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Traditional Chinese medicine perspective on constitution transformations in perinatal women: A prospective longitudinal study
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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
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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
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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
18 (20.9) 68 (79.1)
35.83 7.16 36.07 8.25
.11
32.33 7.05 32.09 7.07
.13
22.17 4.61 24.26 5.37
.81
Employment status Employed Unemployed
69 (80.2) 17 (19.8)
35.28 7.42 39.06 9.66
1.77
31.54 6.36 34.59 9.08
1.62
29.25 6.50 33.06 9.20
1.99*
Parity Primipara Multipara
36 (41.9) 50 (58.2)
36.65 8.91 30.00 6.08
1.27
33.00 7.75 27.00 6.08
1.31
23.22 4.54 24.26 6.12
.82
Delivery type Vaginal delivery Caesarean section
44 (67.7) 21 (32.3)
36.32 7.97 35.86 8.30
.22
31.32 7.36 34.43 6.45
1.66
23.39 5.53 25.24 4.91
.57
Planned pregnancy No Yes
31 (36.5) 54 (63.5)
35.48 7.56 36.26 8.30
.43
32.23 6.74 31.96 7.25
.17
23.77 5.80 23.94 5.40
.52
Exercise regularly No Yes
70 (81.4) 16 (18.6)
35.79 7.85 36.00 7.98
.10
32.03 7.25 32.13 6.00
.05
23.74 5.63 24.19 5.13
.21
Perceived workload Mild Medium Excessive
27 (31.4) 50 (58.1) 9 (10.5)
37.11 8.86 35.34 7.97 36.56 5.32
.45
34.41 8.38 30.82 6.43 32.67 3.91
2.39*
24.33 6.46 23.18 4.81 25.89 6.07
.98
*
Yin-Xu score
x2/t
Items
p < .05.
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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Table 2 The transformation of constitution scores through pre-pregnancy, pregnancy and postpartum. Weeks
Trimesters/postpartum
Pre-pregnancy The first trimester The second trimester The third trimester Postpartum 1 week Postpartum 6 weeks Postpartum 6 months
0 10 20 30 43 49 66
Yang-Xu scores
Yin-Xu scores
Tan-Shi-Yu-Zhi scores
Mean SD
Mean SD
Mean SD
25.26 4.82 36.02 8.00 33.40 7.83 34.45 8.61 27.22 6.05 25.67 4.74 25.24 5.63
25.48 4.46 32.14 7.03 31.59 7.03 32.95 7.48 28.30 6.52 27.78 5.32 27.41 6.43
19.94 3.09 30.00 7.21 27.76 7.70 29.59 8.27 23.83 5.51 22.57 4.64 22.12 5.28
Fig. 1. The constitutional transformation from pre-pregnancy (0 week), pregnancy to 6 months postpartum.
during pregnancy, and 6 months postpartum (n = 86). The results indicated that significant changes occurred for all three constitutions (p < .0001). A least significant difference test was conducted for posthoc comparison and indicated that the pre- and postnatal
6-month scores were higher than those in the pre-pregnancy scores (for all three constitutions). Regarding the Yang-Xu constitution, the scores obtained at all three trimesters were higher than those obtained at postpartum. Notably, the 1-week postnatal score was higher compared with the 6-week and 6month postnatal scores, indicating that constitution imbalance improved following delivery. Regarding the Yin-Xu constitution, the scores for all three trimesters were higher than the postnatal scores. Furthermore, the third-trimester score was higher than the second-trimester score, and the postnatal scores were higher than the pre-pregnancy scores. These results suggested that the Yin-Xu constitution was exacerbated by pregnancy and improved after delivery; it was not, however, entirely restored at 6 months postpartum. The first and third trimester Tan-Shi-Yu-Zhi constitution scores were significantly higher than the second-trimester and postnatal scores. In addition, the second-trimester score was higher than the postnatal scores; the 1-week postnatal score was higher than the 6-week and 6-month postnatal scores. These results indicate that the Tan-Shi-Yu-Zhi constitution was more imbalanced during the first and third trimesters compared with other perinatal periods. The Tan-Shi-Yu-Zhi constitution improved substantially following delivery (Table 3). The differences over time were analysed using the trends in constitutional change (Table 2). The paired t-test analysis indicated that all three constitutional scores exhibited significant differences between pre-pregnancy and the first trimester and between the third trimester and the first postnatal week. In addition, the lowest scores were during the postnatal 6-month period (25.24 5.63) and the pre-pregnancy period (25.26 4.82) for the Yang-Xu constitution. It showed no significant difference between the pre-pregnancy and 6-month postpartum periods, suggesting that the Yang-Xu constitution scores of the 6-month postpartum period were similar to the pre-pregnancy scores. The remaining two constitutions did not demonstrate this phenomenon (Table 4).
Table 3 Repeated measurement of the three constitutions from pre-pregnancy, pregnancy to 6 months postpartum (N = 86). Constitutions
Sum of the squares (SS)
Degree of freedom (df)
Mean square (MS)
F-Value
Yang-Xu Within subjects Between subjects Residual
11646.15 2237.29 10918.42
6 84 504
1941.03 26.63 21.66
89.60*
Yin-Xu Within subjects Between subjects Residual
4002.43 14750.16 9494.99
6 84 504
667.07 175.60 18.84
35.41*
Tan-Shi-Yu-Zhi Within subjects Between subjects Residual
7907.15 13604.80 9194.28
6 84 504
1317.86 161.96 18.24
72.24*
LSD II > 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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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 <.001 <.001 .98
7. Discussion The results of this study demonstrate that the average scores of the 86 participants obtained during pregnancy and the 6-month postpartum period for all three constitutions (Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi) were all higher than the pre-pregnancy scores. In addition, the scores of the three trimesters were higher than those of the postnatal scores, demonstrating the changing patterns in perinatal constitutions. Pregnant women tend to exhibit Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions. One possible reason may be because qi and blood are the critically important in women during their prenatal care and delivery periods.28 Thus, women tend to have deficient constitutions during pregnancy. The results of this study were consistent with the results of those of Zeng’s study,4 which demonstrated that qi and blood are needed to provide prenatal care during pregnancy. The blood of a pregnant woman is critical for ensuring the health of the foetus.23 An imbalance in the mother’s liver or spleen may yield minor changes in the constitution as the foetus develops.4 Wang6 found that the scores of the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions significantly increased in the first trimester compared with those of pre-pregnancy, which indicated that prenatal women tend to present with deficiency-type constitutions. These results are consistent with the results of the present study. However, Wang6 did not examine the changes in consecutive trimesters for each participant. The present study, conversely, is a longitudinal study designed to comprehensively collect empirical data for each woman during all three trimesters. In this study, the highest scores of the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions occurred during the first trimester (36.02 8.00), third trimester (32.95 7.48), and first trimester (30.00 7.21), respectively. All three constitutions demonstrated the lowest scores at pre-pregnancy (25.26, 25.48, and 19.94, respectively). These outcomes are consistent with that of Wang,6 who reported an average score of 34.87 for the Yang-Xu constitution during the first trimester. The Yang-Xu constitution was also the highest score for the first trimester. The pre-pregnancy scores obtained in the present study matched closely to those of Wang et al.,27 who reported average scores of 25.25, 25.27, and 19.98 for the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions, respectively. In addition, the scores for the Yin-Xu constitutions obtained during all three trimesters were higher than the pre-pregnancy scores, indicating that the prenatal constitutions were inclined towards Yin-Xu. This phenomenon conforms with the Western medical principle that the physiological anaemia that occurs during pregnancy is the result of an increase in blood plasma during pregnancy, resulting in a reduced average haemoglobin level to approximately 7%.29 Our study results also indicated that the Tan-Shi-Yu-Zhi constitution was more imbalanced during the first and third trimesters compared with other perinatal periods. This phenomenon is consistent with the common symptoms of frequent urination during the first trimester and oedema of the limbs during the third trimester because of Kidney-Xu or weakness of the Spleen-Stomach resulting in poor circulation and stasis, according to TCM theories.23 The study results also indicated that the average 1-week postnatal scores were lower than the third-trimester scores for all three constitutions, indicating improvement in constitutional
t value 11.64 6.31 3.06
Tan-Shi-Yu-Zhi p value <.001 <.001 .003
t value 15.13 7.93 4.35
p value <.001 <.001 <.001
imbalance. This outcome may be attributed to the participants practicing traditional Chinese customs of ‘‘doing the month’’ for postnatal care. Based on the belief that exposure to cold and dampness induces qi and blood deficiencies and sickness, women should refrain from contact with cold water and hair washing. In addition, postnatal women are forbidden from consuming raw or cold foods. Instead, they are encouraged to consume warm foods29 that are believed to replenish the blood and improve stasis.31 Examples include ‘‘Sheng-Hwa-Tang’’ (a concoction of Chinese herbs) for tonic blood and qi, sesame oil chicken stew, and Eucommia. Constitutional imbalances can be alleviated using a combination of dietary and behavioural adjustments. The results of our research indicate that the Yang-Xu constitution may be restored to the near pre-pregnancy state at the 6-month postpartum period. However, we found that the Yin-Xu and Tan-Shi-Yu-Zhi constitutions were not fully restored to pre-pregnancy levels at 6 months postpartum. Future research involving a 1- to 2-year (or more) follow-up should be conducted to further examine the comprehensive transformation in constitution.
8. Conclusion We conducted a prospective, longitudinal study to examine the transformation of perinatal constitution. The results indicated that women’s constitution varied before and after pregnancy; specifically, their constitution was more imbalanced during pregnancy than it was before pregnancy and demonstrated a gradual recovery pattern from pregnancy to postpartum. The average scores for the Yang-Xu and Tan-Shi-Yu-Zhi constitutions were highest in the first trimester, whereas the highest score for the Yin-Xu constitution was obtained in the third trimester. From the perspectives of time as a main axis, all three constitutions exhibited significant differences from pre-pregnancy to the 6 months postpartum. Regarding constitution as the basis of temporal comparison, only the average 1-week postnatal score for the Yin-Xu constitution was higher than those of the Yang-Xu and Tan-Shi-Yu-Zhi constitutions. These findings may be a valuable reference for healthcare professionals in providing perinatal care and as empirical evidence for use in future intervention-based research. A limitation of this study is that this research only focused on three constitutions (Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi) during the perinatal transformation. Future studies need to further explore other constitutions, including heat-dampness, qi-stagnation, and balanced constitutions. Another potential limitation of our study is that the basis of constitutional typing used in this research is a questionnaire although it has good reliability (Cronbach’s a = .9027–.92). Future research could combine questionnaires with the four diagnostic methods (including inspection, auscultation/ olfaction, history taking, and palpation) or Skin Response Measurement Device (MEAD). Hormones change following pregnancy, and each trimester may have different uncomfortable symptoms. Research regarding the exploration of relationships among various constitutions and different uncomfortable symptoms should also be explored. Furthermore, it is possible that some women’s diet changed and may have contributed to their constitution transformation during and after pregnancy. Studies
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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regarding the correlation between constitutions and diet could be explored in the future. Conflict of interest The authors report no conflict of interest. Acknowledgement This study was funded by the National Science Council of Taiwan (Grants NSC 98-2314-B-037-056-MY2). References 1. Tang W, Wang J, Hu JP, Wang YH, Han XX. An investigation of ‘‘determination and treatment’’ for clinical practice. Chin Arch Tradit Chin Med 2005;23(12):2181–3. 2. Liu CL, Guo JC, Xun YH. Progress of constitutional theory in traditional Chinese medicine. J Zhejiang Univ Tradit Chin Med 2009;33(1):138–9. 3. Su YC. The study of the classic literature in Chinese medicine for constitutional enhancement. The committee on Chinese Medicine Pharmacy, Department of Health, Executive Yuan. 2006. 4. Zeng SH. A little experience in syndrome differentiation of Jin Kui Yao Lue. Guid J Tradit Chin Med Pharmacol 2005;11(12):10–5. 5. Pi KW. Chinese Medicine diet in doing the month. Basic training program in traditional Chinese medicine nursing. Symposium at the meeting of the Taiwan Traditional Chinese Medicine Nurses Association. 2007. 6. Wang HL. Relationships between constitution and uncomfortable symptoms of first trimester for pregnant women. [Unpublished master’s thesis] Taiwan, ROC: Kaohsiung Medical University; 2008. 7. Yao SL, Zhang ZZ, Yang XS, Xu X, Cao J, Xie GY, et al. Analysis of composite traditional Chinese medicine constitution: an investigation of 974 volunteers. J Chin Integr Med 2012;10(5):508–15. 8. Peng TC, Lee MS. Establishment and development scales of the yin element in women’s bodies in Chinese medicine. J Health Sci 2001;3(4):315–29. 9. Wu HY, Hsu CH, Deng SM, Hu WL, Hung YC. To analyze the factors of constitutions of shift nurses. J Chin Med 2012;23(1):73–82. 10. Li J, Wu CY, Luo WB, Wang NN, Xu Z. Study on the relationship between Yang deficiency constitution and diseases. Liaoning J Tradit Chin Med 2008;36(8): 1161–2. 11. Su YC. Body constitution questionnaire in traditional Chinese medicine and establishment of staging indicators [book one]. Annu Rep Tradit Chin Med 2007;25(5):45–144.
12. Lin JD, Chen LL, Lin JS, Chang CH, Huang YC, Su YC. BCQ : a body constitution questionnaire to assess Yin-Xu part 1: establishment of a provisional version through a Delphi process. Forsch Komplementmed 2012;19(5):234–41. 13. Lin JD, Lin JS, Chen LL, Chang CH, Huang YC, Su YC. BCQs: a body constitution questionnaire to assess stasis in traditional Chinese medicine. Eur J Integr Med 2012;4(4):379–91. 14. Wang Q. A study of three constitutional key issues in traditional Chinese medicine [book one]. J Tradit Chin Med 2006;47(4):250–2. 15. Sun Y. Exploring the constitution and the pattern identification in traditional Chinese medicine. Hebei J Tradit Chin Med 2006;28(8):626–7. 16. Wang L. A study on constitutional characteristic differences between men and women. Chin J Basic Med Tradit Chin Med 1998;2:7–9. 17. Lu MY. Relationship between evolution of human constitution and modern life-style. J Shandong Univ Tradit Chin Med 2002;26(1):48–52. 18. Li DT. The forming factors of Qi deficiency. J Basic Med Tradit Chin Med 1998;4(9):8–10. 19. Chen TY, Chuang HT. The new interpretation about Suwen in Huang Di Nei Jing. Taipei City, Taiwan, ROC: The National Research Institute of Chinese Medicine; 1995. 20. Wang XH, Xu LR, Luo W. Prevention from diseases in pregnancy and the relationship between eugenics and circumstance. Tradit Chin Med Res 2003;16(4):4–5. 21. Chen HZ, Zeng ZM. A study of the constitution type and the clinical significance in women. Guangxi J Tradit Chin Med 1988;11(1):15–7. 22. Chen BY, Zeng L, Zhao Y. An association study of uterine cramping and the constitution of pregnant women in traditional Chinese medicine. Jiangsu J Tradit Chin Med 2012;44(3):27–8. 23. Lo YK, Tseng CK, Liu MJ, Chia KC, Mao MJ, Chang YC. Gynecology of traditional Chinese medicine. Taipei City, Taiwan, ROC: J-Yin; 1996. 24. Wang JS, Li YD, Cui JP, Li JG. An association study about the constitution of mother–infant. Chin Arch Tradit Chin Med 2006;24(11):2100–1. 25. Zhu TY. 100 cases of traditional Chinese medicine constitution. J Chengdu Univ TCM 1996;19(4):48–50. 26. Su YC, Chen LL, Lin JD, Lin JS, Huang YC, Lai JS. BCQ+: a body constitution questionnaire to assess Yang-Xu part 1: establishment of a first final version through a Delphi process. Forsch Komplementmed 2008;15(6):327–34. 27. Wang HL, Chen LL, Su YC, Chen LM, Lin LC, Chou FH. Relationship between pre-pregnancy constitution and discomfort in the first trimester. J Nurs Healthc Res 2010;6(1):3–12. 28. Pan PG, Pan BQ, Huang M, Yu L. Exploration of the spleen and stomach theory and constitutional healthcare in pregnant women. New J Tradit Chin Med 2006;38(10):8–9. 29. Hung LC, Lin LH, Chen CW, Wang SF, Wu HL, Wang HL, et al. Maternal-newborn nursing. 1st ed. Taipei City, Taiwan, ROC: Yeong Dah; 2013. 31. Yu CY, Yang YO, Chin CC. Multiple viewpoints in ‘‘Doing the Month’’. Chang Gung Nurs 2010;21(4):451–6.
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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.
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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
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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
18 (20.9) 68 (79.1)
35.83 7.16 36.07 8.25
.11
32.33 7.05 32.09 7.07
.13
22.17 4.61 24.26 5.37
.81
Employment status Employed Unemployed
69 (80.2) 17 (19.8)
35.28 7.42 39.06 9.66
1.77
31.54 6.36 34.59 9.08
1.62
29.25 6.50 33.06 9.20
1.99*
Parity Primipara Multipara
36 (41.9) 50 (58.2)
36.65 8.91 30.00 6.08
1.27
33.00 7.75 27.00 6.08
1.31
23.22 4.54 24.26 6.12
.82
Delivery type Vaginal delivery Caesarean section
44 (67.7) 21 (32.3)
36.32 7.97 35.86 8.30
.22
31.32 7.36 34.43 6.45
1.66
23.39 5.53 25.24 4.91
.57
Planned pregnancy No Yes
31 (36.5) 54 (63.5)
35.48 7.56 36.26 8.30
.43
32.23 6.74 31.96 7.25
.17
23.77 5.80 23.94 5.40
.52
Exercise regularly No Yes
70 (81.4) 16 (18.6)
35.79 7.85 36.00 7.98
.10
32.03 7.25 32.13 6.00
.05
23.74 5.63 24.19 5.13
.21
Perceived workload Mild Medium Excessive
27 (31.4) 50 (58.1) 9 (10.5)
37.11 8.86 35.34 7.97 36.56 5.32
.45
34.41 8.38 30.82 6.43 32.67 3.91
2.39*
24.33 6.46 23.18 4.81 25.89 6.07
.98
*
Yin-Xu score
x2/t
Items
p < .05.
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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Table 2 The transformation of constitution scores through pre-pregnancy, pregnancy and postpartum. Weeks
Trimesters/postpartum
Pre-pregnancy The first trimester The second trimester The third trimester Postpartum 1 week Postpartum 6 weeks Postpartum 6 months
0 10 20 30 43 49 66
Yang-Xu scores
Yin-Xu scores
Tan-Shi-Yu-Zhi scores
Mean SD
Mean SD
Mean SD
25.26 4.82 36.02 8.00 33.40 7.83 34.45 8.61 27.22 6.05 25.67 4.74 25.24 5.63
25.48 4.46 32.14 7.03 31.59 7.03 32.95 7.48 28.30 6.52 27.78 5.32 27.41 6.43
19.94 3.09 30.00 7.21 27.76 7.70 29.59 8.27 23.83 5.51 22.57 4.64 22.12 5.28
Fig. 1. The constitutional transformation from pre-pregnancy (0 week), pregnancy to 6 months postpartum.
during pregnancy, and 6 months postpartum (n = 86). The results indicated that significant changes occurred for all three constitutions (p < .0001). A least significant difference test was conducted for posthoc comparison and indicated that the pre- and postnatal
6-month scores were higher than those in the pre-pregnancy scores (for all three constitutions). Regarding the Yang-Xu constitution, the scores obtained at all three trimesters were higher than those obtained at postpartum. Notably, the 1-week postnatal score was higher compared with the 6-week and 6month postnatal scores, indicating that constitution imbalance improved following delivery. Regarding the Yin-Xu constitution, the scores for all three trimesters were higher than the postnatal scores. Furthermore, the third-trimester score was higher than the second-trimester score, and the postnatal scores were higher than the pre-pregnancy scores. These results suggested that the Yin-Xu constitution was exacerbated by pregnancy and improved after delivery; it was not, however, entirely restored at 6 months postpartum. The first and third trimester Tan-Shi-Yu-Zhi constitution scores were significantly higher than the second-trimester and postnatal scores. In addition, the second-trimester score was higher than the postnatal scores; the 1-week postnatal score was higher than the 6-week and 6-month postnatal scores. These results indicate that the Tan-Shi-Yu-Zhi constitution was more imbalanced during the first and third trimesters compared with other perinatal periods. The Tan-Shi-Yu-Zhi constitution improved substantially following delivery (Table 3). The differences over time were analysed using the trends in constitutional change (Table 2). The paired t-test analysis indicated that all three constitutional scores exhibited significant differences between pre-pregnancy and the first trimester and between the third trimester and the first postnatal week. In addition, the lowest scores were during the postnatal 6-month period (25.24 5.63) and the pre-pregnancy period (25.26 4.82) for the Yang-Xu constitution. It showed no significant difference between the pre-pregnancy and 6-month postpartum periods, suggesting that the Yang-Xu constitution scores of the 6-month postpartum period were similar to the pre-pregnancy scores. The remaining two constitutions did not demonstrate this phenomenon (Table 4).
Table 3 Repeated measurement of the three constitutions from pre-pregnancy, pregnancy to 6 months postpartum (N = 86). Constitutions
Sum of the squares (SS)
Degree of freedom (df)
Mean square (MS)
F-Value
Yang-Xu Within subjects Between subjects Residual
11646.15 2237.29 10918.42
6 84 504
1941.03 26.63 21.66
89.60*
Yin-Xu Within subjects Between subjects Residual
4002.43 14750.16 9494.99
6 84 504
667.07 175.60 18.84
35.41*
Tan-Shi-Yu-Zhi Within subjects Between subjects Residual
7907.15 13604.80 9194.28
6 84 504
1317.86 161.96 18.24
72.24*
LSD II > 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.
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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 <.001 <.001 .98
7. Discussion The results of this study demonstrate that the average scores of the 86 participants obtained during pregnancy and the 6-month postpartum period for all three constitutions (Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi) were all higher than the pre-pregnancy scores. In addition, the scores of the three trimesters were higher than those of the postnatal scores, demonstrating the changing patterns in perinatal constitutions. Pregnant women tend to exhibit Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions. One possible reason may be because qi and blood are the critically important in women during their prenatal care and delivery periods.28 Thus, women tend to have deficient constitutions during pregnancy. The results of this study were consistent with the results of those of Zeng’s study,4 which demonstrated that qi and blood are needed to provide prenatal care during pregnancy. The blood of a pregnant woman is critical for ensuring the health of the foetus.23 An imbalance in the mother’s liver or spleen may yield minor changes in the constitution as the foetus develops.4 Wang6 found that the scores of the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions significantly increased in the first trimester compared with those of pre-pregnancy, which indicated that prenatal women tend to present with deficiency-type constitutions. These results are consistent with the results of the present study. However, Wang6 did not examine the changes in consecutive trimesters for each participant. The present study, conversely, is a longitudinal study designed to comprehensively collect empirical data for each woman during all three trimesters. In this study, the highest scores of the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions occurred during the first trimester (36.02 8.00), third trimester (32.95 7.48), and first trimester (30.00 7.21), respectively. All three constitutions demonstrated the lowest scores at pre-pregnancy (25.26, 25.48, and 19.94, respectively). These outcomes are consistent with that of Wang,6 who reported an average score of 34.87 for the Yang-Xu constitution during the first trimester. The Yang-Xu constitution was also the highest score for the first trimester. The pre-pregnancy scores obtained in the present study matched closely to those of Wang et al.,27 who reported average scores of 25.25, 25.27, and 19.98 for the Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions, respectively. In addition, the scores for the Yin-Xu constitutions obtained during all three trimesters were higher than the pre-pregnancy scores, indicating that the prenatal constitutions were inclined towards Yin-Xu. This phenomenon conforms with the Western medical principle that the physiological anaemia that occurs during pregnancy is the result of an increase in blood plasma during pregnancy, resulting in a reduced average haemoglobin level to approximately 7%.29 Our study results also indicated that the Tan-Shi-Yu-Zhi constitution was more imbalanced during the first and third trimesters compared with other perinatal periods. This phenomenon is consistent with the common symptoms of frequent urination during the first trimester and oedema of the limbs during the third trimester because of Kidney-Xu or weakness of the Spleen-Stomach resulting in poor circulation and stasis, according to TCM theories.23 The study results also indicated that the average 1-week postnatal scores were lower than the third-trimester scores for all three constitutions, indicating improvement in constitutional
t value 11.64 6.31 3.06
Tan-Shi-Yu-Zhi p value <.001 <.001 .003
t value 15.13 7.93 4.35
p value <.001 <.001 <.001
imbalance. This outcome may be attributed to the participants practicing traditional Chinese customs of ‘‘doing the month’’ for postnatal care. Based on the belief that exposure to cold and dampness induces qi and blood deficiencies and sickness, women should refrain from contact with cold water and hair washing. In addition, postnatal women are forbidden from consuming raw or cold foods. Instead, they are encouraged to consume warm foods29 that are believed to replenish the blood and improve stasis.31 Examples include ‘‘Sheng-Hwa-Tang’’ (a concoction of Chinese herbs) for tonic blood and qi, sesame oil chicken stew, and Eucommia. Constitutional imbalances can be alleviated using a combination of dietary and behavioural adjustments. The results of our research indicate that the Yang-Xu constitution may be restored to the near pre-pregnancy state at the 6-month postpartum period. However, we found that the Yin-Xu and Tan-Shi-Yu-Zhi constitutions were not fully restored to pre-pregnancy levels at 6 months postpartum. Future research involving a 1- to 2-year (or more) follow-up should be conducted to further examine the comprehensive transformation in constitution.
8. Conclusion We conducted a prospective, longitudinal study to examine the transformation of perinatal constitution. The results indicated that women’s constitution varied before and after pregnancy; specifically, their constitution was more imbalanced during pregnancy than it was before pregnancy and demonstrated a gradual recovery pattern from pregnancy to postpartum. The average scores for the Yang-Xu and Tan-Shi-Yu-Zhi constitutions were highest in the first trimester, whereas the highest score for the Yin-Xu constitution was obtained in the third trimester. From the perspectives of time as a main axis, all three constitutions exhibited significant differences from pre-pregnancy to the 6 months postpartum. Regarding constitution as the basis of temporal comparison, only the average 1-week postnatal score for the Yin-Xu constitution was higher than those of the Yang-Xu and Tan-Shi-Yu-Zhi constitutions. These findings may be a valuable reference for healthcare professionals in providing perinatal care and as empirical evidence for use in future intervention-based research. A limitation of this study is that this research only focused on three constitutions (Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi) during the perinatal transformation. Future studies need to further explore other constitutions, including heat-dampness, qi-stagnation, and balanced constitutions. Another potential limitation of our study is that the basis of constitutional typing used in this research is a questionnaire although it has good reliability (Cronbach’s a = .9027–.92). Future research could combine questionnaires with the four diagnostic methods (including inspection, auscultation/ olfaction, history taking, and palpation) or Skin Response Measurement Device (MEAD). Hormones change following pregnancy, and each trimester may have different uncomfortable symptoms. Research regarding the exploration of relationships among various constitutions and different uncomfortable symptoms should also be explored. Furthermore, it is possible that some women’s diet changed and may have contributed to their constitution transformation during and after pregnancy. Studies
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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