Throughout history women have tried to control or enhance their fertility with various levels of societal support. Many herbal remedies are traditionally used as contraceptives (to prevent ovulation or fertilisation), abortifacients (to prevent implantation), emmenagogues (to stimulate uterine flow) or oxytocics (to stimulate uterine contractions, particularly to promote labour) . By 1988, the Natural Products Alert database had recorded 4,410 plants used as emmenagogues, 2,630 as abortives and 1,249 as contraceptives . Women are increasingly turning to fertility-enhancing plants to combat against the negative effects of industrial pollutants on fertility . This increases the need and even the ethical imperative for further scientific study on medicinal plants.
There are indications that even in developed countries such as Australia, women do not feel well served by what is currently available. In one Australian study seventy-two women, aged 18 to 50 years were interviewed and they claimed to be dissatisfed with contraceptive choices including their side effects . Younger women were more accepting of medical opinion, while many older women rejected medical interference in contraceptive decisions . There have also been reports of women in some developing countries unknowingly receiving a tetanus vaccine laced with the anti-fertility drug human chorionic gonadotropin (hCG) ; indicating that their individual interests were overridden by scientific authorities and that they need to be more proactive in maintaining their own health.
The Mount Hope Women's Hospital opened in Trinidad in 1981. It provides general access to standardised obstetric care for the general public. This is a tertiary care University of the West Indies-affiliated institution which receives referral of high and low risk pregnancies from other clinics, hospitals and doctors. A 1998 paper reported that for the Hospital's first 16 years of operation there were 33 obstetric deaths and 89, 286 mothers of live births or stillbirths, giving a maternal mortality rate of 36.9 per 100 000 births . Thirty-two deaths were directly related to childbearing. Pregnancy-induced hypertension accounted for 17 deaths (eclampsia and severe pre-eclampsia). Antenatal care was defined as adequate or substandard. Avoidable factors were identified under three categories: poor patient compliance, faulty clinical management and administrative failure in the provision of medical facilities .
A more recent 6-year prospective perinatal audit at the Mount Hope Women's Hospital in Trinidad was conducted in order to determine foetal outcome, and the common causes of foetal and early neonatal deaths . Of a total of 30,987 births, there were 469 stillbirths and 391 early neonatal deaths, producing a perinatal mortality rate of 27.7 per 1000 total births. Stillbirths resulted from the hypertensive disorders of pregnancy, abruptio placentae, diabetes mellitus, intrapartum foetal distress and lethal congenital anomalies . Neonatal deaths were caused by respiratory distress syndrome (57.8%), birth asphyxia (22.2%) and sepsis (13.5%) . Another study of early onset Group B streptococcal (GBS) infection in neonates at the Mount Hope Women's Hospital over the period 1996–97 found that the incidence of early onset neonatal GBS sepsis was five to six times higher than that reported in the USA and UK .
A World Health Organization (WHO) study showed that in Latin America and the Caribbean, hypertensive disorders were responsible for the most maternal deaths (point estimate 25.7%, range 7.9–52.4; ten datasets, 11 777 deaths). Abortion deaths were the highest in Latin America and the Caribbean (12%), and were as high as 30% of all deaths in some countries in the region. Deaths due to sepsis were higher in Latin America and the Caribbean (odds ratio 2.06) than in developed countries .
These studies show that a reliance on midwife-supported home births and women's traditional knowledge for unremarkable pregnancies should be considered so that women have more control over their own fertility which may result in better patient compliance and would reduce the burdens on the public hospitals allowing more time and resources to be spent on problematic pregnancies. It may also improve the standards of antenatal care that pregnant women receive and reduce the number of abortion-related deaths. This approach has already been proven in Jamaica . The Victoria Jubilee (Lying-In) Hospital (VJH) in Jamaica promoted antenatal screening and selective booking for hospital birth of mothers considered unsuitable for home delivery. These included primigravidae, grandmultiparae, abnormal presentations, multiple pregnancies and women with previous obstetric problems. 'Normal' women were referred to community midwives . The community midwife's role was expanded in the 1970s to include provision of family planning, antenatal, post-natal and child welfare services as well as attending home births. This integration into the community health team provided an avenue for midwives' continuing education, direct supervision and job security .
Previous research has shown that Caribbean women and Creoles have always used bitter herbs to control their fertility [10-13]; some of this knowledge may have been passed on to the current generation. Plants used before the 1950s were lignum vitae (Guaiacum officinale), seed under leaf (Phyllanthus niruri), gully root (Petiveria alliacea) and more poisonous purges like oleander (Nerium oleander) and mudar (Calotropis procera) . Native Americans may have been the first to use lignum vitae as antiseptics, for syphilis and as stimulants .
Caribbean traditional reproductive health care focuses equally on the pregnancy, parturition and the postpartum period . Research in Jamaica illustrated that birth, defecation and menstruation are defined traditionally as cleansing processes . After births or miscarriages, mild purgatives are given to induce the quick delivery of the placenta and pregnancy-related waste matter through the vagina . Emmenagogues are used to restore the menses, to "clean out" the womb, and to restore vitality after pregnancy . All purgatives are classified as a "washout" and many women use "washout" ingredients as emmenagogues [10-13].
Latin American and Caribbean women also choose plants for reproductive conditions based on the properties that correspond to the hot-cold valence, irritating action, emmenagogic, oxytocic, anti-implantation and/or abortifacient effects . Activities, food and medicines are classified in various ethnomedicinal systems as hot or cold. The hot-cold valence in this context refers to the traditional belief that heat opens the body and facilitates the blood's free flow, whereas cold causes the blood to stop flowing and clog the arteries, veins and womb . One cause of infertility is described as "cold in the uterus" and fertility enhancers are considered to be "hot" [12,15]. In Mexico infertility in women is considered a "cold" illness and "hot" remedies are prescribed . Uteroactive plants used in Mexico are described in metaphorical terms of "warming" or "irritating" . "Warming" the body, blood and womb, causes the womb to "open" to release detained menstrual flow or expel a full – term foetus or unwanted conceptus . "Irritating" plants "open" the uterus and stimulate contractions that will release blocked menstrual blood or push out a full – term foetus or unwanted conceptus .
This paper presents the plants used for reproductive purposes in Trinidad and Tobago. Plants were used for unspecified male problems, for erectile dysfunction and prostate problems. The plants used to address women's reproductive problems were used mainly for infertility, menstrual pain and childbirth. Unlike a previous publication on plants used for reproductive problems in Trinidad and Tobago , these plants had no comparable use for animals.