Self-medication practice and contributing factors among pregnant women

Background The practice of self-medication during pregnancy is a global challenge that necessitates high attention as it poses a potential threat to the pregnant mother and fetus. However, little is known regarding self-medication practice and its contributors among pregnant women in our setting. Objective The main aim of this study was to investigate the practice of self-medication and its contributing factors among pregnant women Methodology A cross sectional study was conducted among pregnant women at antenatal care follow-up of Ayder comprehensive specialized hospital, Tigray, Ethiopia. Written informed consent was obtained from each participant before interview. Simple random sampling technique was employed to recruit participants in to the study. Data were collected by interviewing participants using the structured questionnaire. Binary logistic regressions analysis was performed to determine the contributing factors of self-medication practice during pregnancy. A p value of less than 0.05 was considered as significant. Results A total of 250 pregnant women were included in the study. Of the total, 40.8% practiced self-medication during the current pregnancy. Morning sickness (39.2%), headache (34.3%), and upper respiratory tract infections (29.4%) were the leading indications for self-medication. According to participant report, ease of access to medicines (25.5%), feelings that the disease is minor (21.6%) and timesaving (19.6%) were the most commonly reported reasons for self-medication practice. Absence of health insurance (AOR: 2.75, 95%CI: 1.29–5.89) and being on first trimester of pregnancy (AOR: 2.44, 95%CI: 1.02–5.86) were significant contributors of self-medication practice among pregnant women. Conclusion In our study, high prevalence of self-medication was reported among pregnant women. Self-medication practice during pregnancy was higher among pregnant women on first trimester and those who were not having health insurance. Therefore, intervention programs should be designed to minimize the practice of self-medication during pregnancy.


Background
The practice of self-medication during pregnancy is a global challenge that necessitates high attention as it poses a potential threat to the pregnant mother and fetus. However, little known regarding self-medication practice and its contributors among pregnant mothers in our setting.

Objective
The main aim of this study was to investigate the practice of self-medication and its contributing factors among pregnant women M eth odology: A cross sectional study was conducted among pregnant women at antenatal care follow-up of Ayder comprehensive specialized hospital, Tigray, Ethiopia. Written informed consent was obtained from each participant before interview. Simple random sampling technique was employed to recruit participants in to the study. Data were collected by interviewing participants using the structured questionnaire. Binary logistic regressions analysis was performed to determine the contributing factors of self-medication practice during pregnancy. A p value of less than 0.05 was considered as significant.

Results
A total of 250 pregnant women were included in the study. Of the total, 40.8% practiced self-medication during the current pregnancy. Morning sickness (39.2%), headache (34.3%), and upper respiratory tract infections (29.4%) were the leading indications for self-medication. According to participant report, ease of access to medicines (25.5%), feelings that the disease is minor (21.6%) and timesaving (19.6%) were the most commonly reported reasons for self-medication practice. Absence of health insurance (AOR: 2.75, 95%CI: 1.29-5.89) and being on first trimester of pregnancy (AOR: 2.44, 95%CI: 1.02-5.86) were significant contributors of selfmedication practice among pregnant women.

Conclusion
In our study, high prevalence of self-medication was reported among pregnant women. Self-medication practice during pregnancy was higher among pregnant women on first trimester and those who were not having health insurance. Therefore, intervention programs should be designed to minimize the practice of self-medication during pregnancy. The data underlying the results presented in the study are available from (include the name of the third party • All relevant data are within the manuscript and its Supporting Information files. and contact information or URL). This text is appropriate if the data are owned by a third party and authors do not have permission to share the data.

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Additional data availability information: 2 Abstract Background: The practice of self-medication during pregnancy is a global challenge that necessitates high attention as it poses a potential threat to the pregnant mother and fetus. However, little known regarding self-medication practice and its contributors among pregnant mothers in our setting. Objective: The main aim of this study was to investigate the practice of selfmedication and its contributing factors among pregnant women Methodology: A cross sectional study was conducted among pregnant women at antenatal care follow-up of Ayder comprehensive specialized hospital, Tigray, Ethiopia. Written informed consent was obtained from each participant before interview. Simple random sampling technique was employed to recruit participants in to the study. Data were collected by interviewing participants using the structured questionnaire. Binary logistic regressions analysis was performed to determine the contributing factors of self-medication practice during pregnancy. A p value of less than 0.05 was considered as significant. Results: A total of 250 pregnant women were included in the study. Of the total, 40.8% practiced self-medication during the current pregnancy. Morning sickness (39.2%), headache (34.3%), and upper respiratory tract infections (29.4%) were the leading indications for self-medication. According to participant report, ease of access to medicines (25.5%), feelings that the disease is minor (21.6%) and timesaving (19.6%) were the most commonly reported reasons for self-medication practice. Absence of health insurance (AOR: 2.75, 95%CI: 1.29-5.89) and being on first trimester of pregnancy (AOR: 2.44, 95%CI: 1.02-5.86) were significant contributors of self-medication practice among pregnant women. Conclusion: In our study, high prevalence of self-medication was reported among pregnant women. Self-medication practice during pregnancy was higher among pregnant women on first trimester and those who were not having health insurance. Therefore, intervention programs should be designed to minimize the practice of self-medication during pregnancy. Key words: Pregnancy, self-medication, Ethiopia

Introduction
According to the World Health Organization (WHO), self-medication is defined as the act of using medications by patients or individuals to treat self-diagnosed disorders or symptoms on their own initiative without getting advice from health care provider [1][2][3] . Self-medication includes use of over counter drugs available without a physician's prescription, irregular use of prescribed medicines, use of leftover drugs from previous prescriptions, and use of herbal and traditional medicines [4,5]. Owing to the limited access to health care service and scarcity of resources, the practice of self-medication is a common in developing countries including Ethiopia [6,7] . According to the meta-analysis reported in 2018, the prevalence of self-medication in Ethiopia ranged from 12.5%-78.1% with an average of 44% [8].
The practice of self-medication during pregnancy has been increasing worldwide, particularly in developing countries owing to the poor health care system [9][10][11]. Likewise, the practice of self-medication during pregnancy is increasing in Ethiopia with a reported prevalence ranged from 15.5%-70% [8,12,13].
In clinical practice, self-medication during pregnancy still remained a significant medical challenge [14,15]. Although drugs are frequently used during pregnancy in clinical practice, their safety has not been wellestablished as pregnant women are often excluded from clinical trials due to the fear of harm on the mother or the developing fetus [15,16]. Therefore, unless absolutely necessary, drugs should be avoided during pregnancy [17].
Despite this fact, there is high level of self-medication use during pregnancy [18]. Self-medication can affect both the fetus and the mother and it could cause detrimental effects on the fetus including malformation/teratogenicity, fetal toxicity, low birth weight, premature birth, respiratory problems as well as death [15,18,19]. It has been reported that at 4 least 10% of birth defects are resulted from the exposure of pregnant women to drugs [15] .
The prevalence of self-medication varies across different communities and it could be affected by several factors including lack of access to healthcare service, unregulated distribution of medicines, patients' attitudes toward healthcare providers, socio-economic factors, long waiting times, cost of the drugs, educational level, age, income, education level, satisfaction, and belief of people's toward medication and disease. [9,12,[20][21][22] Despite the potential harmful effect of self-mediation practice during pregnancy [15,16], there is little awareness about the impact of selfmedication practice among pregnant mothers in developing countries including Ethiopia [7,10,23]. Hence, evaluation of self-medication practice and its contributors will provide information for health policy makers and relevant stakeholders to develop strategies to prevent the risks associated with self-medication practice during pregnancy. In our setting, though there are some studies on self-medication in general population [7,8], studies regarding self-medication practices during pregnancy are scanty. Our study, therefore, investigated the practice of self-medication and its contributing factors during pregnancy.

Study design and setting
An institutional based cross-sectional study was conducted from January to April 2019 at antenatal care follow up of Ayder comprehensive specialized hospital (ACSH), Tigray region, Ethiopia. ACSH is the largest public hospital in Tigray region whiles it the second in Ethiopia next to black lion hospital. It provides service for about 10 million people in the catchment area.

Study participants and data collection procedure
All pregnant mothers who had antenatal care (ANC) follow up in ACSH were the source population. Pregnant women at any gestational age who came for ANC to ACSH hospital during the study period were included in this study. Pregnant women who are critically ill to give response, unable to hear/ communicate and those who are unwilling to give consent were excluded from the study.
The sample size for this study was determined using the single population proportion formula for the prevalence of self-medication practice.
Accordingly a sample of 262 participants was calculated assuming 26.6% prevalence of self-medication practice during pregnancy according to a study conducted in Addis Abeba [24], 95% confidence level, 5% margin of error, and 10% contingency for nonresponse rate. From 262 participants approached, 12 patients were excluded from the study due to unable to hear [1], critically ill to give response [4], and unwillingness to give consent [7].
The participants were recruited into the study during their appointment for ANC using simple random sampling technique We collected the data using an interviewer administered structured questionnaire (S1 Table). . The questionnaire was developed based on previous studies [9,13,14] and it was amended to fit the current study. The questionnaire was translated to local language (Tigrigna), and then back translated to English to ensure consistency of meaning. Pre-test was carried out on 5% of the sample before the commencement of the actual data collection and slight amendments were made on the questionnaire based on the findings. The questionnaire involves data related to socio-demographics, obstetrics factor, and self-medication practices. Fifth year clerkship pharmacy students were employed to collect the data for this study and they were given training and orientation. 6

Data analysis
We analyzed the data using the Statistical Package for the Social Science (SPSS version 24.0) (S2 Table) (Table 4).

Discussion
The practice of self-medication is a global challenge that necessitates high attention because it poses a potential threat to the pregnant mother and fetus [14,25]. In developing countries including Ethiopia, clinicians may not be aware of the actual burden of self-medication and its contributing factors during pregnancy. Thus, conducting such kind of study will help them to design and develop strategies to prevent /minimize self-medication practice during pregnancy. Our study, therefore, investigated the practice of selfmedication and its contributing factors among pregnant women. The current study revealed that a significant proportion of pregnant women practiced selfmedication either with modern and/or herbal medicine without consulting healthcare professionals.
Despite the potential harmful effect of self-mediation during pregnancy [15,16], nearly half (40.8%) of pregnant women practiced selfmedication during their current pregnancy. This result is comparable with the findings reported from Tanzania [14] and Iran [22]. In contrast, higher findings were reported from previous studies conducted in Democratic Republic of Congo [26], Nigeria [27] and Ethiopia [12]. On the other hand, our finding is higher compared to the findings reported from Addis Abeba [24] and Netherland [28]. These variations could be attributed to the differences in level of awareness about risks of self-medication in pregnancy, population demographics, access to healthcare service, and restriction policies of dispensing practices.
Morning sickness, headache, and upper respiratory tract infections were the leading indications for self-medication in this study. In Tanzanian study [14], malaria, morning sickness, and headache were the leading illness that led to self-medication. Unlike our study, malaria was the most common indication for self-medication in Tanzanian study [14]. This could be due to the less prevalence of malaria in our study setting. 13 In the present study, the most commonly reported reasons for selfmedication practice during pregnancy were ease of access to medicines, feeling that disease is minor and prolonged waiting time. In agreement with our study, similar finding were reported from previous studies conducted in Addis Ababa [24] and democratic republic of Congo [26]. The ease of access to medications without prescription could be attributed to the poor drug regulatory system and weak enforcement on restricting prescription drugs sale without prescription as well as nonprescription drugs sale to pregnant women.
Moreover, it could be augmented due to the lack of attention and priorities of health policy makers and other stakeholders on the burden of self-medication risks [24]. Therefore, necessary measures should be taken to strengthen regulatory system and enforce regulations so as to reduce the practice of selfmedication during pregnancy.
Our study revealed that pregnant women without health insurance were more prone to self-medication practice which is consistent with a finding reported from Iran [22]. The possible explanation is that those who have health insurance are more likely to visit health institution and see a doctor.
Thus, they are more likely to get prescribed medication as the cost of their visit and medication can be compensated by the insurance.
Pregnant women on first trimester were more likely to practice selfmedication compared to those on third trimester. This finding is supported by a study conducted in Tanzania [14]. The possible justification for higher selfmedication practice during first trimester of pregnancy could be due to the more frequent occurrence of symptoms and/or illnesses including morning sickness, headache, and fever in the first trimester than other trimester during pregnancy. More importantly, this finding is worrisome as drug exposure in this period is more likely to cause congenital abnormalities [29][30][31].
Therefore, more emphasis should be given to the use of medication during first trimester of pregnancy.
14 Finally, our study had some limitations. Our study was a crosssectional suggesting that it cannot provide adequate evidence of causality regarding self-medication and its contributing factors. During interview, pregnant women were expected to recall information from their past experience; therefore, recall bias might affect the study findings. The findings of our study could be affected by the difference in population demographics, healthcare system and regulations and knowledge of the participants. Therefore, it should be extrapolated to other countries with caution.

Conclusion
In our study, a high prevalence of self-medication was reported among pregnant women. Self-medication practice during pregnancy was higher among pregnant women on first trimester and those who were not having health insurance. Therefore, healthcare providers should provide more emphasis to the risky participants and implementation of national health insurance needs to be encouraged. Moreover, intervention programs should be designed to minimize the practice of self-medication during pregnancy.