“Traditional postpartum practices and rituals: a qualitative systematic review” (2007), by Cindy-Lee Dennis, Kenneth Fung, Sophie Grigoriadis, Gail Erlick Robinson, Sarah Romans and Lori Ross

In the 2007 paper “Traditional postpartum practices and rituals: a qualitative systematic review,” Toronto-based researchers showed that women from different cultures around the world follow similar postpartum practices after giving birth. At the University of Toronto in Toronto, Canada, Cindy-Lee Dennis, Kenneth Fung, Sophie Grigoriadis, Gail Erlick Robinson, Sarah Romans, and Lori Ross examined fifty-one studies from over twenty countries that focused on traditional postpartum practices. The authors found that across the twenty countries, each culture’s postpartum practice included a specified rest period, a prescribed diet, and organized support from family members. In the literature review, Dennis and her team concluded that healthcare providers should consider the major similarities between cultural postpartum practices to deliver culturally competent perinatal care.

Although Western cultures have fewer instances of cultural postpartum practices, increasing immigration rates have led to a more diverse patient population in the US and other modern Western countries. Those patients have culturally-influenced health beliefs and practices that differ from Western medical beliefs and practices. Since the late twentieth century, researchers such as Dennis and her colleagues have highlighted the intersection of culture and health as an important factor in promoting successful physician-patient relationships. Dennis and her team, as well as the authors of the studies in their literature review, focused specifically on postpartum practices.

The postpartum period, also called postnatal or puerperal period, refers to the weeks immediately after a woman has given birth. During that time, the woman’s body returns to its pre-pregnancy state by producing contractions that cause the woman’s uterus, which held the fetus, to shrink. The after-effects of childbirth also include vaginal bleeding or lochia. Because those changes usually take place over the six to eight weeks after a normal vaginal delivery, the postpartum period is also estimated to cover six to eight weeks. In addition to the physical changes, soreness, and fatigue that accompany childbirth, the woman also experiences significant emotional and psychological changes as she begins to care for the infant.

Postpartum practices include culturally-influenced behavioral adjustments that women and their families follow during the postpartum period to help the woman recover from giving birth. Family members offer practical, social, and emotional assistance as the woman follows dietary adjustments and hygiene practices for a specific amount of time, usually three to five weeks. The existence of postpartum practices has been noted in Southeast Asia, the Middle East, South America, and Africa. While the US Western healthcare system does not have any standardized postpartum practice, increasing globalization has led to the appearance of postpartum practices in Western cultures. That means physicians in the West will increasingly treat patients who subscribe to cultural postpartum practices.

According to Dennis and her colleagues, the researchers were motivated to conduct a literature review of papers relating to cultural postpartum practices for several reasons. First, researchers have given little attention to the postpartum period compared to the period before childbirth and the period during childbirth. Second, the authors conducted their literature review to explore the significant differences in postpartum care between Western cultures and East Asian, South Asian, and Middle Eastern cultures. In addition to the benefits of studying potential positive and negative effects of the different postpartum practices for the woman who has given birth, Dennis and her team also linked the importance of their investigation to increasing rates of migration and resulting cultural diversity. As physicians have increased opportunities to encounter women of other cultural backgrounds, Dennis and her team argue that it is essential for physicians to understand how traditional postpartum beliefs play a role in culturally competent healthcare. As they state in their article, to the authors’ knowledge, no such comprehensive cross-cultural literature review exists.

To conduct the literature review, the research team collected all peer-reviewed, health-related publications that addressed traditional maternal practices in the postpartum period, which they defined as the first year following childbirth. The researchers did not include studies that only addressed infant-focused practices or studies written in non-English languages. After searching for articles published between 1966 and July 2006, the researchers found fifty-one studies that met their inclusion criteria. The studies included women from East, Southeast, and South Asia, the Middle East, Latin America, as well as other cultures.

After examining the data for similarities, the researchers presented their results in a published paper. The authors organize their results by theme into several tables, summarizing the characteristics of each study and highlighting the perceived connection between certain foods and health benefits during the postpartum period. In their discussion section, the authors comment on the six themes that emerged from their data as well as limitations to their investigation. They conclude the paper with a section titled “Future Perspective,” in which they recommend that institutional policies and programs change to account for the traditional postpartum practices of different cultures.

The six themes identified by the researchers in the results section are organized support, rest period and restricted activities, diet, hygiene practices, infant care and breastfeeding, and other postpartum rituals. In the six sections corresponding to those themes, the researchers explain how the theme related to postpartum practices, and which cultures showed evidence of that particular theme.

The researchers define the first theme, organized support, as the support given by family members to the woman and the new infant for a specified period of time. According to the researchers’ analysis, all of the studies they reviewed claimed that organized support was generally provided by the mother of the woman who had given birth, the mother-in-law, other female relatives, or the husband. Outside of the immediate family, traditional birth attendants or older respected female community members also provided help. The support ranged from doing household chores and cooking to teaching the woman how to care for her infant. According to the researchers, instances of organized support appeared in Nigerian, Jordanian, Korean, Guatemalan, Eastern Indian Hindu, and Chinese cultures.

In the next section on the second theme, rest period and restricted activities, the authors explain that the specified period for organized support usually matches the specified rest period for the woman who had just given birth. Because women finish with post-pregnancy bleeding within six weeks, some cultures consider the postpartum period to be six weeks long. In their literature review, however, the authors found that most of the cultures under investigation designated the rest period between three to five weeks. That length of time also corresponded to the name given to all of that culture’s postpartum practices, such as zuoyuezi (doing the month) in China and Taiwan, sam chil il (twenty-one days) in Korea, and la cuarenta (forty days) in Mexico. According to the authors, most cultures supported the belief that if the woman does not properly recover from childbirth within the postpartum period, she may incur illnesses later in life.

Continuing their discussion of the second theme, rest period and restricted activities, the authors found that the cultures in their review prohibited activities that might affect the woman’s present and future health. For example, in Vietnam and China, activities relating to eyesight, such as crying, reading, and watching the television, were linked to future eye problems and therefore discouraged. Due to postpartum bleeding, or lochia, that is present after birth, many cultures also expected women to refrain from sexual activity. As noted by the authors, that was not only because the presence of blood is taboo in certain cultures, but also to aid the woman’s healing after childbirth.

The third major theme that the researchers noted in their analysis of different cultures’ postpartum practices was diet. Cultures encouraged postpartum women to eat foods linked to health restoration and prohibited postpartum women from eating foods linked to illness. According to Dennis and her colleagues, the belief that specific foods have health properties is a key element in ancient East Asian medical philosophy. While most notable in traditional Chinese medicine, which emphasizes the balance of two opposing forces called yin and yang, the duality of opposing forces also exists in other ancient medical systems, such as Ayurvedic medicine.

The theory of opposing forces relates to the properties of food, with certain foods classified as hot or cold depending on an intrinsic quality of the food, rather than the actual temperature. Dennis and her colleagues comment that the intrinsic hot-cold qualities are especially important in postpartum practices because many cultures share the belief that the state of pregnancy is hot due to the presence of blood, while the postpartum period is cold due to the loss of blood. Therefore, in many cultures, after giving birth, the woman is encouraged to eat hot foods and avoid cold foods. Examples of hot food include chicken, eggs, and milk, which led the authors to note that intrinsically hot foods are often high in protein. Hot ingredients include sesame oil, rice wine, turmeric, and white pepper, and many of the ideal foods are heated, such as herbal tea or soup. In the diet subsection, the authors include a table that categorizes all the encouraged and discouraged foods by country and perceived health benefit.

The authors also highlight other factors aside from the intrinsic qualities of certain foods that influence the diet followed during the postpartum period. Dennis and her team found that women in Guatemala, Malaysia, Nepal, Korea, and China included medicinal herbs in their diet to help with certain aspects of postpartum recovery such as improving weight loss and getting rid of postpartum blood. Additionally, they found that many of the diet prescriptions were specifically related to breastfeeding and improving breast milk supply. Women in Asian cultures also adjusted their diet based on the stage of recovery, meaning that some foods were eaten immediately following childbirth, while others were avoided until one week after delivery. Lastly in the third theme of the article, the authors note that religious beliefs play a small role in postpartum diet. Whereas many cultures similarly recommend chicken and high-protein foods, vegetarian postpartum diets exist in cultures with religions that forbid meat. Hindu women who are strict vegetarians do not eat eggs, fish, or meat.

In the next section about the fourth theme, hygiene and physical warmth practices, Dennis and her colleagues discuss the cultural beliefs that childbirth and blood are associated with uncleanliness and contamination. While still considered unclean due to postpartum bleeding, women must follow special hygiene practices, abstain from sexual activity, and refrain from visiting other people’s homes or receiving visitors. In addition to special hygiene practices, the authors cite examples of specific bathing restrictions that the women follow, which relate to the theory of opposing hot and cold forces. For example, women in Guatemala associate cold water and cold baths with sore bones, decreased milk supply, sickness, and generally bad health for the woman who gave birth. As discussed in the article, the link between water, heat, cold, and health extends to the prohibition of hair washing among Arabic and Thai women, the promotion of steam baths in Thailand, and the use of hot massages and hot wraps in Malaysia.

In the fifth theme, infant care and breastfeeding, Dennis and her colleagues highlight the role of family and community members during the postpartum period. In the cultures examined in the study, family members or midwives often play a dominant role in caring for the infant, instead of the mother, who only spends time with the infant when breastfeeding. The authors state that in certain cultures, breastfeeding is delayed to avoid infant ingestion of colostrum, or the initial milk produced by the woman’s body that is thicker, yellower, and higher in protein than breast milk. Guatemalan women expressed the belief that colostrum was not only dirty, but could cause diarrhea in the infant.

The authors present other postpartum rituals as the last theme in the last section of their results. Firstly, the researchers discuss the practice of binding the woman’s abdomen to flatten the stomach and supposedly aid the body’s disposal of lochia. They found that the practice was common in Thailand, Vietnam, Mexico, and Guatemala. In Malaysia, Korea, or cultures influenced by the Muslim religion, women bury or burn the placenta, the organ in the woman’s uterus that nourished the infant during pregnancy. According to the authors, all of the postpartum rituals are conducted to contribute to the health of the woman and the infant.

After presenting the major cross-cultural similarities between postpartum practices in the reviewed literature, the authors discuss their review findings. Namely, Dennis and her colleagues highlight potential historical influences of the hot-cold theory, cultural explanations for organized support, as well as the social and psychological implications of following postpartum practices for the women and their families. The authors state that there was inadequate evidence as to whether poorly performed postpartum behaviors cause illnesses later in life, though adhering to the practices may provide positive psychosocial benefits for the women and their families. In other words, while the physiological and preventive benefits of postpartum are unclear, the practices may improve the women’s health because the women and their families believe in the positive effects of the practices.

The research team also discusses the diverse origins of postpartum rituals in various cultures and how the rituals may change in the face of modernization, globalization, and immigration. Because there is increased opportunity for cultural exposure as more people relocate to other countries, the authors emphasize that Western physicians and healthcare professionals should consider traditional postpartum practices as an important factor in healthy physician-patient interactions during and after childbirth.

Lastly, Dennis and her colleagues reiterate that their review findings are based only on English, health-related, peer-reviewed literature, and should not be considered representative of all cultures. They also highlight the possibility that non-English health-related literature exists that could provide further relevant information about postpartum practices. The authors propose further investigating the benefits and risks associated with postpartum practices, but also adjusting institutional policies and educational programs to meet the needs of women who follow such postpartum practices after giving birth.

The cultural relevance and positive and negative effects of traditional postpartum practices have become a prevalent research subject, evident from the fifty-one studies that Dennis and her colleagues examined in “Traditional postpartum practices and rituals.” In addition to anthropological studies that document the existence of such postpartum practices, many studies examine the usefulness of such postpartum practices by investigating whether or not the prescribed social support can protect women from postpartum depression. While stronger evidence is still needed to support the link between the mental health of postpartum women and their adherence to postpartum rituals, the widespread existence of traditional postpartum practices continues to play a role in the physician-patient relationship, especially in modern medical settings.