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OBSTETRICS
Use of herbal treatments in pregnancy
Carol Louik, ScD; Paula Gardiner, MD, MPH; Katherine Kelley, RPh, MPH; Allen A. Mitchell, MD

OBJECTIVE: Interest in herbal treatments has increased without data RESULTS: Among 4866 mothers of nonmalformed infants, 282 (5.8%)
on safety, efficacy, or rates of use in pregnancy. We examined antenatal reported use of herbal or natural treatments. Use varied by study center
herbal and natural product use among mothers of nonmalformed in- and increased with increasing age.
fants in 5 geographic centers.
STUDY DESIGN: We used data on nonmalformed infants from the Slone CONCLUSION: Although rates of use are low, there remains a need for
Epidemiology Centers case-control surveillance program for birth defects investigation of the safety of these products. Given sparse data on effi-
to examine rates and predictors of herbal use. Exposures were identified cacy, even small risks might well outweigh benefits.
through maternal interview. In addition to overall use, 5 categories based on
traditional uses and 2 natural product categories were created; topical Key words: complementary medicine, drug safety, herbal treatments,
products and herbal-containing multivitamins were excluded. pregnancy

Cite this article as: Louik C, Gardiner P, Kelley K, et al. Use of herbal treatments in pregnancy. Am J Obstet Gynecol 2010;202:439.e1-10.

I t is widely recognized that use of


herbal and complementary medical
treatments has increased in the United like medications, the Food and Drug Ad-
M ATERIALS AND M ETHODS
The Slone Epidemiology Center at Bos-
ton University has been conducting the
States over the last decade.1 While pas- ministration does not formally approve Birth Defects Study (also known as the
sage of the Dietary Supplements Health dietary supplements prior to marketing. Pregnancy Health Interview Study), a
and Education Act of 1994 provided While use of these products is believed form of case-control surveillance to
some guidelines for these supplements, to be increasing, little is known about identify the risks and safety of various
the legislation included no safety or effi- their use specifically during pregnancy. antenatal environmental exposures, par-
cacy standards that must be met and, un- A few small studies have considered spe- ticularly medications, in relation to birth
cific subpopulations and geographic re- defects since 1976; the methods have
gions,2-8 but there are few data available been described previously.11,12 Since the
From the Slone Epidemiology Center (Drs on current use of herbal treatments studys inception, infants with birth de-
Louik and Mitchell and Ms Kelley) and the among the general population of preg- fects have been identified in birth and
Department of Family Medicine (Dr
nant women in the United States. tertiary care hospitals in various geo-
Gardiner), Boston University, Boston, MA.
Knowledge of use is particularly impor- graphic areas, and, since 1993, a sample
Received June 25, 2009; revised Oct. 7, 2009;
accepted Jan. 20, 2010. tant given that there is some evidence to of nonmalformed infants was also iden-
Reprints: Carol Louik, ScD, Slone suggest that anxiety about harming the tified at study hospitals in all study cen-
Epidemiology Center at Boston University, fetus leads some women to avoid phar- ters. Depending on the size of the hospi-
1010 Commonwealth Ave., Boston, MA maceutical treatment,9 and it is possible tal, between 310 nonmalformed infants
02215. clouik@bu.edu. that they may be substituting herbal are selected at random from hospital dis-
This study was supported in part by the products, perceived to be more natu- charge lists. In 1998, ascertainment of
National Institute of Child Health and Human
Development Grant HD27697; National Heart,
ral. Alternatively, they may be using malformed subjects was modified in
Lung, and Blood Institute Grant HL 50763; and herbal and other natural products in ad- Massachusetts to involve the states birth
Cooperative Agreement no. U50/CCU113247 dition to traditional medications, which defects registry system, and an analogous
with the Centers for Disease Control and raises concerns about possible interac- change was made to identify nonmal-
Prevention through the Massachusetts
tions.10 Thus, it is important to under- formed infants from a random sample of
Department of Public Health. Additional
support for the Slone Epidemiology Center stand the extent to which herbal and birth certificates. The current report is
Birth Defects Study was provided by Aventis other natural treatments are used in based on mothers of nonmalformed in-
Inc and Sanofi Pasteur Inc. pregnancy, the specific products used, fants included in the study from 5 study
0002-9378/free the reasons why they are used, and fac- centers (greater Philadelphia, PA;
2010 Mosby, Inc. All rights reserved.
tors that may predict which women are greater Toronto, Ontario, Canada; San
doi: 10.1016/j.ajog.2010.01.055
most likely to use herbal and other natu- Diego, CA; and state-based birth defects
For Editors Commentary, ral products. In this article, we examine registries in Massachusetts and New
see Table of Contents use in pregnancy of herbal and other nat- York State) who were interviewed from
ural treatments. 1998 2006.

MAY 2010 American Journal of Obstetrics & Gynecology 439.e1


Research Obstetrics www.AJOG.org

(eg, ginseng is included in both cough


FIGURE 1
and cold remedies and weight loss or
Overall herbal use according to study center sports enhancement). A woman was
among 4866 mothers of nonmalformed infants considered to be exposed if she reported
use of the product at any time from 2
months prior to the LMP through the
end of pregnancy; use according to
month of gestation was also investigated.
We examined a wide range of potential
predictors of use of herbal and other nat-
ural treatments in pregnancy: age; eth-
nicity; education; family income; marital
status; body mass index; smoking status;
alcohol consumption; coffee and tea
consumption; parity; history of chronic
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010. conditions, including asthma, diabetes,
hypertension, and herpes; conditions
occurring during pregnancy, including
Mothers of eligible subjects are inter- as well as herbal or home remedies. respiratory infections, morning sickness,
viewed within 6 months of the babys Women who report use of any treatment urinary tract infections, fevers, and tox-
birth by trained nurse-interviewers us- are asked to retrieve the bottle or package emia; use of prescription or nonpre-
ing a standardized questionnaire. The if it is still available. scription medications (other than
interview elicits demographic informa- For this analysis, we considered a herbal); study center; and LMP year.
tion about the mother and father and de- product to be herbal if it contained 1 Multiple logistic regression was used to
tailed information regarding maternal ingredient that was botanical in origin, evaluate each potential risk factor while
illnesses and medications used from 2 regardless of the part of the plant from controlling for the effects of others.
months prior to the last menstrual pe- which the ingredient is derived. We ex-
riod (LMP) through the end of preg- cluded topical treatments and all multi-
nancy. This study was approved by Bos- vitamins, whether or not they contained R ESULTS
ton University Medical Centers an herbal ingredient from the analysis. There were 4866 interviews of mothers
Institutional Review Board and, as ap- Because this is a survey of reported use of of nonmalformed infants available for
propriate, the institutional review herbal and other natural products rather study, with LMP years between 1997
boards of participating institutions, and than an investigation of risks and safety 2005. Among women we were able to lo-
informed consent was obtained from all of specific ingredients, we focused pri- cate, the participation rate was 68.0%;
participants. marily on products rather than specific this rate ranged from 64% in New York
Information on drug exposures dur- ingredients, although we also examined to 61% in Massachusetts. Massachusetts
ing the time period from 2 months prior 4 ingredients thought to be of particular subjects represented about 60% of the
to the date of the LMP through the end of interest: chamomile, ephedra, ginger, study sample; Philadelphia, PA, 15%;
pregnancy is elicited through a series of and ginseng. Toronto, Ontario, Canada, 13%; and the
questions designed to maximize recall We created 5 categories of products remainder were from San Diego, CA,
and accuracy of reporting. We inquire based on their traditional uses: cough and New York State. Overall, 282 women
first about illnesses that subjects may and cold remedies (eg, echinacea, ar- (5.8%) reported using an herbal or other
have had and any treatments used for nica), nausea and vomiting of pregnancy natural treatment. As shown in Figure 1,
them. The women are then asked about (NVP) (eg, ginger, raspberry), psychiat- use varied considerably by center.
common indications for medication use ric and sleep disorders (eg, valerian, Table 1 reveals a clear increase in use
(eg, headache, depression, heartburn, Gingko biloba), weight loss or sports en- with increasing age (P .05), but few
fluid retention), specific medication cat- hancement (eg, Metabolife [Metabolife other factors seemed related to overall
egories (eg, vitamins, antibiotics, laxa- International, Inc., San Diego, CA], gin- herbal and other natural product use.
tives), and, finally, specific medications seng), and bladder or other female Hispanic women reported more herbal
(eg, Advil, Tylenol products, Prozac, Al- problems (eg, chamomile, cranberry and other natural use compared with
legra). Each of these questions includes juice). We also investigated 2 additional whites, but the 95% confidence interval
the following statement: Please include natural product categories: probiotics (CI) included 1.0. There was no evidence
medications prescribed by a health care (eg, acidophilus) and lipids and omega that use of herbal and other natural
provider and medications you may have fatty acids (eg, fish oil, evening primrose products increased over time. Women
obtained without a prescription from oil). A given product could be included who experienced NVP or who had a res-
stores, pharmacies, friends, or relatives, in 1 of these categories, if appropriate piratory infection had higher rates of

439.e2 American Journal of Obstetrics & Gynecology MAY 2010


www.AJOG.org Obstetrics Research

TABLE 1
Factors associated with use of herbal and other natural product treatments
during pregnancy among 4866 mothers of nonmalformed infants
Any herbal use,
(n 282)
Womens characteristics n % Crude OR (95% CI) Adjusted ORa (95% CI)
Age, y
.......................................................................................................................................................................................................................................................................................................................................................................
20 8 2.2 0.39 (0.190.82) 0.52 (0.191.42)
.......................................................................................................................................................................................................................................................................................................................................................................
2024 34 5.2 0.95 (0.621.46) 0.74 (0.441.26)
.......................................................................................................................................................................................................................................................................................................................................................................
2529 (Reference) 66 5.4 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
3034 106 6.2 1.15 (0.841.58) 1.19 (0.841.68)
.......................................................................................................................................................................................................................................................................................................................................................................
3539 53 6.7 1.24 (0.861.81) 1.34 (0.882.04)
.......................................................................................................................................................................................................................................................................................................................................................................
40 14 13.5 2.71 (1.475.02) 2.95 (1.495.83)
................................................................................................................................................................................................................................................................................................................................................................................
BMI
.......................................................................................................................................................................................................................................................................................................................................................................
Underweight 5 2.2 0.35 (0.140.86) 0.30 (0.110.81)
.......................................................................................................................................................................................................................................................................................................................................................................
Normal (Reference) 184 6.0 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Overweight 64 6.6 1.10 (0.821.48) 0.91 (0.661.27)
.......................................................................................................................................................................................................................................................................................................................................................................
Obese 24 4.4 0.72 (0.471.12) 0.70 (0.431.14)
................................................................................................................................................................................................................................................................................................................................................................................
Ethnic background
.......................................................................................................................................................................................................................................................................................................................................................................
White (Reference) 205 5.8 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
African origin 15 4.4 0.74 (0.441.27) 1.16 (0.622.17)
.......................................................................................................................................................................................................................................................................................................................................................................
Other 24 6.8 1.19 (0.771.84) 1.44 (0.872.39)
.......................................................................................................................................................................................................................................................................................................................................................................
Hispanic 38 6.1 1.05 (0.731.50) 1.58 (0.982.54)
................................................................................................................................................................................................................................................................................................................................................................................
Smokers
.......................................................................................................................................................................................................................................................................................................................................................................
During pregnancy 29 5.6 1.12 (0.741.69) 1.40 (0.852.29)
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 142 5.0 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Before pregnancy 111 7.3 1.48 (1.151.91) 1.31 (0.971.76)
................................................................................................................................................................................................................................................................................................................................................................................
Education, y
.......................................................................................................................................................................................................................................................................................................................................................................
High school 12 2.7 0.42 (0.230.77) 0.41 (0.171.00)
.......................................................................................................................................................................................................................................................................................................................................................................
Completed high school (Reference) 132 6.2 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
High school 138 6.0 0.96 (0.751.22) 0.85 (0.631.17)
................................................................................................................................................................................................................................................................................................................................................................................
Income, $/y
.......................................................................................................................................................................................................................................................................................................................................................................
10,000 8 3.4 0.54 (0.261.12) 0.80 (0.322.05)
.......................................................................................................................................................................................................................................................................................................................................................................
10,00045,000 65 5.7 0.92 (0.691.23) 1.03 (0.711.48)
.......................................................................................................................................................................................................................................................................................................................................................................
45,000 (Reference) 190 6.2 1.00 (Reference) 1.00 (Reference)
................................................................................................................................................................................................................................................................................................................................................................................
Center
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 133 4.5 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 52 6.9 1.56 (1.122.17) 1.40 (0.952.07)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 56 9.2 2.14 (1.542.96) 2.13 (1.493.06)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 37 7.8 1.80 (1.232.63) 2.23 (1.413.52)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 4 6.1 1.37 (0.493.82) 1.11 (0.323.89)
................................................................................................................................................................................................................................................................................................................................................................................
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010. (continued )

MAY 2010 American Journal of Obstetrics & Gynecology 439.e3


Research Obstetrics www.AJOG.org

TABLE 1
Factors associated with use of herbal and other natural product treatments
during pregnancy among 4866 mothers of nonmalformed infants (continued)
Any herbal use,
(n 282)
Womens characteristics n % Crude OR (95% CI) Adjusted ORa (95% CI)
LMP year
.......................................................................................................................................................................................................................................................................................................................................................................
19971998 49 5.3 0.83 (0.551.26) 1.01 (0.621.65)
.......................................................................................................................................................................................................................................................................................................................................................................
19992000 96 6.6 1.05 (0.731.50) 1.20 (0.771.87)
.......................................................................................................................................................................................................................................................................................................................................................................
20012002 91 5.2 0.81 (0.561.16) 0.75 (0.491.14)
.......................................................................................................................................................................................................................................................................................................................................................................
20032005 (Reference) 46 6.3 1.00 (Reference) 1.00 (Reference)
................................................................................................................................................................................................................................................................................................................................................................................
Alcohol use
.......................................................................................................................................................................................................................................................................................................................................................................
During pregnancy 108 7.2 1.33 (1.021.74) 1.34 (0.821.57)
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 124 5.5 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Before pregnancy 49 4.5 0.81 (0.581.13) 0.68 (0.461.01)
................................................................................................................................................................................................................................................................................................................................................................................
Marital status
.......................................................................................................................................................................................................................................................................................................................................................................
Married (Reference) 215 6.0 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Other 67 5.3 0.89 (0.671.18) 1.25 (0.841.85)
................................................................................................................................................................................................................................................................................................................................................................................
Total pregnancies
.......................................................................................................................................................................................................................................................................................................................................................................
1 (Reference) 72 4.8 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
2 93 6.1 1.28 (0.941.76) 1.14 (0.801.64)
.......................................................................................................................................................................................................................................................................................................................................................................
3 117 6.4 1.35 (1.001.82) 1.12 (0.781.60)
................................................................................................................................................................................................................................................................................................................................................................................
Coffee use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 80 4.4 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 197 6.6 0.65 (0.500.85) 1.11 (0.801.53)
................................................................................................................................................................................................................................................................................................................................................................................
Decaffeinated coffee use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 161 4.9 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 117 7.7 0.62 (0.490.80) 1.37 (1.021.84)
................................................................................................................................................................................................................................................................................................................................................................................
Tea use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 78 3.9 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 201 7.2 1.91 (1.462.50) 1.77 (1.302.39)
................................................................................................................................................................................................................................................................................................................................................................................
Asthma
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 271 5.9 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 11 4.5 1.31 (0.712.42) 1.39 (0.444.39)
................................................................................................................................................................................................................................................................................................................................................................................
Diabetes
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 272 5.9 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 10 4.3 1.40 (0.732.66) 1.37 (0.493.85)
................................................................................................................................................................................................................................................................................................................................................................................
Hypertension
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 258 5.9 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 24 5.1 1.15 (0.751.77) 1.77 (0.615.18)
................................................................................................................................................................................................................................................................................................................................................................................
Herpes
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 278 5.8 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 4 4.5 1.30 (0.473.56) 1.34 (0.325.55)
................................................................................................................................................................................................................................................................................................................................................................................
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010. (continued )

439.e4 American Journal of Obstetrics & Gynecology MAY 2010


www.AJOG.org Obstetrics Research

TABLE 1
Factors associated with use of herbal and other natural product treatments
during pregnancy among 4866 mothers of nonmalformed infants (continued)
Any herbal use,
(n 282)
Womens characteristics n % Crude OR (95% CI) Adjusted ORa (95% CI)
Chronic condition
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 237 6.1 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 45 4.7 0.76 (0.551.05) 0.51 (0.171.55)
................................................................................................................................................................................................................................................................................................................................................................................
Upper respiratory infection
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 87 4.4 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 195 6.7 1.55 (1.202.01) 1.41 (1.041.89)
................................................................................................................................................................................................................................................................................................................................................................................
Fever
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 207 5.5 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 75 7.0 0.77 (0.581.01) 1.03 (0.761.41)
................................................................................................................................................................................................................................................................................................................................................................................
Urinary tract infection
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 241 5.6 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 41 7.2 1.30 (0.921.83) 1.42 (0.962.10)
................................................................................................................................................................................................................................................................................................................................................................................
Toxemia
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 275 5.8 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 7 5.1 0.88 (0.411.90) 0.79 (0.312.01)
................................................................................................................................................................................................................................................................................................................................................................................
Morning sickness
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 91 4.8 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 191 6.5 1.38 (1.071.78) 1.43 (1.071.89)
................................................................................................................................................................................................................................................................................................................................................................................
BMI, body mass index; CI, confidence interval; LMP, last menstrual period; OR, odds ratio.
a
Adjusted for all other factors in the table.
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010.

herbal and other natural use than enhancement treatments showed little
TABLE 2
women who did not (see below), and it is variation. Several classes of herbs were
Rates of use of herbal and natural
interesting to note that women who related to tea consumption (NVP, probi-
drank decaffeinated coffee or tea were otics, and lipids and omega fatty acids),
product classes defined by
also slightly more likely to use herbal or while others were more related to coffee
intended use among 4866
other natural products. consumption (psychiatric and sleep dis-
mothers of nonmalformed infants
The rates of use for each of the catego- orders and weight loss or sports en- Intended use n %
ries of herbal and other natural prepara- hancement). There were several catego- Probiotics 92 1.90
...........................................................................................................
tions based on their traditional uses are ries that were inversely related to alcohol Bladder or female problems 56 1.20
...........................................................................................................
presented in Table 2. We evaluated the use prior to pregnancy, including cough
Cough and cold remedies 56 1.20
same factors as possible predictors of use and cold remedies, psychiatric and sleep ...........................................................................................................

of these categories. Because rates of use disorders, and probiotics. Weight loss or sports 52 1.10
enhancement
were low, most CIs were wide and in- It is useful to note that all women who ...........................................................................................................

cluded 1.0 (data not shown), but there used a cough or cold herbal remedy re- Nausea and vomiting of 46 1.10
were some factors that suggested differ- ported having an upper respiratory in- pregnancy
...........................................................................................................

ences, and these differed across the cate- fection. Similarly, women who experi- Lipids and omega fatty acids 43 0.90
...........................................................................................................
gories. Selected results are shown in Ta- enced nausea and vomiting were much Psychiatric and sleep 26 0.50
ble 3. As was true for overall use, use of more likely to have used an NVP herbal disorders
most herbal and other natural classes (odds ratio [OR], 10.9; 95% CI, 2.6 46), ...........................................................................................................
Louik. Herbal treatment use in pregnancy. Am J
varied by center, but psychiatric and and women who reported urinary tract Obstet Gynecol 2010.
sleep disorders and weight loss or sports infections were more likely to have used

MAY 2010 American Journal of Obstetrics & Gynecology 439.e5


Research Obstetrics www.AJOG.org

TABLE 3
Selected factors associated with categories of herbal and other natural
product use among 4866 mothers of nonmalformed infants
Factor Exposed, n Crude OR (95% CI) Adjusted OR (95% CI)
Cough and cold remedies 56
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 22 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 14 2.54 (1.294.99) 2.92 (1.326.47)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 13 3.00 (1.505.99) 3.28 (1.517.13)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 7 2.06 (0.884.85) 3.13 (1.039.48)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 0
................................................................................................................................................................................................................................................................................................................................................................................
Alcohol use
.......................................................................................................................................................................................................................................................................................................................................................................
During pregnancy 21 1.11 (0.631.95) 1.00 (0.502.02)
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 29 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Before pregnancy 5 0.35 (0.140.91) 0.31 (0.110.87)
................................................................................................................................................................................................................................................................................................................................................................................
Upper respiratory infection
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 0 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 56
................................................................................................................................................................................................................................................................................................................................................................................
Nausea and vomiting 46
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 16 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 13 3.24 (1.556.78) 2.66 (1.046.84)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 9 2.86 (1.266.50) 3.32 (1.288.60)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 7 2.83 (1.166.93) 3.80 (1.3510.68)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 1 2.85 (0.3721.80) 2.95 (0.3028.81)
................................................................................................................................................................................................................................................................................................................................................................................
Tea use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 12 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 33 2.04 (1.053.96) 2.26 (0.955.42)
................................................................................................................................................................................................................................................................................................................................................................................
Morning sickness
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 4 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 42 6.90 (2.4719.26) 10.90 (2.5845.98)
................................................................................................................................................................................................................................................................................................................................................................................
Psychiatric and sleep disorders 26
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 18 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 1 0.22 (0.301.66) 0.28 (0.042.19)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 5 1.41 (0.523.82) 0.71 (0.202.61)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 2 0.72 (0.173.11) 1.11 (0.215.91)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 0
................................................................................................................................................................................................................................................................................................................................................................................
Alcohol use
.......................................................................................................................................................................................................................................................................................................................................................................
During pregnancy 15 4.60 (1.6712.67) 4.59 (1.2017.53)
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 5 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Before pregnancy 6 2.40 (0.78.0) 2.32 (0.5010.66)
................................................................................................................................................................................................................................................................................................................................................................................
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010. (continued )

439.e6 American Journal of Obstetrics & Gynecology MAY 2010


www.AJOG.org Obstetrics Research

TABLE 3
Selected factors associated with categories of herbal and other natural
product use among 4866 mothers of nonmalformed infants (continued)
Factor Exposed, n Crude OR (95% CI) Adjusted OR (95% CI)
Coffee use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 3 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 20 4.17 (1.2414.04) 2.46 (0.688.94)
................................................................................................................................................................................................................................................................................................................................................................................
Weight loss or sports enhancement 52
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 26 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 13 2.00 (1.023.91) 1.85 (0.834.11)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 8 1.56 (0.703.47) 1.71 (0.734.02)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 5 1.25 (0.483.26) 1.40 (0.484.13)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 0
................................................................................................................................................................................................................................................................................................................................................................................
Coffee use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 10 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 42 2.63 (1.315.25) 2.16 (0.974.82)
................................................................................................................................................................................................................................................................................................................................................................................
BMI
.......................................................................................................................................................................................................................................................................................................................................................................
Underweight 0
.......................................................................................................................................................................................................................................................................................................................................................................
Normal (Reference) 28 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Overweight 13 1.47 (0.762.85) 1.16 (0.562.41)
.......................................................................................................................................................................................................................................................................................................................................................................
Obese 11 2.18 (1.084.40) 1.83 (0.834.04)
................................................................................................................................................................................................................................................................................................................................................................................
Bladder or female problems 56
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 22 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 8 1.45 (0.643.28) 1.17 (0.463.00)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 14 3.23 (1.646.35) 2.87 (1.405.91)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 10 2.94 (1.386.26) 2.25 (0.935.47)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 2 4.14 (0.9517.99) 1.26 (0.1411.63)
................................................................................................................................................................................................................................................................................................................................................................................
Urinary tract infection
.......................................................................................................................................................................................................................................................................................................................................................................
No (Reference) 42 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes 14 2.54 (1.384.69) 3.53 (1.836.79)
................................................................................................................................................................................................................................................................................................................................................................................
Probiotics 92
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 38 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 17 1.79 (1.003.18) 1.44 (0.722.87)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 22 2.94 (1.735.01) 2.88 (1.585.27)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 13 2.22 (1.174.19) 3.22 (1.506.92)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 2 2.40 (0.5710.16) 1.38 (0.1612.02)
................................................................................................................................................................................................................................................................................................................................................................................
Alcohol use
.......................................................................................................................................................................................................................................................................................................................................................................
During pregnancy 27 0.81 (0.511.30) 0.62 (0.361.09)
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 51 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Before pregnancy 14 0.56 (0.311.02) 0.45 (0.230.90)
................................................................................................................................................................................................................................................................................................................................................................................
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010. (continued )

MAY 2010 American Journal of Obstetrics & Gynecology 439.e7


Research Obstetrics www.AJOG.org

TABLE 3
Selected factors associated with categories of herbal and other natural
product use among 4866 mothers of nonmalformed infants (continued)
Factor Exposed, n Crude OR (95% CI) Adjusted OR (95% CI)
Tea use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 17 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 73 3.19 (1.875.42) 3.14 (1.695.84)
................................................................................................................................................................................................................................................................................................................................................................................
Lipids and omega fatty acids 43
................................................................................................................................................................................................................................................................................................................................................................................
CENTER
.......................................................................................................................................................................................................................................................................................................................................................................
Boston, MA (Reference) 18 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Philadelphia, PA 5 1.11 (0.413.00) 1.00 (0.323.12)
.......................................................................................................................................................................................................................................................................................................................................................................
Toronto, Ontario, Canada 11 3.10 (1.466.61) 2.87 (1.266.54)
.......................................................................................................................................................................................................................................................................................................................................................................
San Diego, CA 7 2.52 (1.056.06) 2.38 (0.816.97)
.......................................................................................................................................................................................................................................................................................................................................................................
New York State 2 5.06 (1.1522.28) 2.04 (0.2119.94)
................................................................................................................................................................................................................................................................................................................................................................................
Tea use
.......................................................................................................................................................................................................................................................................................................................................................................
Never (Reference) 8 1.00 (Reference) 1.00 (Reference)
.......................................................................................................................................................................................................................................................................................................................................................................
Ever 35 3.25 (1.507.02) 2.76 (1.186.46)
................................................................................................................................................................................................................................................................................................................................................................................
BMI, body mass index; CI, confidence interval; OR, odds ratio.
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010.

an herbal treatment for bladder or fe- etary blend of herbs, including ephedra) limited to the 2 months prior to the LMP
male problems (OR, 3.5; 95% CI, 1.8 (0.2%). (Metabolife was removed from and the first gestational month and that
6.8). Obese women were more likely to the market early in 2004 and no use was use of ginger, a product used for nausea
have used a weight loss or sports en- reported after that time; we have ad- and vomiting, peaked during the first
hancement herbal (OR, 1.8; 95% CI, justed the denominator to correspond to trimester.
0.8 4.0). the appropriate time period.) We exam-
The most commonly reported herbal ined these according to gestational
C OMMENT
preparations (excluding vitamins) were month of use (Figure 2). Although the
Use of herbal and other natural treat-
ginger (0.6%), echinacea (0.6%), fish oil number of women reporting use in each
ments has been reported to be increasing
(0.4%), herbal tea (0.4%), cranberry month is too small to draw inferences, it
in the United States and Canada, and, as
(0.2%), and Metabolife (vitamin E, mag- is important to note that use of
acceptance of alternative medicine ther-
nesium, zinc, chromium, and a propri- Metabolife, a weight loss product, was
apies as valid treatment grows, herbal
and other natural use is likely to con-
FIGURE 2 tinue. Because herbal and other natural
Most commonly reported herbal products according to gestational remedies are not regulated to the same
month of use among 4866 mothers of nonmalformed infants degree as traditional pharmaceutical
products, it is important to monitor
their use; this is particularly the case in
pregnancy, a potentially vulnerable time
for both mother and fetus. In this study,
we found that although herbal and other
natural products as a group are used by
approximately 6% of pregnant women,
use of individual products is quite low,
with the most common (ginger and echi-
nacea) reported by only 0.6% of preg-
nant women. Rates of use of herbal and
other natural treatments have remained
LM, lunar month. fairly consistent over time.
Louik. Herbal treatment use in pregnancy. Am J Obstet Gynecol 2010. Increasing age was associated with
greater use of herbal and other natural

439.e8 American Journal of Obstetrics & Gynecology MAY 2010


www.AJOG.org Obstetrics Research

products as a whole, as has been reported in response to a question concerning ied herbal and other natural products
by other investigators,3,13,14 but the fac- medication use. Including multivita- confer benefit to the pregnant woman, it
tor most strongly and consistently asso- mins would have yielded higher rates of is particularly important to identify even
ciated with herbal and other natural use herbal use but could have been mislead- small risks, which would appreciably af-
was geographic region. This association ing, because women may have been un- fect the benefit-risk calculus. Further
remained strong even after adjustment aware that the multivitamin they used studies should focus on the safety of spe-
for race and ethnicity and may reflect contained a single herb, eg, lycopene. (In cific herbal and other natural ingredients
cultural variations across regions that fact, we found that of the 85 distinct mul- found in these products with respect to a
encompass factors beyond race and eth- tivitamin products reported by women wide range of pregnancy conditions and
nicity. This observation would support in this study, 55 [65%] contained at least outcomes. f
previous studies of herbal use in preg- 1 herbal ingredient.) Our rate of use is
nancy conducted in specific populations similar to the 1 other study that also ex-
ACKNOWLEDGMENTS
that found varying rates of herbal use. cluded multivitamins; Refuerzo et al,13
We thank Dawn Jacobs, RN, MPH, Fiona Rice,
Among these populations, use ranged using subjects from a single, urban hos- MPH, Rita Krolak, RN, Kathleen Sheehan, RN,
from 59% among rural West Virginia pital, found that, after excluding prena- Moira Quinn, RN, Clare Coughlin, RN, Nancy
women3 to 24% among women in Tai- tal vitamins and iron supplements, 4.1% Rodriquez-Sheridan, Carolina Meyers, and
wan.15 Although these differences may of women reported using an herbal or Meghan Malone-Moses, MPH, for their assis-
tance in data collection, and Nastia Dynkin for
be largely explained by varying defini- other natural remedy, which is slightly
computer programming; the staff of the Massa-
tions of herbal products, it is interesting lower than our overall rate of 5.8%. chusetts Department of Public Health Center
that among Australian women, large dif- In a study such as this, where medica- for Birth Defects Research and Prevention; Dr
ference were noted depending on the tion use is collected retrospectively, one Charlotte Druschel and the New York State
mothers country of birth.3 In the must be concerned about the accuracy of Health Department; and Drs Christina Cham-
bers and Kenneth Jones of the University of
present study, it is also important to note reported exposures. While all interviews
California, San Diego, as well as the medical
that about 60% of subjects came from a were conducted within 6 months of de- and nursing staff at all participating hospitals for
single center, Massachusetts. livery, the time interval between expo- assistance with case ascertainment: Boston
When we examined use of herbal and sure and interview could be, in some in- Center: Baystate Medical Center, Beth Israel
other natural treatments according to stances, close to 18 months, and it is Deaconess Medical Center, Boston Medical
Center, Brigham and Womens Hospital,
their traditional uses, we found indirect quite possible that some women were
Brockton Hospital, Cambridge Hospital, Caritas
evidence to suggest that these products unable to recall substances that were Good Samaritan Medical Center, Charlton Me-
are largely used for their intended pur- used infrequently. While our interview is morial Hospital, Childrens Hospital, Emerson
pose. All women who used a cough/cold designed to maximize recall by using a Hospital, Falmouth Hospital, Haverhill-Hale
treatment reported having had an upper series of prompts to elicit drug use and a Hospital, Jordan Hospital, Kent Hospital, Law-
rence General Hospital, Lowell General Hospi-
respiratory infection, most women who calendar to help focus on dates, report-
tal, Melrose-Wakefield Hospital, Metro West
used a product for NVP had experienced ing may still be incomplete. However, it Medical Center-Framingham, Mt Auburn Hos-
episodes of NVP during their pregnan- is unlikely that underreporting would af- pital, New England Medical Center, Newton-
cies, and most women who used prod- fect the relative frequency of use of spe- Wellesley Hospital, North Shore Medical Cen-
ucts for bladder conditions had experi- cific herbal and other natural products. ter, Rhode Island Hospital, Saints Memorial
enced a urinary tract infection. We also These data derive from an ongoing Medical Center, South Shore Hospital, South-
ern New Hampshire Medical Center, St. Eliza-
found that the gestational timing of use program of case-control surveillance for beths Medical Center, St. Lukes Hospital, St.
of some of these products was consistent risk factors for congenital malforma- Vincent Hospital, University of Massachusetts
with their traditional uses: ginger, an ac- tions and represent one of the largest Memorial Health Care, Women and Infants
knowledged treatment for nausea and studies to date of herbal treatments in Hospital; Philadelphia Center: Abington Memo-
vomiting, was most commonly used rial Hospital, Albert Einstein Medical Center, Al-
pregnancy. In this article, we examined
fred I. duPont Hospital for Children, Bryn Mawr
during the first trimester, when NVP is use of products as they are purchased Hospital, Chester County Hospital, Childrens
most likely to occur. and not individual components of these Hospital of Philadelphia, Christiana Care Health
Our overall rate of use is somewhat products. The fact that overall use was Services, Community Hospital, Crozer-Chester
lower than has been reported by oth- relatively low (5.8%), and use of specific Medical Center, Doylestown Hospital, Frank-
ers,16 for which there are several possible ford Hospital, Hahnemann University Hospital,
individual products was even lower, does
the Hospital of the University of Pennsylvania,
explanations. Definitions of herbal not diminish the need for further inves- Lankenau Hospital, Lancaster General Hospi-
products differ among studies, with tigation of their safety during pregnancy. tal, Lehigh Valley Hospital, Nanticoke Memorial
some considering all forms of nutritional Indeed, several studies have identified Hospital, Pennsylvania Hospital, Sacred Heart
supplements and others using more re- concerns that should be further ex- Hospital, St. Christophers Hospital for Chil-
dren, St. Mary Medical Center, Temple Univer-
stricted definitions. In the present study, plored,17-21 particularly in view of the
sity Health Sciences Center, Reading Hospital
we excluded all topical treatments and all fact that evidence of the efficacy of these and Medical Center, Thomas Jefferson Univer-
multivitamins containing herbs and in- products is largely unstudied. In the ab- sity Hospital; Toronto Center: Grand River Hos-
cluded only those teas that were reported sence of evidence that most of the stud- pital, Guelph General Hospital, Hamilton Health

MAY 2010 American Journal of Obstetrics & Gynecology 439.e9


Research Obstetrics www.AJOG.org

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439.e10 American Journal of Obstetrics & Gynecology MAY 2010