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Abstract

Background: The postpartum period is the most critical period in the mother’s and child’s lives, and integrative medical approaches, including Korean medicine, are preferred for promoting postpartum recovery and managing postpartum symptoms. The socially disadvantaged class is known to be more vulnerable to postpartum depression, obesity, and bleeding, and the National Medical Center is undertaking Korean medicine-based postpartum health management projects for the socially disadvantaged mothers. However, clinical evidence and research data on integrative medicine-based postpartum care to expand the scope of these postpartum programs to help these women are lacking. Aim: To investigate the barriers, benefits, and limitations of integrative medical postpartum health management programs for the socially disadvantaged mothers and investigate the experiences of this population. Methods: A qualitative research methodology is used, and a semi-structured, open-ended interview will be conducted. The interview will be conducted among 10 or fewer participants, with each interview session lasting for 60–120 min. Data will be analyzed using grounded theory framework proposed by Strauss and Corbin. Significance: This study will shed light on the users’ experiences and benefits, unmet needs, and limitations of Korean medicine-based postpartum management programs for the socially disadvantaged mothers. The findings will be useful for the improvement of postpartum care programs and used as foundational data for the protocols of quantitative studies in the future.

Keywords

grounded theory research Korean medicine postpartum care postpartum depression postpartum health management program postpartum period postpartum symptoms qualitative research socially disadvantaged class

Background

The postpartum period is defined as the time following the delivery of the fetus, placenta, and relevant products of conception during which the reproductive organ is restored to the non-pregnant state (Joo & Yoo, 2015) This is a crucial period that is marked by physical and psychological reintegration, including the mother’s physical recovery and changes to assume the role of a mother (Soomunsa, 2012). The World Health Organization explains that the postpartum period’s significance is often depreciated despite being the most critical period in the mother’s and child’s lives (World Health Organization, 2014). During this period, mothers experience physical problems, including rapid fluctuations in hormones, breastmilk production, postpartum pain, pain at the episiotomy site, and extreme fatigue, as well as emotional problems, including psychological burden of having to care for a newborn; these problems have a grave impact on the mother’s quality of life (McGovern et al., 2006). In particular, 10%–15% of women experience postpartum depression (O’Hara, 2009), a mental health problem wherein preventive interventions can have dramatic benefits (O’Hara & Swain, 2009). As postpartum depression can have an adverse effect on the mother–child interaction (Sevimli et al., 2020) and can easily be neglected due to the absence of characteristic clinical features, an aggressive support system should be implemented, starting from the primary care settings, to promote healthy delivery and foster desirable parenting environments (Park & Seo, 2021). In Western medicine, normal recovery is considered possible in the due course of time and without any particular medical intervention post-delivery in most cases (Yoo, 2004), and postpartum complications are managed based on organic injuries (Song & Yoo, 2011), with a focus on physical care that primarily involves the care of the reproductive organs (Jeong, 2000). However, post-delivery women experience a wide range of symptoms, varying from physical pain to systemic syndrome, which includes autonomic dysfunction (Lee et al., 2007), and although depression manifests as physical complaints (Yoon et al., 2009), these symptoms are not addressed in Western medicine.

Thus, an integrative medical approach, including Korean medicine (KM), is preferred to promote postpartum recovery and manage the abovementioned post-puerperal symptoms. In the United States in 2006, 67% of women aged 18–44 years were reported to avail of complementary and alternative medicine (CAM) services, such as mind–body therapies, biologically based therapies, and manipulative body therapies, for prenatal and postpartum care (Johnson et al., 2016). A prospective observational study conducted in Korea that examined the effects of a 6-week herbal therapy primarily based on saenghwatang-gamibang, acupuncture at SP06 and LR03, pharmacoacupuncture, moxibustion, interferential current therapy, and hot pack, was reported to have a positive effect on the quality of life postpartum (Kim et al., 2017a, 2017b). Furthermore, the significant medical effects of integrative medical approaches have been documented in a Malaysian study that reported markedly positive effects of CAM-based postpartum care comprising manipulative body therapies, including massage, reflexology, hot stone compression, and body wrapping in postpartum women (Nik Yusof Fuad et al., 2020).

Postpartum women belonging to socially disadvantaged classes are reported to be more vulnerable to depression (Goff et al., 2020), postpartum obesity (Silfee et al., 2018), preeclampsia, and postpartum bleeding (Choe et al., 2016). In Korea, there are more welfare provisions available for socially disadvantaged postpartum women to increase the maternal age and low fertility rate (Lee et al., 2002). The National Medical Center that is in charge of public health has been undertaking KM-based postpartum health care projects for the socially disadvantaged classes since 2017. KM-based postpartum care includes acupuncture, moxibustion, pharmacoacupuncture, cupping, and herbal medicine. The treatment targets all aspects from mental health to physical symptoms of new mothers. These KM-based interventions can prevent postpartum inflammation, thrombosis, and anemia (Park, 2001); alleviate finger arthralgia, low back pain, pelvic pain, and coccyalgia in the early postpartum period (Jang & Kim, 2015); and help manage postpartum depression and acute mastitis secondary to lactational stagnation (Seo & Kim, 2003). Therefore, postpartum care programs are anticipated to promote the postpartum recovery of socially disadvantaged women. However, more clinical evidence and research data on integrative medicine-based postpartum care are needed to expand the scope of these postpartum programs to help these women.

The collection of such clinical evidence requires a qualitative survey of the specific types of integrative medical interventions undertaken for specific symptoms and their benefits among socially disadvantaged postpartum women. In particular, earlier observational studies primarily reported the effectiveness and safety of combined interventions, although it is important to pinpoint which element of the interventions contributed to the treatment outcomes. Furthermore, the psychological, social, and economic barriers confronting integrative medical treatment should be investigated. These findings will serve as the foundation for subsequent quantitative studies. In this context, we intend to conduct a qualitative study using in-depth interviews to investigate the experiences, barriers, benefits, and limitations of integrative medicine-based postpartum care programs in socially disadvantaged postpartum women. The aim of this study is to devise improvement strategies for postpartum health care programs and to investigate the gap in the perspectives of health care service consumers and providers.

Explanation and Justification of the Method

Objectives and Research Questions

The primary purpose of the study is to conduct a qualitative study on the experience of participants in a postpartum health care project:

1. Experience with childbirth and postpartum care for vulnerable mothers: experience with psychological and physical changes after childbirth, demand for economic, social, and medical support necessary for postpartum care, and an in-depth understanding of overall postpartum care experience

2. In-depth understanding of the participants’ experience with KM postpartum health care: the motivation for seeking KM medicine postpartum health care services, expectations, effects, limitations, and improvement plans

3. Strategies for revitalizing postpartum health care projects in the future: system, awareness, and evidence

4. Recognition of the differences in perspectives and strategies between users and providers of medical services

The secondary purpose is to identify the efficacy and problems of the project by conducting a qualitative study of mothers who actually participated in the project and to present new implications and strategies for program improvement and expansion. These data will be useful in public health.

The research questions are as follows:

1. What are the difficulties of using KM postpartum care?

2. Why did you choose a KM treatment approach for postpartum care, and what are the benefits?

3. What improvements have you experienced after receiving the KM-based postpartum care?

Research Design and Study Setting

We chose a qualitative analysis approach because the study’s aim was to examine and analyze the participants’ lived experiences and opinions. Qualitative research methodology is an excellent means to understand the patients’ values and preferences.

A qualitative exploration of the needs and expectations of patients who seek KM-based postpartum care services and the improvements needed in this methodology will enable a more fundamental examination of the effectiveness of Korean medical interventions and clarify the targets and objectives of future research and health projects. The interviewer will ask questions previously described in the interview guideline (see Table 1) as well as follow-up questions based on the participant’s responses. This study will be conducted from May 7, 2020, to May 6, 2021, at the NMC. The NMC has conducted a Korean Medicine Postnatal Health care Program (KM-PHP) for socially disadvantaged postpartum women since 2017. Seoul residents within 3 months of delivery who are considered to belong to a socially disadvantaged class (Type I or II medical aid beneficiaries or medical aid beneficiaries with a median income ≤80%) are eligible to benefit from the KM-PHP. Eligible women are given tailored treatment, such as herbal medicine, acupuncture, moxibustion, herbal acupuncture, and chuna, within a certain cost range, based on their postpartum symptoms (e.g., pain, fatigue, edema, dysesthesia, and depression). The treatment generally lasts for a month, and additional treatment may be given depending on the patient’s situation. We will conduct a 1:1 in-depth interview with the participants of this program to examine the women’s experiences with the KM-based postpartum care.

Table 1.

Semi-structured open-ended interview guide.

Understanding of delivery and postpartum care experiences
Q1	How have your mind and body changed after the delivery?
Q2	What type of assistance was most needed during your postpartum care?
Q3	What types of financial, social, and medical help would you like?
Q4	How did you care for your body after the delivery? What did you experience during the process?
Q5	Are you ready to take care of your child? If not, what additional assistance do you need to take good care of your child?
In-depth understanding of KM-based postpartum care experiences
Q6	How did you participate in the KM-PHP?
Q7	What expectations did you have of the KM-PHP?
Q8	What physical and psychological changes did you experience after participating in the KM-PHP?
Q9	What were some shortcomings of the KM-PHP? How do you want them to be changed?

Note. KM = k=Korean medicine; KM-PHP = Korean medicine postnatal health care program.

The interviews will be conducted in a conference room at the NMC or at other places that are easily accessible to the participants to help them relax, and each interview is scheduled to last for 60–120 min.

Recruitment

Inclusion Criteria

1. Prior participation in the NMC’s KM-PHP

2. Voluntary consent to participate in the study

Exclusion Criteria

1. Severe mental health status, intellectual disability, mood disorder, and other cognitive problems that impair communication and thus hinder the individual’s participation in the interview.

Recruitment and Sample Size

Study participants will not be recruited through a theoretical sampling method; instead, women who visited the NMC for the KM-PHP who meet the inclusion criteria will be included in the study if they sign a written informed consent for study participation. After obtaining the consent form, the interview can be conducted in person or online at a later date in accordance with the participant’s preference.

This study draws on the principles of grounded theory. Although the sample size cannot be determined with grounded theory, as there are generally 6–10 participants in Korean studies (Hong & Whee, 2020). Thus, we will set the maximum number of interviewees to 10; even if the sample does not reach 10, we will end the study when the data reaches saturation with sufficiency and appropriateness. Saturation refers to a state wherein no new information emerges and sufficient data have been obtained to replicate the study (Fusch & Ness, 2015).

Data Handling

Data Collection

This study uses a semi-structured, standard open-ended interview method for data collection. This type of interview is the most widely used method in qualitative studies, as it enables interviewees to express their opinions freely within a partly established structure and constitutes the least possibility of researcher bias. One shortcoming of this approach is the lack of limit to the types of responses that the participants can give, which may result in a massive amount of data; as a result, it would be difficult to code the data based on similar themes for analysis.

The interview guide was developed in advance based on a discussion with a research team that comprised KM-licensed doctors with rich experience in qualitative research. The study questions were in-depth questions about postpartum changes, general postpartum care, and KM-based postpartum care (Table 1). The interview process is delineated below (Figure 1).

Figure 1.

Interview process.

The interviews will be audio- or video-recorded (if a video conference software is used) after obtaining participant’s consent, and the participants’ facial expressions or characteristic behaviors that may not be captured through audio recording will be recorded in writing for reference during the analysis. Each participant will be interviewed once (for up to two interviews); after the interviews, any responses that may be incomplete will be supplemented through an additional interview, phone interview, or email interview.

Analysis

Data Analysis Plan

In this study, we will use grounded theory research analysis proposed by Strauss and Corbin (1997). We will purchase the Nvivo12 PLUS (QSR International, Burlington, MA, USA) software to analyze the qualitative data. Interview recordings will be transcribed ad verbatim.

With this technique, instead of collecting all study data at once through theoretical sampling for analysis, primary analysis will be performed during or after the first round of data collection to make decisions regarding the additional data to be collected, and the process of collecting and analyzing the data is repeated. Herein, the researcher collects data, simultaneously analyzes them, and returns to the field to collect additional data, and this entire process is repeated. Each concept and category are formulated via induction through repetitive comparison. The researcher reads the interview transcript and field notes for each participant several times, extracts significant contents, and clusters similar content. Clustering similar content results in the creation of several comparable groups. Then, subcategories that encompass similar contents and broader categories that encompass similar subcategories are also established. Appropriate themes are formed after finalizing the categories.

The first round of analysis is performed by the interviewer, and to ensure the objectivity of the analytical process and results, the transcripts and analysis results are shared with an external researcher with a PhD in KM and experience in qualitative research and are revised based on the advice and discussion. The external researcher does not have access to patient information and case report form (CRF) and only has access to de-identified interview transcripts and results of analysis.

Trustworthiness

Triangulation was performed to compare nonverbal expressions, CRF, and audio-recordings in order to establish the reliability and validity of a qualitative study. In addition, the validity of the coding performed by the main interviewer will be verified by one independent researcher. The quality of the study reporting is enhanced by using the consolidated criteria for reporting (COREQ) guidelines, and for the data analysis, a randomization table will be created using Excel to randomly select and verify the data.

Data Management

To protect the participants’ privacy and confidentiality of the study data, all data will be stored in a double-locked cabinet, and electronic data will be stored in a locked file in a computer with restricted access. The participants will be given a number according to their number in the enrollment list when signing the informed consent (study enrollment), and the participants’ names will be coded with initials. The interview data will only be used for research purposes. Any personally identifiable information (e.g., name, resident registration number, address, and phone number) will not be used in the article, and we will ensure that the confidentiality of personal information is protected and that the participants will be informed of this fact. The recordings will be encrypted and stored in a password-protected computer in the laboratory and will be discarded by shredding or incineration at 3 years after the study’s conclusion. Per Article 15 of the Enforcement Decree of the Bioethics and Safety Act in 2020 (Enforcement Decree of the Bioethics and Safety Act, 2020), all research-related records will be retained for 3 years from the end of the study, and documents that passed this storage period will be discarded per Article 16 of the Enforcement Decree of the Personal Information Protection Act.

Ethics and Dissemination

This study will be performed in adherence to the Declaration of Helsinki of 1964. Information about the study and a written informed consent form will be provided to all participants. The consent form and information sheet will include information about the title of the study, background and objectives, inclusion criteria, research method, anticipated study duration, benefits of participation, side effects, risks, or discomforts from participation, compensation, and cost. The decision to participate in the study is made voluntarily, and there are no disadvantages for nonparticipation. Furthermore, participants may withdraw from the study at any time, and upon withdrawal, their personal information will not be used in the study and will be permanently deleted. The researcher will obtain a written informed consent from the participants after providing an adequate explanation about the study. The participants’ anonymity will be ensured, and all personally identifiable information will not be disclosed.

This study protocol was submitted to the Institutional Review Board (IRB) of the NMC and was approved on May 7, 2020 (IRB No. H-2004-116-006). The protocol of this qualitative study was registered on the Clinical Research Information System (Registration no. KCT0005968) on March 8, 2021. The study results will be disseminated through newspapers, journals, and conference proceedings.

Rigor

Many methodologies have been utilized and will continue to be carried out in the future. Our study approach meets the trustworthiness criteria set out by Lincoln and Guba (1986).

1. Credibility: To meet the credibility criteria, during the interview process, the interviewer will pay close attention when collecting, analyzing, and reporting information without manipulation. Transcripts recorded by the researcher will be handed over to the interviewee for further verification.

2. Transferability: Although the study will be conducted on vulnerable mothers, the results of this study can be applied to the general postpartum women.

3. Dependability: During the interview process, LDE will take field notes to document the subjects’ immediate responses and to maintain the consistency of the research results.

4. Conformability: The interviewer will have an open attitude to ensure long-term interview participation and to preserve the neutrality of the study. All measures will be taken, including documenting the interview.

Full Copies of Interview Schedules/Focus Group Schedules/Fieldwork Plans

For the interview questions that we will use in our study, please see Table 1.

Discussion

This study is a qualitative research for gaining an in-depth understanding of the lived experiences of socially disadvantaged postpartum women who participated in a KM-PHP. After this study is completed, the lived experiences of low-income postpartum women who participated in an integrative medicine postpartum care program can be analyzed in depth, which would provide information about the benefits and limitations of the program and the mothers’ unmet needs in terms of integrative medicine-based postpartum care.

After delivery of a baby, women recover their pre-pregnancy anatomical and functional states and mentally adjust to a mother’s roles during the postpartum period. In general, the 6-week period after delivery is considered a crucial period for the mother’s recovery of health and neonatal management, and many health experts emphasize the importance of maternal and neonatal care during this postpartum period (Kim & Yoo, 1998). In Western medicine, the postpartum period is defined as a period in which pregnancy- and delivery-induced uterine and physical changes revert to their pre-pregnancy states (Korean Society of Obstetrics and Gynecology, n.d.). Thus, while medical treatment and care are deemed necessary to promote effective healing and to prevent complications, normal recovery is considered possible after some time without special medical treatment for most cases of natural or cesarean section deliveries (Hwang, 2001). Pharmacotherapy is considered the standard of care for postpartum depression in Western medicine and thus is widely used, but postpartum women often are hesitant to take antidepressants out of concern for their adverse effects or their impact on breastfeeding (Chung et al., 2012).

According to the 2013 report (Lee, 2013) by the Korea Institute for Health and Social Affairs, an in-depth interview with pregnant women revealed that the greatest challenges after delivery were physical issues regarding postpartum care, delayed recovery, and childrearing, and that the women also had severe mental stress; based on which, the report called for policies to address the physical and mental health of mothers and children after delivery. Thus, more aggressive medical and social interventions will be needed. With regard to KM-based postpartum care, studies have examined medical interventions using acupuncture (Kim et al., 2017a, 2017b), electroacupuncture (Su et al., 2020), moxibustion (Wang et al., 2019), and herbal medicine (Kim et al., 2018), but research on women’s experiences with postpartum recovery and KM-based treatment is scarce.

Furthermore, previous studies have neither assessed the current postpartum care programs administered by each local government and agency as part of their effort to manage high-risk pregnant women and to encourage pregnancy nor conducted an in-depth exploration of the unmet needs or difficulties in utilizing integrative medicine among postpartum women. Existing projects pertaining to low fertility mostly provide prenatal support (subfertility), and postpartum support includes maternal and newborn health management programs (postpartum helper support, postpartum care subsidy), financial support for congenital metabolic disorder, early diagnosis of neonatal hearing impairment, and financial support for preterm infants; thus, there is a lack of continuous health support projects for mothers who delivered the baby and who often are the primary caretakers.

In addition, although Korea’s national health insurance system covers KM-based treatment, thus enabling consumers to utilize KM interventions at a relatively reasonable cost, herbal medicine—the primary intervention used for postpartum care—is not covered by health insurance and may be expensive. To address this concern, various local governments in the Jeju Sepcial Self-Governing Province, the city of Yeongju in Gyeongbuk, the city of Suncheon in Jeonnam, Damyang-gun in Jeonnam, and the Association of Korean Medicine have recently launched a project to provide herbal medicine for postpartum women, as research on this project is lacking. Qualitative studies have been conducted on postpartum depression in Korean women (Lee, 2015), the postpartum care experiences of Chinese immigrant primiparas (Eun et al., 2016), and interventions for postpartum depression and counseling programs for husbands (Yonghun et al., 2018), but these studies have not dealt with the utilization of integrative medicine.

Therefore, the present study will be able to explore the experiences of socially disadvantaged women with a KM-based postpartum care program, their unmet needs, and the limitations of the programs.

These findings will be useful as foundational data for developing postpartum programs in the future or for the protocols of quantitative studies. This study protocol has a few limitations. First, this study is an interview-based qualitative study; therefore, we would not be able to verify the effects of KM-based postpartum treatment. However, we would be able to examine the aspects that were helpful and the subjective effects of the program in postpartum women; therefore, the findings of this study are expected to present data on the focus areas for subsequent quantitative studies. Another limitation of the study is that the participants will be limited to the beneficiaries of a postpartum care program. We chose this study population in an attempt to conduct an in-depth exploration of a specific class of postpartum women, that is, the socially disadvantaged postpartum women; however, subsequent studies should enroll a representative sample from the entire population of postpartum women as well as include other stakeholders, such as health care providers and policymakers.

Supplemental Material

sj-pdf-1-ijq-10.1177_16094069211046429 – Supplemental Material for Lived Experience of Participants of a Korean Medicine-Based Postpartum Program: A Protocol for a Qualitative Research Study

Supplemental Material, sj-pdf-1-ijq-10.1177_16094069211046429 for Lived Experience of Participants of a Korean Medicine-Based Postpartum Program: A Protocol for a Qualitative Research Study by Inae Youn, Han-Song Park, Do-Eun Lee, Hyo-Weon Suh and Joohee Seo in International Journal of Qualitative Methods

Footnotes

Declaration of Conflicting Interests

The authors declared that there is no conflict of interest with respect to the research, authorship, and/or publication of this article

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Research Institute of Public Health of the National Medical Center [grant number NMC2020-PR-02] in 2020.

ORCID iDs

Inae Youn

Han-Song Park

Do-Eun Lee

Hyo-Weon Suh

Joohee Seo

Supplemental Material

Supplemental material for this article is available online.

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