Socio-demographic characteristics of the families and health workers and traditional medicine practitioners are presented in table . All health workers and traditional medicine practitioners interviewed were female.
Demographic characteristics of families, health workers and traditional medicine practitioners
The following section illustrates five major themes that emerged from interviews: reasons for "doing the month", dietary precautions, hygiene, behavioural precautions and infant feeding.
Tradition versus change: reasons for "doing the month"
All families followed an adapted version of the ritual of "doing the month". The purpose is to help the new mother regain her strength and health in order to care for the new baby, resume normal activities and protect her future health. In most families this lasted thirty days. Traditionally, the grandmother usually looks after the mother. There is widespread emphasis that "doing the month" properly will safeguard future health. It was commonly believed that this period is the weakest time of a woman's life. As one husband explained:
"Some women have good health, but they do not do the postpartum period well, and their health becomes poor. Other women with poor health do the postpartum period well and their health becomes better. It is a period of great change, so we do not want to take any risk" (Husband, urban family 3).
However, conflict of knowledge within families was apparent. Some information was obtained from books, Internet and health professionals, although most came from older family members. One husband described this:
"Old family members and friends tell us to have traditional food during this period. We follow their advice because we don't know what to do in this period. But if we do follow this diet we still don't know if we will have some problems. The doctor gave us some suggestions, but our parents promoted the traditional way. It is difficult to make a choice" (Husband, urban family 4).
Most families wanted to follow the beliefs and practices of their parents and grandparents. Some perceived modern beliefs and practices as "foreign" to their cultural context. They were reluctant to risk following a modern practice and a problem occurring.
"We are not certain if the foreign way can be done here. It is not that we don't believe in it, we just don't want to try that way. So if we can follow the traditional way, we just follow it" (Husband, urban family 2).
Health workers spoke of changes in the traditional practices that have occurred over the years and reasons for these changes. They cited social and economic development, accompanied by improvements in education, communication and living standards. One health worker explained:
"I think our society has developed and the minds of people have changed. It has changed naturally... living standards have improved; there is a better and more hygienic environment. The buildings are brighter and we have more space" (Health worker 1, rural).
Families' explanations revealed several dietary precautions that were taken seriously during the postpartum period.
Eating more food
There was a belief that the postpartum woman should eat a lot of food. Two main reasons were given: first, women at this time are weak, and food will help rebuild her strength, promote recovery and improve breastfeeding. Second, the carer's own experience (usually the mother's own mother) of "doing the month" was, in some instances, during a time when food was short. They believed this affected their health long term. As one carer explained:
"I hope she can eat as much as possible. When I did the month I only ate three meals a day. I hope she can eat more to help her recover more quickly" (Grandmother, rural family 4).
Mothers reported that they consumed more food than normal. The number of meals ranged from five to eight in a day, starting at 5 am and finishing with a meal before sleeping at night. However, this was not true for all mothers: some were not able to eat so much food. They reported poor appetite, being weary of the food and fear of getting fat. For some women, there was a conflict between limiting the types of food that could be eaten and increasing the amount of food. One mother explained problems with this diet:
"After one month of eating the same food, I was bored and fed up with eating" (Mother, rural family2).
Health workers and traditional medicine practitioners said that they thought eating more food and a variety of food was generally beneficial, but some women gained too much weight because they did little exercise and ate too much fat in their diet.
Eating "hot" food (protein rich)
All families believed in eating food seen as "hot" within the context of TCM. Meat and eggs were regarded as "hot" foods. Food could also be made "warmer" by adding ginger and wine. This food, which was also viewed as full of protein, was thought to enrich the blood, help the mother's recovery, encourage expulsion of lochia and stimulate production of breast milk. Traditional medicine practitioners and health workers all believed this, recognising that having lost energy and blood during delivery, both yin and yang are weakened. In order to restore the balance, "warm" food should be consumed. For example, one mother said:
"We have to eat more hot food because we bleed at delivery. Hot food will enrich the blood and help the recovery process. Cold food will stop this from happening" (Mother, rural family 4).
All mothers consumed "hot" or "warm" foods during the month. Mothers living in the city ate mostly chicken, and often added wine, ginger or dates. However, some families said food that was too "hot" could cause the baby to become restless, and cause nosebleeds in the mother. They therefore reduced the frequency and amount of wine added to food. In the rural area mothers had a more varied diet: eating a lot of fish, rabbit, pork, chicken and duck, but few added wine to food. This mother illustrates a common reason for following the strict diet, related to the perceived long term benefits:
"My grandmother said to me – 30 days will pass easily, but 30 years will pass with more difficulty. I think the benefits of the diet will last for 30 years" (Mother, urban family 2).
Avoiding "cold" food (fruit and vegetables)
Almost all families believed that food viewed as "cold" within TCM should be avoided during this period. Many grandmothers believed most fruit and vegetables to be "cold", and were unable to identify "warmer" ones. Rural families identified numerous effects of eating "cold" food: diarrhoea in baby and mother, body swelling, stomach discomfort, aches and pains and cough. In the urban area they were more concerned that there would be delay in expelling lochia.
"She ate some vegetables, but not very many. They can cause diarrhoea and the baby will also get diarrhoea through the breast milk" (Grandmother, rural family 4).
All mothers in rural and urban areas could identify vegetables and fruit perceived as "warmer" and ate these in the postpartum period in order to improve their own health and enrich the breast milk. However, most mothers ate fewer kinds of vegetables and fruit, avoiding ones thought to be "cold". In the rural area, half the mothers ate vegetables less frequently and in less quantity, whereas the other half said they ate a usual amount of vegetables.
"She eats vegetables – spinach, cauliflower, carrot, fish and meat. Generally she eats the same things as usual, but not so many vegetables. I did not let her eat some cold vegetables, like cabbage. It causes a cough and this can also be passed to the baby through the milk" (Grandmother, rural family 5).
A few mothers complained of mild constipation, which they associated with eating "hot" food and too few vegetables. A few were concerned that lack of vitamins would affect the quality of breast milk. Traditional medicine practitioners and health workers agreed that "cold" food should be avoided. However, they all promoted a diet that included fruit and vegetables. Health workers saw only a few women with constipation, haemorrhoids, anaemia, poor healing or infections.
Perceptions and practices may be divided into three distinct sub themes: bathing and washing hair; vulval and perineal hygiene; and dental hygiene.
No bathing or washing hair
Traditionally, women should not bathe or wash hair in the postpartum period, and this was well known in all families. They believed that as the postpartum woman's skin is loose, water can enter the body through holes in the skin. This will cause body swelling, arthritis and rheumatism later in life or a cold which can be passed to the baby. Similarly, hair washing will cause a headache.
Most urban and rural women stated that they usually bathed or showered daily or alternate days when they were not in the postpartum period. Most rural mothers seemed to adapt the tradition by bathing with boiled water, or boiled water with wine or motherwort herb (a common herb with medicinal properties) to prevent the problems of absorption through the skin. Wine and motherwort are both thought to have disinfecting properties and will therefore prevent infection. They believed that as they were with the baby all the time, they needed to be clean to protect the baby from illness. It also made them feel comfortable and happy.
"I added wine to the water because the skin is loose. It is safer when you add wine to the water. Old people say that you cannot use water to bathe. They say that the skin is loose and the wind can enter through the pores and cause illness" (Mother, rural family 3).
In contrast, most mothers in the urban area used a towel to clean the skin, either dry or dampened with cooled boiled water. A few mothers bathed using boiled water. Health workers said that most women use a towel to clean in this period. Some mothers adopted the more traditional ways as they believed that it was important for their future health. Others simply wished to follow the advice of their elders. This is revealed in one mother's response:
"Old people take care of me. I cannot do everything I like and not listen to them at all. So I also adopted some of their suggestions" (Mother, rural family 2).
Some women recognised that it was only for thirty days and they were able to cope with the discomfort. Others found it more difficult to accept as they were used to bathing frequently.
The health workers found that a small number of mothers developed a skin rash and spots because of restrictions in hygiene. Some mothers were worried that they could not bathe. No other health problems were identified. Traditional medicine practitioners and health workers did not support the traditional practice of not bathing in the postpartum period. They said that there is no harm in bathing with warm water and using motherwort, wine or boiled water is not necessary.
Vulval and perineal hygiene
Careful hygiene to reduce the risk of infection seemed to be the more important belief with respect to the vulval and perineal area. All mothers in rural and urban areas washed the vulva area every day. They used alcohol, boiled water or iodine to clean incisions or tears. There were no reported problems with infections or poor healing. Health workers promoted vulval and perineal hygiene. They also stated that most mothers cleaned their incision or tear when they returned home. They reported very few instances of infections or poor healing.
"When I stayed in the hospital the nurse cleaned the perineum for me. When I came home I used some medicine from the hospital to clean the incision. It healed well. I used boiled water and sometimes iodine to clean it" (Mother, rural family 4).
No brushing teeth
Many people believed that brushing teeth during this period would make teeth loose and gums bleed. Traditional medicine practitioners and health workers did not agree, saying that it was necessary to brush teeth.
None of the mothers in the rural area and only two in the urban area carried out their usual dental hygiene habits of brushing teeth at least once daily. There were a variety of practices carried out: using cotton to clean teeth for two weeks and then brushing; using a soft brush with hot water to make it softer; swilling the mouth with boiled water for two weeks and then brushing; and swilling the mouth for entire month.
When mothers did not brush their teeth they complained of poor appetite and bad taste or smell in the mouth. Some were only able to carry out the traditional practice for a short time and stressed importance on dental hygiene. The health workers saw no health problems associated with these restrictive practices, except that women complained of a poor appetite.
"In the first 7 days I used cloth to clean my mouth. After 10 days I used a soft brush. I can't avoid brushing my teeth for a whole month. It's impossible" (Mother, rural family 1).
Staying inside the home, avoiding housework, resting in bed, abstaining from sexual activity and limiting visitors are topics around behaviour which emerged from discussions.
Staying inside the home
All families believed that when the mother goes outside wind will enter her body and cause illnesses, namely arthritis and rheumatism later in life but also headache, poor appetite and catching a cold.
"She must avoid wind coming straight on to her body. It can cause arthritis, backache and shoulder ache. This is very important in doing the month" (Grandmother, urban family 4).
This belief was strongly adhered to: all mothers in both urban and rural areas stayed at home. In addition, some urban mothers stayed in their rooms for part of the month, not being allowed into the rest of the flat. Most mothers seemed to be able to cope with this restriction and concentrate on resting and looking after the baby.
"We don't go out of the house because firstly we want to follow tradition and secondly we have to look after the baby and we have no time to go out and enjoy ourselves. It would be better if we did have some time to go out and relax" (Mother, urban family 6).
Although the traditional medicine practitioners supported the practice of mothers staying in the home, they did not give the same rationale. They believed that postpartum women are vulnerable to problems such as increased bleeding and colds, but not to arthritis and rheumatism as suggested by some family members. Most health workers felt that although there was no harm in going outside, there was no need for women to leave the home during this period.
The belief that a mother should not do housework during the month, as she is weak and needs rest was common. Housework requires her to be in contact with either water or wind, which will then enter the body and cause arthritis and chronic aches.
"I am scared she will get arthritis and backache. I did all the washing when I had my babies and now I have arthritis in my feet" (Grandmother, rural family 2).
In all families there were people to look after the new mothers and do the housework during this period. However, two mothers still did some light housework towards the end of the month. One urban mother said it made her feel less tired and helped time go more quickly. The rural mother did some housework, as the grandmother was busy with farm work. Traditional medicine practitioners and health workers all supported the belief that women should rest during this period.
Resting in bed
The traditional belief is that mothers should lie in bed for the whole month, recovering from childbirth and preventing future illnesses by keeping out of the wind. Most of the grandmothers advised this, but the majority of mothers and husbands felt this was not necessary.
"My mother said to rest as much as possible. She suggested lying in bed. She said that too many activities would cause leg pain. So I decided to do some exercise and then rest" (Mother, rural family 4).
Two mothers stayed in bed for the entire month as instructed by the grandmothers. The others wanted to rest, as they were tired from sleep disturbances, and needed time to recover from childbirth.
"During this month, I wanted to sleep a lot because every two hours I had to feed the baby. I had to breastfeed the baby 2 or 3 times a night" (Mother, urban family 3).
Others also wanted to do some walking around the home to promote blood circulation, reduce weight and relieve boredom. Mothers felt uncomfortable, hot and had backache if they stayed in bed for long periods. Only one rural mother and two urban mothers did some other exercises. According to the traditional medicine practitioners, TCM does not support the belief that mothers should stay in bed and not do any activity. Traditional medicine practitioners and health workers both advised some exercises but also plenty of rest during this period, so that the mother would make a good recovery.
Abstaining from sexual activity
The common view is that sexual activity should be forbidden during the postpartum period. There were several reasons for this restriction: the woman is weak; she has no energy and is concentrating on looking after the baby; she needs to rest; the scar has not healed; she is still bleeding; and it can cause an infection. Health workers and traditional medicine practitioners supported this restriction. All families followed this restriction for a period ranging from one to three months.
"I think there are restrictions about sex in the postpartum period. I was so weak after the birth. There should be no sex for 42 or 56 days" (Mother, urban family 1).
The traditional belief imposes a strict restriction on social activity and visitors. Most grandmothers and husbands in both areas, although stating they had no restriction on visitors, believed that there should be limited visitors during this period. The reasons for this were: it allows more time for the woman to rest and recuperate; some visitors may pass infections to mother or baby; they may disturb the baby or affect milk production. In the rural area some families believed that if people were to visit in the first three days, then they could continue to visit for the whole month. Other families followed the principle of allowing people to visit in the first three days and then visit again only after 14 days. Families said that this restriction is commonly known, and is not strictly imposed by the family.
"There are no restrictions, but I did not want her disturbed too often. As the baby is newborn and the mother is weak, they both need rest and a quiet environment. Some visitors may have an illness that we do not know about. The baby's immunity is poor and he may get this" (Husband, urban family 5).
In the urban area, there is a tradition that the mother can be visited whilst she is in hospital but not when she has gone home. Although most families did not have a clear restriction about this, many of their friends and families adhered to this belief.
Mothers seemed to be happy to receive visitors. Some wanted to have more visitors and social interaction. Others were happy with the number of visitors they received. In the urban area family members commented that visitors would improve the mother's mood.
"I like people visiting. I want to talk to people. I feel bored when I stay at home alone" (Mother, urban family 3).
Health workers promoted restricted visiting as they felt that too many visitors may increase the risk of illness in mother and baby. Traditional medicine practitioners did not express any views.
Interviews with families revealed the following sub-themes: breastfeeding is best, and giving honeysuckle to treat skin rashes.
Breastfeeding is best
All the families believed that breast milk was the best food for the baby. They said breast milk has enough nutrition for up to four months; promotes immunity in the baby; makes the uterus smaller; is convenient and is easily absorbed. They also noted that breastfeeding helps the relationship between the mother and baby.
Despite these widely held beliefs, only two mothers exclusively breastfed their babies, whilst the others gave milk powder or water during the first three days as they felt there was no breast milk for the baby. Many women continued to give milk powder or water during the month. The reasons for this were: the baby would be used to another food should the breast milk not be enough or when the mother went out; the milk powder has extra nutrition that may not be available in the breast milk; the husband can feed the baby; and breastfeeding for long periods will cause back ache.
"I think mixed feeding is very good and can provide balanced nutrition for the baby. The baby may lack something if he is only breastfed. Milk powder has other nutrients. But the milk powder is not as fresh or natural as breast milk" (Husband, rural family 2).
Respondents reported that all babies appeared healthy and were growing well. Traditional medicine practitioners supported exclusive breastfeeding; health workers expressed their support for exclusive breastfeeding, but also said that if a woman did not have enough milk it was acceptable to give milk powder. Health workers did not identify any differences in growth, occurrence of infections or jaundice between breastfed and milk powder fed babies. However, they did report that more babies who were fed milk powder had diarrhoea.
Giving honeysuckle for skin rash
When asked about childcare practices during the postpartum period, respondents sometimes reported giving honeysuckle as an oral medicine to the baby to relieve heat, skin rashes and eye discharge. It was related to restoring the balance of yin and yang in the baby. In the urban area four of the families used honeysuckle, whereas only one family in the rural area used this herb. Most felt that the herb was effective, but some were concerned about its effects on the baby's stomach and gut.
"We also gave some honeysuckle because the baby was hot and had some eczema. But we did not let the baby have much. I am not sure it worked, but I liked to try. I was also afraid that the herb may hurt the baby's stomach. But if we did not give this herb we would worry about the eczema" (Husband, urban family 4).
Both health workers and traditional medicine practitioners advised against this practice. They said that honeysuckle is "cold" and will harm the yang of the baby and damage the spleen and stomach.