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The Use of Brewed Herbs Mouthwash for Overcoming Morning Sickness

The most common discomfort at first trimester of pregnancy is nausea followed by vomiting, known as morning sickness. The condition tends to be worse if it is not treated properly, which will cause poor pregnancy outcome. Some brewed herbs including cloves, cinnamon, and nutmeg can be used as mouthwash to relieve nausea and vomiting, however there were lack of study to prove its efficacy. This study was aimed to determine the effectiveness of brewed herbs (cloves, cinnamon, and nutmeg) mouthwash in dealing with morning sickness among pregnant women. This is a quantitative – pre experiment study with one group pretestpostest design, held in the work area of Candiroto Subdistrict Public Health Center-Temanggung Regency. A total sampling was conducted with 45 respondents. Pregnancy-Unique Quantification of Emesis/Nausea (PUQE) index was used as measurement tool, and Wilcoxon statistical test was applied. The result showed both brewed clove and nutmeg were effective in overcoming morning sickness (p-value 0.001 and 0.016 respectively; z-score -3.426 and -2.401 respectively), while cinnamon was not (p-value 0.19, z-score -1.604). The PUQE-score mean difference for clove, nutmeg, and cinnamon were 6.47; 0.93; and 0.53 respectively. It can be inferred that clove is the most effective herb in overcoming morning sickness compared to nutmeg and cinnamon. It is recommended for pregnant women to use brewed clove as mouthwash in alleviating morning sickness. Health practitioners were suggested to promote the use of brewed clove in dealing with morning sickness. There is an opportunity for the health office in collaboration with local herbal industry to develop nonpharmacological product such as clove mouthwash to treat morning sickness.


INTRODUCTION
Pregnancy is a reproductive process that requires special care to achieve safe labor and give birth to a healthy baby. Nausea and vomiting which usually occurs in the morning, known as morning sickness, is a common complaint experienced by pregnant women, especially at first trimester 1 . It occurs in 50-90% of pregnant women. The incidence in primigravida is around 60-80% and 40-60% in multigravida. This condition can last for months 2 . Morning sickness is caused by increasing of estrogen and Human Chorionic Gonadrotropin (hCG), which might continue to hyperemesis gravidarum if not treated immediately 3 . Continual morning sickness can decrease body fluids, and poor blood circulation that can interfere with maternal health and fetal development 4 . Researchers found that early onset of the nausea and vomiting within the first five weeks of gestation was significantly tied to the likelihood of a child having a developmental delay. Various efforts can be made by health professionals in helping to overcome morning sickness pharmacologically, however it can be harmful. Therefore, non-pharmacologically measures such as herbal remedy is preferred. Cinnamon is usually used to treat nausea and vomiting in form of cinnamon tea which contains essential oils, safrole, eugenol, calcium oxalate, cinnamaldehyde, resin, tannin and tanners. Essential oils in cinnamon have a distinctive odor as relaxant as well as a sedative effect which can inhibit receptors at the vomiting center 5 . Cloves contain essential oils, eugenol, oleanolic acid, galotanic acid, phenilin, karyofilin, resin and gum. Essential oils in cloves can also help reduce nausea and vomiting, and are often used to treat morning sickness in pregnancy 6 . In addition, nutmeg contains a lot of essential oils that can neutralize and are useful as carminative, spasmolytic, and antiemetic so that it can be used to treat nausea and vomiting 7 . Cloves and nutmeg contain eugenol which is harmful if consumed, therefore it is recommended to use them as antiemetic in form of mouthwash 8 . There has never been a study regarding the use of brewed clove, cinnamon and nutmeg as mouthwash in reducing morning sickness.

MATERIALS AND METHOD
This study was a pre-experimental, with one group pretest-posttest design. The population of this study were all first and second trimester pregnant women within the working area of Candiroto Community Health Center. Data were obtained from 45 pregnant women as respondents which drew by a total sampling technique. Samples were taken based on inclusion criteria, namely pregnant women who experience nausea vomiting, general condition is good, do not experience gastrointestinal diseases such as typhoid, gastritis, no history of cinnamon, cloves and nutmeg allergy and no other psychological stress. The exclusion criteria were pregnant women taking anti-nausea drugs or disobey to do the intervention routinely. Data collection begins by dividing the respondents into 3 groups, they are the group of cinnamon, cloves, and nutmeg. Each group consisted of 15 respondents. Subsequently they were given a questionnaire before treatment to measure the incidence of nausea and vomiting that was filled in by the respondents accompanied by 1 enumerator in each group. An allergic test was conducted prior the treatment by rinsing the respondents' mouth using brewed cinnamon, cloves and nutmeg. The researcher then asked for help and approval from the respondent's family (husband /significant others) who lived one house with the respondent to supervise the treatment. Treatment for the first group by means of ± 1 cm cinnamon brewed with 200 ml hot water. The second group was treated with 5 clove buds brewed with 100 ml of hot water. Third group was 1 teaspoon of nutmeg powder brewed with 250 ml of hot water. The mixture is awaited cold then used to rinse mouth for 7 consecutive days, in the morning before consuming any food. Then again measuring the frequency of nausea and vomiting of pregnant women using a questionnaire on the 8th day with the help of enumerators. The measurement tool in form of Pregnancy-Unique Quantification of Emesis / Nausea (PUQE) Index was calculated based on 3 questions including nausea, experiencing retching (movement and sound before vomiting), dry mouth and not causing vomiting and vomiting 9 . Bivariate analysis of Wilcoxon statistical test was conducted with a significant level of 0.05. The Occurrence of Morning Sickness Before and After Cinnamon Mouthwash Treatment The mean value of morning sickness incidence before given cinnamon was 10.40 (moderate and severe levels) 9 . The occurrence of morning sickness can be caused by changes in the endocrine system that occurs during pregnancy, especially caused by high fluctuations in levels of hCG (human Chorionic Gonadotrophin), at 12 -16 first week, where it becomes the highest level 3 . An increase in the amount of placental tissue also increases the total hours of nausea in early pregnancy. The results showed that morning sickness level after having cinnamon mouthwash was 9.87 which considered still at the level of moderate and severe. The content of essential oil in cinnamon affects nausea in terms of having a distinctive odor which acted as relaxant. Besides, it has a sedative effect and can work to inhibit receptors at the vomiting center 5 . The simple brewing process might cause the ingredients extracted from the cinnamon was not wellcontrolled which might reduce its efficacy. This was likely to be the cause of pregnant women who experience morning sickness and take brewed cinnamon were still experience moderate and severe level of morning sickness.

The Occurrence of Morning Sickness Before and After Clove Mouthwash Treatment
Before given the brewed clove mouthwash, the mean value of the occurrence of morning sickness was 10.87 (severe and moderate levels). The occurrence of morning sickness varying from mild to unbearable all day long. Nausea vomiting in pregnancy can affect both the mother and the fetus 2 . Therefore, it needs to be given an intervention, one of them is the non-pharmacological method 10 . Essential oils in cloves are very effective in dealing with nausea and vomiting 6 . The mean value of the incidence of morning sickness after treatment was 4.40 (mild and moderate levels) 9 . Cloves contain essential oils, eugenol, oleanolic acid, galotanic acid, phenilin, karyophylline, resin and gum 6 . The chemical properties and pharmacological effects of cloves are warm and they taste sharp and aromatic. Cloves also have the benefits in dealing with toothache, sinusitis, nausea and vomiting, bloating, colds, headaches, inflammation of the stomach, coughing, late menstruation, rheumatism, measles, and others 11 .

The Occurrence of Morning Sickness Before and After Nutmeg Mouthwash Treatment
Before having nutmeg mouthwash, the mean value of the incidence of morning sickness was 10.93 which is at moderate and severe levels. The mean value of the incidence of morning sickness after getting nutmeg is 10 (moderate level). Nutmeg contains a lot of essential oils, fatty oils, saponins, miristisin, elimination, lipase enzymes, pectin, hars, tanned substances, lemonena, and oleanonic acid 7 . Nutmeg have a distinctive odor that can be used to relieve nausea 12 . The study of nutmeg leaf proven that it has a substance which can be used as a health drink to reduce nausea and vomiting 11 .

Effectiveness of cinnamon mouthwash for morning sickness
The Wilxocon test with p value of 0.109 means that cinnamon was not effective in reducing the incidence of morning sickness, with the percentage of the morning sickness incidence at moderate level (86.7%) more than the severe level (13.3%), and after given cinnamon the result remained the same. This proved that cinnamon were not effective in alleviating morning sickness. Cinnamon has antioxidant properties widely used as a flavor in food and drink which is usually done by adding the original ingredients directly into food or fluid 11 . Although essential oils in cinnamon have a distinctive odor that can be used as relaxant, sedative and inhibit receptors at the vomiting center 5 , but the amount of flavor extracted can be reduced by simple brewing process which lessen its efficacy 11 . In addition the use of cinnamon to overcome morning sickness must be limited for pregnant women 13 because it can stimulate uterine contractions and in some cases can cause premature labor. So in this study the size of cinnamon is only ± 1 cm . This might cause the cinnamon is not effective.

Effectiveness of clove mouthwash for morning sickness
The p value of 0.001 with the Z value of -3.426 meant that clove was effective to reduce morning sickness. This was supported by the percentage level of the incidence of morning sickness before the treatment was Advances in Health Sciences Research, volume 13 moderate level (80%) more than the severe level (20%), and after the treatment it decreased to mild levels (86.7%) more than the moderate level (13.3%). Giving clove for mouthwash in the morning before consuming anything can reduce the rate of nausea and vomiting in pregnancy by 3 times compared to before intervention. The typical clove aroma is produced by the eugenol compound, which is the main compound (72-90%) 14 .
The results of this study indicate that clove is effective for reducing the incidence of morning sickness because it contain essential oils, eugenol, oleanolic acid, galotanic acid, phenilin, karyophylline, resin and gum. Clove oil is a natural source of Eugenol. Eugenol plays an important role in the pharmaceutical industry because it can be used as an analgesic, stimulant, coronary odoris, medication for heartburn and relieving nausea and vomiting 11 . Essential oils in cloves are very effective in dealing with nausea and vomiting, therefore it is often used to treat morning sickness in pregnancy. The sharp aroma and taste of cloves comes mainly from eugenol will help to overcome the symptoms of morning sickness 6 .

Effectiveness of nutmeg mouthwash for morning sickness
The p value = 0.016 and the Z value = -2.401, meant that nutmeg was proven to be effective in reducing the incidence of morning sickness, supported by the percentage of morning sickness incidence before treatment was moderate level (86.7%) more than the severe level (13, 3%), and after the treatment the incidence of morning sickness was at a moderate level (93.3%) more than the mild level (6.7%). After gargling using brewed nutmeg in the morning before consuming anything, complaints of nausea and vomiting can be reduced by 2-fold. The results showed that nutmeg was effective for treating nausea and vomiting. Nutmeg is an Indonesian native plant originating from Banda Island. This plant has economic and multipurpose value 11 . Nutmeg contains a lot of essential oils, fatty oils, saponins, miristisin, elimination, lipase enzymes, pectin, hars, tanned substances, lemonena, and oleanonic acid 7 . Nutmeg contains a lot of essential oils, fatty oils, saponins, miristisin, elimination, lipase enzymes, pectin, hars, tanned substances, lemonena, and oleanonic acid 7 . Nutmeg fragrance have many health benefits and are widely used to relieve nausea or symptoms of motion sickness while driving 11 . Nutmeg is one of the native plants of Indonesia, especially in Eastern Indonesia, such as Maluku. Various benefits of nutmeg, especially the fruit has been widely known, one of which is in the pharmaceutical field as one of the non-pharmacological alternatives to overcome various complaints. Essential oils and other nutmeg preparations have strong anti-oxidant effects that can inhibit oxidative stress. The content of other substances such as myristicine, elemicine which has a unique effect resembling the effects of narcotics which if explored deeply will certainly provide diverse benefits. One of them is to overcome the symptoms of morning sickness 15 . Nutmeg seed produces essential oils of 2-15% while nutmeg mace produces 7-18% of essential oils 16 . Nutmeg oil has a distinctive aroma determined by the content of the compounds in the oil, both the main compound and the minor compound. Nutmeg oil compounds give a distinctive odor, such as ± 88% hydrocarbon monoterpenes with the main components of camphene, pinene, myristicin, and alcohol monoterpenes such as geraniol, lonalool, terpineol, and other components such as eugenol and methyl eugenol 10 . Nutmeg with a strong aroma that can be used as a sedative-hypnotic drug and empirically nutmeg seeds are often used by the community as sleeping pills and cold medicines 11 .

CONCLUSION
The results showed that clove and nutmeg were effective to overcome morning sickness. Clove was more effective compare to nutmeg. Pregnant women can use brewed clove mouthwash to deal with nausea and vomiting at appropriate dose because it was proven to be the most effective. Health practitioners were suggested to promote the use of brewed clove in dealing with morning sickness. There is an opportunity for the health office in collaboration with local herbal industry to develop non-pharmacological product such as clove mouthwash to treat morning sickness.

ACKNOWLEDGEMENT
We thank the pregnant women for their voluntary participation, the midwives and the head of Candiroto Subdistrict Public Health Center for the extraordinary support.