Preamble

Pregnant and Postpartum Women's Intention to Use Traditional Chinese Medicine and Its Influencing Factors

LI Zanmei¹, LI Jiao¹, YANG Lin¹, MA Liangkun², XUAN Lei³, YAO Weiwei⁴

¹Institute of Medical Information and Library, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100020, China
²Department of Obstetrics and Gynecology, Chinese Academy of Medical Sciences/Peking Union Medical College Hospital, Beijing 100730, China
³Department of Traditional Chinese Medicine, Chinese Academy of Medical Sciences/Peking Union Medical College Hospital, Beijing 100730, China
⁴Beijing MYYA Health Management Co., Ltd, Beijing 100730, China

Corresponding authors: MA Liangkun, Professor; E-mail: maliangkun@pumch.cn
XUAN Lei, Associate Chief Physician; E-mail: xuanlei6336@163.com

Abstract

Background: Traditional Chinese Medicine (TCM) possesses a profound theoretical foundation and extensive practical applications in maternal and child health. China has been actively promoting TCM integration in this domain. However, insufficient perinatal TCM knowledge and limited safety awareness among pregnant and postpartum women pose challenges to its development. Research on TCM utilization behaviors is essential for improving service uptake in this population.

Objective: To investigate TCM utilization patterns and intentions among perinatal women and identify influencing factors.

Methods: A cross-sectional study was conducted among 264 perinatal women receiving care at maternal and child health institutions across multiple regions of China from June to October 2023. An extended Theory of Planned Behavior (TPB) questionnaire assessed four TPB constructs (attitude, subjective norms, perceived behavioral control, intention) and past TCM use. Data were analyzed using SPSS 20.0 and AMOS 26.0, with structural equation modeling (SEM) to examine path relationships.

Results: All 264 questionnaires were valid (100% response rate). Ninety-nine (37.5%) pregnant or breastfeeding women reported having used TCM during the perinatal period. Multivariate logistic regression analysis indicated that the stage of pregnancy/childbirth (OR=0.519, 95%CI=0.386-0.697) and previous history of TCM use (OR=9.399, 95%CI=4.500-19.633) were significant influencing factors (P<0.05). Participants demonstrated relatively positive attitudes (5.49±1.13), strong usage intentions (4.95±1.04), high perceived behavioral control (5.22±1.12), strong subjective norms (4.99±1.12), and satisfactory prior TCM experiences (4.90±1.16). SEM indicated that all TPB constructs and past experiences significantly predicted intention to use TCM (P<0.001), with subjective norms exhibiting the strongest effect (β=0.435).

Conclusion: Low TCM utilization rates and regional disparities exist among perinatal women, with intention heavily influenced by significant others' opinions and prior TCM experiences. It is crucial to implement tailored interventions, including region-specific TCM service reforms, enhanced focus on subjective norms in perinatal care, and life cycle-oriented TCM service systems to optimize TCM utilization and advance its role in maternal and child health.

Keywords: Traditional Chinese medicine services; Maternal health management; Behavioral intention; Theory of planned behavior; Cross-sectional study

Introduction

Traditional Chinese Medicine (TCM) represents a treasure of ancient Chinese science that has contributed significantly to the prosperity of the Chinese nation. In the context of modern medicine, the inheritance and innovative development of TCM constitutes an important component of socialism with Chinese characteristics [1]. TCM possesses a profound theoretical foundation in maternal and child health, with extensive practical applications and demonstrated efficacy in perinatal healthcare management, including preconception care, hyperemesis gravidarum, threatened miscarriage, gestational hypertension, postpartum depression, and lactation insufficiency [2]. To fully leverage the unique role of TCM in maternal and child healthcare and implement national strategic plans for promoting TCM inheritance and innovation, the National Health Commission and the National Administration of Traditional Chinese Medicine jointly issued the "Implementation Plan for Promoting Traditional Chinese Medicine in Maternal and Child Health (2021-2025)" (hereinafter referred to as the "Implementation Plan") [3], providing comprehensive guidance for advancing TCM in maternal and child health to support high-quality population development. TCM services have been deeply integrated into China's maternal health management system, yielding numerous positive outcomes.

Traditional and complementary medicine is widely used among pregnant and postpartum women worldwide [4]. Research indicates that TCM utilization rates among this population range from 7% to 96%, with herbal medicine being the preferred treatment for some pregnant women when ill [5]. A large-scale cohort study published in 2023 involving nearly 200,000 pregnant and postpartum women found that from 2014 to 2018, 26.13% of pregnant women and 55.63% of postpartum women in Xiamen used TCM, with usage increasing significantly over time [6]. However, TCM's complex composition and unclear mechanisms of action raise important safety concerns for perinatal use [7]. Pregnant and postpartum women often lack adequate knowledge about perinatal TCM care and have limited safety awareness, relying primarily on non-medical professionals for information [8-10], creating multifaceted risks and challenges for safe TCM use during pregnancy. Therefore, strengthening research on TCM utilization behaviors among perinatal women is crucial for improving their health literacy, developing targeted interventions, and advancing TCM in maternal and child health.

The Theory of Planned Behavior (TPB) is a well-established framework widely applied to predict and explain health behaviors [11-12]. The theory posits that behavioral intention (the likelihood of performing a behavior) predicts actual behavior, while intention is influenced by subjective norms (perceived social pressure to perform or not perform the behavior), attitudes, and perceived behavioral control (perceived ease or difficulty of performing the behavior). TPB has been extensively used to study health-related behaviors during pregnancy, including smoking, alcohol consumption, nutrition, and breastfeeding [13]. For example, BEN NATAN et al. [14] surveyed 201 pregnant smokers aged 19-46 in Israel using TPB and found that the theory effectively predicted smoking intention, providing recommendations for developing smoking cessation interventions. Recently, researchers have applied TPB to study TCM use intention and behavior [15]. ROCHELLE et al. [16] analyzed TCM use among 272 Chinese individuals in Britain, finding that being female, older age, strong attachment to Chinese culture, significant others' opinions, and recent TCM use experiences all influenced their TCM utilization behaviors.

Based on this literature, this study posits that TPB may also have potential for identifying factors influencing TCM use intention among perinatal women. Past behavior experiences often predict future behavior [17], and prior TCM use has proven to be an important predictor of intention to use TCM, complementary and alternative medicine, or nutritional supplements during pregnancy and lactation [18-21]. Therefore, this study extends TPB by adding "past TCM use experience" as a covariate to develop a theoretical model of factors influencing perinatal women's TCM use intention (Figure 1 [FIGURE:1]). Through a multi-regional survey, this research aims to comprehensively understand TCM utilization patterns among Chinese perinatal women and explore influencing factors of their TCM use intention, providing references for implementing targeted TCM services and advancing maternal and child health TCM initiatives.

Methods

1.1 Study Subjects

From June to October 2023, a convenience sampling method was used to survey pregnant and lactating women receiving maternal healthcare services at multiple maternal and child health institutions across China. When women visited these institutions, trained members of the Maternal and Child Health Management Committee of the China Pharmaceutical Education Association, distributed across various maternal and child health institutions nationwide, guided voluntary participants to complete anonymous questionnaires through the Wenjuanxing platform. To prevent multiple submissions, each device was allowed to complete the questionnaire only once.

Inclusion criteria were: (1) literate and able to understand the questionnaire; (2) voluntary participation with signed informed consent; (3) aged 15-49 years; (4) currently pregnant or lactating; (5) able to access the internet via mobile phone or computer. This study was approved by the Ethics Committee of Peking Union Medical College Hospital (Approval No.: I-24PJ1428), and all participants provided informed consent. Sample size was calculated using the 10-fold rule for measurement items [15]. A total of 264 questionnaires were distributed, with 264 valid questionnaires returned, yielding a 100% valid response rate.

1.2 Research Methods

An extended TPB questionnaire was designed based on literature review, assessing four TPB variables (subjective norms, behavioral intention, perceived behavioral control, attitude) and past TCM use experience. The theoretical model is shown in Figure 1 [FIGURE:1].

1.3 Statistical Methods

SPSS 22.0 was used for descriptive statistics (demographics, clinical characteristics, and TPB constructs) and reliability analysis (Cronbach's α ≥0.6 acceptable, ≥0.8 good). Multivariate logistic regression analysis explored factors influencing TCM use. AMOS 26.0 conducted structural equation modeling analysis. Exploratory factor analysis (eigenvalue >1, factor loading >0.5) verified construct validity, followed by confirmatory factor analysis (χ²/df=1-5, GFI/CFI>0.90, RMSEA<0.05) to confirm measurement model fit [22]. Composite reliability (CR>0.7) and average variance extracted (AVE>0.5) tested convergent validity. Finally, structural equation modeling examined the effects of attitude, subjective norms, perceived behavioral control, and past TCM use experience on perinatal TCM use intention. P<0.05 was considered statistically significant.

Results

2.1 Basic Characteristics of Participants

The demographic characteristics of the 264 participants are shown in Table 1 [TABLE:1]. The mean age was 31.0 years, with 70.8% (187/264) aged 25-34, 69.0% (182/264) employed, 76.9% (203/264) holding university degrees or higher, 60.9% (161/264) reporting good health status, and 76.9% (203/264) reporting no adverse pregnancy history. Distribution across pregnancy stages and monthly household income was relatively balanced. Women from four provinces/municipalities—Fujian, Beijing, Guangdong, and Sichuan—accounted for 84.9% (224/264) of participants.

2.2 Current Status of TCM Use Among Participants

Overall, 56.1% (148) of participants had used TCM outside pregnancy, while 37.5% (99) used TCM during the current perinatal period. The number and rate of TCM use by stage were: first trimester (10, 15.6%), second trimester (20, 31.7%), third trimester (22, 30.6%), and lactation period (45, 75.0%).

Using perinatal TCM use as the dependent variable (use=1, non-use=2) and pregnancy stage (first trimester=1, second trimester=2, third trimester=3, lactation=4, other=5), past TCM use history (yes=1, no=2), age group (<20=1, 20-24=2, 25-29=3, 30-34=4, 35-39=5, 40-44=6, ≥45=7), education level (middle school=2, high school=3, college/bachelor=4, master's or above=5), employment status (employed=1, unemployed=2), monthly household income (≤5,000 yuan=1, 5,001-10,000=2, 10,001-20,000=3, 20,001-50,000=4, >50,000=5), self-rated health status (poor=1, fair=2, good=3, very good=4), and adverse pregnancy history (yes=1, no=2) as independent variables, multivariate logistic regression analysis revealed that pregnancy stage and past TCM use history were significant influencing factors (P<0.05), as shown in Table 2 [TABLE:2].

2.3 TCM Use Intention and Influencing Factors

Descriptive statistics for TPB constructs and past TCM use experience showed: attitude score (5.49±1.13), behavioral intention score (4.95±1.04), perceived behavioral control score (5.22±1.12), subjective norms score (4.99±1.12), and past TCM use experience score (4.90±1.16). Exploratory factor analysis yielded a KMO statistic of 0.960 and Bartlett's test of sphericity value of 5,539.327 (P<0.001), indicating suitability for factor analysis. The cumulative variance contribution rate was 84.527%, with all item factor loadings >0.700.

Structural equation modeling examined path relationships among variables in the theoretical model. Confirmatory factor analysis showed all fit indices within acceptable ranges (χ²/DF=1.53, GFI=0.96, CFI=0.99, RMSEA=0.04), confirming TPB as a valid predictive model for perinatal TCM use intention. The effects of the four TPB variables (subjective norms, behavioral intention, perceived behavioral control, attitude) and the past TCM use experience covariate on perinatal TCM use intention are shown in Figure 2 [FIGURE:2] and Table 3 [TABLE:3]. Results indicated that subjective norms (β=0.435), perceived behavioral control (β=0.294), attitude (β=0.304), and past TCM use experience (β=0.240) all positively influenced perinatal TCM use intention (P<0.001). Additionally, subjective norms (β=0.459), perceived behavioral control (β=0.591), and past TCM use experience (β=0.306) positively influenced attitude toward perinatal TCM use (P<0.001).

Discussion

3.1 TCM Service Utilization Among Perinatal Women Requires Improvement

Among the 264 perinatal women in this study, the self-reported TCM utilization rate was 37.5%, which falls short of the Implementation Plan's target that by 2025, 90% of tertiary and 70% of secondary maternal and child health institutions should provide specialized TCM services. This indicates that TCM service utilization among perinatal women needs improvement. According to TPB, behavioral intention is a key predictor of actual behavior. This study found that perinatal women had relatively high TCM use intention (4.95±1.04). Strategies to bridge the intention-behavior gap include strengthening perinatal TCM health education and training to foster positive attitudes, encouraging support and recommendations for TCM use from family and healthcare providers to create a positive social environment, optimizing perinatal TCM service processes and accessibility to enhance perceived behavioral control, and developing personalized TCM use plans based on individual circumstances. These measures could effectively translate TCM use intention into actual behavior, thereby increasing the likelihood of TCM service utilization.

3.2 Regional Variations in TCM Service Utilization Require Tailored Strategies

TCM use rates varied considerably among the four regions with the largest participant representation: Beijing had the highest rate (59.3%, 35/59), followed by Guangdong (55.8%, 24/43), Sichuan (30.8%, 12/39), while Fujian had the lowest (9.6%, 8/83). These findings corroborate other studies showing regional differences and diversity in perinatal TCM use [23-24]. Beyond socioeconomic levels, cultural differences, and methodological variations, regional disparities in implementing localized policies for maternal and child health TCM work based on national guidelines also contribute to these differences. For example, Beijing implemented the "Ascending-Descending-Floating-Sinking" project focusing on TCM gynecology and pediatrics [25]; Fujian's TCM health promotion initiative emphasized establishing preconception care clinics in TCM hospitals and TCM specialty services in maternal and child health institutions [26]; and Guangdong developed demonstration bases for TCM work in maternal and child health institutions, aiming to cultivate 15 model institutions within three years [27]. These region-specific policies address local needs and challenges, directly influencing implementation priorities and affecting service delivery to perinatal women. While consolidating TCM work focused on gynecology and pediatrics, regions should also tailor strategies to deepen reform of TCM service models specifically for obstetrics and perinatal populations to further enhance service utilization.

3.3 Leveraging Family and Friends' Influence While Maximizing Healthcare Providers' Role to Promote TCM Services

This study found that subjective norms—opinions of significant others such as family and friends—were the strongest predictor of TCM use intention (β=0.435, P<0.001). Similar findings have been reported for other perinatal health behaviors including diet, exercise, and self-medication [28-29]. For instance, KARIMIAN et al. [28] found that pregnant women in Kashan, Iran who perceived family and friend approval were more likely to use herbal remedies during pregnancy (P<0.05). Compared to Western-influenced women, those from non-Western cultures tend to rely more heavily on family and friends when considering complementary and alternative medicine [30-32]. As LEE et al. [29] noted, subjective norms are deeply rooted in Asian culture and may predict behavioral intention better than attitudes alone. ZHENG et al. [9] found that family and friends' recommendations were primary information sources for traditional/complementary medicine use among breastfeeding women in Macau, with 55.6% reporting insufficient information to make informed decisions and healthcare professionals playing a minimal role in providing such information.

Pregnancy and the postpartum period represent a uniquely sensitive life stage when women are more susceptible to influence from family and friends, sometimes prioritizing others' opinions over their own attitudes. While perinatal medication use carries various risks, safety profiles for many TCM treatments during pregnancy remain unknown [7]. Influenced by traditional beliefs that TCM is natural and harmless, unsupervised perinatal TCM use—intentional or unintentional—poses potential health and safety hazards. Family and friends may lack sufficient TCM knowledge to provide safe recommendations. In response to the growing demand for perinatal TCM services, healthcare providers should pay greater attention to subjective norms in perinatal care. Strategies include enhancing TCM health literacy across the general population to improve family and friends' awareness and trust, thereby leveraging their influence to increase perinatal women's acceptance of TCM services and enhance service capacity in maternal and child health. Additionally, efforts should strengthen perinatal women's own TCM knowledge and health literacy to promote service uptake. Addressing the limited role of medical professionals in providing perinatal TCM information requires recognizing and mobilizing healthcare providers as key players, strengthening their TCM knowledge and skills training to ensure they can provide appropriate and safe TCM services.

3.4 Understanding Past TCM Use Experiences and Developing Life Cycle-Oriented TCM Service Systems

This study found that past TCM use experience significantly influenced both intention and behavior regarding TCM use during pregnancy and lactation, consistent with previous research [21,33]. Prior experiences with TCM, complementary and alternative medicine, or traditional medicines in various countries significantly predict subsequent use during pregnancy or lactation. For example, WEN et al. [23] found that prior herbal medicine use increased the likelihood of use during pregnancy among 16,553 Taiwanese women (OR=5.69, 95%CI=5.46-5.93). Furthermore, this study revealed a positive correlation between past TCM use experience and attitude (β=0.306, P<0.001), suggesting that positive past experiences may help develop favorable attitudes toward TCM during the perinatal period and enhance use intention.

Advancing TCM in maternal and child health is a gradual process. Under the Healthy China strategy, TCM health services are evolving toward comprehensive, life cycle-oriented development [34]. Developing a TCM service system covering the entire life cycle and integrating TCM health concepts and practices into daily life is crucial for promoting perinatal TCM services. Additionally, healthcare providers should assess past TCM use during maternal health services to strengthen safety management and better guide appropriate TCM use behaviors and health management.

Conclusion

This multi-regional survey of pregnant and lactating women at maternal and child health institutions across northern, southern, eastern, and southwestern China demonstrates that TPB can predict factors influencing perinatal TCM use intention. Subjective norms, attitudes, perceived behavioral control, and past TCM use experience all significantly influence Chinese perinatal women's TCM use intention. Given the high intention but low actual utilization, regional disparities, and strong influence of significant others and past experiences, we recommend: (1) implementing tailored, region-specific strategies to deepen reform of perinatal TCM service models; (2) strengthening attention to subjective norms in perinatal healthcare; (3) effectively leveraging family and friends' influence while enhancing healthcare providers' capacity; and (4) accelerating development of life cycle-oriented TCM service systems. These measures will promote TCM service application among perinatal women and advance TCM work in maternal and child health.

Limitations

This study has several limitations. First, TCM use data were self-reported through questionnaires, which may involve measurement bias. Second, as a cross-sectional study using convenience sampling across multiple provinces, the sample may not be representative of all perinatal women in China. Future research should expand the scope and sample size and employ qualitative methods to provide multi-dimensional insights into perinatal TCM utilization behaviors and service uptake.

Author Contributions

LI Zanmei: conceptualized the study, designed the research protocol, and drafted and revised the manuscript. LI Jiao: managed research implementation. YANG Lin: participated in protocol discussion and manuscript revision. YAO Weiwei: collected and organized data and performed statistical analysis. MA Liangkun and XUAN Lei: conducted feasibility analysis and quality control.

Conflict of Interest: The authors declare no conflict of interest.

ORCID IDs:
LI Zanmei: https://orcid.org/0009-0009-4024-2446
LI Jiao: https://orcid.org/0000-0001-6391-8343
YANG Lin: https://orcid.org/0000-0001-9211-0079
MA Liangkun: https://orcid.org/0000-0001-5758-0198
XUAN Lei: https://orcid.org/0009-0000-2653-7795
YAO Weiwei: https://orcid.org/0009-0008-1171-4565

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Received: September 13, 2024; Revised: April 10, 2025
Edited by: JIA Mengmeng