G Model
WOMBI-392; No. of Pages 6 Women and Birth xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUANTITATIVE
Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study Shih-Hsien Kuo a,e,f, Hsiao-Ling Wang b,f, Tzu-Chi Lee c, Te-Fu Chan d, Fan-Hao Chou e,*, Lih-Mih Chen e, Wei-Ting Lin e a
Department of Nutrition and Health Science, College of Health and Medical Science, Fooyin University, Kaohsiung City, Taiwan, ROC Department of Nursing, Tzu Hui Institute of Technology, Kaohsiung City, Taiwan, ROC Department of Public Health, Kaohsiung Medical University, Kaohsiung City, Taiwan, ROC d Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan, ROC e College of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan, ROC b c
A R T I C L E I N F O
Article history: Received 14 November 2014 Received in revised form 8 January 2015 Accepted 8 January 2015 Keywords: Constitution Traditional Chinese medicine Pregnancy Postpartum Women
A B S T R A C T
Background: Pregnancy is an important stage in life for many women. Humans are complex organisms that are prone to exhibiting gradual alterations in their constitutions that fluctuate with age, diet, and living environment. This is particularly true during the pre- and postnatal periods, in which qi and blood are required to ensure foetal growth. Aim: To examine women’s constitutional transformation of pre-pregnancy, pregnancy, and postpartum. Methods: A prospective, longitudinal study was conducted, and structural questionnaires were used to collect data. The participants were healthy pregnant women 21–49 years of age. Data were collected at six times: during the first (weeks 6–13), second (weeks 14–27), and third (weeks 28–40) trimesters and during the postnatal admission (1-week postnatal) and home self-care (6-week and 6-month postnatal) periods, yielding 86 valid questionnaires. A cubic polynomial regression analyses with generalised estimation equations (GEEs) method was used to reveal the trend of constitution score by different constitutions. Findings: Significant differences (p < .0001) for the scores of Yang-Xu (yang-deficiency), Yin-Xu (yindeficiency), and Tan-Shi-Yu-Zhi (phlegm-dampness and blood-stasis) constitutions were observed at pre-pregnancy, pregnancy, and 6 months postpartum. A least significant difference test showed that the scores obtained in the pregnancy period and at 6 months postpartum were higher than those of pre-pregnancy, indicating mitigated constitutional imbalance during postpartum. The highest scores of the Yang-Xu and Tan-Shi-Yu-Zhi constitutions occurred in the first trimester (36.02 8.00 vs. 30.00 7.21), and the highest scores of Yin-Xu constitution occurred in the third trimester (32.95 7.48). The lowest scores of the Yang-Xu constitution were obtained at 6 months postpartum (25.24 5.63) and during pre-pregnancy (25.26 4.82), and those of the Yin-Xu and Tan-Shi-Yu-Zhi constitutions were observed in the pre-pregnancy (25.48 4.46 vs. 19.94 3.09). The 6-month postnatal scores of the YangXu constitution nearly recovered to the prenatal level, whereas those of the other two constitutions did not. Conclusion: The results indicate that women’s constitutions underwent changes throughout the perinatal stages. These findings provide a valuable reference for healthcare professionals in administering perinatal care and demonstrate empirical evidence for use in future intervention-based research. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
* Corresponding author at: College of Nursing, Kaohsiung Medical University, No. 100, Shi-Chuan 1st Road, San Ming District, Kaohsiung City 80708, Taiwan, ROC. Tel.: +886 73121101; fax: +886 73218364. E-mail address: [email protected] (F.-H. Chou). f These authors contributed equally to this work. http://dx.doi.org/10.1016/j.wombi.2015.01.002
1871-5192/ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Kuo S-H, et al. Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.01.002
G Model
WOMBI-392; No. of Pages 6 2
S.-H. Kuo et al. / Women and Birth xxx (2015) xxx–xxx
1. Introduction Pregnancy is an important stage in life for many women. The physiological changes caused by foetal development (following postnatal adaptation) from newborn birth influence maternal physical health. Constitution, according to theories of traditional Chinese medicine (TCM), is defined as an individual characteristic in light of congenital heredity and acquired factors, which includes appearance, physical function and mental status.1 It demonstrates complex but stable characteristics in the morphological, structural, physical, and psychological dimensions. These characteristics can determine an individual’s susceptibility to disease and pathological tendencies.2 Data from the four diagnostic methods of Chinese medicine (including inspection, auscultation/olfaction, history taking and palpation) may be analysed according to Chinese medicine theories to arrive at a constitutional diagnosis, for example ‘Qi vacuity pattern’.3 Furthermore, humans are complex organisms that are prone to exhibiting gradual alterations in their constitutions following changes in age, diet, and living environment.4 Regarding pregnant women, theories of TCM have asserted that giving birth causes a deficiency in qi and blood causing them to be physically weak. Thus, postnatal women are prone to blood stasis and illness when exposed to either cold or dampness. In addition, qi/blood deficiency renders postnatal women susceptible to the common cold and other illnesses.5 Consequently, constitutional changes during the perinatal period are particularly important. During pregnancy, minor constitutional changes occur over time because of the need to replenish qi and blood, which ensure proper foetal growth.4 An ancient Chinese idiom states that women are inclined to fear cold during early pregnancy (which creates uncomfortable symptoms) but have adverse reactions to heat in the later pregnant stages. This implies that the constitution undergoes substantial changes during the stages of pregnancy. Wang6 reported significant differences in constitution before and after pregnancy, observing that the average scores from a constitutional scale increased during pregnancy. Nevertheless, little empirical research has addressed constitutional changes in relation to the perinatal period. Therefore, the aim of the study was to explore the constitutional changes that occur from pre-pregnancy, pregnancy, and postpartum to provide evidence-based data regarding perinatal constitutional changes. The study may thus be used as a reference for healthcare professionals in promoting maternal and child well-being. 2. Literature review Constitution is a unique physiological state that is formed based on a combination of influences (e.g., environment, sleep-wake cycle, and diet) during the physical development process.2 Yao et al.7 categorised constitution into nine types: balanced, qi-deficiency, yang-deficiency, yin-deficiency, phlegm-dampness, heat-dampness, blood-stasis, qi-stagnation, and inherited special constitutions. Some scholars have classified constitution into four types: susceptible to cold, water retention, weak energy, and poor digestive function,8 or into three categories: qi-stagnation, yang-abundance, and balanced.9 A balanced constitution is the ideal constitution, which exhibits a balance of yin-yang. The most common constitution is that of yang-deficiency.10 A person with a yang/qi deficiency (Yang-Xu) constitution exhibits reduced physical function and a myriad of symptoms, including fatigue, shortness of breath, soft stool, and polyuria.11 A yin/blood-deficiency (Yin-Xu) constitution is associated with increased thirst, hot flashes, hard stool, and oligouria.12 The symptoms of the phlegm-dampness and blood-stasis (Tan-Shi-YuZhi) constitutions include dizziness, chest tightness, and numbness in the lower extremities.13 Differences in constitution primarily stem from congenital factors (e.g., paternal and maternal contributions to fertilisation
and foetal development) or acquired influences (e.g., living environment, dietary habits, and societal circumstances).14 Huangdi Neijing, an ancient Chinese medical text, states that the constitution formed by paternal and maternal contributions is merely a foundation but remains unfixed and thus inclined to change based on a variety of influences in an acquired environment. These influential factors include heredity,15 age,8 gender,16 diet and nutrition,17 physical exertion,15 energy,18 geographic environment,19 and the current living environment.17 In other words, constitution is closely related to emotion and lifestyle. Regarding fertilisation, the maternal constitution determines the congenital constitution of the foetus; after birth, age and various acquired factors cause changes in the constitution and may lead to disease susceptibility during the various stages of life. A woman’s constitution changes during pregnancy because foetal growth and prenatal care require qi and blood. If the mother has a balanced constitution, the foetus is likely to have a normal development. Due to the placental connection between the foetus and mother, maternal organ’s yin-yang levels and flow of qi, blood, and body fluid can influence the constitution of the foetus.20 During pregnancy, a yin-deficiency constitution can cause bleeding and emotional instability of the mother and retarded foetal growth; a yang-deficiency constitution may lead to water retention in the lower extremities; and a blood-stasis constitution can cause discomfort, including abdominal pain and chest tightness.4,21 The research of Chen et al.22 indicated that mothers with a yang-deficiency constitution tend to experience abdominal pain, which leads to an increased risk of premature delivery. TCM suggests that the postnatal constitutions tend to result from a deficiency in blood and blood stasis. Specifically, a deficiency may result from the depletion of qi and blood during delivery that cannot properly be restored in a timely manner. Blood stasis results from the stagnation of blood flow during the late stages of pregnancy. In addition, the existence of lochia in the postpartum period may lead to stasis of blood, which may affect the evolution of the uterus and new blood cell production.23 A study by Wang et al.24 demonstrated that deficient-, cold-, or phlegm-dampness constitution mothers tend to give birth to deficient- or coldconstitution babies, whereas heat-dampness constitution mother tend to give birth to heat-dampness constitution babies. In conclusion, the body constitutions of the mother and baby are mutually influential. To give birth to a balanced constitution baby, it is important for the mother to properly nurse, which may lead to a reduced susceptibility to disease in the child. 3. Methods A prospective longitudinal study was conducted. Data were collected using structured questionnaires. Approval was obtained from the Institutional Review Board of Kaohsiung Medical University Hospital (KMUH-IRB-970397). Sampling was obtained at a medical centre in Southern Taiwan. All of the participants provided their signed written consent. The recruited participants included pregnant women 21–49 years of age,1,25 who presented with no systemic diseases, could communicate in Mandarin or Taiwanese, and were willing to participate in the study. Using established prenatal examination schedules (developed by the Ministry of Health and Welfare, Taiwan), data were collected at six times: prenatally during the first (weeks 6–13), second (weeks 14–27), and third (weeks 28–40) trimesters; following admission to the postnatal ward (within 1 week after delivery); and after discharge home (6 weeks and 6 months following delivery). Data were collected on site during the prenatal examination and postnatal hospitalisation periods. The questionnaires were mailed to the participants for completion after they returned home. Of the 93 questionnaires distributed, 7 were excluded because of
Please cite this article in press as: Kuo S-H, et al. Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.01.002
G Model
WOMBI-392; No. of Pages 6 S.-H. Kuo et al. / Women and Birth xxx (2015) xxx–xxx
miscarriage (4 participants) and loss of contact (3 participants), which yielded 86 valid questionnaires and a return rate of 92.5%.
3
also performed cubic polynomial regression analyses using the generalised estimation equation (GEE) method to show the trend of constitution scores by different constitutions.
4. Research instruments The variables in the study included demographic data and Traditional Chinese Medical Constitutional Scale (TCMCS). The demographic data were collected based on the study objectives, clinical experience, and a literature review and were evaluated for accuracy, relevance, and suitability by four experts. The TCMCS was developed by Su et al.26 and consists of three subscales to assess the Yang-Xu constitution (19 items), the Yin-Xu constitution (19 items), and the Tan-Shi-Yu-Zhi constitution (16 items). Because some of the items were shared by the subscales, the total number of items included in the scale was 44. This scale was developed and classified by the Delphi review, literature reviews, clinical experience, and qualitative interviews of the mothers. A 5-point Likert scale was used to score the constitution scale, where a high score indicated an imbalanced constitution. The validity and reliability of the TCMCS has been assessed in previous research regarding the prenatal constitution of women.27 The Cronbach’s a values for the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitution subscales have been reported as .83, .80, and .78, respectively (.90 [n = 235] for the entire scale). In the present study, the Cronbach’s a values for the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitution subscales were .82, .79, and .81, respectively (.92 [n = 86] for the entire scale). 5. Data analysis The SPSS statistical software (version 14.0) was used. Descriptive statistics were used to examine the demographic characteristics and constitution scores of the participants. Repeated measurements were performed to analyse the constitutional changes for each trimester and postpartum periods. Researchers
6. Results The average age of the 86 participants was 33.06 2.92, and nearly 60% were multipara (n = 50, 58.2%) and had no experience of miscarriage (n = 60, 69.8%). Most participants held a bachelor’s degree (n = 68, 79.1%) and were employed outside the home (n = 69, 80.2%). More than half of the women had a medium work load (n = 50, 58.1%). Most participants reported a pre-pregnancy bedtime after 11:00 p.m. (n = 58, 67.4%) and before 11:00 p.m. while pregnant (n = 57, 66.3%). The results of the t-tests and a one-way analysis of variance indicated no significant differences in the first trimester (recruiting time) constitution scores and demographics (Table 1) except employment status for the Tan-Shi-Yu-Zhi constitution score and perceived workload for the Yin-Xu constitution score. Table 2 shows the distribution of scores for the three constitutions. The highest score of the Yang-Xu constitution occurred in the first trimester (36.02 8.00), followed by the third trimester (34.45 8.61). The lowest score was during the postnatal 6-month period (25.24 5.63). Regarding the Yin-Xu constitution, the third trimester demonstrated the highest score (32.95 7.48), followed by the first trimester (32.14 7.03); the pre-pregnancy period demonstrated the lowest score (25.48 4.46). The highest score for the Tan-Shi-Yu-Zhi constitution was observed in the first trimester (30.00 7.21), whereas the lowest score occurred in the pre-pregnancy period (19.94 3.09). The trend of different constitution scores, based on the findings of the cubic polynomial regression analyses with GEE, is shown in Fig. 1. All three constitutions have a similar trend of constitution scores throughout the observed period and are consistent with the data in Table 2. Repeated measurements were performed using time as the x-axis to analyse changes in the three constitutions of before,
Table 1 Demographic characteristics of participants in the first trimester (N = 86).
x2/t
Tan-Shi-Yu-Zhi score
x2/t
n (%)
Yang-Xu score
Age (years) 21–34 35–48
54 (62.8) 32 (37.2)
35.65 7.93 36.66 8.19
.56
31.96 6.94 32.44 7.26
.30
23.19 5.30 24.91 5.77
.55
Education level I, III, V, VI, VII III > I, V, VI, VII IV > I, V, VI, VII V > I, VI, VII II > I, V, VI, VII III > I, V, VI, VII IV > I, III, V, VI, VII V > I; VI > I; VII > I II > I, III, V, VI, VII III > I, V, VI, VII IV > I, III, V, VI, VII V > I, VI, VII VI > I; VII > I
Note: I: pre-pregnancy; II: first trimester; III: second trimester; IV: third trimester; V: 1 week postpartum; VI: 6 weeks postpartum; VII: 6 months postpartum. * p < .0001.
Please cite this article in press as: Kuo S-H, et al. Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.01.002
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WOMBI-392; No. of Pages 6 S.-H. Kuo et al. / Women and Birth xxx (2015) xxx–xxx
5
Table 4 The difference of constitution scores among pre-pregnancy, pregnancy and postpartum. Yin-Xu
Yang-Xu t value Pre-pregnancy vs. first trimester Third trimester vs. 1 week postpartum 6 months postpartum vs. pre-pregnancy
16.33 8.93 .02
p value
WOMBI-392; No. of Pages 6 Women and Birth xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUANTITATIVE
Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study Shih-Hsien Kuo a,e,f, Hsiao-Ling Wang b,f, Tzu-Chi Lee c, Te-Fu Chan d, Fan-Hao Chou e,*, Lih-Mih Chen e, Wei-Ting Lin e a
Department of Nutrition and Health Science, College of Health and Medical Science, Fooyin University, Kaohsiung City, Taiwan, ROC Department of Nursing, Tzu Hui Institute of Technology, Kaohsiung City, Taiwan, ROC Department of Public Health, Kaohsiung Medical University, Kaohsiung City, Taiwan, ROC d Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan, ROC e College of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan, ROC b c
A R T I C L E I N F O
Article history: Received 14 November 2014 Received in revised form 8 January 2015 Accepted 8 January 2015 Keywords: Constitution Traditional Chinese medicine Pregnancy Postpartum Women
A B S T R A C T
Background: Pregnancy is an important stage in life for many women. Humans are complex organisms that are prone to exhibiting gradual alterations in their constitutions that fluctuate with age, diet, and living environment. This is particularly true during the pre- and postnatal periods, in which qi and blood are required to ensure foetal growth. Aim: To examine women’s constitutional transformation of pre-pregnancy, pregnancy, and postpartum. Methods: A prospective, longitudinal study was conducted, and structural questionnaires were used to collect data. The participants were healthy pregnant women 21–49 years of age. Data were collected at six times: during the first (weeks 6–13), second (weeks 14–27), and third (weeks 28–40) trimesters and during the postnatal admission (1-week postnatal) and home self-care (6-week and 6-month postnatal) periods, yielding 86 valid questionnaires. A cubic polynomial regression analyses with generalised estimation equations (GEEs) method was used to reveal the trend of constitution score by different constitutions. Findings: Significant differences (p < .0001) for the scores of Yang-Xu (yang-deficiency), Yin-Xu (yindeficiency), and Tan-Shi-Yu-Zhi (phlegm-dampness and blood-stasis) constitutions were observed at pre-pregnancy, pregnancy, and 6 months postpartum. A least significant difference test showed that the scores obtained in the pregnancy period and at 6 months postpartum were higher than those of pre-pregnancy, indicating mitigated constitutional imbalance during postpartum. The highest scores of the Yang-Xu and Tan-Shi-Yu-Zhi constitutions occurred in the first trimester (36.02 8.00 vs. 30.00 7.21), and the highest scores of Yin-Xu constitution occurred in the third trimester (32.95 7.48). The lowest scores of the Yang-Xu constitution were obtained at 6 months postpartum (25.24 5.63) and during pre-pregnancy (25.26 4.82), and those of the Yin-Xu and Tan-Shi-Yu-Zhi constitutions were observed in the pre-pregnancy (25.48 4.46 vs. 19.94 3.09). The 6-month postnatal scores of the YangXu constitution nearly recovered to the prenatal level, whereas those of the other two constitutions did not. Conclusion: The results indicate that women’s constitutions underwent changes throughout the perinatal stages. These findings provide a valuable reference for healthcare professionals in administering perinatal care and demonstrate empirical evidence for use in future intervention-based research. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
* Corresponding author at: College of Nursing, Kaohsiung Medical University, No. 100, Shi-Chuan 1st Road, San Ming District, Kaohsiung City 80708, Taiwan, ROC. Tel.: +886 73121101; fax: +886 73218364. E-mail address: [email protected] (F.-H. Chou). f These authors contributed equally to this work. http://dx.doi.org/10.1016/j.wombi.2015.01.002
1871-5192/ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Kuo S-H, et al. Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.01.002
G Model
WOMBI-392; No. of Pages 6 2
S.-H. Kuo et al. / Women and Birth xxx (2015) xxx–xxx
1. Introduction Pregnancy is an important stage in life for many women. The physiological changes caused by foetal development (following postnatal adaptation) from newborn birth influence maternal physical health. Constitution, according to theories of traditional Chinese medicine (TCM), is defined as an individual characteristic in light of congenital heredity and acquired factors, which includes appearance, physical function and mental status.1 It demonstrates complex but stable characteristics in the morphological, structural, physical, and psychological dimensions. These characteristics can determine an individual’s susceptibility to disease and pathological tendencies.2 Data from the four diagnostic methods of Chinese medicine (including inspection, auscultation/olfaction, history taking and palpation) may be analysed according to Chinese medicine theories to arrive at a constitutional diagnosis, for example ‘Qi vacuity pattern’.3 Furthermore, humans are complex organisms that are prone to exhibiting gradual alterations in their constitutions following changes in age, diet, and living environment.4 Regarding pregnant women, theories of TCM have asserted that giving birth causes a deficiency in qi and blood causing them to be physically weak. Thus, postnatal women are prone to blood stasis and illness when exposed to either cold or dampness. In addition, qi/blood deficiency renders postnatal women susceptible to the common cold and other illnesses.5 Consequently, constitutional changes during the perinatal period are particularly important. During pregnancy, minor constitutional changes occur over time because of the need to replenish qi and blood, which ensure proper foetal growth.4 An ancient Chinese idiom states that women are inclined to fear cold during early pregnancy (which creates uncomfortable symptoms) but have adverse reactions to heat in the later pregnant stages. This implies that the constitution undergoes substantial changes during the stages of pregnancy. Wang6 reported significant differences in constitution before and after pregnancy, observing that the average scores from a constitutional scale increased during pregnancy. Nevertheless, little empirical research has addressed constitutional changes in relation to the perinatal period. Therefore, the aim of the study was to explore the constitutional changes that occur from pre-pregnancy, pregnancy, and postpartum to provide evidence-based data regarding perinatal constitutional changes. The study may thus be used as a reference for healthcare professionals in promoting maternal and child well-being. 2. Literature review Constitution is a unique physiological state that is formed based on a combination of influences (e.g., environment, sleep-wake cycle, and diet) during the physical development process.2 Yao et al.7 categorised constitution into nine types: balanced, qi-deficiency, yang-deficiency, yin-deficiency, phlegm-dampness, heat-dampness, blood-stasis, qi-stagnation, and inherited special constitutions. Some scholars have classified constitution into four types: susceptible to cold, water retention, weak energy, and poor digestive function,8 or into three categories: qi-stagnation, yang-abundance, and balanced.9 A balanced constitution is the ideal constitution, which exhibits a balance of yin-yang. The most common constitution is that of yang-deficiency.10 A person with a yang/qi deficiency (Yang-Xu) constitution exhibits reduced physical function and a myriad of symptoms, including fatigue, shortness of breath, soft stool, and polyuria.11 A yin/blood-deficiency (Yin-Xu) constitution is associated with increased thirst, hot flashes, hard stool, and oligouria.12 The symptoms of the phlegm-dampness and blood-stasis (Tan-Shi-YuZhi) constitutions include dizziness, chest tightness, and numbness in the lower extremities.13 Differences in constitution primarily stem from congenital factors (e.g., paternal and maternal contributions to fertilisation
and foetal development) or acquired influences (e.g., living environment, dietary habits, and societal circumstances).14 Huangdi Neijing, an ancient Chinese medical text, states that the constitution formed by paternal and maternal contributions is merely a foundation but remains unfixed and thus inclined to change based on a variety of influences in an acquired environment. These influential factors include heredity,15 age,8 gender,16 diet and nutrition,17 physical exertion,15 energy,18 geographic environment,19 and the current living environment.17 In other words, constitution is closely related to emotion and lifestyle. Regarding fertilisation, the maternal constitution determines the congenital constitution of the foetus; after birth, age and various acquired factors cause changes in the constitution and may lead to disease susceptibility during the various stages of life. A woman’s constitution changes during pregnancy because foetal growth and prenatal care require qi and blood. If the mother has a balanced constitution, the foetus is likely to have a normal development. Due to the placental connection between the foetus and mother, maternal organ’s yin-yang levels and flow of qi, blood, and body fluid can influence the constitution of the foetus.20 During pregnancy, a yin-deficiency constitution can cause bleeding and emotional instability of the mother and retarded foetal growth; a yang-deficiency constitution may lead to water retention in the lower extremities; and a blood-stasis constitution can cause discomfort, including abdominal pain and chest tightness.4,21 The research of Chen et al.22 indicated that mothers with a yang-deficiency constitution tend to experience abdominal pain, which leads to an increased risk of premature delivery. TCM suggests that the postnatal constitutions tend to result from a deficiency in blood and blood stasis. Specifically, a deficiency may result from the depletion of qi and blood during delivery that cannot properly be restored in a timely manner. Blood stasis results from the stagnation of blood flow during the late stages of pregnancy. In addition, the existence of lochia in the postpartum period may lead to stasis of blood, which may affect the evolution of the uterus and new blood cell production.23 A study by Wang et al.24 demonstrated that deficient-, cold-, or phlegm-dampness constitution mothers tend to give birth to deficient- or coldconstitution babies, whereas heat-dampness constitution mother tend to give birth to heat-dampness constitution babies. In conclusion, the body constitutions of the mother and baby are mutually influential. To give birth to a balanced constitution baby, it is important for the mother to properly nurse, which may lead to a reduced susceptibility to disease in the child. 3. Methods A prospective longitudinal study was conducted. Data were collected using structured questionnaires. Approval was obtained from the Institutional Review Board of Kaohsiung Medical University Hospital (KMUH-IRB-970397). Sampling was obtained at a medical centre in Southern Taiwan. All of the participants provided their signed written consent. The recruited participants included pregnant women 21–49 years of age,1,25 who presented with no systemic diseases, could communicate in Mandarin or Taiwanese, and were willing to participate in the study. Using established prenatal examination schedules (developed by the Ministry of Health and Welfare, Taiwan), data were collected at six times: prenatally during the first (weeks 6–13), second (weeks 14–27), and third (weeks 28–40) trimesters; following admission to the postnatal ward (within 1 week after delivery); and after discharge home (6 weeks and 6 months following delivery). Data were collected on site during the prenatal examination and postnatal hospitalisation periods. The questionnaires were mailed to the participants for completion after they returned home. Of the 93 questionnaires distributed, 7 were excluded because of
Please cite this article in press as: Kuo S-H, et al. Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.01.002
G Model
WOMBI-392; No. of Pages 6 S.-H. Kuo et al. / Women and Birth xxx (2015) xxx–xxx
miscarriage (4 participants) and loss of contact (3 participants), which yielded 86 valid questionnaires and a return rate of 92.5%.
3
also performed cubic polynomial regression analyses using the generalised estimation equation (GEE) method to show the trend of constitution scores by different constitutions.
4. Research instruments The variables in the study included demographic data and Traditional Chinese Medical Constitutional Scale (TCMCS). The demographic data were collected based on the study objectives, clinical experience, and a literature review and were evaluated for accuracy, relevance, and suitability by four experts. The TCMCS was developed by Su et al.26 and consists of three subscales to assess the Yang-Xu constitution (19 items), the Yin-Xu constitution (19 items), and the Tan-Shi-Yu-Zhi constitution (16 items). Because some of the items were shared by the subscales, the total number of items included in the scale was 44. This scale was developed and classified by the Delphi review, literature reviews, clinical experience, and qualitative interviews of the mothers. A 5-point Likert scale was used to score the constitution scale, where a high score indicated an imbalanced constitution. The validity and reliability of the TCMCS has been assessed in previous research regarding the prenatal constitution of women.27 The Cronbach’s a values for the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitution subscales have been reported as .83, .80, and .78, respectively (.90 [n = 235] for the entire scale). In the present study, the Cronbach’s a values for the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitution subscales were .82, .79, and .81, respectively (.92 [n = 86] for the entire scale). 5. Data analysis The SPSS statistical software (version 14.0) was used. Descriptive statistics were used to examine the demographic characteristics and constitution scores of the participants. Repeated measurements were performed to analyse the constitutional changes for each trimester and postpartum periods. Researchers
6. Results The average age of the 86 participants was 33.06 2.92, and nearly 60% were multipara (n = 50, 58.2%) and had no experience of miscarriage (n = 60, 69.8%). Most participants held a bachelor’s degree (n = 68, 79.1%) and were employed outside the home (n = 69, 80.2%). More than half of the women had a medium work load (n = 50, 58.1%). Most participants reported a pre-pregnancy bedtime after 11:00 p.m. (n = 58, 67.4%) and before 11:00 p.m. while pregnant (n = 57, 66.3%). The results of the t-tests and a one-way analysis of variance indicated no significant differences in the first trimester (recruiting time) constitution scores and demographics (Table 1) except employment status for the Tan-Shi-Yu-Zhi constitution score and perceived workload for the Yin-Xu constitution score. Table 2 shows the distribution of scores for the three constitutions. The highest score of the Yang-Xu constitution occurred in the first trimester (36.02 8.00), followed by the third trimester (34.45 8.61). The lowest score was during the postnatal 6-month period (25.24 5.63). Regarding the Yin-Xu constitution, the third trimester demonstrated the highest score (32.95 7.48), followed by the first trimester (32.14 7.03); the pre-pregnancy period demonstrated the lowest score (25.48 4.46). The highest score for the Tan-Shi-Yu-Zhi constitution was observed in the first trimester (30.00 7.21), whereas the lowest score occurred in the pre-pregnancy period (19.94 3.09). The trend of different constitution scores, based on the findings of the cubic polynomial regression analyses with GEE, is shown in Fig. 1. All three constitutions have a similar trend of constitution scores throughout the observed period and are consistent with the data in Table 2. Repeated measurements were performed using time as the x-axis to analyse changes in the three constitutions of before,
Table 1 Demographic characteristics of participants in the first trimester (N = 86).
x2/t
Tan-Shi-Yu-Zhi score
x2/t
n (%)
Yang-Xu score
Age (years) 21–34 35–48
54 (62.8) 32 (37.2)
35.65 7.93 36.66 8.19
.56
31.96 6.94 32.44 7.26
.30
23.19 5.30 24.91 5.77
.55
Education level I, III, V, VI, VII III > I, V, VI, VII IV > I, V, VI, VII V > I, VI, VII II > I, V, VI, VII III > I, V, VI, VII IV > I, III, V, VI, VII V > I; VI > I; VII > I II > I, III, V, VI, VII III > I, V, VI, VII IV > I, III, V, VI, VII V > I, VI, VII VI > I; VII > I
Note: I: pre-pregnancy; II: first trimester; III: second trimester; IV: third trimester; V: 1 week postpartum; VI: 6 weeks postpartum; VII: 6 months postpartum. * p < .0001.
Please cite this article in press as: Kuo S-H, et al. Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.01.002
G Model
WOMBI-392; No. of Pages 6 S.-H. Kuo et al. / Women and Birth xxx (2015) xxx–xxx
5
Table 4 The difference of constitution scores among pre-pregnancy, pregnancy and postpartum. Yin-Xu
Yang-Xu t value Pre-pregnancy vs. first trimester Third trimester vs. 1 week postpartum 6 months postpartum vs. pre-pregnancy
16.33 8.93 .02
p value
