5.1 Research limitation
In this project, two main factors limited the application of results: one related to research subject, another related to research tool. The research subject of this tool were 39 Chinese medical Gynecologists, who were affiliated with Teaching Hospital. The level of the doctors‘ proficiency assured the quality of collected the data, however there may be some biases in the respondents answers: Firstly, the respondents relied mostly on their clinical experience in understanding ―Zuo Yuezi‖. Thus, their understanding of ―Zuo Yuezi‖ phenomenon relied on their patient‘s characteristics. If the patient‘s population was not representative (for example, represents wealth, urban women)- then the bias might have appeared. Second, the third part of the questionnaire is a selection of 69 of over 200 ―Zuo Yuezi‖ tradition elements. During the selection process, some similar elements, like ―consuming sesame chicken‖ and ―consuming sesame chicken soup‖ were merged. Into one element. This process eased the questionnaire filling and data analysis, however due to this process, some level of precision have been lost.It cannot be ruled out then, that some important fifferences between elements had not been discovered and thus the questionnaire did not reflect the whole image of ―Zuo Yuezi‖ behavior.
5.2 Analysis of research subject- Respondents- and discussion.
The research subject in this research were Chinese medical Gynecologists. In Taiwan legal system, however there is no distinction between ―general‖ Chinese medical doctors and those who specialize in gynecology, as there is only one title for all. Thus, another sampling method had to be adapted in this case. This group was selected from the Doctors, affiliated with Teaching Hospitals in Taiwan, members of Committee of
Chinese Medicine and Pharmacy in Department of Health of Executive Yuan. Such sampling method guarantees that the respondents are highly scored and experienced clinicians, and increase the precision of research.
The age of respondents enclosed in a range between 28 and 64 years, with average age 42 years. Only 15.4% of respondents were older than 52 years. This is rather low
128
score, comparing with the score for total population of Taiwan Chinese medical doctors55, where 43.38%of them was 50 years old or older. This group of Chinese medical doctors was characterized by younger age comparing with general population.
Concerning gender, the interviewed group was characterized by very high prevalence of female gynecologists. Only 30.8 % of respondents were males (female/male ratio=2.25). If comparing it with sex ratio in general Chinese medical doctors in Taiwan- 0.34, or Western medicine doctors- 0.1856. This proportion was especially high in the group of youngest respondents.
The years of professional experience, reported by Respondents, ranged between less than year to 35 years, with average professional experience 12.7 years. However, the Respondents did not count their resident hospital training to this score, thus even those with comparatively short experience, might have additionally one to four years clinical experience as a resident.
Although the Respondents were chosen for this research by their affiliation with Chinese medicine departments in teaching hospitals, however asked about their workplace, only 41% considered Teaching Hospital as their workplace. Subsequently, other Respondents reported a range of workplace types: Chinese medicine hospitals, Chinese medicine clinics, Chinese medicine departments in regional and local hospitals.
Almost 60% of respondents were graduated from School of Chinese Medicine;
another one-third was studying Chinese medicine in School of Post-baccalaureate Chinese Medicine. Among sample of Chinese medical Gynecologists, only three had to obtain their license by Chinese Medicine Physician Special License Qualifying
Examination.
89% of interviewee had a resident training experience- mostly four years (28.2%) or one year (23.1). 87.2% of Respondents had been practiced Chinese gynecology. Most
55 行政院衛生署, 醫事人員執業資料查詢
http://www.doh.gov.tw/Medical_Personnel/Index.aspx, accessed:20may 2011
56 行政院衛生署, 醫事人員執業資料查詢
http://www.doh.gov.tw/Medical_Personnel/Index.aspx, accessed: 20 may 2011
129
of them practiced 7 or more years, but second numerous group were these, who had practiced only for 1-2 years.
Among 5 distinguished zones, only 3 were the site of Respondents‘ practice:
Northern, Central and Southern Taiwan. There was no gynecologist in interviewed group practicing in Taiwan islets and Eastern Coast of Taiwan. This may be explained by comparatively low population density and –especially in eastern coastal area- the influence of aboriginal population, that counted 10,31% in Hualien County in 201157.
Asked about sources of information concerning ―Zuo Yuezi‖, almost all (37) respondents answered, that they learn by practice and clinical experience. The sources of theoretical knowledge for 43.6% of Chinese medical Gynecologists were university courses, teaching research for 35.9% and for 30.8%- academic journals. 38.5%
respondents learned about ―Zuo Yuezi‖ from their family experience.
Regarding personal, family experience, that was also an important knowledge source, almost half of Respondents (47.8%) reported five times or more participation in
―Zuo Yuezi‖ beyond their professional duties. In such case, the Respondent could be an advisor for family members and friends, but this could also mean , that the interviewees, mostly woman, could be the subject of ―Zuo Yuezi‖ themselves. All Respondents had at least on time of such experience.
The Respondents‘ clinical practice, as a main source of their knowledge about ―Zuo Yuezi‖ was an important concern for this research. Asked about such practice, all
confirmed their involvement, and 30 Respondents additionally confirmed its frequent character. However, most of Participants have been consulting ―Zuo Yuezi‖ clinical problems only 1-10 times every month. Besides of practical involvement, another duty of Chinese medical Gynecologists was education. It is, however not as popular way of professional skills utilization- 17 Respondents were involved in academic practice 1-5 times every month, 7 of them were educating 6-10 times a month, and only 2 persons were doing so 21 times every month or more. Besides of regular teaching, 89.7%
57 The Hualien County Government official website,
http://ca.hl.gov.tw/fdownload/fdlist.asp?id={6825E170-A5A9-4554-AF9B-30034ECF8FB3}, accessed 27 july 2011.
130
Respondents were giving ―Zuo Yuezi‖ -related lectures, consultations and promotions.
Such events usually took place in student clubs, civil organizations, local medicine practitioner‘s organizations, universities, teaching hospitals, medical associations, postpartum care centers.
Only those Chinese medical doctors, who fitted to institutional category of
―Chinese medical Gynecologists‖, havd been invited to this survey. This was supposed to increase precision to research results, and to ease the results analysis. Firstly, the role that Chinese medical Gynecologists played in ―Zuo Yuezi‖ process must be ascertained.
It may be observed that the range of medical interventions in Traditional Medicine changed significantly since the western medicine entered China. Western medicine expropriated vital areas of obstetrics and gynecology intervention, and pushed the Traditional Chinese medicine to the second-plan role of assistant and system of
prevention. Chou‘s58 argument for such evolution is explained by the example of ―blood dizziness‖- anachronistic methods of Chinese medicine such as drinking child‘s urine to prevent this serious postpartum complication, were replaced by western medicine concept of aseptic, as the method of preventing puerperal fever. Currently, all acute conditions in gynecology and obstetrics as well as parturition itself became the western medicine domain. Postpartum care in normal postpartum however, in western medicine does not require any special treatment or diet modification, provided the diet is light. That is why in most of countries dominated by ―western culture‖ woman spends her postpartum at home (or even gives birth at home, like in Netherlands59 and limits contacts with health care system to routine check-ups for herself and the newborn- considering postpartum changes as ―natural‖ and not requiring any intervention. The situation in Taiwan is different. Traditional Chinese medicine found its chance for competing with western medical system in institutionalizing ―Zuo Yuezi‖, and involving it in the area of medical
58周春燕,女體與國族：強國強種與近代中國的婦女衛生(1895-1949) , 2008 國立政治大學博
士論文,p.157
59 de Jonge A,van der Goes BY, Ravelli ACJ, Amelink-Verburg MP, , Mol BW, Nijhuis JG, Bennebroek Gravenhorst J, Buitendijk SE, Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births , An International Journal of Obstetrics and Gynaecology, 2009; 116,pp 1177–1184
131
intervention. It very well met a tradition of treating pregnancy and parturition as pathology60 and gave the opportunity for developing ―Zuo Yuezi‖ industry. As a
consequence, Chinese medical doctors may participate in ―Zuo Yuezi‖ in two main ways:
as a practitioner who cares about woman health before and during pregnancy, or as a personnel of postpartum care facility. In first case- this contact-by definition- may limit to non-personal relations (because ―Zuo yuezi‖ assumes that woman should stay at home).
In second case- the Chinese medical doctor meets postpartum woman daily, but as a member of a team , he is not free to make all decisions by himself. In both cases Chinese medical doctor stays aside from crucial decisions concerning the manner of ―Zuo Yuezi‖, what is confirmend by the findings of this research. In both cases yet, the Chinese
medical doctor still has a chance to observe changes in woman‘s physiology. He has the comprehensive knowledge to analyze these changes and her behavior, and to find the causal link between them. This is why Chinese medical doctors were chosen for subject in this research.
5.3. Chinese medical Gynecologists’ Attitude towards “Zuo Yuezi”
According to 78,1% of Respondents (vide figure 4.3), the postpartum care called
―Zuo Yuezi‖ originates from traditional Chinese medical theory. Only 13% and 5% of Respondents subsequently, considered ―Zuo Yuezi‖ as originating from folk therapy or modern western medicine concepts. Thus, in this professional grup there was a belief, that
―Zuo Yuezi‖ is closely connected with Chinese medicine, rather that folk medicine.
Simultaneusly, 66,7% of Respondents considered Taiwanese culture as a background of this behavior, that was slightly more than percentage of doctors, who think, that Chinese culture is the background of ―Zuo yuezi‖. This may indicate, that Respondents
acknowledge, that despite ―Zuo Yuezi‖ originates from Chinese Han ethnic group culture (Wong )61, the Taiwanese ―Zuo Yuezi‖ developed independently since Han Chinese
60 Dikoter F. Sex, culture and modernity in China: Medical science and the construction of sexual identities in the early republican period. London: Hurst; 1995,p.80
61翁玲玲, 麻油雞之外, 台北; 稻香出版社, , 1994, p.1
132
emigrants occurred in Taiwan (Figure 2.2), and thus it differs from Mainland Chinese counterpart.
As figure 4.3 shows, almost all Chinese gynecology experts were thinking, that
―Zuo Yuezi‖ is beneficial in aspect of reproductive health, as well as the reason for it lies in tradition. Only 67 of Respondents acknowledged that ―Zuo Yuezi‖ is an opportunity for woman to rest, and even less of them emphasized its psychological and commercial aspect.
Chinese medical Gynecologists observed their postpartum patients‘ attitude to ―Zuo Yuezi‖. The Respondents noticed, that despite of popularity of new media, such as
internet, new generation of woman still entrusts elders and their family members‘
experience in this matter. These knowledge sources were much more important, according to respondents, than television (43.6%), press, (64.1%) internet (61.5%) or even books (74.4%). If the Respondents‘ observations were correct, there might be a distinct family pattern of ―Zuo Yuezi‖ care for each woman.
Asked about factors that influence ―Zuo Yuezi‖ manner, Chinese medical
Gynecologists confirmed Tien‘s62 finding that economic situation is main factor in this case. Some Respondents reminded, that the neonate‘s health status is also a moderating factor , however, this research provided also a new explanation: 71.8% of Respondents confirmed, that for multiparous women, the experience of previous ―Zuo Yuezi‖ is an important moderator for recent ―Zuo Yuezi‖ shape. In another question Respondents were asked which persons will have impact of ―Zuo Yuezi‖ shape. Their answer , shown in figure 4.6 was interesting: besides of postpartum woman herself, her mother, even more frequently than mother-in-law, decides here, and only 2 of Respondents (5.1%) though that the Doctor, who took care of woman before parturition, has any decisive voice in this matter.
Woman must choose place for her confinement. Although some respondents argued, that location is not important, most of women spend their postpartum in their mother‘s houses. Most of respondents confirmed, that it is the best possible location for ―Zuo
62田聖芳,台灣婦女產後照護之變遷—以北部地區為例,國立台灣大學博士論文, ,2006, p.175.
133
Yuezi‖.It is a fascinating finding- the literature data reports, that it used to be mother‘s-in-law duty to take care of young mother and the grandchild. It was the important passage and time of readjustment for two women living together in patrilocal society. Meanwhile, due to social changes, relationships with mother-in-law seem to be not so important anymore. Modern Taiwan women prefer to take advantage of ―Zuo Yuezi‖ and consolidate her relation with mother. In this aspect, Taiwan postpartum tradition
resembles the Japanese custom of Satogaeri, rather than traditional Han postpartum. The second choice for ―Zuo Yuezi‖ site is ―Zuo Yuezi Center‖- professional postpartum nursing institution. It was not only eagerly chosen by woman who can afford it, but also claimed by respondents as second best location for confinement.
Pattern of ―Zuo Yuezi‖ participation changed along the time. Tian63 (2006) conducted research on 3 cohorts of Taiwanese woman in different age; in her research, women older than 55 years, were mostly taking care of their newborn babies by
themselves, and had seldom any help from husband in this matter. According to
Respondents, contemporarily it was still the woman herself, who mainly looks after the newborn (100%) however the mother or mother-in-law, as well as husband support her.
Mothers-in-law or mothers took care of postpartum women who were 35-54 years old at the time of Tian‘s survey. For the youngest puerperal women, besides of mother‘s-in-law care (51.7%) and mother (33.8%) there was an alternative of choosing commercial
postpartum care provider. In some part, the findings of this research were consistent with Tian‘s observation- the Respondents observed, that in several years newborn‘s father will participate in care under postpartum woman (76.9%), and the newborn (69.2%). This research, however, in contrary proved, that it was the postpartum woman‘s mother, who is the main caregiver for woman (100%). It may be estimated, that if Respondents average clinical practice time was 12.7 year, and average age for first pregnancy in Taiwan was near 30 years (29.4 years in 2003)64, it means that the Respondents were meeting most frequently the women, who were aged about 43 years or less today. It
63 田聖芳,台灣婦女產後照護之變遷—以北部地區為例,國立台灣大學博士論文, ,2006, p.119.
64 Hsieh TT, Liou JD, Hsu JJ, Lo LM, Chen SF, Hung TH, Advanced maternal age and adverse perinatal outcomes in an Asian population.Eur J Obstet Gynecol Reprod Biol. 2010;148(1):21-6.
134
covered only the youngest cohort from Tian‘s research, as well as a group of woman, that gave birth within last 5 years from 2011.
There was no one concordant answer concerning the length of ―Zuo Yuezi‖. The Respondents were suggesting, that it should last between 20 and 60 days, that was a wide range, that included most of literature propositions in this matter; the mean time of ‗Zuo Yuezi‖, calculated from all answers was 37.7 days, however, most frequently given value was 40 days.
Most of Respondents believed, that postpartum period is not the only occasion for
―Zuo Yuezi‖. A special treatment and care after a miscarriage, although different from postpartum, also called ―Zuo Yuezi‖ was advisable by almost all Respondents (table 4.22).
It was very difficult to assess the actual benefits of ―Zuo Yuezi‖ in aspect of physiology- it is so, because ―Zuo Yuezi‖ is almost obligatory in Taiwan, and there was no possibility to run any clinical comparison between those women who did and those who did not conduct ―Zuo Yuezi‖. Another difficulty lay in the fact, that one of ―Zuo Yuezi‖ rules is a limited contact with outer world, including medical facilities. In this situation, the opinion of experienced Chinese medical Gynecologists is a valuable source of such information. In this survey, the Respondents were asked two questions
concerning negative outcome of improper ―Zuo Yuezi‖, First two questions included complaints of Respondent‘s patients, that according to these women, are related to ―bad Zuo Yuezi‖, and the second question was about Respondents‘ own opinion regarding this issue. Another two subsequent questions were designed to determine the onset time of such ailments and to define ―improper Zuo Yuezi‖. For two first questions, in both cases, the most frequent outcome of improper ―Zuo Yuezi‖ was a lower back pain (腰酸背痛), that is a common morbidity related to pregnancy (joints laxity due to high relaxine levels).
Parity, younger age, and some psychological factors also influence the increased prevalence of backache after pregnancy65. Generally, comparing woman‘s complaints reported by Respondents (fig. 4.7), and the Respondents‘ observations (fig.4.8), the professionals emphasized changes in constitution, irregular menses as negative outcome,
65 Russell R, Reynolds F. Back pain, pregnancy, and childbirth. BMJ 1997; 314: 1062-1062
135
while the patients concentrates on headache and faster ageing as negative consequence of neglecting ―Zuo Yuezi‖ prescriptions, according to Respondents. The onset time of ―Zuo Yuezi‖ –related health aggravation (table 4.23) if ever, has not been defined precisely, some Respondents placed it directly after postpartum, some -after number of years. The so called ―inappropriate Zuo Yuezi‖ was defined by respondents (figure 4.9) as ―Zuo Yuezi‖ without caregiver, with excessive labor, and exposure to wind and cold.
This part may be concluded by question about ―Zuo Yuezi‖ importance. The results shows, that 85% of Respondents considered ―Zuo Yuezi‖ as very important or important, and only 15% stated, that for some woman it may be not so important.
5.4 Elements of “Zuo Yuezi”
The group of Respondents engaged in this project was characterized by average clinical experience of 12.7 years, where the clinical experience was regarded by Respondents as their most important and main source of knowledge concerning ―Zuo Yuezi‖. General scope on respondents‘ classification of elements brought us to the conclusion that ―Zuo Yuezi‖ is beneficial mainly for postpartum woman. Among 69 elements, 66 was considered by at least 25% (N=10) doctors as related to postpartum mother‘s health, 46- as cultural or ethnological factor, only 3 – as religious factor, and merely 2- as related to newborn‘s health. The Respondents‘ profession may in some part contribute to such results. As gynecologists, the Respondents‘ main concern is woman‘s health, thus they might not emphasize other aspects of ―Zuo Yuezi‖. For four categories of ―Zuo Yuezi‖ elements, there was a tendency of classifying those elements that indicate confinement and reduction of social interaction, as well as related to body and hair washing as cultural. It may be considered as the ―Zuo Yuezi‖ adjustment to lower peri- and postnatal mortality due to higher hygiene standards, better health care, and lower risk of infections.
The mostly approved elements (approval over 80% -Table, Appendix II) may be considered as a part of basic, universal prescription for proper ―Zuo Yuezi‖ in Taiwan.
Such elements referred mainly to diet modification (elements 39, 63, 38, 60, 37, 64, 67,
Such elements referred mainly to diet modification (elements 39, 63, 38, 60, 37, 64, 67,