Letter to Editor “Comments on self-medication with conventional and herbal medicines in pregnancy: prevalence and factors in Northwest Ethiopia”

Dear Editor, We read with great interest the article by Feyisa et al titled1 “Self-medication with conventional and herbal medicines in pregnancy: prevalence and factors in Northwest Ethiopia,” published in Annals of Medicine & Surgery. The authors deserve to be appreciated for addressing the understudied issue of self-medication during pregnancy in a low-resource setting, yet some gaps in the methodology and interpretation need to be addressed. In this study, data were gathered through face-to-face interviews conducted by pharmacy specialists immediately following antenatal care visits, a context likely conducive to the underreporting of stigmatized behaviors. The disproportionate number of women, who give the causes of abstinence as reasons of fear of causing an abortion (84.5%), or provider advice (77.5%), is an indication that they may have over-reported non-use. There were no anti-bias methods used, such as anonymity or validated instruments. This likely led to an underestimation of both conventional and herbal medicine practices. Past researches have indicated that this bias may be minimized by anonymous questionnaires and by avoiding immediate post-consultation settings2. A notable methodological gap is the absence of pregnancy safety classification of the reported medicines. Although the study identifies which drugs and herbs were used, it does not categorize them according to established pregnancy safety frameworks such as the U.S. Food and Drug Administration (FDA) pregnancy risk categories or equivalent systems. By contrast, a cross-sectional study in Ethiopia explicitly applied FDA pregnancy risk categories to the reported drugs and found that 13.6% of self-medicated women had used potentially risky agents (category C, D, or X). Notably, the authors of the current study define the FDA drug classification system in their own operational definitions section, yet never apply it to their findings, a significant missed opportunity that considerably limits the public health implications of this work3. The study also fails to capture data on the dose, duration, and frequency of self-medication, which are critical determinants of fetal risk. Knowing that 77.0% of women used paracetamol is important, but the clinical risk of paracetamol in pregnancy is dose- and duration-dependent, a single dose for acute headache carries a different risk profile than prolonged daily use, which has been associated with adverse neurodevelopmental outcomes in the offspring4. Similarly, the herbal medicines reported, particularly Ruta chalepensis (Tenaadam, used by 31.7%) have documented uterotonic and abortifacient properties at higher doses, yet the study does not quantify how much was consumed or for how long. In comparable studies, such as a cross-sectional study in Ethiopia, dose and duration data were collected alongside the medicines used, enabling a more complete assessment of potential harm5. The omission of dosing information in the current study means that the reported prevalence figures cannot be translated into an estimate of clinical risk at the individual or population level6.