Protocol for the process evaluation of an intervention to improve antenatal smoking cessation support (MOHMQuit) in maternity services in New South Wales, Australia.

INTRODUCTION: Smoking cessation in pregnancy remains a public health priority. Our team used the Behaviour Change Wheel to develop the Midwives and Obstetricians Helping Mothers to Quit smoking (MOHMQuit) intervention with health system, leader (including managers and educators) and clinician components. MOHMQuit addresses a critical evidence to practice gap in the provision of smoking cessation support in antenatal care. It involves nine maternity services in New South Wales in a cluster randomised stepped-wedge controlled trial of effectiveness. This paper describes the design and rationale for the process evaluation of MOHMQuit. The process evaluation aims to assess to what extent and how MOHMQuit is being implemented (acceptability; adoption/uptake; appropriateness; feasibility; fidelity; penetration and sustainability), and the context in which it is implemented, in order to support further refinement of MOHMQuit throughout the trial, and aid understanding and interpretation of the results of the trial. METHODS AND ANALYSIS: The process evaluation is an integral part of the stepped-wedge trial. Its design is underpinned by implementation science frameworks and adopts a mixed methods approach. Quantitative evidence from participating leaders and clinicians in our study will be used to produce individual and site-level descriptive statistics. Qualitative evidence of leaders' perceptions about the implementation will be collected using semistructured interviews and will be analysed descriptively within-site and thematically across the dataset. The process evaluation will also use publicly available data and observations from the research team implementing MOHMQuit, for example, training logs. These data will be synthesised to provide site-level as well as individual-level implementation outcomes. ETHICS AND DISSEMINATION: The study received ethical approval from the Population Health Services Research Ethics Committee for NSW, Australia (Reference 2021/ETH00887). Results will be communicated via the study's steering committee and will also be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER: Australian New Zealand Trials Registry ACTRN12622000167763. https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12622000167763.

Study protocol of an economic evaluation embedded in the Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) trial.

BACKGROUND: Tobacco smoking during pregnancy is the most important preventable risk factor for pregnancy complications and adverse birth outcomes and can have lifelong consequences for infants. Smoking during pregnancy is associated with higher healthcare costs related to birth complications and during childhood. Psychosocial interventions to support pregnant women to quit are effective, yet provision of smoking cessation support has been inconsistent. The Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) intervention provides systems change, and leadership and clinician elements, to support clinicians to help women stop smoking in pregnancy. There have been few long-term analyses conducted of the cost-effectiveness of smoking cessation interventions for pregnant women that target healthcare providers. This protocol describes the economic evaluation of the MOHMQuit trial, a pragmatic stepped-wedge cluster-randomised controlled implementation trial in nine public maternity services in New South Wales (NSW), Australia, to ascertain whether MOHMQuit is cost-effective in supporting clinicians to help women quit smoking in pregnancy compared to usual care. METHODS: Two primary analyses will be carried out comparing MOHMQuit with usual care from an Australian health care system perspective: i) a within-trial cost-effectiveness analysis with results presented as the incremental cost per additional quitter; and ii) a lifetime cost-utility analysis using a published probabilistic decision analytic Markov model with results presented as incremental cost per quality-adjusted life-year (QALY) gained for mother and child. Patient-level data on resource use and outcomes will be used in the within-trial analysis and extrapolated and supplemented with national population statistics and published data from the literature for the lifetime analysis. DISCUSSION: There is increasing demand for information on the cost-effectiveness of implementing healthcare interventions to provide policy makers with critical information for the best value for money within finite budgets. Economic evaluation of the MOHMQuit trial will provide essential, policy-relevant information for decision makers on the value of evidence-based implementation of support for healthcare providers delivering services for pregnant women. TRIAL REGISTRATIONS: ACTRN12622000167763, registered 2 February 2022.

The step in time study: A feasibility study of a mobile app for measuring walking ability after massage treatment in patients with osteoarthritis.

BACKGROUND: Massage therapy is a popular intervention for those suffering osteoarthritis, however, there is a paucity of evidence to support its effectiveness in osteoarthritis. A simple measure that could potentially assess the benefits of massage treatment is walking speed which is a predictor of mobility and survival length, particularly in ageing populations. The primary aim of the study was to assess the feasibility of using a phone app to measure walking ability in people with osteoarthritis. METHODS: This feasibility study used a prospective, observational design to collect data from massage practitioners and their clients over a 5-week period. Feasibility outcomes included practitioner and client recruitment and protocol compliance. The app MapMyWalk was used to record average speed for each walk. Pre-study surveys and post-study focus groups were conducted. Clients received massage therapy in a massage clinic and were instructed to walk in their own local community for 10 min every other day. Focus group data were analysed thematically. Qualitative data from clients' pain and mobility diaries were reported descriptively. Average walking speeds were graphed for each participant in relation to massage treatments. RESULTS: Fifty-three practitioners expressed interest in the study, 13 completed the training, with 11 successfully recruiting 26 clients, 22 of whom completed the study. 90% of practitioners collected all required data. A strong motivation for participating practitioners was to contribute to evidence for massage therapy. Client compliance with using the app was high, but low for completing pain and mobility diaries. Average speed remained unchanged for 15 (68%) clients and decreased for seven (32%). Maximum speed increased for 11 (50%) clients, decreased for nine (41%) and remained unchanged for two (9%). However, data retrieved from the app were unreliable for walking speed. CONCLUSIONS: This study demonstrated that it is feasible to recruit massage practitioners and their clients for a study involving mobile/wearable technology to measure changes in walking speed following massage therapy. The results support the development of a larger randomised clinical trial using purpose-built mobile/wearable technology to measure the medium and long-term effects of massage therapy on people with osteoarthritis.

The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services.

BACKGROUND: Smoking during pregnancy is the most important preventable cause of adverse pregnancy outcomes, yet smoking cessation support (SCS) is inconsistently provided. The MOMHQUIT intervention was developed to address this evidence-practice gap, using the Behaviour Change Wheel method by mapping barriers to intervention strategies. MOHMQuit includes systems, leadership and clinician elements. This implementation trial will determine the effectiveness and cost-effectiveness of MOHMQuit in improving smoking cessation rates in pregnant women in public maternity care services in Australia; test the mechanisms of action of the intervention strategies; and examine implementation outcomes. METHODS: A stepped-wedge cluster-randomised design will be used. Implementation of MOHMQuit will include reinforcing leadership investment in SCS as a clinical priority, strengthening maternity care clinicians' knowledge, skills, confidence and attitudes towards the provision of SCS, and clinicians' documentation of guideline-recommended SCS provided during antenatal care. Approximately, 4000 women who report smoking during pregnancy will be recruited across nine sites. The intervention and its implementation will be evaluated using a mixed methods approach. The primary outcome will be 7-day point prevalence abstinence at the end of pregnancy, among pregnant smokers, verified by salivary cotinine testing. Continuous data collection from electronic medical records and telephone interviews with postpartum women will occur throughout 32 months of the trial to assess changes in cessation rates reported by women, and SCS documented by clinicians and reported by women. Data collection to assess changes in clinicians' knowledge, skills, confidence and attitudes will occur prior to and immediately after the intervention at each site, and again 6 months later. Questionnaires at 3 months following the intervention, and semi-structured interviews at 6 months with maternity service leaders will explore leaders' perceptions of acceptability, adoption, appropriateness, feasibility, adaptations and fidelity of delivery of the MOHMQuit intervention. Structural equation modelling will examine causal linkages between the strategies, mediators and outcomes. Cost-effectiveness analyses will also be undertaken. DISCUSSION: This study will provide evidence of the effectiveness of a multi-level implementation intervention to support policy decisions; and evidence regarding mechanisms of action of the intervention strategies (how the strategies effected outcomes) to support further theoretical developments in implementation science. TRIAL REGISTRATION: ACTRN12622000167763, registered February 2nd 2022.

Women's reasons for taking complementary medicine products in pregnancy and lactation: Results from a national Australian survey.

BACKGROUND: and purpose: Pregnant and breastfeeding women commonly use complementary medicine products (CMPs), including dietary supplements and herbal medicines. This study investigated women's reasons for use. MATERIALS AND METHODS: A national, cross-sectional, online survey conducted between July-September 2019 investigated reasons for CMP use during pregnancy and lactation. Australian women who were currently pregnant and/or breastfeeding participated. Data analysis included descriptive statistics, Chi-square and principal component analyses. RESULTS: Of the 810 women surveyed (n = 354 pregnant; n = 456 breastfeeding), most reported prior CMP use and felt that CMPs had been beneficial to maintaining and optimising their own and their children's health. However, when ill, they preferred medicines prescribed by doctors or pharmacists. Perceived benefits to their unborn or breastfeeding babies' health and their own health (both cohorts), the health of their pregnancy (pregnant participants), and benefits to the breastfeeding process and breastmilk supply (breastfeeding participants) were important reasons for women's CMP use. CONCLUSION: Women's reasons for CMP use centred on perceived benefits to their own health and the health of their babies. Women's prior positive experiences with CMP use, combined with preferences for pharmaceutical use when ill, indicates their use of CMPs can be considered complementary, rather than alternative, to biomedical health care.

Demographics, health literacy and health locus of control beliefs of Australian women who take complementary medicine products during pregnancy and breastfeeding: A cross-sectional, online, national survey.

BACKGROUND: Pregnant and breastfeeding women's use of complementary medicine products (CMPs) is common, and possibly associated with autonomous health care behaviours. However, the health literacy levels and health locus of control (HLOC) beliefs of women who use CMPs in pregnancy and lactation have not been previously assessed in a large Australian sample. AIM: The aim of this study is to determine the health literacy levels and HLOC beliefs of women who use CMPs in pregnancy and lactation and determine the types of CMPs used. METHODS: A cross-sectional, national, online survey of Australian pregnant or breastfeeding women aged 18 years and older, and currently using CMPs was conducted. RESULTS: A total of 810 completed surveys (354 pregnant and 456 breastfeeding women) were analysed. Most had adequate functional health literacy levels (93.3%). Health care practitioners (HCPs) HLOC mean scores were the highest for the sample, followed by Internal HLOC beliefs mean scores. Almost all (n = 809) took at least one dietary supplement, the most popular being pregnancy and breastfeeding multivitamins, iron supplements and probiotics. Use was generally in line with clinical recommendations, except for low rates of iodine supplementation. Herbal medicine use was lower for the total sample (57.3%, n = 464), but significantly higher (p < .0001) for the breastfeeding cohort, with consumers taking one to four herbal medicines each. The most popular herbs were raspberry leaf, ginger, peppermint and chamomile (pregnant respondents) and chamomile, ginger and fenugreek (breastfeeding respondents). CONCLUSIONS: Respondents were health literate, with high scores for Internal and HCP HLOC scales, suggesting that they are likely to demonstrate self-efficacy, positive health behaviours and work well in partnership with HCPs. HCPs can facilitate discussions with pregnant and breastfeeding women using CMPs, while considering women's health literacy levels, health beliefs and goals.

Transitioning to practice: a qualitative investigation of Australian graduate naturopath's experiences of being in practice.

BACKGROUND: The transition from student to practitioner can be challenging, resulting in stress, burnout and attrition. While there has been ample research examining graduate medical and allied health practitioner experiences of transitioning to practice, there is a paucity of research exploring such experiences in newly qualified naturopathic medicine practitioners. In light of this knowledge gap, the objective of this study was to ascertain the experiences of practicing as a naturopath in Australia within the first 5 years post-graduation. METHODS: Using a qualitative descriptive approach, recent graduates of an Australian Bachelor of Naturopathy (or equivalent) program were invited to participate in a semi-structured telephone interview to address the study objective. Data were analysed utilising a framework approach. RESULTS: A total of 19 new graduates (94.7% female; 57.9% aged 40-59 years) undertook an interview. Five inter-related themes emerged from the data: practitioner, practice, proprietorship, professions, and perceptions. Connected with these themes were contrasting feelings, multiplicity of duties, small business challenges, professional collaboration, and professional identity, respectively. CONCLUSIONS: Participants were generally content with their decision to become a naturopath. However, most were confronted by a range of challenges as they transitioned from graduate to practitioner, for which many felt ill-prepared. In light of the complexity of the issue, and the potential impact on the sustainability of the profession, it is evident that a multi-pronged, multi-stakeholder approach would be needed to better support graduate naturopath transition to practice.

Using Facebook to recruit to a national online survey investigating complementary medicine product use in pregnancy and lactation: A case study of method.

BACKGROUND: Online recruitment can be targeted efficiently to recruit specific samples for survey research. It has been shown to be a cost-effective method of recruitment, and useful for geographically dispersed populations. OBJECTIVES: To describe the use of Facebook to recruit a targeted sample of expectant and breastfeeding mothers to a national online survey. Different techniques to assess response rates using data provided by Facebook are also described. METHODS: Participants accessed an anonymous online survey through a link included in posts from a Facebook page specifically set up for the research. Recruitment strategies were primarily of two types. Firstly, Facebook was paid to promote posts by displaying them on potential participants' Facebook feeds. Secondly, by purposive and snowball recruitment through the sharing of posts on relevant Facebook pages. Post success was measured by the reach, impressions, link clicks, post clicks, and click through rates; and for boosted posts, the cost per day, and cost per engagement with the post as well. Traditional methods of calculating response rates, and response rates using post clicks and survey link clicks were calculated. RESULTS: After 10 weeks of recruitment, 1418 participants had enrolled in the study, and of these 810 (57.1%) completed the 20-minute (70 question) survey. Women participated from across Australia. Both paid and purposive approaches to promotion contributed to recruitment success. Paid promotions at higher costs for fewer days were the most successful. Total paid promotion costs were (Australian) $1147.97 (or $1.44 per completed survey). Purposive promotion was slower, but also contributed significantly to the number of people who saw the posts and clicked through to the survey. Traditional response rate calculations showed a response rate of 0.8%. Using post clicks and survey link clicks in calculations, resulted in response rates of 23.1% and 42.7%, respectively. CONCLUSIONS: A combination of paid promotions and purposive and snowball recruitment on Facebook were used to successfully recruit 1418 participants resulting in 810 completed surveys over a 10-week period, at a low cost per participant. Use of additional methods to measure response rates may be useful in measuring the success of using Facebook posts in recruitment.

The effects of Hedera helix on viral respiratory infections in humans: A rapid review.

BRIEF OVERVIEW: Based on the evidence identified in this rapid review, Hedera helix preparations and herbal complex preparations including H. helix may be a therapeutic option for treating early symptoms of respiratory tract infections. The best effectiveness for H. helix preparations has been proven for coughing, as an expectorant and to reduce the frequency and intensity of cough. Only weak evidence was found for all other researched symptoms. Both adults and children tolerate H. helix well. Currently, there is insufficient evidence to recommend the use of this supplement in the treatment or prevention of COVID-19. However, the current evidence justifies further research to better understand its applicability in coronavirus infections. VERDIC: tCurrent evidence suggests H. helix may improve the frequency and intensity of cough associated with viral respiratory infection. The overall applicability of additional findings is limited by the poorly defined outcome measures employed. However, studies focused explicitly on expectoration did report an increased conversion from dry to productive cough, and an improvement in expectoration amount, consistency and colour. These effects may be explained by a related finding of reduced oropharyngeal congestion and improved inflammatory markers (erythrocyte sedimentation rate and c-reactive protein). A decrease in frequency of night cough and respiratory pain was also reported, as was improved sleep quality and reduced cough-related sleep disturbance.Some studies also measured general respiratory tract infection symptoms and identified clinical improvement or resolution of fever, fatigue, sore throat, sneezing, wheezing, nasal congestion, post-nasal drip and body-ache. A reduced need for antibiotic prescriptions was also identified. While not consistently reported, the majority of studies also found H. helix reduced the overall severity of viral bronchitis and related conditions. Tolerability was rated as between 'good' and 'high'. Adverse events were rare or non-existent in almost all studies, and those that were reported were defined as non-serious and not drug-related.

Factors influencing women's decision-making regarding complementary medicine product use in pregnancy and lactation.

BACKGROUND: The prevalence of complementary medicine product (CMP) use by pregnant or breastfeeding Australian mothers is high, however, there is limited data on factors influencing women's decision-making to use CMPs. This study explored and described the factors influencing women's decisions take a CMP when pregnant or breastfeeding. METHODS: Qualitative in-depth interviews and focus group discussions were held with 25 pregnant and/or breastfeeding women who currently used CMPs. Participants' health literacy was assessed using a validated single-item health literacy screening question and the Newest Vital Sign. Interview and focus group discussions were audio-recorded, transcribed verbatim and thematically analysed. RESULTS: Participants were a homogenous group. Most had higher education, medium to high incomes and high health literacy skills. They actively sought information from multiple sources and used a reiterative collation and assessment process. Their decision-making to take or not to take CMPs was informed by the need to establish the safety of the CMPs, as well as possible benefits or harms to their baby's or their own health that could result from taking a CMP. Their specific information needs included the desire to access comprehensive, consistent, clear, easy to understand, and evidence-based information. Women preferred to access information from reputable sources, namely, their trusted health care practitioners, and information linked to government or hospital websites and published research. A lack of comprehensive, clear, consistent, or evidence-based information often led to decisions not to take a CMP, as they felt unable to adequately establish its safety or benefits. Conversely, when the participants felt the CMPs information they collected was good quality and from reputable sources, it reassured them of the safety of the CMP in pregnancy and/or breastfeeding. If this confirmed a clear benefit to their baby or themselves, they were more likely to decide to take a CMP. CONCLUSIONS: The participants' demographic profile confirms previous research concerning Australian women who use CMPs during pregnancy and lactation. Participants' high health literacy skills led them to engage in a reiterative, information-seeking and analysis process fuelled by the need to find clear information before making the decision to take, or not to take, a CMP.

Complementary medicine products information-seeking by pregnant and breastfeeding women in Australia.

OBJECTIVE: Complementary medicine product use in pregnancy and lactation is common but little is known about women's health literacy and information-seeking regarding this. The objectives of this study were to identify and explore pregnant or breastfeeding women's sources of, and rationale for seeking complementary medicine products information, the types of information sought, and how women felt their health care practitioners can help them receive information that meets their needs. DESIGN: A qualitative research design consisting of in-depth interviews and focus group discussions was conducted. Data were thematically analysed. Participants also completed two validated health literacy screening tools. SETTING: Communities in regional and metropolitan settings in Sydney and Northern New South Wales, and South-East Queensland, Australia. PARTICIPANTS: Twenty-five women (n = 7 pregnant, n = 17 breastfeeding, n = 1 both pregnant and breastfeeding) who currently used complementary medicine products participated. Eleven women were pregnant with or breastfeeding their first child; 14 had between one and four older children. FINDINGS: Twenty-four participants had high health literacy according to the validated screening tools. Around half of the participants had used complementary medicine products for most of their lives and 17 had used complementary medicine products to resolve or manage complex health conditions in adulthood or childhood. Women sought complementary medicine products information from three main sources. 1) Practical and safety information on complementary medicine products was sought from health care practitioners and published research; 2) health care practitioners were also sources of information on reasons for complementary medicine products recommendations and physiological actions; and 3) sharing experiences of complementary medicine products use with other mothers appeared to help women understand what to expect when taking complementary medicine products, support social-emotional wellbeing and encourage participants to look after their own health. Participants strongly expressed the desire for their mainstream biomedical health care practitioners to be more informed in, and open to, complementary medicine product use in pregnancy and breastfeeding. KEY CONCLUSIONS: Participants' high health literacy skills may have influenced them to seek comprehensive information on complementary medicine products from a variety of professional and lay sources. Their use of complementary medicine products in pregnancy and breastfeeding was a natural consequence from previous positive experiences with complementary medicine products and/or therapies. IMPLICATIONS FOR PRACTICE: Maternity care practitioners can positively enhance their interactions with pregnant or breastfeeding women who use complementary medicine products by respectfully discussing use within the context of these women's values and health goals, and by furthering their own education in complementary medicine products' safety, efficacy and indications in pregnancy and breastfeeding.

Women's health literacy and the complex decision-making process to use complementary medicine products in pregnancy and lactation.

BACKGROUND: Little is known about women's decision-making processes regarding using complementary medicine products (CMPs) during pregnancy or lactation. OBJECTIVES: To explore the decision-making processes of women choosing to use CMPs in pregnancy and lactation; and to investigate how women's health literacy influences their decisions. DESIGN, SETTING AND PARTICIPANTS: In-depth interviews and focus group discussions were held with twenty-five pregnant and/or breastfeeding women. Data were analysed using thematic analysis. RESULTS: Key to women's decision making was the desire to establish a CMPs safety and to receive information from a trustworthy source, preferably their most trusted health-care practitioner. Women wanted positive therapeutic relationships with health-care practitioners and to be highly involved in the decisions they made for the health of themselves and their children. Two overarching components of the decision-making process were identified: (a) women's information needs and (b) a preference for CMP use. Women collated and assessed information from other health-care practitioners, other mothers and published research during their decision-making processes. They showed a strong preference for CMP use to support their pregnancy and breastfeeding health, and that of their unborn and breastfeeding babies. DISCUSSION AND CONCLUSIONS: Complex decision-making processes to use CMPs in pregnancy and lactation were identified. The participants showed high levels of communicative and critical health literacy skills in their decision-making processes. These skills supported women's complex decision-making processes.

Complementary medicine products: Information sources, perceived benefits and maternal health literacy.

BACKGROUND: Maternal health literacy plays an important role in women's decisions regarding health care during pregnancy and lactation. This systematic review aimed to investigate the use of complementary medicine products by pregnant and breastfeeding women; information sources accessed, and the role health literacy plays in women's use of complementary medicine products. METHODS: Seven databases were searched for peer-reviewed quantitative or mixed- methods studies (1995-2017). Thematic analysis identified key themes regarding women's use of complementary medicine products for perceived benefits to the mother, pregnancy, baby and/or breastfeeding process. RESULTS: 4574 papers were identified; 56 met the inclusion criteria. Most (n=53) focused on the use of complementary medicine products during pregnancy; six focused on use in lactation. Herbal medicines were the main complementary medicine product type discussed (n=46) for both pregnancy and breastfeeding. Women perceived complementary medicine products to be beneficial in supporting their own pre and postnatal health, their pregnancies, growing foetuses, labour and birth, and/or breastfeeding. Health care professionals, followed by other interpersonal relationships and the media were the most commonly reported information sources accessed. An interactive model of health literacy revealed that information sources within a woman's health literacy environment, combined with other information sources, influenced her decision making regarding complementary medicine product use. CONCLUSIONS: Pregnant and breastfeeding women use complementary medicine products for various self-perceived benefits related to their own, unborn or breastfeeding babies' health. Examining these with reference to an interactive health literacy model helps identify the decision-making process mothers undergo when choosing to use complementary medicine products.

An integrative review of dietetic and naturopathic approaches to functional bowel disorders.

OBJECTIVES: Naturopathy and dietetics have evolved as two separate but parallel professions that use diet to promote optimal health and manage many illnesses and diseases. Given the increasing recognition of the influence of diet on health outcomes, there is increasing demand for the services of both professions. The aim of this research was to investigate similarities and differences between naturopathic and dietetic approaches to functional bowel disorders (FBDs). DESIGN: For this integrative review AMED, CINAHL, the Cochrane Database of Systematic Reviews, EMBASE, Medline and PubMed databases were searched for articles that focused on dietetic or naturopathic diagnosis and treatment of food intolerance expressing as a FBD in adults. (Registration: PROSPERO 2016 CRD42016049469). RESULTS: Of the 55 papers in the final review, 10 discussed complementary medicine approaches to FBDs. Both dietitians and naturopaths used similar holistic approaches to diagnosis and treatment, adjusted diets as a primary treatment approach, and individualised treatment for their patients. The professions differed in their use of vitamin, mineral and herbal supplements and in their willingness to recommend other treatments like osteopathy and acupuncture. CONCLUSIONS: There is much overlap between dietetic and naturopathic approaches to assessment and treatment of FBDs. Further publications that describe naturopathic treatments for FBDs are needed to confirm these results and to provide opportunities for increased recognition and scrutiny of any distinctively naturopathic approaches. Without doing so, naturopathic practices are likely to remain marginalised and poorly understood. Moreover, the opportunity to fully contribute to the management of lifestyle-related diseases will be missed.

Complementary medicine products used in pregnancy and lactation and an examination of the information sources accessed pertaining to maternal health literacy: a systematic review of qualitative studies.

BACKGROUND: The prevalence of complementary medicine use in pregnancy and lactation has been increasingly noted internationally. This systematic review aimed to determine the complementary medicine products (CMPs) used in pregnancy and/or lactation for the benefit of the mother, the pregnancy, child and/or the breastfeeding process. Additionally, it aimed to explore the resources women used, and to examine the role of maternal health literacy in this process. METHODS: Seven databases were comprehensively searched to identify studies published in peer-reviewed journals (1995-2017). Relevant data were extracted and thematic analysis undertaken to identify key themes related to the review objectives. RESULTS: A total of 4574 articles were identified; 28 qualitative studies met the inclusion criteria. Quantitative studies were removed for a separate, concurrent review. Herbal medicines were the main CMPs identified (n = 21 papers) in the qualitative studies, with a smaller number examining vitamin and mineral supplements together with herbal medicines (n = 3), and micronutrient supplements (n = 3). Shared cultural knowledge and traditions, followed by women elders and health care professionals were the information sources most accessed by women when choosing to use CMPs. Women used CMPs for perceived physical, mental-emotional, spiritual and cultural benefits for their pregnancies, their own health, the health of their unborn or breastfeeding babies, and/or the breastfeeding process. Two over-arching motives were identified: 1) to protect themselves or their babies from adverse events; 2) to facilitate the normal physiological processes of pregnancy, birth and lactation. Decisions to use CMPs were made within the context of their own cultures, reflected in the locus of control regarding decision-making in pregnancy and lactation, and in the health literacy environment. Medical pluralism was very common and women navigated through and between different health care services and systems throughout their pregnancies and breastfeeding journeys. CONCLUSIONS: Pregnant and breastfeeding women use herbal medicines and micronutrient supplements for a variety of perceived benefits to their babies' and their own holistic health. Women access a range of CMP-related information sources with shared cultural knowledge and women elders the most frequently accessed sources, followed by HCPs. Culture influences maternal health literacy and thus women's health care choices including CMP use.