Fung-Kei Cheng

Review article

Taijiao：a traditional Chinese approach to enhancing fetal growth through maternal physical and mental health

Fung-Kei Cheng

A R T I C L E I N F O

Article history：

Received 13 April 2016

Received in revised form

25 April 2016

Accepted 4 May 2016

Available online 17 June 2016

Bio-psycho-social approach

Gynecology-obstetrics care

Maternal-fetal symbiosis

Maternal health promotion

Despite the fact that Taijiao（traditional Chinese eugenics）has been part of the Chinese obstetrical culture over the years，there is insufficient scientific evidence for its effectiveness.This literature review analyzes the discourse on Taijiao associated with physical and psychological maternal-fetal symbiosis，together with relevant peripheral research outcomes.Taijiao combines maternal health and external environment for benefits in fetal growth through preventive，indirect，and direct measures.Discussing practical implications and future research directions，this review reveals a modernized Taijiao to be a holistic，noninvasive pregnancy management system using a multi-disciplinary approach that enhances infantile life quality，reduces negative consequences of pregnancy deficits and child development，and saves public health expenditure.

©2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons.org/licenses/by-nc-nd/4.0/）.

1.Introduction

Taijiao，as ancient Chinese eugenics is articulated in philosophical，medical，literature，and historical texts，has been widely adopted among pregnant women in China.It commenced more than 3600 years ago and has been part of China's obstetrical culture since the Han Dynasty.1Taijiao acknowledges the significance of maternal physical and psychological health as well as the external environment，in affecting not only fetal growth2but also infant development.It combines Chinese medical theories and clinical experience，3even applying Western medicinal concepts to Taijiao from the early 20th century，4in order to promote maternal and neonatal health.Thus，academia has increased its interest inTaijiao，despite a scarcity of empirical studies.5This literature review analyses the present discourse related to such conventional wisdom，which has been agreed upon in updated，relevant peripheral research studies.Initially，the review describes the concept and practices of Taijiao，while subsequently assessing its underpinnings in scholarly projects，which brings out practical implications and future inter-disciplinary research for modernizing the use of Taijiao that contributes to the health of the citizenry over their whole lifetime.

Commonly translated as“fetal education”，6，7tairefers to fetus and jiao to teach.In addition，various other renditions also exist；for example，antenatal training，8prenatal training，9prenatal education，10prenatal influence，11and fetal or prenatal instructions.12However，Taijiao dissociates embryos from education or training in the womb，even though fetal associative learning，13-16fetal language learning，17and short-term memory after 30 weeks18may be feasible.The term Taijiao is used throughout this review to reflect this idea more accurately，being closely connected to fetal protection and development by means of maternal health promotion，19thereby illustrating a maternal-fetal synchrony.20

Taijiao is a series of purposive preparations during gestation that exert direct or indirect influences on physical and psychological aspects of pregnant women for the sake of positive fetal development regarding physiologicaland mentalhealth：21，22Taijiao inception is recommended as early as the second month of pregnancy.23Its benefits comprise better embryonic growth of sensory，neurological，and physical functions，along with infantile development in language learning and psychological well-being，24thus indicating an extended impact on progression from the fetus and adolescent stages to the whole life span.

2.Maternal-fetal symbiosis

Chinese literature details Taijiao methods that can be distributed among various domains：preventive，indirect，and direct methods.

http：//dx.doi.org/10.1016/j.cnre.2016.06.001

2095-7718/©2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons. org/licenses/by-nc-nd/4.0/）.

2.1.Preventive methods

Liu，25a renowned scholar in the Han Dynasty，emphasized preventive measures，including the avoidance of graceless sleeping，sitting and standing postures，of noxious and toxic foods，and of unpleasant scenes，and unlovely sounds.Research supports his propositions，cautioning that inappropriate sitting and standing postures can possibly result in low birth weight，26and improper sleeping positions may potentially lead to stillbirth.27，28

Furthermore，sleeping quality affects maternal and fetal outcomes；however，sleeping problems are common，29particularly in late pregnancy，30because ofhormonaland psychological changes.31Sleeping disorders and short sleep duration may induce pre-term deliveries32and a greater latency in post-partum depression.33

Harmful substances primarily degrade health in pregnancy especially liquor，narcotics，and nicotine.Prenatal alcohol consumption evokes alcohol-related neuro-developmental disorders，developmental delays，and central nervous system dysfunction. Alcohol-affected neonates will suffer from behavioral，learning，and mental disabilities，hurting their self-regulation and adaptive skills.34Similarly，the data elucidate a correlation between prenatal substance abuse and lower birth weight，resulting in higher risks related to childhood psychotic problems.35Probing substantial evidence，scholars warn of the effects of cigarettes smoking in pregnancy，covering sudden infant death syndrome，placental disruption，perinatal mortality，fetal growth restriction，lower birth weight，child behavioral deficits，neuro-cognitive decrements，intelligence reduction，chronic pulmonary diseases，and childhood cancer.36-45Even maternal passive smoking shows positive correlation with pre-term birth，46，47asthma in childhood，48and child behavioral problems.49These may further associated with ongoing difficulties in adolescence as well.50-52

Environmental noises deteriorate sleep quality and therefore affect the endocrine system，being adversely associated with anxiety.53，54Apart from the inimical consequences of poor sleep，as accounted forearlier，noise-generated stress55，56can cause miscarriage，prematurity and intrauterine retardation，and noiseinduced hearing loss in newborns.57Noise exposure during pregnancy should be obviated.

2.2.Indirect methods

Indirect Taijiao58refers to fetal growth affected by maternal conditions and external factors，including emotions，diet and nutrition，exercise，climate，and living environment.Folk practices also apply in choosing good names for babies，and looking at beautiful baby photographs，59which nurture psychological satisfaction in pregnant women.

Evidence-based research shows gestational psychological state to be a determinant of mental maternal-fetal association60；therefore，emotional training is an essential component in maternal programs.61Negative emotions，such as anger and panic，not only devastate the maternal mental state but also impact fetal development.62，63Women who are depressed in maternity produce a chemically imbalanced prenatal environment that impacts embryonic growth，64，65including its physiology and behavior，66and childhood mental health.67，68Akin to depression，maternal stress and anxiety damage fetal neurodevelopment，69and engender lifetime detrimental effects on the brain，70potentially resulting in offspring schizophrenia.71

Balanced nutrients build health and strong bodily functions；poor nutrition in pregnant women results in a higher incidence of growth retarded newborns.72In addition to healthy diets，vitamin D supplementation is proposed during pregnancy and early childhood，which is likely to reduce autism.73Taking balanced energy，protein，and mineral supplementation is also suggested because this decreases stillbirth and neonatal mortality，74and enhances infant health.75In contrast，over-nutrition and maternal obesity impair fetal growth，76possibly yielding attention-deficit hyperactivity disorder symptoms and behaviors among offspring.77

Together with diet and nutrition，maternal activities contribute to embryonic development78and minimize the risk of a mother being overweight.Regular safe physical exercises are positively indicated for fetal growth79and favorable long-term health effects.80They also reduce the risk of inadequate birth weight，81achieve better maternal and fetal emotional states，82，83shorten labor and hospital stays，84and decrease pregnancy-related lumbopelvic pain.85Recently，guided yoga programs for pregnant women have become prevalent，which is conducive to utero-fetalplacental circulation86and improvements in labor and birth outcomes.87Prenatal meditation is effective for pregnant women in dealing with pregnancy challenges and improving emotional wellness and social relationships.88

Unfavorable environmental factors hinder maternal and embryonic health.89Long exposure to a polluted indoor environment can incur spontaneous abortion or premature birth.90Chemicals such as pesticides restrict fetal growth in weight，length，and head circumference.91Moreover，adverse outcomes in climate change hamper the health of pregnant women，fetuses，and newborns.92

2.3.Direct methods

Direct Taijiao refers to sensory stimulation（not limited to sound，light，and vibration）provided to pregnant women in order to yield advantageous fetal outcomes，including music Taijiao，dialogue Taijiao，massage Taijiao，touching Taijiao，and light Taijiao，93among which music Taijiao is the most popular.

The auditory-motor system is nearly developed around the 16th week of pregnancy，94andphysiological and behavioral responses to musical rhythm are observable.95The findings of a project conducted with 31 participants in the experiment group and 29 in the control group96demonstrated that infants who received music Taijiao were able to recognize the Taijiao music，reflecting infantile listening memory.Music Taijiao consists of popular music，97music appreciation，singing，and the use of musical devices.98In one study，260 pregnant women listened to 15 minutes of soft music throughout a four-dimensional ultrasound，while at the same time touching the abdomen.10Results included decreases in umbilical artery resistance index and systolic-diastolic ratios，denoting an increase in umbilical cord blood flow in placental perfusion with a reduction in resistance，growth of fetal aortic flow velocity and cardiac output；but a reduction in resistance index and systolicdiastolic ratios in the fetal middle cerebral artery.These reflect positive effects on fetal development due to improved blood circulation，cardiac output，and blood supply to the brain.Similarly，a randomized controlled trial with 126 participants in the intervention group and 134 in the control group assessed how antenatal music exposure affects neonatal behavior.99Women in the 20th week of pregnancy in the intervention group listened to the prerecorded music 50 minutes every day.Outcomes reported better regulations in behavioral states and autonomic stability of the participants，and better motor performance in their newborns. These suggest the future invention of marketable products100；for instance，Taijiao music trousers for pregnant women.101

Touching and dialogue Taijiao are likely beneficial to fetuses.An intervention group with 1350 participants（using these two methods）reported shorter checking duration for fetal heart rate and less unidentified checking results through an electronicinstrument compared with a control group with 1352 participants.102This prevented diagnostic errors in protecting maternal and fetal health.

3.Evaluating the effects of comprehensive Taijiao interventions

Researchers have investigated the effectiveness of Taijiao by offering maternal programs.Lü and colleagues103conducted research with 100 participants，evenly distributed between a control group and an experiment group.The participants in the experimentgroupjoinedacomprehensiveTaijiaoprogram，including psychoeducation and diet guidance，8 hours of sleep，and hour-long walks.They listened to 30-minute music sessions over the first 20 weeks，once or twice a day.They also adopted dialogue and touching Taijiao，recited poetry daily，appreciated painting，and spent time relaxing.Significant variations were apparent in the experiment group：more regular delivery cases（88%versus 80%），less premature labor and abnormal delivery（8%versus 24%），greater willingness to breastfeeding（80%versus 64%），and more 3000 g-infant minimum birth weights（58%versus 34%）.Follow-up observation（of children aged 30 months）reported better child development in the experiment group，including standing，walking，and language learning.Results indicated benefits in infantile sensory development that is important for intelligence development.

One survey with 404 respondents in Nanchong，Sichuan104reported that music Taijiao（96.2%），touching Taijiao（87.7%），language Taijiao（81.4%），and emotional taijaio（67.8%）are the most popular.Taijiao music（55.4%）and light music（27.2%）were commonly used.More than half（67.2%）touched their abdomen for less than 5 minutes.With respect to language Taijiao，82.3%talked to the fetus，while 52.6%sang or told stories.In addition to emotional Taijiao related to self-regulation（70.6%），improvements in family relationships（48.8%），and provision of a comfortable living environment（45%）were adopted.

Another 30 cases were monitored for TORCH（Toxoplasma gondii，rubella，cytomegalovirus，and herpes simplex virus）indexes，from Taijiao embryos to infants，in which a Taijiao series was implemented，consisting of nutrition guidance，pregnancy knowledge，music，art appreciation，dialogue，and hotline counseling.11Results displayed relationships between Taijiao and fetal brain development.Comparing 60 healthy children to 60 children with autism，the findings of another researchproject indicated that more parents of the healthy children started Taijiao within the first three months of pregnancy，105showing potential benefits of early Taijiao to fetal development.

4.Practical implications and future research directions

With the advent of the relaxation of one-child policy in 2016 in China，an increase in birth rate is expected.Meanwhile，rapid economic growth leads to prosperity，which demands a high quality of gynecology-obstetrics care for pregnant women，fetuses，and children.Given the complex dynamic of maternal emotions and fetal physiological and psychological development，it is recommended that communities provide pregnancy-friendly facilities，in addition to advanced medical technology，including esthetic and warmly designed wards，amicable care and services（for example，soft music，gentle lighting，and comfortable temperature），thereby attaining encouraging results，such as a reduction in prenatal and neonataldepression.Nevertheless，well-designed research is needed in order to look into how to optimize the effects of this synergy.

Current prenatal training programs focus on pregnant women. However，they disregard the positive correlation between social relationships and emotional health，106which comprises family and working relationships.In particular，the father's role is overlooked，107and the Yin-Yang theory8related to Taijiao is seldom discussed.Research has explained genetic influences on alcohol consumption in fathers，and reinforces positive involvement in preventing their partner's alcohol use.108Hence，harmonious couple interaction not only contributes to the inborn physical health of fetuses but also reduces stress levels in pregnant women，109which calls for in-depth examinations，especially in developing countries，as to how fathers can contribute to Taijiao or enrichment in prenatal programs.

Aside from the family relationship，peer relationships in the workplace are important for working women.Public health and labor policy makers take the responsibility for promoting supportive organizational culture and enacting related policies to facilitate pregnancy-friendly workplaces.Taijiao extends from the individual to the social realm，accommodating contemporary contexts.

In addition to the prevalence of Western medical concepts incorporated into Taijiao in order to modernize this traditional practice，its usefulness can also be widened through coupling with other Chinese elements，for example，qigong，110，111and taiji，112or integrating into creative programs，for instance，aromatherapy，113art therapy，114massage therapy，115and passive hydrotherapy.116Such a synthesis blossoms out from traditional Chinese medicinal theories，forming an alternative resource to gynecology-obstetrics care that offers options for users and practitioners.However，evidence-based projects are necessary for reliability and validity.

5.Conclusions

Taijiao approaches traditional Chinese maternal health through a comprehensive view related to the physical and mental aspects of both pregnant women and embryos.It links the maternal body--mind complex to that of the fetus117through direct and indirect measures，such as cultivating tenderness，receiving nutrition，living in a quiet room，listening to music，reading poetry，behaving gently，viewing beautiful scenes，and listening to praise.9，118This biopsycho-social approach initiates a holistic perspective，119in alignment with modern medical principles and practices.This literature review reveals a modernized Taijiao in a cross-disciplinary model for non-invasive pregnancy management that can enhance infant life quality and reduce health expenditures across a spectrum of maternal and adolescent circumstances.

Conflicts of interest

All contributing authors declare no conflicts of interest.

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How to cite this article：Cheng F-K.Taijiao：a traditional Chinese approach to enhancing fetal growth through maternal physical andmentalhealth.ChinNursRes.2016；3：49-53.http：// dx.doi.org/10.1016/j.cnre.2016.06.001

E-mail address：oasischeng@yahoo.com.

Peer review under responsibility of Shanxi Medical Periodical Press.