Exploring traditional medicine utilisation during antenatal care among women in Bulilima District of Plumtree in Zimbabwe

Traditional medicine utilisation during antenatal care has been on the increase in several countries. Therefore, addressing and reinforcing the Sustainable Development Goal of maternal mortality reduction, there is a need to take traditional medicine utilisation during pregnancy into consideration. This paper explores traditional medicine utilisation during antenatal care among women in Bulilima District of Plumtree in Zimbabwe. A cross-sectional survey was conducted on 177 randomly selected women using a semi-structured questionnaire. Fisher's Exact Test, Odds Ratios, and Multiple Logistic Regression were utilised to determine any associations between different demographic characteristics and traditional medicine utilisation patterns using STATA SE Version 13. The prevalence of Traditional Medicine utilisation among pregnant women was estimated to be 28%. Most traditional remedies were used in the third trimester to quicken delivery. The majority of women used holy water and unknown Traditional Medicine during pregnancy. There was a strong association between age and Traditional Medicine utilisation as older women are 13 times more likely to use Traditional Medicine than younger ones. Women use traditional medicine for different purposes during pregnancy, and older women's likelihood to use Traditional Medicine is higher than their counterparts. The traditional system plays an essential role in antenatal care; therefore, there is a need to conduct further studies on the efficacy and safety of utilising Traditional Medicines.

www.nature.com/scientificreports/ beyond human capabilities 17 . In addition, the Zimbabwe Maternal and Perinatal Mortality Study conducted by the Ministry of Health and Child Care in 2007 found that women prefer to go into labour at traditional birth attendants and faith healers' homes 21 . In Zimbabwe's rural areas, lack of access to western medicines has been an influencing factor for women to use TM. In addition, better modern health facilities with required expertise and equipment are largely centralised in urban setups, making it difficult for rural women to access these services 22 .
There have been several strategies that have been implemented in rural Zimbabwe including the establishment of Maternal Waiting Homes (MWH) to try and reduce barriers such as cost of transport, distance and prevent maternal complications (just to name a few) to improve access of women to modern maternal health services 3,23 . However, most women still prefer to utilise TM despite campaigns that discourage women from utilising TM as some have unforeseen adverse reactions 24 . The majority of users; therefore utilise TM secretly and rarely disclose to the health service providers. In Plumtree, particularly in Bulilima District, the average distance walked by women to the nearest health facility is estimated at between 5 and 10 km, influencing them to consult the traditional system which is readily available in their communities 25 . Generally, it is suggested that there should be a health facility within a 5 km radius in different communities and women should not walk more than the 5kms in search of maternal services 18 . Therefore, this study explores traditional medicine utilisation trends during antenatal care among women in Bulilima District of Plumtree in Zimbabwe. This study presents a window of opportunity to determine the TM utilisation patterns that would inform policy makers in coming up with strategies that would strengthen the current existing health systems.

Methods
Study area. Bulilima is one of the seven districts with 22 wards located in Matabeleland South province and is in Region 5, prone to severe drought 26 . The district has one main referral hospital with sixteen clinics that usually refer pregnant women with complications to a district hospital and has an average household size of 5 27 . Generally, it is estimated that this district is home to 57,681 28 . The average distance that women walk to the nearest clinic is estimated to be 5-10 km. The study area is illustrated in Fig. 1 which was developed using Quantum Geographic Information System (Credit: QGIS 3.12.2 by the QGIS development team). Although a similar study was conducted in Harare, Zimbabwe which is an urban set up with a different population composition predominantly the Shona tribe, our study was entirely rural-based and in a different region of the country with predominantly Kalanga and Ndebele speaking people relying on different TM as compared to some other regions as the belief systems differ 27,29 .

Data collection tools.
Pre-testing of a semi-structured questionnaire and data collection was done by the researchers who are all Trained Public Health Specialists between January 2020-February 2020 from women delivered at the clinic or home in Bulilima district but registered at the clinic. The questionnaire was categorised into two sections, that is: the first section delved on socio-demographic characteristics (age, race, ethnicity, education, marital status, parity). The second section comprised questions on the source, different types, reasons, and frequency of TM used. The questionnaire was developed in English and then translated to the local language that is "isiNdebele," which is mainly spoken and taught within the district. Ethical approval and consent to participate. Permission to carry out the study was sought from relevant authorities that are Provincial Medical Director for Matabeleland South, District Medical Officer for Bulilima and National University of Science and Technology, particularly the Department of Environmental Science and Health. Moreover, the research abides by the Nuremberg code and principles stated in the Helsinki Declaration for the safety of participants involved in the study 46 . Written consent was obtained from all the respondents who participated in the study. Permission was sought from parents of adolescents who were less than 18 years of age, and there were also required to assent to the study.

Results
Response rate and demographics characteristics of women. Out of the targeted 185 women, 177 responded to a pre-tested questionnaire presenting a response rate of 96%. Some of the women had left their places of residence and could not be obtained. However, a response rate of 96% was considered sufficient by the researchers to make meaningful inferences. The majority of women were having a partner 132 (74.6%), and 139 (78.5%) are Christians, while 110 (62.2%) are unemployed. Also, the results show that only one woman was within the age of 50-54, as indicated in Table 1: Traditional medicine used during antenatal. The majority of individuals used holy water and an unknown type of traditional medicine, while ten women used only one type of traditional medicine. Fig. 2 and Table 2 show different types of TMs used by women.
Prevalence and safety perception of traditional medicine use. The prevalence of TM use was 50 (28.3%) during pregnancy, and also a more significant number of women use traditional medicines during their third trimester. Table 3 clearly shows prevalence, safety, and other variables of traditional medicines utilisation pattern. www.nature.com/scientificreports/ Demographic characteristics and TM use. There was a strong significant association between age and TM utilisation as older women are 13 times more likely to use TM than younger ones. Religion and parity were associated with TM use. On the other hand, marital status, Tribe, Level of education, employment status, and place of delivery was not associated with TM utilisation as shown in Table 1. Age is the only variable significantly associated with the frequency of TM use during pregnancy, as indicated in Table 4.

Discussion
The study found out that most women had a partner, were Christians, and was unemployed. Most researchers that conducted studies in Zimbabwe supports our findings as they revealed that most women attending antenatal care in public institutions are unemployed and are in a relationship 31,32 . Results indicated that older women's likelihood of using traditional medicine during pregnancy is higher than their younger counterparts. These findings are supported by a study conducted in Taiwan, which indicates that older women are likely to use traditional,  www.nature.com/scientificreports/ complementary medicines than their younger counterparts 33 . Findings denote that marital status, Tribe, Level of education, employment status, and place of delivery were not significantly associated with traditional medicine utilisation. Studies conducted in Zimbabwe concur with our findings that religion is not related to the use of TMs during pregnancy 34 . Our findings indicated that the prevalence of TM use was 28.25%. Most scholars who conducted their studies on maternal health and traditional medicine use in Sub-Saharan countries (Zimbabwe 52%, Nigeria 68%, Mali 80%, South Africa 55-93.6%, Mali 80%, Tanzania 55%) contradicts with our findings as they note that the prevalence ranges from 52 to 80% 29,[35][36][37][38][39] . Even though other scholars contradict our findings, multinational studies conducted in Europe, Australia, South, and North America are aligned with our results as they revealed a prevalence of 28.9% use herbal medicine during pregnancy 7 .  www.nature.com/scientificreports/ Women revealed in our study that they use several TMs to induce and shorten labour, these include isikhukhukhu (Snuggle-lea: Pouzolzia hypoleuca Wedd), and inkunzane (Boot protectors/devil thorn; Dicerocaryum species). Other scholars who conducted their studies in Zimbabwe concur with our results as they indicate that Snuggle-lea (Pouzolzia hypoleuca Wedd) was used to induce labour 9,11 . It is highlighted in this study that the majority of individuals were using holy water and an unknown type of traditional medicine. These results are in line with a study conducted by Mureyi 29 , that indicated holy water as a common TM used. In addition, scholars have noted that several herbs and their compounds are used during pregnancy are unknown [40][41][42] .
In Zimbabwe the Traditional health system is recognised and plays an important role in ensuring services are available to those that need them 43 . In pursuance of SDG (3), there is a need to ensure that utilization of www.nature.com/scientificreports/ traditional medicines leads to outcomes that do not jeopardise progress towards attaining this specific goal on maternal health 44,45 .

Limitations
This study cannot be generalised to the entire country since the study population was rural-based and can be affected by recall bias even though women recruited gave birth during January-December 2019. Above all, the research was not funded, and as such, there could have been a need for a substantial cohort to make meaningful inferences. Authors are also involved in a project that intends to explore maternal complications and TM use and find the active ingredient of TM used by women during antenatal care.

Conclusion
Women indeed used traditional medicine for different purposes during pregnancy, and the likelihood of older women to use traditional medicines was higher than in young women. Most dominant traditional remedies were used in the last trimester to quicken delivery by women. TM utilisation plays a significant role in pregnancy; therefore, there is a need that particular attention is paid to it and possibly more research to be conducted to assess its efficacy, safety as it gives a cheaper alternative to women who might not afford to access conventional modern health services.