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Traditional postpartum practices and rituals: A qualitative systematic review

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REVIEW

Traditional postpartum practices and rituals: a qualitative systematic review

Cindy-Lee Dennis1, Kenneth Fung2, Sophie Grigoriadis3†, Gail Erlick Robinson4, Sarah Romans5 & Lori Ross6

†Author for correspondence1University of Toronto, Faculty of Nursing, 115 College Street, Toronto, ON, M5T 1P8, CanadaTel.: +1 416 946 8608;E-mail: cindylee.dennis@utoronto.ca2Toronto Western Hospital,University Health NetworkToronto, CanadaTel.: +1 416 603 5349; Fax: +1 416 603 5292E-mail: ken.fung@uhn.on.ca3University Health NetworkWomen’s College Hospital and University of Toronto,200 Elizabeth Street, 8EN-229, M5G 2C4, CanadaTel.: +1 416 340 4462;Fax: +1 416 340 4198;E-mail: sophie.grigoriadis@uhn.on.ca4University of Toronto Faculty of Medicine, Toronto, Canada Tel.: +1 416 340 3048;Fax: +1 416 340 4198;E-mail: gail.robinson@uhn.on.ca5University of Toronto,Faculty of Medicine, Toronto, Canada Tel.: +1 416 351 3740;Fax: +1 416 351 3746;E-mail: sarah.romans@wchospital.ca6University of Toronto,Faculty of Medicine, Toronto, Canada Tel.: +1 416 535 8501; ext. 7383;Fax: +1 416 205 9522;E-mail: l.ross@utoronto.ca

part of

Keywords: culture, doing the month, postpartum, rituals, support

10.2217/17455057.3.4.487 © 2

Many cultures around the world observe specific postpartum rituals to avoid ill health in later years. This qualitative systematic review examined the literature describing traditional postpartum practices from 51 studies in over 20 different countries. Commonalities were identified in practices across cultures. Specifically, the themes included organized support for the mother, periods of rest, prescribed food to be eaten or prohibited, hygiene practices and those related to infant care and breastfeeding, among others. These rituals allow the mother to be ‘mothered’ for a period of time after the birth. They may have beneficial health effects as well as facilitate the transition to motherhood. In today’s society, with modernization, migration and globalization, individuals may be unable to carry out the rituals or, conversely, feel pressured to carry out activities in which they no longer believe. The understanding of traditional postpartum practices can inform the provision of culturally competent perinatal services.

The postpartum period is a time for women torecover and take on new roles. In many cultures,it is also seen as a precarious period, renderingthe new mother vulnerable to illness, and spe-cific traditional practices are observed to ensurerecovery and avoid ill health in later years. Bycontrast, while great strides in antepartum andintrapartum care have been achieved in Westernor ‘modern’ cultures, as indicated by loweredmaternal and infant mortality rates, there hasbeen a comparative lack of attention to the post-partum period. This may be due to Westernpostpartum care focusing primarily on theimmediate physical health of mothers and theirinfants through the use of technological inter-ventions [1]. Postpartum practices in Western‘technocentric’ cultures do not typically extendbeyond the first few days postpartum. By con-trast, ‘ethnokinship’ cultures (e.g., many culturesof East Asia, South Asia and the Middle East)emphasize the practice of social support ritualsfor a more protracted postpartum period [1].Given these cross-cultural differences, it wouldbe valuable to explore the potential positiveand/or negative effects these extended post-partum practices may have on the physical andmental health of mothers. Furthermore, consid-ering increasing rates of migration betweencountries and the resulting cultural diversityamong childbearing women in many healthcaresettings, it is essential to understand traditionalpostpartum practices and the ways in whichthey may influence the provision of perinatalhealthcare. This understanding can inform the

provision of culturally competent perinatal serv-ices. At present, no recent, comprehensive,cross-cultural examination of postpartum prac-tices exists in the literature. Therefore, theobjective of this qualitative systematic review isto assemble accounts of the various practicesassociated with the postpartum period acrosscultures, identify commonalities in practices orrationales for practices across cultures, and con-sider the implications of these practices for theprovision of perinatal healthcare.

MethodsInclusion/exclusion criteriaThe review considered all peer-reviewed publica-tions in the health-related literature that focusedon maternal traditional practices in the post-partum period (i.e. within the first year follow-ing childbirth) using qualitative or quantitativemethodology. General review articles were alsoincluded. Studies were excluded if a descriptionof postpartum practices was not included, or ifonly infant-focused practices were described.Studies were limited to the English language dueto a lack of translating resources.

Search strategyA detailed search of the following databases wasconducted for articles published between 1966and July 2006: MEDLINE, CINAHL, Psy-cINFO, EMBASE, Proquest and the WHOReproductive Health Library. Variations of thefollowing keywords were used in the search:practices, rituals, customs, postpartum, postnatal

007 Future Medicine Ltd ISSN 1745-5057 Women's Health (2007) 3(4), 487–502 487

REVIEW – Dennis, Fung, Grigoriadis, Robinson, Romans & Ross

488

and childbirth. All studies identified wereassessed for relevance based on the informationprovided in the title, abstract and descrip-tor/MeSH terms; a full report was retrieved forall studies that appeared to meet the inclusioncriteria. Where relevant articles were identified,the reference lists were searched and links to‘related articles’ in electronic databases wereaccessed and additional studies were reviewed forrelevance. For all identified studies that met theinclusion criteria, data were extracted by authorsand organized by common postpartum practice.

ResultsOver 71 abstracts were examined resulting in 51studies meeting the inclusion criteria (Table 1).These studies were conducted in over 20 differ-ent countries and included women from the fol-lowing origins: East, Southeast and South Asia,the Middle East, Oceania, Latin America, Africaand others. The majority of studies (n = 31,61%) included specific qualitative methodsusing interviews for data collection and sevenstudies were solely literature reviews. The resultsare summarized under thematic clusters of com-mon traditional postpartum practices foundacross cultures: organized support, rest period,diet, hygiene practices, infant care, breastfeedingand other postpartum rituals.

Organized supportOrganized support, usually in the form of familymembers caring for the new mother and her infantfor a specified period of time, is almost universallyprovided in the early postpartum period by themother, mother-in-law, other female relatives [2–10]

or husband [11–12]. Respected elder female com-munity members [11,13], traditional birth attend-ants [14] or young women from the community [15]

may also be involved in providing care for themother. The support often includes practicalassistance (e.g., household chores or cooking), aswell as information for the mother regarding howto care for herself and the infant [3,9,16,17]. Forexample, in Japanese culture, the practice ofSatogaeri bunben typically involves the womantraveling to her family home at 32–35 weeks gesta-tion to be cared for by her mother until approxi-mately 8 weeks postpartum [10]. Similarly, in theAmish of Tennessee (USA) the new mother is pro-vided with organized support from extended fam-ily members and the community [18]. Othercultures that practice a similar period of organizedsupport include Nigerian, Jordanian, Korean,Guatemalan, Eastern Indian Hindus and Chinese.

Rest period & restricted activities Organized support typically corresponds to aprescribed period of rest, during which themother is prohibited from performing her usualhousehold chores. In most cultures, the restperiod spans between 21 days and 5 weeks, andis considered a period of vulnerability for futureillness [19]. For example, in Korea, a 3–5 weekrest period is known as sam chil il [20]. In China,many women participate in zuo yue (or tso-yueh-tzu in Taiwan), commonly referred to as ‘doingthe month’. This is a formalized, month-longperiod of rest during which mothers are assistedby extended family to promote recovery andallow ‘loose’ bones to return to their previouspositions [2,21–25]. Many Thai women remain athome and are cared for by female family mem-bers and their husbands for approximately30 days, a practice known as yu duan [12,26].Among Mexican women, a 40-day rest period isknown as la cuarenta [7]. Among Muslim women,a 40-day period of rest is observed according toIslamic beliefs [17,30–31]. A designated period ofrest is similarly practiced among Amish [18], Japa-nese [10], Hmong [27], Malay [4,28], Eastern IndianHindus [29] and South African [32] women.

There are within-culture differences in theextent to which these periods of organized sup-port and period of rest are observed. Youngerwomen and those living in major urban centresmay be less likely to participate in these prac-tices or may observe them for a shorter period oftime [31,33]. As another example, many factorsaffect the traditional practice of yu duan in Thaiwomen [12]. Mothers of female infants observe alonger rest period since females are thought towork harder in life than males and thereforedeserve additional time with their mother ininfancy. Yu duan is considered particularlyimportant for primiparous women. Availabilityof family members and friends to facilitateYu duan may be a limiting factor [13]. Middle-and upper-class women may be able to hire peo-ple to provide the necessary support, while poorerwomen may be unable to practice or shorten theperiod since they or their husbands may need toreturn to work [34]. Some women believe that tra-ditional practices are only necessary for womenliving in their native countries, and are no longerimportant postimmigration [35].

Not observing the traditional period of post-partum rest is generally believed to result in pre-mature aging or ill health, either immediately orin later life. In the Vietnamese culture, facial wrin-kling is perceived by some to be very shameful, as

Women's Health (2007) 3(4) future science groupfuture science group

Traditional postpartum practices and rituals: a qualitative systematic review – REVIEW

Tab

le 1

. Ch

arac

teri

stic

s o

f in

clu

ded

stu

die

s .

Ori

gin

Stu

dy

Ob

ject

ive

Des

ign

Sam

ple

Ref

.

East

Asi

an

Chi

nese

Brat

hwai

te

(200

4)To

exp

lore

the

con

nect

ions

bet

wee

n cu

lture

and

ex

pect

atio

n su

rrou

ndin

g th

e ch

ildbi

rth

expe

rienc

e Q

ualit

ativ

e (e

thno

grap

hic)

usi

ng

inte

rvie

ws

Six

prof

essi

onal

Chi

nese

wom

en in

C

anad

a[4

7]

Che

ung

(199

7)To

exa

min

e ho

w w

omen

exp

erie

nce

post

nata

l car

e in

a

Scot

tish

sett

ing,

the

ir be

liefs

, nee

ds a

nd e

xper

ienc

e,

and

why

any

diff

eren

ces

exis

t

Qua

litat

ive

usin

g se

mis

truc

ture

d an

d no

nstr

uctu

red

inte

rvie

ws

Ten

Chi

nese

wom

en, t

en h

ealth

wor

kers

, fiv

e re

lativ

es, f

ive

Chi

nese

wom

en's

fr

iend

s in

Sco

tland

[36]

Chu

(200

5)To

exa

min

e po

stna

tal e

xper

ienc

e an

d he

alth

nee

dsQ

ualit

ativ

e us

ing

sem

istr

uctu

red

inte

rvie

ws

30 m

igra

nt C

hine

se w

omen

in B

risba

ne

Aus

tral

ia f

rom

thr

ee d

iffer

ence

pla

ces

of

orig

in: T

aiw

an, H

ong

Kon

g an

d C

hina

[40]

Hol

royd

(199

7)To

exp

lore

cul

tura

l pra

ctic

es d

urin

g th

e po

stpa

rtum

pe

riod

Qua

litat

ive

(eth

nogr

aphi

c) u

sing

in

terv

iew

sSe

ven

mul

tipar

ous

wom

en in

Hon

g K

ong

[65]

Hol

royd

(200

4)To

iden

tify

wom

en’s

cultu

ral b

elie

fs a

nd b

ehav

iors

re

late

d to

‘doi

ng th

e m

onth

’ and

sug

gest

how

thes

e ar

e m

odifi

ed in

ligh

t of

con

tem

pora

ry r

ealit

ies

and

expe

rienc

es w

ithin

the

con

text

of

rapi

d so

cial

cha

nge

Qua

litat

ive

(eth

nogr

aphi

c) u

sing

te

leph

one

inte

rvie

w10

0 pr

imip

arou

s w

omen

in H

ong

Kon

g[4

4]

Kar

tchn

er

(200

3)To

exp

lore

the

mea

ning

of

the

child

birt

h ex

perie

nce

Qua

litat

ive

(phe

nom

enol

ogic

al) u

sing

in

-dep

th in

terv

iew

sTe

n pr

imip

arou

s w

omen

in B

eijin

g an

d C

hong

quin

g[6

7]

Kit

(199

7)To

det

erm

ine

the

inci

denc

e of

pos

tnat

al d

epre

ssio

n at

6

wee

ks p

ostp

artu

m a

nd t

o su

rvey

soc

iocu

ltura

l pra

ctic

eQ

uant

itativ

e us

ing

stru

ctur

ed

ques

tionn

aire

s15

4 po

stpa

rtum

Chi

nese

, Mal

ay a

nd

Indi

an w

omen

in S

erem

ban,

Mal

aysi

a[4

]

Leun

g (2

005)

To e

xam

ine

wom

en’s

perc

eptio

ns o

f st

ress

and

sup

port

in

‘doi

ng t

he m

onth

’Q

ualit

ativ

e us

ing

in-d

epth

inte

rvie

w20

pos

tpar

tum

wom

en in

Hon

g K

ong

[6]

Liu-

Chi

ang

(199

5)To

exp

lore

wor

ries

of p

ostp

artu

m m

othe

rs w

ho

part

icip

ate

in T

so-Y

ueh-

Tzu

Qua

litat

ive

usin

g fo

cus

grou

ps21

prim

ipar

ous

wom

en in

a m

ajor

city

in

sout

hern

Tai

wan

[22]

Mat

they

(200

2)To

des

crib

e th

e fr

eque

ncy

of t

radi

tiona

l pra

ctic

es f

or

imm

igra

nt w

omen

and

the

ir pe

rcep

tions

of

follo

win

g su

ch p

ract

ices

Qua

ntita

tive

usin

g st

ruct

ured

qu

estio

nnai

res

and

inte

rvie

ws

102

mig

rant

Chi

nese

wom

en in

Syd

ney,

A

ustr

alia

[23]

Pills

bury

(197

8)To

des

crib

e ‘d

oing

the

mon

th’ a

fter

chi

ldbi

rth

Qua

litat

ive

usin

g in

terv

iew

s an

d lit

erat

ure

revi

ew80

wom

en, h

erba

lists

, and

phy

sici

ans,

an

d co

nsul

tatio

n w

ith W

este

rn-t

rain

ed

phys

icia

ns in

Tai

wan

and

Chi

na.

[37]

Tien

(200

4)To

det

erm

ine

nurs

es’ a

nd p

ostp

artu

m w

omen

’s kn

owle

dge

of a

nd a

ttitu

des

tow

ard

the

trad

ition

al

cust

om o

f 1-m

onth

con

finem

ent f

ollo

win

g de

liver

y an

d fa

ctor

s in

fluen

cing

the

ir at

titud

es

A c

ross

-sec

tiona

l sur

vey

usin

g st

ruct

ured

que

stio

nnai

res

121

post

part

um w

omen

and

nur

sing

st

aff

in T

aipe

i City

, nor

ther

n Ta

iwan

[24]

Chi

en (2

006)

To e

xam

ine

adhe

renc

e to

pos

tpar

tum

pra

ctic

es in

Ta

iwan

and

its

asso

ciat

ion

with

phy

sica

l sym

ptom

s an

d de

pres

sion

Qua

ntita

tive

ques

tionn

aire

202

post

part

um w

omen

in T

aiw

an;

150

from

pos

tpar

tum

war

ds a

nd 5

2 fr

om

a po

stpa

rtum

car

e ce

nter

[25]

489future science groupfuture science group www.futuremedicine.com

REVIEW – Dennis, Fung, Grigoriadis, Robinson, Romans & Ross

Kor

ean

Cho

i (19

86)

To e

xplo

re K

orea

n be

liefs

and

att

itude

s to

war

ds

preg

nanc

y, b

irth

and

post

part

um p

ract

ices

Des

crip

tive

usin

g st

ruct

ured

qu

estio

nnai

res

and

‘obs

erva

tion’

21 K

orea

n m

othe

rs in

Los

Ang

eles

are

a,

CA

, USA

[56]

Kim

-God

win

(2

003)

To d

escr

ibe

com

mon

pos

tpar

tum

hea

lth b

elie

fs u

sing

an

exem

plar

fro

m K

orea

n w

omen

giv

ing

birt

h in

the

USA

Des

crip

tive

usin

g se

lf-ex

perie

nce

and

liter

atur

e re

view

Kor

ean

wom

en in

the

USA

, gen

eral

[39]

Schn

eide

rman

(1

996)

To d

escr

ibe

trad

ition

al p

ostp

artu

m p

ract

ices

of

Kor

ean

wom

enD

escr

iptiv

e us

ing

self-

expe

rienc

e an

d lit

erat

ure

revi

ewK

orea

n w

omen

, gen

eral

[8]

Sich

(198

1)To

des

crib

e tr

aditi

onal

chi

ldbe

arin

g be

havi

or a

nd it

s re

latio

n to

mod

ern

mat

erni

ty a

nd o

bste

tric

al c

are

Qua

litat

ive

usin

g pa

rtic

ipan

t ob

serv

atio

n an

d in

terv

iew

s 30

pre

gnan

t w

omen

fro

m v

illag

es in

K

angw

ha d

istr

ict

in r

ural

Kor

ea; a

lso

inte

rvie

wed

vill

age

wor

kers

, mid

wiv

es,

phys

icia

ns, h

eale

rs

[33]

Japa

nese

Yosh

ida

(200

1)To

des

crib

e th

e in

cide

nce

and

clin

ical

fea

ture

s of

po

stna

tal d

epre

ssio

n C

ross

-cul

tura

l stu

dy u

sing

qu

estio

nnai

res

98 J

apan

ese

wom

en in

Eng

land

and

88

Japa

nese

wom

en in

Jap

an

[10]

Sou

th-E

ast

Asi

an

Thai

Kae

wsa

rn

(200

3a)

To g

ain

an u

nder

stan

ding

of

the

trad

ition

al p

ract

ices

th

at a

re fo

llow

ed in

rela

tion

to p

ostp

artu

m c

are

and

the

ratio

nale

s un

derp

inni

ng s

uch

prac

tices

Des

crip

tive

surv

ey u

sing

qu

estio

nnai

res

500

post

part

um w

omen

in U

bon

Ratc

hath

ani,

Thai

land

[38]

Kae

wsa

rn

(200

3b)

To in

vest

igat

e nu

rses

’ tra

ditio

nal b

elie

fs r

egar

ding

br

east

feed

ing

and

rela

ted

post

part

um c

are

Des

crip

tive

surv

ey u

sing

qu

estio

nnai

res

372

mat

erni

ty n

urse

s in

Ubo

n Ra

tcha

than

i, Th

aila

nd[5

0]

Liam

putt

ong

(200

4)To

exa

min

e tr

aditi

onal

pos

tpar

tum

bel

iefs

and

pra

ctic

esQ

ualit

ativ

e us

ing

in-d

epth

inte

rvie

ws

30 p

regn

ant

or p

ostp

artu

m w

omen

in

Chi

ang

Mai

pro

vinc

e, n

orth

ern

Thai

land

[12]

Rice

(199

9)To

des

crib

e th

e ex

perie

nce

of p

ostp

artu

m c

are

Qua

litat

ive

(eth

nogr

aphi

c) u

sing

in-

dept

h in

terv

iew

s an

d pa

rtic

ipan

t ob

serv

atio

n

26 T

hai i

mm

igra

nt w

omen

livi

ng in

M

elbo

urne

, Aus

tral

ia[3

5]

Vie

tnam

ese

Dav

is (2

001)

To e

xam

ine

the

mea

ning

of

post

part

um e

xper

ienc

e fo

r So

uth-

East

Asi

an w

omen

Q

ualit

ativ

e (p

heno

men

olog

ical

) usi

ng

in-d

epth

inte

rvie

ws

15 V

ietn

ames

e, t

hree

Cam

bodi

an, o

ne

Hm

ong

refu

gee/

imm

igra

nt w

omen

livi

ng

in t

he U

SA (n

ot a

ll pe

rinat

al)

[3]

Fish

er (2

004)

To e

xam

ine

depr

essi

ve s

ympt

omat

olog

yC

ross

-sec

tiona

l sur

vey

usin

g st

ruct

ured

in

terv

iew

s an

d qu

estio

nnai

res

506

post

part

um w

omen

in H

o C

hi M

inh

City

, Vie

tnam

[51]

Smal

l (19

99)

To e

xplo

re w

omen

’s vi

ews

of m

ater

nity

car

e an

d th

eir

expe

rienc

es o

f ea

rly m

othe

rhoo

dQ

ualit

ativ

e us

ing

sem

istr

uctu

red

inte

rvie

ws

104

post

part

um im

mig

rant

Vie

tnam

ese

wom

en in

Mel

bour

ne, A

ustr

alia

(Tur

kish

an

d Fi

lipin

o w

omen

wer

e al

so in

clud

ed)

[9]

Hm

ong

Jam

buna

than

(1

995)

To e

xplo

re c

ultu

ral p

ract

ices

and

bel

iefs

in t

he

post

part

um p

erio

dQ

ualit

ativ

e us

ing

sem

istr

uctu

red

inte

rvie

ws

52 c

hild

bear

ing

Hm

ong

wom

en in

W

isco

nsin

, USA

[11]

Mor

row

(198

6)To

exp

lore

birt

hing

tra

ditio

nsQ

ualit

ativ

e us

ing

in-d

epth

inte

rvie

ws

15 H

mon

g m

en a

nd w

omen

imm

igra

nts

in Is

la V

ista

, CA

, USA

[26]

Rice

(200

0)To

exa

min

e tr

aditi

onal

and

cha

ngin

g be

liefs

and

pr

actic

es r

elat

ed t

o th

e po

stpa

rtum

per

iod

Qua

litat

ive

(eth

nogr

aphi

c) u

sing

in-

dept

h in

terv

iew

s27

Hm

ong

wom

en, t

hree

sha

man

s, t

wo

med

icin

e w

omen

, and

one

mag

ic h

eale

r in

Mel

bour

ne, A

ustr

alia

[13]

Tab

le 1

. Ch

arac

teri

stic

s o

f in

clu

ded

stu

die

s (c

on

t.).

Ori

gin

Stu

dy

Ob

ject

ive

Des

ign

Sam

ple

Ref

.

490 Women's Health (2007) 3(4) future science groupfuture science group

Traditional postpartum practices and rituals: a qualitative systematic review – REVIEW

Cam

bodi

anW

hite

(200

4)To

exp

lore

pos

tpar

tum

bel

iefs

and

pra

ctic

esQ

ualit

ativ

e (e

thno

grap

hic)

usi

ng fo

cus

grou

ps a

nd s

emis

truc

ture

d in

terv

iew

s10

9 K

hmer

wom

en w

ho h

ad g

iven

birt

h in

the

last

3 y

ears

and

20

Khm

er b

irth

atte

ndan

ts in

Cam

bodi

a

[34]

Whi

te (2

002)

To d

escr

ibe

an e

mic

per

spec

tive

of w

hat K

hmer

wom

en

view

as

norm

al a

nd v

iew

as

com

plic

atio

ns d

urin

g pr

egna

ncy,

birt

h an

d po

stpa

rtum

Qua

litat

ive

(eth

nogr

aphi

c) u

sing

focu

s gr

oups

and

sem

istr

uctu

red

inte

rvie

ws

129

rura

l and

urb

an w

omen

of

child

bear

ing

age,

tra

ditio

nal b

irth

atte

ndan

ts a

nd t

rain

ed m

idw

ives

in t

hree

ru

ral p

rovi

nces

and

Phn

om P

enh

[52]

Mal

aysi

anC

hee

(200

5)To

inve

stig

ate

the

prev

alen

ce, s

ocio

–cul

tura

l and

ps

ycho

soci

al r

isk

fact

ors

for

perin

atal

dep

ress

ion

Pros

pect

ive

coho

rt s

tudy

usi

ng

inte

rvie

ws

and

mai

led

surv

eys

559

wom

en r

ecru

ited

ante

nata

lly in

Si

ngap

ore

[28]

Lade

rman

(1

987)

To d

escr

ibe

hum

oral

ism

in p

regn

ancy

, chi

ldbi

rth

and

the

post

part

um p

erio

dRe

view

bas

ed o

n et

hnog

raph

ic

rese

arch

Wom

en in

Mal

aysi

a, g

ener

al[4

2]

Sou

th A

sian

Indi

anC

houd

hry

(199

7)To

des

crib

e m

ater

nal a

nd c

hild

car

e pr

actic

esRe

view

art

icle

Wom

en in

Indi

a, g

ener

al[1

9]

Mah

at (1

998)

To d

escr

ibe

child

bear

ing

prac

tices

and

nur

sing

im

plic

atio

nsRe

view

art

icle

Hin

du ‘E

aste

rn In

dian

s’, g

ener

al[2

9]

Rodr

igue

s (2

003)

To in

vest

igat

e th

e cu

ltura

l val

idity

of

the

cons

truc

t of

po

stna

tal d

epre

ssio

n an

d its

soc

ial a

nd c

ultu

ral c

onte

xts

Qua

litat

ive

usin

g in

-dep

th in

terv

iew

s39

wom

en (1

9 w

omen

with

and

20

with

out

post

nata

l dep

ress

ion)

in n

orth

G

oa, I

ndia

[54]

Paki

stan

iFi

kree

(200

4)To

exp

lore

tra

ditio

nal b

elie

fs a

nd p

ract

ices

and

to

unde

rsta

nd c

are-

seek

ing

beha

vior

sQ

ualit

ativ

e us

ing

focu

s gr

oups

and

in-

dept

h in

terv

iew

sQ

uant

itativ

e us

ing

stru

ctur

ed

ques

tionn

aire

s

525

post

part

um M

uslin

wom

en in

5 lo

w

soci

o–ec

onom

ic s

ettle

men

ts in

Kar

achi

, Pa

kist

an

[48]

Nep

ales

eRe

issl

and

(198

9)

To d

escr

ibe

the

inte

grat

ion

of m

oder

n an

d tr

aditi

onal

ob

stet

ric p

ract

ices

Qua

litat

ive

usin

g ob

serv

atio

n 40

birt

hs in

a h

ospi

tal w

ard

as w

ell a

s di

scus

sion

s w

ith t

he w

omen

’s fa

mili

es in

Ja

nakp

ur in

the

eas

tern

Tar

ai o

f N

epal

[41]

Gen

eral

Gat

rad

(200

4)

To d

escr

ibe

Hin

du b

irth

cust

oms

Revi

ew a

rtic

leH

indu

wom

en, g

ener

al[4

6]

Ara

b

Bedo

uin

Hun

dt (2

000)

To d

escr

ibe

wom

en’s

repr

oduc

tive

heal

th p

ract

ices

du

ring

the

40-d

ay p

ostp

artu

m p

erio

d Q

ualit

ativ

e us

ing

in-d

epth

indi

vidu

al

and

grou

p in

terv

iew

sBe

doui

n w

omen

in N

egev

, Isr

ael –

259

in

terv

iew

ed in

hos

pita

l pos

tnat

ally,

92

inte

rvie

wed

at

hom

e du

ring

40-d

ay r

est

perio

d, a

nd 1

48 in

terv

iew

ed in

a g

roup

fo

rmat

at

6 m

onth

s po

stpa

rtum

, whi

ch

incl

uded

15

in-d

epth

inte

rvie

ws

[31]

Jord

ania

nN

ahas

(199

9a)

To d

escr

ibe

the

pers

onal

exp

erie

nces

, per

cept

ions

and

ca

re m

eani

ngs

of J

orda

nian

wom

enQ

ualit

ativ

e (e

thno

grap

hy) u

sing

in-

dept

h in

terv

iew

s22

Jor

dani

an w

omen

who

imm

igra

ted

to

Sydn

ey, A

ustr

alia

[1

7]

Tab

le 1

. Ch

arac

teri

stic

s o

f in

clu

ded

stu

die

s (c

on

t.).

Ori

gin

Stu

dy

Ob

ject

ive

Des

ign

Sam

ple

Ref

.

491future science groupfuture science group www.futuremedicine.com

REVIEW – Dennis, Fung, Grigoriadis, Robinson, Romans & Ross

Egyp

tian

Leba

nese

Pale

stin

ian

Nah

as (1

999b

)To

exp

lore

the

live

d ex

perie

nces

of

post

part

um

depr

essi

on a

mon

g M

iddl

e Ea

ster

n w

omen

Qua

litat

ive

(phe

nom

enol

ogic

al) u

sing

in

-dep

th in

terv

iew

s18

Leb

anes

e, 1

4 Eg

yptia

n an

d 13

Pale

stin

ian

wom

en li

ving

in S

ydne

y,

Aus

tral

ia

[45]

Gen

eral

Font

e (2

005)

To d

escr

ibe

post

part

um p

ract

ices

am

ong

Mus

lin

imm

igra

nt w

omen

and

how

Isla

m in

fluen

ces

the

perin

atal

exp

erie

nce

Revi

ew a

rtic

leM

uslim

wom

en, g

ener

al[3

0]

Oce

ania

Fijia

nBe

cker

(199

8)To

exp

lore

the

appa

rent

soc

ial m

edia

tion

of p

ostp

artu

m

som

atic

illn

ess,

na

tado

ka n

i vas

ucu

Stru

ctur

ed a

nd s

emis

truc

ture

d in

terv

iew

s; q

uest

ionn

aire

s85

pos

tpar

tum

wom

en in

the

Sig

atok

a D

istr

ict,

Fiji

[16]

Haw

aiia

nM

aybe

rry

(199

9)To

pro

file

exam

ples

of

spec

ific

inte

rven

tions

use

d in

a

Haw

aiia

n pr

ogra

m t

o ill

ustr

ate

a un

ique

app

roac

h to

th

e de

liver

y of

cul

tura

lly c

ompe

tent

car

e

Des

crip

tive

usin

g se

lf-ex

perie

nce

Haw

aiia

n w

omen

, gen

eral

[55]

Lati

n A

mer

ica

Gua

tem

alan

Cal

liste

r (1

998)

To g

ain

an u

nder

stan

ding

of

the

cultu

ral m

eani

ngs

of

givi

ng b

irth

Qua

litat

ive

(eth

nogr

aphy

) usi

ng in

-de

pth

inte

rvie

ws

20 p

ostp

artu

m w

omen

of

mix

ed M

ayan

an

d La

dino

her

itage

in t

he S

acat

epeq

uez

Dis

tric

t of

Gua

tem

ala

[43]

Lang

(199

7)To

des

crib

e th

e be

liefs

and

pra

ctic

es o

f th

e tr

aditi

onal

m

idw

ives

Qua

litat

ive

usin

g in

terv

iew

s an

d di

rect

ob

serv

atio

n24

mid

wiv

es in

the

rur

al m

unic

ipal

ity o

f Sa

n M

igue

l Poc

huta

, Gua

tem

alan

[4

9]

Mex

ican

Nis

ka (1

998)

To d

ocum

ent

the

pres

ence

of

an in

terg

ener

atio

nal

fam

ily r

itual

tha

t fa

cilit

ated

ada

ptat

ion

to p

aren

thoo

dQ

ualit

ativ

e (e

thno

grap

hy) u

sing

in-

dept

h in

terv

iew

s25

Mex

ican

Am

eric

an f

irst-

time

mot

hers

in

Hid

algo

Cou

nty,

Tex

as[7

]

Afr

ican

Ken

yaM

poke

(199

3)To

ass

ess

pres

ent

prac

tices

sur

roun

ding

pre

gnan

cy a

nd

child

birt

h w

ithin

the

con

text

of

wha

t is

kno

wn

abou

t th

eir

trad

ition

al p

ract

ices

Cro

ss-s

ectio

nal s

urve

y us

ing

stru

ctur

ed q

uest

ionn

aire

s 20

6 M

aasa

i wom

en in

sev

en a

reas

m

akin

g up

the

Olo

sho

Oib

or s

ublo

catio

n of

the

Ngo

ng d

ivis

ion

in K

enya

[14]

Sout

h A

fric

aSe

lepe

(200

0)To

des

crib

e th

e tr

aditi

onal

chi

ldbi

rth

belie

fs a

nd

prac

tices

Qua

litat

ive

usin

g in

terv

iew

s an

d di

rect

ob

serv

atio

nSe

ven

trad

ition

al b

irth

atte

ndan

ts in

the

M

anxi

li ar

ea o

f K

waZ

ulu,

Sou

th A

fric

a[3

2]

Oth

er

Kan

adie

r M

enno

nite

Cam

pbel

l (2

004)

To e

xplo

re c

hild

bear

ing

prac

tices

Qua

litat

ive

usin

g in

terv

iew

s45

Kan

adie

r M

enno

nite

s in

Alb

erta

, C

anad

a[1

5]

Am

ish

Finn

(199

5)To

des

crib

e a

tran

scul

tura

l nur

se's

exp

erie

nces

im

mer

sed

in a

hip

pie

subc

ultu

re

Des

crip

tive

usin

g se

lf-ex

perie

nce

Am

ish

wom

en a

t a

’ Far

m’ n

ear

Sum

mer

tow

n, T

enne

ssee

[18]

Tab

le 1

. Ch

arac

teri

stic

s o

f in

clu

ded

stu

die

s (c

on

t.).

Ori

gin

Stu

dy

Ob

ject

ive

Des

ign

Sam

ple

Ref

.

492 Women's Health (2007) 3(4) future science groupfuture science group

Traditional postpartum practices and rituals: a qualitative systematic review – REVIEW

future science groupfuture science group

it is seen to be evidence that the mother mayhave poor relationships with her family memberswho typically provide postpartum support [3]. InThai culture, practicing yu duan is believed toprotect a new mother from lom pid duan, ill-nesses thought to develop as a result of inappro-priate postpartum care [12]. Cambodian womenbelieve that violations of postpartum traditionsmay result in toas, specific illnesses followingchildbirth with distinct patterns of symptomsdepending on the specific type of violation. Inaddition, if the new mother feels unsupportedby her partner, she may develop pruey cet or ‘sadheart’, primary symptoms of which are unhap-piness/depression, frustration, anger, unhappi-ness and ‘crazy’ behavior [34]. Finally, somecultures believe a major potential consequenceof incomplete postpartum recovery is futureinfertility (e.g., Hmong women [13]; Arabwomen [31]).

During the postpartum period of rest, specificactivities may be prohibited. Among Vietnameseand Chinese women, crying, reading or watch-ing television are not allowed in order to preventlater eye problems [3,36,37]. In Cambodian cul-ture, women are discouraged from feeling strongemotions or ‘thinking too much’ [34]. In manycultures, sexual activity is avoided for a variablelength of time, ranging from 20–100 days [16,36].Often, this practice is encouraged not only bythe cultural community, but also by medicalpractitioners, to encourage appropriate healingfollowing childbirth [38,34]. In Cambodian cul-ture, sexual activity before the new mother con-siders herself to be ready is thought to beassociated with negative health consequences [34].In other cultures (e.g., Jordanian and Chinese),postpartum women are considered to be ‘pol-luted’ and therefore sexual activity is consideredto be dangerous for the partner [17,36]. Fijianwomen are to avoid any activities perceived to bepotentially harmful to the mother or the infantsuch as sitting up, physical exertion, combingher hair or exposing herself to the sun [16].

Diet In many cultures, certain foods are especiallyencouraged to promote healing or restorehealth, while consuming prohibited foods arethought to cause illness either immediately or inthe future. One of the best-known philosophiesthat influence ancient East Asian medicine,such as traditional Chinese medicine, is thebelief in the duality of opposing forces in theform yin and yang. Yin describes properties

such as darkness, cold, wetness, softness, quies-cence and feminity, while yang describes theopposite and includes properties such as bright-ness, heat, dryness, hardness, activity and mas-culinity [37]. By extension, foods in manycultures may be classified as ‘hot’ or ‘cold’ basedon the presumed intrinsic property of the foods.This is usually considered independent of thefoods’ temperature, except for specific interpre-tations or idiosyncratic beliefs [36]. Similardichotomies from traditional Chinese medicineor other ancient medical systems, such aAyurvedic medicine, influence many of the die-tary practices in Asia, as well as in many othernon-Western cultures, including parts of LatinAmerica and Africa [39]. Although there are sim-ilarities, not all cultures classify the same foodsidentically (Table 2).

In many cultures, blood and the state ofpregnancy itself are often conceived as a state of‘hotness’ and, conversely, the postpartumperiod is conceived as a cold and vulnerablestate [25,26,39,40]. Hot foods are therefore encour-aged to restore harmony and balance, whilecold foods are to be avoided. It would appearthat these hot foods are often high in protein.For example, among mothers in India, hotfoods such as milk, ghee, nuts and jagerry arethought to help regain balance [19], while in theChinese culture chicken or pig’s feet preparedwith other hot ingredients are often consumedduring the postpartum period. Other examplesof encouraged and discouraged foods are givenin Table 2.

Special tonics are sometimes used during thepostpartum period, consisting of herbs or foodswith special medicinal properties. In Nepal,sathora, a herbal tonic, and haluua, a kind ofwheat semolina with added heating substancessuch as ginger, cumin and turmeric, are used topromote milk production, warm the motherand expel childbirth blood [41]. Malaysianmothers also use ‘hot’ herbal medicines [42].Among Guatemalan women, herbal teas con-taining artemesia, pimipinela, oregano andwhite honey are taken for pain relief [43]. Greenherbs, such as tshuaj quib, are used by Hmongwomen for diverse reasons including relievingaches and pains, producing extra blood, ‘wash-ing out’ childbirth blood and placenta, replac-ing energy and strength, promoting appetite,improving weight loss and increasing breastmilk [13]. They may also use chicken soupboiled with the plant ntiv to rid of postpartumblood [27]. In Korea, brown seaweed miyuk and

493www.futuremedicine.com

REVIEW – Dennis, Fung, Grigoriadis, Robinson, Romans & Ross

494

Table 2. Examples opostpartum period.

Belief

Perceived positive ou

Modulates postpartum releasing unclean (napa

Modulates postpartum discharging dirty blood.decreases flatus

Modulates postpartum acting as a uterine cleanto control bleeding

Certain foods help to regafter parturition

Certain foods are proscr

‘Hot’ foods are promote

‘Hot’ foods are encoura

‘Hot’ foods are encoura

‘Hot’ food are encourag

‘Hot’ foods are encoura

Certain foods reduce defoods, which are avoide

Perceived negative ou

Cause lower back pain aailments

Cause ill health by inducabdominal pain

Toxic or bias foods are abecause they cause stomand postpartum hemorr

‘Cold’ foods are avoided

‘Cold’ foods are avoided

‘Cold’ (thandi) substancavoided because they cabones and long term he

‘Cold’ foods are avoideddigestive upsets and utehemorrhage

f perceived positive and negative health outcomes of foods consumed during the

Food Country Ref.

tcome

bleeding by k) blood

Goandh (semolina, sugar and nuts in clarified butter [asli ghee]) and herbal mixtures with tumeric powder and dried dates in milk

Pakistan [48]

bleeding by Wine

Fermented rice with egg (chiu-niang-tan), ginger, rice wine, inner organs, chicken soup and noodles in brown sugar broth; wine may be consumed directly or used in cooking

China [37,44]

bleeding by sing agent

Dried ginger India [19]

ain balance Milk, ghee, nuts and jagerry India [19]

ibed Only seaweed soup (tangle) and rice are to be eaten after the childbirth – other foods are considered harmful

Korea [56]

d Chicken, especially black-bone chicken (Gallus domesticus); the chicken may be prepared with other hot ingredients such as sesame oil, rice wine, dry longan (guiyun), brown sugar; chicken liver; kidneys; eggs; pig liver; pig kidney; pork; pig feet may be prepared with ingredients such as red vinegar, red (dark brown) sugar and ginger

China [36,37,40,47]

ged Warm chicken and rice, poached egg with white pepper and yellow tumeric root teas

Hmong [3,11,13]

ged Khaw, a dish of beef, pork or fish braised with salt, pepper and palm sugar are used by those who could afford it; others eat rice porridge borbor or rice with salt and pepper

Cambodia [34]

ed Milk, eggs, salty, bitter and spicy foods Maylasia [42]

ged Acid and salty foods India (Hindu cultures)

[46]

sire for salty d

In parts of China, sweet foods in general or sweet chicken and porridge in particular are preferred.

China [37]

tcome

nd kidney Salty foods China [37]

ing lower Rice, prawn and fish Pakistan [48]

voided ach pains

hage

Certain fish Malaysia [42]

Raw foods, fruits and certain vegetables China [37]

Sweet foods India (Hindu cultures)

[46]

es are use pain in alth ailments

Yogurt, cold water Pakistan

[48]

to prevent rine

Juicy or sour fruits and vegetables Malaysia [42]

Women's Health (2007) 3(4) future science groupfuture science group

Traditional postpartum practices and rituals: a qualitative systematic review – REVIEW

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beef broth miyuk guk are used for cleansing thebody of lochia and postpartum blood andincreasing breast milk [8,33]. Shenghuatang, aherbal soup with ingredients including dangquai (Chinese Angelica Root, Ligusticum acuti-lobum) and ginger, is used among some Chinesemothers to help renew blood in the early post-partum period [23,24,40]. Dang quai is also usedin combination with other foods for anemia andgynecological conditions. Du Zhong, powderedEucommia ulmoides bark, is sometimes an addedingredient in special broth [25,36] and deer antlersmay be used as a tonic [44].

Cultural beliefs regarding the process ofchildbirth may prescribe different types of dietat various stages across the postpartum period.For example, in Nepal, warming foods such asheated milk are given immediately followingdelivery. To avoid indigestion and diarrhea,foods such as rice cannot be eaten until the sec-ond or third day, at which time the stomachand womb have started contracting towards itsnormal state [41]. In Chinese women, varioussanctioned foods are often introduced in a par-ticular order [44]. For example, the consumptionof sesame oil-chicken is delayed postnatally dueto the belief that the sesame oil is ‘heavy’ andmay lead to a vaginal infection if consumed tooearly [37].

Although not only practiced during the post-partum period, it is important to note that reli-gious beliefs influence diet as well. Hinduwomen are often strict vegetarians, and do noteat eggs, fish or meat. In Islam, certain foodssuch as pork are prohibited according to theQuran and Islamic teachings, and are consid-ered haram (unlawful) foods; permissible halalfoods require special methods of preparation orslaughter. In Judaism, kashrut are dietary lawsbased on the Torah and religious teachings thatdetermine which foods are kosher (permissible)including the type of food and the necessarypreparation procedures.

Finally, certain dietary prescriptions are relatedto breastfeeding. Muslim mothers are encour-aged to consume ‘hot’ foods and drinks, whilefruits and raw, sour, spicy, greasy or oily foods areavoided [45]. Spicy foods are also avoided by bothChinese and Korean mothers [44]. Hindu moth-ers avoid ‘cold’ foods when their infant has a coldor ‘hot’ foods when the infant has a fever [46].Some Kanadier Mennonite women believe thatraw foods can ‘taint’ their breast milk whilewatermelon, cabbage, beans and hot peppersmay stimulate the infant and interfere with

sleep patterns [15]. They also believe that puttinghands in hot soapy water will decrease breastmilk supply while eating alfalfa seeds willincrease it. To increase milk production, Chi-nese mothers use various foods includingpapaya, fish soup, black root pickled with porkfeet, and broiled freshwater fish [44,47], whileKorean mothers use miyuk guk broth [8,33]. Thaiwomen advocate the consumption of hot drinksto increase breast milk production [38].

Hygiene & physical warmth practices In many cultures, postpartum women are seenas contaminated, and therefore special hygienepractices are required. Jordanian mothers washtheir genitalia thoroughly with soap and waterbecause they are thought to be temporarily ‘pol-luted’ by childbirth [17]. Muslim women take apurification bath called a ghusl after they havestopped bleeding [30]. In some cultures (e.g.,Arabic, Thai and Chinese), women are consid-ered to be unclean until the postpartum periodof rest has been completed or bleeding has dis-continued. Prior to this, women are often pro-hibited from sexual intercourse [25,30]. They arealso prohibited from entering other people’shomes, or entering through the front door oftheir own home [13,37] to avoid offending guard-ian gods or spirits. Similarly, family membersmay be unwilling to eat food prepared by thenew mother during this period to avoid illnessor death [31]. Among Hindus, the new mother isnot allowed to cook or receive male visitorsuntil the tenth or twelfth day postpartum whenshe is considered ‘clean’ and can carry out nor-mal household chores [46]. For some EasternIndian Hindus, the whole family is consideredimpure. No outsiders are allowed to eat or drinkin the house until a day determined by casteand a ritual bath and religious ceremony is per-formed [29]. In Pakistan, heavy postpartumbleeding is considered ‘healthy’ in order torelease the ‘unclean’ menstrual blood that accu-mulated prenatally [48]. For the Hmong women,any material that contacts childbirth bloodmust be washed in the house and buried in ahole in the dirt floor to avoid attracting theattention of spirits, which could harm themother or infant [13].

In many cultures, specific bathing restrictionsor prohibitions exist, some of which relate to the‘hot’ and ‘cold’ beliefs already described. Coldbaths or showers are often strictly prohibited toavoid blood clots, sore bones and joints, and anitchy body [3,11,13]. In Guatemala, midwives

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believe that bathing in cold water causes fever,infection, edema and decreased milk supply, andthat bathing too soon causes stomach pains orprolapsed uterus [49]. In Mexico, bathing isrestricted to protect the mother from cold or ‘evilair’ [5,7]. Similar concerns are reflected in someEastern Indian Hindus and Chinese beliefs thatair conditioners and fans are dangerous for newmothers [6,29]. By contrast, warms baths areacceptable in the Hmong culture [3,11,13] and inMalaysia [42], India [19] and Thailand [38]. AmongArabic and Thai women, it is acceptable to take aquick, warm shower but hair washing is prohib-ited [17,38]. A steam bath (sitting on hot bricksand medicinal leaves or inhaling steamed medic-inal herbs) is prescribed in Thailand to sweat outpoisonous water and absorb good water, dry theperineum and assist healing [12,50]. Among Jorda-nian and Guatemalan women, sitz baths are rec-ommended to facilitate healing [17,43]. Thaimothers practice Kao krachome, where severaltypes of herbs are boiled in a pot. The motherthen sits on a bed and covers herself and the potwith a blanket. Kao krachome is believed to helpsweat out ‘poisonous’ water so that the mothercan absorb ‘good’ water in order to promotehealthy skin and protect against blurred vision,dizziness, headaches and fatigue in later life.

A related practice found among Asian cul-tures is to actively warm the new mother to bal-ance the loss of ‘hot’ blood during delivery. InMalaysia, mothers bathe in warmed water, bind‘hot’ substances around their abdomens and lieabove or near a fire source [42]. For 3 days, thenew mother receives a thorough massage fromher midwife to increase circulation and to bringhealing heat to all parts of her body [28]. Thaiwomen practice yu fai: a practice where themother, wearing warm clothes and wrapped inblankets, lies on a wooden bed over a warm firefor 30 days to flush out retained blood and pla-centa, increase involution of her uterus, flattenher stomach, remove stretch marks and healperineal tears [13,38,50]. Mothers are also mas-saged with hot salt to loosen tendons and pre-vent blood clots. Vietnamese mothers keepwarm to avoid the ‘wind’ and prevent head-aches, facial wrinkling, varicose veins and otherhealth problems [3,9,51]. A fire is also placedunder the mother’s bed to prevent blood clotsand backaches. Chinese mothers may followsimilar practices [37]. Cambodian mothers placeheated rocks on their stomach to prevent bloodclots and flatten their stomach [3,34]. They ‘roast’on a bamboo bed over a wood or charcoal fire

for 3 days and nights to heat sawsaye (fibers, lig-aments) and to prevent uterine blood clots,ensure good skin and promote overall long-term health [34,52]. During roasting, mothers tiestrings around their waist/wrist, paint limecrosses in corners of homes or on necks orankles, and place thorns under their bed toward off priey krawlah pleungh, a spirit thatattacks a woman while roasting, causing sei-zures, fainting, loss of consciousness and bizarrebehaviors. Herbs are used with hot rocks (tshuajntxhawb) to treat ill health arising from notkeeping the body warm enough. Hmong moth-ers wear warm clothing to avoid the ‘wind’ andsleep near a fire for 3 days postpartum [5,11,13].The mother’s straw bed is then burnt. Thispractice was developed to cope with the scarcityof blankets and sanitary pads and to avoidwashing material containing childbirth blood inwater sources.

Infant care & breastfeeding In some cultures where there is an extended post-partum rest period for the mother, relatives willassist or play a dominant role in infant care. Forexample, in Nepal, both in hospital and at home,the mother remains a peripheral figure in infantcare during the first few days postpartum [41].The infant’s paternal grandmother or aunt estab-lishes the initial bond. In India, the responsibil-ity for infant care is assumed by the localmidwife or dai, who visits daily and spendshours massaging the mother and infant [19]. Ifthe dai is not available, the other women in thehousehold will assist. An overt expression ofaffection for the infant by the mother in thepresence of older relatives is uncommon.

In addition to dietary practices described,there are specific cultural practices related tobreastfeeding. In certain Hindus, female familymembers symbolically wash the mother’s breastsprior to the initiation of breastfeeding [46]. Thaiwomen massage their breasts to encourage milkproduction [38]. In orthodox Jewish women,although breastfeeding is allowed, mechanicalbreast pumps may not be used on the Sabbath asthis is seen as work. Women may hand expressthe milk, as long as it is expressed either over thesink or into a salt-laden container so that it maynot be used [53]. Due to beliefs surroundingcolostrum, breastfeeding in some cultures maybe delayed. Among South Asian women, colos-trum is perceived to be indigestible or puss-likeand the practice of withholding colostrum maybe widespread [41,43]. Gartrand and colleagues

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noted that Hindu families in India wait 2 daysbefore initiating breastfeeding [46]. This may alsobe in part related to the ancient Indian scriptureSushruta that advocates breastfeeding begin onthe fifth or sixth day postpartum after the cele-bration Chhatti [19]. Among Guatemalanmidwives, approximately a third of them feltbreastfeeding should be delayed for 3 daysbecause colostrum is dirty and could causediarrhea [43]. The duration of breastfeeding varies.Arabic mothers often breastfeed for 2 years [17],while Hindu mothers wean due to infant mobil-ity at approximately 6 months following theAnnaprassana ceremony [46].

Other postpartum rituals A common practice in Thailand, Vietnam,Cambodia, Mexico, Guatemala and among theHmong is binding of the abdomen to return itto its normal size [3,5,11,13,43]. Among Muslimfamilies, the baby’s abdomen is bound aroundthe umbilical area to prevent abdominal colic,while the mother’s abdomen is bound to has-ten uterine involution and to flatten the stom-ach [45]. Among mothers in Goa (India), an oilmassage is believed to improve strength andmaintain general health [54], while Hawaiiansuse lomilomi massage to remove tensions,emotional anxieties and negative thoughts andfeelings [55].

Several cultures have special practices relatedto the placenta. In Malaysia, the placenta, con-sidered the baby’s sibling, is placed in a ‘wind-ing’ sheet and coconut shell and then buried [42].In the Muslim culture, the placenta is also bur-ied [45], while among rural Koreans the placentais burned on the third day postpartum and theashes are either buried or scattered on a road in along black line to promote longevity [33].

Finally, some rituals are based on spiritual orsuperstitious beliefs. In Mexico, a specializedsequence of visits from female relatives is per-formed to neutralize spiritual impurities [5,7]. InNepal, senior women of the household blessthe new mother by applying a tikka to her fore-head [41]. In parts of rural Korea, little moundsof yellow earth are placed by the family’s frontdoor to announce the birth of the baby and thesex, a practice called Iwanyt’o p’iuda [33]. Alter-natively, a straw rope, pine branches, red pep-pers or charcoal are hung across the entrance inother areas of Korea. These indicators warnothers not to enter the house, as outsiders,especially a woman in mourning, are thoughtto bring danger to the child and mother and

prevent breast milk production. In addition,anyone who has recently travelled is forbiddento enter the house [56].

DiscussionThe review findings clearly suggest that signifi-cant diversity in postpartum practices in terms oftheir explicit manifest content, duration ofobservance and the participants involved exist.These differences probably reflect the divergingunderlying explanatory models regarding postpar-tum recovery. Despite differences, commonalitiescan be identified in each of these elements.

Common manifest content among postpartum practicesOne of the pervasive themes across many cul-tures affecting multiple behavioral domains isthe concern for the balance between ‘hot’ and‘cold.’ The roots of these beliefs can be tracedback to ancient medical systems, including theChinese, Indian and Greek [42], all bearing acomponent of humoral theories. While theexact descriptions of the ‘elements’ and ‘forces’differ (e.g., the two forces of Yin–Yang in theChinese and the three doshas in Ayurveda), allemphasize maintaining a balance of opposingforces to promote health. Their similarity maybe due to early mutual influences on each other.Some had advanced ‘diffusional’ theories, whichhypothesized these ancient systems as influenc-ing other cultures across the world. However,more recent interpretive anthropological worksuggest that theories of hot and cold might haveexisted to varying degrees in many indigenouscultures, and were later influenced by theseancient medical systems [57]. It is noteworthythat in many cultures, the ‘hot–cold’ theory,while existent, does not influence everyday lifeexcept in important life transitions, such aspregnancy and postpartum periods.

Prescribed support is another commonlyemphasized postpartum practice. As noted, oneproposed cultural classification is that culturesthat emphasize postpartum support can be iden-tified as ethnokinship, while modern Westernculture is technocentric [1]. While this is partiallyconsistent with the literature describing non-Western cultures as relatively collectivistic andWestern cultures as relatively individualistic,such distinction depends on the definition of‘technology’. Technology, from the Greek wordtechnologia, is defined as “the practical applica-tion of knowledge, especially in a particulararea,” and can include, for example, the use of

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traditional heating methods and prescribed diets.Whether these diverse cultural groups truly placegreater value on support for the mother duringthe postpartum period versus their own theoriesand technologies remains to be elucidated.

The increased support provided to the newmother temporarily changes her role from that ofa caregiver to that of being one who is cared for.This practice therefore sanctions a social rolethat is diametrically opposite to the norm. Thisso-called ritual of reversal is well described inanthropological writings and is generally seen toreinforce the value or importance of the usual,prescribed. For a very short, tightly circum-scribed period, the mothers are mothered inorder to value and protect their future capacityfor mothering.

Duration of postpartum practicesThe duration of postpartum practices vary con-siderably but tend to be unambiguously definedin terms of days postpartum, in comparison withWestern medicine where puerperium has beenabstractly defined, such as the period of timeafter birth during which the body returns to itsphysiological state. This exerts a certain amountof psychological pressure for women, as thedefined period is seen as a narrow window ofopportunity to health versus illness, and harmdone during this period is not easily reversed. Insome cultures, women feel they need to haveanother pregnancy and postpartum period tocorrect their health status [40].

Participants of postpartum practicesIn many non-Western cultures, female familymembers are often involved in postpartum prac-tices with prescribed roles. Despite most culturesbeing patriarchal, pregnancy and postpartumrelated traditions are seen as the women’sdomain; this may be due to consideration ofwomen’s experience and expertise or men’s fear ofcontamination. In cases where mother-in-lawsare involved, as in many Asian cultures, there isalso a noticeable reversal of power as the newmother is accorded rest while the mother-in-lawbecomes the caregiver. However, some reportssuggest that this can also give rise to interper-sonal conflict [58], and the quality of support maybe important in determining its value.

Rationales of postpartum practicesWhile there may be different reasons cited forpostpartum practices, the restoration of mater-nal health is a common underlying theme across

cultures. This contrasts with the focus on infantcare in the postpartum period in modern West-ern medicine. For example, breastfeeding isemphasized immediately after birth and for thelimited few days in the hospital, often at theexpense of the mother’s rest and sleep. Post-partum practices are usually undertaken in thebelief that these practices have a protective effectfor future illnesses. This may partially accountfor the persistence of beliefs and traditions, asthere is no readily available mechanism for dis-confirmation of beliefs. Some women whoreported not having engaged in these rituals dueto scepticism, expressed regret when theyencountered common illnesses, such as arthritisor back pain, later on in life.

From a Western medical perspective, some rit-uals may indeed have beneficial health effects,such as ensuring adequate rest, privacy, support,nutrition and proper hygiene. However, there isa lack of evidence linking postpartum behaviorsand illnesses in later life. From a psycho–socio-cultural perspective, the postpartum practicesmay serve multiple functions. They facilitate therole transition for the new mother and extendedfamily members, often rewarding the status ofthe new mother. The latter, however, maydepend on whether an infant son is born in somecultures. The practices may also be seen as a signof respect for certain religions or traditions, andin some cases, as a status symbol, since some ofthe rituals may require a certain amount ofsocioeconomic means. Currently, the authors areexamining the functional and substantive bene-fits and disadvantages of postpartum practices onmaternal mental health in a later, linked review.

Diverse origins & variability in practiceThere are many sources of variability in post-partum practices, both within and between cul-tural groups. Some traditional postpartumpractices are based upon what we would considersupernatural or religious beliefs. In fact, medicalanthropology has long described health and ill-ness belief frameworks in diverse cultures thatinclude different types of beliefs, such as reli-gious, magical or supernatural beliefs [59,60]. Fur-thermore, the various health beliefs andexplanatory models may vary depending on thelevel of observation among the different socialspheres of a culture [61]. Designated professionalhealers or medical practitioners may differ intheir beliefs from folk healers such as shamansand midwives, which may also differ from laypopular beliefs at large.

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For instance, postpartum theories in traditionalChinese medicine may bear similarity but notexact correspondence to beliefs of folk medicalpractitioners or the lay public. At each level, thereare further variations depending on regional differ-ences, for example, between Hong Kong, Taiwanand mainland China. It has also been recently rec-ognized that the Western interpretation of tradi-tional Chinese medicine as a coherent organizedsystem of thought grounded in logical basic theo-ries may be a cultural misunderstanding and mis-perception [62]. Chinese medicine encompasses abroad and heterogeneous array of ideas throughoutits history [63]. Furthermore, compared with theWestern philosophical ethos, there is a greater cul-tural acceptance of contradictory and even mutu-ally exclusive beliefs [64]. All of these factors lead tovariable and at times contradictory descriptions ofpostpartum practices.

In addition, it is important to acknowledge thedynamic nature of these practices as they areinfluenced by factors such as modernization, glo-balization and immigration [65]. For example, onestudy found that there is variability in adherenceto traditional postpartum rituals among a sampleof women in Taiwan, suggesting lower adherenceto some customs that might have originallyderived from concerns regarding the lack of cleanfacilities and resources [25]. There are also socialfactors, such as socioeconomic status and politicalsystems, which may limit or modify these prac-tices. Finally, an individual may have multiplecultural and/or religious identities, as well as per-sonal, idiosyncratic beliefs, leading to further var-iations of practice [44,67]. Thus, there may besignificant differences between the practicesdescribed in this review and actual individualbehaviors observed in practice.

Implications for clinical practiceTraditional postpartum practices have significantimplications for the provision of culturally com-petent healthcare. At the individual healthcareprovider level, increased awareness of, and knowl-edge about these practices can avoid causingundue distress to those receiving care. For exam-ple, a new mother may wish to have a number offemale relatives with her during her postpartumhospital stay for support [9,17]. They may beuncomfortable with male staff, due to culturalbeliefs regarding modesty or potential concernsregarding contamination. New mothers may feeluneasy about drinking ice water, having a shower,or other ‘routine’ hospital practices shortly aftergiving birth, yet feel compelled to comply due to

the power dynamics inherent in the healthcareprovider–patient relationship. Physicians, nursesand other allied healthcare professionals need toopen a dialogue with their patients about theirwishes regarding postpartum practices and negoti-ate a mutually agreeable care plan, which mayextend beyond the hospital stay. Depending onthe patient’s preference, this may include involve-ment of family members, as they may haveascribed authority or prescribed roles in postpar-tum care. For those in need of mental health caredue to postpartum psychopathologies, thereshould be an exploration of issues related to post-partum practices. It is important to reiterate that anumber of factors lead to individual variations inadherence to traditional practices as discussed andthat open exploration, rather than assumption, isnecessary for appropriate care.

LimitationsThere are several limitations to this review. Thesearch was restricted to English, health-related,peer-reviewed literature. There may be relevantinformation that is published in other languagesor other non-health-related publications, such asanthropological works. Not all cultural groups areequally represented due to the availability of stud-ies, reflecting the need for additional research. It isvery likely that cultures not described in thisreview also have postpartum practices that havenot yet been described in the English-language,health-related literature. Research from manystudies, being qualitative in nature, is not meantto be representative of entire cultures. It is impor-tant to reiterate the caution against overgeneraliza-tion of cultural practices of any given culturebased on available information, which is derivedfrom studies conducted in particular regions at aparticular point in time, as many factors reviewedabove lead to considerable variability in practice.

Future perspectiveIn the future, as we understand more regardingthe benefits and risks associated with postpartumpractices, professional cultural competence mustinclude changes in institutional policies and pro-grams such as patient educational programsfocusing on prenatal care, labor and delivery, andinfant care matters such as breastfeeding. Cur-rently in Taiwan, specialized centers are set up tofacilitate postpartum practices [66]. While this isnot immediately applicable or feasible in mostother places, it is an example of innovative serv-ices that may be established in the future to meetthe needs of new mothers.

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Executive summary

Introduction

• The postpartum perioprecarious and specifi

Methods & results

• This review assembleddifferent countries.

Organized support

• Organized support, usis provided in the earl

Rest period & restricte

• In most cultures thereusual household chor

Diet

• Certain foods may beeither immediately or

Hygiene & physical w

• Special hygiene practipractices or specific bor special treatment o

Infant care & breastfe

• Certain practices invobreastfeeding have al

Discussion

• The restoration of maBy contrast, in moder

• Postpartum practices duration of the practimembers as often the

• There are many factopatients individually re

Future perspective

• The understanding of

d is a time for women to take on the role of mother and to recover. Many cultures view this period as c traditional rituals are observed to ensure recovery and avoid ill health in later years.

and identified commonalities in postpartum cultural practices across cultures from over 20

ually in the form of family members caring for the new mother and her infant for a specified period of time y postpartum period in many cultures in order to value and protect future capacity for mothering.

d activities

is a prescribed period of rest of 21–40 days during which the mother is prohibited from performing her es.

encouraged to promote healing or restore health, or prohibited because they are thought to cause illness, in the future.

armth practices

ces are required in some cultures as the women are considered ‘contaminated’. In many cultures, warming athing restrictions or prohibitions exist. Other rituals may involve binding of the stomach, receiving massage f the placenta.

eding

lve the mother taking a nondominant role in initial infant care. Specific cultural practices related to so been described.

ternal health is a common underlying theme across cultures – the new mother becomes mothered herself. n Western medicine during the postpartum period the focus is on infant care. are usually undertaken in the belief that these practices have a protective effect for future illnesses and the ces vary. Psychologically they facilitate the role transition for the new mother and the extended family female family members are involved.

rs leading to variability in postpartum beliefs and practices. Healthcare providers need to explore with their garding their beliefs and wishes regarding these practices.

traditional postpartum practices can inform the provision of culturally competent perinatal services.

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