learning about herbs for cervical ripening from a colleague and only 4% from formal research publications (McFarlin et al., 1999). These data support the need to move toward the use of the primary literature as a means of promoting more evidencebased care. The use of herbs by pregnancy indication demonstrated clear di¡erences between the practices of LMs and CNMs/CMs. Speci¢cally, for every indication, LMs were more likely to use herbs in their practice. The only indication in which usage rates
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were high and similar in frequency between groups was for nausea and vomiting in pregnancy where 83% to 86% of midwives used herbs. Over 50% of CNMs/CMs also felt comfortable in using herbs for lactation and labor induction. The types of indications with the greatest discrepancy in the use of herbs between CNMs/CMs and LMs were dysfunctional labor/prolonged latent phase (61% di¡erence), perineal healing/discomfort (53% di¡erence), anemia (52% di¡erence), and preterm labor (52% di¡erence). The majority of CNMs/CMs indicated that they had no preference for a particular herbal manufacturer or supplier. The purity and potency of an herb can vary depending on the manufacturer and manufacturing process. Furthermore, intentional and unintentional contaminants, pesticides, bacteria, and heavy metals may have the potential to a¡ect pregnancy outcomes. It is expected that the recently implemented Good Manufacturing Practice Standards issued by the Food and Drug Administration in 2007 will help to minimize introduction of these contaminants (United States FDA, 2007). The types of herbs used for speci¢c pregnancy indications were similar between CNMs/CMs and LMs with ginger being highlighted most frequently for nausea and vomiting in pregnancy. Ginger has favorable support from randomized controlled trials (RCTs) as an e¡ective remedy for this indication (Borrelli, Capasso, Aviello, Pittler, & Izzo, 2005; Chittumma, 2007; Ensiyeh & Sakineh, 2009; Ozgoli, Goli, & Simbar, 2009; Pongrojpaw, 2007). Results from 10 RCTs (5 comparisons to placebo, 4 comparisons to vitamin B6, and 1 comparison to dimenhydrinate) and an observational cohort suggest no negative e¡ect on birth outcomes. Nonetheless, the total population of women studied remains small and could fail to detect an adverse event if it were serious but infrequent. Some practitioners may also have concerns regarding in vitro and animal data which report a mutagenic e¡ect of 6gingerol and early embryonic loss in rats given 15 to 50 g/L of ginger tea (Nakamura & Yamamoto, 1982; Wilkinson, 2000). The other frequently used herbs, black cohosh, blue cohosh, fenugreek, comfrey, yellow dock, and nettle, have not been adequately studied in RCTs for the reported pregnancy indications. Blue cohosh when used as a single herb or in combination with black cohosh has some data that suggests that it should not be used for labor induction due to its vasoconstrictive properties on coronary arteries and associated case reports of seizure, hypoxia, con-
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gestive heart failure, and stroke in infants possibly related to maternal use (Finkel & Zarlengo, 2004; Gunn & Wright, 1996; Jones & Lawson, 1998). The current study also reports two additional AEs involving uterine hyperstimulation and fetal tachycardia with a combination of black and blue cohosh and four adverse events for blue cohosh involving meconium staining, fetal tachycardia, and two unspeci¢ed reactions. As such, the risk of using blue cohosh appears to outweigh any bene¢t. Fenugreek is theorized to stimulate sweat glands, and because the breast is a modi¢ed sweat gland, it has been used to induce lactation (Gabay, 2002). Comfrey has been used historically as a topical wound healing agent, which could explain why midwives use it for perineal healing (Kucera & Kucera, 2007). Importantly, comfrey should never be used internally because it contains hepatotoxic pyrrolizidine alkaloids (Liu et al., 2009). Nettle is also known as common nettle or stinging nettle. It has been used historically for anemia, but there is insu⁄cient reliable information about the e¡ectiveness of nettle for this indication (Jellin, 2010). Similarly, yellow dock has not been studied for anemia (Jellin). The current study had some limitations. The survey was only sent to one third of the CMs/CNMs provided on the ACNM mailing list for the state of California. This was done to limit the scope of the survey to 500 midwives in total but may have excluded CMs/CNMs who were more or less inclined to use herbs in their practice. Although the survey response rate (32%) was similar to other surveys of this kind, having a greater response rate would have provided more complete data. In addition, selection bias may have contributed to the lower response rate with midwives who did not use herbs in their practice being less inclined to respond. Forty-three percent of CNMs/CMs and 5% of LMs reported not using herbs in their clinical practice. As with any survey, our results were also subject to recall bias, particularly with regard to hours devoted to education on herb use, references recommended and herb-related AEs. AEs were self-reported associations and the details of each patient case were not provided, therefore AE causality cannot be con¢rmed. The current study has some implications for practice. Speci¢cally nurses may expect midwives to be more knowledgeable and comfortable in using herbs. This level of comfort however is supported less by empirical evidence and more by historical use. If a patient or a practitioner wishes to use an herb for pregnancy an evidence-based approach
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should be taken. This involves a review of available clinical trial data, adverse reports, and possible drug^herb interactions. Resources that should be searched include, but are not limited to,The Natural Standard, Natural Medicines Comprehensive Database International Bibliographic Information on Dietary Supplements (IBIDS) Database and The Cochrane Collaboration Reviews (Basch & Ulbricht, 2010; Jellin, 2010, http://grande.nal.usda. gov/ibids/, http://www2.cochrane.org/reviews/).
Chittumma, P. (2007). Comparison of the e¡ectiveness of ginger and vitamin B6 for treatment of nausea and vomiting in early pregnancy: A randomized double-blind controlled trial. Journal of the Medical Association of Thailand, 90, 15-20. Cochrane Collaboration. (2010). Cochrane database of systematic reviews [electronic database]. Chichester, U.K.: Wiley. Retrieved from http://www2.cochrane.org/reviews/. Einarson, A., Lawrimore, T., Brand, P., Gallo, M., Rotatone, C., & Koren, G. (2000). Attitudes and practices of physicians and naturopaths toward herbal products, including use during pregnancy and lactation. Canadian Journal of Clinical Pharmacology, 7, 45-49. Ensiyeh, J., & Sakineh, M. A. (2009). Comparing ginger and vitamin B6 for
This survey found that herbs are commonly used and recommended by midwives practicing in California. Important di¡erences appear to exist between CNMs/CMs and LMs with regard to herb use and level of comfort in using and recommending herbs to their clients. In turn, there was a notable di¡erence in the level of education devoted to the use in herbs by CNMs/CMs and LMs. Given the level of herb use in both disciplines, having de¢ned curricula devoted to herbs as part of professional education is important. Ginger was the most commonly used herb for nausea/vomiting and is one of a few herbs to have evidence for this indication. More research is needed to evaluate the safety and e⁄cacy for most of the other herbs used by midwives. More importantly, improved surveillance methods are needed to document the safety of herbs used in pregnancy.
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