The Problem of Traditional African Pharmacopoeia in Obstetrics: Use of Plants for Utero-Tonic Purposes and Materno-Fetal Outcome in Douala (Cameroon)

Introduction: The use of traditional preparations for the induction or acce-leration of labor remains a common practice in our country in particular and in Africa in general with sometimes derogatory outcomes for the mother and the fetus. Goal: The objective was to assess immediate maternal and neonatal outcomes in women who reported having used the traditional pharmacopoeia for utero-tonic purposes. Methodology: We conducted a multi-centric cross-sectional study with prospective data collection in the maternities of the Laquintinie Hospital, Bonassama District and Nylon Hospitals. It took place over a period of seven months, from 1st October risk (RR = 0.4, CI = 0.24 - 0.926). Stimulation of labor was the first indication in 85% of women, the rectal evacuation enema was the main route used (67%). The majority of plants used were those of the families Asteraceae, An-thericaceae, and Malvaceae. In per partum, 42% had a brilliant dilatation; there was a statistically significant association between the occurrence of dynamic dystocia (CI = 0.28 - 1.54, p = 0.006) and the risk of perineal tear (RR = 3.13, CI = 1.68 - 5.85; p = 0.007). The APGAR score at 5 min of life was less than 7 in 64% of cases (p = 0.027). The caesarean section rate was 69%. Conclusion: Traditional products with uterotonic effects are frequently used and unregulated with its corollary of materno-fetal complications.


Introduction
The relations between plants and men have existed since antiquity [1]. Plants, vital components of biological diversity, are used primarily for human well-being.
In Africa, the use of medicine and traditional pharmacopoeia is very common in the countryside and even in urban areas. This situation could be explained by the poverty of the populations, the insufficiency of infrastructures and personnel in modern medicine, but also by religious or superstitious considerations [2].
Despite the progress of Western medicine, few people in Africa have taken a step back from traditional medicine. It provokes infatuation among the population at all levels because it is the secretion of our socio-cultural milieu. Africans, regardless of their social status or level of education, remain attached to their traditions and often resort to it whenever the need arises. Cosmogonic perceptions and religious beliefs reinforce this trend. As a result, the belief in the harmlessness of medicinal plants because of their natural origin makes them an alternative to conventional therapy [3]. In the United States, some pregnant women use Calophyllum thalictroides for its utero-tonic effect [4]. In China, traditional herbal preparations account for between 30% and 50% of drug consumption [5]. In France, Sophie Barbelet demonstrated the utero-tonic effect of the essential oil of Syzigium aromaticum [6]. In Ivory Coast, KoffiN'guessan et al. in 2010 highlighted the use of 34 plant species, to facilitate childbirth [7]. Studies in South Africa estimated that between 43% and 55% of women used traditional oxytocics during pregnancy [8].
Another study in Nigeria found that 62% of women surveyed had used herbal medicines during pregnancy [9]. In Kenya and Ghana, traditional birth attendants provided herbal medicines to women during pregnancy or delivery for their utero-tonic effects [10] [11]. The fact that traditional medicines can have utero-tonic effects is an important aspect of public health [12]. Studies in Malawi and Uganda have suggested that traditional medicines may be involved in a sig-

Methods
This was a multicentric cross-sectional study with prospective data collection conducted at Laquintinie Hospital in Douala and at Bonassama and Nylon District Hospitals over a seven-month period from October 1st, 2016 to April 31st, 2017. This included any woman who reported having used an unconventional pharmacopoeia for utero-tonic use as a self-medication before or after the onset of uterine contractions. A standardized form was submitted to them and then a survey in nature with visual identification of the substance was carried out for determination of the scientific name. This form included, in addition to the names of the plants, the sociodemographic, gestational and clinical variables collected in the records of the deliveries. The evaluation of uterine contractions (UC) was done by external tocography to record intensity, frequency and duration of the UCs. The operational definitions were: • hyperkinesia of frequency: >5 UC/10 min; • hyperkinesia of intensity: >80 mmHg at the tocograph or >3 +++ by manual method; • excluded were those having benefited from conventional oxytocics or having benefited from a mixture of conventional oxytocics and medicinal plants.

-Sampling
We proceeded to a consecutive recruitment of the pregnant women for the study with a basic sample set at 245. The recruitment procedure concerned parturient in the delivery room, postpartum deliveries as well as postoperative caesarean section women meeting the eligibility criteria, followed by the collection of data in the collection form preconceived for the study.
Prospecting and harvesting of the plant material consisted of the presentation of the samples to the interviewees for validation before their deposit at the Cameroonian national herbarium to obtain the scientific names.
The therapeutic properties of these plants were determined using documentation related to the work on phytochemical screening.
The data obtained was entered and processed with CSPRO 6.

Results
We included 168 deliveries out of 245 surveyed (77 respondents reported using made-up plants and bark that we could not record), a frequency of 68.5% of our deliveries. The mean age was 27.17 ± 0.41 years with extremes of 16 and 43 years and a peak in the range of 23 -32 (69%). Our study population was predominantly married (42%), with a secondary level of education (54%) and an income generating activity (70%) ( Table 1).  Table 3). Stimulation of labor was the primary indication for 85% of women (Table 4). The maternal survey identified 22 plants used for supposed utero-tonic effects and hibiscus was the most commonly used, 25% of cases ( Figure 1). Leaves were the most commonly used plant parts in the plant in 75% (Figure 2) prepared mainly by maceration ( Figure 3) and a use most often by rectal enema evacuator ( Figure 4). This use exposed some of them to pejorative consequences with statistically significant incidences of 42% of brilliant dilatations (70 cases) with labor time <  (Table 5).

1) Prevalence
In our study, we recorded 168 women who admitted to using an utero-tonic plant (68.57%). This prevalence is similar to that obtained in Nigeria by Olu-     This discrepancy, in our opinion, is due to the cultural disparity of the surveyed communities. 6) Complications Both maternal and fetal complications were observed when utero-tonic plants were taken in our series. Frequency hyperkinesia, intensity hyperkinesia, fetal distress, dynamic dystocia, an APGAR score of less than 7, brilliant dilatation, and perineal tears showed a statistically significant difference. The immediate consequence was a doubling of the number of caesareans with a frequency of 69% and the duration of labor influenced the mode of delivery. These results are similar to those obtained by Aka [7]. However, there are similarities in the families Asteraceae, Euphorbiaceae, Zingiberaceae. This is because tropical plants are common to most of sub-Saharan Africa. This variability is due to the different methods of investigation (localities and vegetation). c) Plant part: The most used part was the leaf (75%), followed by fruits (12%), and finally stems (7%). This result is consistent with that obtained by Ngene et al. in 2015 [19] in an ethnobotanical survey in the city of Douala (52%). However, this result contrasts with those obtained by Nguessan et al. in 2010 [7] where stems and their bark were mostly used (45.92%). This is because our plants were mostly herbaceous with easy access to the leaves. Unlike the Ivorian study where the predominance of trees was noted making it difficult to access the leaves. d) Mode of preparation: Maceration is the most popular method of preparation (57%), followed by chewing (25%) and grinding (13%). This result is close to that established by Adjanohoun and Aké Assi (1979). However, this result contrasts with that of Nguessan et al. in 2010 in an ethnobotanical study had found kneading (69.70%) [7]. This is explained by the fact that in our study the most used vegetable part was the leaves whose maceration is the best mode of extraction. Nguessan et al. 2010 had found the bark whose best extraction is kneading [7]. In this study, Hibiscus-rosa-sinensis was used to facilitate childbirth [19].

Conclusion
The reported use of utero-tonic plants in pregnant women is an effective practice at the Hospital Laquintinie; this practice is more the responsibility of multiparas and induces dynamic dystocia, a high rate of caesarean section with a bad neonatal state. Given the maternal and foetal complications reported in our study, it is necessary to initiate case-control studies with hibiscus mainly used in our study in order to assess its operability and thus the prevention of uncontrolled issues.

Limits of the Study
We have not been able to identify all utero-tonic plants of informal use. Such were the case of those in the form of made-up products and the barks and concerned 77 surveyed.
The concept of utero-tonic plants was declarative and therefore subjective, which could lead to over or underestimation of the effect.
The dosage and the dose-effective effect were not analysed in our study. This therefore limits any relevance in the analysis and conclusion.