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Self‐medication among pregnant women attending outpatients' clinics in northern Jordan‐a cross‐sectional study

Abstract Self‐medication can facilitate patients’ access to medicinal products, save time, and reduce financial and health‐care service use burden. On the other hand, irresponsible use of self‐medications can result in adverse consequences. Self‐medication is common among different demographic groups including pregnant women. In general, medicinal products might have harmful effects on mothers and baby. This study aimed to assess self‐medication practices among pregnant women in the northern region of Jordan. A cross‐sectional study was conducted on pregnant women attending outpatient clinics in the northern region of Jordan. Self‐medication practices among the target population were assessed using a survey questionnaire that was administered through interviewer‐assisted mode. Data were collected between December 2019 and September 2020, and descriptive statistics and inferential analysis were applied. A total of 1,313 pregnant women were surveyed (response rate = 95.50%). Self‐medication and the use of herbal remedies were practiced by 33.10% and 32.14% of the participant, respectively. Headaches and general pains were the most frequently reported conditions treated by self‐medication practice with either conventional medicinal products or herbal remedies. The gravidity (≥4) and the gestational stage (≥28 weeks) were the predictors of self‐medication practice. This study showed that self‐medication was not widely practiced by pregnant women in the northern region of Jordan. Disease simplicity and previous history were the main motives for self‐medicating. Efforts should be made by health‐care providers to address pregnant women and educate them to increase their awareness about the unsafe use of medicines and the harmful effects on fetus.

In Jordan, the practice of self-medication has been extensively investigated in the past two decades. [28][29][30][31] Similar to other developing countries, the practice of self-medication in Jordan includes utilizing non-prescription and prescription medications, especially antibiotics. [28][29][30][31][32] The primary source of self-medicated products is pharmacies, where medications can be purchased with or without the consultation of a pharmacist or other health-care professionals. 31 Other sources of self-medication products are medicinal products shared between family members, friends, and neighbors and leftover medicinal products. 30,31 The most predominant products used by Jordanians for self-medication are analgesics, cough and cold medicines, antibiotics, vitamins, antacids, laxatives, and antimotility agents. 28,33 While there is a number of studies that have investigated and described the prevalence and patterns of self-medication practices among different population groups in Jordan, [34][35][36] there is no clear evidence available on self-medication practices among pregnant women. Therefore, this current study aimed to identify the prevalence and patterns of self-medication and the most commonly used self-medicated products and herbal remedies among pregnant women in Jordan.

| Study settings, design, and subjects
This study was a cross-sectional study that targeted pregnant women attending outpatients' clinics in the northern region of Jordan. Self-medication was defined as taking medications, herbal products, or supplements without rational prescriptions or as OTC medications. Pregnant females who are pregnant ≥8 weeks were invited to participate in the study and were recruited after obtaining a signed consent, and those who refused to participate were excluded from the study.

| Sample size
For the study, a minimal sample of 385 participants were needed.
The sample size was calculated based on a 95% confidence interval, a standard deviation of 5%, 0.05 level of significance, and unlimited population size. The minimal sample would give adequate power for bivariate, multivariable analysis to be carried out. The sample size was calculated using Raosoft software sample size calculator.

| Data collection tool and study instrument
Self-medication practices among the targeted population were examined using a questionnaire instrument. The questionnaire was developed by the research team based on an extensive literature review, and guided by the study's aims and objectives. 22,24,37 A panel of experts reviewed the initial draft of the questionnaire. The draft was piloted on a convenient sample of 10 pregnant women.
The resulting data from the pilot study were excluded from the final analysis. Following the expert review and survey piloting, necessary amendments were made.
The final version of the questionnaire consisted of 34 questions divided into four sections as per the following: section one: participant's demographics and characteristics such as age, employment status, and level of education. Section two: participant's obstetric history such as gravidity, parity, number of miscarriages, and the gestational age of the current pregnancy. Section three: self-medication practices during pregnancy. Section four: utilization of herbal medicines during pregnancy (Supplementary Material 1).
In order to secure a high response rate, and to minimize the possibility of missing data and incomplete questionnaires, the questionnaire instrument was administered through interviewer-assisted administration route. Two research assistants (clinical pharmacists) were trained to carry out face-to-face structured interviews systematically.
In the period between December 2019 and September 2020, a total of 1,375 pregnant women attending outpatients' clinics were approached by the research assistants. Eligible participants were provided with the participant's information sheet, which outlined the research aim and objectives and the voluntary nature of their participation. Participants in the study were asked to sign and return the participant's consent form. Each participant was assigned an anonymous participant identification code.

| Statistical analysis
Descriptive statistics in the form of frequencies, percentages, mean, and standard deviation (SD) were used to report patient demographics, and Pearson's Chi-square test and T-test were used for group comparison in traits. Univariate analysis was used to compare participants who practiced self-medication and who did not. The comparison was carried out in terms of age, employment status, level of education, and obstetric history such as gravidity, gestational age, and mode of previous deliveries.
Associations between participants' demographics and gestational history and self-medication practices were examined using binary logistic regression; a two-sided p < 0.05 was considered as statistically significant. Data analysis was carried out using IBM Statistical Package for the Social Sciences (SPSS®).

| Ethical consideration
The

| Demographic data
Over 9 months, a total of 1,313 of 1,375 women agreed to take part in the study (response rate of 95.50%), 62 women declined to participate due to time limitation or personal reasons. The vast majority of recruited participants, 1,237 (94.2%), were attending hospital-based outpatient clinics. The mean age of participants was 28.54 ± 8.36 years. The majority of the study participants, 978 (74.50%), were unemployed, and only 78 (5.90%) were employed at a medical field at the time of the interviews. Regarding the level of education, 818 participants (62.30%) had an academic degree (college or university).

| Patterns of self-medication practices during pregnancy
Self-medication was reported by 434 (33.1%) participants, of which 362 (83.4%) used one medicinal product without prescription. Only nine self-medicating participants (2.1%) reported that they had got harmful effect from self-medication practice while only four of them (0.9%) needed hospitalization.
Among the conditions for which participants use medications without a prescription, headache and joint pain were the most frequently reported by 371 (85.5%) participants, followed by common cold by 51 (11.8%) of the study participants. Therefore, it was not surprising that analgesics and pain killers were the most frequently used medications without prescription, used by 383 (88.2%) participants. On the other hand, 58 (13.4%) participants reported the utilization of antibiotics without prescription. Of the 434 selfmedication practicing participants, 345 (79.5%) got their medication from the pharmacy ( Table 2).
Practicing self-medication was driven by previous experiences with the disease and simplicity of the condition as reported by 47.7% and 36.6% of self-medicating participants, respectively. On the other hand, among the 879 (66.9%) participants who avoided self-medication, 563 (64.1%) were concerned about harming their fetuses, and 548 (62.4%) were worried about abortion ( Figure 1).

Participants' group
Overall Study Participants N (%) reported the concomitant use of herbal remedies and nonprescription medicines (Table 3).

(3.5%)
Inability to read the leaflet 5 (1.2%) Abbreviation: NSAID, non-steroidal anti-inflammatory drugs. a Participants were able to provide more than one answer.

| Predictors of self-medication in pregnancy
Univariate analysis showed that being an older mother, being pregnant for four or more times, and the gestational age of ≥28 weeks were significantly associated with self-medication (p < .001

| DISCUSS ION
Self-care practice and intervention are being promoted as costeffective tools that can maintain health and well-being and save scarce resources. Self-medication is one of the frequently reported self-care practices at the individual level. 9,38 Self-medication is a common practice in Jordan, and it is driven by a variety of socioeconomic factors. 7,39 This is the first study that investigated selfmedication practices among pregnant women in Jordan. The study targeted pregnant women attending outpatients' clinic in the northern region of Jordan. The questionnaire instrument collected data related to participants' demographics, obstetric history, selfmedication patterns, drivers for self-medication, factors associated with self-medication, sources of medical information, and the utilization of herbal remedies.
Similar to the globally reported prevalence of self-medication among pregnant women, emerging evidence from this study showed that pregnant women did not widely practice self-medication practice, with around one-third (33%) self-medicated themselves. 22 However, the prevalence of self-medication among Jordanian pregnant women is lower than that reported by the general population. 33 The lower prevalence could be explained by the notion that pregnant women are generally more concerned about the harm, especially teratogenic effect that medicinal products may have on their fetus. 40,41 Gastrointestinal conditions, such as heartburn, hemorrhoids, constipation, nausea, and vomiting, are among the most frequently reported complaints during pregnancy. 42 However, only 9% of the self-medicating participants used medicines to treat nausea and vomiting, and only 7.1% and 3% of herbal remedies users relied on these remedies to manage excessive intestinal gases and constipation, respectively. Not relying on self-medication and herbal remedies can be attributed to the fact that these complaints are self-limiting in general and can be treated by non-pharmacological intervention and lifestyle modifications. 43 In line with national, regional, and international trends, self-medicating participants mainly used medicinal products to manage headaches and pain, and their medicine of choice was analgesic, especially paracetamol, which was the pain reliever of choice during pregnancy. 34,44-47

F I G U R E 1 Reasons for avoiding self-medication
Similar to global studies, mainly in developing countries, our study showed that familiarity with the disease and its simplicity were the main drivers for self-medication among the study cohort. 24,48 The same motives were reported in the study that targeted pharmacy students in Jordan. 34 Frequently, the absence of medical health insurance, limited access to health-care professionals, and the high cost of medical fees were reported to drive selfmedication practices. 20,22,33 However, in this study, insurance was not significantly associated with self-medication practice nor was accessibility to health-care service. The lack of influence of health The effect of previous experiences was also evident in assessing factors associated with self-medication practices. Results showed that practicing self-medication was found to be significantly associ-

| LI M ITATI O N S
The current study targeted pregnant women attending outpatients' clinic in the northern region of Jordan "location-based sampling", which minimizes the diversity in the study sample and hence limit the generalizability of the study findings.
The use of interviewer-administered response mode may trigger response bias, where participants feel that they have to provide a socially desirable response. Self-medication is not widely encouraged for pregnant women, so there is a possibility that some participants provided an inaccurate account of their self-medication practices. Participants might be obliged to provide socially acceptable answers, and not to be viewed as irresponsible mothers with tendencies of harming their fetuses.

| CON CLUS ION
Our study showed that one-third of the study participants selfmedicated or used herbal remedies during pregnancy. Being in the third trimester and the number of previous pregnancies (gravidity ≥4) were found to be predictors of self-medication practice. It is recommended that health-care providers, such as pharmacists and physicians, should address pregnant women and educate them to increase their awareness about the unsafe use of medicines and the harmful effects on fetuses. Pharmacists should follow evidence-based practice guidelines and consider the harmful risk when dispensing medications for pregnant women without rational prescriptions or even OTC medication.
The study can be enhanced by targeting a more diverse population and recruitment sites. The future research should look more deeply and comprehensively into socioeconomic factors such as income, type of insurance (private vs. public), place of residence (urban vs. rural), social norms, and behavioral cues.

ACK N OWLED G M ENTS
Thanks to all participants from Jordan who took part in this study and the research assistants who collected the data and interviewed the participants.

CO N FLI C T O F I NTE R E S T
The authors have declared no conflict of interest.

AUTH O R CO NTR I B UTI O N S
Mervat M Alsous conceived and designed the research, analyzed the data, and wrote and revised the manuscript. Sayer I Al-azzam con-

DATA AVA I L A B I L I T Y S TAT E M E N T
Raw data of the study are available from the corresponding author upon reasonable request.