To our knowledge this is the first study to investigate how traditional practitioners treat pregnant and lactating women. Using a plant taxonomist with knowledge of the local language and culture as interpreter was essential to capture essential information about various medicinal plants and establish confidence and trust with the traditional practitioners. It was clear that the traditional practitioners felt confident and had long experience with treating pregnant women and that they played an essential part of maternity care for pregnant women in these areas in Mali. Importantly, they recognized that some plants could have harmful effects for pregnant women, that the effect would vary according to which part of the plant was used, how they were prepared and their administration route, and adapted their recommendations to whether the woman was pregnant or not. Their knowledge was also supported by scientific literature for plants such as Khaya senegalalensis, Opilia amentacea, and Cassia sieberiana (Table 2).
For the most common diseases and ailments they had a large range of medicinal plants to choose from, like malaria where 48 plants were mentioned with fidelity levels of 82% and 71%, and 66% for Combretum micranthum, Trichilia emetica and Vepris heterophylla, respectively.
An important message for health workers is that medicinal plants rich in alkaloids and traditionally used as purgatives should not be used in pregnancy. Their mode of action warrants great caution even if there is limited human evidence of toxicity in pregnancy. E.g. roots of Securidaca longipedunculata, but also stem and root bark of Khaya senegalensis, Opilia amentacea (syn. Opilia celtidifolia), Cassia sieberiana, Sarcocephalus latifolius (syn. Nauclea latifolia). As shown in Table 2 for most of these plants, relevant toxicological and pharmacological evidence comes from traditional use and some animal studies. Our findings fit well with a previous study that showed that TPs in the district of Bamako, Mali, have broad knowledge about plant toxicity .
Treatment of malaria is an important public health priority in Mali as in many African countries [4, 23]. In our study the TPs explained that they identified and treated the symptoms of malaria. In this way the TP may provide medicines complementary to conventional malaria medication. Ideally, conventional malaria medicines should be used as described in WHO guidelines . However, when access to conventional drugs or diagnostics, costs or cultural factors make these guidelines difficult or impossible to follow, medicinal plants may be the only alternative. Of note, a few TPs informed us that they sometimes referred patients to the doctor, thus indication of a possible collaboration between TPs and doctors.
There is still a way to go to “roll back” malaria in Mali [23, 25]. Our previous studies have shown that there is a strong belief that malaria may be caused by evil spirits  and reports show that large parts of the population do not receive conventional drugs against malaria [4, 27]. Educating TPs and health care personnel jointly and including TPs actively in the national campaigns against malaria could be an important way forward to meet this major public health challenge.
Perhaps not surprisingly, depression was not readily recognized and although 20 different medicinal plants were mentioned, no plant was mentioned more than twice. On the other hand, they treated symptoms that could be related to depression like lack of appetite and tiredness. In many African countries having a mental illness is still a taboo and patients with mental illnesses are consequently stigmatized [28, 29]. Our results support a public health initiative to increase awareness about mental illnesses among the public and health care personnel.
The training and system for registration of traditional practitioners that has been set in place and incorporated into the health care system in Mali might have helped to preserve knowledge inherited through generations and legitimate its use in the society where access to conventional medicines is limited. For this model to promote safe motherhood it is essential that such a system is in place and that the risks and benefits of medicinal plants are weighted in a similar manner as conventional medicines. Our concern is that although traditional use has generated important knowledge about the safety of several medicinal plants in pregnancy, systematic studies on the safety commonly used medicinal plants in pregnancy are lacking. As pregnant women cannot be included in randomized controlled trials of obvious ethical reasons, priorities for future research should be characterization of the components and biological activity of commonly used medicinal plants in Mali and incorporating medicinal plants in pharmacovigilance systems in African countries. Likewise, health workers should be educated and encouraged to report adverse pregnancy outcomes (e.g. spontaneous abortion, malformations) after use of medicinal plants. By doing so society would gain knowledge about these plants teratogenic potential and enable signal detection of harmful plants to the mother and unborn child, respectively. We believe that collaborating with traditional practitioners may be an important asset in such future research. In addition, a study on pregnant women’s use and attitudes towards medicinal plants should be undertaken to get the patients perspectives about treatment of ailments and diseases in pregnancy. Although several studies have been published on the use of medicinal plants in pregnancy in other African countries as the Ivory Coast , Nigeria [31, 32], Zambia  and Tanzania , indicating a widespread use of medicinal plants in African countries, no such study has previously been conducted in Mali.
The Department of Traditional Medicine at the National Institute of Research in Public Health are currently undertaking several pharmacognostic and an epidemiological study relevant to these research areas.
There are some limitations to the study that should be acknowledged. Firstly, this study was conducted in three regions in Mali, and may not be representative of the entire country. The TPs who participated in the study may feel more confident and therefore more willing to discuss their practices with us than less experienced ones. By including practitioners with a large age range and number of pregnant women treated per month, both genders and traditional practitioners from three regions in Mali we hope to have overcome this potential bias. Furthermore, time could be a limiting factor; to explore the details of how medicinal plants were used, the interview lasted in average over 40 minutes, and sometimes the TPs would become impatient to finish the interview. Our results should be interpreted with the advantages and limitations of our study in mind.