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ABSTRACT
Postpartum health beliefs and practices among non-Western cultures are each distinct, but have many similarities. Two common belief systems surround 1) the importance of hot and cold, and 2) the necessity of confinement during a specific period of time after giving birth. This article describes common postpartum health beliefs among women in Guatemala, China, Jordan, Lebanon, Egypt, Palestine, India, and Mexico, and offers an exemplar from the author’s experiences as a Korean woman giving birth in the United States. Cultural competence in the provision of postpartum care is essential for nurses in the healthcare world of the 21st century.
I am a Korean-born woman and a Registered Nurse who came to the United States as an adult, and gave birth during the 1990s in the United States. My birth experiences brought up many unexpected cultural conflicts between the postpartum beliefs of my home culture and those of the United States. This led me to consider what other foreign-born women feel after giving birth in the United States, and how much American nurses know about cultural beliefs other than those of American-born women. I decided to learn more about this, and work toward educating American nurses along the way. This article is the result of what I have learned.
Every year the population of the United States becomes increasingly ethnically diverse. According to Census 2000, 75.1% of the U.S. population is White, 12.3% is African American, 3.6% is Asian, 0.9% is American Indian/Alaska Native, 0.1% is Native Hawaiian/other Pacific Islander, 5.5% is “other” races, and 2.4% consists of people describing themselves as two or more races. About 13% have Hispanic origin; this population is expected to grow rapidly over the coming years (U.S. Bureau of Census, 2001). Of the Registered Nurses in the United States, 87.7% are White, 4.9% are African American, 3.5% are Asian, 2.0% are Hispanic, and 0.5% are Native American (U.S. Department of Health and Human Services, 2001).
Beliefs and practices surrounding the postpartum period are culturally patterned (Brettell & Sargent, 1997), and marked differences exist between Western and non-Western cultures. A lack of cultural knowledge on the part of registered nurses can make appropriate care difficult to deliver (Lauderdale, 1999). Although women from non-Western cultures may wish to preserve their own traditional postpartum practices, their cultural preferences or expectations might be neglected due to healthcare providers’ lack of cultural competence (Lauderdale, 1999). Although considerable diversity exists among non-Western cultures, there are also many common postpartum practices that nurses can learn to recognize in providing maternity healthcare. The two common non-Western postpartum beliefs described in this article are (1) hot-cold beliefs and (2) postpartum confinement beliefs. These beliefs will be examined for cultures from Guatemala, China, Jordan, Lebanon, Egypt, Palestine, India, and Mexico.
Hot and Cold Beliefs
One common belief in many non-Western cultures is the necessity of maintaining a “hot-cold balance” within the body and with the environment after the birth of a baby. Hot-cold concepts of healthcare (also called humoral theories) are centuries old in the traditional cultures of Latin America, Asia, and Africa (Manderson, 1987;Spector, 2000). In many non-Western cultures, blood is considered “hot.” Therefore, after giving birth, when the woman has lost blood she is considered to be in a cold state. Accordingly, postpartum care in these cultures is aimed at keeping the new mother warm; it is believed that this will restore her humoral balance.
In rural Guatemala, traditional midwives emphasize the application of heat in the postpartum period (Lang & Elkin, 1997). New mothers are instructed to use heated water to preserve their warmth; they might take a sweatbath, a sitz bath, or an herbal bath, according to region. Guatemalans believe that a hot bath increases the flow of milk, “lowers” the milk into the breasts, and prevents breast milk from becoming “cold.” Although Western-educated healthcare providers generally discourage hot baths, such baths provide ritual as well as physical cleansing in Guatemala culture (Lang & Elkin, 1997).
According to the Chinese custom of zuo yue zi (“doing the month”), the new mother should not go out into the sunshine, walk about, read, cry, bathe, wash her hair, touch cold water, or engage in sexual intercourse (Galanti, 1997;Holroyd et al., 1997). After giving birth, the mother is expected to be kept warm, and to be protected from “the wind.” It is important to keep the room warm, lest cold or wind enter the new mother’s joints. No matter how hot the weather, the traditional Chinese woman will want the windows closed and the air conditioning off. Bathing is considered dangerous. Southeast Asian women observe very similar postpartum practices (Davis, 2001).
In a phenomenological study exploring experiences of postpartum depression among 45 Middle Eastern women (Lebanese, Egyptian, and Palestinian), Nahas, Hillege, and Amashen (1999) reported that the interviewees believed that their “bones are still open” after birth, and having cold food and drink would result in health problems such as arthritis and rheumatism. The interviewees also believed that hot meals keep new mothers warm and increase their milk supply (Nahas et al., 1999). Jordanian women maintain this same belief (Nahas & Amashen, 1999).
In a study of contemporary Mayan Indian culture in Yucatan , Mexico, Jordan (1993) reported that for the first week following childbirth, the Mayan mother and infant are considered “hot” and must remain secluded in the house to protect them from “cold” evil wind. Among Mexican Americans, the postpartum preference for a warm environment may restrict full bathing or hair washing for up to 40 days after giving birth (Purnell, 1998).
Postpartum Confinement
Although the length of the postpartum period varies cross-culturally, the notion of a 40-day postpartum is common in many non-Western cultures (Lauderdale, 1999;Nahas et al., 1999). In almost all non-Western societies, 40 days after birth is seen as necessary for recuperation. Among most non-Western cultures, family members (especially female relatives) provide strong social support, help new mothers at home during that period. The new mother’s activities are strictly limited, and her needs are taken care of by (typically) female relatives and midwives (Holroyd et al., 1997;Nahas & Amashen, 1999).
For example, in Guatemala, a traditional midwife visits the mother every day or two, for up to 2 weeks after birth, to check the baby’s cord, to massage the mother, and to wash the families’ clothes and linens, so that the new mother may rest (Lang & Elkin, 1997).
Chinese women believe rest is essential after birth. During the customary 30-day postpartum confinement, female relatives or live-in helpers perform household activities for the new mother (Holroyd et al., 1997). The new mother must be confined to her home during a 30-day postpartum period and must perform a variety of avoidance rituals (Holroyd, Katie, Chun, & Ha, 1997).
In India, postpartum confinement typically lasts up to 40 days. This seclusion is to protect the new mother and her infant not only from evil spirits, but also from exposure to illness, because both are considered to be in a vulnerable state after birth (American Public Health Association, 2001).
In the Middle East, resting 40 days after having a baby is customary in Jordan, Lebanon, Egypt, and Palestine (Nahas & Amashen, 1999;Nahas et al., 1999). During this 40-day period, someone comes to the house or stays with the new mother to take care of the baby, the house, and the other children, so that “all new mothers have to do is rest” (Nahas & Amashen, 1999, p. 42).
Although not a 40-day prohibition, in Mayan Indian culture in Mexico, a new mother and infant must remain inside for 7 days and have limited contact with non-household visitors. After the first week, the mother may increase her activities. She resumes her full, normal activities only after the 20th-day sobada, a postpartum massage by a midwife, which constitutes the formal termination of the childbirth process (Jordan, 1993).
Some Differences Between Western and Non-Western Postpartum Practices
In the traditional non-Western view, birth is part of a holistic and personal system, involving moral values, social relations, and relation to the environment, as well as the physical aspects. Birth ceremonies often are used to recognize the importance of the event in the culture (Leininger, 1995). Special foods are prepared to express the reward of motherhood, as well as to symbolize a new baby’s entry into the family and community (Callister & Vega, 1998;Leininger, 1995).
In contrast, Western postpartum practices are based on the biomedical model. In a Western framework, pregnancy might be “managed” by a physician who performs a special medical or obstetrical role (Lauderdale, 1999). According to Davis-Floyd (1997), the message conveyed to American women is that the role of the woman is less important than that of the physician during giving birth. Gifts and celebrations are centered around the newborn rather than the mother (e.g., baby showers, christenings, visits from friends and relatives to see the baby) (Lauderale, 1999). It is interesting that women’s status has been considered relatively higher in Western cultures than in non-Western cultures, yet paradoxically less recognition seems to be given to new mothers in the United States.
A Korean Woman’s Postpartum Experience in the United States
I came to the United States in 1992, was married to an American in 1995, and gave birth in the United States twice in the late 1990s. My first experience giving birth was difficult and included a third degree laceration and significant pain after giving birth. Nevertheless, approximately 30 minutes after giving birth, my nurse suggested that I take a shower, explaining that a shower would refresh and strengthen me. I felt a certain degree of conflict, for Korean culture prohibits bathing immediately after giving birth. However, I followed her instruction, largely because my culture also teaches respect for authority.
After the shower, the nurse brought an ice container full of bottles of juice, explaining that because I had lost a lot of blood and fluids, I needed to drink as much liquid as I could. Again, I felt a conflict, for Korean practice (which follows the humoral theory) dictates that a new mother is not supposed to drink cold liquids.
Circumstances required that my husband and I had to stay at a home other than our own for a few days after my discharge from the hospital; the homeowner kept the temperature of the home very low. Again, according to Korean practice, a new mother is supposed to cover up with blankets and keep warm to protect her loose bones; according to this belief, if I failed to do so, I would suffer from bone pain or rheumatism in my old age. Although as a nurse I had been educated in Western postpartum practices, I found I still believed in the traditional Korean postpartum practices, whether or not they had grounding in Western medical theory.
Another frustration was food. After I gave birth, my husband brought me the same meals that Americans usually eat at home, such as bagels or muffins for breakfast, and sandwiches for lunch. I wondered why my husband and his family did not prepare special foods for me, since I was a new mother. I sorely missed miyuk-kuk, the hot and smelly seaweed soup, which is routinely served to every new mother in Korea. Other American attitudes and behaviors also confused and disappointed me. Approximately 7 days after I gave birth to our baby daughter, my husband’s family gathered to celebrate her arrival. I felt that all their concern was for the baby, rather than for me, the new mother. In Korea, very elaborate consideration and attention is granted to the new mother after birth. As a Korean, I also looked forward to enjoying the role of a patient until my full recovery, usually lasting 1 month. I remembered my sister’s postpartum period in Korea. After having her baby, she came to our home to receive postpartum care from our mother. For about a month, my sister’s only duties were to eat and sleep to restore her health. In contrast, my American husband and his family treated me as a healthy person who could resume normal activities almost immediately. For example, my husband expected me to drive to the pediatrician’s clinic for the baby’s first physical checkup 7 days after giving birth.
After my second birth experience 3 years later I felt less conflict, for I had learned how to negotiate differences between my culture and my husband’s. Because I had become more acculturated, I felt less conflict with American practices, but nevertheless, I still felt that a new mother receives inadequate consideration in the United States. Within an hour of giving birth, a nurse brought me my baby and asked me to sleep with her, explaining that this would increase infant-mother attachment. During the night, I called my nurse twice and asked her to take the baby to the nursery, because I was still tired, and wanted to sleep without interruption. Korean culture had taught me that maternal rest is crucial to recovery. But the nurse’s comments made me feel guilty—as if I were an incompetent and lazy mother—so I held the baby thorough the night. The next morning, when I told my husband about the experience, he was delighted that our new daughter had slept with her mother. Again, I saw that in America less consideration is given for maternal rest than in Korea.
Clinical Implications
Given the extent of ethnic and racial diversity in the United States, it is not possible to know details about each non-Western country’s postpartum practices. However, a rudimentary knowledge of the most common non-Western postpartum beliefs and practices will enable nurses and midwives to avoid unnecessary conflicts and provide more appropriate and effective care.
Galanti (1997) gave an example of conflicts when describing a Vietnamese woman who returned to the hospital with a high fever and abdominal pain 12 days after giving birth. During her stay, she rejected most of the food and liquids prepared by the hospital, refused to take a shower or wash her hair, and would not get out of bed except to use the bathroom. When she insisted on covering up with many blankets in spite of her high temperature and sweating, the nurses feared for her health. In this case, a familiarity with non-Western “hot-cold” beliefs and practices would have made the nursing care plan easier to devise. A refusal by an Asian mother to have a full shower should be understood in terms of the belief that cold temperatures are detrimental to recuperation after childbirth. Flexibility on the part of nurses who work with new mothers needs to be incorporated into the “routine” postpartum care we feel is necessary. Nurses can ask new mothers about their cultural beliefs, and incorporate those preferences into the plan of her care. Sometimes, generic (folk) practices may be combined with Western healthcare practices for the provision of effective healthcare. In the case of the Vietnamese woman, a sponge bath could be substituted for the routine shower, and additional clean bed blankets might be offered.
Because culturally specific dietary prescriptions are common in the postpartum period among non-Western countries, the choice of certain cultural foods by non-Western women should be respected, if there are no dietary restrictions for health reasons (Lauderdale, 1999). Although prescribed foods differ among non-Western countries, generally there is a very strong emphasis on “heating” food during the postpartum period, while at the same time “cooling” food is prohibited. Therefore, the routine distribution of ice water or cold juices can be modified by offering warm tea, coffee, or broth.
Nurses and midwives can assess the new mother’s level of acculturation and assimilation, linguistic abilities, and education level. Less acculturated women may feel an intense level of stress when confronted with cultural beliefs of healthcare in the United States (Balcazar, Peterson, & Krull, 1997). In my case, my second childbirth experience was much less stressful than my first, because I had become more acculturated to Western practices.
In conclusion, nurses and midwives need to recognize that cultures reflect life experiences; they should be sensitive to cultural differences in postpartum beliefs and practices as the first step toward developing their cultural competence. Many professional sources of information are available to increase cultural competence, as well as in-service education programs related to non-Western postpartum beliefs and practices (Moore & Moos, 2002).
Non-Western new mothers may lack the extensive familial and social support that they enjoyed in their own countries. Nurses and midwives can help provide this extra support.
References
1. American Public Health Association (2001). South Asia case study-India: Norms of maternal care in India and impact on utilization on maternal health services in the U.S. Retrieved June 14, 2001 from http://www.apha.org/ppp/red/indiaPostpartum.htm . [Context Link]
2. Balcazar, H., Peterson, G., Krull, J. L. (1997). Acculturation and family cohesiveness in Mexican American pregnant women: Social and health implications. Family and Community Health, 20( 3), 16–31. [Context Link]
3. Brettell, C. B., & Sargent, C. F. (1997). Gender in cross-cultural perspective (2nd ed.). Upper Saddle River, NJ; Prentice Hall. [Context Link]
4. Callister, L. C., Vega, R. (1998). Giving birth: Guatemalan women’s voice. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27, 289–295. [Context Link]
Callister, L. C. (2001). Culturally competent care of women and newborns: Knowledge, attitude, and skills. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 209–215.
6. David-Floyd, R. E. (1997). Gender and ritual: Giving birth the American way. In C. B. Brettell & C. F. Sargent (Eds.), Gender in cross-cultural perspective (2nd ed., pp. 403–415). Upper Saddle River, NJ: Prentice Hall. [Context Link]
7. Davis, R. E. (2001). The postpartum experience for Southeast Asian women in the United States. MCN, The American Journal of Maternal Child Nursing 26( 4), 208–213. [Context Link]
8. Galanti, A. (1997). Caring for patients from different cultures: Case studies from American hospitals (2nd ed.). Philadelphia: University of Pennsylvania Press. [Context Link]
9. Holroyd, E., Katie, F. K. L., Chun, L. S., Ha, S. W. (1997). “Doing the month”: An exploration of postpartum practices in Chinese women. Health Care for Women International, 18, 301–313. [Context Link]
10. Jordan, B. (1993). Birth in four cultures: A cross-cultural investigation of childbirth in Yucatan, Holland, Sweden, and the United States (2nd ed.). Montreal, Canada: Eden Press Women’s Publications. [Context Link]
11. Lang, J. B., Elkin, E. D. (1997). A study of the beliefs and birthing practices of traditional midwives in rural Guatemala. Journal of Nurse-Midwifery, 42( 1), 25–31. [Context Link]
12. Lauderdale, J. (1999). Childbearing and transcultural nursing care issues. In M. M. Andrews & J. S. Boyle (Eds.). Transcultural concepts in nursing care (3rd ed., pp. 81–106). Philadelphia: Lippincott. [Context Link]
13. Leininger, M. (1995). Transcultural nursing (2nd ed.). New York: McGraw-Hill. [Context Link]
14. Manderson, L. (1987). Hot-cold food and medical theories: Overview and introduction. Social Science and Medicine, 25, 329–330. [Context Link]
15. Moore, M. L., & Moos, M. K. (2002). Cultural competence in the care of childbearing families. New York: March of Dimes Birth Defects Foundation. [Context Link]
16. Nahas, V., Amashen, N. (1999). Culture care meanings and experiences of postpartum depression among Jordanian Australian women: A transcultural study. Journal of Transcultural Nursing, 10( 1), 37–45. [Context Link]
17. Nahas, V., Hillege, S., Amashen, N. (1999). Postpartum depression: The lived experiences of Middle Eastern migrant women in Australia. Journal of Nurse-Midwifery, 44( 1), 65–72. [Context Link]
18. Purnell, L. D. (1998). Mexican-Americans. In L. D. Purnell & B. J. Paulanka (Eds.), Transcultural health care: A culturally competent approach (pp. 397–421). Philadelphia: F. A. Davis. [Context Link]
19. Spector, R. (2000). Cultural diversity in health and illness (5th ed.). Upper Saddle River, NJ: Prentice Hall Health. [Context Link]
Stewart, S., Jambunathan, J. (1996). Hmong women and postpartum depression. Health Care for Women International, 17, 319–330.
21. U.S. Bureau of Census (2001, May). Overview of race and Hispanic origin. Retrieved June 7, 2001, from http://www.census.gov/prod/2001pubs/ . [Context Link]
22. U.S. Department of Health and Human Services (DHHS). (2001). Fact sheet: National sample survey of registered nurses 2000. Rockville, MD: Division of Nursing, Bureau of Health Professions. [Context Link]