Abstract
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 to recover and take on new roles. In many cultures, it is also seen as a precarious period, rendering the new mother vulnerable to illness, and specific traditional practices are observed to ensure recovery and avoid ill health in later years. By contrast, while great strides in antepartum and intrapartum care have been achieved in Western or ‘modern’ cultures, as indicated by lowered maternal and infant mortality rates, there has been a comparative lack of attention to the post-partum period. This may be due to Western postpartum care focusing primarily on the immediate physical health of mothers and their infants through the use of technological interventions [1]. Postpartum practices in Western ‘technocentric’ cultures do not typically extend beyond the first few days postpartum. By contrast, ‘ethnokinship’ cultures (e.g., many cultures of East Asia, South Asia and the Middle East) emphasize the practice of social support rituals for a more protracted postpartum period [1]. Given these cross-cultural differences, it would be valuable to explore the potential positive and/or negative effects these extended post-partum practices may have on the physical and mental health of mothers. Furthermore, considering increasing rates of migration between countries and the resulting cultural diversity among childbearing women in many healthcare settings, it is essential to understand traditional postpartum practices and the ways in which they may influence the provision of perinatal healthcare. This understanding can inform the provision of culturally competent perinatal services. At present, no recent, comprehensive, cross-cultural examination of postpartum practices exists in the literature. Therefore, the objective of this qualitative systematic review is to assemble accounts of the various practices associated with the postpartum period across cultures, identify commonalities in practices or rationales for practices across cultures, and consider the implications of these practices for the provision of perinatal healthcare.
Methods
Inclusion/exclusion criteria
The review considered all peer-reviewed publications in the health-related literature that focused on maternal traditional practices in the post-partum period (i.e. within the first year following childbirth) using qualitative or quantitative methodology. General review articles were also included. Studies were excluded if a description of postpartum practices was not included, or if only infant-focused practices were described. Studies were limited to the English language due to a lack of translating resources.
Search strategy
A detailed search of the following databases was conducted for articles published between 1966 and July 2006: MEDLINE, CINAHL, PsycINFO, EMBASE, Proquest and the WHO Reproductive Health Library. Variations of the following keywords were used in the search: practices, rituals, customs, postpartum, postnatal and childbirth. All studies identified were assessed for relevance based on the information provided in the title, abstract and descriptor/MeSH terms; a full report was retrieved for all studies that appeared to meet the inclusion criteria. Where relevant articles were identified, the reference lists were searched and links to ‘related articles’ in electronic databases were accessed and additional studies were reviewed for relevance. For all identified studies that met the inclusion criteria, data were extracted by authors and organized by common postpartum practice.
Results
Over 71 abstracts were examined resulting in 51 studies meeting the inclusion criteria (
Characteristics of included studies.
Organized support
Organized support, usually in the form of family members caring for the new mother and her infant for a specified period of time, is almost universally provided in the early postpartum period by the mother, mother-in-law, other female relatives [2–10] or husband [11–12]. Respected elder female community members [11,13], traditional birth attendants [14] or young women from the community [15] may also be involved in providing care for the mother. The support often includes practical assistance (e.g., household chores or cooking), as well as information for the mother regarding how to care for herself and the infant [3,9,16,17]. For example, in Japanese culture, the practice of Satogaeri bunben typically involves the woman traveling to her family home at 32–35 weeks gestation to be cared for by her mother until approximately 8 weeks postpartum [10]. Similarly, in the Amish of Tennessee (USA) the new mother is provided with organized support from extended family members and the community [18]. Other cultures that practice a similar period of organized support include Nigerian, Jordanian, Korean, Guatemalan, Eastern Indian Hindus and Chinese.
Rest period & restricted activities
Organized support typically corresponds to a prescribed period of rest, during which the mother is prohibited from performing her usual household chores. In most cultures, the rest period spans between 21 days and 5 weeks, and is considered a period of vulnerability for future illness [19]. For example, in Korea, a 3–5 week rest 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 ‘doing the month’. This is a formalized, month-long period of rest during which mothers are assisted by extended family to promote recovery and allow ‘loose’ bones to return to their previous positions [2,21–25]. Many Thai women remain at home and are cared for by female family members and their husbands for approximately 30 days, a practice known as yu duan [12,26]. Among Mexican women, a 40-day rest period is known as la cuarenta [7]. Among Muslim women, a 40-day period of rest is observed according to Islamic beliefs [17,30–31]. A designated period of rest is similarly practiced among Amish [18], Japanese [10], Hmong [27], Malay [4,28], Eastern Indian Hindus [29] and South African [32] women.
There are within-culture differences in the extent to which these periods of organized support and period of rest are observed. Younger women and those living in major urban centres may be less likely to participate in these practices or may observe them for a shorter period of time [31,33]. As another example, many factors affect the traditional practice of yu duan in Thai women [12]. Mothers of female infants observe a longer rest period since females are thought to work harder in life than males and therefore deserve additional time with their mother in infancy. Yu duan is considered particularly important for primiparous women. Availability of family members and friends to facilitate Yu duan may be a limiting factor [13]. Middle-and upper-class women may be able to hire people to provide the necessary support, while poorer women may be unable to practice or shorten the period since they or their husbands may need to return to work [34]. Some women believe that traditional practices are only necessary for women living in their native countries, and are no longer important postimmigration [35].
Not observing the traditional period of post-partum rest is generally believed to result in premature aging or ill health, either immediately or in later life. In the Vietnamese culture, facial wrinkling is perceived by some to be very shameful, as it is seen to be evidence that the mother may have poor relationships with her family members who typically provide postpartum support [3]. In Thai culture, practicing yu duan is believed to protect a new mother from lom pid duan, illnesses thought to develop as a result of inappropriate postpartum care [12]. Cambodian women believe that violations of postpartum traditions may result in toas, specific illnesses following childbirth with distinct patterns of symptoms depending on the specific type of violation. In addition, if the new mother feels unsupported by her partner, she may develop pruey cet or ‘sad heart’, primary symptoms of which are unhappiness/depression, frustration, anger, unhappiness and ‘crazy’ behavior [34]. Finally, some cultures believe a major potential consequence of incomplete postpartum recovery is future infertility (e.g., Hmong women [13]; Arab women [31]).
During the postpartum period of rest, specific activities may be prohibited. Among Vietnamese and Chinese women, crying, reading or watching television are not allowed in order to prevent later eye problems [3,36,37]. In Cambodian culture, women are discouraged from feeling strong emotions or ‘thinking too much’ [34]. In many cultures, sexual activity is avoided for a variable length of time, ranging from 20–100 days [16,36]. Often, this practice is encouraged not only by the cultural community, but also by medical practitioners, to encourage appropriate healing following childbirth [38,34]. In Cambodian culture, sexual activity before the new mother considers herself to be ready is thought to be associated with negative health consequences [34]. In other cultures (e.g., Jordanian and Chinese), postpartum women are considered to be ‘polluted’ and therefore sexual activity is considered to be dangerous for the partner [17,36]. Fijian women are to avoid any activities perceived to be potentially harmful to the mother or the infant such as sitting up, physical exertion, combing her hair or exposing herself to the sun [16].
Diet
In many cultures, certain foods are especially encouraged to promote healing or restore health, while consuming prohibited foods are thought to cause illness either immediately or in the future. One of the best-known philosophies that influence ancient East Asian medicine, such as traditional Chinese medicine, is the belief in the duality of opposing forces in the form yin and yang. Yin describes properties such as darkness, cold, wetness, softness, quiescence and feminity, while yang describes the opposite and includes properties such as brightness, heat, dryness, hardness, activity and masculinity [37]. By extension, foods in many cultures may be classified as ‘hot’ or ‘cold’ based on the presumed intrinsic property of the foods. This is usually considered independent of the foods' temperature, except for specific interpretations or idiosyncratic beliefs [36]. Similar dichotomies from traditional Chinese medicine or other ancient medical systems, such a Ayurvedic medicine, influence many of the dietary practices in Asia, as well as in many other non-Western cultures, including parts of Latin America and Africa [39]. Although there are similarities, not all cultures classify the same foods identically (
Examples of perceived positive and negative health outcomes of foods consumed during the postpartum period.
In many cultures, blood and the state of pregnancy itself are often conceived as a state of ‘hotness’ and, conversely, the postpartum period is conceived as a cold and vulnerable state [25,26,39,40]. Hot foods are therefore encouraged to restore harmony and balance, while cold foods are to be avoided. It would appear that these hot foods are often high in protein. For example, among mothers in India, hot foods such as milk, ghee, nuts and jagerry are thought to help regain balance [19], while in the Chinese culture chicken or pig's feet prepared with other hot ingredients are often consumed during the postpartum period. Other examples of encouraged and discouraged foods are given in Table 2.
Special tonics are sometimes used during the postpartum period, consisting of herbs or foods with special medicinal properties. In Nepal, sathora, a herbal tonic, and haluua, a kind of wheat semolina with added heating substances such as ginger, cumin and turmeric, are used to promote milk production, warm the mother and expel childbirth blood [41]. Malaysian mothers also use ‘hot’ herbal medicines [42]. Among Guatemalan women, herbal teas containing artemesia, pimipinela, oregano and white honey are taken for pain relief [43]. Green herbs, such as tshuaj quib, are used by Hmong women for diverse reasons including relieving aches and pains, producing extra blood, ‘washing out’ childbirth blood and placenta, replacing energy and strength, promoting appetite, improving weight loss and increasing breast milk [13]. They may also use chicken soup boiled with the plant ntiv to rid of postpartum blood [27]. In Korea, brown seaweed miyuk and beef broth miyuk guk are used for cleansing the body of lochia and postpartum blood and increasing breast milk [8,33]. Shenghuatang, a herbal soup with ingredients including dang quai (Chinese Angelica Root, Ligusticum acutilobum) and ginger, is used among some Chinese mothers to help renew blood in the early post-partum period [23,24,40]. Dang quai is also used in combination with other foods for anemia and gynecological conditions. Du Zhong, powdered Eucommia ulmoides bark, is sometimes an added ingredient in special broth [25,36] and deer antlers may be used as a tonic [44].
Cultural beliefs regarding the process of childbirth may prescribe different types of diet at various stages across the postpartum period. For example, in Nepal, warming foods such as heated milk are given immediately following delivery. To avoid indigestion and diarrhea, foods such as rice cannot be eaten until the second or third day, at which time the stomach and womb have started contracting towards its normal state [41]. In Chinese women, various sanctioned foods are often introduced in a particular order [44]. For example, the consumption of sesame oil-chicken is delayed postnatally due to the belief that the sesame oil is ‘heavy’ and may lead to a vaginal infection if consumed too early [37].
Although not only practiced during the post-partum period, it is important to note that religious beliefs influence diet as well. Hindu women are often strict vegetarians, and do not eat eggs, fish or meat. In Islam, certain foods such as pork are prohibited according to the Quran and Islamic teachings, and are considered haram (unlawful) foods; permissible halal foods require special methods of preparation or slaughter. In Judaism, kashrut are dietary laws based on the Torah and religious teachings that determine which foods are kosher (permissible) including the type of food and the necessary preparation procedures.
Finally, certain dietary prescriptions are related to breastfeeding. Muslim mothers are encouraged to consume ‘hot’ foods and drinks, while fruits and raw, sour, spicy, greasy or oily foods are avoided [45]. Spicy foods are also avoided by both Chinese and Korean mothers [44]. Hindu mothers avoid ‘cold’ foods when their infant has a cold or ‘hot’ foods when the infant has a fever [46]. Some Kanadier Mennonite women believe that raw foods can ‘taint’ their breast milk while watermelon, cabbage, beans and hot peppers may stimulate the infant and interfere with sleep patterns [15]. They also believe that putting hands in hot soapy water will decrease breast milk supply while eating alfalfa seeds will increase it. To increase milk production, Chinese mothers use various foods including papaya, fish soup, black root pickled with pork feet, and broiled freshwater fish [44,47], while Korean mothers use miyuk guk broth [8,33]. Thai women advocate the consumption of hot drinks to increase breast milk production [38].
Hygiene & physical warmth practices
In many cultures, postpartum women are seen as contaminated, and therefore special hygiene practices are required. Jordanian mothers wash their genitalia thoroughly with soap and water because they are thought to be temporarily ‘polluted’ by childbirth [17]. Muslim women take a purification bath called a ghusl after they have stopped bleeding [30]. In some cultures (e.g., Arabic, Thai and Chinese), women are considered to be unclean until the postpartum period of rest has been completed or bleeding has discontinued. Prior to this, women are often prohibited from sexual intercourse [25,30]. They are also prohibited from entering other people's homes, or entering through the front door of their own home [13,37] to avoid offending guardian gods or spirits. Similarly, family members may be unwilling to eat food prepared by the new mother during this period to avoid illness or death [31]. Among Hindus, the new mother is not allowed to cook or receive male visitors until the tenth or twelfth day postpartum when she is considered ‘clean’ and can carry out normal household chores [46]. For some Eastern Indian Hindus, the whole family is considered impure. No outsiders are allowed to eat or drink in the house until a day determined by caste and a ritual bath and religious ceremony is performed [29]. In Pakistan, heavy postpartum bleeding is considered ‘healthy’ in order to release the ‘unclean’ menstrual blood that accumulated prenatally [48]. For the Hmong women, any material that contacts childbirth blood must be washed in the house and buried in a hole in the dirt floor to avoid attracting the attention of spirits, which could harm the mother or infant [13].
In many cultures, specific bathing restrictions or prohibitions exist, some of which relate to the ‘hot’ and ‘cold’ beliefs already described. Cold baths or showers are often strictly prohibited to avoid blood clots, sore bones and joints, and an itchy body [3,11,13]. In Guatemala, midwives believe that bathing in cold water causes fever, infection, edema and decreased milk supply, and that bathing too soon causes stomach pains or prolapsed uterus [49]. In Mexico, bathing is restricted to protect the mother from cold or ‘evil air’ [5,7]. Similar concerns are reflected in some Eastern Indian Hindus and Chinese beliefs that air conditioners and fans are dangerous for new mothers [6,29]. By contrast, warms baths are acceptable in the Hmong culture [3,11,13] and in Malaysia [42], India [19] and Thailand [38]. Among Arabic and Thai women, it is acceptable to take a quick, warm shower but hair washing is prohibited [17,38]. A steam bath (sitting on hot bricks and medicinal leaves or inhaling steamed medicinal herbs) is prescribed in Thailand to sweat out poisonous water and absorb good water, dry the perineum and assist healing [12,50]. Among Jordanian and Guatemalan women, sitz baths are recommended to facilitate healing [17,43]. Thai mothers practice Kao krachome, where several types of herbs are boiled in a pot. The mother then sits on a bed and covers herself and the pot with a blanket. Kao krachome is believed to help sweat out ‘poisonous’ water so that the mother can absorb ‘good’ water in order to promote healthy skin and protect against blurred vision, dizziness, headaches and fatigue in later life.
A related practice found among Asian cultures is to actively warm the new mother to balance the loss of ‘hot’ blood during delivery. In Malaysia, mothers bathe in warmed water, bind ‘hot’ substances around their abdomens and lie above or near a fire source [42]. For 3 days, the new mother receives a thorough massage from her midwife to increase circulation and to bring healing heat to all parts of her body [28]. Thai women practice yu fai: a practice where the mother, wearing warm clothes and wrapped in blankets, lies on a wooden bed over a warm fire for 30 days to flush out retained blood and placenta, increase involution of her uterus, flatten her stomach, remove stretch marks and heal perineal tears [13,38,50]. Mothers are also massaged with hot salt to loosen tendons and prevent blood clots. Vietnamese mothers keep warm to avoid the ‘wind’ and prevent headaches, facial wrinkling, varicose veins and other health problems [3,9,51]. A fire is also placed under the mother's bed to prevent blood clots and backaches. Chinese mothers may follow similar practices [37]. Cambodian mothers place heated rocks on their stomach to prevent blood clots 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, ligaments) and to prevent uterine blood clots, ensure good skin and promote overall long-term health [34,52]. During roasting, mothers tie strings around their waist/wrist, paint lime crosses in corners of homes or on necks or ankles, and place thorns under their bed to ward off priey krawlah pleungh, a spirit that attacks a woman while roasting, causing seizures, fainting, loss of consciousness and bizarre behaviors. Herbs are used with hot rocks (tshuaj ntxhawb) to treat ill health arising from not keeping the body warm enough. Hmong mothers wear warm clothing to avoid the ‘wind’ and sleep near a fire for 3 days postpartum [5,11,13]. The mother's straw bed is then burnt. This practice was developed to cope with the scarcity of blankets and sanitary pads and to avoid washing material containing childbirth blood in water sources.
Infant care & breastfeeding
In some cultures where there is an extended post-partum rest period for the mother, relatives will assist or play a dominant role in infant care. For example, in Nepal, both in hospital and at home, the mother remains a peripheral figure in infant care during the first few days postpartum [41]. The infant's paternal grandmother or aunt establishes the initial bond. In India, the responsibility for infant care is assumed by the local midwife or dai, who visits daily and spends hours massaging the mother and infant [19]. If the dai is not available, the other women in the household will assist. An overt expression of affection for the infant by the mother in the presence of older relatives is uncommon.
In addition to dietary practices described, there are specific cultural practices related to breastfeeding. In certain Hindus, female family members symbolically wash the mother's breasts prior to the initiation of breastfeeding [46]. Thai women massage their breasts to encourage milk production [38]. In orthodox Jewish women, although breastfeeding is allowed, mechanical breast pumps may not be used on the Sabbath as this is seen as work. Women may hand express the milk, as long as it is expressed either over the sink or into a salt-laden container so that it may not be used [53]. Due to beliefs surrounding colostrum, breastfeeding in some cultures may be delayed. Among South Asian women, colostrum is perceived to be indigestible or puss-like and the practice of withholding colostrum may be widespread [41,43]. Gartrand and colleagues noted that Hindu families in India wait 2 days before initiating breastfeeding [46]. This may also be in part related to the ancient Indian scripture Sushruta that advocates breastfeeding begin on the fifth or sixth day postpartum after the celebration Chhatti [19]. Among Guatemalan midwives, approximately a third of them felt breastfeeding should be delayed for 3 days because colostrum is dirty and could cause diarrhea [43]. The duration of breastfeeding varies. Arabic mothers often breastfeed for 2 years [17], while Hindu mothers wean due to infant mobility at approximately 6 months following the Annaprassana ceremony [46].
Other postpartum rituals
A common practice in Thailand, Vietnam, Cambodia, Mexico, Guatemala and among the Hmong is binding of the abdomen to return it to its normal size [3,5,11,13,43]. Among Muslim families, the baby's abdomen is bound around the umbilical area to prevent abdominal colic, while the mother's abdomen is bound to hasten uterine involution and to flatten the stomach [45]. Among mothers in Goa (India), an oil massage is believed to improve strength and maintain general health [54], while Hawaiians use lomilomi massage to remove tensions, emotional anxieties and negative thoughts and feelings [55].
Several cultures have special practices related to the placenta. In Malaysia, the placenta, considered the baby's sibling, is placed in a ‘winding’ sheet and coconut shell and then buried [42]. In the Muslim culture, the placenta is also buried [45], while among rural Koreans the placenta is burned on the third day postpartum and the ashes are either buried or scattered on a road in a long black line to promote longevity [33].
Finally, some rituals are based on spiritual or superstitious beliefs. In Mexico, a specialized sequence of visits from female relatives is performed to neutralize spiritual impurities [5,7]. In Nepal, senior women of the household bless the new mother by applying a tikka to her forehead [41]. In parts of rural Korea, little mounds of yellow earth are placed by the family's front door to announce the birth of the baby and the sex, a practice called Iwanyt'o p'iuda [33]. Alternatively, a straw rope, pine branches, red peppers or charcoal are hung across the entrance in other areas of Korea. These indicators warn others not to enter the house, as outsiders, especially a woman in mourning, are thought to bring danger to the child and mother and prevent breast milk production. In addition, anyone who has recently travelled is forbidden to enter the house [56].
Discussion
The review findings clearly suggest that significant diversity in postpartum practices in terms of their explicit manifest content, duration of observance and the participants involved exist. These differences probably reflect the diverging underlying explanatory models regarding postpartum recovery. Despite differences, commonalities can be identified in each of these elements.
Common manifest content among postpartum practices
One of the pervasive themes across many cultures affecting multiple behavioral domains is the concern for the balance between ‘hot’ and ‘cold.’ The roots of these beliefs can be traced back to ancient medical systems, including the Chinese, Indian and Greek [42], all bearing a component of humoral theories. While the exact descriptions of the ‘elements’ and ‘forces’ differ (e.g., the two forces of Yin–Yang in the Chinese and the three doshas in Ayurveda), all emphasize maintaining a balance of opposing forces to promote health. Their similarity may be due to early mutual influences on each other. Some had advanced ‘diffusional’ theories, which hypothesized these ancient systems as influencing other cultures across the world. However, more recent interpretive anthropological work suggest that theories of hot and cold might have existed to varying degrees in many indigenous cultures, and were later influenced by these ancient medical systems [57]. It is noteworthy that in many cultures, the ‘hot–cold’ theory, while existent, does not influence everyday life except in important life transitions, such as pregnancy and postpartum periods.
Prescribed support is another commonly emphasized postpartum practice. As noted, one proposed cultural classification is that cultures that emphasize postpartum support can be identified as ethnokinship, while modern Western culture is technocentric [1]. While this is partially consistent with the literature describing non-Western cultures as relatively collectivistic and Western cultures as relatively individualistic, such distinction depends on the definition of ‘technology’. Technology, from the Greek word technologia, is defined as “the practical application of knowledge, especially in a particular area,” and can include, for example, the use of traditional heating methods and prescribed diets. Whether these diverse cultural groups truly place greater value on support for the mother during the postpartum period versus their own theories and technologies remains to be elucidated.
The increased support provided to the new mother temporarily changes her role from that of a caregiver to that of being one who is cared for. This practice therefore sanctions a social role that is diametrically opposite to the norm. This so-called ritual of reversal is well described in anthropological writings and is generally seen to reinforce the value or importance of the usual, prescribed. For a very short, tightly circumscribed period, the mothers are mothered in order to value and protect their future capacity for mothering.
Duration of postpartum practices
The duration of postpartum practices vary considerably but tend to be unambiguously defined in terms of days postpartum, in comparison with Western medicine where puerperium has been abstractly defined, such as the period of time after birth during which the body returns to its physiological state. This exerts a certain amount of psychological pressure for women, as the defined period is seen as a narrow window of opportunity to health versus illness, and harm done during this period is not easily reversed. In some cultures, women feel they need to have another pregnancy and postpartum period to correct their health status [40].
Participants of postpartum practices
In many non-Western cultures, female family members are often involved in postpartum practices with prescribed roles. Despite most cultures being patriarchal, pregnancy and postpartum related traditions are seen as the women's domain; this may be due to consideration of women's experience and expertise or men's fear of contamination. In cases where mother-in-laws are involved, as in many Asian cultures, there is also a noticeable reversal of power as the new mother is accorded rest while the mother-in-law becomes the caregiver. However, some reports suggest that this can also give rise to interpersonal conflict [58], and the quality of support may be important in determining its value.
Rationales of postpartum practices
While there may be different reasons cited for postpartum practices, the restoration of maternal health is a common underlying theme across cultures. This contrasts with the focus on infant care in the postpartum period in modern Western medicine. For example, breastfeeding is emphasized immediately after birth and for the limited few days in the hospital, often at the expense of the mother's rest and sleep. Postpartum practices are usually undertaken in the belief that these practices have a protective effect for future illnesses. This may partially account for the persistence of beliefs and traditions, as there is no readily available mechanism for dis-confirmation of beliefs. Some women who reported not having engaged in these rituals due to scepticism, expressed regret when they encountered common illnesses, such as arthritis or back pain, later on in life.
From a Western medical perspective, some rituals may indeed have beneficial health effects, such as ensuring adequate rest, privacy, support, nutrition and proper hygiene. However, there is a lack of evidence linking postpartum behaviors and illnesses in later life. From a psycho–sociocultural perspective, the postpartum practices may serve multiple functions. They facilitate the role transition for the new mother and extended family members, often rewarding the status of the new mother. The latter, however, may depend on whether an infant son is born in some cultures. The practices may also be seen as a sign of respect for certain religions or traditions, and in some cases, as a status symbol, since some of the rituals may require a certain amount of socioeconomic means. Currently, the authors are examining the functional and substantive benefits and disadvantages of postpartum practices on maternal mental health in a later, linked review.
Diverse origins & variability in practice
There are many sources of variability in postpartum practices, both within and between cultural groups. Some traditional postpartum practices are based upon what we would consider supernatural or religious beliefs. In fact, medical anthropology has long described health and illness belief frameworks in diverse cultures that include different types of beliefs, such as religious, magical or supernatural beliefs [59,60]. Furthermore, the various health beliefs and explanatory models may vary depending on the level of observation among the different social spheres of a culture [61]. Designated professional healers or medical practitioners may differ in their beliefs from folk healers such as shamans and midwives, which may also differ from lay popular beliefs at large.
For instance, postpartum theories in traditional Chinese medicine may bear similarity but not exact correspondence to beliefs of folk medical practitioners or the lay public. At each level, there are further variations depending on regional differences, for example, between Hong Kong, Taiwan and mainland China. It has also been recently recognized that the Western interpretation of traditional Chinese medicine as a coherent organized system of thought grounded in logical basic theories may be a cultural misunderstanding and mis-perception [62]. Chinese medicine encompasses a broad and heterogeneous array of ideas throughout its history [63]. Furthermore, compared with the Western philosophical ethos, there is a greater cultural acceptance of contradictory and even mutually exclusive beliefs [64]. All of these factors lead to variable and at times contradictory descriptions of postpartum practices.
In addition, it is important to acknowledge the dynamic nature of these practices as they are influenced by factors such as modernization, globalization and immigration [65]. For example, one study found that there is variability in adherence to traditional postpartum rituals among a sample of women in Taiwan, suggesting lower adherence to some customs that might have originally derived from concerns regarding the lack of clean facilities and resources [25]. There are also social factors, such as socioeconomic status and political systems, which may limit or modify these practices. Finally, an individual may have multiple cultural and/or religious identities, as well as personal, idiosyncratic beliefs, leading to further variations of practice [44,67]. Thus, there may be significant differences between the practices described in this review and actual individual behaviors observed in practice.
Implications for clinical practice
Traditional postpartum practices have significant implications for the provision of culturally competent healthcare. At the individual healthcare provider level, increased awareness of, and knowledge about these practices can avoid causing undue distress to those receiving care. For example, a new mother may wish to have a number of female relatives with her during her postpartum hospital stay for support [9,17]. They may be uncomfortable with male staff, due to cultural beliefs regarding modesty or potential concerns regarding contamination. New mothers may feel uneasy about drinking ice water, having a shower, or other ‘routine’ hospital practices shortly after giving birth, yet feel compelled to comply due to the power dynamics inherent in the healthcare provider–patient relationship. Physicians, nurses and other allied healthcare professionals need to open a dialogue with their patients about their wishes regarding postpartum practices and negotiate a mutually agreeable care plan, which may extend beyond the hospital stay. Depending on the patient's preference, this may include involvement of family members, as they may have ascribed authority or prescribed roles in postpartum care. For those in need of mental health care due to postpartum psychopathologies, there should be an exploration of issues related to postpartum practices. It is important to reiterate that a number of factors lead to individual variations in adherence to traditional practices as discussed and that open exploration, rather than assumption, is necessary for appropriate care.
Limitations
There are several limitations to this review. The search was restricted to English, health-related, peer-reviewed literature. There may be relevant information that is published in other languages or other non-health-related publications, such as anthropological works. Not all cultural groups are equally represented due to the availability of studies, reflecting the need for additional research. It is very likely that cultures not described in this review also have postpartum practices that have not yet been described in the English-language, health-related literature. Research from many studies, being qualitative in nature, is not meant to be representative of entire cultures. It is important to reiterate the caution against overgeneralization of cultural practices of any given culture based on available information, which is derived from studies conducted in particular regions at a particular point in time, as many factors reviewed above lead to considerable variability in practice.
Future perspective
In the future, as we understand more regarding the benefits and risks associated with postpartum practices, professional cultural competence must include changes in institutional policies and programs such as patient educational programs focusing on prenatal care, labor and delivery, and infant care matters such as breastfeeding. Currently in Taiwan, specialized centers are set up to facilitate postpartum practices [66]. While this is not immediately applicable or feasible in most other places, it is an example of innovative services that may be established in the future to meet the needs of new mothers.
Executive summary
The postpartum period is a time for women to take on the role of mother and to recover. Many cultures view this period as precarious and specific traditional rituals are observed to ensure recovery and avoid ill health in later years.
This review assembled and identified commonalities in postpartum cultural practices across cultures from over 20 different countries.
Organized support, usually in the form of family members caring for the new mother and her infant for a specified period of time is provided in the early postpartum period in many cultures in order to value and protect future capacity for mothering.
In most cultures there is a prescribed period of rest of 21–40 days during which the mother is prohibited from performing her usual household chores.
Certain foods may be encouraged to promote healing or restore health, or prohibited because they are thought to cause illness, either immediately or in the future.
Special hygiene practices are required in some cultures as the women are considered ‘contaminated’. In many cultures, warming practices or specific bathing restrictions or prohibitions exist. Other rituals may involve binding of the stomach, receiving massage or special treatment of the placenta.
Certain practices involve the mother taking a nondominant role in initial infant care. Specific cultural practices related to breastfeeding have also been described.
The restoration of maternal health is a common underlying theme across cultures – the new mother becomes mothered herself. By contrast, in modern Western medicine during the postpartum period the focus is on infant care.
Postpartum practices are usually undertaken in the belief that these practices have a protective effect for future illnesses and the duration of the practices vary. Psychologically they facilitate the role transition for the new mother and the extended family members as often the female family members are involved.
There are many factors leading to variability in postpartum beliefs and practices. Healthcare providers need to explore with their patients individually regarding their beliefs and wishes regarding these practices.
The understanding of traditional postpartum practices can inform the provision of culturally competent perinatal services.