International Journal of Clinical Pharmacy

https://doi.org/10.1007/s11096-018-0608-x

RESEARCH ARTICLE

Complementary medicines in pregnancy: recommendations

and information sources of healthcare professionals in Australia
Christine E. Gilmartin1   · To‑Hao Vo‑Tran1 · Laura Leung1

Received: 1 October 2017 / Accepted: 15 February 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract
Background The use of oral complementary and alternative medicines, including herbal supplements, has been increasing in
pregnant women worldwide despite limited safety data. The decision of healthcare professionals to recommend these products
to pregnant patients is controversial and not well documented. Objective To explore the recommendations and information
sources that healthcare professionals use to determine the safety of oral non-prescribed supplements during pregnancy.
Setting An Australian metropolitan maternity hospital. Method An electronic survey was distributed to doctors, midwives,
pharmacists, dietitians, lactation consultants and physiotherapists. Main outcome measure The nature of recommendations
and information sources that healthcare professionals use to determine the safety of oral non-prescribed supplements during
pregnancy. Results Responses were received from 54 healthcare professionals. Forty of 54 (74.1%) were concerned about the
safety of their patients’ supplements, while 35 of 54 (64.8%) felt that they had access to trustworthy safety information. Sup-
plements most commonly recommended as safe to use were ginger (40.7%), probiotics (29.6%) and raspberry leaf (22.2%).
Participants specifically requested further safety information for raspberry leaf, evening primrose oil, fish oil, probiotics,
ginger, vitamin C, valerian, turmeric, blue cohosh and colloidal silver. Written resources most frequently consulted included
­MIMS® (61.1%) and ‘Google Searches’ (29.6%), and healthcare professionals most referred to were pharmacists (74.1%),
doctors (22.2%), and naturopaths or herbalists (3.7%). Conclusion The recommendations of maternity heath care profession-
als and quality of information sources used varied. Further education and access to unbiased safety information is required
to empower healthcare professionals to provide informed recommendations to pregnant patients.

Keywords  Australia · Complementary medicines · Herbal medicines · Information · Pregnancy

Impacts on practice

• This study demonstrates the need to empower mater-

nity healthcare professionals to seek appropriate safety
information regarding complementary and alternative
Electronic supplementary material  The online version of this medicine use during pregnancy so that they can provide
article (https​://doi.org/10.1007/s1109​6-018-0608-x) contains informed recommendations to patients.
supplementary material, which is available to authorized users. • The findings of this study reveal the requirement for
maintaining access and awareness of up-to-date resources
* Christine E. Gilmartin
christine.gilmartin@thewomens.org.au and local protocols, so that healthcare managers and clin-
ical teachers can support and train the current and next
To‑Hao Vo‑Tran
tohao.votran@thewomens.org.au generation of healthcare providers accordingly.
• This study also highlights to health researchers the need
Laura Leung
laura.leung@thewomens.org.au to address the paucity of safety information for comple-
mentary and alternative medicines in the pregnant patient
1
The Royal Women’s Hospital Pharmacy Department, The cohort, so that future patients may be prevented from
Royal Women’s Hospital, Cnr. Grattan St. & Flemington Rd, taking contraindicated supplements.
Parkville, VIC 3052, Australia

13
Vol.:(0123456789)

• The trends of information queries regarding the use of com-
plementary and alternative medicines in this study may
guide the direction and focus of future safety information
research.
Introduction
Complementary or alternative medicines (CAMs) can be
defined as health care practices or therapies which are not
integrated into the dominant health care system, and can
include traditional or herbal supplements [1]. Australia has
experienced an increase in the awareness and use of CAMs,
and has some of the highest utilisation rates in the world [2].
The use of these oral non-prescribed supplements, includ-
ing some non-prescribed vitamins, is significantly higher
in women and those with a higher education and higher
income [2]. Reported rates of herbal medicine use in preg-
nant women may vary according to Australian geographical
area but has been reported to be as high as 36% of pregnant
women in a previous Victorian study [3]. The perception of
control over health, and the beliefs that herbal supplements
are natural, holistic, “non-chemical”, free of side-effects, and
accessible, have all been cited as major factors in women’s
decisions to use these products [4]. Despite their popularity,
there is limited robust safety evidence available for many
commonly-used products for use during pregnancy [3, 5].
Some products requiring caution have been found to not pro-
vide clear safety information, and some patients choose to
import products for personal use from countries outside Aus-
tralian jurisdiction, potentially making safety information
even more difficult to locate [6]. Explicit safety information
is important as cases of poor outcomes of prenatal exposure
to CAM products have been reported, including intrauterine
growth restriction, preterm labour, gestational hypertensive
disorders, fetal distress, and renal, cardiac and neural tube
defects [7–12]. It is of additional concern that a 2016 mul-
tinational study of herbal medicine use in pregnancy found
that while many women used products considered only low
risk, those using a contraindicated preparation were more
likely to have done so with consultation of a healthcare prac-
titioner than an informal source [13]. As such, combined
with the potential for harm to the fetus and scarcity of large
clinical studies, healthcare professionals providing care to
pregnant women must ensure that their advice pertaining to
supplement use is based on the most robust evidence avail-
able [13]. The opinions and practices of healthcare profes-
sionals regarding CAMs in a maternity healthcare setting are
however not well documented.
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International Journal of Clinical Pharmacy
Aim of the study
The aim of this study was to investigate the recommenda-
tions and information sources of maternity healthcare pro-
fessionals regarding the use of oral non-prescribed herbal
medicines and complementary supplements at an Australian
metropolitan tertiary hospital.
Ethics approval
The Human Research and Ethics Committee of the site was
notified of this project and approval was granted to conduct
the investigation as a quality-assurance audit.
Method
An electronic survey (see electronic supplementary mate-
rial) was sent to maternity healthcare professionals in Octo-
ber 2016. The recipients of the survey included all doc-
tors, pharmacists, midwives, nurses, lactation consultants,
dietitians, and physiotherapists currently practicing at the
study site and expected to provide frequent care to mater-
nity patients. Email lists of recipients were obtained from
the heads of relevant departments, with nurse/midwives
representing the largest profession group at the site. The
survey was composed of 13 questions which explored par-
ticipant demographics, the frequency and nature of patient
queries about CAM safety, their opinion of CAM safety in
pregnancy, and information sources they use. Survey ques-
tions were mostly multiple-choice in design, closed-ended,
and phrased in plain language. Where appropriate, survey
responses were accepted in the form of single-selection only,
multiple-selection enabled (“select all that apply”), and free
text for responses that did not conform to a provided option.
Participants were instructed to consider only oral formu-
lations of non-prescription dietary or herbal supplements
which are not routinely initiated to correct or prevent a medi-
cally diagnosed disorder in pregnant patients. The survey
requested that the following supplements were specifically
not to be referred to in responses: pregnancy multivitamins,
vitamin D (colecalciferol), vitamin B1 (thiamine), vitamin
B6 (pyridoxine), vitamin B9 (folic acid), vitamin B12 (cya-
nocobalamin), magnesium, calcium, iron, and meal replace-
ment products such as ­Sustagen®. Survey responses were
anonymous and resulting data was pooled. Responses were
entered into a Microsoft E ­ xcel® spreadsheet and analysed
descriptively. Data analysis was performed using the statisti-
cal software program SPSS Statistics 22 (IBM).
International Journal of Clinical Pharmacy
Results
The electronic survey (see supplementary electronic mate-
rial) was sent to 219 maternity healthcare professionals
(Table 1), of whom 54 (24.7%) responded. Over half the
respondents (33 of 54, 61.1%) reported to have been prac-
tising for greater than 5 years. No participants declared that
they had a potential conflict of interest pertaining to their
recommendations of CAM use in pregnancy.
Thirty-five of 54 (64.8%) participants reported being
asked by their pregnant patients about the safety of CAMs
at least once a month, while 40 of 54 (74.1%) expressed
that they are sometimes concerned about the safety of their
patients’ supplements. Thirty-four of 54 (63.0%) partici-
pants disclosed that they do not feel knowledgeable about
the safety of CAMs in pregnancy. However, a similar propor-
tion (35 of 54 (64.8%)) felt that they have ready access to
quality safety information about CAMs.
Twenty-four of 54 (44.4%) participants did not recom-
mend any CAMs to their patients as safe to use during preg-
nancy [14] (Table 2). Ginger (zingiber officinale) was most
commonly recommended (22 of 31; 71.0%) as safe, followed
by raspberry leaf, (rubus idaeus, 12 of 31; 38.7%) and fish
oil (9 of 31; 29.0%). A majority of these participants typi-
cally recommended greater than 2 different supplements (20
of 31; 64.5%).
The indications described for the CAMs that were recom-
mended as safe to use were consistent for ginger (nausea),
chamomile (matricaria chamomilla, sleeping difficulty),
and raspberry leaf (uterine tone and induction or efficiency
of labour). Participants who listed the use of cranberry for
urinary tract infections did not specify if they recommended
it for use in treatment or prevention of infection. Described
indications varied significantly for vitamin C (ascorbic acid),
probiotics, and fish oil (Table 2).
More than half of the participants (29 of 54; 53.7%) stated
a preference for more pregnancy-specific safety information
about CAMs. Ten of 29 (34.5%) participants wanted access
to further information about all commonly used CAMs, but
specifically mentioned supplements included raspberry leaf
Table 1  Participant response rate by profession
Profession Survey respondents Survey recipients
Midwife and/or nurse, n (%) 19 (13.2) 144 (65.8)
Doctor, n (%) 16 (39.0) 41 (20.1)
Pharmacist, n (%) 11 (73.3) 15 (7.4)
Dietitian, n (%) 6 (60.0) 10 (4.6)
Physiotherapist, n (%) 1 (20.0) 5 (2.3)
Lactation consultant, n (%) 1 (25.0) 4 (1.8)
Total, n (%) 54 (24.7) 219 (100)
(9 of 29; 31.0%), fish oil (4 of 29; 13.8%), evening primrose
oil (oenothera biennis, 4 of 29; 13.8%), probiotics (3 of 29;
10.3%), followed by ginger, vitamin C, valerian (valeriana
officinalis), turmeric (curcuma longa), blue cohosh (caulo-
phyllum thalictroides), and colloidal silver (each accounting
for 1 of 29; 3.4%).
When searching written information sources for safety
data of CAMs use in pregnancy, most participants favoured
the medicine database ­MIMS® (33 of 54; 61.1%) (Table 3),
which features a compilation of manufacturer-provided prod-
uct information. The minimum level of evidence required by
participants before recommending a supplement as safe to
use in pregnancy was most commonly an online database
such as M­ icromedex® or M ­ IMS® (21 of 54; 38.9%), with
no participants willing to accept case studies or anecdotal
evidence as their sole source of safety information. In the
event of uncertainty requiring referral to another healthcare
professional or other personnel, participants most frequently
sought the advice of pharmacists (40 of 54; 74.1%), followed
by doctors (12 of 54; 22.2%), then naturopaths or herbalists
(2 of 54; 3.7%). Four participants specified that they sought
the advice of the pharmacists operating the medicines infor-
mation service (MIS) provided by the hospital.
Discussion
The safety recommendations and information sources
regarding supplement use in pregnancy used by healthcare
professionals were varied in this study. An important finding
was the high variability of indications for which supplements
were recommended, as well as the frequent responses of
“general health” and “general well-being.” This may be a
result of a perceived faith in the supplements’ value in treat-
ing multiple non-specific ailments, or possibly a reflection of
what some critics believe is a tendency of manufacturers to
suggest ambiguous or unproven benefits [15, 16].
Existing safety data for the three supplements most fre-
quently recommended in this study (ginger, probiotics, and
raspberry leaf) can be considered neither alarming nor hav-
ing the robustness to suggest an absolute recommendation
as safe to use in pregnancy [17]. While multiple studies
observing oral ginger use in pregnancy report no increased
risks of harm to the mother or fetus, some concerns persist
regarding ginger’s potential to increase risk of bleeding and
postpartum haemorrhage [17–20]. Current published stud-
ies suggest that probiotics generally appear safe and well
tolerated in healthy pregnant individuals, possibly due in
part to limited systemic absorption [21]. However, safety
data for probiotics may depend on the strains within the pro-
prietary product, which usually contain one or more vari-
eties of bifidobacterium, lactobacillus and saccharomyces
strains, as well as occasionally streptococcus thermophilus
13
 International Journal of Clinical Pharmacy

Table 2  Dietary and herbal supplements recommended to pregnant women

Supplements Frequencya Indications
(n = 54)

NIL—does not recommend any 24 –

Ginger 22 Nausea
Probiotics 16 General well-being
Diarrhoea or gastrointestinal symptoms secondary to antibiotics
Indigestion
For concurrent use with antibiotics
Gastro-intestinal complaints
Immune system enhancement
Thrush
Raspberry leaf 12 After 36/40 weeks
Uterine tone
Uterine irritability
Induction of labour
Improved efficiency of labour
Fish oil 9 Joint pain
Mental health
Cardiac health
General well-being
For women with low dietary fish intake
For women who are breastfeeding while pregnant
Support for foetal neurodevelopment
Prolonged gestation
Inflammatory complaints
High cholesterol
Cranberry 9 Urinary tract infections
Recurrent urinary tract infections
Evening primrose oil 4 Induction of labour
Uterine health
Vitamin C 5 Prevention and/or treatment of cold & flu/upper respiratory tract infections
‘General health’
To take with iron supplements to improve absorption
‘Collagen booster’/skin repair in 2nd & 3rd trimester
Floradix® formula liquid herbal iron 3 Iron deficiency
­extractb Iron supplementation for women intolerant to other formulas due to consti-
pation, inability to swallow tablets
Chamomile 1 Difficulty sleeping
Blue cohosh 1 (indication not specified)
Garlic 1 (indication not specified)
a
 Some participants recommended more than one supplement
b
 Floradix® formula liquid herbal iron extract ingredients include Iron (from ferrous gluconate), Vitamin B1, Vitamin B2, Vitamin B6, Vitamin
B12, Vitamin C, rosehip, carrot, nettle wort, spinach, couch grass, angelica, fennel, ocean kelp, African Mallow Blossom, orange peel, wheat
germ powder, yeast extract, honey, and juices from pear, grape, black currant, orange, blackberry, cherry and beetroot [14]

[17, 22]. Safety evidence in pregnancy cannot be located for
some strains, for example, saccharomyces and streptococcus
thermophilus [21, 23–25]. In addition to blue cohosh and
evening primrose oil, raspberry leaf has been a CAM sup-
plement favoured in the past by some healthcare providers
for use in labour augmentation [26]. While the consumption
of medicinal products containing raspberry leaf is possibly
safe in late pregnancy under healthcare professional supervi-
sion, the lack of efficacy evidence may not justify even the
low perceived risk of use [17, 27, 28]. Although the efficacy
of supplements was not strictly the focus of this study, it is
important to note that there is still potential for pregnant
patients to come to harm from untreated or sub-optimally
treated conditions by using ineffective complementary or
alternative treatments in lieu of conventional medicine. For
example, the use of cranberry for the treatment of urinary
tract infections in pregnancy in place of antibiotics may
result in dire consequences for mother and fetus should an
infection be allowed to advance untreated.
Information sources for deriving safety data pertaining
to herbal or complementary supplement use in pregnancy
should ideally be evidence-based, practical, up-to-date,

13
International Journal of Clinical Pharmacy
Table 3  Information sources used for pregnancy-specific safety data of complementary and herbal supplements
Information sources most frequently u­ seda
Information source
MIMS
Google search
Journal articles
Manufacturer product information
Micromedex
Books
Natural medicines database
Internal hospital guidelines
Australian dietary guidelines
Minimum acceptable level of safety information required before recommending a supplement as safe to use in pregnancy
Information source
Medicine databases (e.g. ­Micromedex®, ­MIMS®)
Randomised controlled trials
Expert opinion
Observational or epidemiological studies
Past experience
Case studies or anecdotal evidence
Would not recommend any non-prescribed supplements or herbal medicines as safe
to use in pregnancy
Total:
a
 Some participants mostly consulted more than one information source for data regarding safety in pregnancy
easily accessible, and unbiased. The database ­MIMS®,
preferred by some study participants, has the advantages
of having electronically accessible and propriety product-
specific information. Unfortunately, due to the scarcity of
safety studies of their product in pregnancy, many manufac-
turers conservatively advise women who are or may become
pregnant to not use their product. While this is certainly a
safe recommendation to adhere to, clinicians often require
further information to compare the benefits and risks for
some patients. Many healthcare professionals prefer the
accessibility and speed of the internet when faced with such
a query. However, despite the merits of search engines like
Google, the largely unregulated nature of this information
source means that clinicians would need to navigate some
amount of poor quality and possibly biased information that
their search terms may retrieve [29]. The electronic data-
bases ­Micromedex® and Natural Medicines ­Database® were
not highly favoured by the participants, but they both contain
broadly sourced and unbiased information in a relatively eas-
ily accessible format. Natural Medicines D ­ atabase® particu-
larly was recommended by a 2016 review of drug informa-
tion sources conducted by the National Prescribing Service
[30]. While the topic of drug interactions between medicines
and herbal or complementary supplements were not specifi-
cally explored in this study, it is important to note that this
Frequency (n = 54) Percentage (%)
33 61.1
15 27.8
15 27.8
12 22.2
11 20.4
8 14.8
6 11.1
3 5.6
1 1.9
Frequency (n = 54) Percentage (%)
21 38.9
15 27.8
7 13.0
6 11.1
4 7.4
0 0
1 1.8
54 100
too is an essential consideration when assessing safety of use
in pregnancy. Reputable online information resources are
also available for this purpose, such as for example, Stock-
ley’s Drug Interactions on Medicines ­Complete®. Overall,
due to the low number of participants in this study favouring
preferred information sources, education may be pertinent
to clarify to health professionals what constitutes a quality
information source.
The integration of herbal or alternative medicines into
conventional medical care remains controversial, with some
maternity healthcare professionals often recommending
herbal medicine products for pregnancy-related conditions
and others considering them entirely contraindicated dur-
ing pregnancy [26, 31]. The uncertainty regarding CAM
safety observed in this investigation has also been described
in previous studies. Many respondents (71.8%) to a 2010
online survey of mostly UK-based healthcare professionals
believed that the public has a misplaced trust in herbal treat-
ments, but that they themselves had a “quite poor” (36.2%)
or “very poor” (10.4%) knowledge of these supplements
[32]. The survey found that a large proportion of respond-
ents (50%) also preferred general internet searches such as
Google for further information, and that 21.3% of health-
care professionals would not attempt seeking further safety
data about a patients’ herbal supplement before initiating a
13

concomitant prescription medicine [32]. These respondents
claimed their reason for this was that they would not know
how to find or interpret the information [32]. Similarly, this
study indicated that the participant responses pertaining to
safety information searching highlights a need to educate
maternity healthcare professionals on the search strategies
and resources required to quickly retrieve the most robust
information available.
While these results were useful in identifying areas of
intervention regarding information searching, this study
involved a relatively small number of participants of vary-
ing professional group proportions. Authors acknowledge
that low response rates may potentially impact the validity
or bias of results. Therefore, future studies examining larger
participant numbers from possibly a variety of healthcare
settings are needed in order to further explore the experi-
ences of individual professions. Another limitation is that
this study does not explore participants’ gestation-specific
safety concerns, perceived level of efficacy, preferences for
strengths or doses, or specific proprietary products of the
supplements that they recommend as safe. It is important
to note the large variety of brands and products available
to consumers on the Australian market. This wide range of
products may be an added disadvantage for healthcare pro-
fessionals who may reassure patients that their products are
safe to use based on a part-description or without viewing
the label and product information.
Conclusion
In summary, this study found that while most maternity
healthcare professionals expressed concern about the safety
of patient’s self-initiated complementary or herbal supple-
ments in pregnancy, their recommendations and the quality
of information sources varied. In this current climate of high
herbal medicine usage and sub-optimal quantity of safety
data, it is essential that maternity healthcare professionals
can easily locate appropriate information where available.
Further education and access to unbiased safety information,
including regarding drug-interaction potential, is required
to empower maternity healthcare professionals to provide
informed recommendations to their pregnant patients.
Acknowledgements  Study investigators would like to acknowledge
the Medicines Information Service of the Royal Women’s Hospital
pharmacy department for their input.
Funding  No funding has been received for this study or the preparation
of this manuscript except for ordinary wages.
Conflicts of interest  The authors do not have any conflict of interest
to declare.
13
International Journal of Clinical Pharmacy
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