Introduction

Postpartum maternal health care influences the health of both the mothers and their children greatly. Like prenatal care, the postpartum health care that is typically provided during the six-week period after childbirth is very important to the mothers' health.¹ In developing countries, over 60% of maternal deaths occur during the postpartum period. A great number of postpartum complications can be avoided. Physical as well as psycho-social problems can be detected early via an effective postpartum care. Effective postpartum care is essential to maximize survival of mothers and new born regardless of where a woman delivers. Ironically, in developing countries, about 70% of women do not receive any postpartum care.²

In general, Western postpartum practices are based on the biomedical model, whereby the role of the woman is less important than that of the physician. In contrast, the traditional non-Western perspective emphasizes that birth is part of a holistic and personal system, involving moral values, physical aspects, social relations, and relation to the environment. Postpartum health beliefs and practices among non-Western cultures are each distinct, but have many similarities.

In general, most Asian traditional practices of postpartum care aim to restore the balance in the body elements i.e. soil, water, wind and fire. These practices aim at restoring the normal function of sex and reproductive organs, increasing wellbeing and energy of the mothers, encouraging wound healing, weight loss and aesthetic reasons. Giving birth is a period that is described as ‘cold’ hence proper care is given to balance this. These postpartum care practices are practiced throughout the whole confinement period.³ Two most common belief systems in traditional postpartum care includes the importance of balancing hot and cold elements within the body mostly via modification of food intake, clothing and sanitary habits as well as the necessity of confinement during a specific period of time after giving birth.⁴

In Malay ‘Pantang’ literally means ‘restriction’.Pantang’ refers to the ‘do’s and don’ts’ during the postpartum confinement period. Traditional postpartum care or ‘pantang’ in Malaysia is a complementary care regime widely practiced among women after giving birth regardless of the socio-demographic and cultural differences. In Malaysia, the three major ethnic groups i.e. Malays, Chinese and Indians each have their own confinement practices. However these three ethnic groups share some similar principles and elements including prescribed confinement period, postpartum diet, massage, hot compress (bertungku), corset (bengkung), herbal baths and medicinal tonics as well as certain specific lifestyle measures.

Anthropologists G. Stern and L. Kruckman⁵found that mothers in Asian countries do better after birth than those in Western countries. They describe that many postpartum problems, especially postpartum depression, were virtually non-existent. By contrast, about 14% of mothers in developed countries suffer moderate to severe postpartum depression. They attribute the lower level of depression to the traditional postpartum care or ‘pantang’.

How and whether or not the traditional postpartum confinement period and care actually have any effects on women’s health has still not been fully understood. Especially for the fact that even though in general, the names and tools used are same, different families inherit different level of practice and technique making it hard to objectively asses its effects. Due to the dearth in research conducted on traditional postpartum care practices health care professionals are not able to understand the existing health benefits of the practices nor are they able to detect the potential harm of these practices.

The objective of this study was to describe the beliefs and practices related to the traditional postpartum care among women in a village in Penang, Malaysia.

Methodology

Setting: the study was conducted in a village located in the island of Penang in Malaysia. Most of the villagers were Malay Muslims working as fisherman or employed in the tourism industry.

Sampling: all the women in the village who had given birth were eligible to participate. Those who did not consent or were unable to communicate effectively were excluded.

Study Design: a descriptive cross sectional study was chosen as the study design to achieve the objective of the research.

Tools: Trained research assistants collected the data in the respondent’s homes. Besides the baseline demographic date, information was collected on the post-partum confinement period and the aspects of traditional post-partum care such as dietary modification, massage, hot compress, corset, herbal application and lifestyle changes. For these practices the respondents were asked whether they were aware of it but did not practice, they were aware of it and practiced, or if they were not aware of it at all.

Analysis: Data was analysed using PASW (Predictive Analysis Software) version18.0. Results were tabulated and depicted graphically.

Ethics: Verbal informed consent was sought before starting the interview. The anonymity of the participants is assured.

Results

All the 68women who were eligible out of the total 300 villagers agreed to participate. The age of respondents ranged from 21 to 80 years old with the mean age of 46.1 years old. Most of them were in the age group of 51-60followed by 41-50. Most of the respondents were Malays, Muslims, married, housewives and the highest level of education up to secondary school as shown in table 2.

Figure 1

Table 1: Demographic profile of the respondents

The confinement period ranged from 30 to 150 days. The mean perceived confinement period was 53 days. This is depicted in figure 1. Irrespective of the number of days most believed that it was important to strictly follow the confinement period. The most common reason given for the practice of confinement was self-belief (59) followed by convenience i.e. they were housewives hence they can practice it (3) and family pressure (3).

Figure 2

Figure 1: Perceived minimum confinement period

As shown in Table 2, irrespective of the age group, education level and employment, most perceived the confinement period to be more than 45 days. However the findings were not statistically significant.

Figure 3

Table 2: Crosstabulation between the demographic profile and the perceived minimum confinement period

Figure 2 shows the practice of some of the more common beliefs and practices of post-partum care regimens amongst the Asian community. Most women in this village were aware and practiced these common postpartum regimens except for the encouragement of more food intake and the limitation of contact with others. Use of corset which is popular among Malaysian women during postpartum is less used in this community.

Figure 4

Figure 2: Awareness and practices of common traditional postpartum care regimens

As shown in table 3 and 4, older women were more likely to restrict their water intake (p=0.001) and consume traditional herbs (p=0.050).

Figure 5

Table 3:Cross tabulation between the demographic variables and the postpartum diet practice

Figure 6

Table 4:Cross tabulation between the demographic variables and traditional herbs consumption/physical practice

Figure 7

Figure 3:Sources of awareness for traditional postpartum practices

As shown in Figure 3,irrespective of the type of practices, the most common source of awareness was family tradition followed by the recommendations of the midwife except for the practice of lifestyle changes where the most common source was family tradition followed by acquired health education.

Figure 8

Figure 4:Level of perceived importance of each aspect in postpartum care

As shown in Figure 4, irrespective of the type of regimen, overwhelming majority perceived that the regimens were either important or very important.

Figure 9

Figure 5:Reasons for the practices of postpartum care

Figure 5 shows that most practices stem from self-belief. Respect for family tradition and family pressure are other frequent reasons.

The only reported complications due to the practice of traditional postpartum care or ‘pantang’ were caused by diet and traditional herbs. The complications were constipation and haemorrhoids. As shown in Figure 6, even when there were complications the possibility of practicing these regimens again in the future was still high. Most women claimed that they would repeat the same regimens of traditional postpartum care in subsequent pregnancies and they would advise their children on the importance of practising it.

Figure 10

Figure 6:Complications and possibility of future practice

Discussion

The very strong level of belief and practice in the traditional practices with regards to postpartum care in this community is consistent with previous studies on the same topic.

The traditional Malay belief in terms of confinement period is consistent with the number of maximum days that can be regarded as ‘nifas’ i.e. lochia, as defined by Islamic jurisprudence as the maximum postpartum confinement period which is 44 or 45 days. In the Islamic Women Health Rules (‘FiqhWanita’), it is believed that, per vaginal bleeding that exceeds 44, 45 or 60 days (depending on the scholar) is considered ‘istihadhah’ i.e. diseased blood which alerts for some pathological bleeding hence different regulations apply in terms of acts of worship e.g. prayers, fasting and pilgrimage.⁶ This is then adopted in the Malay community as the confinement period perhaps for the sake of convenience in monitoring mothers during the postpartum care. In the classic Hindu mystic beliefs, 44 is a mystical number believed to represent the 4 elements that needs to be balanced after the imbalanced act of giving birth i.e. soil, water, wind and fire. 44 days is also the traditional belief for the number of days for the process of creation and death of humans. There are also 44 angels believed to be guarding these 4 elements and the four galaxies traditionally believed to be present in the universe.³ One hundred days is also quite common however, it is more exclusively attributed to prohibition of sexual intercourse rather than the full practice of traditional postpartum care.³

Irrespective of the number of days, in most Asian cultures, family members (especially female relatives) or midwives provide strong social support and help new mothers at home during this period.⁴ The experience and observations of the practice especially among the elder family members are very influential. Many believe that women who are not strict about confinement period suffer ill health and infertility in later years.⁷ This could be a reason why many women in Malaysia still practise postpartum confinement religiously regardless of socio-economic status.³ However it is important to remember that a very big majority of those who practice these postpartum regimens do so on their own accord without the pressure from family members. Due to work commitment especially among the educated women living in urban areas in Malaysia, it is quite common these women, including traditional midwives and masseuses who provide care services during the confinement period are rather lenient about the number of confinement days.⁸ In Malaysia most employers provide 60 consecutive days as confinement leave.⁹

In a biomedical perspective however, all functions of the reproductive organ i.e. the uterus, vagina and cervix in an uncomplicated delivery will become relatively back to its pre-gestational state by two weeks and hence there isn’t a need for restriction in any activity of daily living unless the mother complains of any unusual symptoms.¹⁰

Generally, the women in this community were aware, emphasised the importance and practiced these common postpartum care regimens with the exception of practices like increasing food intake (which is only common among the Chinese) and limiting contact with others. This is consistent with the claim that postpartum care is one aspect of women health that is largely influenced by the traditional standards. This indicates the importance of taking into account traditional practices and belief when assessing and managing mothers in maternal and child health services, which is not yet emphasized in the standard care provided by the country’s health services.

It can be seen from the finding of this study that the midwives have a strong influence in postpartum care among these villagers. These midwives hence have the potentially important role to play as health information disseminators.

The discussion on the traditional postpartum care comparing with the documented health effects based on western health model and the implication on health is tabulated for easy understanding (tables 5-8).

As shown in Table 5, prohibition of gassy food and the encouragement of food intake are consistent with western belief although the limitation of water and certain foods like vegetable and fruit intake may form a risk for dehydration, constipation and malnutrition. Although there are studies which reported the benefits of the traditional herbs especially for constipation and jaundice but the potential side effects of these need to be further explored to avoid potential dangers as shown in table 6.

As shown in table 7 and 8,hot compress, massage and use of corset although have no scientific evidence in their benefits however there are no recorded complications of on these practices. Limitation of movement is encouraged in both western and traditional practice but the contention is the period of immobilization. Prolonged immobilization should be discouraged to avoid possible complications especially deep vein thrombosis.

By understanding the practices and the reasons, the stakeholders of maternal and child health in the community will be able to provide a holistic approach which is crucial in the management of postpartum mothers who will benefit from both biomedical and traditional health services as opposed to the conflicts which usually occur between biomedical, traditional and alternative medicine.¹¹

The commonly believed superiority of the modern and the devaluation of indigenous cultures and knowledge systems results in incomplete healthcare delivery. Mothers in this part of the world are still inclined towards traditional practices in postpartum care. The modern healthcare providers should encourage good practices and advice against the hazardous practices.

Figure 11

Table 5: Traditional postpartum diet compared with the documented health effects based on the western health model and its implication on health

Figure 12

Table 6: Traditional postpartum supplements of traditional herbs compared with the documented health effects based on western health model and its implication on health.

Figure 13

Table 7: Physical aspect of traditional postpartum care compared with the documented health effects based on western health model and its implication on health

Figure 14

Table 8: Lifestyle aspect of traditional postpartum care compared with the documented health effects based on western health model and its implication on health

Conclusion

Traditional postpartum practices are prevalent among women in this community which implies a strong belief in the practice of ‘pantang’ within the Malay culture. Self-belief forms the basis for the practices of traditional postpartum care among the respondents of this community.

Acquired health education influences lifestyle changes, which is valuable in promoting healthy habit during postpartum period. Education should be targeted to their families especially the female family members to change any potential harmful practices which may adversely affect maternal and child health.

Health professionals should be aware of the patients’ culture and which traditional belief complements professional care. Healthcare providers should also advise and educate women about the importance of adhering to the standard practice of postpartum care while outlining appropriate strategies for integration of mothers’ traditional beliefs and modern approaches of postpartum care.

Limitation

Because of the small sample size the results obtained may not truly reflect the true level of belief and practice of traditional postpartum confinement period and care in the population. However this study can be used as a foundation for larger studies in this field. Future studies on a multiracial and more urbanised population would yield interesting results.