Ethnogynaecological Knowledge of Traditional Medicinal Plants Used by the Indigenous Communities of North Waziristan, Pakistan

Background Since the beginning of civilization, medicinal plants have been used in human healthcare systems. Studies have been conducted worldwide to evaluate their efficacy, and some of the results have triggered the development of plant-based medications. Rural women in Pakistan frequently experience gynaecological disorders due to malnutrition and heavy physical work during pregnancy. Due to the low economic status, the remoteness of the area, and the lack of modern health services, herbal therapy for gynaecological disorders is common among the indigenous tribes of the study area. Methods Field surveys were carried out from April 2018 to October 2020 to collect data regarding medicinal plants used for different gynaecological disorders. A semistructured questionnaire was used to collect ethnogynaecological data. Results In total, 67 medicinal plant species belonging to 38 families are being used to treat 26 different gynaecological problems. The herbaceous growth form and the Lamiaceae family were recorded with the maximum number of plant species (42 species and 7 species, respectively). Leaves are the most highly utilized plant part, with 16 species. In the case preparation method, decoction was the dominant method (25 species, 36.76%). The informants reported the maximum number of species for the treatment of irregular menstrual flow as 11 species (15.28%). The highest relative frequency of citation (RFC) value was obtained for Acacia modesta (0.37), and the use value (UV) for Tecomella undulata (0.85). The highest informants' consensus factor (ICF) value (1.0) was obtained for emmenagogue and tonic each after delivery. The highest consensus index (CI%) value was calculated for Acacia modesta (36.92%). The Lamiaceae had the highest family importance value (FIV) (98.46%). Conclusion This is the first ever quantitative study focusing mainly on ethnogynaecological study conducted in the tribal areas of North Waziristan which highlights the importance of traditional herbal remedies for their basic medical requirements. The results of this study would serve as a baseline for advanced phytochemical and pharmacological screening, as well as conservationists for further studies.


Introduction
Ethnogynaecology is a new branch of ethnobotany, which mainly deals with the use of therapeutic plants for curing gynaecological disorders such as menses problems, abortion, lactation, infertility, gonorrhea, leucorrhoea, and delivery disorders [1,2]. It has been documented that sexual and other women's basic healthcare problems are reported to account for 18% of the total worldwide diseases [3]. Medicinal plants used to treat gynaecological disorders such as menstrual pain, abortion, leucorrhoea, pregnancy, infertility, lactation, and delivery problems have been documented in some areas of this region's ethnic groups [4]. e tribal communities have been preparing medication from the available medicinal plant species, which are widely used to cure common women's ailments. e tribal communities depend on therapeutic plants because of their efficacy, lack of basic medical care facilities, and ethnic preferences [5]. e medicinal plants used in traditional remedies are mostly collected from the wild. Tribal people have diverse knowledge of traditional medicine based on local plants for basic medical care [6]. In tribal communities, traditional healers possess a lot of information about medicinal plants. In these regions, medicinal plants are important for the indigenous people, providing access to basic healthcare [7]. e traditional medicinal system acts as the principal supplier of primary healthcare services in the tribal areas because of the lack of modern healthcare facilities, the remoteness of the region, and a strong cultural belief in the efficacy of folk medicines [8].
e use of medicinal plants in everyday life has a long history and still has immense importance in aboriginal civilization [9]. In remote areas, therapeutic plants still play an important role [10] and are still used as the basic healthcare system. According to the literature, more than 50,000 flowering taxa have been used for medical purposes all over the globe [11]. Pakistan has diverse flora comprised of about 6000 flowering plant species [12,13] and about 600 plant species have been identified with medicinal values [14]. About 80% of the inhabitants of remote areas of Pakistan are still dependent on medicinal plants [15]. Plant-derived medicines account for about 25% of all medicines available in the modern pharmacies, with many more artificial compounds isolated from plants.
In Pakistan, rural women frequently experience gynaecological disorders due to malnutrition, poor living standards, and hard physical work during pregnancy. A local woman, who is locally called "Dayiah," is found in each village and specializes in herbal therapy to relieve gynaecological disorders with local medicinal plants [16]. e highest use of the therapeutic plant in rural communities is due to the high price of allopathic medicine and its side effects [17]. A traditional way of life, as well as a lack of a suitable approach to modern health facilities, motivates rural women to consult with nearby midwives and indigenous healers [18].
ere is very limited literature on ethnogynaecology [19], whereas many reports on ethnobotanical and ethnomedicinal knowledge are available across the globe [18,20]. Some ethnomedicinal surveys have been conducted to study the role of herbal therapy in women's medical and reproductive health disorders [20,21]. Similarly, little literature is available about medicinal plants used by pastoral women for the healing of gynaecological problems. ere is very little work carried out in Pakistan and in the whole world [22,23]. Moreover, due to modernization and the lack of interest of younger generations in indigenous knowledge, which is declining speedily, ethnoecological information may vanish if not properly recorded [24]. In today's society, allopathic medicines, anti-inflammatory medicines, surgery, and nonsteroidal analgesics are commonly used to treat gynaecological disorders. ese remedies are effective but usually have side effects, particularly when medicines are used for a long time. Moreover, some medicines used during the entire pregnancy period can harm the embryo [20].
is study aimed to record different types of plant species used against various gynaecological problems encountered by the female inhabitants of the tribal district of North Waziristan, Pakistan. e area is dominated by the Wazir and Dawar tribes, with low financial status, poor infrastructure, no modern medical facilities, and a lack of modern resources [14]. Many women and men in the region seek healing from a traditional therapist for a variety of problems related to the female reproductive organs. Such traditional knowledge has not been reported before from the study area as no ethnoecological documentation has been done earlier. Hence, this survey aims to report the ethnomedicinal knowledge of indigenous herbal remedies for the cure of gynaecological disorders and to preserve this precious but fast-vanishing indigenous knowledge of the tribal communities of the study area.

Study Area. Tribal district North Waziristan, Khyber
Pakhtunkhwa, Pakistan, is the hilly region that lies between 32°35′ and 33°20′ north latitudes and 69°25′ and 70°40′ east longitudes, with an altitude of 2143-7717 feet. North Waziristan falls under the Irano-Turanian Region [25]. e area is bounded by mountains that are connected with Kohe-Sulaiman in the south and Koh-e-Sufaid in the north. North Waziristan is bounded on the south by the district of South Waziristan; on the north by Kurram Agency, Hangu district, and Afghanistan; on the east by the district of Bannu; and on the west also by Afghanistan (Figure 1). e area is fertile and is irrigated by 3 rivers, namely, the Tochi, Kurram, and Katu rivers. e annual rainfall is 45 cm. e North Waziristan area contains 4,707 square kilometers (1,817 sq mi). ere are two major tribes in the study area, that is, Wazir and Dawar. Pushto is the major language. e study area is one of the major war-affected areas of Pakistan. e total population in the conflict-affected area of North Waziristan is approximately 840,000. e region has been targeted with shelling and air raids, and at least 456,000 people, including nearly 200,000 children (42%), fled ahead of or during the ground assaults to safer parts of Pakistan and neighbouring Afghanistan.

Field Surveys and Medicinal Plants' Collection.
e ethnogynaecological surveys were carried out in the tribal district (North Waziristan) from April 2018 to October 2020. Medicinal plants were collected during field visits [26,27]. A collection number was given to each plant specimen with the help of tags. Plants were serially tagged and appropriately placed in the field presser. Snapshots of the collected plants were also captured [28,29].

Questionnaires and Interviews.
A semistructured questionnaire was used to collect the information regarding indigenous knowledge from the local informants and Hakeems of the study area [30][31][32]. Preference was given to elderly people and Hakeems. e collected specimens and photographs were further used in the interviews to recheck the information with other informants as well [28,29]. A total of 130 local informants were interviewed, belonging to different age groups (35 years to 65 years), of which 105 were male and 25 were female, including housewives (daei/ midwives and traditional healers) ( Table 1) [33]. During the survey, local names, botanical names, folk uses, used parts, mode of preparation, mode of application (e.g., juice, paste, decoction, infusion, and powder), and growth/life form were documented by the local people of the study area. rough semistructured interviews [34,35], knowledge about gender and age differences and occupation background and information about the herbal recipes for gynaecological disorders were documented [36].

Plant Identification and Preservation.
e plant taxonomist Dr. Rahmatullah Qureshi identified the herbarium specimens and confirmed them with the help of available published literature [37]. ese will be compared with identified specimens in the Herbarium of Pakistan Islamabad (ISL), Quaid-e-Azam University Islamabad. Medicinal plant species were also photographed at the time of collection [38,39]. e collected plants' specimens were dried, pressed, poisoned with 1% HgCl 2 solution, and mounted on standard-sized herbarium sheets (11.5 × 17.5 inch). A voucher number was assigned and the voucher specimens were submitted to the herbarium of the Department of Botany, Hazara University, Mansehra, Pakistan, for future references.

Relative Frequency of Citation (RFC).
e RFC value for indigenous therapeutic plants is based on the number of informants for each plant species. A relative frequency of citation (RFC) is obtained by dividing the frequency of citation (FC) by the total number of informants in the survey (N). RFC was calculated by using the following formula [43,44]: where FC is frequency of citation and N is total number of informants taking part in the survey (N � 130).

Use Value (UV).
Use value (UV) of a species was determined by the following formula [45]: where U is number of use reports documented by the informants for a given medicinal plant and n is total number of informants interviewed for a specific medicinal plant.

Consensus Index (CI%).
e percentage of local informants regarding their indigenous knowledge of therapeutic plants used to treat gynaecological problems was calculated by consensus index (CI%) [31]. e following formula was used: where "n" is the number of informants citing the medicinal plant species and "N" is the total number of respondents for the species during the survey.

Fidelity Level (FL%).
e fidelity level (FL) is the percentage of informants who mention the utilization of particular medicinal plant species to cure specific ailments in the study area. e fidelity level (FL) is calculated by the following formula [46]: where "Np" is the particular number of citations for a specific disease and "N" is the total number of respondents citing the plant species for any ailments.
Evidence-Based Complementary and Alternative Medicine 2.5.5. Informant Consensus Factor (ICF). Informant consensus factor (ICF) was used to determine the informants' agreement on the reported treatment for any diseases group or ailment category [47]. e ICF value ranges from 0 to 1. us, the following formula was used: where Nur is the number of useful reports in any disease category and Nt is the number of plant species used.

Family Importance Value (FIV).
To determine the importance of a family, the family importance value (FIV) was applied [44] using the following formula: where FC is number of informants mentioning the family and N is total number of informants taking part in the survey (N � 130).

Informants' Demography.
is study was conducted in the tribal district of North Waziristan, Pakistan. Inhabitants use medicinal plants for the cure of different gynaecological disorders. Demographic knowledge was acquired from the gender, age, education level, and practice of the informants. A total of 130 informants were interviewed, including 80.77% male and 19.23% female (Dayiahs). All the informants spoke Pushto. e dominance of male informants in the study area was greater as compared to females. ere were certain cultural barriers due to which female informants could not talk with male interviewers outside of their families, but the investigated female informants gave their assent. Many of them were over 65 years old (47.69%), followed by 50-65 years old (40.77%) and 35-50 years old (11.54%). Participants were 76 herbalists, 29 professionals, and 25 housewives (Table 1). e majority of herbal healers in this study were males. ese results are similar to the previous literature [48]. Based on educational facilities, the indigenous knowledge and use of therapeutic plants for the treatment of gynaecological disorders were more prevalent in the illiterate people, that is, 40.77%, and the same traditional knowledge was declining in the graduate level (5.38%) of the study area. Based on age, it was observed that the indigenous knowledge and use of medicinal plants remedies for gynaecological disorders were more prevalent in the elders. e same results were documented by other authors from nearby areas and other countries [49,50]. e inherited traditional knowledge of therapeutic plants is transferred orally and verbally from their ancestors and passed from generation to another [24]. Noticeably, information and knowledge related to the traditional medication of gynaecological disorders are vanishing due to the death of older females (Dayiahs) in the community. Hence, there is a dire need to conserve this indigenous knowledge from extinction [5].

Indigenous Medicinal Plants' Diversity.
e study area has a wealthy floral diversity. For their basic medical care needs, tribal people have varying knowledge of traditional medicine associated with medicinal plants. All medicinal plant species along with their qualitative analysis (botanical names, family name, parts used, mode of preparation, mode of application, and disease treated) and quantitative analysis (RFC, FL, ICF, UV, and UR) of each medicinal plant species were calculated and are presented in Table 2. In this study, 67 medicinal plants belonging to 38 families were recorded as being used to treat gynaecological disorders by the indigenous people of tribal district of North Waziristan, Pakistan. Approximately, 84% of the rural population depends on herbal therapeutic plants [51]. In rural areas of Pakistan, approximately 75% of the inhabitants are still reliant on traditional knowledge for their basic healthcare system [52], because there is no modern healthcare facility provided to them. us, most of the inhabitants are dependent on herbal remedies in the study area. e most dominant family was the Lamiaceae with 7 species, followed by Asteraceae and Rosaceae with 4 species each (Table 2). e family Lamiaceae is predominant in the study area similar to the results reported in the previous work [53].

Life Form of the Ethnomedicinal Flora.
In terms of life forms, the most dominant life form used in gynaecological remedies was herbs (42 species, 62.69%), followed by shrubs (15 species, 22.39%), trees (7 species, 10.45%), ferns (2 species, 2.99%), and sedge (1 species, 1.49%) ( Figure 2). e frequent use of herbs in herbal remedies has also been documented in other areas of the globe [54,55]. Herbs often have a high content of bioactive compounds [56], are easily accessible, and have profuse growth in wild varieties. Similar to other studies carried out by [57], easy accessibility of herbaceous plants or therapeutic plants, valuable healing action, and reasonable cost of the healthcare system are the major factors for the preference and advancement of herbal medication in the economically backward rural communities [58].

Plant Parts Used in Herbal Remedies.
Various plant parts are regarded as useful in various ailments. e indigenous communities of North Waziristan, Pakistan, use approximately all parts of the medicinal plants as remedies for gynaecological problems. e most highly utilized parts for herbal remedies observed were leaves (16 species, 22.54%), followed by the whole plant (15 species, 21.13%), roots (12 species, 16.90%), seed (7 species, 9.86%), fruits (6 species, 8.45%), aerial parts, gum and shoots (3 species, 4.23% each), bark and bulb (2 species, 2.82% each), and flower and rhizome (1 species, 1.41% each) ( Figure 3). e collection of leaves and medication preparation from leaves are so easy as compared to the other plant parts. For these purposes, leaves are commonly used in folk remedies [59]. e removal of leaves from the medicinal plants can cause less harm as compared to the removal of other parts of the plant [60]. e high use of leaves in herbal remedies preparation is also reported in other study areas [61][62][63].

Preparation of Remedies. Medicinal plants were used by the indigenous people in diverse ways and in various recipes.
A total of 14 modes of preparation were used in the indigenous communities. In the current study, decoction (25 species, 36.76%) is the dominant methodology used for the preparation of herbal remedies, followed by powder (22 species, 32.35%), juice (4 species, 5.88%), paste (3 species, 4.42%), herbal tea, poultice, raw, and smoke (2 species, 2.94% each) (Figure 4). Similarly, decoction and powder were reported as the most commonly used methods for preparing herbal remedies in other studies [64,65]. Evidence-Based Complementary and Alternative Medicine   8 Evidence-Based Complementary and Alternative Medicine       14 Evidence-Based Complementary and Alternative Medicine 3.6. Mode of Administration. In this study, the dominant modes of administration/application were orally advised (62 species, 92.54%), followed by inhaling and topical (2 species, 92.54% each), and chewing (1 species, 1.49%) ( Figure 5). e majority of oral administration was also reported in other study areas [66,67].

Indigenous Plants Used for the Treatment of Gynaecological Disorders.
Tribal people have a wide range of knowledge about traditional medicine based on local plants for basic medical care [6]. During this ethnogynaecological study, 26 gynaecological disorders were documented, which were treated by using 67 medicinal plants (Table 3). e common gynaecological disorder in the study area was irregular menstrual flow, which was treated by using 11 plant species (15.28%), followed by leucorrhoea (8 species, 11.11%), enhanced milk flow and gonorrhea (6 species, 8.33% each), excessive menstruation (4 species, 5.56%), abnormal stoppage of menstruation, abortion, easy delivery, miscarriage, and vomiting (3 species, 4.17% each).   e recorded data were analyzed through different statistical indices like RFC, UV, CI%, ICF, FL%, and FIV.

Relative Frequency of Citation (RFC).
A relative frequency of citation was used to assess the most commonly used therapeutic plants [68] for gynaecological disorders. In this study, the RFC ranged from 0.11 to 0.37 (Table 2). Based on RFC values, the most valuable medicinal plant having a high degree of RFC was Acacia modesta (0.37), followed by Cydonia oblonga (0.36), Berberis lycium, Tecomella undulata, Trianthema portulacastrum, and Withania somnifera (0.35). e lowest RFC value was calculated for Ajuga parviflora (0.11). ose therapeutic plant species having the highest RFC value should be further analyzed pharmaceutically and phytochemically to identify their bioactive compounds for medicinal discovery [69,70].

Use Value (UV).
According to [45], the use value indexation is a quantitative technique of ethnobotany that correlates the importance of plant species among aboriginal communities with regard to their uses. e use value in our documented data ranged from 0.27 to 0.85 and the use reports (URs) ranged from 9 to 39 (Table 2). e highest use value was reported for Tecomella undulata (0.85), followed by Cydonia oblonga (0.81), Withania somnifera (0.78), Acacia modesta (0.77), and Berberis lycium (0.76). e lowest use value (UV) was recorded for Cyperus rotundus (0.27). It was observed that the maximum use values were due to the higher number of use reports (URs) in the study area. e highest used values of documented therapeutic plants might indicate their indigenous professional expertise, which leads to a preference option for the disorder [71]. Medicinal plants with the lowest UV do not mean that they are not medicinally important, but it is shown that the traditional knowledge about these medicinal plants is limited [72].
erapeutic plants for which the use value (UV) is high due to their frequent distribution in the research area and the inhabitants are well known for their medicinal value [35].

Consensus Index (CI%).
e percentage of informants having traditional indigenous knowledge of medicinal plant species used for illness control (in this study, gynaecological disorders) was determined using a consensus index (CI%) [73], which indicates the citation by percent of informants [74]. e consensus index (CI) value ranges from 10.77% to 36.92% (Table 2). e maximum CI value was obtained for Acacia modesta (36.92%), followed by Cydonia oblonga (36.15%), Tecomella undulata, and Withania somnifera (35.38%). e lowest consensus index (CI) value was calculated for Ajuga parviflora (10.77%). CI indicates an agreement on the fact that Acacia modesta and Cydonia oblonga are the most important and well-known therapeutic plants used for the treatment of gynaecological disorders in North Waziristan. (FL%). Fidelity level (FL%) is used to determine the medicinal plant species that are most preferred by indigenous people for the cure of any specific ailment [46]. e therapeutic plants with the highest healing

Informant Consensus Factor (ICF).
e informant consensus factor (ICF) establishes the even sharing of informants' information regarding the medicinal plants, which validates that all the local people in the research area use plants for the treatment of the same ailment in same or different methods. In other words, the ICF value explains the cultural consistency in the use of a group of medicinal plants to treat a specific ailment [76]. To determine the informants' consensus factor (ICF), various diseases were grouped into 14 different disease categories based on taxa and use reports (Table 4). In this study, the ICF values ranged from 0.96 to 1.0. e highest ICF value was reported for emmenagogue and tonic after delivery (1.0), followed by antiseptic (0.99), and the lowest ICF value was reported for menstrual problems (0.96). Similar results were reported by [77] demonstrating that emmenagogue disorder has the highest ICF values.

Family Importance Value (FIV).
e family importance value increases with the increase in the frequency of citations of all species. In this work, the most important family, based on the frequency of citations, was Lamiaceae with an FIV value of 98.46%, followed by Rosaceae (93.85%), Apiaceae (86.92%), Solanaceae (86.15%), Asteraceae (76.92%), and Mimosaceae (75.38%). Convolvulaceae has the lowest family importance value, with 13.85% (Table 5).
Medicinally important plant species of the families Asteraceae, Apiaceae, Lamiaceae, and Rosaceae are mentioned as  Such flora need preservation through sustainable use, appropriate management, and conservation. A regional awareness campaign regarding the state of indigenous flora, sustainable plant harvesting, and the conservation of valuable therapeutic plants will lead to better outcomes. Local inhabitants, local stakeholders, and plant collectors should be aware of the conservation of plant resources in the region, and the indigenous people should be involved in conservation practices.

Novelty and Future Impacts.
is study was compared with previously published literature of neighbouring areas and distant areas of utilization of medicinal plants for ethnogynaecological disorders [18,[80][81][82][83][84][85][86]. e comparative study between previously reported medicinal plants showed that some medicinal plants have the same or different medicinal uses, while some were documented for the first time and others were not previously documented. e following 9 species were reported for the first time to cure gynaecological diseases: Acacia modesta (aphrodisiac), Cnicus benedictus (enhance milk flow), Cocculus pendulus (amenorrhea), Cydonia oblonga (leucorrhoea), Cyperus rotundus (enhance milk flow), Peganum harmala (antiseptic), Prunus domestica (vomiting), Tamarix aphylla (antiseptic), and Tecomella undulata (leucorrhoea) ( Table 2). Many ethnomedicinal studies have similar medicinal uses of therapeutic plants for the treatment of various ailments all over the globe. is study adds some new therapeutic plant uses, which may provide baseline data for phytochemical and pharmacological screening for the detection of new drugs in future studies. e discovery of drugs from therapeutic plants links an interdisciplinary approach to joining ethnomedicinal, pharmacological, botanical, and natural methods. However, any medicinal plants in this study area are not subjected to detailed pharmacological screenings.

Conclusion
is study focuses on pastoral women's health and healing. In rural areas, modern health facilities are insufficient or not available. Rural people (midwives, traditional healers) have indigenous knowledge of herbal remedies for treating gynaecological disorders. In the research area, 67 therapeutic plants are used to treat 26 different types of gynaecological disorders. Leaves are the dominant part used in the preparation of herbal remedies for gynaecological disorders. Menstrual problems were the most prevalent ailment category treated using 26 therapeutic plants in the study area. Decoction and powder were reported as the most commonly used methods for preparing herbal remedies, which clearly shows the consistency with other studies as well [53,54]. e highest use value was reported for Tecomella undulata (0.85), followed by Cydonia oblonga (0.81) and Withania somnifera (0.78). It was observed that the medicinal plants having maximum UV were due to their higher number of use reports (URs) in the study area. e literature reveals that the therapeutic plants with higher UV are because of their frequent distribution in the research area and the inhabitants are well known for their medicinal value [62], which leads them to be the preferred option for the particular ailment [59]. e cultural consistency in the use of a group of medicinal plants to treat a specific ailment group was explained using ICF [47], through which the consistency of our results was found in accordance with Sadeghi et al. [20]; they reported that emmenagogue disorder has the highest ICF values. Some medicinal plants, like Berberis lycium, Fritillaria imperialis, Gymnosporia nemorosa, Pistacia integerrima, and Tecomella undulata are under extreme pressure as a result of the indiscriminate collection by locals. We believe that forest protection and floral habitat conservation are critical. For this, the government and nongovernmental organizations (NGOs) must design appropriate programmes with the participation of local people who must be educated about the need to maintain precious forest resources and participate in forestation for future generations. is survey provides a baseline for future clinical and pharmacological studies in the field of gynecology. erefore, it is necessary to focus on the medicinal uses of the reported plants [48]. Detailed clinical and pharmacological trials are needed to find out the bioactive components for the treatment of the gynaecological disorder.
Data Availability e figures and tables supporting the results of this study are included within the article, and the original datasets are available from the first author or the corresponding author upon request.

Conflicts of Interest
e authors declare that there are no conflicts of interest in this article.