"'Doing the Month': Confinement and Convalescence of Chinese Women After Childbirth" (1978), by Barbara L.K. Pillsbury

In 1978 Social Science and Medicine published Barbara L.K. Pillsbury's article, "'Doing the Month': Confinement and Convalescence of Chinese Women After Childbirth," which summarized the results of Pillsbury's study on Chinese childbirth customs. Pillsbury, a professor of cultural anthropology at San Diego State University in San Diego, California, conducted over eighty interviews with people in Taiwan and China, including civilians, herbalists, and physicians over a four-month period in 1975. She aimed to highlight how a traditional Chinese post-childbirth custom known as zuo yuezi (sitting the month) persisted in modern Chinese society. The practice refers to the month-long period that women who have just given birth must spend resting, or in convalescence, adhering to a strict set of rules that address dietary needs and other cultural rituals. Pillsbury's "Doing the Month" provides a description and analysis of zuo yuezi (sitting the month), highlighting how traditional Chinese medicine persists in an increasingly westernized Chinese society, specifically in the case of childbirth and reproductive medicine.

Traditional Chinese medicine is an ancient system of medicine that has been practiced, studied, and documented in Chinese classical literature. The Chinese medical system is predicated upon the principles that humans are connected to their natural environment and that imbalance in that relationship leads to disease. The yinyang (opposites) theory addresses the existence of two complementary yet opposing forces. Yin, which means "shady," corresponds to qualities such as coldness, darkness, wetness, femininity, and rest. Yang, which means "sunny," corresponds with opposing qualities like heat, light, dryness, masculinity, and movement. According to Chinese medical theory, the balance between yin and yang exists everywhere in the universe, from the natural environment to the human body and can differ between individuals. Women, considered to be more yin or cold in nature, are more prone to illnesses resulting from excess yin, or coldness, particularly following childbirth. The zuo yuezi practice, also referred to by Pillsbury as doing the month, is a series of cultural rituals and dietary rules aimed at restoring the imbalance caused by childbirth.

Pillsbury's article is twelve pages and is divided into six sections and a reference section: the introduction, "'Rules' and Folk Rationale for Doing the Month," "Chinese Medical Theory as Regards to Doing the Month," "Western Medical Theory and Practitioners Regarding Doing the Month," "Persistence and Integration," and "Comparative Perspective and Conclusion." In the introduction, Pillsbury highlights the need for ethnographic studies in light of increasing cross-cultural health programs. As an ethnographic study, the objective of Pillsbury's study was to highlight how a specific subject is approached by a specific culture.

In the case of Pillsbury's study, the objective was to analyze the practice of zuo yuezi from the perspective of three medical systems that coexist in China: folk medicine, Chinese medicine, and Western medicine. Pillsbury explains in the introduction that folk medicine and Chinese medicine are distinguished by the way that information is passed along and by the type of people who pass it. Folk medicine involves general theories and simple remedies that are shared among the public, whereas Chinese medicine involves literature that has been passed through generations and taught to Chinese doctors and herbalists. Pillsbury interviews laypersons to generate the "Rules and Folk Rationale" section. She then uses Chinese and Western medicine literature, as well as interviews with health professionals, to analyze the rules of zuo yuezi in the "Chinese Medical Theory" and "Western Medical Theory" sections. Through the Western medical perspective, the author discusses the various ways in which zuo yuezi has persisted and been adjusted in modern society and the possible implications of such changes for immigrant Chinese women living in Western countries.

Although one of Pillsbury's long-term objectives was to improve the physician-patient relationship between non-Chinese physicians and Chinese immigrant women, she conducted the bulk of her interviews and patient observations in Taiwan. She interviewed Chinese physicians and herbalists in Taiwan and in the People's Republic of China, and she interviewed Western physicians in Taiwan and the US. Finally, Pillsbury used Chinese and Western medical literature to supplement her interviews.

Pillsbury then uses the introduction to emphasize the cultural importance of zuoyuezi by addressing its linguistic use. She argues that it is significant because the practice is called "the month" in mandarin Chinese, a term that is unanimously understood as the month following childbirth. Pillsbury notes that the English equivalent of "the month" in the United States is the term puerperium, which refers to the same postpartum adjustment period. She hypothesizes that because physicians and women focus less on the puerperium in the US, Western researchers focus less on research relating to postpartum medicine and health in China.

In the first main section, "'Rules' and Rationale for Doing the Month," Pillsbury summarizes the results of her interviews with her participants, who varied in age, education level, economic status, household size, and either an urban or rural location. From the field data, Pillsbury compiled twelve rules for doing the month, listed in order of importance as emphasized by her participants. Pillsbury notes several themes among the rules that are key beliefs in Chinese medical theory. First, women, who are naturally yin or cold in nature, are particularly susceptible to cold temperatures after giving birth and should therefore avoid contact with cold water, cold air, and cold foods. Second, according to Chinese medicine, blood is unclean, and the presence of blood while giving birth makes a woman unclean. Third, a woman's joints open up and remain open after childbirth, making her vulnerable to "catching wind," which is another reason to avoid contact with cold things and the wind.

For each of the twelve rules, Pillsbury briefly explains the rule as well as variations and exceptions to the rule that were substantiated by participants, literature, and her earlier ethnographic studies in Taiwan. The first rule, and the rule given the most importance by the participants, is that women who have just given birth should not wash their hair or body for a month. Pillsbury's participants also extend the rule to dishwashing and clothes-washing, reasoning that any exposure to cold air or cold water can have long-term consequences on a woman's health.

The second rule is that women should not go outside for the entire month after delivery. According to Pillsbury's informants, the gods would be offended at seeing the blood that was present in a woman's body after giving birth. For that reason, women can bypass the second rule by wearing a hat, carrying an umbrella, or not being exposed to the sun while outside. The second reason for not going outside is to lessen the chance of wind exposure and subsequent sickness.

The third and fourth rules state that women should not eat raw or cold food, and that they should eat chicken. The description of cold food refers not just to the temperature of the food, but more importantly, to an intrinsic quality of the food. Pillsbury uses the example that ducks and fish are considered cold because they swim in water, and root vegetables are cold because they grow underground, where it is dark and wet. Conversely, chickens, which live on land and avoid water, are considered hot. The balance of cold and hot foods corresponds to the balance of yin and yang, for which hot foods restore health, and cold foods do the opposite. According to Pillsbury's participants, chicken is so highly recommended that the general rule is to eat one chicken a day, although most people do not reach that standard.

The fifth, sixth, and seventh rules again involve actions that the woman should not do: she should not expose herself to the wind, she should not move or walk around, and she should not go to other people's homes. In addition to avoiding the wind to deter sickness, women should lie flat on their back in bed for as long as possible to straighten out the back after months of pregnancy. Similar to the second rule, the seventh rule says that if a woman visits others after giving birth, she might offend the host's house gods because of her recent exposure to blood.

The eighth rule states that one should not get sick during the month after delivery. And the final rules stipulate that a woman who has just given birth should not read or cry, should not have sexual intercourse, should not eat at the table with the rest of the family, and should not burn incense. Whereas reading and crying are thought to be bad for eyesight, Pillsbury states that sexual intercourse is thought to bring misfortune to the couple, particularly due to the presence of birth blood. For the same reason, eating at the table and burning incense at temples may bring misfortune to the family by offending the gods.

Following her descriptions of the rules, Pillsbury classifies the twelve rules into three overarching principles. Pillsbury's first principle is that women should avoid doing things that will cause disease or specific ailments. The first principle is tied to the Chinese medical theory that women's bodies are extremely vulnerable to wind and to cold water after childbirth, and that sicknesses incurred during the month have long-lasting consequences. Her second principle, that women should avoid offending the gods or contaminating others by their birth blood, relates to actions that potentially expose what is considered unclean blood to the gods and to others. The last principle, that women should avoid raw, cold foods, and instead should eat hot foods, concerns the theory that a woman's body is extremely vulnerable to excess coldness after birth and can be restored through hot foods.

Pillsbury concludes the "Rules and Rationale" section with observations from her interviews that do not pertain to one of the rules. She notes that the participants emphasized the importance of having someone to accompany the woman during her month of convalescence, a role usually filled by the husband's mother. Pillsbury then highlights how the practice of doing the month is seen as both a curative and preventative therapy. Though the rules are implemented to help the woman recover from giving birth, they are also critical in preventing long-term health harms that arise from breaking the rules. According to the informants, the only way to fix such consequences is to become pregnant again and follow the rules correctly.

After summarizing the results of her interviews, Pillsbury analyzes the results from the perspective of traditional Chinese medicine in the section, "Chinese Medical Theory as Regards Doing the Month." According to Pillsbury, her participants agreed that while classic Chinese literature offers little information on the specific directions of doing the month, it explains the fundamental theories supporting the rules. The theory of hot and cold, yin and yang, balance and imbalance, dictate how diet helps restore the yinyang imbalance that is caused by childbirth. Pillsbury highlights how balance and imbalance are manifested in what is considered as strong or poor blood circulation, respectively. According to her participants, the foods and herbs that restore imbalance or improve circulation are called pu-p'in (supplementary product), and are recommended by Chinese doctors and herbalists. Supplementary products can be taken for any length of time because the state of balance in each individual is constantly in flux. Pillsbury concludes the section on Chinese medical theory by arguing that Chinese medicine tends to be more preventive than curative, as supported by the long-term use of supplementary products and certain rules in doing the month.

Pillsbury then analyzes the results from the perspective of Western medicine in the section, "Western Medical Theory and Practitioners Regarding Doing the Month." She interviewed Western-trained health professionals to provide contrasting opinions on zuo yuezi. She categorized the answers according to the three groups of physicians that provided them. The first group included physicians in the US who were unfamiliar with Chinese medicine, but acknowledge some potential benefit from doing the month. The second group was comprised of Chinese physicians educated in Western medicine who consider zuo yuezi an unnecessary, potentially dangerous practice of little value. Finally, the last group is made up of Chinese physicians who practice Western medicine and argue that certain aspects of zuo yuezi are beneficial, even if not for the reasons given by Chinese medical theory.

Analyzing the twelve rules from the perspective of Western medicine, Pillsbury states that together, the rules constitute a month-long period of rest that seems beneficial. However, according to Pillsbury, when certain rules are examined individually, they appear dysfunctional due to improved medical technology and overall living circumstances. Examples include prohibitions against bathing, washing one's hair, and going outdoors. Pillsbury recognizes that these rules may be necessary in areas with poorly insulated homes and cold running water, but also acknowledges that with more advanced plumbing and sanitation, the rules may be difficult to follow in warmer seasons and warmer climates.

Pillsbury claims that Western medicine may not be able to produce practical explanations for other rules of zuo yuezi, such as the prohibition of crying and reading, or the avoidance of exposure to wind and water. However, she explains how the logic behind certain rules may parallel Western scientific thinking. For example, the Chinese theory of open joints after childbirth could be corroborated by the fact that a woman's ligaments are expanded after giving birth. Similarly, prohibitions against performing household tasks like dishwashing, Western physicians advise women to rest after childbirth.

With regard to diet, Pillsbury states that most informants do not adhere to the actual rule of consuming one chicken per day, which could harm the woman's health. Pillsbury reasons that chicken is typically expensive and is usually saved for special occasions. With an extreme rule such as consuming one chicken per day, families that attempt to follow it will likely increase the woman's protein intake to a level acceptable by Western nutritional standards. Although Pillsbury notes that the exclusion of most fruits and vegetables seems to be dysfunctional, she acknowledges that certain vegetables, such as spinach, are known to leech minerals from the consumer's body. Moreover, she states that a majority of Chinese vegetables cause gas, which can lead to diarrhea in the breastfed infant.

Following her analysis of doing the month from the perspective of Chinese medical theory and Western medical theory, Pillsbury uses the section "Persistence and Integration" to discuss why the zuo yuezi practice persists in societies that have increasing exposure to Western medicine. She lists three major reasons derived from her interviews: curing pregnancy-induced imbalances, preventing future illnesses, and preventing future misfortune to postpartum women and those around them. Pillsbury states, however, that most informants were not analytical of their own reasons for doing the month. Instead, many choose to follow the practice, despite its inconveniences, because their surrounding friends and family had done it and because the risk of incurring future health issues was too great. According to Pillsbury, most of her informants shared accounts of other women who had either failed to do the month correctly, or had not done the month at all, and later experienced respiratory, muscular, or other chronic ailments that they attributed to the postpartum period.

In the last section of the paper, "Comparative Perspective and Conclusion," Pillsbury emphasizes her reasons for using a comparative perspective of Chinese medical theory and Western medical theory. Through the comparative perspective, Pillsbury argues that she provides information about postpartum maternal care in China and Taiwan for non-Chinese health professionals who may interact with Chinese pregnant women.

Pillsbury also provides several hypotheses as a result of her study. First, she posits that prior to twentieth century medical advances, the postpartum period was the most dangerous period in a woman's life, leading to the development and persistence of cultural practices to help women through that time. Pillsbury then hypothesizes that other cultures addressed that issue by prescribing similar diet modifications and other cultural rituals. She provides examples of the Mayan Indians, who had specific term for the fixed twenty-day confinement after delivery. The Zapotec Indians defined their postpartum period as forty days, and according to Pillsbury, also followed modified diets relating to hot and cold food.

Pillsbury concludes the study by highlighting that all of her informants, totaling over a hundred Chinese and Chinese-Americans, consider the zuo yuezi practice to be beneficial for physical health, social relations, mental health, or some combination of the three. Pillsbury concludes that though some of the individual practices or rules may seem outdated or even dangerous, as in the case of a restricted vegetables and fruits diet; as a whole, the practice remains heavily integrated into Chinese culture, and should be considered as such by both Western and Chinese health professionals.

Towards the end of the twentieth century, more Western clinical and cultural studies focused on the efficacy and safety of traditional Chinese medicine, or other traditional health systems. Pillsbury's 1978 "Doing the Month" is one such study. The article was one of the first studies conducted by Western researchers on the postpartum practices of Chinese women, specifically, the longstanding Chinese customs of zuo yuezi. Other researchers have cited Pillsbury's article in studies of how different social and cultural practices may influence postpartum depression.