Dr. Hashim Mohamed
Dr. Johina Abdin
Dr. Deyaa Al Kozaai
Dr. Khalila Al Jazar
Dr. Fareeda Al Masseh
Dr. Mohamed Hashim
Dr. Faten Abo Kalila

Correspondence:
Dr. Hashim Mohamed
Consultant, Family Medicine,
Director of Umm Gwalina H. C
P.O. Box. 3050
Hamad Medical Corporation
email: fmcc2000@gmail.com

INTRODUCTION

Complementary and alternative medicine (CAM) is defined as biologic, energy , spiritual and mind - body therapies that are not prescribed within the boundaries of convention health care systems⁽¹⁾ including a variety of ingested therapies, herbs, vitamins and homeopathic medicine⁽²⁾. Traditionally complementary & alternative medicine (CAM) use has been associated with developing countries, but recently complementary medicine has boomed worldwide, with a staggering increase in the use of (CAM) observed in Australia, Europe and the USA⁽³⁾. Although the use of (CAM ) among females was higher than males in studies done in developed countries, most of the these studies fell short in their capacity to highlight racial/ethnic differences in (CAM) use⁽⁴⁾. Cultural factors arising from religious beliefs can translate into practice thereby having a profound impact on health especially among followers of the Islamic faith, Christianity and Hinduism⁽⁵⁾.
Qatar, an Arabian Gulf state has witnessed a rapid socio-economic transition over the last 2 decades resulting in an influx of expatriates mainly from the South East Asian region harnessing the three faiths above. Pregnant females in particular have used (CAM) for a variety of reasons ranging from pregnancy related disorders including, nausea and vomiting, induction of labour, up to the other end of the spectrum that is, treating cancer. Many people including pregnant females have a perceived "natural status" attached to herbal medicine in particular and (CAM) in general leading them to draw the conclusion that (CAM) therapies are not associated with adverse side effects. Thereby, it is imperative that health practitioners re-evaluate the format and extent of history to encompass the potential for diverse and substantial CAM usage.
Additionally, health care profession has yet to assume a concentrated effort in education, research, guidelines and public policy to address this global phenomenon.

This is a cross sectional study of pregnant females attending primary health care antenatal clinic in Doha, Qatar.
This study was designed to determine the prevalence of CAMs use among adult pregnant females in Qatar. The survey was conducted between January to February 2009.
A multistage stratified cluster sampling design was developed using the administrative divisions of the Qatari primary health care center antenatal clinics in regions that had approximately equal number of inhabitants in Qatar. Each person is entitled to primary care that is free at the point of access and is delivered by the primary care team. The primary care physicians caring for pregnant females act as gate keepers for indicated cases that require referral to specialist care such as high risk pregnancies including recurrent abortions, twins and diabetic females.
Pregnant females register at their respective health centers via a booking visit by a family practitioner trained to care for pregnant females.
At the booking visit and after confirming pregnancy via blood test, socio-demographic details are recorded, including a detailed obstetrical and gynecological history, physical examinations including vital signs, weight and height and blood pressure, and fundal height with routine blood investigations, which consist of complete blood count, blood group, Rh - group, R.P.R, hepatitis screening and GGT in high risk cases. High risk cases such as twin pregnancy, threatened and recurrent abortions and diabetic patients are referred to hospital after the initial visit. Education is delivered by the visiting health educator.
The follow up continues at primary care level until 34 weeks of gestation then patients are referred to hospital.

All females registered at antenatal clinics across the country were potentially eligible for inclusion in the study. The source for identification of subjects was the computerized antenatal clinic register.
The total population of pregnant females for the year 2008 included on the register was 18,376, excluding those who were followed up in private sectors and those jointly looked after between primary and secondary care, diabetic patients and high risk cases including twin pregnancy and threatened abortions.

Power calculation
The existing literature suggests a likely prevalence of CAM use in pregnancy of up to 47%⁽⁶⁾ and the likely response of the total sample of pregnant females was estimated to be ~ 80%. At this range of prevalence and level of response, the precision of a prevalence based on ~ 480 responders at (95% CI) is within + 5% (absolute), which is a level of precision judged to be adequate⁽⁷⁾. An estimated sample size of 383 would be required to meet the specific objectives of the study. Of the total of 22 primary health care antenatal clinics available, 8 were selected at random, of these 4 were located in urban and 4 in semi urban areas of Qatar. During the study period 450 subjects were approached, of whom 393 agreed to participate, giving a response rate of 89%.

Data collection
Trained family physicians, four in total, administered a previously validated and reliable semi-structured questionnaire⁽⁷⁾ via a face-to-face interview lasting an average 15 minutes. Prior explanation of CAM was offered to participating subjects. CAM was defined as a broad domain of healing practices, theories and beliefs other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period⁽⁸⁾. The questionnaire contained 20 items divided into three sections utilizing closed and open ended questions.
The first section contained socio demographic data, presence of chronic medical disease, use of CAMs in previous or outside pregnancy. The second section assessed the use of CAMs during current pregnancy and it's relation to each trimester. The third section assessed pregnant female opinion regarding safety and efficacy of CAMs use during pregnancy. Translation of the questionnaire was followed by an independent back translation to compare the source with the translated text, which was carried out to determine if questions were phrased unambiguously.

Data analysis
The chi-square (x²) test was used to analyze categorical variables which were expressed as percentage values.
On the other hand continuous variables were reported as mean value + standard error of mean (SEM) and analyzed using ANOVA or the t- test.
A P-value <0.05 was considered statistically significant. All analyses were performed using SPSS for Windows, version 14.0 (Chicago Inc., Illinois, USA).

Pregnant females approached numbered 450 subjects and a total of (393) pregnant females agreed to participate, with a response rate of (87%).
The mean age of the final sample (393 pregnant females) was (29 + years); most women were multiparous (66.7%).
Educational attainment level was as follows; (74.6%) pregnant females had a (university) degree, (21.9 %) had a secondary school degree and 3.5% had primary education ninety eight (24.5 %) subjects reported suffering from chronic disease:
Diabetes (25 cases), hypertension (10 cases), Low back pain (25 cases), Osteoarthritis (10 cases), Asthma (12 cases), hepatitis (6 cases), Chronic headache (8 cases), hypothyroidism (2 cases). The majority of participants (67.5 %) reported to have used CAM during the first trimester, (37.7%) during the second and (28.9%) during the third trimester (Figure 1). With regard to modalities of CAM used, the majority (65.2%) of pregnant females used herbal remedies, (26.1%) used food supplements, (6.5%) oil massage, (1.1%) multivitamins and (1.1% cupping (Figure 2).

Questionnaire's validity and reliability
The questionnaire's reproducibility exceeded 0.7 for every item by computing all K- values using test - to - retest evaluation⁽¹⁾.
CAM usage outside and/or in previous pregnancies
(58%) of females reported to have used CAMs during previous pregnancies. The characteristics of pregnant females, divided into "users" or "non-users" of CAM are illustrated in Table (1).
x² - and t - test did not show any difference among all variables except for secondary and high school education see Table (1).

CAM usage during current pregnancy
The characteristics of subjects, according to CAM utilization in current pregnancy are illustrated in Table (2). Subjects who had used CAM in current pregnancy is reported at a (29%) prevalence versus (41.6%) non-use, P <0.001. Therefore the only characteristic included in the model which was statistically significant in both current and previous users was high level of education (P<0.001).
Percentage of herbal varieties used
Among pregnant females (24%) used herbal mixes, (17%) used ginger, (1%) aniseed, (9%) fenugreek, (9%) mint and (8%) used thyme, sage and lemon, whereas (6%) used chamomile (Figure 3).
Information source
The primary source of information for pregnant subjects during gestation was their friends/family (65%), magazine/ TV/ newspaper (13%), internet (7%), general practitioner (4%), gynaecologist (4%), others (4%), herbalist (2%) and pharmacist (1%) (Figure 4). In our study gynaecologists represented only (4%) unlike in studies conducted in Europe. In previous pregnancy females relied mainly on (gynaecologist) for information (28.9%), general practitioner (26.3%), internet (24.1%), friends/family (11.7%), whereas outside pregnancy, herbalists were the main source for information (23.4%), followed by family/friends (17.9%), internet (16.2%), TV/ magazine (13.7%), general practitioner (13.3%), pharmacist (9.7%) and gynecologist (5.8%) (Figure 5).
Pregnant female opinion about safety of CAMs
With regards to safety (52.4%) of pregnant females thought that CAM was safer than traditional medicine, (25.7%) less safe, (10.4%) equally safe and (11.5%) had a don't know response (Figure 6).
Pregnant females opinion about efficacy of CAMs
Efficacy on the other hand was as follows ; (56.2%) of pregnant females thought CAM was more efficacious than traditional medicine, (37.7%) thought it was less effective and (6.1%) equally effective (Figure 7).
Reasons for different CAM used is variable according to pregnant females' belief which is influenced partially by cultural factors as well as others see Table (3).

Figure 1. CAM use in relation to Trimmester Period

Figure 2. Modalities of CAM used

Figure 3. Percentages of herbal varieties used

Figure 4. sources on CAM during current pregnancy (n=114)

Figure 5. Information sources on CAM in previous pregnancy or outside of pregnancy (n=114)

Figure 6. Pregnant women's opinions about safety of CAM when compared with traditional medications (n=114)

Figure 7. Pregnant women's opinion about efficacy of CAM when compared with traditional medications (n=114).

This is the first Qatari study investigating knowledge, attitude and practice of CAMs in pregnant women, and is also the first work conducted with the aim of characterizing CAM users. These results emphasize that the use of CAMs during pregnancy is a common habit among pregnant women. In fact 58% of the surveyed subjects used at least one CAM during their lifetime and 29% in their current pregnancy. The reliability and validity of the questionnaire has been established in a previous study⁽⁸⁾. The prevalence of CAM use seems to be higher in Qatari than what is reported in studies performed in the USA and in other European countries. Most research on drug use in pregnancy report a prevalence of between 3.6 and 15.9% CAM use (including homeopathic and herbal drugs)^(9-11). (A)Furthermore, previous epidemiological studies conducted in Italy mainly dealt with the use of herbal remedies. Zaffani et al.⁽¹²⁾ conducted a research on 1,044 randomly selected Italian women where 47.0% of the sample reported using at least one herbal product, including utilization in pregnancy or to treat their children's disease. Herbal products were mainly taken in combination with conventional drugs or homeopathic remedies.⁽⁴⁾
Although the prevalence of CAM use during pregnancy reported in the present study is (29%) nevertheless, in our sample, no significant difference was present in socio-demographic variables between CAM users and non-users including parity, nationality, co-morbid conditions and income, except among highly educated women, aged 29-34 years confirming previous results of studies performed in other countries (13,14). However, it is worth mentioning that these studies were focused on phytotherapy, while the present study was aimed at exploring the use of any CAMs. So these socio-demographic features may therefore pertain to subjects seeking a phytotherapeutic approach, while the use of CAMs appears, in general, to be less restricted to social classes. The importance of studying CAM use in pregnancy underlies the possible maternal and foetal risks of some non-conventional medications. The safety profile of Ginseng, Valerian, St. John's Wort, Gingko, Propolis, and Chamomile is not clearly defined^(15,16) and for some of them, their use in pregnancy is contraindicated because of the potential harm for the mother and/or foetus as well as the potential adverse effect affecting childbirth^(17-23). Consistently, fenugreek, ginger, chamomile, consumed by 21% of the participants, are not supported by adequate information on their safety profile in pregnancy, and women could use these preparations without knowing their actual formulation. On this topic a fatal case report of anaphylaxis due to chamomile tea during pregnancy has been reported^(24-26). Finally ginger was also in common use among pregnant females. Ginger (Zingiber officinale Roscoe) contains many volatile oils, starch, triglycerides, niacin and vitamins. Ginger has many pharmacological actions including being an antiemetic, positive inotropic, carminative, promoting secretion of saliva and gastric juices. Ginger is thought to increase the effects of anticoagulants and may interfere with anti diabetic and cardiac therapies. Therefore its use in early pregnancy is not recommended.⁽²⁷⁾
Although our survey reported the use of chamomile among pregnant females during their current pregnancy,chamomile however has been reported to have the potential to interact with anticoagulants thereby increasing bleeding tendency⁽²⁸⁾ and anaphylaxis. On the other hand sage (Salvia officinalis) with prolonged use may lead to epileptiform convulsions⁽²⁹⁾, hence some authors recommended regular blood glucose testing when this product is used⁽³⁰⁾. Sage is also known to enhance the effects of anti-hypertensive and anti-diabetic medications⁽³¹⁾. Furthermore, fenugreek is known to have the potential of interaction with antihypertensive medications and anticoagulants thereby requiring therapeutic monitoring including serum glucose level and coagulation profile. The increased percentage (67.5%) of taking CAMs during the first trimester of pregnancy is quite alarming knowing the potential for interaction and teratogenicity and more than half of pregnant women seem to be confident with CAMs and consider CAMs safer than conventional medicines. A positive note emerging from these data is that pregnant women refer primarily to gynecologists and general practitioners as their principal source of information for CAM use during pregnancy. However, only 28.9% of participants consulted gynaecologists, confirming the risk that CAMs could be used without an accurate clinical control.

Limitations
Firstly, the items that investigated the previous use of CAMs could be affected by recall bias. Secondly, not including females attending hospital and private clinic in Qatar may affect the generalizability of our finding to the whole population.

Conclusion
Given the high prevalence of CAM use among pregnant females in pregnancy and especially in the first trimester and the relative lack of evidence of either harm or efficacy, it is imperative that health care workers do enquire about CAM use as part of routine work up. Secondly, pregnant females should have preconception counseling regarding different CAMs available in the market especially where safety and efficacy are concerned.

Acknowledgements
We would like to acknowledge the sincere efforts of Umm Gwalina Health Center nursing staff.

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