In this study, a significant percentage of mothers (97.1%) had used TCIM during breastfeeding, which is higher than the percentage of complementary medicine use in Australia (59.9%), China (45%), Taiwan (87.7%), USA (16%) and Sierra Leone (37%), but is close to the results reported in Italy (97.3%) [16, 19, 21, 25, 27, 28]. Of course, if we consider the ASP, this rate (52.1%) will be very close to the results of Australia and China. Perhaps one of the reasons for the difference to the results of countries such as Taiwan or Sierra Leone is the lack of using the ASP index. Therefore, to facilitate comparison of prevalence indicators among different communities, standardization based on the ASP is suggested.
The rate of TCIM uses varies from country to country . This may be due to variations in study design (sampling technique, inclusion/exclusion criteria, etc.), differences among individuals living in different communities (cultural, economic, etc.), or variations in herbal medicine species deepening on the native vegetation of each country. As a result, the availability and popularity of TCIM compounds varies between countries.
In this study, the main reason for using TCIM among breastfeeding was to induce lactation (66.4%). However, in Italy and Sierra Leone, mothers often used TCIM for other reasons, with only 2.8% and 2.1% of them using TCIM to induce lactation, respectively [16, 28]. This figure was lower in Iran even compared with Australia, where more than half of mothers (60.4%) used complementary medicine to increase their milk. The high use of TCIM galactagogues in our study could be due to religious beliefs and the emphasis of Islam on breastfeeding . Support for working mothers and national breastfeeding promotion programs in Iran  may also contribute toward continuing breastfeeding and making use of TCIM galactagogues.
In our study, 64.2% of mothers who used TCIM had received academic education. This figure is lower relative to the United States (81%) and Macau (87%), but higher compared with Sierra Leone (5.7%) and Malaysia (18.1%) [16, 25, 32, 33]. A number of recent studies have shown a positive association between higher education and increased TCIM usage . It is possible that with higher education, a greater awareness of the benefits and risks of TCIM is achieved, resulting in increased rational use of TCIM products. In the present study, multivariable regression analysis also showed a much higher prevalence of TCIM usage among breastfeeding mothers with higher education relative to those with lower education.
Interestingly, we found that 36.6% of breastfeeding mothers using TCIM were employed, which is less than the figures reported in the United States (56%), Malaysia (89.2%), and Sierra Leone (52.1%) [16, 25, 33]. On the other hand, our multivariable regression analysis showed that working mothers used TCIM about 75% less than housewives. Perhaps one of the reasons behind this difference is the lack of referral of working mothers to medical centers due to employment and less opportunity for regular follow-ups. If this is the case, local health systems must work toward raising awareness about the risks of missing regular maternity follow-ups.
In our study, as in similar research conducted in Taiwan and Australia, the mothers were predominantly primiparous (64.4%) [2, 27]. This may be explained by a higher rate of referrals among women in this group due to less experience concerning the breastfeeding process. Notably, 65.8% of mothers who had used TCIM did not have breastfeeding problems. The high rate of TCIM usage (97.1%) in this group may be due to the effect of advertisements regarding the use of galactagogues or the mothers’ desire to boost their milk quality and achieve better infant weight gain.
In our study, most recommendations regarding TCIM usage came from relatives and medical staff (general practitioners and midwives). The extent to which Iranian physicians prescribe TCIM products and consider them to be effective has been investigated in prior studies . In comparison, the highest proportion of recommendations regarding the use of complementary medicine came from friends in the Malaysian study (60%) and from family in the Australian study (61.5%), showing consistency with our data [2, 33]. In Italy, however, obstetricians/gynecologists made the most TCIM recommendations (44%) . Belief in the effectiveness of complementary medicine (43.1%), in the harm of chemical drugs (28.1%), and in the safety of TCIM (27%) were other factors contributing to high rate of TCIM use seen in our study. In Sierra Leone, the affordability, availability, effectiveness, and safety of TCIM products contributed to their usage . In the Malaysian study, most mothers (65%) chose herbal galactagogues because of their natural components . Attention to these factors and planning to provide correct information to breastfeeding mothers should be prioritized by infant health planners at the national and regional levels.
One substantial finding of the present study is that most breastfeeding mothers (73%) were reluctant to report the use of TCIM compounds to medical staff. In line with this finding, 88.6% of mothers did not report TCIM treatments in Sierra Leone, mostly because they deemed it to be unnecessary . Also, in our study, only 62% of the medical staff had asked regarding the history of TCIM usage. The need to inform mothers about the use of TCIM according to their health status is a matter that should be discussed , and it seems necessary for staff in health centers to ask all breastfeeding mothers about TCIM usage.
In our study, 39% of mothers who used TCIM believed that TCIM reported no side effects. Also, 51.9% considered complementary medicine to have minimal complications, and 99.8% of mothers who used herbal galactagogues during breastfeeding had experienced no side effects. According to a recent review, most mothers believe herbal medicines to be safer than chemical medicines . Likewise, most mothers in Italy held that herbal medicines are safe and low-risk . This is while herbal medicine is not completely harmless. For example, fennel, which has been introduced as a galactagogues in several studies, can lead to photosensitivity, dermatitis, diarrhea, and estrogenic effects. Due to the possibility of cross-allergenicity, mothers who are allergic to products of the Apiaceae family (e.g., carrots and celery) must avoid using fennel [17, 28, 37].
Although the risk of complications is higher in the breastfeeding mother, the infant may also experience adverse effects following the use of herbal medicine by the mother . Therefore, medical staff should discuss the effectiveness and side effects of TCIM with breastfeeding mothers, and the safety and effectiveness of TCIM products should be evaluated . In fact, some studies have shown that mothers themselves desire to be provided with further information about TCIM [2, 36].
Numerous studies have been performed on galactagogues, though in many cases the studies have not been sufficiently valid or have not used an appropriate method [17, 38]. In galactagogues, like other TCIM drugs, we must consider contaminations and effective substances. Standardization and the development of pure herbal products are also important, and their safety should be checked against the Generally Recognized As Safe list [17, 39]. Despite the fact that 59.5% of breastfeeding mothers in our study reported that the use of galactagogues had led to a definite increase in breast milk and although side effects were reported in only 2 cases, about 60% of mothers who used TCIM during breastfeeding believed that TCIM galactagogues could not be recommended to all mothers. According to the literature, this lack of recommendation may be due to the low efficacy of TCIM or the possibility of adverse effects . The effects of past TCIM usage and a higher number of past deliveries should also not be overlooked, where our multivariable regression analysis showed that these two factors boost the chance of choosing to use TCIM by approximately 80% and 60%, respectively.
According to our findings, the most commonly used herbal medicines among breastfeeding mothers were mint, fennel, thyme, and chamomile, with the predominant reason of usage being to induce lactation. In the US study, chamomile and cranberry were most widely used among mothers following childbirth, while the Italian study revealed fennel, licorice, and aloe to be the most commonly used herbal products [25, 28]. In Australia, the plants most widely used during breastfeeding were fenugreek and ginger. Furthermore, chamomile was used is 7.2% of cases, predominantly for relaxation purposes, while 4.9% of breastfeeding mothers reported the use of fennel for increasing their milk and minimizing infantile colic . The most common non-herbal medicine used by breastfeeding mothers in our study was iron supplements (24%). In the US study, omega-3 was found to be the predominantly used supplement among postpartum mothers (6.6%) . This difference can be due to culture dissimilarities and variations in the availability, affordability, and the method of use of these products in different countries and regions.
Among the plants that were used for more than 10 days were garlic and senna, which should be avoided during breastfeeding according to the references of PM. Rhazes states that plants that have a cold and dry or very hot temperament reduce breast milk , though some studies have revealed that garlic and senna can increase breast milk . In the studies of Bazzano et al. and Nice et al., garlic was included in the list of common herbal galactagogues [43, 44]. On the other hand, Mennella et al. used garlic capsules and placebos in their study and found no significant differences in lactation between the intervention and control groups, with infantile colic being reported as an adverse effect in both groups . Another study showed that garlic can alter the smell of milk, thereby making it undesirable for the infant. In the study by Nice et al., it was noted that garlic can prolong the duration of breastfeeding but can also cause discontinuation if it is inappropriate for the infant . It seems that studies on the use of these two herbs during breastfeeding are contradictory, meaning that the advice of PM scholars to avoid their long-term use (more than 10 days) is perhaps reasonable.
In the present work, the study population was mothers who referred to government health centers, who may differ in terms of demographic characteristics from those who attend private health sector. Nonetheless, it should be noted that the majority of Iranian mothers refer to government health centers during breastfeeding. On the other hand, our findings are based on data obtained using a structured interview, where the possibility of inaccurate responses from the mothers cannot be overlooked. One of the strengths of our work is the use of multivariable regression analysis, which removes the effects of confounding factors.