INTRODUCTION

There has been a rise in the use of traditional medicine in recent years and is widely embraced around Asia and the world [1, 2]. Traditional medicine refers to the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, used in the maintenance of health and the prevention, diagnosis, improvement, or treatment of physical and mental illness [1]. In many developing countries, including Malaysia, the community uses traditional medicine, mostly in the form of herbs as folk remedies for the management of acute and chronic illnesses [2]. Women are frequently reported to use herbs more often than men for various health issues, possibly due to their inclination to access healthcare [2]. In Malaysia, herbal remedies are popular among Malay women for post-partum care, which women traditional practitioners are often sort after. However, despite the popular use of plants for post-partum management [3, 4], very little is known regarding the knowledge among women traditional practitioners and Malay post-partum treatment.

Local practitioners’ knowledge of traditional medicine and herbal use for Malay women is commonly focused on both indigenous groups [5] and non-indigenous people [6]. However, despite the popularity of herbal use among Malay women for women’s health, very often, details of the herbs used by consumers are lacking [4, 7]. Most concerning is that women's traditional practitioner knowledge has also decreased at an alarming rate [5]. The need to preserve the knowledge of herbal use for traditional medicine is vital due to the important role of plants in the discovery of bioactive agents in modern medicine [8]. In addition to this, the need to identify plants used by traditional practitioners is important to optimize safety and efficacy. Despite the perceived safety of herbal medicine, many studies have reported unwarranted adverse effects with traditional medicine [9]. This is concerning as various herbal remedies are often recommended by practitioners for post-partum care [7]. Despite their knowledge of herbal remedies, many practitioners may not be aware of the potential adverse effects on women and their children when recommending the herbs [9]. Thus, close monitoring of herbal remedies recommended by traditional practitioners, especially among women is required to reduce the incidence of adverse side effects, and drug-herb interactions and to optimize efficacy.

Among Malay women, herbal remedies are used frequently after childbirth due to their perceived natural and safer origins [3, 7]. Herbal remedies are also thought to be easily accessible and cheaper than conventional medicines [2]. Given the vast rainforests in Malaysia, a diverse number of plants exist, many unexplored and potentially useful as medicinal sources. In view of this diversity, the use of post-partum herbal remedies among Malay women is reported to differ from one state to another [7]. The distinct variances could be largely due to differences in the availability of plants [4]. Most often, the use of multiple herbs is recommended for one indication, either as a herbal drink, to be taken orally, or used as a bath mixture [2, 7]. It is interesting to note that at times, one herb is used by various practitioners for the same indication, as observed for post-partum care, prompting the possibility of its effectiveness and efficacy in solving the target issue [7].

There is a need to document the uses of these herbs to ensure the preservation of traditional medicine practice, especially among women. Documenting the different plants used could also provide valuable clues in the search for improved safe use of herbal remedies. With rapid modernization and development of rural areas occurring globally, there is a serious threat to medicinal plant diversity. Changes to traditional lifestyles can further threaten the continuity of familiarity with traditional medicine knowledge. This is especially a challenge as practitioners rarely document the use of different plant types and their parts and amount in herbal preparations. Therefore, this work aimed to identify common post-partum herbal remedies used among Malay women traditional practitioners in Perak, Malaysia, in an attempt to preserve their knowledge.

MATERIALS AND METHODS

A cross-sectional study was performed among female traditional practitioners in Perak. At least one practitioner from each district was selected. The inclusion criteria of traditional practitioners were recognized as a traditional healer in the village or known to utilize medicinal plants for self-treatment or the family, must possess knowledge of the uses of medicinal plants, and must be mentioned at least by three villagers. Those that did not complete the interview were excluded from the study. Both purposive and snowball sampling approaches were utilized in the selection of practitioners. Oral informed consent was obtained before inclusion in the study.

Perak is a state that is situated in the north-central region of Peninsular Malaysia. It is divided into eleven districts: Hulu Perak, Kerian, Larut Matang and Selama, Bagan Datuk, Perak Tengah, Hilir Perak, Kuala Kangsar, Muallim, Kampar, Batang Padang and Manjung [10, 11]. It has a land area of 2.1 million hectares, with approximately half or equivalent to 998,306.02 hectares of which being forest area [10-12].

Data was collected using a researcher-assisted questionnaire. The data collection was performed using a questionnaire adapted from previous work [13], which was divided into three parts, A, B and C. Part A consisted of demographic data of the practitioner such as age, income, location, and level of education, category of practice, duration of practice and occupation. Part B includes data on sources of knowledge, efforts to preserve or disseminate knowledge, and methods of preservation of traditional practice. Respondents were also asked whether they were well versed in taxonomy or pharmacognosy, processing techniques or quality control methods with regards to the plants used, methods of gathering plants, and availability [13, 14]. In Part C, details of the most common plants used for managing women post-partum were collected. This was followed by details of the plants used for herbal remedies such as; the vernacular name of the plant, part of the plants used, its medicinal uses, and methods of preparation [13, 14].

Analysis of data was performed using SPSS Statistics for Windows, version 24 (IBM Corp., Armonk, N.Y., USA). All data were divided into categories and presented as frequency and percentages. Continuous data such as age and income were presented as mean and standard deviations (SD). 

RESULTS AND DISCUSSION

A total of 36 female practitioners were included in the study. Approximately half of the practitioners (n=19, 52.7%) had other jobs, of which 1 (2.8%) was a rubber tapper and homesteader, respectively, 8 (22.2%) practitioners were also petty traders and 9 (25%) were traditional massage therapists. Of the 36 practitioners, 10 (27.8%) were plant collectors/ sellers and the remaining 26 (72.2%) were healers. Details of the traditional practitioners are shown in (Table 1).

A total of 10 (27.8%) practitioners revealed that they obtained knowledge of medicines via inspirations and dreams. The remaining 26 (72.2%) received the knowledge of plant use for post-partum herbal remedies via friends and relatives. Details of traditional practitioners’ sources of knowledge are shown in (Table 2).

A total of 138 plants based on Malay plant names were used for post-partum care. However, on closer inspection, 138 different Malay plants represented 126 scientific names. The families of medicinal plants species used for post-partum care were mostly Zingiberaceae (n=20), Lamiaceae (n=11), and Acanthaceae (n=8) (Figure 1).

The most common plant part used were leaves (n=86, 62.3%), followed by roots (n=29, 21.0%), rhizomes (n=15, 10.9%), seeds (n=12, 8.7%), fruits (n=11, 8.0%), whole plants (n=8, 5.8%), flowers (n=5, 3.6%), barks (n=5, 3.6%), bulbs (n=2, 1.4%) and tubers (n=1, 0.7%).

The 20 most common plants are reported in (Table 3). Of the total 36 practitioners, the most common plant used among them were fragrant lemongrass ‘serai wangi’ (Cymbopogon nardus) (n=18, 50%), noni ‘mengkudu’ (Morinda citrifolia L.) (n=15, 41.7%) and screwpine ‘pandan’ (Pandanus amaryllifolius, Roxb.) (n=14, 38.9%). From the 20 most common plants used, most were in the form of leaves (n=14, 70%), followed by fruits (n=3, 15%), seeds (n=2, 10%) and rhizomes (n=1, 5%). The plants were used in either external or oral form.

External preparations reported were in the form of baths, steam baths, massage oils, and powders. Baths are prepared by boiling herbs in water for a few minutes, and cold water was added before being used for bathing. Steamed baths are herbs added into boiling water, and the steam used for a steam bath. Massage oils are coconut oils infused with herbs that are used for body massages. Powders are herbs that are dried and crushed into fine powder to be used on the body, giving a warm sensation. It was reported that the most common use of the plants in external form was baths (n=78, 44.1%).

Internal preparations included maajun, boiled drinks, powder, juice, and raw herbs. Maajun is a preparation of rolling dry herbs into a small ball-like form and it is then taken orally, either swallowed whole or chewed. Boiled drinks are herbs that are boiled and simmered for a few minutes and ingested while warm. Powders are dried herbs that are crushed fine, mixed into boiling water, and taken with or without sugar. Herbal juices are preparations that are added with fruit juice and water. Raw herbs are herbs in their natural form and are usually taken with meals, very much like ingesting salads. The most common type of internal form used for post-partum use were powders in oral form (n=57, 32.2%).

Post-partum care is essential among Malay women, with many opting for herbal remedies during this time to optimize their health [15, 16]. During this post-partum period, many Asian mothers go through a period termed ‘confinement’ [3, 15], which may last between a few weeks to a little more than a month, often guided by a women's traditional practitioner. During this period, the mother is required to go through a strict diet, extended rest, and many opt for herbal remedies. The lack of modern medicines available for post-partum care makes this a lucrative area for traditional practitioners in Malaysia, as new mothers look for alternative remedies to facilitate recuperation during the confinement period. Herbal remedies for post-partum care are thought to accelerate the recovery process [15]. Various herbs are used by mothers for post-partum care [16]. However, they are often uncertain of what is taken as practitioners very rarely divulge the contents of their remedies. This is not surprising, as evidently, many traditional practitioners admit that they do not document or disseminate their knowledge. This lack of documentation [17, 18] has become increasingly worrying as preservation of traditional medicinal practice becomes more limited. Safeguarding knowledge of Malay traditional practice in post-partum care is indeed warranted.