2. Literature Review
2.3. Traditional Postpartum Care in Taiwan
In ancient Chinese tradition the confinement was based not only on medical premises, religious factors were also important. In Confucius times confinement started one month before parturition (Confucian The Book of Rites-―禮記‖), however such custom functioned only in rich families, where the woman was not obliged to work, and related taboos were obeyed during this period as well. Directly after delivery the parturient woman was fed immediately with small amount of food, usually fried eggs with sesame oil, which is called chinese :‖ya fu‖, and in Minnan phonetics ―dei-bak" (墊 腹/壓腹) and it has the meaning of refilling emptied abdomen. 4243. The period of ―Zuo Yuezi‖ confinement starts at the same time. The confinement lasts until the newborn is one month old, and the family will hold the rite of full month (滿月).
1) The “Zuo Yuezi” discourse
The discourse of ―Zuo Yuezi― incorporates many concepts from Traditional Chinese medicine. The rule of polarity in nature (yin-yang theory), the concepts of humors, known as theory of five phases, share a lot of similarities with many other cultures around the world. When analyzing ―Zuo Yuezi‖ custom, one will notice that for food taboo during postpartum the „hot-cold‖ differentiation discourse is used.
In nursing research44, such terms as "hot" and "cold" does not indicate only properties of the object but also its function. These simple, contradictive categories are a very useful tool in theory and practice of Traditional Chinese medicine. It means that food is a career of certain property or energy (氣), which may be passed to human body by consuming food. There is a rationale to believe, that this theory originated from beyond written history, as the first herbology classis "Shen Nong Ben Cao Jing"(―神農本
42 翁玲玲, 麻油雞之外, 台北; 稻香出版社, 1994,p.37
43 謝玉萍, 金門傳統生育禮俗之探討, 銘傳大學碩士論文, 2004, pp.89-95
44 Chen LL, Wang CC. 2008, Attitude and behavior towards postpartum recuperation in traditional Chinese medicines. Journal of Nursing Research. 2000;8(1):49–58
29
草經‖)), and following ―Ben Cao Gang Mu (本草綱目)‖45 introduce hot/cold typology for each described herb.
As every region has its own specific fauna and flora, due to varying geographic and climatic condition, the range of above categories is variable. In Table 2.2 there are example categories of foods popular in Taiwan, divided into three categories: hot/ warm, cold/ cool and balanced.
45李時珍,本草綱目，國立中國醫藥研究所出版, 1988
30
Table 2.2 The characteristics of foods according to hot/cold theory
Categories and
31
32 recuperation in traditional Chinese medicines. Journal of Nursing Research.
2000;8(1):49–58
2) The way of “Zuo Yuezi”
The necessity of ―Zuo Yuezi‖ is dictated by belief, that during pregnancy, and after delivery woman‘s body is in the state of illness or abnormality (coldness and vacuity).
Some authors46 state, that this specific way of considering pregnancy and parturition as pathological processes is characteristic for traditional Chinese culture, while others47 argues that modern medicalization of postpartum care contributes to this phenomenon.
Traditional ―Zuo Yuezi‖ is not an evidence-based practice, and there is still no sufficient evidence on its positive impact of such practice on woman‘s physiology. The research proving, that consumption of Chinese herbs: ―Sheng-hua Tang‖( 生 化 湯 ) and
―Duzhong‖(杜仲) during postpartum may result in faster uterine involution are still not convincing48, moreover, there are reports on adverse effect of ―Zuo yuezi‖ practices.
Another research on ―Shenghua Tang‖ consumption outcome49, showing that this
46 Dikötter.F. Sex, culture and modernity in China: Medical science and the construction of sexual identities in the early republican period. London: Hurst; 1995, p.79
47 呂木蘭,現代坐月子的女性觀點—以坐月子中心的產婦為例, 國立清華大學碩士論文,
1998,p.109
48 Ho M, Li TC, and Su SY, ,The Association between Traditional Chinese Dietary and Herbal Therapies and Uterine Involution in PostpartumWomen Evidence-Based Complementary and Alternative Medicine, eCAM 2011;2011():918291
49 Chang, P.J., Tseng, Y.C., Chuang, C.H., Chen, Y.C., Hsieh, W.S., Hurng, B.S., Lin, S.J., & Chen, PC. Use of Sheng-Hua-Tang and health-related quality of life in postpartum women: A
population-based cohort study in Taiwan. International Journal of Nursing Studies, 2010;47(1),
33
decotion may have positive impact on postpartum woman in both physical and mental aspect, but only when it is administered for one month. Prolonged usage may have opposite effect.
The Term “Zuo Yuezi”
Even the term ―Zuo Yuezi‖ itself is somehow problematic. The term ―Zuo Yuezi‖ in literal Chinese may be written in three different forms: 坐月子/做月子/作月子. In second popular Taiwanese dialect there is another word for describing the same tradition: 做月內 (pronounced as chor goeh-lai). The popularity of each one was measured by Google search engine: (2011.04.26) by results number: 14,800,000 results for 坐月子,3,240,000- 做月子 and 1,050,000 for 作月子 phrase was found. Similarly, for minnan counterpart-
―Zuo yue nei‖ the ―sit‖ character was most popular, as well (坐月內-4,460,000; 作月內 151,000; 做月內 1,380,000.). These Chinese expressions may be translated into English as sitting (for) a month (坐月子) and also doing the month (做月子/作月子). According to Wong‘s research the term doing the month (作月子) is the proper one, because this term refers to ‗exercising‘ all ritual and dietary behaviors of the custom, not only by postpartum women herself but also her family as well50. Nevertheless, there is a common belief, that when referring to the situation of confinement and discharging from household duties that postpartum women can really ‗sit‘ and rest, the term ‗Sitting for a month‘ could be used to describe the status of the woman. This form is also adopted by the business of postpartum care centers. Because this research subject is not a linguistic analysis of tradition, and the researcher is not an expert, for comprehensive describing the custom from different perspectives including the subjective view of postpartum women and from family circumstance, the study skips the above argument and takes simply the phonetic term ―Zuo Yuezi‖ in Chinese pinyin.
13-19.
50翁玲玲, 麻油雞之外, 台北; 稻香出版社, , 1994, pp.31-34
34
Attitude Towards Taboos and Rules of “Zuo Yuezi”
Research in Taiwan suggests that the adherence to ―Zuo Yuezi‖ rules was positively correlated with lower occurrence of postpartum morbidities 51
In her field study in fisherman‘s villages Wong finds, that regardless economic situation of family, women tries to follow basic rules of postpartum rite of passage:
confinement, repletion, labour avoiding. She emphasizes the ritual and social aspect of
―Zuo Yuezi‖ suggesting also its positive influence on postpartum woman‘s psychology.
Quality of Life during “Zuo Yuezi”
Another research52 explores the influence of ―Zuo Yuezi‖ discourse on woman‘s health concept. The author analyses this influence in three dimensions: avoiding the physical and psychological lesion, different locations of postpartum confinement, physical and psychological morbidities caused by failure in doing ―Zuo Yuezi‖ properly.
In this research the subject of survey were Taiwanese women, who gave birth in 60‘s.
It clarifies the woman‘s attitude to postpartum common taboos and explains the causal relation between the quality of ―Zuo Yuezi‖ and its health outcome. Respondents report, that vision impairment may be a consequence of shedding tears, incorrect position or excessive labor may cause an uterus prolapse; other problems may occur in result of labor or exposure to wind and cold. The location ―Zuo Yuezi‖, according to respondents, is also very important.
Stress and Support during Postpartum Period
Another aspect of ―Zuo Yuezi‖ 53 is its impact on stress level, that onset after parturition. Some aspect of postpartum care may ease tension and decrease the stress level. Childbirth and motherhood as a transition stage, requires adaptation and rearrangement. Constant supervision, practical help and emotional support from the
51黃久華, ,產婦執行坐月子習俗遵循度與產後健康狀態之相關性研究 , 陽明大學碩士論文,
2009, p.94
52楊淑玲, ,生育習俗對中老年婦女保健觀念之影響, 高雄醫學大學碩士論文,2004, p.126
53 Heh SS, ―Doing theMonth" and Social Support , Fu-Jen Journal of Medicine Vol.2 (2): 2004
35
families are essential for a woman in her new role of being mother. ―Zuo Yuezi‖ is designed to make this support easy to achieve and sustain. It may be also taken for reward for woman‘s contribution to family continuation.
“Zuo Yuezi” Significance for Woman and Families
Important point of Wong's research is that she has illustrated that through the postpartum ritual, the family could reregulate the relationships between the mother and other families, especially her mother-in-law. However, due to the change of modern family structure, while nuclear family has become the main type, the function of the relationship inside of the family has declined. The liaison between daughter-in-law and mother-in-law weakened, but simultaneously, the relations between married woman and her own mother, traditionally neglected or even forbidden in Han culture, has been strengthen and appreciated. Such relations, has been analyzed through food context54 (explored mother-daughter interactions as represented by the provision of food during
―Zuo Yuezi‖. Mothers were caring for their daughters in postpartum. The daughter‘s reactions was increasing intimacy, being nostalgic, and expressing appreciation.
54 Tien, SF, Mother-Daughter Relationships Expressed in the Food Con text of Postpartum Convalescence ---Findings From a Preliminary Study, Journal of Nursing Research, 2003, 11;1
36 3
. Methodology
3.1 Research Design
Theoretical preparations for survey lasted from November, 2010. The self – administered Questionnaire survey was conducted in May, 2011. After literature review and consultations with the specialists, the 12-page-questionnaire was designed and sent to Participant‘s workplace.
3.2 Research Subject and Sampling
The subject chosen for this study was a ―purposive sample‖ of licensed Chinese medicine Practitioners, specializing in Traditional Chinese gynecology. Participants were qualified to this group in two ways:
a. If were practicing as Chinese medical Gynecologists in Chinese Medicine Department of Teaching Hospital, enlisted in the Committee on Chinese Medicine and Pharmacy, Department of Health of Executive Yuan.
b. They were known to and recommended by the teachers council in the School of Chinese Medicine CMU.
3.3 Research Tool
The Questionnaire was composed of three parts:
a. Chinese medical Gynecologists‘ professional background and demographic data; age, sex, years of experience, workplace type and location, education and specialization b. 21 questions; (Single, triple, multiple-choice questions) concerning clinical and
personal experience of ―Zuo Yuezi‖ and knowledge about factors that are shaping modern ―Zuo Yuezi‖ form.
c. A Table with ―Zuo Yuezi‖ elements
37
The thorough analysis of Taiwanese doctoral and master theses related to ―Zuo Yuezi‖ (the list of dissertations is attached as Appendix III) resulted in recognizing separate elements which were constructing ―Zuo Yuezi‖. Original list included 203 different elements, which had been divided into 4 categories:
Daily life- 83elements
Diet- 109 elements
Social activity- 11 elements
Ritual- 6 elements
After consulting academic teachers, this number was limited to 106 elements (the
―ritual‖ category was removed), and in this form the list was attached as the third part of the pre-test questionnaire. After pre-testing, the final number of ―Zuo Yuezi‖ elements included in the questionnaire was limited to 69. The complete questionnaire for references, was attached in the end of this thesis.
3.4 Data Collection
The questionnaires were collected by mail or had been returned personally between 6-23 may 2011.
3.5 Data Analysis
The data obtained in this survey were primarily input in Microsoft Excel sheet, and, subsequently exported as database into SPSS program. All statistics were run with help of these two programs. Collected data, due to sample size, were mainly analyzed in descriptive way. All results are represented by valid percent and or frequency..
38
4. Results
4.1 The Characteristics of Respondents.
4.1.1 Age
The Respondents age ranged between 28 and 64 years. The mean of age was 42.3 years. The respondents were divided into four groups, according to the age. The group of 33-42 year old was most numerous. Please refer to the Table 4.1 and Table 4.2.
Table 4.1 Descriptive statistics of Respondents‘ age.
N Minimum Maximum Mean Std. Deviation
Age 39 28 64 42.3 9.8
Table 4.2 Frequency for Respondents in age groups.
Age group-years 28-32 33-42 43-52 >52 Total
Valid Percent 25.6 30.8 28.2 15.4 100.0
4.1.2 Gender
Almost 70% of respondents were women,as show in Table 4.4. This tendency was even more distinct for group of younger doctors (28-42 years), where male doctors were dominated by female counterparts (as Figure 4.1 shows).. This pattern was also valid considering age-correlated factor- the professional experience.
Table 4.3 Composition of respondents group by gender Male Female Total
Frequency 12 27 39
Percent 30.8 69.2 100.0
39
Figure 4.1 Distribution of respondents according to gender and age
4.1.3 Experience
As Table 4.5 shows, the The experience of respondents in Traditional Chinese gynecology ranged between less than one year and thirty five years, with average experience 12.7 year.
Table 4.4 Frequencies for the Respondents‘ professional experience in years N Minimum Maximum Mean Std. Deviation
Years of Experience 39 0.8 35 12.7 9.4
For analysis purpose, the experience was divided into four categories. As it is shown in Figure 4.2, most of respondents (61.5%) had less than 13 years of experience, and only 23% practiced for more than 20 years.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
28-32 33-42 43-52 >52
Age
female male
40
Figure 4.2 Years of respondents‘ professional experience
4.1.4 Type of Workplace
The respondents predominantly (41%) practiced Chinese medicine in Teaching Hospitals. Another popular workplace for respondents were Chinese medicine Departments in Regional Hospitals and Chinese medicine Hospitals. 15.4% of
interviewee worked in Chinese medicine Clinic, and only one of them- in Local Hospital, please refer to Table 4.5.
Table 4.5 Frequencies for he type of Respondents‘ workplace
Frequency Percent
Chinese medicine Clinic 5 12.8
Chinese medicine Hospital 9 23.1
Chinese medicine Department in Local Hospital 1 2.6 Chinese medicine Department in Regional
Hospital 8 20.5
Chinese medicine Department in Teaching
Hospital 16 41.0
Total 39 100.0
,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0
<6 7-13 14-20 >20
Years of Experience
Years of Professional Experience
Valid Percent
41
4.1.5 Educational Background
As shown in Table 4.6, almost 60 percent of respondents graduated from a School of Traditional Chinese medicine. The second significant group (33%) was the practitioners educated in School of Post-baccalaureate Chinese medicine, and only 3 respondents passed different path of education and obtained their license through Special License Qualifying Exam.
Table 4.6 Frequencies for educational background of respondents
Frequency Percent
School of Traditional Chinese medicine 23 59.0
School of Post-baccalaureate Traditional Chinese medicine 13 33.3 Chinese medicine Physician Special License Qualifying
Examination 3 7.7
Total 39 100.0
4.1.6 Resident Training in Teaching Hospital
Table 4.7 shows the period of respondents‘ resident training in teaching hospital.
Table 4.7 Frequencies for the period of Respondents‘ resident training in teaching hospital
Frequency Percent
No 11 28.2
Yes, one year 9 23.1
Yes, two years 6 15.4
Yes, three years 2 5.1
Yes, four years 11 28.2
Total 39 100.0
42
4.1.7 Chinese medicine Obstetrics Practice
Almost half of all respondents (48.7%) had experience of 7 years practice in Chinese medicine obstetrics. Please refer to Table 4.8.
Table 4.8 Frequencies for the period of respondents‘ Chinese medicine obstetrics practice Frequency Percent
No 5 12.8
Yes, 1-2 years 8 20.5
Yes, 3-4 years 3 7.7
Yes, 5-6 years 4 10.3
Yes, 7 or more years 19 48.7
Total 39 100.0
4.1.8 Practice Location
The most area of workplaces of respondents was in central Taiwan (41.0%), after that were the northern and southern Taiwan, non of respendent worked in eastern Taiwan, please refer to Table 4.9.
Table 4.9 Frequencies for the Respondents‘ Workplace Frequency Percent
Northern Taiwan 12 30.8
Central Taiwan 16 41.0
Southern Taiwan 11 28.2
Total 39 100.0
43
4.1.9 The Source of Respondents’ Knowledge on "Zuo Yuezi"
Table 4.10 shows the source of respondents‘ knowledge on ―Zuo Yuezi‖. The question is multiple choices question. Almost all respondents (94.9%) gained their knowledge from clinical experience or practice.
Table 4.10 Frequencies for the source of respondents‘ knowledge on ―Zuo Yuezi‖
(Multiple choices question – the sum of percent > 100%)
Frequency Percent
School /university courses 17 43.6
Practice or clinical experience 37 94.9
Specialized education 4 10.3
Teaching and research 14 35.9
Academic journals 12 30.8
Media 2 5.1
Family experience 15 38.5
4.1.10 Private Participation in "Zuo Yuezi"
Nearly half of respondents had five or more times of private participation in ―Zuo Yuezi‖, as shown in Table 4.11.
Table 4.11 Frequencies for the Respondents‘ private participation in ―Zuo Yuezi‖
Frequency Percent
once 7 17.9
twice 3 7.7
three times 8 20.5
four times 2 5.1
five times or more 19 48.7
Total 39 100.0
4.1.11 Clinical Involvement in "Zuo Yuezi" Practice
All participants affirmed such involvement, but the frequency of such practice differed, as Table 4.12 shows.
44
Table 4.12 Frequencies for the clinical involvement of respondents in ―Zuo Yuezi‖
How many times per month the interviewee performs a clinical service?
Is the clinical practice a regular duty?
Yes No Total
1-5 times 13 8 21
6-10 times 12 0 12
11-20 times 2 0 2
21 times or more 2 0 2
Total 29 8 37
4.1.12 Educational Involvement in "Zuo Yuezi" Practice
35 participants answered YES, but the answers differed by frequency, as shown in Table 4.13.
Table 4.13 Frequencies of educational practice of respondents in ―Zuo Yuezi‖
How many times per month the participant performs an educational service?
Is the education practice a regular duty?
Yes No Total
1-5 times 8 9 17
6-10 times 6 1 7
11-20 times 3 1 4
21 times or more 2 0 2
Total 19 11 30
4.1.13 "Zuo Yuezi"- Related Lectures, Consultations or Promotion
Most of respondents provided related lectures, consultations or promotion on ―Zuo Yuezi‖, as Table 4.14 shows.
45
Table 4.14 Respondents‘ ―Zuo Yuezi‖-related lectures, consultations or promotion
Frequency Percent
No 4 10.3
Yes 35 89.7
Total 39 100.0
For those respondents, whos answer was affirmative, the different circumstances of such practice is shown in Table 4.15.
Table 4.15 Frequencies for the occasions or places where respondents providing lectures, consultations or promotion
Frequency Percent
Courses in university hospital/medical association 9 23.1 Courses in local medicine practitioners‘ association 20 51.3
Courses in postpartum care center 5 12.8
Courses at university 13 33.3
Courses student club or civil organization 23 59.0
4.2 Experience of “Zuo Yuezi”
This part includes 17 questions, describing clinical and personal experience of Chinese medical Gynecologists in ―Zuo Yuezi‖ practice. The questions‘ subject in this part were the cultural and social background and conditions of ―Zuo Yuezi‖ tradition, it‘s location, time, involvement of third party, ―Zuo Yuezi‖ health outcome and significance, and, finally, the respondents‘ role and manner of involvement in ―Zuo Yuezi‖.
4.2.1 Reason for "Zuo Yuezi"
The respondents were asked what is the reason for ―Zuo Yuezi‖ existence and continuation. As Figure 4.3 shows, 95% of them claimed, that it benefits in terms of reproductive health. 90% -agreed that “Zuo Yuezi” in modern times is a
continuation of tradition. 67% treated this custom as postpartum woman‘s opportunity for rest. Slightly more than one-third of respondents (36 and 38%) considered ―Zuo
46
Yuezi‖ as fashion, commercial phenomenon or treated it as beneficial in social and psychological aspect. (multiple choice question )
Figure 4.3 Reasons for ―Zuo Yuezi‖.
(Multiple choice question- percent does not sum to 100%)
4.2.2 "Zuo Yuezi" Background
Asked about ―Zuo Yuezi‖ background, Taiwanese Chinese medical Gynecologists answered, as shown in Figure 4.4 that it was based on Traditional Chinese Medical theory (71.8%), traditional Taiwanese (66.7%) or Chinese (61.5) culture. Only 5.1% of
respondents considered modern medicine as the background of ―Zuo Yuezi‖. 12.8% of Chinese medical Gynecologists though that it is a kind of folk therapeutic method.
(multiple choice question)
It is a fashion trend and commercial phenomenon
It is beneficial for puerperal women’s social position and psychological
condition
It is justifies postpartum womans rest from work, labor and daily burden It is a continuation of traditional culture It is beneficial in aspect of reproductive
physiology
Frequency
"Zuo Yuezi" is
47 Figure 4.4 The background of ―Zuo Yuezi‖
4.2.3 The Source of "Zuo Yuezi" Information
As Figure 4.5 shows, the belief that modern mothers learn about postpartum care from elders (100%) or experienced relatives and friends (92.3%) prevailed in the sample group. Taiwanese women learned about ―Zuo Yuezi‖ from books (74.4%), press (64.1%), internet (61.5%) and television (43.6%). School education (0.0%) provided no ―Zuo Yuezi‖ information. (multiple choice question)
48 Figure 4.5 Sources of ―Zuo Yuezi‖ information.
4.2.4 Decisive Factors for "Zuo Yuezi" Fashion:
According to respondents, following factors played important role in defining the way of ―Zuo Yuezi‖: As shown in Table 4.17, the most important factor was economy situation (82.1%), followed by the multiparous woman‘s experience of previous puerperium (71.8%) and newborn‘s health condition (35.9%). Woman‘s education, in Chinese medical doctor‘s opinion, might also play some role in decision making (38.5%) as well as her occupation (20.5%) and habitation (20.5%). (multiple choice question)
Table 4.16 Frequencies for the decisive factors for ―Zuo Yuezi‖ fashion
Table 4.16 Frequencies for the decisive factors for ―Zuo Yuezi‖ fashion