Journal of Midwifery & Women’s Health www.jmwh.

org
Original Research

Preliminary Clinical Evaluation of Acupuncture Therapy

in Patients With Postpartum Sciatica
Bing-Shu He, PhD, Yang Li, APN, Tong Gui, PhD

Introduction: This study evaluated clinical outcomes following acupuncture treatment of postpartum sciatica.
Methods: One hundred eleven women with postpartum sciatica were enrolled in an acupuncture group (n = 86) or a control group (n = 25),
according to their preference. Participants in the acupuncture group attended acupuncture therapy sessions 3 times a week for 4 weeks, while
participants in the control group were assigned to bed rest. Outcome measures included the Roland Disability Questionnaire for sciatica, a visual
analog scale for leg pain, and patient-reported perceived recovery. In addition, participants were surveyed after treatment to assess the acceptability
of acupuncture therapy.
Results: The outcome scores for disability and leg pain were significantly lower in the acupuncture group compared with the control group
(P ⬍ .05). All 86 women in the treatment group stated that acupuncture improved their well-being after treatment. At one month after treatment,
98% of participants in the treatment group reported recovery compared with 24% of the control group participants (P ⬍ .001). After treatment,
95% of lactating women in the acupuncture group believed that acupuncture had no significant interference with breast milk production. No
adverse effects of acupuncture were reported. All participants in the acupuncture group stated they would choose acupuncture in case of relapse.
However, the recurrence rate of sciatica in the acupuncture group (32%) was comparable to that of the control group (35%) at the one-year
follow-up interview.
Discussion: Compared with bed rest, acupuncture might be an effective and acceptable strategy to relieve symptoms of postpartum sciatica.
J Midwifery Womens Health 2018;63:214–220  c 2018 by the American College of Nurse-Midwives.

Keywords: acupuncture, postpartum, sciatica

INTRODUCTION Various management strategies have been proposed for pa-

Sciatica, more accurately called lumbosacral radicular syn-
drome, is a common condition worldwide.1,2 Despite the fact
that about 90% of sciatica cases are caused by an interverte-
bral disc herniation resulting in nerve root irritation (known
as discogenic sciatica),1 some percentage of sciatica patients
have no disc disease. Yoshimoto et al2 reported that 16.4% of
sciatica patients showed no nerve root compression in lum-
bar magnetic resonance imaging. Among these cases of sciat-
ica without evidence of disc disease, most were explained as a
consequence of conditions associated with pregnancy.2–5
The incidence and prevalence of sciatica in pregnancy
have rarely been investigated. Three studies have identified
prevalence rates of 17%,6 22.1%,4 and 24.6%7 in pregnant
women in America, Australia, and Mediterranean countries,
respectively. Although some women experience sciatica re-
lief after giving birth, others suffer an escalation of preexist-
ing pain or begin to experience symptoms for the first time
during the postpartum period,8 which might be the result of
weight gain, injuries to the coccyx during the birth process,
or a postpartum emotional condition.9 While there are no ex-
act data on the prevalence of sciatica in postpartum women,
this painful postpartum condition is not uncommon in clini-
cal practice.10
Sciatica can lead to chronic problems, such as long-term
pain and disability,1,10 and negatively affect quality of life.
Address correspondence to Bing-Shu He, PhD, Department of Or-
thopaedic Surgery, Hubei Woman & Child Hospital, Wuhan 430070,
China. Email: hbs102626@163.com
tients with sciatica.1 However, analgesic drugs and surgery
are often contraindicated postpartum due to concerns about
their potential risks to breastfed infants and maternal milk
production.11 Therefore, the application of physical therapy
modalities might be the preferred option for treating postpar-
tum sciatica.
Acupuncture, as one such analgesic modality, is a tech-
nique of Traditional Chinese Medicine (TCM)12 and is con-
sidered to be at the forefront of complementary and alter-
native medicine; it is increasingly used in Western countries
because of acceptability and efficacy.13,14 In the realm of TCM,
the human body is a whole organism.13 Qi (a basal energy
or vital force of the body) and Blood (transport of nourish-
ment and vitality in the body) circulate between the organs
along channels called meridians.15 Stimulating acupoints lo-
cated on meridians removes channel obstruction, promotes
Qi and Blood circulation, and balances the flow of energy, thus
improving the symptom and ameliorating the progression of
diseases.15 From the viewpoint of Western medicine, the neu-
roanatomical basis of acupuncture treatment might be due to
local intramuscular or nerve stimulation, or systemic action
associated with the sympathetic ganglions. However, because
the theory of TCM, on which acupuncture therapy is based,
is fundamentally different from that of Western medicine, the
mechanism of acupuncture analgesia based on the principles
of Western medicine is still unclear.14
Particularly for sciatica, many studies15–17 have reported
that acupuncture may be more effective than drugs in reliev-
ing leg pain and lumbago and improving global assessment

214 1526-9523/09/$36.00 doi:10.1111/jmwh.12681 

c 2018 by the American College of Nurse-Midwives
 ✦ Postpartum sciatica is not uncommon in clinical practice, but treatments such as analgesic drugs and surgery are of-
ten contraindicated in this period due to concerns about their potential risks to breastfed infants and maternal milk
production.
✦ Acupuncture has been used to treat sciatica and has been shown to be safe and effective for other postpartum disorders.
✦ This study describes a small series of the postpartum women with sciatica who were treated with acupuncture based on
Traditional Chinese Medicine theory.
✦ During 4 weeks of acupuncture treatment and 4 weeks after the last acupuncture session, disability and leg pain were
significantly lower in women treated with acupuncture compared to those in a control group assigned to bed rest. Women
in the acupuncture group self-reported significantly improved recovery.
✦ Acupuncture might be an effective and acceptable strategy to relieve symptoms of postpartum sciatica.

of sciatica and showed short-term and long-term benefits for
this common disorder. Importantly, acupuncture has been
demonstrated to be relatively safe and rarely associated with
serious adverse effects in patients with sciatica.16 Emerging
evidence has shown the beneficial effect of acupuncture in im-
proving pregnancy-related low back pain and/or pelvic girdle
pain.18,19 Acupuncture is considered relatively safe for preg-
nant women,19,20 and some clinical trials21,22 have reported
that adverse effects of acupuncture on neonates after birth
were rare. In terms of postpartum conditions, recent stud-
ies have mainly focused on the efficacy of acupuncture in
lactation support23 and other postpartum disorders, such as
bleeding,23 constipation,21 pyogenic sacroiliitis24 and postpar-
tum depressive symptoms.22 Nevertheless, the effectiveness of
acupuncture intervention on postpartum sciatica is still un-
clear. The purpose of this study was to evaluate the effective-
ness of acupuncture based on TCM theory as an intervention
for alleviating postpartum sciatica.
METHODS
Design and Setting
This preliminary study was a prospective controlled clini-
cal trial. The study took place in the Acupuncture Center,
Department of Orthopaedic Surgery, Hubei Woman & Child
Hospital.
Sample
Women with postpartum sciatica were consecutively re-
cruited from an outpatient orthopedic clinic at Hubei Woman
& Child Hospital. The inclusion criteria included women
1) within the first 3 months after giving birth, 2) having
symptoms of unilateral well-localized leg pain, which usually
radiated from the back to the foot or ankle, 3) with physical ex-
amination showing tenderness points along the sciatic nerve
on the involved side, and 4) willing to receive either acupunc-
ture or bed rest without other treatment interventions such
as medications. Imaging techniques and laboratory tests, in-
cluding computed tomography, magnetic resonance imaging,
ultrasound, and electromyogram, were used to exclude other
disorders such as spinal disc herniation, spinal stenosis, tu-
mors, pelvic injury, and lumbar muscle strain. All participants
gave informed consent after explanation of the study.
Intervention
Participants who met the inclusion criteria were divided into 2
groups: an acupuncture group and a control group, as per their
choice. Those in the acupuncture group attended acupunc-
ture therapy sessions 3 times a week for 4 weeks. The first
session was given one day after the initial clinic visit. Clas-
sical acupuncture treatment was provided by a physician with
postgraduate acupuncture training who had 15 years of ex-
perience. The acupuncture technique was applied based on
manual stimulation of a certain group of loci (Figure 1) us-
ing filiform silver acupuncture needles (Hwato, Suzhou Med-
ical Instrument Factory, China) of 30 mm or 60 mm in
length and 0.3 mm in diameter. Primary acupoints included
Jingmen (GB25), Huantiao (GB30), Fengshi (GB31), Shenyu
(BL23), Chengfu (BL36), and Qihai (CV6). Supplementary
acupoints including Sanyinjiao (SP6) and Zusanli (ST36) were
selected based on individual participants’ TCM syndrome; the
supplementary acupoints were added for all the sessions of
treatment.
Generally, the needles were inserted at the depth of 5
to 30 mm (depending on acupuncture point locations) with
a Deqi sensation. Because Qi is weak in the postpartum pe-
riod from the perspective of TCM,24 the technique of tonicity,
which could induce recovery from physiologic disorders, was
applied according to the method reported by Leung.25 Par-
ticipants were stimulated for 30 to 45 minutes (depending on
tolerance and comfort) in each session.
The 25 participants who did not want to receive acupunc-
ture and other forms of treatment were assigned to the control
group. To make the control intervention somewhat compa-
rable to the acupuncture group, we asked them to undergo a
minimum of 2 hours of bed rest 3 times a week for 4 weeks
at home. Bed rest was described to them as without bear-
ing weight and in a comfortable position. A research assistant
conducted household visits to collect data from the partici-
pants in the control group.

Journal of Midwifery & Women’s Health r www.jmwh.org 215

 Figure 1. Diagram Showing the Locations of Acupuncture Points Used in Patients with Postpartum Sciatica
 Primary acupoints; R Supplementary acupoints.

Data Collection
Baseline demographic data were collected prior to any inter-
vention. Information about risk factors for sciatica (eg, weight
gain, coccygeal injury, emotional condition) was recorded
for each participant. Overweight was defined as a body
mass index (BMI) of 25 or more. Coccygeal injuries in-
cluded a bruise, dislocation, or fracture of the coccyx in the
past medical or pregnancy history. Women were screened
at their enrollment visit for postpartum depression with the
Edinburgh Postnatal Depression Scale, a standardized self-
reported questionnaire,26 with a cutoff score of 12. During
this study period, psychiatric consultations and appropriate
psychological interventions were provided for those who were
diagnosed with postpartum depression.
Outcomes were measured by the Roland Disability Ques-
tionnaire (RDQ) for sciatica, a visual analogue scale (VAS)
for leg pain and back pain, and a Likert self-rating scale for
patient-reported recovery. The RDQ for sciatica, a disease-
specific scale consisting of 23 items reflecting functional status
in a variety of daily living activities, produces scores ranging
from 0 to 23, with higher scores indicating worse functional
disability. The VAS anchors were 0 indicating no pain and 100
indicating the worst pain ever experienced. Both of these in-
struments are considered to be reliable and valid in measuring
disability and intensity of pain, respectively.27,28 The RDQ and
VAS scores in acupuncture and control groups were analyzed
as continuous outcome variables at baseline, one, 2, 3, 4, 6, and
8 weeks (once each week) after the enrollment visit.
Self-reported recovery was measured using a 7-point Lik-
ert scale,27 ranging from 1 (complete disappearance of symp-
toms) to 7 (very much worse). Recovery was measured after
the first session, after the last session, at one and 12 months
after treatment for the acupuncture group, and at one day
and one, 2, and 13 months after the enrollment visit for the
control group. Complete or nearly complete disappearance of
symptoms (Likert scores 1-2) was defined as “satisfactory re-
covery,” whereas “minimally improved” to “very much worse”
(Likert scores 3-7) were defined as “unsatisfactory recovery.”
During 4 weeks of acupuncture treatment, the measure-
ments of RDQ, VAS scores, and patient-reported recovery
were made in the clinic immediately after the last therapy
session of each week. After treatment was completed, data
were collected during household visits. The RDQ, VAS scores,
and patient-reported recovery in control group participants
were collected during household visits by a research assis-
tant through in-person interviews. Adherence to the require-
ments of bed rest (a minimum of 2 hours, 3 times a week
for 4 weeks) was also supervised and verified by this research
assistant.
At the one-year follow-up interview at home, participants
in the acupuncture group were also asked whether acupunc-
ture treatment interfered with the process of lactation (ie,
maternal milk production), whether any adverse effects of
acupuncture were noted, and whether they would choose
acupuncture treatment for any recurrence of sciatica.
Statistical Analyses
For descriptive statistics, means and standard deviations
(SDs) were compared for normally distributed data. Univari-
ate analysis was conducted using the Wilcoxon rank-sum test.
Chi-square testing was used to analyze differences in the gen-
eral characteristics of participants and patient-reported recov-
ery between the acupuncture and control groups. All analyses
were conducted using IBM-SPSS version14.0 (IBM Corpora-
tion, Armonk, NY).
Ethical Considerations
Approval to conduct the study was given by the ethics com-
mittee of Hubei Woman & Child Hospital. The study followed
the ethical guidelines of the Helsinki Declaration.29

216 Volume 63, No. 2, March/April 2018

 Table 1. General Characteristics of Participants with Postpartum Sciatica (N = 111)
Overall Acupuncture Group Control Group
Variable (N = 111) (n = 86) (n = 25) P Valuea
Age, mean (SD), y 31.3 (7.8) 30.5 (6.2) 32.6 (8.1) .168
Weight, mean (SD), kg 63.6 (9.5) 63.9 (9.6) 62.7 (10.3) .589
Postnatal days, mean (SD), d 40.7 (39.8) 40.6 (39.1) 41.0 (40.2) .964
Breastfeeding, n (%) 82 (73.9) 62 (72.1) 20 (80.0) .594
Leg pain only, n (%) 37 (33.3) 30 (34.9) 7 (28.0) .688
Pelvic girdle pain and leg pain, n (%) 8 (7.2) 6 (7.0) 2 (8.0) .791
Low back pain and leg pain, n (%) 48 (43.2) 41 (47.7) 7 (28.0) .129
Pain in a wide range of areas involving the leg, low back, and pelvic girdle, n (%) 18 (16.2) 17 (19.8) 1 (4.0) .115
Overweight,b n (%) 54 (48.6) 43 (50.0) 11 (44.0) .763
History of coccygeal injury, n (%) 16 (14.4) 12 (14.0) 4 (16.0) .947
Postpartum depression,c n (%) 31 (27.9) 24 (27.9) 7 (28.0) .807
a
P value for differences between treatment and control groups.
b
Overweight was defined as a BMI of 25 or more.
c
Women were screened at their enrollment visit for postpartum depression with the Edinburgh Postnatal Depression Scale, with a cutoff score of 12.

RESULTS
During a period of 6 years (2010-2016), we recruited a to-
tal of 111 consecutive participants with postpartum sciatica;
all completed this study. Demographics and characteristics
of intervention and control groups are displayed in Table 1.
Mean age at diagnosis for the entire group was 31 years
3 months (range: 26 to 42 years). Participants visited the
clinic for sciatica between one day and 58 days after birth.
Most women (73.9%) were breastfeeding. Thirty-seven pa-
tients (33.3%) experienced only leg pain; 8 patients (7.2%)
had pelvic girdle pain; low back pain occurred concurrently
with leg pain in 48 patients (43.2%); and 18 (16.2%) women
had a chief concern of pain in a wide range of areas involving
the leg, low back, and pelvic girdle. In this study, 54 patients
(48.6%) were overweight; 16 (14.4%) had the history of coccyx
injuries; and 31 women (27.9%) were diagnosed with postpar-
tum depression.

Effect of Acupuncture on Disability and Leg Pain

As shown in Figure 2, during the 4 weeks of acupuncture treat-
ment and 4 weeks after the last acupuncture session, outcome
scores for disability and leg pain were significantly lower in the
acupuncture group compared with the control group (P ⬍ .05
and P ⬍ .01, respectively).

Patient-Reported Recovery
As shown in Table 2, after 4 weeks of acupuncture treat-
ment, all 86 (100%) women in the acupuncture group re-
ported complete or nearly complete disappearance of symp- Figure 2. Repeated Measurement Analysis Curves of Mean Scores
for RDQ for Sciatica (top panel) and VAS for Leg Pain (lower panel)
toms. In addition, 39 women (45%) reported that they felt
The points are the mean values with SD shown as bars. n = 86 in
significant improvement of pain after the needles were re- acupuncture group; n = 25 in control group.
moved in the first session, but none in the control group
Abbreviations: RDQ, Roland Disability Questionnaire; VAS, visual analog scale.
stated self-reported recovery at the identical time point *P ⬍ .05; **P ⬍ .01 compared with the identical control group.
(P ⬍ .01).
The reported prevalence of perceived recovery at
2 months after the enrollment visit (ie, one month after
treatment in the acupuncture group) was 98% (84/86) among

Journal of Midwifery & Women’s Health r www.jmwh.org 217

 Table 2. Patient-Reported Recovery After Either Acupuncture Treatment or Bed Rest for Postpartum Sciatica
Evaluation Time Pointa
After the first session of acupuncture treatment or 1 day after the enrollment visit
After the last session of acupuncture treatment or 1 month after the enrollment visit
1 month after acupuncture treatment or 2 months after the enrollment visit
12 months after acupuncture treatment or 13 months after the enrollment visitc
a
During acupuncture treatment, the measurements of patient-reported recovery in acupuncture group were made in the clinic immediately after the first and the last sessions
of acupuncture treatment, respectively. Measurements were obtained via in-person home visits for the control group and after the completion of treatments for the
acupuncture group.
b
The number and proportion of participants who responded they had complete or nearly complete disappearance of symptoms.
c
Because 9 patients (4 in the acupuncture group, 5 in control group) were lost to follow-up, the number of patients in acupuncture group or control group was 82 or 20,
respectively.
those who received the acupuncture treatment but only 24%
(6/25) for those in the control group (P ⬍ .01).
At 13 months after the enrollment visit (ie, 12 months af-
ter acupuncture treatment for the intervention group), 9 par-
ticipants (4 in the acupuncture group, 5 in the control group)
were lost to follow-up. Of the responding 82 participants in
the acupuncture group, 67% (55 participants) documented
satisfactory recovery, compared with 50% (10/20) in control
group. At this time point, no significant difference in per-
ceived recovery was found between the groups.
We found that the recurrence rate of pain in the acupunc-
ture group was 32% (26/82) at the one-year follow-up inter-
view, which was comparable to the 35% recurrence in control
group (7/20). In 26 recurrent cases in the acupuncture group,
73% (19 cases) were accompanied by overweight (BMI of 25
or more); 31% (8 cases) were with a history of coccygeal injury,
and 54% (14 cases) had postpartum depression, suggesting the
recurrence might be associated with the unsolved clinical risk
factors for sciatica.
Acceptance of Acupuncture Therapy
At the one-year follow-up interview, 95% of 62 lactating
women in the acupuncture treatment group stated that
acupuncture had no significant interference on breast milk
production, despite the fact that 3 women reported various
degrees of decrease in milk yield during therapy. None
reported that adverse effects of acupuncture intervention
occurred during and after the treatment. Moreover, 100% of
participants indicated that they would choose acupuncture
treatment if they were to suffer relapses of sciatica pain in the
future.
DISCUSSION
The results of this preliminary clinical study suggest that the
analgesic action of acupuncture could be effective for postpar-
tum sciatica, as manifested by the lower RDQ and VAS scores,
and the higher patient-reported prevalence of perceived re-
covery in the acupuncture group. While existing research15–17
has demonstrated that acupuncture is effective for sciatica in
general, to our knowledge, this is the first report on acupunc-
ture treatment for postpartum sciatica.
According to the principles of TCM, the condition that is
congruent with postpartum sciatica is called postpartum body
218
Acupuncture Group Control Group
(n = ) (n = )
n ()b n ()b P Value
39 (45) 0 (0) .0001
86 (100) 5 (20) ⬍.0001
84 (98) 6 (24) ⬍.0001
55 (67) 10 (50) .2442
pain, the underlying imbalance of which is Qi and Blood Stasis
in the postpartum Tixu (physically weak) state.30,31 This im-
balance can lead to meridian deficiency and cause the mus-
cle spasm and tension that trigger the intense shooting pain
of sciatica.31 The acupoints used in this study, such as GB25,
GB30, GB31, BL23, and BL36, are commonly found along
the bladder (BL) and gallbladder (GB) meridians and are
used empirically for treating pain in the waist and leg (in
terms of TCM theory).32 These same 5 acupoints are com-
monly utilized as classic acupuncture points for the treat-
ment of sciatica.33,34 Although the neuroanatomic basis of
these acupoints for sciatica treatment is unknown, it has been
suggested that acupuncture at certain points, including GB25
and GB30, can increase the pain threshold in persons with
sciatica.35 Acupoint BL23 is located at the erector spinae and
quadratus lumborum muscle, where low back pain or sciat-
ica is felt.14 Acupuncture at this point may exert its effect
locally via intramuscular stimulation, which might stimulate
the nerve fibers in the muscle and trigger the release of va-
soactive substances, thereby improving local blood flow and
promote healing.14 Acupoint GB30 is located at the sciatic
nerve and acupuncture stimulation at GB30 may increase
blood flow in the nerve.14 Using a rat model with acute sciatic
nerve injury, Dai et al36 found that electroacupuncture stimu-
lation at GB30 could improve the function of the injured sci-
atic nerve. In addition, we added another primary acupoint
(CV6), which is thought to tone the Qi, and is relevant to gy-
necology and maternity care,37 especially for the state of “post-
partum Qi and Blood Stasis, or postpartum Tixu.”
The additional points including Sanyinjiao (SP6) and
Zusanli (ST36) with TCM properties to “invigorate the
Blood,” “dissolve the Stasis,” “dispel the Wind,” and “open
the meridian”38–42 were also selected in our study, when
the patients were diagnosed with a TCM syndrome called
Postpartum Qi Deficiency.43 In TCM, Sanyinjiao (SP6),
which can regulate the channel Qi of the liver, spleen, and
kidney,38 is commonly used for gynecologic, genitourinary,
and emotional disorders. Experimental research has shown
that acupuncture on SP6 could have an effect on the con-
traction of the uterus and pain relief,39 and SP6 acupres-
sure has been reported effective in decreasing pain and du-
ration of labor for primigravida women in labor.40 Similarly,
the general function of Zusanli (ST36) is strengthening de-
ficiency conditions by harmonizing the Qi and Blood, and
Volume 63, No. 2, March/April 2018
improving general weakness.41,42 Zhao et al44 found that cen-
tral arginine vasopressin, a nonapeptide posterior hormone
of pituitary governing analgesia in human and nonhuman
species, might be involved in the relief of pain sensation
caused by acupuncture at ST36 in sciatica patients. In rats with
sciatica, repeated electroacupuncture stimulation at ST36 and
Yanglingquan (GB34) can effectively relieve chronic neuro-
pathic pain via remodeling the synaptic structure of the hy-
pothalamic paraventricular nucleus.45
Despite the fact that significantly enhanced perceived
recovery was reported after the acupuncture treatment, es-
pecially after the first session, it should be noted that, at
12 months after acupuncture treatment, there was no signif-
icant difference between the acupuncture and control groups
in perceived recovery. Patients with sciatica who had unre-
solved clinical risk factors such as overweight, coccygeal in-
juries, and depression were more likely to have recurrent sci-
atica, even in the acupuncture group. These data suggested
that acupuncture might only relieve symptoms of sciatica
and provide a positive therapeutic effect in the short term.
Nonetheless, postpartum patients reported high acceptance
for acupuncture therapy.
Our preliminary results provide a foundation for future
studies about the therapeutic effects of acupuncture on post-
partum sciatica. However, there were some limitations of this
study to consider. This was a single-center, nonrandomized
study with a relatively small sample size and a convenience
control sample. The acupuncture protocol was developed em-
pirically based on the TCM theory, and it was unclear if
acupuncture was better than any treatment other than bed
rest. In addition, although most women in acupuncture group
reported that breast milk production was unaffected by treat-
ment, we did not measure breast milk production in any effi-
cient way. The patients were asked about whether acupunc-
ture treatment interfered with the process of lactation only
once at the one-year follow-up interview; women in the con-
trol group were not asked about milk production. Therefore,
further well-designed studies are needed to clarify the optimal
protocol, exact role, and action mechanism of acupuncture in
the treatment of postpartum sciatica.
CONCLUSION
In summary, the results of this prospective clinical study pre-
liminarily suggest that the use of acupuncture might be effec-
tive in relieving the symptoms of postpartum sciatica com-
pared with bed rest. There was no evidence of adverse effects
and few reports of decreased breast milk production from
participants. Participants were willing to choose acupuncture
treatment for relapse of sciatica. However, more rigorously de-
signed and higher-quality studies with larger sample sizes are
needed to further confirm these findings.
AUTHORS
Bing-Shu He, PhD, is a clinical assistant professor and
acupuncturist at the Department of Orthopaedic Surgery,
Hubei Woman & Child Hospital, Wuhan, China.
Yang Li, APN, is a nurse at the Department of Orthopaedic
Surgery, Hubei Woman & Child Hospital, Wuhan, China.
Journal of Midwifery & Women’s Health r www.jmwh.org
Tong Gui, PhD, is chairman and professor of the Depart-
ment of Orthopaedic Surgery, Hubei Woman & Child Hos-
pital, Wuhan, China.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
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Volume 63, No. 2, March/April 2018