Received: 1 April 2010
Accepted: 9 September 2010
The aim of the study was to compare postpartum practices and rituals in women in the UK and Taiwan, within three months of delivery, using convenience sampling. The inclusion criteria were no medical complications in either pregnancy orchildbirth. A six-part, semi-structured self-report questionnaire was used to collect data from 50 women in the UK and 51 women in Taiwan. Key themes were identified from content analysis of qualitative data. The ritual customs followed weredivided into the following four subgroups: choosing and predicting the gender of the baby:there was a significant difference (54% in Taiwan and 16% in the UK) in the proportion of women in the two countries who had used ritual customs to identify the gender of their baby . .food fads during pregnancy and the postpartum period: one-third of the women in the UK and half of those in Taiwan had developed and followed different food fads during the course of their pregnancy . taboos: 52% of the women in Taiwan and 22% of those in the UK had heard advice about not holding the newborn too much . herbs used during pregnancy and after giving birth:major differences between the two cultures wereobserved.The majority of the women who were studied in both countries reported that their husband or partner was the most helpful person during the postnatal period, for example, because they shared the housework and looked after the baby. Quantitative analysis using SPSS (version 13.0) showed that there was a highly significant difference (P
childbirth, health beliefs, postnatal women, postpartum practices, postpartum rituals
Ritual is a very important part of culture, and the rituals of social transition are present in every society. They relate to changes in the life cycle and in social position, thus linking the physiological and social aspects of an individual’s life. Childbirth signals a major life cycle transition for a woman, irrespective of the culture to which she belongs, and is generally considered to be a time of ‘ritual danger’ (Hoban, 2007, pp. 99–101) for the woman herself, the entire family or the community. In many cultures a pregnant woman is believed to be in a state of transition from one social status to another, and is therefore often considered to be in an ambiguous and abnormal situation, vulnerable to outside dangers, and sometimes herself dangerous to other people (Helman, 1994). In order to deal with this danger and the uncertainty associated with childbirth, societies have produced a set of internally consistent practices and beliefs about the management of both the physiological and social aspects of childbirth, which have resulted in highly ritualised birth practices. One common example is a special postnatal rest period, after giving birth, during which the new mother is cared for by other women and is required to follow certain dietary and other rules. This period of rest and seclusion usually lasts between 20 and 40 days (McGilvray, 1982). In Chinese societies this practice is referred to as ‘doing the month’, and in the UK there are vestiges of the 40-day ‘lying-in’ period. In 1902, UK legislation on midwifery practice defined ten days as the necessary time for lying in after the birth, during which period the mother was expected to rest and to receive attention from a midwife. It seems that women highly valued this time (Marks, 1996), but developments in maternity care and the routines of hospital practice have resulted in other arrangements, such as 24-hour transfer home from hospital. Many women in the UK now resume household duties by the end of the first week after giving birth, and few have the benefit of support from female relatives living nearby. They do not generally receive as much care from their mothers by comparison with the traditional arrangements for Chinese mothers.
Although the actual content and intensity of the rules relating to the rituals of the social transition to motherhood may differ between the UK and Taiwan, the underlying principles are the same. This study examines how UK and Taiwan–Chinese cultures influence the birth experience and the postnatal ritual customs in which women engage during the first three months after giving birth. Its aim was to compare postpartum practices and rituals in the two countries.
The theoretical framework that was used for the study was developed from a systematic literature review of transcultural research on childbearing from around the world, with particular reference to traditional beliefs and practices (e.g. Steinberg, 1996). The key issues that were identified provided the basis for the development of an initial draft of a questionnaire which consisted of six sections that explored the comparative childbirth experiences of women in the UK and Taiwan. The review was initially undertaken using PubMed, CINAHL, Ovid, Medline and the Chinese equivalent of the International Scientific Citation Index (TSSCI), utilising a variety of search terms such as postnatal women, postpartum practices, postpartum rituals, childbirth, cultural comparison and health beliefs. This informed the development of a six-part questionnaire designed to collect both quantitative and qualitative data. This initial draft version of the questionnaire was first tested individually on seven women (three immigrant Chinese and fourUKwomen) at various stages of pregnancy in order to establish its content validity. A second draft questionnaire was then tested using a convenience sample of 10 postnatal women, and the two-week test–retest reliability was calculated. In addition, an advisory group consisting of three midwives (two British and one Chinese) independently evaluated the questionnaire for content validity as well as for clarity, completeness and readability.
The calculation of a Pearson correlation coefficient for the six main constructs of the questionnaire enabled the final version of the questionnaire for the study to be prepared. The internal consistency of the instrument was also evaluated, and a Cronbach’s alpha value of 0.87 was obtained, with subscale reliability coefficients ranging between 0.82 and 0.93. The content of the final version of the questionnaire consisted of a total of six sections covering the following areas:
1 the sociodemographic characteristics of the woman
2 her experience of ritual customs and cultural beliefs
3 information about the health of the baby
4 the woman’s experience of birth in hospital
5 the woman’s experience of maternity care in the community
6 details concerning the role of and support provided by informal caregivers as well as the relationship of the woman with her husband or partner.
The completed questionnaire was translated from English into a Mandarin Chinese edition for use in Taiwan, and this initial translation was then reviewed with regard to its accuracy by a Taiwanese academic specialising in Chinese literature, before being backtranslated by a bilingual Chinese/English professional administrator. The lead researcher (YCH) then compared the original and final versions of the questionnaire, and made any adjustments necessary to ensure consistency between the English and Chinese versions. The questionnaire was administered by one of the investigators (YCH), who visited each participant either at home or in her chosen setting for a 40-minute interview. Data collection took three months in the UK and six months in Taiwan.
The participants were recruited from Sheffield in the UKand from Taipei County/BanCiao in Taiwan. Both of these cities have a similar industrial background, population size (550 000) and social class distribution (UK National Statistics, 2001; Taiwan National Statistics, 2008). A convenience sample of postnatal women was obtained from the records of a primary healthcare team in the UK and from the local public health station in Taiwan. To be included in the study, women had to be within three months of delivery and have reported no serious complications during pregnancy or childbirth, which had resulted in delivery of a healthy baby. In the UK, 52 mothers were invited to participate, of whom 50 (98%) agreed to take part. In Taiwan, 53 women were invited to participate, of whom 51 (98%) agreed to do so.
A content analysis methodology was used to examine the key ideas that the participants had regarding preand postnatal ritual practices, customs and beliefs (Neuendorf, 2002). Qualitative data were extracted verbatim from the questionnaires, and significant statements were identified using the original framework to compare the six different aspects of the childbirth experiences of women in the UK compared with those in Taiwan.
The analysis of the extracted statements was independently conducted by two qualitative researchers, who both analysed the transcripts and then met with one another and a member of the research team (YCH) to discuss the outcome of the analysis. During this part of the evaluation, both of the reviewers constantly compared and contrasted their interpretations of the data, returning to the original transcripts to check for credibility, before reaching a consensus on the analysis. This procedure was guided by the qualitative research schema of Lincoln and Guba (1994).
The extended version of the Statistical Package for the Social Sciences (SPSS), version 13, was used for the quantitative data analysis. Associations were tested using the Chi-squared test.
In the UK, ethical permission to conduct the studywas granted by the South Sheffield Ethics Committee. In Taiwan, the Department of PublicHealth, Taipei County Institutional Review Board reviewed and approved the study. In both countries, mothers were provided with an information sheet at the time of enrolment in the study, and all of them signed an informed consent sheet stating that they could withdraw from the study at any time without consequence for their care, and that all replies were kept in strict confidence. Verbal consent was also obtained for their participation at the time of interview.
In both countries, 78% of the women were aged between 25 and 35 years. In Taiwan, 79% of the women were in full-time employment, compared with 54% of those in the UK. The majority of the women in Taiwan were married (92%), with 1% being single. In the UK, 62% of the mothers were married, 14% were single, and the remaining 24% were either in established relationships or were divorced. There was a significant difference between the proportion of women in the UK (66%) and the proportion in Taiwan (34%) who had received higher education. Approximately 72% of the women in the UK described themselves as Christian, whereas 60% of the women in Taiwan declared themselves to be Buddhist or Taoist. In total, 40% of the women in the UK and 53% of those in Taiwan were primigravidae, and no significant differences were found when comparing the mothers’ self-report of the health of their babies at delivery and during the three-month postpartum period in the UK and Taiwan (P > 0.05, Chi-squared test).
In both countries, 44–48% of the mothers reported that they had no preference with regard to the gender of their baby, and 66% of the mothers in Taiwan and 86% of those in the UK had chosen to breastfeed during their hospital stay. However, on returning home, the percentage of women in Taiwan who continued to breastfeed had dropped to 36%, and the corresponding figure in the UK was 68%.
Mothers in both countries were asked about the ritual customs which they had heard of or had followed during pregnancy and after childbirth. In the UK, the number of customs that women had heard about ranged from 1 to 9 (mean, 5.5; SD, 2.18). By contrast, in Taiwan the number of customs which women had heard about ranged between 1 and 11 (mean, 8.39; SD, 1.91). There was a highly significant difference (P < 0.001, t-test) in the number of ritual customs followed in the two countries, with a mean of 5.5 (SD 2.7) customs followed by women in the UK, compared with a mean of 10.5 (SD 1.5) customs followed by the Taiwanese women during pregnancy and childbirth. Sociodemographic variables such as the mother’s age, employment status, level of education, marital status and social class, and the parity of the mother and her declared religion, were found not to be related to the total number of ritual customs followed by the mothers.
The ritual customs which the women had followed during pregnancy and the three-month postpartum period were divided into the following four subgroups:
• choosing and predicting the gender of the baby
• food fads during pregnancy and the postpartum period
• herbs used during pregnancy and after giving birth.
There was a significant difference in the proportion of women in the two countries who had tried to choose the gender of their baby (54% of the women in Taiwan compared with only 16% of the women in the UK; P < 0.001, Chi-squared test), for example, by conceiving during a particular month of the traditional Chinese calendar. There was no equivalent of this practice reported by the women in the UK, although 15% of the women had timed sexual intercourse to coincide with ovulation in order to become pregnant, rather than choosing the gender of the baby. There were also differences between the women in the UK and Taiwan with regard to the method that they had used during their pregnancy to try to predict the gender of their baby. It was found that 16% of the women in Taiwan had tried to predict the baby’s gender by observing the shape of their abdomen (a flat, round abdominal swelling was considered more likely to predict a female baby). In the UK, the swinging of a wedding ring suspended by a strand of the mother’s hair or a red-coloured string over the palm with a rotational movement was considered to predict a girl, whereas a side-to-side oscillation was interpreted as predicting a boy.
One in three of the women in the UK and almost half of the Taiwanese women had developed and followed different food fads during the course of their most recent pregnancy. For example, a number of Taiwanese women said that they had developed strong cravings for instant noodles, soya milk, watermelon or sour plums during their pregnancies. Around 16% of the women in theUKhad heard that certain foods, such as cheese, should not be eaten during pregnancy, and 18% of these women had taken this advice. It was also found that 64% of the Taiwanese women had heard that some foods which are considered to be ‘hot’, such as sesame chicken, should not be eaten during pregnancy, and 54% of them said that they would follow this advice to avoid ‘hot’ food. There was a highly significant difference between the two countries in the proportion of women who had heard about the foods which should not be eaten after giving birth (41% of women in the UK, compared with 92% of those in Taiwan; P < 0.001, Chi-squared test). For example, in Taiwan the foods to be avoided during the postpartum period were generally those considered to be ‘cold’ (e.g. salad and fruit), and similar dietary advice was followed by more than half of the women in both countries (79% in Taiwan and 63% in the UK).
Many of the mothers in both countries had heard advice that they should not hold the newborn ‘too much.’ In Taiwan, 52% of the women followed this advice, whereas the equivalent figure in the UK was only 22% (P < 0.001, Chi-squared test). A greater percentage said that ‘women should not lift heavy things after giving birth’ (87% of women in Taiwan and 65% of those in the UK; P < 0.01, Chi-squared test). There were highly significant differences in the proportion of women in Taiwan and the UK who avoided ‘bad’ feelings during pregnancy because of the risk that these would affect the unborn baby and make him or her unhappy (99% of the women in Taiwan and 47% of those in the UK; P < 0.001, Chi-squared test).
In total, 92% of the women in Taiwan and 3% of those in the UK said that, as a traditional postpartum practice, they had tried to avoid washing in the shower or bath after giving birth, by using a hand sponge to clean themselves. One Taiwanese woman reported that her mother-in–law had insisted that she could only wash her body and her hair in Chinese rice wine for one month.
In addition, 40% of the Taiwanese women but only 10% of the women in the UK had heard traditional advice about how to avoid birthmarks on the unborn baby (P < 0.001, Chi-squared test). Of these individuals, 75% of the Taiwanese women and 42% of the women in the UK said that they followed this advice (P<0.01, Chi-squared test). Taiwanese women reported that they had avoided birthmarks on their babies by not moving their bed and by avoiding using a hammer and nails anywhere in the house during their pregnancy. Some of the women in the UK stated that they had not eaten strawberries during their pregnancy for the same reason.
The majority of the women in the UK were aware of the belief that if awoman scorches a nappy, she is going to become pregnant again straight away, whereas none of the Taiwanese women had heard about this belief (P < 0.001, Chi-squared test). Approximately twothirds of the women in the UK reported believing that if they were breastfeeding their baby, the food that they ate would affect the baby, whereas only 23% of the Taiwanese women reported this belief. The women in the UK believed that eating certain vegetables, such as broccoli, would give their babies colic. The Taiwanese women avoided watermelon and Chinese leaves during the postpartum period in order to prevent diarrhoea in their babies. In addition, the Taiwanese women believed that eating pork feet with peanut sauce and fish soup when breastfeeding would increase the production of milk and strengthen their babies’ bones.
Major differences between the two cultures were observed in this area. The Chinese traditional medical system uses herbs widely in daily life. For example, the use of Seng-hau soup and other traditional medicines is very popular among postnatal women. At least 90% of the Taiwanese women had consumed Seng-hau soup and used other traditional medical remedies to ‘clean the womb’ by stimulating contractions post delivery, and to ‘clear the kidneys’ during the postpartum period. It is important to note that the words ‘soup’ and ‘tea’ in this context, when translated into Mandarin Chinese, are actually general terms in traditional medicine. When the word ‘food’ was used to refer to a form of postnatal supplement, 95% of the women described various supplements, whereas when the word ‘tea’ was used as a descriptor this was not thought to be a dietary supplement, but in a different category altogether. The response rates were therefore lower when the Taiwanese women were asked about tea supplements (18% during pregnancy and 72% in the postnatal period). The women in the UK used raspberry leaf tea or camomile tea after birth for ‘calming down’ and to avoid indigestion. The understanding and perceptions of the women in theUKwith regard to food supplements were also different from those of the Taiwanese women, and 30% of them had heard about the use of special food supplements after delivery, 40% knew about the tea used during pregnancy, and 12% knew about its use after delivery. Table 1 compares the use of postnatal food supplements by women in the UK and Taiwan.
The women in the UK reported that the most helpful person during the postnatal period was their husband or partner, mainly because they shared the housework and looked after the baby. This was followed by the mother’s parents, while other members of the family, including the parents-in-law, were considered to be less helpful. Taiwanese women also considered their husband or partner to be the most helpful person during the postnatal period. Only 13% reported that their parents or parents-in-law helped to share the housework and to look after the baby during this time. In total, 44% of the Taiwanese women reported that they needed extra emotional support from their partner, and 23% said that they needed more practical help from their immediate family. In the UK, 20% of the women reported a need for more emotional support from their husband or partner, with 22% also needing extra practical help fromtheir family. Women in both countries stated that healthcare professionals were the least frequently sought source of emotional support. Table 2 shows an overall comparison of traditional postpartum practices and rituals heard by mothers in the UK and in Taiwan. It can be seen that the total number of practices and rituals that mothers in Taiwan had heard of was higher than the corresponding figure for their UK counterparts.
Chinese traditional birth rituals require a woman to be confined at home for one full month after giving birth, and to observe a broad set of restrictive prescriptions and proscriptions. Taiwanese women normally return home two days after giving birth in hospital, and during this month of confinement it is expected that the woman’s mother or mother-in-law will look after the baby. The rules and principles observed during this month include strictures such as avoiding the slightest contact with cold water. This is manifested in practice as ‘Do not wash yourself, your hair, your baby, your clothes or even the dishes for the entire month.’ The purpose of this traditional stricture is to avoid water entering the body through any of its joints or orifices, or even the soles of the feet, because this might result in ‘wind entering the body’ (according to Feng Shui principles, this is pinyin – translation of Chinese characters). The concern is that such ‘wind’ may result in asthma, arthritis or chronic aches and pains in the future, which can only be cured by a subsequent pregnancy and a properly observed ‘month.’ It is also believed that a woman needs strong social support and food supplements to assist her recovery during this time.
Pillsbury (1978) has pointed out that the ‘lying in’ period of Western birth culture has given way to the puerperium, which does not have the same symbolic importance as many cultures give to the time after birth. Even the postnatal clinic which used to symbolically mark the end of the ‘lying in’ period, and which took place at six weeks, is now only occasionally held, and baptisms and the churching of ‘unclean’ women, which also took place about 40 days after childbirth, are much less frequent ceremonies than in the past.
It is clear from our study that Taiwanese women have both heard of and follow more practices and rituals during the postpartum period than their counter parts in the UK. Kao (1992) and Hern (1992) reported that between 71% and 95% of Taiwanese pregnant women followed ritual practices, and those women who had fewer years of formal education were more likely to follow the traditional practices in the belief that such practiceswould prevent illness in later life. In the UK, there is little published evidence about both the number of practices and their adoption either during pregnancy or following childbirth. Our study has systematically compared the knowledge and use of postpartum practices and rituals in the UK and Taiwan, and has shown that these phenomena are more widespread in the UK than has perhaps been generally considered to be the case, although they are less prevalent than in traditional Taiwanese culture.
There are also interesting comparisons to be made between the ways in which the women in the UK and in Taiwan tried during pregnancy to avoid feelings which they thought might affect their unborn child. In both cultures the majority of the women thought that it was best for their babies if they tried to keep calm and relaxed. In the study reported here, 47% of the women in the UK and 71% of the Taiwanese women acted on this belief.Astudy by Chou (1982) found that 82% of Taiwanese women believed that a mother’s feelings could affect her unborn baby, although only 58% of them acted on this belief (Kao, 1992). The Taiwanese women were particularly concerned to avoid ‘bad temper’ during pregnancy. However, the women in the UK reported far fewer strategies for relaxation during pregnancy, and often tried to carry on their life as normally as possible, and to avoid or ignore anything that might upset them.
Differences were also observed in the amount of time that elapsed before the women in the two countries resumed their social lives. The Taiwanese women who were ‘doing the month’ did not resume their social lives or their domestic responsibilities during this period. However, the reality of ‘doing the month’ in Taiwan is that only one in three women actually receive support and help from their parents or parents-in-law. In addition, because of the lack of community-based support from healthcare professionals, it is likely that although the women do know the traditional requirements, they find it increasingly difficult to make ‘doing the month’ a reality. Some of the more highly educated Taiwanese women were able to have their confinement in private ‘doing the month centres’, and to take the traditional rest, with professional maternal-child nurses and obstetricians to look after them and their newborn baby.
Mothers from both countries reported that they did not receive sufficient help from their social networks, whichmade it difficult for them to resume their normal social lives (e.g. by going out). In particular, the women in the UK needed help because of their breastfeeding, whereas the Taiwanese women complained that the amount of housework they had to do, together with ‘doing the month’, made it very difficult for them to have any kind of social life. In addition, the women in both countries were expecting more help from others to enable them to cope with the new circumstances of being a mother as well as a housewife. Babysitters were seldom used in either country, for a variety of reasons, including a shortage of people who were willing to undertake that role, and reluctance to ask anyone to look after a very young baby.
For Chinese women, the purpose of ‘doing the month’ is to demonstrate the social transition to being amother. It reflects the broader context of Chinese social relationships, and goes beyond simple health and medical reasons, involving more complex social and psychological aspects. The significant meaning of ‘doing the month’ appears to be that the confinement is perceived as a ‘reward’ for the Chinese women following the enormous changes of pregnancy and childbirth. Because the woman has successfully given birth and brought joy to the family, she deserves to be rewarded and taken care of. ‘Doing the month’ also encourages women to have further pregnancies.
In addition, ‘doing the month’ provides women with a legitimate opportunity to establish or reconfigure their social network and consolidate or expand their power within the family. Traditionally, until she has a baby, a Chinese woman has neither rights nor social status, and is required to carry out her husband’s requests and those of her mother in-law as befits her position within the female hierarchy of the family. If she fails to develop a good relationship with her mother-in-law, less help may be forthcoming to support her during her ‘month.’ However, if she gives birth to a son, she gains a markedly improved social position and rights within her husband’s family, and the relationship between the woman and her motherin- law is therefore redefined.
Given these complexities of traditional Chinese culture, changing family structures and conflicts arising fromfamily relationships are more likely to have a major impact on Taiwanese women’s need for emotional support during the postpartum period. Some authors (e.g. Grigoriadis et al, 2009) have claimed that ‘doing the month’ gives a measure of protection against postnatal depression, as well as greater maternal satisfaction with their care during the postpartum period, although current studies suggest that the key protective element may be the presence of welcome support rather than the specific ritual. These authors undertook a systematic review of both qualitative and quantitative studies that focused on traditional practices and rituals within the first year following childbirth, and their relationship to postpartumdepression. Overall they found some evidence that postpartumritualswhich dictate appropriate and desired social support may be of some protective value, depending on numerous contextual factors. However, in a previous cross-cultural comparison of postpartum women in Taiwan and the UK, Huang and Mathers (2001) found a similar prevalence of postnatal depression in both countries and, despite a high level of adherence to various rituals in Taiwan, they concluded that there was no protective effect of ‘doing the month.’ This finding is supported by the work of Leung et al (2005).
Family structures in theUKemphasise the separateness of individuals, and their degree of autonomy and individuality, rather than their interconnectedness. Urbanisation in Taiwan has involved an increasing transition from the traditional family structures to a more individualised structure. The core of a Taiwanese family is now the mother–child dyad, rather than the husband–wife dyad of the West (Lam, 1997). To Western eyes this hierarchical system may seem repressive and unfair, a negation of individual choice and self-fulfilment, but to traditional Chinese men and women it does not appear so. For a Chinese woman, giving birth is not just about demonstrating her fertility, but also provides an opportunity to transcend her life through a creative act (Lu, 1985; Wong, 1994).
The present study has a number of limitations, including the sample size and the deep-seated Chinese tradition of attaching positive value to speaking in normative statements. This happens to a degree that frequently leaves many Westerners perplexed and frustrated about the ‘actual truth’, and which makes direct comparisons in cross-cultural studies very difficult. In order to understand any sphere of Chinese activity, it is essential to distinguish between the statements made by the women that are expressed as norms, and the ideals which Chinese people believe represent their actual behaviour. For example, the majority of the Taiwanese women in the present study reported that they followed the advice not to take a bath or to wash their hair for an entire month as the first rule after giving birth, but this may not actually have occurred to the extent that was reported. However, the opportunity to provide free text on the questionnaire responses may have enabled the Taiwanese respondents to more accurately reflect their experiences during the postnatal period.
Postpartum practices and rituals are present in every society and are associated with the social transition to motherhood. Comparative studies of the postpartum practices of other cultures can shed important light on the meaning that such rituals have for women during the universal experience of childbirth, and can inform culturally competent care from their caregivers, who may have a different cultural identity. Raleigh et al (2010) have reported that women from ethnic-minority communities in the UK have poorer outcomes and report more adverse experiences across some dimensions of maternity care. Those authors recommend that such differences are addressed in order to inform improvements in maternity services for these groups and reduce inequalities. The importance of our study lies in its emphasis on cultural variation in women’s responses to pregnancy and birth. Such information can potentially improve the culturally competent care (Flowers, 2004) that is provided by healthcare professionals to members of the Chinese community in the UK as well as members of the UK community in Taiwan.
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